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ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
34: DATE
36:
Page 1 of 25
INCIDENT REPORTING AND
INVESTIGATION SOP
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
34: DATE
36:
Page 2 of 25
1. PURPOSE .............................................................................................................................................................. 3
2. DEFINITIONS ......................................................................................................................................................... 3
3. ROLES AND RESPONSIBILITIES ............................................................................................................................... 9
3.1 PROJECT MANAGER ...................................................................................................................................................... 9 3.2 PROJECT CONSTRUCTION MANAGER ................................................................................................................................ 9 3.3 LINE MANAGERS .......................................................................................................................................................... 9 3.4 SUPERVISORS............................................................................................................................................................. 10 3.5 PROJECT SHE MANAGER ............................................................................................................................................. 10 3.6 ALL EMPLOYEES ......................................................................................................................................................... 10
4. PROCEDURES ...................................................................................................................................................... 10
4.1 GENERAL .................................................................................................................................................................. 10 4.2 STATISTICAL REPORTING .............................................................................................................................................. 11 4.3 ASSESSMENT OF INCIDENT POTENTIAL ............................................................................................................................ 11 4.4 TRAINING.................................................................................................................................................................. 12 4.5 GUIDE TO INVESTIGATION ............................................................................................................................................ 12
5. ANNEXURE 1 – SUSTAINABLE DEVELOPMENT CATEGORY TABLE......................................................................... 24
6. ANNEXURE 2 – REPORTING REQUIREMENTS ....................................................................................................... 25
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
34: DATE
36:
Page 3 of 25
1. PURPOSE The purpose of this document is:
To assess in a systematic way, the potential of incidents which could adversely affect our business;
To identify the immediate and underlying causes of those incidents so that appropriate action may be taken to prevent recurrence;
To satisfy legal and contractual obligations, and
To provide all levels of employees and contractors with a consistent approach to incident investigation in order to achieve a quality reporting, investigation, analysis and follow-up standards.
This procedure covers the requirements associated with the reporting and investigation of incidents associated with the Tshipi Project activities. In contracting situations, the relevant contractor must ensure that this procedure is followed. Contractors at the Tshipi Project have the same roles and responsibilities as employees to initiate incident reports and take part in investigations.
2. DEFINITIONS
Near Hit – Where a dangerous act / condition occurred and no one got injured and no damage to property, but the likelihood exists that as a result of the act / condition an injury could be caused or property could be damaged.
Health / Hygiene Incident (Occupational Illness / Disease) – an incident which affects the health or hygiene of an employee. An Occupational Illness or Disease is contracted or exacerbated as a result of the conditions or environment of employment. The basic difference between injury and illness is the single event concept. If the event resulted from something that happened in one instance, it is an injury. If it resulted from prolonged or multiple exposure to a hazardous substance or environment factor, it is an illness. Categories may include:
Noise Induced Hearing Loss
Musculoskeletal Injury (e.g. Repetitive strain injuries / occupational overuse syndrome).
Dust disease.
Occupational Exposure Disease / Disorder (e.g. Lead / chemical).
Dermal Condition (e.g. Dermatitis).
Vibration injury.
Occupational Cancer.
Allergic Reaction / Environmental Sensitivity.
Respiratory Diseases / Disorders (e.g. Asthma / rhinitis)
Caissons Disease (Decompression Illness).
Cardio Vascular diseases / Disorder.
Infections Disease.
Ingestion Injury.
Mental Illness / Condition (e.g. Work-related stress).
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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Page 4 of 25
Nervous System Disorder
Reproductive Disorders
Environmental Incident – an incident which results in an impact on the environment, and can classed as one of the following categories:
Category 1: Negligible (caused negligible, reversible environmental impact, requiring very minor or no remediation)
Examples (for guidance only):
A slow droplet oil leak from a compressor, engine or other equipment.
A hydraulic hose on a loader fails and the contents of the hose are lost.
A fuel oil spill-over or splash back whilst fueling a vehicle.
Employee or contractor not following an internal Environmental Procedure.
Visible fume from a building rooftop resulting from an uncontrolled process.
Process water overflow from closed process loop to plant roadway or surface water collection pond.
Category 2: Minor (caused minor, reversible environmental impact, requiring minor remediation)
Examples (for guidance only):
Incorrect storage of hazardous materials.
Engine failed causing approximately 20 litres of oil to spill onto a roadway.
Tailings dust carried off site.
Decommissioned mobile equipment left without drip trays and oil has contaminated two or more square metres of bare ground.
A forklift has punctured a 44 gallon drum containing waste oil.
A hose feeding a waste oil tank is dislodged and the oil that escapes enters a body of surface water.
A fully loaded concentrate transport truck is bogged on the side of Highway.
Mercury concentration in waste water exceeded maximum allowed concentration.
Category 3: Significant (caused moderate, reversible environmental impact with short-term effect, requiring moderate remediation)
Examples (for guidance only):
A complaint from the public was received via the local regulator regarding product that was discovered in a nearby water source.
A sewage treatment plant overflowed and sewage was discharged off site and into a creek.
A major storm event caused the discharge of contaminated water off site.
Any license limit that is exceeded for an extended period.
Any event resulting in numerous community complaints or media exposure.
Seepage is identified at the base of a concentrator runoff pond.
A truck rollover on a public road resulting in a moderate spillage of chemical, oil, fuel or product that is contained within a limited area and that does not impact sensitive habitat that is difficult to remediate.
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
34: DATE
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Page 5 of 25
Category 4: Serious (caused serious environmental impact, with medium-term effect, requiring significant remediation.)
Examples (for guidance only):
NOTE: Category 4 or 5 Environmental Incidents must also be reported as Critical Incidents (CI). Incidents that could have resulted in Category 4 or 5 Environmental Incidents must be reported as High Potential Risk Incidents (HPRI) – refer to the CI and HPRI definitions in this document.
Significant Sulphur dioxide plume that affects the local community.
Category 5: Disastrous (caused disastrous environmental impact, with long-term effect, requiring major remediation.)
Examples (for guidance only):
NOTE: Category 4 or 5 Environmental Incidents must also be reported as Critical Incidents (CI). Incidents that could have resulted in Category 4 or 5 Environmental Incidents must be reported as High Potential Risk Incidents (HPRI) – refer to the CI and HPRI definitions in this document.
A train derailment that causes a significant spillage (large volume) of sulphuric acid to flow over a wide area.
Property Damage – an incident which results in the damage to company property.
First Aid Case (FAC) – A first aid case (FAC) is a minor work related injury which in normal circumstances can be treated by the victim himself/herself. This usually includes application of non-prescription medicines e.g. antiseptic ointment and small wound dressings. If the treatment given by a medical professional amounts only to that described in this definition the case will remain an FAC. First Aid Injuries Include:
Visits to a medical practitioner / physician solely for observation, counselling or first aid treatment.
Diagnostic procedures such as x-rays and blood tests, including the administra-tion of prescription medications used solely for diagnostic purposes, e.g. Eye drops to dilate pupils.
Using a non-prescription medication at non-prescription strength, i.e. Using medication that does not require a physician’s prescription.
Administration of immunisations, e.g. Tetanus, hepatitis, influenza.
Cleaning, flushing or soaking wounds on the surface of the skin.
Using wound coverings such as bandages, band-aids, gauze pads, etc, or using butterfly bandages or steri-strips.
Using hot or cold therapy.
First degree burns.
A series of less than five preventative treatments by a physiotherapist or chiropractor, without medical restriction by a physician.
Using non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc.
Using temporary immobilisation devices while transporting an injured person, e.g. Splints, slings, neck brace, back boards, etc.
Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister.
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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Page 6 of 25
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.
One time administration of oxygen therapy.
Medical Treatment Case (MTC) – A medical treatment case (MTC) is a work related injury which has not been classified as an LTI or RWI, and which results in the injured receiving attention which under normal circumstances would only be received from a medical professional (e.g. doctor, nurse, paramedic, physiotherapist etc.) via medical treatment and/or prescription. The injured will be able to resume his/her regular duties on the day following that of the injury. The following notes apply:
An injury which first resulted in (for example) an LTI and where the injured after resuming work continues to receive medical treatment for that injury will remain reported as an LTI.
Precautionary examinations, such as the taking of X-rays, are not considered to be MTCs. The application of sutures (stitches), or the removal of a foreign body embedded in the eye, are examples of MTCs. The criterion is the treatment, not the examination.
Medical Treatment Injuries include:
Any work-related injury resulting in a loss of consciousness.
Use of prescription medication, i.e. Medication that can only be prescribed by a medical practitioner / physician. (Except for a single dose of prescription medication administered on the first visit to the physician).
Use of stitches / sutures or staples to close a wound.
Infection from a work-related injury requiring antibiotics.
Second and third degree burns – based on the treatment required and the risk of infection e.g. a burn from a small drop of molten metal to the wrist may only require first aid treatment, whereas if a broader area is affected then medical treatment may be required.
Removal of foreign bodies from the eye requiring more than irrigation or cotton swabs to remove them.
The use of casts, splints or other rigid stays to immobilise parts of the body. A positive x-ray diagnosis for fracture(s).
Surgical removal of foreign material or dead skin i.e. Surgical debridement.
Removal of a fingernail or toenail.
A series of five or more treatments by a physiotherapist or chiropractor.
Admission to hospital for observation for more than 12 hours.
A Lost Time Injury (LTI) – occurs when a person is injured in the execution of his/her duties and as a result of this injury is unable to perform his/her regular duties for one full shift or more on the day following the day on which the injury was incurred, whether a scheduled work day or not.
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
34: DATE
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Page 7 of 25
A lost time injury is registered as a safety statistic when the injury is confirmed as a work-related compensable case by the jurisdictional worker’s compensation board. The injury must also be confirmed by a medical practitioner / physician, as deemed appropriate by the jurisdictional worker’s compensation board. A fatality is also recorded as an LTI. The following notes apply:
Days lost are calendar days regardless of whether the injured was due at work or not on any of those days and includes scheduled time off. Regular duties are those duties associated with the job description of the injured.
Normal daily travel to and from work is only considered as being work related if the transportation is owned, hired or contracted by the Company.
Restricted work (or light duties) which may follow on from lost time will be counted as lost time.
Lost Time Injury Days (LTID) – are the actual number of calendar days a person was unable to work due to an occupational injury, illness or disease, from but not including, the last day worked. Lost Days shall be accumulated on a monthly basis until the ill or injured person returns to work, or up to a maximum of twelve months for any individual occurrence. If employment is terminated a maximum of twelve months lost time shall be assigned. In the case of a fatality, 12 months lost time shall be assigned with an automatic 12 months lost time in the month in which the fatality occurred.
Disabling Injuries – Disabling Injuries are LTI‟s and RWI‟s.
Restricted Work Injury (RWI) – A restricted work Injury, illness or disease (RWI) is a work related injury, illness or disease which results in the injured being able to return to work on the following shift, but unable to carry out his/her regular duties (light duty or light work). The following notes apply:
Restricted work days are calendar days regardless of whether the injured was due at work or not on any of those days and includes scheduled time off.
RWI’s only occur if restricted work days are the only consequence of the injury, illness or disease (in other words, if no full days are lost).
Restricted work days may occur after a lost time injury and the resulting lost days. In this case the event will remain an LTI and not be reduced to, or double reported as an RWI.
Restricted Work Injury Days (RWID) – is the number of calendar days a person was assigned Restricted Work Duties due to an occupational injury, illness or disease from, but not including, the last day worked. Will be accumulated until the ill or injured person returns
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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Page 8 of 25
to work or up to a maximum of twelve months for any individual occurrence. If employment is terminated 12 months time lost shall be assigned.
Permanent Disabling Injury (PDI) – this is also know as a permanent damage injury, and is any occupational injury:
From which there has not been, or is not expected to be, full recovery. This must be confirmed by a medical practitioner / physician, as deemed appropriate by the jurisdictional workers’ compensation board.
Which has substantial negative consequences for the individual, egg, permanent damage to body and body and function, all part or full amputations, including loss of appendages.
A Permanent Disabling Injury shall be recorded in the month of the injury occurrence.
A Permanent Disabling Injury shall also be recorded as an LTI, RWI, MTI or Occupational Disease, as appropriate.
Minor Permanent Disability (Minor PD) – such as partial loss of a digit, hearing or sight impediment etc.
Major Permanent Disability (Major PD) – such a disability includes loss of an eye, loss of a limb, hearing loss, paralysis from the waist down or redeployment with loss of income. Note PD’s are not used as part of the LTIFR calculation.
Fatality – A death resulting from an occupational injury, illness or disease, identified within the reporting period. A fatality is also recorded as an LTI, with an automatic 180 calendar days lost time assigned to it in the month in which the fatality occurred. (e.g. Fatality occurs in September, record 180 LTI days lost in September).
Critical Incident (CI) – An incident which falls into one of the following three categories: 1. Injury or Damage to Assets or Loss of Operations
An event, which has caused:
single or multiple fatalities; or
life threatening injury to a person(s), i.e. injuries that require immediate, aggressive action by site, ambulance and medical staff, such as urgent or emergency surgery, admittance to an intensive care or high dependency facility
damage to assets or property, or loss of operations, to a value greater than US$0.5 million
2. Environment - Category 4 (Serious) or Category 5 (Disastrous) Environmental Incidents.
3. Media Attention - Public exposure of a serious, negative consequence.
High Potential Risk Incident (HPRI) - An event, or near miss, which could have:
killed, or permanently disabled, a person(s);
or caused life threatening injury to a person(s);
or caused damage to assets or loss of operations to the value of greater than US$10 million; or
caused a Category 4 or Category 5 environmental incident.
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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Page 9 of 25
Caused media attention / public exposure of a serious, negative consequence.
Project Incident Statistics - are the monthly returns of:
Fatalities;
Lost Time Injuries;
Medical Treatment Cases;
First Aid Cases
Near Hits Damages Environmental Incidents
Hygiene / Health Incidents (Occupational Illness / Disease)
Hours of Exposure – Is the total number of hours worked by all employees (permanent or temporary) and contractors in the reporting period.
Lost Time Injury Frequency Rate (LTIFR) – Is the rate of occurrence of LTI‟s per 200,000 hours worked:
LTIFR = Number of LTIs x 1 000,000 Hours per exposure
Reportable Injury Where an employee got seriously injured and the injury must be reported, according to
the Occupational Health and Safety Act and Compensation for Occupational Injuries and Diseases Act, to the Department of Labour.
Total Recordable Injuries Total Recordable Injuries include
Lost Time Injuries, inclusive of fatalities (LTI’s).
Restricted Work Injuries (RWI’s).
Medical Treatment Injuries (MTI’s) Total Recordable Injuries = LTI’s + RWI’s + MTI’s.
3. ROLES AND RESPONSIBILITIES
3.1 PROJECT MANAGER
Define arrangements for project incident reporting;
Provide a progress report to the executive board.
3.2 PROJECT CONSTRUCTION MANAGER
Ensure that Line Managers are aware of their responsibilities, in regards to inci-dent reporting and investigation, where deemed necessary to ensure effective information flow and coordination of remedial actions;
Implement, monitor and verify the effectiveness of this procedure.
3.3 LINE MANAGERS
Ensure that employees are adequately trained for the implementation of this procedure;
Investigate external notification requirements and prepare (but not issue) external notifications;
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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Page 10 of 25
Conduct regular reviews of all incidents reported within their areas, ensure that necessary actions arising from these reviews are followed up;
Ensure timely completion of corrective/preventative actions and provide regular progress reports to the Project Construction Manager;
Authorise and close out all incident reports within their area.
3.4 SUPERVISORS
Ensure that all incidents within their respective area are identified, investigated and reported in accordance with this procedure.
3.5 PROJECT SHE MANAGER
Establish the training standards required by this procedure;
Coordinate delivery of appropriate training courses in incident investigation and reporting; (ICAM)
Confirm return to work progress has been followed:
Maintain files of original incident reports in accordance with prevailing company and legal requirements;
Provide assistance to Line Managers in setting up appropriate teams for investigation and follow-up of serious safety related incidents;
Review incident reports, initiate further investigations and/or recommend extra corrective action as considered necessary to reduce risk
3.6 ALL EMPLOYEES
Report incidents to their supervisors as soon as practicable within the shift that the incident occurs or as soon as the employee becomes aware of a hazard; Participate in subsequent investigations and implementation preventative action as required.
4. PROCEDURES
4.1 GENERAL
All incidents occurring on site/premises must be reported and investigated in accordance with this procedure;
This document should be read in conjunction with any related project procedures. If there are any variants that arise between project procedures and this procedure, the matter should be raised with the Project SHE Manager.
Contractors shall notify the Project Management Representative immediately of any non-conformance to procedures or of any other incident within the Contractor and his sub-contractors‟ areas of responsibility in writing.
The contractor shall investigate all incidents on the ICAM format provided by the Project SHE department.
ICAM investigations shall be completed for:
Medical Treatment Cases
Lost time Injuries
Fatalities
Any incident with the potential to cause serious harm or result in a fatal. (HPRI)
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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Page 11 of 25
Any Incident so defined by the Project SHE Manager
ICAM investigation shall be completed and submitted within 24 hours to the Project SHE Manager.
4.2 STATISTICAL REPORTING Each of the contractor SHE Officers is responsible for collecting, recording, calculating
and reporting the SHE statistics. SHE statistics are to be reported to the Project SHE Manager.
The Project SHE Manager is responsible for consolidating the SHE statistics from
each contract and reporting these to the Project Management Team Each week each Contractor is required to report (qualitative) all incidents which have
occurred during the week:
Incidents and incident trends for week and month to date.
Injuries (all new injuries during the week to be reported on the initial accident notification report), including FAC’s, MTC’s, LTIs, SIs, PDs and fatalities.
Proactive Safety initiatives for forthcoming week based on work programme
Report on medical condition of personnel previously injured while on duty Report on status of remedial actions (actions closed, in progress, not yet started).
4.3 ASSESSMENT OF INCIDENT POTENTIAL 4.3.1 Sustainable Development Category Table
The Sustainable Development Category Table (Refer to Annexure 1) will be used as a tool by the Supervisor or Line Manager to assign a Category for Incident Potential. The aim of the Sustainable Development Category Table is to: - Increase the awareness of SHE implications of any incident; - Assess the significance of an incident in terms of its potential for injury,
damage, environmental impact and its likelihood of reoccurrence, and - To provide guidance in determining the depth or extent of incident
investigations and its follow-up.
4.3.2 Basis for Potential Categorisation The assessment of incident potential provides focus on events that pose signifi-
cant threat to our business. We identify four categories of potential incidents and their subsequent reporting and investigation requirements. These are illustrated in Annexure 2 – Reporting Requirements.
Where an incident has potential consequences relating to two or more dimen-
sions, the highest potential level shall be assigned. When assigning a level of investigation and reporting the measure of exposure rather than the actual injury or damage must be taken into account to ensure that credible possible consequences are considered and hence, „potential‟ equates to „reasonably possible‟. Usually, an additional failed defence or coincidental event should be added to the actual event to identify the potential event and associated potential level of investigation.
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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Page 12 of 25
4.4 TRAINING Employees who are expected to lead the investigation shall have undergone training
in Incident Investigation techniques, specifically ICAM. Investigation team members are required to be familiar with the investigation process
and documentation used during the process.
4.5 GUIDE TO INVESTIGATION 4.5.1 The Investigation Process
The investigation process for incidents will involve some or all of the following steps, depending on assessment of the potential:
Internal and external notification of the incident;
Definition of terms of reference and appointment of investigators;
Detailed investigation including inspections, interviews, etc.;
Time Line of incident
Root cause analysis;
Recommendation for remedial action;
Investigation report;
Management review and endorsement of recommendations;
Implementation of action items;
Distribution of investigation findings; and
Follow-up and close out.
4.5.2 Immediate Response Any person involved in or witnessing an incident, or identifying a hazard, must
initiate appropriate action to ensure the safety and medical treatment of injured personnel and to prevent consequential injury or loss at the incident site. This must be followed up by notification of the circumstances to his or her immediate Supervisor.
All reported incidents must be investigated initially by the responsible supervisor.
In each case the supervisor must ensure that an incident report is raised and that the relevant Line Manager and the Project SHE Manager are copied.
Any incident must be reported immediately and the client must be notified
timeously within the same shift depending on the severity and classification status. E.g. all high potential and medical incidents must be reported immediately.
A preliminary Incident Report must be completed within the same shift The Project SHE Manager or the Construction Manager will decide if a full ICAM
must be conducted and this report must be available within 24 hours of the incident.
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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4.5.3 Investigation Team In the event of a serious incident, an investigation team will be established. The
size and composition of the investigation team will depend upon: - The extent of injury, damage or loss; - The potential for injury, damage or loss; - The potential for negative impact on repetition; - Technical complexity/requirement for specialist knowledge; and - Statutory requirements.
The relevant Line Manager should initiate incident investigations, setting up a
team as required. At least one member of the team must be competent to lead the incident
investigation; The investigation team shall comprise of three or more people such as:
- The supervisor of the work area involved; - A person outside the department; - A person with appropriate skills/competence in the area being investigated; - A person who is competent in incident investigation and experienced in the
use of ICAM; - Person with the appropriate technical/system expertise.
All members must be willing and able to devote the time necessary to the
investigation. 4.5.4 Preliminary Investigation
Preliminary investigation requires the following: - Incident Report Form must be completed; - Agreed corrective actions and actionees should be determined; - Line management must review corrective actions and ensure that all
actions are completed; - On completion of all items the incident report form must be signed off, as
closed-out, by line management and when finalised, sent to the SHE Manager.
4.5.5 Detailed Investigation A detailed investigation requires the following:
- Incident report form to be completed; - Line management to appoint an investigation team and define terms of
reference appropriate to the incident severity.
Scope and Aims The scope of the investigation should be such as to achieve the following primary
aims:
To identify the root cause/s of the incident such that actions can be taken to prevent recurrence of future incidents;
To review the application of management practices and their impact on SHE;
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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Page 14 of 25
To establish the facts surrounding the incident for use in relation to potential insurance claims or litigation;
To meet relevant statutory requirements on incident reporting.
Timing
Investigations must take place as soon as possible after the incident has occurred. The quality of evidence can deteriorate rapidly and delayed enquiries are usually not as conclusive as those conducted immediately.
Where possible, the site should remain untouched until at least a preliminary investigation has taken place (within 1 hour). If this is not feasible because of residual hazards or other serious factors, photograph or sketch the area, then carry out remedial actions.
For serious incidents the scene should be cordoned off until the Project SHE Manager releases the area for normal activity.
The incident must be logged within the same shift.
ICAM (when required) must be completed within 24 hours.
Incident notification / Alert (Flash Report) to be forwarded to the Project SHE Manager for communication within 36 hours of the incident.
4.5.6 Investigation Report Format – ICAM
Summary of incident;
Investigation team
Terms of reference;
Description of incident/sequence of events;
Results of investigation and cause analysis including root causes;
Recommendations and action items;
Appendices as appropriate (include copies of notification faxes, fault tree analysis, photographs, sketches etc);
The investigation report must be sent to the Line Manager who will review the recommended actions and assign actionees to carry out improvements;
On completion of all items, the detailed investigation report must be closed out by the Line Manager and when finalised, sent to the Project SHE Manager
4.5.7 The Investigation Method – ICAM The Incident Cause Analysis Method (ICAM) is used to carry out incident investi-
gations. The objectives of incident investigations using this procedure are to:
Establish the facts.
Determine direct, underlying and contributing causes / factors and latent hazards. Review adequacy of existing controls and procedures.
Report the findings.
Developing corrective actions which can improve efficiency, reduce risk and prevent recurrence.
Detect developing trends that can be analyzed to identify specific or recurring problems. Identify any key learning’s for distribution within the organisation and externally as required.
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
34: DATE
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The method of conducting an investigation consists of the following activities:
Fact finding;
Inspecting the location;
Gathering and recording physical evidence;
Interviewing witnesses.
Review documents, procedures and records;
Resolving conflicts in evidence;
Identifying missing information;
Recording additional factors and possible underlying causes including human factors.
4.5.8 Data Collection During this phase of the investigation as many relevant facts as possible should
be collected to help in understanding the incident and the events leading up to it. The collection of data can be divided into five main areas:
People.
Environment.
Equipment.
Procedures.
Organisation.
Interviews should be conducted individually and should begin soon after an incident to obtain information about the immediate events associated with the incident, including how the activity that was involved in the incident was planned and conducted. Interviews could include the following individuals:
Individuals directly involved in the incident.
Supervisory personnel.
Personnel at the scene.
Management
Emergency Services personnel (if illness or injuries involved). Safety personnel.
Subject matter experts.
People being interviewed should not be denied the right to have an adviser present if they so wish. Keep the interview short, informal, simple and use language the person understands. Opinions are acceptable provided they are recognised as such.
Data
Collection
Who or What Collection Methods Example Questions
People ▪ Witnesses
▪ Associated people
▪ Interview
▪ Written statement
▪ Observation
▪ Explain in their own words what happened?
▪ What could have been done differently to prevent the outcome?
▪ Whether they knew of any previous incidents or near hits associated
with conducting the task?
Environment ▪ Weather
▪ Workplace
▪ Incident scene
▪ Observation/ Review
▪ Inspection/ Photography
▪ Event reconstruction
▪ What were the weather conditions?
▪ Were any housekeeping issues involved?
▪ What were the workplace conditions?
▪ What surrounding noises were present?
▪ What were the light conditions?
▪ Were toxic or hazardous gases, dusts or fumes present?
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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Equipment ▪ Vehicles
▪ Plant
▪ Tools
▪ Infrastructure, etc.
▪ Inspection
▪ Testing
▪ Operation
▪ How did the equipment function?
▪ Were hazardous substances involved?
▪ What identification did they have?
▪ Were any alternative substances available?
▪ What Personal Protective Equipment (PPE) was being used?
Procedures ▪ Existing maps
▪ Charts
▪ Documents
▪ Reports
▪ Photographs, etc.
▪ Review
▪ Comparison
▪ What work procedure was used?
▪ Was a risk assessment conducted prior to the task?
▪ Had conditions changed that would have affected the way normal
procedure worked?
▪ What tools and materials were available?
▪ How did the safety devices work?
▪ What lockout or isolation procedures were used?
Organisation ▪ Review
▪ Comparison
▪ Review
▪ Comparison
▪ What applicable safety rules were communicated to employees? When?
▪ What written procedures were available?
▪ How were they enforced?
▪ What supervision was in place?
▪ What training was given in how to do the work? When? Is it still valid and
current?
▪ How were hazards identified?
▪ What procedures had been developed to overcome them?
▪ How were unsafe conditions corrected?
Additional data sources include:
Pre-incident photographs – If available, these photographs may be com-pared with post incident photographs to help explain the incident. Staged photographs of the incident may be taken at a later time if they will help clarify the final report.
Diagrams and sketches – These may be used as substitutes for photo-graphs and can be especially useful when it is necessary to illustrate move-ments (e.g. personnel location or vehicle movements before and during an incident). Record directions, distances, and other relevant factors.
Maps – These show the relative locations of buildings and events. Maps should be used for plotting the location of personnel who are injured or have become ill as a result of a hazardous material release. This empirical “time and place‟ information is also useful for planning adequate evacuation distances in future emergencies.
Documents – A review of documents may also uncover contributing factors and should include:
Applicable regulations.
Training, medical and work history records.
Applicable procedures, work instructions, equipment manuals and mainte-nance records.
Incident reports, audit reports.
Material Safety Data Sheets (MSDS).
Organisational policies and procedures.
4.5.9 Data Organisation After the collection of data and analysis, it should be possible to organise the
data to provide the sequence of events leading up to the incident, the incident itself and events post incident until control was regained. The data collected during the investigation should be correlated in a logical and sequential way.
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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Several data organising techniques such as Timelines, Event and Condition Charts (Timeline) Trees are available to assist in understanding the incident. The technique used for determining the sequence of events in the incident should meet the following requirements:
Provide a framework to organise the data collected.
Assist in ensuring the investigation follows a logical path.
Aid in the resolution of conflicting information and the identification of missing data.
Provide a diagrammatical display of the investigative process for management briefing.
Events and Condition Chart / Timeline
4.5.10 Data Analysis The analysis of incidental data can identify trends which highlight the com-
position of the organization’s risk exposure. It can also address the effectiveness of the SHE strategies and identify the incident caused factors that must be controlled to improve the organization’s SHE performance. In order to benefit from the collecting and analyzing SHE data, there must be a process to address negative trends that re identified. Action plan must be developed to address negative trends. When an incident analysis clearly shows that improvement trends have resulted from the implementation of health and safety programs, it is important to celebrate the success, recognise those responsible and share practices and programmes to achieve the success with other NE sites.
The data analysis includes the following activities:
Analyzing the Findings.
Identification of the Absent or Failed defenses.
Identification of the Individual and Team actions.
Identification of the Tasks and Environmental conditions.
Identification of the Organisational factors.
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
34: DATE
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Page 18 of 25
Possible Absent or Failed Defenses Include:
Awareness Awareness is knowing the risks and how to manage them. To understand the
nature and severity of the hazardous conditions present at the worksite. Awareness
problems reflect continuous shortcomings in those involved on site or those
supervising and managing processes.
Examples include: Induction Training, Ongoing Training, Communication, Hazard/Aspect Register
Detection Detection is how to see the event coming and prevent it. To provide clear warning
of both the presence and the nature of a potentially hazardous situation
Examples include: Warning Lights, Traffic
Warning Signs, Gas Detectors, Speed
Sensors.
Control and
Recovery Control and interim recovery is getting out of trouble without injury or damage. To
restore people or equipment to a safe state with minimal injury or damage.
Examples include: Procedures, Residual
Current Device, Bypass Valves,
Emergency Shut Down Systems.
Protection and
Containment Protection and Containment is preventing escalation of the problem. To limit the
adverse consequences of any unplanned release of mass, energy or hazardous
material.
Examples include: PPE, Fire Extingui-
shers, Spill Response Kits, Bunded
Areas.
Escape and
Rescue Escape and Rescue is caring for the injured and making the site safe. To evacuate
all potential victims from the hazard location as quickly and as safely as possible.
Examples include: Safe Access/ Egress,
Emergency Planning, Emergency
Communication.
Possible Individual / Team actions include:
Slips – errors in which the right intention or plan is incorrectly carried out. These usually occur during well-practiced and familiar tasks in which actions are largely automatic.
Lapses – failures to carry out an action. Lapses typically involve failures of memory.
Mistakes – involve deficiencies or failures in the judgment process. These occur when rules are applied incorrectly or knowledge relevant to the situation is inadequate, and a flawed plan is developed. When carried out, the plan will not lead to the desired outcome.
Violations – deliberate deviations from safe operating practices, procedures, standards or rules. These can be further categorized as:
Routine (the breach of rules or corner cutting has become implicitly accepted, and a normal activity).
Exceptional (one-off violation enacted in unusual circumstances).
Acts of sabotage (deliberate action intended to cause damage). Possible Task / Environmental Conditions include:
Workplace Factors
Error Factors Common Factors Violation Factors • Change of routine
• Poor signal / noise ratio
• Poor man/system interface
• Designer/user mismatch
• Educational mismatch
• Hostile environment
• Domestic problems
• Poor communications
• Poor mix of “hands on” work and written
instruction (Reliance on undocumented
knowledge)
• Poor shift patterns and overtime
working.
• Time shortage
• Inadequate tools and equipment
• Poor procedures and instructions
• Poor tasking
• Inadequate training
• Hazards not identified.
• Under-resourcing
• Inadequate supervision
• Poor access to job Poor housekeeping
• Poor supervisor/worker ratio
• Poor working conditions
• Inadequate mix of experienced and
inexperienced workers
• Violations tolerated
• Compliance goes unrewarded
• Procedures protect the system not the
individual
• Little or no autonomy
• Perceived license to bend rules
• Adversarial industrial climate
• Low operator pay
• Low operator status
• Unfair management sanctions
• Blame culture
• Poor supervisory example
• Task allows for easy shortcuts
Human Factors
Error Factors Common Factors Violation Factors
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
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• Preoccupation
• Distraction
• Memory Failures
• Perceptual set (tendency to perceive
one thing and not another)
• False perceptions
• Confirmation bias
• Situational awareness
• Incomplete knowledge
• Inaccurate knowledge
• Interference and reasoning
• Stress and fatigue
• Disturbed sleep patterns
• Error proneness
• Insufficient ability
• Inadequate skill
• Skill overcomes danger
• Unfamiliarity with task
• Poor judgment
• Overconfidence Performance anxiety
• Time pressures Monotony and boredom
• Emotional status
• Age and gender
• High risk target
• Behavioural beliefs (gains > risks)
• Subjective norms condoning violations
• Personality
• Perceived bahavioural control
• Low morale
• Bad mood
• Job dissatisfaction
• Attitude to the system
• Misperception of hazards
• Low self esteem
• Learned helplessness
Possible Organisational Factors include: The following are the ICAM classified Organisational Factors:
Hardware (HW)
Training (TR)
Organisation (OR)
Communication (CO)
Incompatible Goals (IG)
Procedures (PR)
Risk Management (RM)
Management of Change (MC) Organisational Culture (OC) Regulatory Influence (RI) Maintenance Management (MM) Design (DE)
Contractor Management (CM)
Factor Causes End Results
Hardware (HW) • Poor stock or ordering system
• Poor quality due to the local availability
• Poor state of existing equipment
• Equipment not fit for purpose
• Lack of resources available to buy, maintain or improve
equipment
• Theft
• Inappropriate use of tools or equipment
• Absence or unavailability of tools or equipment
• Improvisation . i.e. Using tools unsuitable for the job
Factor Causes End Results
Training (TR) • Training not directed to all the job skill requirements
• Ineffective pre-employment selection process
• Poor training needs assessment
• No assessment of training effectiveness
• Differing standards of training
• Training the wrong people
• Making assumptions about a person’s knowledge or skills
• Employees unable to perform their jobs
• Excessive time spent in training
• Excessive supervision needed
• Increased numbers of people required for the job
• Jobs taking longer, or poor quality, wasting material
Factor Causes End Results
Organisation (OR) • Poorly defined departments or section
• Unclear accountability, responsibility or delegation
• Lack of definition of objectives
• No structure to co-ordinate different activities
• Poor planning
• Excessive bureaucracy
• Frequent re-organisations
• Multi-layer hierarchy, slow response to changes
• Wrong person, or nobody, takes responsibility
• Resources used for non-business needs
• Decisions delayed or deferred
• People are only held responsible not accountable for their
actions / decisions
• Poor control or management of events Rules and
procedures not enforced
Factor Causes End Results
Communication
(CO)
• Language problems and cultural barriers
• Lack of clear line of communication
• Poor feedback
• Misunderstanding or incorrect interpretation
• Doing the wrong thing, at the wrong time or place
• Missing information, people not informed, do not report
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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• No standard communication format
• Missing or excessive information
• Inability to make contact with the correct person
• Unreceptive or hostile target
• People not knowing who to inform
• Not knowing where information is located
Factor Causes End Results
Procedures (PR) • Poor knowledge of the procedure writer
• Poor feedback on practicality
• Non-operational objectives
• Failure to have a revision control system
• Ambiguous, non-comprehensive, incorrect and outdated
documents
• Difficult access for the users
• No procedures for some specific tasks
• Too many, overlapping or conflicting procedures
• Failure to communicate existing or new procedures
Factor Causes End Results
Goals (G) • Conflict between safe work and production priorities
• Conflict between work and personal priorities
• Imbalance between safety requirements and budget
constraints
• Suppressing information about hazards or injuries
• Shortcutting a procedure
• Overruling or relaxing procedures
• Putting people under pressure
• Operating closer than normal to operating limits
Factor Causes End Results
Organisational
Culture (OC)
• Diverse and conflicting values and beliefs of the people
within an organisation
• Poor (or filtered) organisational level reporting and rela-
tionships
• Factions and politics
• Unaddressed employee fears and anxieties
• Low levels of trust and stress
• Getting away with unnecessary risk taking
• Inappropriate social interaction
• Poor leadership
• Inconsistency between organisation’s values and actions
• Lack of compliance, performance monitoring and review
• Poor communications between divisions
• Failure to complete tasks
• Non-adherence to rules
• Poor commitment to safety, environment and community
issues
• Reluctance for voluntary resolution of identified hazards
• Low occurrence reporting
• Lack of clear management structures/processes Low staff
morale and motivation
• Miscalculation of the level of acceptable risk Ambiguous
expectations of behaviour requirements
• Slow acceptance of change, restricting continual
improvement process
Factor Causes End Results
Regulatory
Influence (RI)
• Ambiguous regulations
• Duplicated safety practices
• Multiple requirements for documentary evidence
• Conflicting regulatory requirements
• Lack of knowledge regarding regulatory requirements
• Delays in meeting regulatory requirements
• Additional resources to meet regulatory requirements
• Prescriptive regulatory requirements
• Restrictive work practices
• Difficulties in interpreting regulations
• Non-reporting of hazards due to fear of enforcement
action/penalty
• Inability to demonstrate compliance or satisfy other legal
requirements
• Potential revocation of operating license or other
regulatory sanctions
Factor Causes End Results
Risk & Change
Management (RM)
• Inadequate or poorly conducted risk management process
• Goals, objectives, scope and boundaries of risk
management activity not clearly determined
• Hazard identification process not being systematic, or
covering all operations and equipment
• Risk assessment conducted without the appropriate
competencies and experience
• Inappropriate selection or poor Implementation of risk
control measure
• Inadequate monitoring of risk control effectiveness
• Risk levels above ALARP
• Uncontrolled hazards and consequences Unexpected
incident and accident rate Inappropriate risk ranking and
allocation of risk control resources
• Incomplete, inadequate or out of date
• Risk Register
• Breach of local regulatory requirements
Factor Causes End Results
Maintenance
Management (MM)
• Poor planning, controlling, execution and recording of main-
tenance
• State of equipment not communicated to relevant people
• Shortage of specialized maintenance personnel
• Absent/inadequate manuals and documents
• Incorrect maintenance strategy
• Defective or malfunctioning equipment
• Makeshift or unplanned maintenance
• Breakdown before life expectancy
• Unexpected rapid corrosion
• Equipment not operable in the way intended
Factor Causes End Results
Design (DE) • No standardization of equipment or usage • Extra effort to do the job
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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Page 21 of 25
• No adapting to human needs and limitations
• Poor designer – user communication
• Time or financial constraints
• No indication of system status provided by design (on/off)
• Inadequate design premise data
• Unexpected performance of tools and equipment
• Inability to operate equipment properly
• Inability / difficult in controlling processes
• Long or repeated training requirements
• Equipment is unused or improvised usage
Factor Causes End Results
Contractor
Management (CM)
• Inadequate or poorly conducted contract management
process
• Lack of consideration of risk associated with the contract
• Poorly defined selection criteria, i.e. cost over performance
• Lack of formal contractor evaluation procedure
• Lack of a clearly defined work scope
• Contract not clearly defining SHE obligations performance
and reporting requirements
• Unclear reporting relationships, lines of communication,
roles and responsibilities
• The failure to identify / plan bridging requirements between
the contractor and company standards
• Inadequate or poorly conducted SHE compliance and
performance monitoring and review
• Risk levels above ALARP
• Deterioration in production and safety performance
• Requirement for additional supervision
• Substandard competency and manning levels
• Differing, conflicting or poor interface of procedures and
systems of work
• Poor employee / contractor relations, industrial relation
issues, high personnel turnover Imbalance between
contract compliance, production and SHE goals
• Lack of reporting of hazards, near-hits and incidents
4.5.11 Investigation by Local Authorities In the event that local authorities decide to conduct and manage their own
investigation, the Construction manager will liaise with the authorities and to assist in assembling the information required. Notwithstanding the involvement of local authorities, NE Project Management shall carry out its own investigation in the incident.
See SAMRASS 1 to 9 as per Mine Health and Safety Act Regulation
4.5.12 Recommendations The ultimate objective of the investigation is to initiate any action which may
be required to prevent further incidents. This can best be achieved by addressing all absent or failed defences and organisational factors identi-fied by the ICAM analysis. Not all contributing factors can be completely eliminated, and some may be eliminated only at a prohibitive cost. The investigation team should work with line management in the development of corrective actions.
Recommendations should be:
Actionable: Action description must be sufficiently defined to enable unambiguous implementation. The party responsible for the action must be specified.
Achievable: Actions must be feasible, and appropriate deadlines set for implementation.
Appropriate: Actions must be proportional to the risk posed and must act on root causes
4.5.13 Requirements for Formal Reports
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
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Page 22 of 25
Reports arising from detailed investigations will usually require more space than is available on a standard incident form. In such cases, the basic details should be filled out on the form and a copy included in the appendix of the formal report. Also, additional copies should be attached if more than one person is injured. All formal reports will be retained on file by the Project SHE Manager and shall contain the following: - Executive Summary; - Investigation Team and Terms of Reference; - Description of Incident; - Sequence of Events; - Results of Investigation and Cause Analysis; - Recommendations on Corrective and Preventative Actions; and - Appendices:
Incident Report Form
Witness(es) Statements (if necessary)
Photographs (if taken)
Other Relevant Documents
4.5.14 Implementation of Recommendations Review of both investigation report and implementation of recommended
actions must be formalised with an agreed time schedule to ensure effective follow-up. Appropriate resources must be made available for timely completion of action item.
Incident investigation must be seen as a continual improvement process.
Address the Organisational Factors in order to identify areas to improve error prevention. Address the absent or failed defences in order to identify areas for improvement of error trapping and error mitigation.
An effective incident investigation requires strong management commitment
and involvement. Management must support the investigation process and act on the results. It must make sure that the investigators are capable and have sufficient resources for an effective investigation. It is management’s responsibility to evaluate the quality and outcome of all incident investiga-tions.
4.5.15 Incident Reporting Formats All incidents shall be reported to the Project SHE Manager immediately via
phone. The appointed responsible manager for the company shall be held accountable to ensure compliance.
The following incident reporting formats shall be used and complied with as
follows:
Deviations – Deviation Report & Action Plan TSW/CON/051
All Incidents - Preliminary Incident Report TSW/CON/027 / Incident Flash Report
TSW/CON/076
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
34: DATE
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Page 23 of 25
All FAC / MTC / LTI / HPI / Fatal during weekly period - Incident feedback report
TSW/CON/073
Near Hits – Near Hit Report TSW/CON/029
Health & Hygiene (Occ Injury / Illness) Incidents – Mini ICAM TSW/CON/071 /
ICAM report TSW/CON/070
Environmental Incidents – Mini ICAM TSW/CON/071 / ICAM report TSW/CON/070
Damage to plant and equipment - Damage report TSW/CON/026
First Aid Cases (FAC) – Mini ICAM TSW/CON/071
Medical treatment cases (MTC) – ICAM report TSW/CON/070
High Potential Incidents (HPRI) – ICAM report TSW/CON/070 / HPRI Notification
TSW/CON/072
Lost Time Injuries (LTI) – ICAM report TSW/CON/070
Fatal – ICAM report TSW/CON/070
4.5.16 Incident Feedback Sessions – Steering Committee The Committee will be responsible to ensure the evaluation of proper incident investigations and that sufficient and adequate preventative control measures are implemented to ensure no-repeats. The appointed responsible Contractor Manager, Supervisor and Safety Officer shall be required to attend this session when incidents were experienced the previous week. The appointed Contractor Manager shall be responsible for feedback and not the Line Management. Feedback shall be demonstrated and made available on the format supplied by the Project SHE Manager.
4.5.17 Reporting of CI’s and HPRI’s As per Xstrata Reporting requirements,
All Critical Incidents (CI‟s) shall be verbally reported through the chain of command to:
Commodity Business Executive Management Team
Commodity Business Corporate Affairs Manager
Commodity Business Safety and Environment Manager (s)
General Manager SHE
An Alert / Report shall be generated for all Critical Incidents (CI’s) and High Potential Risk Incidents (HPRI’s) and shall be forwarded to the appropriate people within 24 hours for all CI’s and within 72 hours for all HPRI’s. The Alert shall be generated by the Project SHE Manager and will be forwarded to the Project Manager and Project Leader, who will forward the Alert to:
Appropriate Senior Managers in the Commodity Business
Commodity Business Safety and Environment Manager(s)
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
34: DATE
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Page 24 of 25
Commodity Business Chief Executive
General Manager SHE
A full investigation of all CI‟s and HPI’s shall be carried out, and a detailed report shall be shall be forwarded within 30 days to:
Appropriate Senior Managers in the Commodity Business
Commodity Business Safety and Environment Manager(s)
Commodity Business Chief Executive
General Manager SHE
5. ANNEXURE 1 – SUSTAINABLE DEVELOPMENT CATEGORY TABLE
Category 1: Low Category 2: Minor Category 3: Moderate Category 4: Major Category 5: Critical
8.1.1 Injuries
▪ Low level short-term
inconvenience or
symptoms.
▪ No measurable
physical effects.
▪ First Aid Injuries
▪ Medical treatment
injuries (MTI)
requiring
hospitalization.
▪ Irreversible disability
(<30%) to one or more
persons.
▪ RWI/LTI less than 14
days.
▪ Single fatality and/or
severe disability (>30%) to
one or more persons.
▪ LTI >14 days/Extensive
injuries requiring full admis-
sion into hospital.
▪ Short or long term health
effects leading to
multiple fatalities.
▪ Irreversible human
health effects to >50
persons.
▪ Fatality.
8.1.2 Environmental Effects
▪ Technical non-com-
pliance with environ-
mental regulations or
incident resulting in
no environmental
harm.
▪ Minor incident that
causes negligible
impact on environ-
ment, are readily
controlled by esta-
blished procedures.
▪ Incident cause moderate
localized reversible
environmental impacts.
▪ Incidents which cause
serious environmental
impact that can be rectified
in the medium term (1 – 12
months).
▪ Incidents which cause
major environmental
consequences and long
term impact (greater
than 12 months).
8.1.3 Operational Impact (SD Incidents)
▪ Easily addressed or
rectified by imme-
diate corrective
actions.
▪ No loss of produc-
tion.
▪ No damage to equip-
ment.
▪ Minor or superficial
damage to equip-
ment and/or facility.
▪ No loss of produc-
tion.
▪ Moderate damage to
equipment and/or facility.
▪ Loss of production <one
week.
▪ Major damage to facility
requiring significant correc-
tive / preventive action.
▪ Loss of production <six
months.
▪ Future operations and
site seriously affected.
▪ Loss of production >six
months
8.1.4 Legal
▪ Low-level legal issue
which could result in
a fine but
prosecution is
unlikely.
▪ Minor legal issues,
non-compliances
and breaches of
regulation which
could result in minor
prosecution or
possible litigation.
▪ Serious breach of
regulation resulting in an
investigation or report to
the authority with
prosecution and/or
moderate fine.
▪ Major breach of regulation
with potential of major fine
and/or investigation and
prosecution by authority.
▪ Very serious litigation,
including class actions.
ORIGINATOR
CLIENT AUTHORITY
NAME 31: Henk Myburgh NAME
33: Tshipi Mine NAME
35:
SIGN: SIGN: SIGN:
DATE 32: 20.09.12 DATE
34: DATE
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Page 25 of 25
Category 1: Low Category 2: Minor Category 3: Moderate Category 4: Major Category 5: Critical
8.1.5 Public / Government / Media / Reputation / Community
▪ Public concern
restricted to local
complaints.
▪ Ongoing scrutiny /
attention from
regulator.
▪ Community enquiry.
▪ Minor, adverse local
public or media
attention and com-
plaints.
▪ Significant hardship
from regulator.
▪ Reputation is adver-
sely affected with a
small number of
people.
▪ Community com-
plaint or Community
MTI as a result of
NE Operations.
▪ Local newspaper atten-
tion.
▪ Community LTI/RWI less
than 14 days as a result
of NE Operations.
▪ Significant adverse media /
public NGO attention.
▪ May lose license to operate
or may not gain approval of
permits.
▪ Environment / management
credentials are damaged.
▪ Community LTI/RWI more
than 14 days as a result of
NE Operations.
▪ Serious public or media
outcry.
▪ Damaging NGO
campaign.
▪ License to operate
threatened.
▪ Share price may be
affected.
▪ Community fatality as a
result of NE.
6. ANNEXURE 2 – REPORTING REQUIREMENTS (Refer to Annexure 1 for Risk Matrix)
Requirements Low Risk – Category 1 Medium Risk – Category 2 Significant Risk – Category 3 High Risk – Category 4
VERBAL
NOTIFICATIONS
▪ Immediate to Area
Supervisor.
▪ Immediate to SHE
Manager
▪ Immediate to Area
Supervisor.
▪ Immediate to Line Manager.
▪ Immediate to SHE Manager
▪ Immediate to Area Supervisor.
▪ Immediate to SHE Manager
▪ Immediate to Construction
Manager
▪ Immediate to Project Manager.
▪ Immediate to Project General
Manager
▪ As per Category 3.
REPORTING TIME,
NOTIFICATION OF
INCIDENT
▪ Within the shift to
persons on the
distribution list below.
▪ Within the shift to persons on
the distribution list below.
▪ Immediate to persons on the
distribution list below.
▪ As per Category 3.
INVESTIGATION
TYPE
▪ Preliminary. ▪ Detailed ICAM. ▪ Detailed ICAM. ▪ As per Category 3.
PERSON
RESPONSIBLE FOR
INVESTIGATION
▪ Immediate Supervisor. ▪ Line Manager. ▪ Project Construction Manager.
▪ SHE Manager.
▪ As per Category 3.
PERSON
RESPONSIBLE FOR
SIGN-OFF
▪ Line Manager. ▪ Project Construction Mana-
ger.
▪ SHE Manager.
▪ Project Manager / Project General
Manager.
▪ As per Category 3.
DISTRIBUTION LIST ▪ Supervisor, Line Mana-
gers, SHE Manager,
Construction Manager.
▪ Supervisor, Line Managers,
SHE Manager, Construction
Manager.
▪ Supervisor, Line Managers, SHE
Manager, Construction Manager,
Project Manager.
▪ As per Category 3.
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