Incident Report Form

Using the ladder in unsafe manner

FADHILI GAS PROGRAM PROJECT

INCIDENT REPORT FORM

F-PRO-152-810-I Date:
Page 1 of 14
Incident Report ID: Rev.:
 Final Incident Report Form
Using the ladder in unsafe manner
Part 2: Incident Investigation
2.1 Incident details
☐ Fatality (FAT) ☐ Lost Time Incident (LTI)
Full IP’s name: N/A
Time off

Date of birth: ID:

Company: Position:
Crew: Lost work days:
(if already known)
Injury

☐ Restricted Work Case (RWC) ☐ Medical Treatment Case (MTC) ☐ First Aid Case (FAC)
Full IP’s name: N/A
No time off

Date of birth: ID:

Company: Position:
Crew: Restricted work days:
(if applicable)
MTC / FAC
justification:

☐ Asset Damage (project) (AD) ☐ Asset damage (3rd party) (AD) ☐ Fire Incident (FI)
Asset: N/A ID:
Owner: Cost (€):
Asset description:
Damage description:
Cause of damage:
With damage

☐ Motor Vehicle Incident (MVI)

Model: N/A License plate:
Owner: VIN number:
Damage description:
Driver’s full name:
No injury

Date of birth: ID:

Company: Position:
Cause of damage:
Passengers:

☐ Environmental Incident (EI)

Env.

Description: N/A
Quantity of emissions / spill (L):

Near Miss (NM)

☐ ☐ Security Breach (SB) (Refer to Attachment 1 of this document to assess Near Miss)

Description: Using the ladder in an Unssafe Manner

No damage

Missing assets: N/A

Cost estimate (€):
Consequences: ☐ 5 ☐ 4 
☐ 3 ☐ 2 ☐ 1
Likelihood: ☐ 5 ☐ 4 
☐ 3 ☐ 2 ☐ 1
Potential risk score: Extreme High Medium ☐ Low
☐

☐ ☐
☒

F-PRO-152-810-I Date:
Page 3 of 14
Incident Report ID: Rev.:
 Final Incident Report Form
Using the ladder in unsafe manner
2.2 Outcome

Place mark on injury zone only in incidents resulting in injury

Head Torso Arms Legs Others

☐ Cheekbone ☐ Abdomen ☐ Arm ☐ Ankle ☐Internal inj.
☐ Chin ☐ Back ☐ Elbow ☐ Foot ☐ Several parts
☐ Ear ☐ Buttocks ☐ Hand ☐ Knee ☐Skin
☐ Eyebrow ☐ Chest ☐ Wrist ☐ Leg
☐ Forehead ☐ Hip
☐ Lips ☐ Neck
☐ Nose ☐ Shoulders
☐ Skull

F-PRO-152-810-I Date:
Page 4 of 14
Incident Report ID: Rev.:
 Final Incident Report Form
Using the ladder in unsafe manner
2.3 People, Environment, Equipment, Procedures, Organization (PEEPO)

PEEPO (People, Environment, Equipment, Procedures, Organization) is a tool used for organizing facts
and ideas that help establishing a timeline of events sequence and a root cause tree, divided in five
categories, for subsequent analysis. Acts, Conditions or deficiencies found in this initial collection of
data are to be examined for their potential as contributing factors to the incident.

Please refer to Incident Report Guidelines, Section 2.3 for more detailed instructions.

Factors Facts and ideas

• Length of employment
• Roster
• Training & competency, PPEs
• Experience
People • Understanding of task
• Fatigue
• Personal Issues / Stress
• Alcohol / drugs, Communication
• 1. Foreman failed to provide safe working
platform
• 2. Foreman kept one eye closed on the activity.
• Nobody was hold the ladder.
• Foreman and worker both were standing on the
same ladder at the time.

• Weather
• Housekeeping • Ladder was rest on pipe, it maybe chance to
• Location / design of work area
Environment • Visibility
slippery.
• Access / egress • Ladder was not secured
• Ground and noise conditions

• Fault or failure
• Design / quality
• Availability
Equipment • Modifications • na
• Maintenance
• Inspections / pre-starts
• Risk assessment on equipment
• Procedure / Safe Work Instruction
• Up to date
• 3. The crew opt to do unsafe act to finish the work
• Identification of hazards quickly.
• Adequate permit • Forman was failure to apply safe working
Procedures • Inspections procedure on the ladder,( Forman’s one leg was
• Last Minute Risk Assessments, JSA positioned on the ladder and the other one on the
• Registers
foundation nearby).
• Management of change
• Supervision
• Provided training
• Corrected Hazards
• Safety systems
Organization • SAOs
• Failed Supervision
• Available safety equipment
• Inspections and maintenance
• Similar incidents

F-PRO-152-810-I Date:
Page 5 of 14
Incident Report ID: Rev.:
 Final Incident Report Form
Using the ladder in unsafe manner

2.4ILCI Loss Causation Model

Lack of Basic Immediate

Incident Loss
control causes causes

Failed to provide Potential of Unsafe act:

safe working falling from Unsafe Use of N/A N/A
creates leadingto causing with the
platform height Ladder
resulting

The International Loss Control Institute (ILCI) Loss Causation Model represents the sequence of events that allow an actual loss to occur. It
can be used to understand the various causes leading to incidents and provides a framework for the subsequent incident investigation.

This model takes a proactive approach to loss prevention and suggests that incidents are symptoms of lack of control in the management
system, which is to be identified. The various events are explained by working backwards from the loss. Please refer to Attachment 2: ILCI
Loss Causation Model for the events checklist and refer to Incident Report Guidelines, Section 2.4 for more detailed instructions.

This model can be replaced by other commercial root cause analysis methods such as TapRooT, SCAT, TRIPOD or similar.

F-PRO-152-810-I Date:
Page 6 of 14
Incident Report ID: Rev.:
 Final Incident Report Form
Using the ladder in unsafe manner

2.5Events timeline (can be replaced with any commercial events timeline)

Event Time Description

Event 1 Before 8:15am The Crew was doing bolt tightening activity.

The crew was found using a ladder unsafely 2 workers at

Event 2 8:15am the same time and the foreman leg is stretched from the
ladder to a concrete foundation.
The crew was stopped and informed to Area HSE and
Event 3 8:15 am
Supervisor.
A stand down meeting was given and the id details of the
Event 4 8:20 am
involved persons were taken.

2.6 Immediate actions

Action Description

Action 1 1. Stop the activity.

Action 2 2. Take the details of the crew

Action 3 3. Give the crew a stand down meeting.

F-PRO-152-810-I Date:
Page 7 of 14
Incident Report ID: Rev.:
 Final Incident Report Form
Using the ladder in unsafe manner

2.7 Preventive / corrective actions follow-up and status

Type
Acti Responsi Closing
(Prev/corr Description Due date
on ble date
)
1. Pre-plan the activities and do 2018/6/5 2018/6/5
A1 Preventive SEG Const
not rush the activities.
2. Stand down meeting for the SEG 2018/6/5 2018/6/5
A2 Corrective
crew shall be done. HSE/Const
3. Disciplinary action shall be 2018/6/5 2018/6/5
A3 Corrective SEG HSE
given for the foreman.
A4 Preventive 4. This issue shall be discussed SEG HSE 2018/6/5 2018/6/5
in morning toolbox meeting.
A5 Preventive 5. Safety alert shall be SEG HSE 2018/6/5 2018/6/5
distributed for awareness.

2.8 Investigation team

Name ID Company Position

Guo Changqing 10549 SEG HSE SUPV
Jesus Valdez 12044 SEG HSE SUPV
Xia Haisen 10416 SEG HSE SUPT

2.9 Additional comments

F-PRO-152-810-I Date:
Page 8 of 14
Incident Report ID: Rev.:
 Final Incident Report Form
Using the ladder in unsafe manner
2.10 Attachments (e.g. photographic evidence)

(Enumerate here and attach separately).

Incident Photo Stand down meeting

Safety alert

F-PRO-152-810-I Date:
Page 9 of 14
Incident Report ID: Rev.:
 Final Incident Report Form
Using the ladder in unsafe manner
Disciplinary Action

F-PRO-152-810-I Date:
Page 10 of 14
Incident Report ID: Rev.:
 Final Incident Report Form
Using the ladder in unsafe manner
Attachment 1: Near Miss Risk Assessment
Consequence Matrix
5 4 3 2 1
Catastrophic Major Moderate Minor Slight/none
Multiple fatalities /
Lost time incident / Restricted work case /
Injury permanent total Single fatality First aid case
partial disability medical treatment case
disability
Loss > 5,000 €, fire
Loss > 500 €, flames, Minor loss,
Mat. emergency services, Loss > 50 €, sparks,
Loss > 50,000 € displacement of overheat,
damage disruption in operations, minor bumps
personnel, bumps noncollisions
crashes
Non-complying
Radioactive spill,
Env. Affection to protected area Contaminated spill emissions Minor spill
uncontrolled spill
(noise/dust/odor)

Likelihood Matrix
5 Almost certain
4 Quite likely
3 Possible
2 Unlikely
1 Remote
Expected to occur frequently (more than once a year)
Expected to occur occasionally (once every year)
Expected to occur under unusual circumstances (once every three years)
Could occur at some time (once every 10 years)
May occur only in exceptional circumstances (unheard of in the industry)

Risk Assessment Matrix

Consequences
5 4 3 2 1
Catastrophic Major Moderate Minor Slight/non
Almost
5
certain
E E E H H
Quite
4 E E H H M
Likelihood

possible

3 Possible E E H M L
2 Unlikely E H M L L
1 Remote H H M L L

Potential Risk Score

Code Risk level Required actions
Immediate priority corrective measures and re-assessment. Risk reduction plan
E Extreme
must be developed and approved by management.
High priority corrective measures. Review and introduce additional controls to
H High
reduce risk.
Confirm presence of reasonable safeguards and management systems. Monitor
M Medium
and maintain.
L Low Monitor and manage risk accordingly.

F-PRO-152-810-I Date:
Page 12 of 14
Incident Report ID: Rev.:
 Final Incident Report Form
Using the ladder in unsafe manner
Attachment 2: ILCI Loss Causation Model
Lack of control
☐ 1. Leadership and administration ☐ 11. Health control and services
☐ 2. Management training ☐ 12. Program evaluation systems
☐ 3. Planned inspections ☐ 13. Purchasing and engineering systems
☐ 4. Job task analysis and procedures ☐ 14. Personal communications
☐ 5. Job and task observations ☐ 15. Group meetings
☐ 6. Emergency preparedness ☐ 16. General promotion
☐ 7. Organizational rules ☐ 17. Hiring and placement
☐ 8. Accident and incident investigations ☐ 18. Records and reports
☐ 9. Accident and incident analysis ☐ 19. Off-the-job safety
☐ 10. PPE
Basic causes
Personal factors Job factors
1. Inadequate capability / behavioral
☐  1. Inadequate leadership supervision
☐
2. Lack of knowledge
☐ ☐ 2. Inadequate engineering
☐ 3. Lack of skill ☐ 3. Inadequate purchasing
☐ 4. Stress ☐ 4. Inadequate maintenance
☐ 5. Fatigue ☐ 5. Inadequate tools / equipment
☐ 6. Improper ventilation ☐ 6. Inadequate work standards
☐ 7. Wear and tear
☐ 8. Abuse or misuse

Immediate causes
Acts Conditions


☐ 1. Violation (intentional) 1. Inadequate/defective guards or protective
☐
barriers
☐ 2. Violation (unintentional) ☐ 2. Inadequate/defective PPE
☐ 3. Inadequate/defective warning systems/safety

☐ 3. Improper position (in the line of fire)
devices
☐ 4. Overexertion or improper posture ☐ 4. Inadequate security provisions or systems
☐ 5. Inadequate design/specification/management
☐ 5. Work or motion at improper speed
of change
☐ 6. Inadequate/defective

☐ 6. Improper lifting or loading
tools/equipment/material/products
☐ 7. Improper use/position of
☐ 7. Inadequate maintenance/inspection/testing
tools/equipment/materials/products
☐ 8. Servicing of energized equipment / inadequate
☐ 8. Congestion, clutter or restricted motion
energy isolation
☐ 9. Failure to warn of hazard 9. Inadequate surfaces, floors, walkways or roads
☐
☐ 10. Hazardous atmosphere
☐ 10. Inadequate use of safety systems
(explosive/toxic/asphyxiating)
☐ 11. PPE not used or used improperly ☐ 11. Storms or acts of nature
☐ 12. Equipment or materials not secured ☐ 12. Inadequate training/competence
☐ 13. Disabled or removed guards, warning systems or
safety devices
13. Inadequate work standards/procedures
☐

☐ 14. Inadequate hazard identification or risk

14. Improper decision making or lack of judgement
☐
assessment
F-PRO-152-810-I Date:
Page 13 of 14
Incident Report ID: Rev.:
 Final Incident Report Form
Using the ladder in unsafe manner
☐ 15. Lack of attention/distracted by other
☐ 15. Inadequate communication
concerns/stress
☐ 16. Acts of violence ☐ 16. Inadequate supervision
☐ 17. Use of drugs or alcohol ☐ 17. Poor leadership/organisational culture
☐ 18. Fatigue ☐ 18. Failure to report/learn from events

Incident
Type of contact Contact with
☐ 1. Struck against ☐ 1. Electricity
☐ 2. Struck by ☐ 2. Heat
☐ 3. Caught in ☐ 3. Cold
☐ 4. Caught on ☐ 4. Radiation
☐ 5. Caught between ☐ 5. Caustics
☐ 6. Slip ☐ 6. Noise
☐ 7. Fall on same level ☐ 7. Toxic or noxious substances
☐ 8. Fall to below ☐ 8. Machinery
☐ 9. Overexertion

Loss
☐ 1. People ☐ 4. Material
☐ 2. Property ☐ 5. Quality
☐ 3. Environmental 6. Safety
☐

F-PRO-152-810-I Date:
Page 14 of 14
Incident Report ID: Rev.: