Rotary Incident Investigation Training R02

HSE Department Incident Reporting & Investigation

Contents 1. Purpose for incident investigation 2. Definition 3. Incident Reporting & Investigation Procedure 4. Summary

Incident Reporting & Investigation 1) Purpose for incident Reporting & investigation To improve health and safety performance by determining an incidents cause, and the necessary corrective actions to be taken in order to avoid similar occurrence in future Determining compliance with the relevant safety regulations Fulfilling legal requirements Determining the cost of an accident Processing workers compensation claims (if necessary) Identify underlying gap. To implement relevant Corrective/Preventive actions to prevent recurrence.

Heinrich's law The Heinrich 300-29-1 Model 1 • Fatality 29 • Loss of Consciousness 300 • Days Away From Work • Transferred or Restricted Work • Medical Treatment Beyond First Aid • First Aid • Dangerous Occurrence • Motor Vehicle Incident without Injuries • Property Damage • Near Miss The Heinrich 300-29-1 Model

2 - Definition  What is an accident? An unexpected and undesirable event, especially one resulting in damage or harm.  What is an incident? An incident as \"an unplanned, undesired event that adversely affects completion of a task.\" Incidents range in severity from near misses to fatal accidents. Incident Accident

2 – Definition Classification of Incident / Accident Classification of Incident / Accident OSHA MOM ( Singapore) Recordable Reportable • Fatality • Fatality • Loss of Consciousness • Dangerous Occurrences • Days Away From Work • Occupational Disease • Transferred or Restricted Work • Hospitalization for at least 24 hours • Medical Treatment Beyond First Aid • MC for more than 3 days (whether In compliance with OSHA 1904 Recording and Reporting consecutive or not) Occupational Injuries and Illness Regulations Part C In compliance with WSH (Incident Reporting) Regulations Non-Recordable • First Aid Non-Reportable • Near Miss • First Aid • Property Damage • Near Miss • Motor Vehicle Incident without Injuries • Property Damage • Environmental Pollution • Motor Vehicle Incident without Injuries • Environmental Pollution

Classification of Incident / Accident Definition - ROTARY PROCEDURE ( REL-HSE-06 ) 4.3 OSHA Recordable Case a) Fatality Any work-related injury/illness that results in the loss of life by the injured person b) Loss of consciousness Any work-related injury/illness involving loss of consciousness regardless of the duration of unconsciousness c) Days away from work Any work –related injury/illness that renders the person temporarily unable to perform any regular job on subsequent day(s) after the day of injury d) Transferred or restricted work Any work-related injury/illness that renders the person temporarily mentally or physically unable to perform any or all of normal job duties over any or all part of a normal workday/shift on subsequent day(s) after the day the injury occurred.

Classification of Incident / Accident Definition - ROTARY PROCEDURE ( REL-HSE-06 ) e) Medical treatment beyond first aid Any work injury or illness that requires medical treatment beyond that considered as first aid and which does not result in a Days Away From Work or a Transferred /Restricted At Work Injury. For any work –related illness that renders the person temporarily unable to perform any regular job on the day of the injury and no subsequent days away from work, transferred or restricted work. In addition, the medical treatment does not include: - Visits to a physician or other licensed health care professional solely for observation or counseling; - The conduct of diagnostic procedures, such as x-rays and blood tests, including the administration of prescription medications used solely for diagnostic purposes (e.g., eye drops to dilate pupils); or - “First aid” as defined in 4.5 a) First Aid. The case is classified as “Medical treatment beyond first aid.

Classification of Incident / Accident Definition - ROTARY PROCEDURE ( REL-HSE-06 ) 4.5 Non-Recordable Case a) First Aid Any work-related injury that results in first aid treatment regardless of the number of treatments required. “First aid” means the following: - Using a non-prescription medication at non-prescription strength; - Administering tetanus immunizations; - Cleaning, flushing or soaking wounds on the surface of the skin; - Using wound covering such as bandages, Band-Aids, Gauze pads, etc.; or using butterfly bandages or Steri-Strips; - Using hot or cold therapy; - Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc.; - Using temporary immobilization devices while transporting an accident victim - Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister; - Using eye patches; - Removing foreign bodies from the eye using only irrigation or a cotton swab; - Removing splinters or foreign material from areas other than the eye by irrigation, tweezers, cotton swabs or other simple means; - Using finger guards; - Using massages - Drinking fluids for relief of heat stress

Classification of Incident / Accident Definition - ROTARY PROCEDURE ( REL-HSE-06 ) b) Near Miss An incident that does not result in injury, death, property or environmental pollution, but it could have resulted in a loss if it had escalated. c) Property Damage Property Damage is an incident resulting in damage or the destruction of public or private property, which exclude motor vehicle incident. d) Motor Vehicle Incident without Injuries A traffic collision occurs when a vehicle collides with another vehicle, pedestrian, animal, road debris, or other stationary obstruction, such as a tree or pole. Any traffic collision incident with injuries sustained should fall within OSHA recordable / MOM reportable / First aid cases. e) Environmental Pollution Environmental pollution is the contamination of the environment as a result of human activities either intentionally or accidentally, which includes air, water, and soil.

Incident / Accident Rate Definition Incident / Accident Rate OSHA MOM ( Singapore) Total Recordable Incident Rate (TRIR) = Accident Frequency Rate (AFR) = (FAT+LC+DAFW+TRAW+MTC) X 200,000 Total No. of MOM Reportable Cases X 1,000,000 Total No. of Man Hours Worked Total No. of Man Hours Worked Days Away, Restricted or Job Transferred Accident Severity Rate (ASR) = Incident Rate (DART) = Total No. of Man Days Lost X 1,000,000 (DAFW + TRAW ) X 200,000 Total No. of Man Hours Worked Total No. of Man Hours Worked

3 – Reporting & Investigation Procedure  Accident Occurrence  Accident Reporting  Investigation Authority  Facts Finding  Analysis and Evaluation  Corrective Measures  Documentation

3 – Reporting & Investigation Procedure  Accident Occurrence Upon Accident Occurrence: -Injured person to be rescued as best as possible without endangering ourselves -Preserve scene of accident -Cordon off area to prevent unauthorized entry -Check and ensure the possibility of incident occurrence -Notify HSE team immediately All supervisors and staff should know the system -Emergency response team (CERT Team) -Accident/incident investigation team -Roles, responsibilities and authorities -Coordinate with emergency response team -Control secondary accident -Preserve accident scene -Communicate with external agencies

3 – Notification Procedure  Accident Notification - ROTARY PROCEDURE Internal Project Senior Notification Mobile App Management Group Chat Notification External Group Chat Notification •Clients Notification •MOM •Police •SCDF •Etc. Who should be informed? WLcoonchtaraaticottnosr hMagoarneueamlgdeernbt.neotiifny ftoorcmlieentds tthoe einxcitdeenrtn/aacclidpenatratsy?per -Project Mobile App Chat Group -Clients: Contract reporting requirements Site HSE Lead (Group Admin) Project Manager -MOM ( Singapore): Corporate HSE Manager Fatality (Inform MOM immediately) BU Head Hospitalisation for at least 24 hours MC for more than 3 days (whether consecutive or -Senior Management Notification Chat Group [Corporate HSE Manager (Group not) Admin), Senior Management] Dangerous occurrences (Inform MOM immediately) Occupational diseases Group Admin -Set up mobile app group chat Corporate HSE Department serve as point of contact for preparation of i-report on events where cases are required to be reported to MOM.

3 – Reporting & Investigation Procedure  Accident Occurrence  Accident Reporting  Investigation Authority  Facts Finding  Analysis and Evaluation  Corrective Measures  Documentation

3 – Investigation Procedure  Accident Reporting Accident Reporting Flowchart – Part 1

3 – Investigation Procedure  Accident Reporting Accident Reporting Flowchart – Part 2

3 – Investigation Procedure  Accident Reporting - ROTARY PROCEDURE OSHA Recordable -Fatality, DAFW, TRAW, MTC, LC OSHA Non-Recordable -First Aid -Property Damage -Near Miss -Motor Vehicle Incident without Injuries -Environmental Pollution Non-industrial related work incident Upon incident occurrence, Preliminary Incident Report (F-HSE-08B) shall be forwarded to Corporate HSE Department within 24 hours; Final Incident Report (F-HSE-09D) shall be submitted to Corporate HSE Department within 5 days. Corrective/Preventive Action Request Form (F-MGT-07G) with section 1-3A completed shall be submitted to Corporate HSE Department within 5 days. The corrective actions shall be closed with supporting evidences and documents and endorsed by relevant parties shall be submitted to Corporate HSE Department within 1 month. The preventive actions implemented by the relevant parties shall be verified and approved by Corporate HSE HOD within 3 month.

3 – Investigation Procedure  Accident Occurrence  Accident Reporting  Investigation Authority  Facts Finding  Analysis and Evaluation  Corrective Measures  Documentation

3 – Reporting & Investigation Procedure  Investigation Authority -MOM Commissioner ( Singapore ) Phone : 6317 1111 Fax : 6535 2550 -Police : 999 -Ambulance : 995 -NEA : 18002255632 -PUB : 18002255782 Formal incident reporting may also be required in accordance to clients and local legal requirements. Initial Actions: -Take control at the scene -Ensure first aid and Emergency service -Identify sources of evidence -Preserve evidence -Determine loss potential -Primary responsibility of emergency response team -Containment -Mitigation

3 – Reporting & Investigation Procedure  Accident Occurrence  Accident Reporting  Investigation Authority  Facts Finding  Analysis and Evaluation  Corrective Measures  Documentation

3 – Reporting &Investigation Procedure  Facts Findings  Scene of accident  Persons to be interviewed  Documents to be checked What to have on hand - To be prepared to complete an investigation promptly following an incident, it is best to have prepared a kit ahead of time that includes: • Investigation forms • A pen • Interview forms • Voice recorder • Barricade markers/tape • Measuring tape • Warning tags or padlocks • Flashlight • Camera or video recorder • Sample containers • PPE

3 – Reporting & Investigation Procedure  Facts Findings Scene of accident -Organizational structure -Relevant background technical • Date & Time information on the associated • Project site process or facility • Location • Workplace No -Maps/location of the accident • Etc site • Method Statements -Normal operating procedures • Safe Work Procedures -Safety management -Working at height processes/procedures and -Hot work assurance procedures -Confined Space -Etc -Identify key human physical and documentary evidence • Photos and/or videos • The protective equipment an individual may have been wearing, • tools that were being used, • and the equipment on or with which the personnel involved in the incident -Define the physical characteristics of the accident scene

3 – Reporting & Investigation Procedure  Facts Findings Persons to be Interviewee (Injured & Witness) Account of interviewed Incident -List of witnesses Interview promptly Establish rapport with witness (treat as equal) -Decide on witness Get the facts. • People from the site Write down the Interviewee (injured / witness’s) statement • People from the (F-HSE-10A) department • People familiar with operations • External parties Guide for Interview Sequence of Event Investigation Please use REL-HSE-06 Appendix Given B1 as a guide for investigation question process -Location - Environment -5W: Who, What, When, - Machine Where, Why - Human/People Factor - Method -1H: How - Material

3 – Reporting & Investigation Procedure  Facts Findings - ROTARY PROCEDURE ( F-HSE-10A ) Sketch for better understanding

3 – Reporting & Investigation Procedure  Facts Findings Documents to be • Permit To Work record checked • Maintenance Record • Training Record -Logbooks • Risk Assessment -Instrument charts • Work Method Statement -As-built drawings • Procedures -Engineering analyses • SDS -Vendor info • Etc. -Correspondence Engineering Analysis

3 – Reporting & Investigation Procedure  Accident Occurrence  Accident Reporting  Investigation Authority  Facts Finding  Analysis and Evaluation  Corrective Measures  Documentation

3 – Reporting & Investigation Procedure  Analysis and Evaluation Root Cause can be thought of as “behind the scenes” causes that allow the immediate cause to occur. A root cause is a factor that caused a non-conformance and should be permanently eliminated through process improvement. Root Cause Analysis is defined as the identification of why an issue occurred vs. only identifying or reporting the issue itself. A root cause analysis allows to discover the underlying or systemic, rather than the generalized or immediate, causes of an incident. Correcting only an immediate cause may eliminate a symptom of a problem, but not the problem itself.

3 –Reporting & Investigation Procedure  Analysis and Evaluation The following examples illustrates the importance of root cause analysis: For example: A worker slips on a puddle of oil on the workshop floor and falls. A traditional investigation A root cause analysis -the cause “oil spilled on the floor” reveal that the oil on the floor -the remedy cleaning up the was merely a symptom of a spill and instructing the worker more basic, or fundamental to be more careful. problem in the workplace. Contributing Factors Root Cause

3 – Reporting & Investigation Procedure  Analysis and Evaluation Contributing Factors To determine the root causes, contributing factors are grouping into the below categories with specific questions asked / analysed: - Environment - Machine - Human/People Factor - Method - Material It is important to consider all possible “what,” “why,” and “how” questions to discover the root cause(s) of an incident.

3 – Reporting & Investigation Procedure  Analysis and Evaluation – ROTARY PROCEDURE

3 – Reporting & Investigation Procedure  Analysis and Evaluation – ROTARY PROCEDURE Root Cause

3 – Reporting & Investigation Procedure  Analysis and Evaluation Root cause analysis using 5 Why START Problem By repeating “why” search for the real Why? 1st Cause (root) cause (try to find it logically by describing physical observations) Why? 2nd Cause Why? 3rd Cause The real (root) cause usually If countermeasures are becomes apparent taken at this stage, the around this stage failure mode will re- Why? 4th Cause occur because the real Why? 5th Cause (root) cause has not been identified and Erdicated It consists of answering 5 times the question “why”, going increasingly in depth to define effective countermeasures.

3 – Reporting & Investigation Procedure  Analysis and Evaluation Root cause analysis using 5 Why When to end the analysis The analysis can be considered terminated once all the causes at the root of the problem have been identified, and from there a series of effective countermeasures will arise.

3 – Reporting & Investigation Procedure  Analysis and Evaluation Root cause analysis using 5 Why Incident description: A worker slips on a puddle of oil on the workshop floor and falls. Why? The slip/fall happened because the workshop floor was slippery. Why? The floor was slippery because there was a puddle of oil. Why? Nobody clean the oil. Why? Worker did not receive instructions on cleaning the oily floor. Walking on an oily floor is a common practice in the workshop. Causes: Why? There was no workshop housekeeping procedure in place. There was no relevant risk assessment training on walking on oily floor.

3 – Reporting & Investigation Procedure  Analysis and Evaluation Root Causes: - There was no workshop housekeeping procedure in place. -There was no relevant risk assessment training on walking on oily floor. Countermeasures: -To set up workshop housekeeping guidelines / procedures -To conduct briefing / training with workers on trip and fall hazards

3 – Reporting & Investigation Procedure  Accident Occurrence  Accident Reporting  Investigation Authority  Facts Finding  Analysis and Evaluation  Corrective Measures  Documentation

3 – Reporting & Investigation Procedure  Corrective Measures - Corrective measures will be directly linked to previous section, e.g. Root cause identification - Corrective measures proposed must be directly addressing each of the root cause identified. In Rotary, Compulsory: -Review/Revise Risk Assessment -Review/Revise Safe Work Procedure - Temporary remedial actions - Permanent remedial actions

3 - Reporting and Investigation Procedure  Corrective Measures - ROTARY PROCEDURE

3 – Reporting & Investigation Procedure  Corrective Measures Procedure for monitoring WSH corrective and preventive actions Regular inspections Internal and external audits Medical Surveys Review accident/injury/lost time occurrences Measurements (e.g. noise level and illumination measurement) Interviews Observations (behavioral based) Review status of preventive measures with person-in-charge

3 – Reporting & Investigation Procedure  Accident Occurrence  Accident Reporting  Investigation Authority  Facts Finding  Analysis and Evaluation  Corrective Measures  Documentation

3 – Reporting & Investigation Procedure  Documentation The relevant documents are kept for at least 3 years. Project Prepare incident investigation report together with Corporate HSE Site data analysis and corrective & preventive measures To be updated Interviews Corporate HSE to keep interviewee’s records Communicate the incident to site personnel Corporate HSE to keep communication records Inform client as per contract reporting requirement Corporate HSE to keep and local legal requirements audit records Keeping records of internal and external audits Review accident/injury/lost time occurrences Corporate HSE to review and analyze every half year Review status of preventive measures with person- Corporate HSE in-charge to keep confidentiality Keep confidentiality of reports

3 – Reporting & Investigation Procedure  Documentation ROTARY FORM ( F-HSE-08B )

3 – Reporting & Investigation Procedure  Documentation ROTARY FORM ( F-HSE-09D ) Sketch for better understanding if no photos

3 – Reporting & Investigation Procedure  Documentation ROTARY FORM ( F-HSE-10A ) Sketch for better understanding

3 – Reporting & Investigation Procedure  Documentation ROTARY FORM ( F-MGT-07G )

4 – Summary  BENEFITS OF ACCIDENT INVESTIGATION  Most accident investigations follow formal procedures  An investigation is not concluded until completion of a final report  A successful accident investigation determines what happened and how and why the accident occurred  Investigations are an effort to prevent a similar or perhaps more disastrous sequence of events  Identifying outmoded procedures  Increased productivity  Improvement of operational & safety procedures  Raise safety awareness level