SAFETY

PERFORMANCE
REPORTING
AND
ACCIDENT
INVESTIGATION

HUMAN BEHAVIOR

SHIELDS = HSE
MANAGEMENT
SYSTEM

PERFORMANCE

NEED FOR A STANDARDIZED SYSTEM

RECORDABLE ACCIDENTS
RECORDABLE INJURY
An unplanned event that results in an injury to a person (cut, fracture, sprain, amputation), which is
the consequence of:
a work related activity
an exposure involving a single incident in the work environment
(deafness from explosion, one-time chemical exposure, back disorder from a slip / trip, fracture
caused by fall from height, animal bite, poor housekeeping resulting in a trip of a person)
OCCUPATIONAL ILLNESS is NOT SAFETY RECORDABLE
OCCUPATIONAL ILLNESS - any abnormal condition or disorder, other than one resulting from an
occupational injury, caused by exposure to environmental factors associated with employment. It
will generally result from prolonged or repeated exposure.
An Occupational Illness can be:
Back problems and lower limb disorders
Cancers and malignant blood diseases
Infectious/preventable diseases (malaria, food poisoning, infectious hepatitis, dysentery)
Noise induced hearing loss
Poisoning (systemic effects of toxic materials)
Skin diseases and disorders (contact dermatitis, allergic dermatitis, rash caused by primary
irritants, sensitizers or poisonous plants)
Physical disorders resulted from heat stress, exposure to low temperatures; effects of ionising
(alpha, beta and gamma rays, radium) and non-ionising (welding flash, ultraviolet rays, sunburn)
radiation).

SAFETY REPORTING STANDARD STD-COR-HSE-002

FORM-048: TRAILLING INDICATORS

SAFETY REPORTING STANDARD STD-COR-HSE-002

FORM-049: PROACTIVE INDICATORS

CALCULATION OF SAFETY
INDICATORS
WORKED MANHOURS
Offshore units
No persons on board/day x No.
days worked x 12 hours/day
Onshore units
No persons present each day x No.
days worked x No. hours
worked/day

AVERAGE MANPOWER
No of persons present at work each
day in a month / no of days worked
in month

EVENTS REPORTED AND ANALYSED

Fatalities
LTI
Work Restricted

Personal Injuries

Medical
treatments
First Aid
Employee slips on the
scaffold and..
suffers a scratch on his
finger
sprain his ankle while
attempting to regain his
balance
falls from scaffold and
suffer multiple fractures
falls from scaffold and
suffer fatal injuries to
head

Near Miss
Employee slips on the
scaffold but he regain
the balance
Safety and Hazard
Observation Cards

Employee fails to put on

safety harness and
before climbing on the
scaffold but was
stopped by his
supervisor

PERFORMANCE MEASURMENT

LTI Frequency Rate

LTIFR =

N . LTI 1,000 ,000

Total Work ed _ Manhours

Severity Rate

SR =

N . LWD 1, 000
Total Work ed _ Manhours

Total Recordable Incidents Frequency

Rate

TRIFR =

N .TRI 1,000 ,000

Total Work ed _ Manhours

PROACTIVE INDICATORS
HSE TRAINING HOURS

Include the safety & environmental training courses provided to Company and
Contractor personnel on Company facilities and on external facilities, agreed by the
Company.
HSE Training Hours have to be considered as Contact hours and it is calculated
by multiplying the number of attendees with the duration of the training session.
In the calculation of HSE Training hours shall not be included Safety Induction
Training such as offshore arrival, neither Emergency Drills.

TOOL BOX TALKS

Brief (10 15 minutes) meetings, focused

on particular safety issues, conducted
prior to work commencing by a
supervising person whose responsibility
is to assure that the appropriate
information is given to promote awareness
and understanding of all the potential
hazards which may affect the safe and
efficient job completion.

PROACTIVE INDICATORS

JOB SAFETY ANALYSIS

Is a procedure used to identify, analyse and record the steps involved in

performing a specific job, the existing or potential safety hazards associated with
each step, and the recommended action(s)/procedure(s) that will eliminate or
reduce these hazards and the risk of a work related injury .

HSE MEETINGS

Any specific HSE meeting held in work site, base camp, offices and naval assets
where HSE matters are predominately discussed. It does not include Project
Progress meeting (even if HSE related matters are discussed)

HSE INSPECTIONS

A planned tour of a workplace to examine the site facilities, equipment, tools and
the employees practices in using them. HSE Inspection may also includes the so
called Safety Walkthroughs

SAFETY & HAZARD

OBSERVATION CARDS

It is a generic term, used to identify all the situations, conditions observed and
reported by the personnel employed in a project or site. Observation reported are
always dealt with immediately after notification, solved by means of short-term
action and recorded

PREPARING THE REPORT

HSE TRAINING REPORT

PREPARING THE REPORT

TOOL BOX TALKS

Name of the participants

Topics discussed during the meeting

PREPARING THE REPORT

WEEKLY SAFETY MEETINGS

ACCIDENT INVESTIGATION

Accidents dont just happen, they are often the

result of a sum of causal factors which taken
separate might have result in near miss or minor
events
An accident is:
Unwanted
Unplanned
Unforeseen
Disruptive
Can have major or minor outcomes

Accidents = Injuries
Why?
Because Injuries costs:

Insurance Premiums
Medical Expenses
Worker Compensation
Rest of work crew takes up the slack

ACTIONS VS. ATTITUDE

? What is easier to see and report?
? Which is easier to change?

What is important to see:

To understand why people do the things they do.

To know there are many factors that cause an accident.
But mostlylook deeply into why accidents happen!

Why the injuries should be investigated:

Prove the victim was at fault? ..no

Avoid law suits against the company.no
Try to make the work place safer!!

PURPOSE OF ACCIDENTS REPORTING AND

INVESTIGATION SYSTEM
An opportunity to change the work climate by correcting unsafe
conditions, procedures, or actions.

Identify the sequence of events leading to accident and the causes of failures associated to
each step;
Find methods to prevent accidents from recurring;
Communicate within the company and/or other companies the problems encountered during
activity carried out;
Provide information on the status of strategies applied by the company to control the risks to
health and safety;

REPORT & INVESTIGATE

COMMUNICATE

EVALUATE

SAFETY HAZARD OBSERVATION CARDS

The purpose of reporting SHOC is to prevent any incident occurring. Each worker should fill the
Card (placed in designated places on site) whenever he notice an unsafe act or condition taking
place on workplace.

LOCATION

FURTHER CORRETIVE ACTIONS TO

PREVENT RE-OCCURRENCE

DESCRIPTION OF THE HAZARD

FOLLOW UP BY HSE
SUPERVISOR IMMEDIATE ACTION

INCIDENT NOTIFICATION
On site the first notification, imediatelly after occurrence,
shall be done verbally.
The notified person will evaluate the situation and take
appropriate action to protect personnel, the environment
and assets.

THE PROCESS
Worker / Employee

Incident

HSE Adviser / Discipline Supervisor

Near-Misses

Accidents /
High Potential Near Misses

Site Superintendent
Site Superintendent /
HSE Manager / Project Manager

RISK MATRIX
Purpose of investigation
Identify the immediate and underlying causes
Enable effective control measures to be developed.
Asses the potential consequence of all accidents / near miss establishing the urgency of response and level of
investigation required and prioritize corrective actions and implementation of control measures.

THE INVESTIGATION TEAM

Site Manager establish the preliminary Investigation level

Transmit the Initial Notification Form

Project Director and Project HSE manager review the consequences

evaluation

Final level of investigation (A, B,C) will be established considering the

worst case identified between the real consequence and the potential
risk

Level A

Level B

Site manager will appoint and

lead Investigation team with
the HSE Coordinator and/or
Discipline Supervisor.

The investigation team includes:

The Project HSE manager will

endorse the classification and
potential consequence of event

Company/Subcontractor Representative

Event Report

Project Director or his deputy

Project HSE manager or his deputy
Contractor Corporate Representative
Others (experts)

Level C
The investigation team shell be
defined jointly with Construction
Business Units managers and
Integrated Projects Senior Vice
President in consultation with
relevant Functions of Contractor
Corporate Management (QHSE,
Assets)

Accident Investigation Report

ACCIDENT INVESTIGATION

Steps in accident investigation

1. Describe who was involved

1. WHO

2. Describe what happened

3. Establish a time line
4. Determine location of accident & all
factors
5. Establish a chain of events to
understand how the accident
occurred
6. Determine the cause & root cause

2. WHAT
3. WHEN
4. WHERE
5. HOW
6. WHY

GATHER THE INFORMATION

1. PEOPLE

2. PARTS

People provide sensory evidence. They are direct

or indirect witness to event.

Parts refer to physical evidence and could be a

failed process, equipment or tool; or relevant
PPE; or liquid and solid samples of the process
taken before and/or after the incident or any
piece of physical evidence considered relevant
to the incident.

Direct witness provides description of what they

saw, smelled, heard or felt, but also time frame of
the incident.
Indirect witnesses may contribute valuable
information leading up to incident and perhaps
during and after the incident which may shed light
on the causes.
Each witness must be carefully interviewed
written statement prepared.

and

3. POSITIONS

Visual examination, chemical analysis, non

destructive tests, mechanical tests are to be
used to examine the physical evidence to
determine the cause of failed part or process
upset.
4. PAPER

Positions refers to placement and/or sequence of

events that occurred before, during or after the
incident. A plot plan must be prepared for
comparison to the official one on the file.

Refers to standards, technical documentation,

maintenance logs, information regarding the
training of personnel, JSA , Tool Box Talk files
or any other documents that could be related
to the incident are to be analyzed.

The positions of the PPE, emergency equipments

and personnel should be taken in consideration as
well.

All the documents represent background

information and could present the gaps into the
system

All the pieces of evidence must be organized and mapped

CAUSAL FACTORS IDENTIFICATION

Direct causes

Underlying causes
Unsafe acts
Unsafe conditions
Root causes
Personal factors
Job Factors

Critical factors are those events or conditions that if eliminated, either would have prevented the
incident or reduced its intensity.

DIRECT CAUSE vs. ROOT CAUSE OF THE ACCIDENT

CAUSE OF THE ACCIDENT

The cause of the accident should describe what the immediate symptoms are
of the accident.
Example: An employee slipped on the floor because there was spilled coffee
that made the floor slippery.

ROOT CAUSE
The root cause of the accident is the basic underlying reason, not always apparent, that
caused the accident.
Example: The root cause of the accident was that the person who spilled the coffee did not
clean it up or establish a warning method to alert others of a hazard.

INCIDENT MAPPING
A critical factors chart in the form of a timeline is developed using building blocks of incident
events and conditions. This is known as data mapping. Chart helps the investigators to
chronologically describe the events leading to the accident.

Events mapping

Creating root causes analysis

Direct cause

Underlying cause 1

Underlying cause 2

Underlying cause
Underlying cause

Underlying cause

Root causes

Root causes

Underlying cause

Underlying cause 3

Root causes

EXAMPLE
Example of Facts Gathering
On July 29, 1999, on or about 10:45 am, Joe Employee was stacking concrete blocks and walked
into a piece of steel re-enforcing bar that was protruding out of the end of the pipe storage
shelving unit located inside the Project Materials compound, striking him in the face. A 1 cut was
received across the middle of Mr. Employees forehead. He proceeded directly to the dispensary,
where he received 4 sutures to close the laceration, then was released at 11:41am in a full duty
status. He went to lunch, then informed his immediate supervisor of the incident upon returning
to work at 12:30.

Direct cause

The accident was caused by Joe not paying attention to his surroundings
and striking his head on the rebar.

Root Cause #1: Somebody didnt properly store the rebar and left it in a
haphazard state that was obviously unsafe.
Root Cause #2: The supervisor has not been taking responsibility for his
work area by monitoring for unsafe conditions.

DIRECT CAUSES OF THE ACCIDENT

SUBSTANDARD ACTS/PRACTICES

SUBSTANDARD CONDITIONS

Failure to follow rules and regulations

Inadequate guards or barriers

Failure to use PPE properly

Inadequate or defective Personal protective equipment

Operating equipment or machinery without authority

Defective equipment, machinery or tools

Incorrect use of equipment or machinery

Inadequate warning system

Using defective equipment or machinery

Adverse weather conditions

Failure to follow repair /maintenance instructions

Poor housekeeping

Failure to warn

Congestion or restricted action

Failure to secure

Inadequate or excess illumination

Making safety device inoperable

Fire and explosion hazard

Improper position for task

Noise or temperature

Improper lifting, rigging, handling, storage

Radiation exposure

Horseplay or inappropriate behaviour

Inadequate ventilation

Under influence of alcohol and/or other drugs

Environmental conditions

Other substandard acts (specify)

Outdated standards, charts, and other documents

Other substandard conditions (specify)

ROOT CAUSES
Personal factors

Ergonomic

Physical capability
Mental/ psychological capability
Physical stress

Workload stress

Mental or psychological stress

Knowledge / training
Skill level
Behaviour

Lack of design

Job factors
Management/ Supervision / Employee leadership
Standards, policies, procedures (PSP)

Confusion requests

Communication
Training
Engineering , design
Purchasing, material handling and material control
Contractor selection
Maintenance
Tools and equipment
Excessive wear and tear
Abuse or misuse

S.M.A.R.T.E.R. CONCEPT FOR CORRECTIVE ACTIONS

An accident investigation report must include corrective actions meant to stop the recurrence of
those kind of events.
Often these corrective actions are mainly oriented on three
standard directions
Discipline

But

Training
Procedures

Lets think SMARTER when we analyze and settle the

corrective actions for prevention of accidents recurrence
Specific

- specify the exact corrective action to be implemented: Who will do what when?

Measurable - fix exact date for applying the corrective actions and check if they are really working : When is done
and if is working?

Accountable - who is the responsible person for implementing the corrective actions and clearly define the due date.
Reasonable - what are the costs for implementing the specific corrective actions: is the corrective action practical?
Timely

Effective

- the corrective actions must prevent or significantly reduce the odds of the accident recurring.

Reviewed

are the corrective actions soon enough established to produce consequences or to reduce risks while
corrective actions are being implemented?

- the corrective actions must be reviewed after an established period of time in order to see if they have
produced the expected effect or need improvement.

REPORTING
The following principles for the preparation of an Incident Investigation Report shall be adhered to:
9

The report should be factual, concise and conclusive;

Unsubstantiated speculation should be avoided at all times;

Interpretations of findings should be based only on the facts as identified in the investigation;

Where events and conditions are listed in the report but are not essential pre-conditions for occurrence of the
incident these should be clearly identified;

An assessment of underlying root causes should be made, based on an analysis of the evidence;

Where events or conditions are listed, that are not critical for the incident to have occurred, this should be
clearly indicated;

The report should be readable as a stand-alone document. References to other documents not in the public
domain, i.e. not readily open to inspection by others, should be avoided;

All previous drafts of the report should be destroyed;

An audit trail of the documents relevant to the incident and the report should be established;

The team leader should ensure that all documentation collected during the investigation and preparation of the
report is properly filed;

The final copy of the report may include a confidentiality statement.

ACCIDENT INVESTIGATION FORM

Site identification

Type of injury

Injured person details

Description of the accident

Accident analysis

Accident Investigation

Root Causes of the accident

Corrective actions

Level B and C of Investigation

It is prepared by the Investigation Team
and
contain
all
findings
and
recommendations.