HSEQT
INCIDENT
INVESTIGATION
Developed By: Ali Ahmad
Date: 02rd June 2024
© Fatimafert Ltd.
INCIDENT INVESTIGATION
INCIDENT INVESTIGATION & REPORTING
Incident
An incident is an unexpected / unplanned occurrence that interferes with the
orderly progress of work and that caused or might have caused one or more of the
following:
• A serious injury or adverse effect on the health of one or more employees.
• Actual or potential significant loss of physical facilities even though potential for
injury was small. To prevent recurrence by understanding.
• An environmental problem, Bird killing can also be classified as environmental
incident
• A situation that could have an unfavorable impact on the public.
OSHA define as the work environment locations where employees work or are
present as a condition of employment
INCIDENT INVESTIGATION & REPORTING
▪ Reporting and analysis of incidents provides valuable opportunity to learn about breakdown or
deficiencies in our safety management system.
▪ Non-Compliance with MOC and Facility/equipment MOC is a violation
▪ Off job incidents must be reported to HSE
▪ Detailed report includes a “Why tree” analysis of the incident
▪ An incident can be major such as unable to work injury, a reportable loss (fire / explosion etc.) or a
condition or action that could have resulted in personal injury or damage to the plant / environment
(nearmiss or close calls). Dept Manager leads investigation team in a case of fatality
▪ Serious incidents and nearmisses recur unless key factors are identified and corrected. Thorough and
persistent investigation of all incidents, coupled with actions directed at prevention of recurrence,
continually improve safety.
INCIDENT INVESTIGATION & REPORTING
The purpose of this procedure is to document the process for investigating incidents that
occur on the plant or Off-the-job in a way that:
▪ Promotes thorough and efficient investigation in a timely manner.
▪ Promotes uniform, accurate, clear, and concise documentation and reporting.
▪ Identifies and implements recommendations to prevent incident recurrence.
▪ Involves the right people to get the information.
▪ Ensures a clear understanding of key factors and key learnings.
▪ Immediate investigation ensures prompt and accurate collection of detail
▪ Participating personnel obtain a positive learning experience.
INCIDENT CLASSIFICATION
1. Injuries
▪ Fatality
▪ Loss Time Incident (LTI)
▪ Restricted Work Case (RWC), This restricts the employee to carry out the normal duties
▪ Medical Treatment Case (MTC)
▪ First Aid Case (FAC)
2. Occupational Illness
▪ Prolonged Exposure to hazardous substances
▪ Occupational illness does not result from a single incident
1. Process Safety Incidents
▪ Process Release
▪ Operational Upset
▪ Fire
▪ Human error
▪ Inoperable safety equipment ▪ Violation of PSM rules
INCIDENT CLASSIFICATION
4. Violations of Safety Procedures / practices
8. Others
5. Vehicle Incidents
▪ Mal-operation of major shop
6. Equipment failure
equipment
▪ Intermixing of 02 process stream
▪ Furnace flame out / backfire
▪ Electrical failures
▪ Falling of person from height
7. Environment Incident without causing injury
▪ Ammonia reporting within or outside plant premises
▪ Excursion of NH3 or other NEQS elements in stream
going to canal
▪ Excursion of ammonia above defined safe limit in
effluent to ponds
▪ Wildlife Damage
▪ Hydraulic Oil leakage to surroundings (environmental
impact)
INCIDENT INVESTIGATION & REPORTING
• Immediate supervisor of an injured person Inform the Medical Centre/Fire Station
• Preparation of incident report by Area 1st line supervisor
• In 24 hours initial incident report reach the Safety Section
Classification:
▪ Based on risk score
Score < 75 (Near Miss Incident)
Score 75~129 (Process Safety Incidents)
Score > 129 (Serious Process Safety Incidents)
▪ Incidents with score higher than 74 require establishment of team and a detailed
investigation report (IR-III).
▪ All FACs & recordable incidents to be investigated by teams.
▪ Investigation reports of Incident score < 75 are approved by area UM.
▪ Investigation reports of Incident score 75~129 are approved by DM.
▪ Investigation reports of Incident score > 129 are approved by DO or above.
▪ Fatality incident deal by DM or above
INCIDENT INVESTIGATION & REPORTING
Protocol:
▪ All incidents to be reported by the area owner within 24 hours of occurrence.
▪ All incidents to be reported by concerned area in charge in morning meeting.
▪ Detailed report of incidents (score < 75) to be submitted within 72 hrs on IR-1 format
after issuance of flash report mentioning the responsible. Within 05 days
▪ Detailed report of incidents (score 75~129) to be submitted on IR-3 format within 09
days after issuance of flash report mentioning the responsible.
▪ Detailed report of incidents (score > 129) to be submitted on IR-3 format within 15 days
after issuance of flash report mentioning the responsible.
▪ TRIR is calculated via (No. of recordable injuries) x 200,000 / Man-hours
INCIDENT INVESTIGATION & REPORTING
Types of Forms:
▪ IR-1 (Initial report raised by area where incident occurred)
▪ IR-2 (Score Sheet)
▪ IR-3 (Detailed report – to be filled in case of incidents score > 74 & injuries)
▪ IR-4 (Flash report)
▪ IR-5 (Off the job incident)
▪ IR-6 (Intimation of Gov authorities in case of LTI or fatality)
▪ IR-7 (Waiver form)
▪ IR-8 (Traffic Incident)
GENERAL INFORMATION
1-Years is maximum time allowed for completion of 'Engineering Jobs' recommendations
Immediate investigation of incidents is important to ensure prompt and accurate collection of
detail
Gathering everyone who can contribute is the first step in the investigation process
Root Cause Failure Methodology is a crucial tool for identifying key factors in an incident
Death of migratory birds within plant operating area is considered an Environmental Incident
Incident reports are only maintained for the past 05 years by the HSE Department.
Flash reports must be distributed to the entire site within 48 hours of receiving the initial
report.
