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1
Incident Reporting Procedure
2
Objectives
Describe the responsibilities and procedures for reporting
and investigating
◦ incidents / near-miss incidents
◦ spills, releases,
◦ injuries, occupational illnesses,
◦ equipment or property damage,
◦ transportation incidents,
◦ fires or explosions
◦ security issues
Incident Reporting Procedure
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Objectives
Describe the importance of investigations in:
◦ Determining the root causes of incidents
◦ Determining corrective and preventive actions to prevent similar
incidents.
Describe the importance of initiating investigation
immediately after the incident situation is under control.
Incident Reporting Procedure
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Definitions
Incident –
◦ Any unplanned event or near miss occurring inside the
facility boundaries affecting employees, processes,
contractor employees, or visitors.
◦ Any off-site events involving company products or
equipment in transit or at customer sites
Incident Owner –
◦ The manager, supervisor or designated person
responsible for the facility, area or activity where the
incident occurred.
Incident Reporting Procedure
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Definitions
OSHA Recordable Cases –
◦ All work related illnesses and deaths, and those work
related injuries which result in:
Loss of consciousness,
Restriction of work or motion, transfer to another job, or
require medical treatment beyond first aid and/or use of
prescription medications.
Initial Notification–
◦ A brief communication providing basic details of an
incident
Incident Reporting Procedure
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Definitions
Investigation Team –
◦ Consist of personnel who shall investigate and analyze
the incident.
◦ If an incident involves contractor personnel, then non-
involved contractor employees may be included as team
members.
◦ Management personnel knowledgeable of investigation
methodologies and techniques shall be included in the
incident investigation.
Incident Reporting Procedure
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Definitions
First Aid –
◦ Any treatment and subsequent observation of minor
scratches, cuts, burns, splinters, and so forth, which do
not ordinarily require medical care or use of prescription
medications.
◦ Such treatment and observation are considered first aid
even though provided by a physician or registered
professional personnel.
Incident Reporting ProcedureDefinitions
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Responsibilities
All personnel are responsible for:
◦ Notifying their immediate supervisor of all incidents
immediately.
◦ Participating in generating the initial notification
◦ Participating in incident investigations as needed.
◦ Participating in generating the investigation report
◦ Completing corrective and preventive actions as
assigned.
Incident Reporting Procedure
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Responsibilities
Facility Manager or Shift Leader, or Control Room
Operator is responsible for:
◦ Being the Incident Owner for all incidents that occur
within their area of responsibility.
◦ Documenting initial incident details.
◦ Contacting regulatory agencies if necessary.
◦ Assigning personnel to the incident investigation team.
Incident Reporting ProcedureResponsibilities
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Responsibilities
Facility Manager or Shift Leader, or Control Room
Operator is responsible for:
◦ Leading and conducting incident investigations.
◦ Communicating with Maintenance when design issues or
equipment failures may be involved in the incident.
◦ Defining and recommending corrective and preventive
actions.
◦ Verifying all corrective and preventative actions assigned
during the incident investigation are completed.
◦ Communicating to employees incident summaries.
Incident Reporting Procedure
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Procedure for Investigation
An Incident Investigation shall begin immediately after
securing the scene.
If the area is quarantined, the investigation shall not
commence until release of the quarantine.
Documents associated with the incident should be attached
to incident file.
The Investigation Team shall produce an Investigation
report including corrective and preventive actions.
Incident Reporting Procedure
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Preparation for Investigation
An effective incident investigation starts before an incident
occurs with a well designed investigation procedure. The
following information will provide guidance when conducting
an investigation:
1. ORGANIZE AN INVESTIGATION TEAM.
◦ As few as two or as many as four employees.
◦ The size of the team may vary based on the type of incident.
◦ Must include at least one employee of supervisor responsibility.
Incident Reporting Procedure
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Preparation for investigation
2. ASSEMBLE AN INVESTIGATION KIT.
◦ This kit may include a camera, paper/pens, reporting forms and
any information such as notes on investigation.
3. SECURE THE ACCIDENT SCENE.
◦ Asses the situation to prevent additional accidents from
occurring based on hazards.
◦ Attend to any immediate medical emergencies.
◦ Preserve any evidence at the scene. DO NOT ENTER AN
ACCIDENT SCENE UNTIL IT HAS BEEN CLEARED FOR SAFETY.
Incident Reporting Procedure
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Doing the investigation:◦ Identifying and collect evidence –
This must be done quickly.
◦ Identifying contributing factors – Can include procedure violations or employee
knowledge.
◦ Photographing the accident scene – Take pictures necessary to reconstruct the scene. Take
close and long range.
◦ Sketch ing the accident scene – Will provide information that a photo will not.
Incident Reporting Procedure
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Doing the investigation:
◦ Writing notes –
Notes should be written as soon as possible while information
is fresh.
Notes, emails, communications should be initiated as soon as
possible by personnel involved in the incident
Consider who, what, when, where, how and why.
Incident Reporting Procedure
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Doing the investigation:
◦ Interviewing affected parties or witnesses –
Prepare interview questions. Ask questions but let the
employees describe their observations. Take notes during the
interview. Get facts, don’t assign blame or criticize. Don’t
focus on expense of the damages or legal issues. End the
interview on a positive note.
Incident Reporting Procedure
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Determining root cause
1. REVIEW ALL EVIDENCE.
◦ This will include all information collected
2. DETERMINE THE ROOT CAUSE.
◦ To determine the root cause, you must first identify
contributing factors (symptoms). As an example, an
employee’s action may have caused the accident, but
why did the employee perform this action.
◦ This could have been the result of procedural violations
or lack of training.
Incident Reporting Procedure
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Determining Corrective Actions
3. DEVELOP CORRECTIVE AND PREVENTIVE ACTIONS.
◦ A root cause may be a mechanical problem or personnel
issue.
◦ Corrective and preventive actions are implemented to
eliminate or reduce the chance of another accident.
◦ Actions are determined by the following methods; input
from employees, hazard assessments, safety
committees.
Incident Reporting Procedure
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Communicating to others in the organization
4. COMMUNICATE RESULTS.
◦ To effectively communicate the findings of the
investigation, a final report must be completed.
◦ The Company will communicate investigation reports
through a safety meeting.
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Approval & Closure
◦ An Incident Report is ready for approval and closure when
The investigation is completed,
The root cause has been identified
Corrective actions have been implemented.
◦ The Facility Manager is responsible for final closure of the
incident record.
Incident Reporting Procedure