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Accident/Incident Reporting and Investigation

Cairo-HSEQ-P-10
1.0 Purpose

The purpose of this procedure is to describe how Accidents and Incidents are reported,
investigated and followed up.

2.0 Scope of application

This procedure covers procedures to be followed in reporting and investigating

accidents and incidents applicable to all SUCO operations, this also includes all
Contractors Accidents & Incidents.

Definitions are as described in Cairo-HSE-P-07, Appendix 6.

3.0 Responsibilities

3.1 Initiator

Anyone who observes an event that could be an accident or incident must report this
occurrence to his immediate supervisor / Area Authority.

3.2 Area Authority

Only persons defined as competent by the Field Manager or Division Manager can act
as Area Authority.

The Initiator discusses the event with the Area Authority who then arranges the report
and investigation.

He completes the immediate causes and defines the initial corrective actions.

The external reporting requirements and timetables for different types of accidents and
incidents are included in Appendix 2 of HSE-P-08. A summary is provided on the
Incident Report Form. See Appendix 1.

In all cases the local (field) reporting form must be completed within one working day
of the event.
Accident/ Incident Report Investigation Forms will be forwarded to Cairo on
completion and as soon as possible, remembering some investigations if conducted
correctly my take numerous days / weeks to complete.

3.3 Field HSE Department

The Field HSE completes the investigation of the basic causes and determines
corrective and preventive actions.

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The Field HSE Department advises in investigations where necessary.

The Field HSE maintains a database of all reports and corrective actions to facilitate
follow-up and tracking.

The Field HSE reports monthly on the status of all corrective actions to the local HSE
Committee Meeting.

The Senior HSE in the Field retains all reports for a minimum period of five years.

3.4 HSE General Manager (Cairo)

He maintains a central file of copies of all investigation reports and all relevant
correspondence. Retention time as long as the issue remains relevant to SUCO
operations with a minimum period of five years.

Cairo HSE maintains a database of all Cairo reports and corrective actions to facilitate
follow-up and tracking. Status of these actions is reported to the monthly Building HSE
Committee Meeting.

He arranges periodic summaries of investigation status to provide an overview of all

SUCO operations. These are presented at the Management Review meeting and
occasionally to the Board Meetings.

He also ensures that all external reporting to EGPC and others is completed as required.

3.5 Field Manager

The Field Manager reviews all Accident/Incident reports and signs the report. He then
arranges to follow up progress of these actions at the monthly HSE Committee meeting
in the Field.

The Field manager is responsible for maintaining a list of all Professional Staff
competent to carry out risk assessments indicating their approval of these staff based on
their qualifications.

4.0 Procedure

4.1 General

When an event which could or does lead to loss is identified then this must be reported
to the relevant Area Authority.

Depending on the scale or potential of the incident further reporting will be made
according to the timetable in Appendix 1.

An initial summary report can be made by E-mail followed by Fax (See Appendix 1) if
the information is not available to complete Appendix 2 fully.

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4.2 Initiation and Initial Reporting

If the event constitutes an emergency situation then the relevant Area Authority must
take appropriate actions to minimize the extent of the loss. Efforts should also be
made to record as much as possible to facilitate future investigation.

When conditions are acceptable he then arranges the reporting on the standard Initial
Report form shown in Appendix 2. On completion and within 24 hours forward the
report to the Cairo.

The main activity is to write down the circumstances of the event in sufficient detail to
allow effective investigation and corrective actions.

This form includes definitions of the scale of the actual or potential loss.

The Area Authority then writes down the suggested immediate causes, selected from the list in
Appendix 3 after utilizing Appendix 4 Analysis Causes.

Finally he suggests the immediate corrective actions, the person assigned to complete them and
the proposed completion date.

He then passes the form to HSE for further investigation.

4.3 HSE Investigation

The Field or Cairo HSE then assign a local serial number to the event and proceed with
the investigation of the basic causes.

Basic causes should be selected from the list in Appendix 3, after utilizing Appendix 4
Analysis Causes.

Corrective actions should be identified to deal with these basic causes, persons assigned
and dates of completion. All Corrective Actions must be tracked and closed.

A Lessons Learnt flyer (LL) will be produced by Field HSE Departments for
distribution to other field locations and a copy forwarded to HSE Cairo and respective
departments.

4.4 Field/Division Manager Authorisation

Once the investigation is completed the Field/Division Manager signs the report and the
actions are transferred to the follow-up system for tracking.

Copies of the report are then sent to:

Local
Area Authority
Relevant Field/Division Manager
Local HSE
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Any person who has an action

Cairo
MDs
Cairo HSE
Respective Departments

4.5 Follow-up

All accidents and incident are reviewed monthly at the relevant HSE Committee
Meetings. These are in the Fields and in Cairo Office.

Any corrective actions proposed should be assessed for risk, as defined in the procedure
HSE-P-09, before implementation.

A database of corrective actions is maintained in each location and the status of each
action is reviewed monthly until it is completed.

Action status is presented at the bi-monthly HSE Committee Meeting in Cairo.

A review of the effectiveness of corrective actions is presented by Field HSE at the

local HSE Meeting and is discussed at the main HSE Committee Meeting in Cairo.

4.6 Close out

The completed corrective actions are verified by examination in internal audit.

Once a year each location is scheduled to have an internal audit covering this topic.

5.0 Appendices

Appendix 1 Initial Accident / Incident Announcement Report

Appendix 2 Accidents and Incidents Report and Investigation Form
Appendix 3 Immediate Causes and Basic Causes
Appendix 4 Incident & Accident Analysis Causes

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Appendix 1

E-mail & then Fax

To: MD's, O-1, O-1D, O-1A, HSE Date:

From: Field Manager

Subject: Accident/Incident Initial Report

Please find below initial report for the Accident/Incident which occurred today.

Date: Time: Location:

Description of Event:

Description of Injury, if any Description of Damage, if any

Description of Environmental Harm, if any Description of estimated other loss, including

production

Initial Actions Taken

The detailed investigation report will be faxed to Cairo shortly.

_____________________

Field Manager

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Appendix 2 Accident/Incident Report and Investigation Form

SUCO Incident Investigation Serial Number: HSE Cairo Reference Number:

Description of Accident/Incident Losses (Circle all relevant): Injury - Health - Environment - Process loss Damage - Other

Date: Time: Duration: Staff Involved: Description of Actual Losses:

Description of Event:

Area
Authority

Losses Category:

Actual: H M L Potential: H M L
Investigation

List Immediate Causes List Basic Causes

Corrective Actions for Immediate Causes

Number Action Person Completion date Completed?

Area
Authority

Area Authority Name: Signature: Date:

Department:
Corrective Actions for Basic Causes

Number Action Completion date Completed?

HSE

HSE Name: Signature: Date:

Field/Division Name: Signature: Date:

Manager

Reporting Guidelines

Accident/Incident Scale Injury Property Damage/ Environmental Reporting

Process Loss
Major or High Potential Fatality More than $50000 Long term (>2 year) damage and poor potential Immediate Report verbally to MDs.
Accident or Incident Broken Bones for recovery to normal state and costing more
Disabling Injuries than $50000 in direct loss or clean up costs. A/I written report faxed to MDs/O-1/HSE
Invoke major emergency plan. within 1 day.

Serious or Potential Serious LTIs, Strains, $5000 to $50000 Leads to immediate environmental damage A/I written report faxed to MDs/O-1/HSE
Accident or Incident MTCs lasting for up to 2 years and costing $5000 to within 1 day.
Serious Cuts $50000 in immediate clean up or control costs.
Non-compliance with legal requirement.

Minor Accident or Incident Small cuts self treated Less than $5000 Monitoring or clean up costs less than $5000 A/I written report sent to O-1/HSE within 3
without Lost Time days

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Appendix 3 Immediate and Basic Causes

Immediate Causes

Substandard actions Substandard conditions

SA01 Defective equipment used SC01 Hazard previously unrecognized
SA02 Inattention to known hazards SC02 Housekeeping, PM standard poor
SA03 Procedures/Instruction not followed SC03 Safety equip. unsuitable, not there, not working
SA04 PPE not worn/worn but defective SC04 Heat or cold exposure hazard
SA05 Help not asked for SC05 Tools, equipment, materials defective
SA06 Safety rule not followed /did not warn SC06 Guards, barriers inadequate
SA07 Gas tester not used SC07 Equipment location unsuitable
SA08 Improper working position SC08 Lighting inadequate
SA09 Wrong or worn out equipment used SC09 Ventilation inadequate
SA10 Substandard conditions not reported SC10 Work area congestion, restricted access
SA11 Work/move too slowly/too quickly SC11 Chemicals, fume, dust exposure hazard
SA12 Equipment, tools used wrongly SC12 Floor uneven, slippery
SA13 Horseplay SC13 Supervision inadequate
SA14 Lack of communication SC14 Noise exposure
SA15 Safety devices bypassed, not working SC15 Radiation exposure
SA16 Working, riding on operating equipment SC16 Inadequate warning system
SA17 Substandard act by another person SC17 Abnormal operating conditions
SA18 Improper loading SC18 Fire, explosion, spill exposure hazard
SA19 Improper lifting SC19 Personal Protective Equipment defective
SA20 Equipment moved to wrong place SC20 Lockout of equipment not possible
SA21 Equipment use without training/permission SC21 Insect, animal bite
SA22 Take short cuts, avoid discomfort SC22 Weather (rain/wind)
SA23 Tired SC23 Sharp edge protrusion
SA24 Unwell SC24 Process operation conditions charged
SA25 Medication/Intoxicant influence SC25 Equipment used for different process
SC26 Procedure/work instruction inadequate

Basic Causes

Personal factors Job factors

PF01 Not able to do job (physically or mentally) JF01 Leadership/supervision deficiency
PF02 Not trained (lack of knowledge or skill) JF02 Work instruction/procedure inaccurate
PF03 Over stressed (physically or mentally) JF03 Maintenance deficiency
PF04 Not motivated JF04 Inspection deficiency
PF05 Unsafe work permit JF05 Unsafe working conditions
JF06 Tools, equipment, materials deficiency
JF07 Wear & tear
JF08 Inadequate work standards
JF09 Abuse or misuse

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Appendix 4 Incident & Accident Analysis Causes

Immediate causes

1 Premises Consider the premises and place of work first and ask Was there anything about the place,
the access or egress which contributed to the event? eg holes in floors causing tripping, inadequate
ventilation, inadequate weather protection. The most likely conclusions may be:

Premises not a significant factor - go to 2.

Adequate premises/access/egress provided but not used - consider working procedures - go to 3.
Adequate place etc once provided but not maintained - consider planning -go to 5.

2 Plant and substances

Consider the precautions for plant, equipment and substances and ask Was there anything about the
adequacy of the controls which contributed to the event? eg inadequate guarding, poor local exhaust
ventilation. (Remember plant and substances may be products supplied by your company.)
The most likely conclusions may be:
Plant and substances not a significant factor - go to 3.
Adequate controls provided but not used - consider working procedures -go to 3.
Adequate controls once provided but not maintained - consider planning -go to 5.

3 Procedures

Consider the systems, instructions and methods of work and ask if they contributed to the event, eg
failure to use good equipment properly. (Consider both normal operation and emergency procedures.)
The most likely conclusions may be:
Correct system/method in use - go to 4.
Correct system/method devised but not used. If so, consider:
clarity and adequacy of instructions - go to 9;
adequacy of supervision - go to 7;
behaviour of person - go to 4.
Correct system/method once devised and used but now lapsed. Consider:
adequacy of monitoring - go to 11.
Correct system/method never devised - consider planning - go to 5.

4 People

Consider the behaviour of the people involved and ask: Did they do or fail to do anything which
contributed to the event? The most likely conclusion may be:
Behaviour not a significant factor.
People unsuitable for the job (eg physical disability, sensitivity to certain chemicals). Consider
whether the person was:

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never suitable - look at recruitment/selection/placement - go to 10;
once suitable - consider the adequacy of health surveillance - go to 6.
Suitable person but not competent - consider whether the person was:
never competent - look at training - go to 10;
once competent but performance not sustained - look at supervision (go to 7) and monitoring (go to
11).
Suitable competent person but did wrong thing. Possibilities include:
unintended actions:- slip - doing the right thing in the wrong way;- lapse - forgetting the right thing.
intended actions:- mistake - choosing the wrong action in error;- violation - purposely doing wrong
thing - routine/non-routine.
Consider:
training - go to 10.
communication - go to 9.
controls/supervision - go to 7.
planning - go to 5.
monitoring - go to 11.
co-operation - go to 8.

5 Planning

Risk control systems (RCSs) are necessary for the supply, use, maintenance, demolition and disposal of
premises and the supply, storage, handling, use, transport and disposal of plant (including all types of
equipment), and substances.
Where inadequate premises, plant and substances or procedures have been provided, consider the
adequacy of the RCSs for the:
Premises
Design of structures/buildings.
Control of structural design changes.
Selection of buildings/workplaces.
Purchase of buildings/workplaces.
Maintenance of buildings/workplaces.
Security.
Demolition.
Procedures
Preparation, circulation, revision.
Practicality.
Technical adequacy.
Where RCSs are absent or inadequate, consider risk assessment arrangements - go to 6.
Where RCSs are not used, consider:
Risk assessment - go to 6.
Organisation: control - go to 7.
Communication - go to 9.
People - go to 4.
Monitoring - go to 11.
Where procedures involve contractors, consider competence - go to 10.

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6 Assessing risks

Consider the adequacy of risk assessment arrangements - if methods of hazard identification and risk
assessment are:
Absent - consider organisation: control - go to 7.
Inadequate - consider competence of those choosing them - go to 10.
Adequate but not used, consider:
organisation: control - go to 7;
monitoring - go to 11.
Satisfactory but the results are inadequate - consider:
competency of those using them - go to 10;
adequacy of technical standards used - go to 9;
clarity of results - go to 9;
involvement of employees - go to 8.

7 Organisation: control

Where arrangements/procedures/systems are absent, not used or supervision is inadequate, consider the
responsibilities of those devising, operating and maintaining the procedures/systems. Ask:
Are responsibilities clearly set out?
Are responsibilities clearly understood?
Do those with responsibilities have the time and resource to discharge their responsibilities?
Are people held accountable for discharging health and safety responsibilities?
Are people rewarded for good performance?
Are people penalised for poor performance?
If not, consider:
competence - go to 10;
the adequacy of senior manager commitment and resources devoted to health and safety.

8 Organisation: co-operation

Consider how those working with risks are involved in risk assessments and devising procedures
(including the operation of any health and safety committee). If inadequate consider:
competence - go to 10.
the adequacy of senior management commitment to co-operation.

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9 Organisation: communication

Consider:
Is there sufficient, up-to-date information on law and technical standards to make good decisions
about how to control risks?
Are written instructions for internal use clear and in sufficient detail?
Are the up-to-date versions of instructions available?
Is there sufficient information supplied to the users of products?
Is there sufficient visible senior management commitment to health and safety.

10 Organisation: competence

Consider the adequacy of arrangements for:

recruitment/selection and placement to check that people have the right physical and mental abilities
for their jobs including, where necessary, medical examinations, and tests of physical fitness,
aptitudes or abilities;
assessing the health and safety competence of contractors as part of contractor selection;
identifying health and safety training needs at recruitment, when there are changes in staff, plant,
substances, technology, processes or working practices. The need to maintain or enhance competence
by refresher training, and the presence of contractors employees, the self-employed or temporary
workers (and assessments of competence);
competent cover for staff absences, particularly for those people with critical health and safety
responsibilities and emergency procedures;
health checks and health surveillance based on risk assessments (including assessments of fitness for
work, following injury or ill health);
provision of health and safety assistance.

11 Monitoring

Consider the adequacy of the checks and inspections made of the workplace precautions and risk
control systems before an accident (ie were they frequent enough, and did they look at the right things
in sufficient detail to ensure the safe use of premises, plant and substances and the implementation of
procedures). If checks were:
absent - consider organisation: control - go to 7.
not adequate - review risk assessment arrangements - go to 6.
not completed - consider organisation: control - go to 7, and review -go to 12.
Consider any previous accident/incident events similar to this one and examine if the investigation or
lessons are helpful. If previous events have not been thoroughly investigated, consider:
the organisation: control - go to 7.
competence - go to 10.
If the lessons have not been put into effect, consider:
organisation: control - go to 7.
review - go to 12.

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12 Review

Consider the arrangements for following up actions to remedy health and safety problems.
If work is outstanding beyond the deadline, consider:
organisation: control - go to 7;
adequacy of resources and commitment to health and safety.
If a second incident occurs before corrections were made, consider:
mechanisms for prioritising remedial actions in investigation process;
competence of those prioritising remedial actions - go to 10.

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