Shell Chemicals Incident Notification Report

General Information
Shell reporting company: SEPC (HOUDINI City:Singapore Site/Location of Incident:
PROJECT) CoB: Chemicals HV5, 3rd level of ADIP Area, Approx 10m high
No of Fatalities: Nil Region:
NA Shell NUOC
(under operational control) (not under operational control)
Initial Notification Date: 7th Dec 09
Date of the Incident: 7th Dec 2009 Time of the Incident: 0900hrs
Update (nr. / date):
Product(s) involved: Not Applicable
Summary:
Description of the Incident

FW supervisor while doing inspection, he was holding on to a permanent handrail on the 3rd level of ADIP area. He noticed an object falling past him and
felt a sharp pain on his left thumb. He was not able to figure out the object.There was no contusion nor mark on the thumb but felt a restriction in the
movement of his thumb. He was
brought to the clinic and X-ray was done and comfirmed that there was no bone injury as well. The area was
inspected immediately after the incident and no issue on housekeeping was observed. If it is the nut that fell, it could pass through the grating. Overall
observation shows that the compliance for small object contaimenet was less than adequate.

The nut that was found

at the lower part of the
platform

The thumb that No indication from

was hit by the which elevation the The only indication that the
object. object fell from. object could be this nut.

Mark what's applicable (multiple choices possible !)

Contractor Involved Employee Involved Third party involved

Consequence Category
People Environment Assets Reputation
Type of Incident
Health Safety Road Spill or Security
(possible Occur Incident Accident Leakage related
Preliminary Classification using RAM
Actual Consequences Potential Consequences
RAM Rating RAM Rating
People 0 0
Environment 0 0
Assets 0 0
Reputation 0 0

Release to the Environment

Type of Release Quantity in Gross Tonnes Duration of the Release
NA NA NA
Others (specify)

Initial Remedial Actions taken after the incident

1. The area was combed to identify the object that fell. No major houskeeping issues was found.
2. HV5 to have an incident sharing session on the 8th Dec with the rest of the I/Cs.

Estimated Cost of the incident

<US$10,000 US$10,000-100,000 US$100,000-1,000,000 >US$1,000,000

Initiator: Naseer
Business Line Manager:
Local HSSE advisor / MTA:
 INSTRUCTION
SITE HSSE MANAGER TO FILL UP FORM (YELLOW SHADED CELL ONLY)
HSSE MANAGEMENT ADVISOR TO COMPLETE FORM (BLUE SHADED CELL ONLY)

This Excel file has 6 spreadsheets as listed below.

Spreadsheet 1 INSTRUCTION
Spreadsheet 2 Notification Report Form (cover page)
Spreadsheet 3 Incident Report Form
Spreadsheet 4 Environmental Related
Spreadsheet 5 Road Transport Related
Spreadsheet 6 Fire and Explosion Related

The forms must be completed as shown in table below below.

Fire and Explosion Related

Notification Report Form

Road Transport Related

Environmental Related
Incident Report Form
Incident Notification Y
Environmental related incidents Y Y Y If Applicable If Applicable
Road Transport related incidents Y Y If Applicable Y If Applicable
Fire and Explosion related incidents Y Y If Applicable If Applicable Y
All Other Incidents Y Y
A INCIDENT BRIEF

Company Shell EPCm √ Implementation Contractors

Category Third Parties Others

Company Name Plant Engineering Construction Pte Ltd

Incident Type
LTI & TRC Fatality(s) Permanent Total Disability Lost Workdays
TRC: Restricted Work Medical Treatment
Others: Illness Non Injurious - loss of containment
√ First Aid Non Injurious - asset damage
Security Incident Non Injurious - others

Crisis Yes √ No

Person(s) Involved
(Name/Job Title/Sex/Age) Dave Cherry (Pipe supervisor, Male)
Person(s) Involved
(Name/Job Title/Sex/Age)
Person(s) Injured
(Name/Job Title/Sex/Age)
Property Damaged N.A

B BROAD INCIDENT TYPE

Loss of Containment Land Transport √ Unsafe act/condition Others

Fire and Explosion Falls and Trips Lifting/Crane Operation (specify: ________)
Pollution/Environment Falling Object Structural Failure
Air Transport Electrical Oxygen Deficiency
Water Transport Assault Security

C ACTUAL ACTIVITY LEADING TO INCIDENT

Using Portable Tools/Equip. Climbing/Descending Excavation Loading

Manual Lifting/Handling √ Walking At Same Level Sampling Unloading
Operating Plant/Machinery Driving/Piloting Draining/Flushing Spading
Handling Hazard Materials Working At High Level Disconnecting
Dismantling/Assembling Welding/Burning Diving
Scaffolding Cleaning Working inside an excavated pit

D ESTIMATED DIRECT LOSS/COST

ASSET DAMAGE (US$) REPAIR COST (US$) PRODUCTION LOSS (US$) ENVIRONMENTAL REHAB (US$)

N.A

E IMMEDIATE CAUSES (May be more than 1 cause)

Information error or omission Inadequate / failure of facilities

√ Failure to follow rules/procedures Misuse of equipment/tools
Inadequate warning safety devices Work environment
Failure to observe/use warning safety devices √ Poor housekeeping
Improper manual handling Inadequate access
Inadequate personnel protective equipment External factors, 3rd party, etc.
Failure to wear personnel protective equipment Others (Specify)
Influence of alcohol/drugs
F GENERAL FAILURE TYPES (May be more than one type)

Defences √ Communication Design

Training Housekeeping Maintenance Management
Hardware Organisation Error Enforcing Condition
Incompatible Goals Procedure √ Fallable Decisions

G CORRECTIVE & PREVENTIVE ACTIONS

No Action Item Action Party Target Date Status

1 The incident and lessons learnt will be cascaded down Rotary 29 Jul '09 open

during TBT re-emphasising falling from height hazzards.

2 To re-inforce to all I/C on the expectation to hace all small F.W 7th Aug open

objects to be placed in a container.

H ENDORSEMENT OF INCIDENT REPORT

Name (Capital) Indicator Date

Investigator Naseer, Baharuddin HSE

Area Mel Townsend Civil, Mech

Superintendent
I1 ENVIRONMENT RELATED
(click box to input) Environment Impact Desription:

I2 TECHNICAL DATA - LOSS OF CONTAINMENT

Duration minutes Hazardous (Yes/No)

Leak Area sq m Leak Volume
Final Pressure Initial Pressure
Type of Detector:
Did detection function? Yes No

(click box to input) Reason for failure:

Leak Stopped by Auto Depressurisation Isolate Others

Extinguished by Auto Manual No fire/explosion

Leaking item Pipe Nipple Weld Seal

Gasket Flange Valve Filling
Drain Pinhole Plug Vent
Hose Others
J1 IMMEDIATE CAUSES - Specific for Transport Incident (May be more than 1 cause)

Information error or omission Misuse of equipment/tools

Driver unfamiliar with vehicle Careless driving or inattention
Driver unfamiliar with route Vehicle incorrectly/over loaded
Failure to follow rules/procedures Road condition / terrain
Reckless driving or excessive speed Untidy site
Driver not following prescribed route Vehicle not properly attended
Speedometer or other instrument not working Load inadequately secured
Failure to observe/use warning safety devices Access
Not relevant for land transport External factors
Inadequate personnel protection (seatbelts/rollbars, stc..) Unsafe actions of other road users/3rd party
Failure to wear seatbelts/crash helmets Careless pedestrian
Influence of alcohol/drugs Weather
Mechanical failure of vehicle Others (specify) - ____________________
Brake failure Driver medically unfit
Tyre failure/burst Driver medically/taken insufficient rest periods
Driver's vision obscured

J2 TECHNICAL DATA - LAND TRANSPORT

On the road
Speed
Vehicle Type Motorcycle
Others (………………………)
Goods Vehicle > 3 tons (rigid) (bicycle, tricycle, etc.)
Goods Vehicle (articulated)

Driver's name
Date of last DDC
Date Joined Company

Driver's historical (1 week) working and driving hours

Incident Incident Incident Incident Incident Incident Incident
day day - 1 day - 2 day - 3 day - 4 day - 5 day - 6
working hrs
driving hrs

Vehicle operator

Vehicle Registration
Product Carried

Operating Department
(Business Unit/Haulier)

Product hazardous
Product spillage
Type of product

Third party detail

Name Age Vehicle type Sex Reistration # Injury
 Sketches of scene of incident
Position Before Impact Position At Impact Position After Impact