006 Incident Investigation and Reporting

Incident Investigation and Reporting

Incident Investigation and Reporting

Incident Investigation and Reporting

Incident Investigation and Reporting

Table of Contents

1.

2.

3.

3.1

3.2

3.3

3.3.1

3.3.2

3.3.3

3.3.4

3.3.5

3.4

3.5

3.6

3.6.1

3.6.2

3.7

4

5

6 Introduction .............................................................................................................. 1 Definitions ................................................................................................................ 1 Guidance for Implementation.................................................................................... 2 Register and classify the incident ............................................................................. 2 Initiate investigation .................................................................................................. 2 Investigate the incident ............................................................................................. 3 Minor incidents ......................................................................................................... 3 Moderate/severe incidents ....................................................................................... 3 Witnesses................................................................................................................. 5 Evidence .................................................................................................................. 6 Photographs, Video Recordings, Drawings and Diagrams ....................................... 6 Report investigation results ...................................................................................... 8 Corrective and preventive action .............................................................................. 8 Communicate investigation results and action taken ................................................ 8 Internal communication ............................................................................................ 8 External communication ........................................................................................... 8 Close out incident ..................................................................................................... 9 Analysis and Review ................................................................................................ 9 Training .................................................................................................................. 10 Records .................................................................................................................. 10 Annexure 1 - Incident Classification Guide ........................................................................ 1-1 Annexure 2 - Incident Register .......................................................................................... 2-1 Annexure 3 - Why Root Cause Analysis Form ................................................................... 3-1 Annexure 4 - Internal Incident Investigation Report ........................................................... 4-1 Annexure 7 - Codes List…………………………………………………………………………..7-1 Annexure 8 - Equipment Incident/Accident Report……………………………………….……8-1 Annexure 9 - Formal Accident Investigation Report…………………………………………...9-1

Procedure –Incident Investigation and Reporting

1. Introduction

When an HSE incident occurs, it is vital to analyse and investigate the incident in order to identify the root (also referred to as basic) causes contributing to its occurrence.

Identifying the root causes allows for appropriate measures to be taken to address the origin of the incident to prevent it from recurring. Depending on the incident, internal and/or external parties may be notified of and involved in the investigation.

Incident investigations are the most critical aspect of an effective incident management system. Investigations should therefore only be facilitated and conducted by appropriately trained Investigators to ensure that valid root causes are identified and appropriate corrective and preventive actions are initiated to eliminate root causes.

2. Definitions

Corrective Action Actions taken to eliminate the cause of an undesirable event to

prevent it from recurring

Incident The occurrence of an event where the specified hazard causes

injury, loss, damage or harm because of the release of or contact

with the hazard

Incident investigation A thorough and systematic inquiry into the circumstances

surrounding an incident to gain a complete understanding of the

causes, effects and remedies of the incident

Incident investigation

report

Leading indicator A formal written statement reflecting the results of the incident investigation A statistic that generally precedes or predicts that an incident or

incidents may be imminent, an indicator that factors and

conditions are present, which may result in an incident or

incidents occurring

Loss potential The injury, harm, damage or loss that results from or could result

from an incident

Lost time injury An injury that causes a loss of time beyond the shift during which

the incident occurred

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Procedure –Incident Investigation and Reporting

Non lost time injury An injury that does not cause a loss of time beyond the shift

during which the incident occurred

Preventive Action Actions taken to eliminate the potential cause of a potential

undesirable event to prevent it from occurring

Root cause The most basic, underlying source or origin of an incident, which

will, if eliminated, prevent recurrence of the incident

Severity

An indicative value of the seriousness/severity/degree of harm of the consequence of an incident

3. Guidance for Implementation

The severity of incidents differs from incident to incident. Incidents are therefore investigated differently to accommodate the differences. They are investigated based on their severity to ensure that the appropriate level of detail is considered and attention paid to more severe incidents.

Severe incidents that caused, or had the potential to cause, serious injury, harm, damage or loss are investigated in detail to ensure that they are afforded the focus and attention they deserve based on their loss potential.

Less severe incidents that caused or had the potential to cause minor injury, harm, damage or loss are not disregarded, but investigated in less detail, since their potential for loss is much lower.

3.1 Register and classify the incident

Upon receipt of a preliminary incident report, the responsible person classifies the incident, based on its loss potential, according to the Incident Classification Guide in Annexure 1.

Following the classification of the incident, the responsible person registers the incident in the Incident Register in Annexure 2.

3.2 Initiate investigation

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