INCIDENT INVESTIGATION AND REPORTING Revision Date: 1 … 7/RTSOG 07... · 2019-07-04 · INCIDENT INVESTIGATION AND REPORTING Revision Date: 1 March 2018 Review Date: 01 April 2021

INCIDENT INVESTIGATION AND REPORTING

Revision Date: 1 March 2018 Review Date: 01 April 2021

RTSOG 7 ROAD TRANSPORT SAFETY OPERATION GUIDE

Engen Petroleum Limited Health, Safety, Environment and Quality Division Safety And Quality Centre of Excellence, Land Transport Safety

Engen Division: Supply and Operations

Procedure Title: Incident Investigation and Reporting

Document Number: RTSOG 7

Next Revision Date: 1st April 2021

Role Review Team Member Designation Date Signature

Review

Review

Dale Braum W Murdzaffa B W Mahmud

HSEQ Systems Specialist

Head Land Transportation DBE

Review

Review

Sandra Redelinghuys

Yastheel Sheochand

HSEQ Ops and Safety

Risk Management and Emergency

Specialist

Review Dale Braum RT Safety Specialist

Role Review Team Member Designation Date Signature

Approver


Incident Investigation and Reporting Page Issue Date2 of 35 Revision1

Aug 2017 01

SME: HSEQ Systems Specialist OWNER: HSEQ Business Partner Review Date 1 Apr 2020

RTSOG 3.5.07 ROAD TRANSPORT SAFETY OPERATION GUIDE

MODULE 7


1.0 INTRODUCTION

Incident Notification and Reporting is essential to Engen to protect company interest. The company

will act in accordance with Engen’s Incident notification procedure, any minor road accident, minor

product spillage, lost time injury, permanent disability, the company is to notify Engen as soon as

practical, must be within 24 hours. Engen Policies and Guidelines require that all incidents be reported

and investigated in accordance with an established timeframe and format.

2.0 SCOPE

This Module provides the procedures and tools required to notify and report any incident involving

BTO and road tankers. The Module includes:

Engen (Incident Notification, Reporting and Investigation Procedure)

Incident Verifications Questionnaire

Notification templates (i.e. SMS, INF) and contact numbers

Incident Classification

Incident Investigation Checklist

Incident Investigation Process Flow

Incident Investigation Report Format

Engen i-HSE

Incident Recommendation and Implementation

The requirement stated in this module will take precedence if contradictory to PTS requirement.

3.0 EXPECTED RESULT

The continuous use of this procedure should result in the reporting, investigation and analysis of all

incidents and significant near missed of BTO and RT Contractors and provide for an effective

mechanism for sharing lessons learned from these incidents with other Haulers and other Functional

groups within the ENGEN /PETRONAS organization.





3.1 Incident Verification Questionnaire

Below questionnaire is use to assist the company to get the initial information on the incident. The

information need to be converted to an SMS notification to Engen Management. This is crucial as

the company need to get the initial information as correct as possible to identify the initial rating

of the incident with consultation of HSE personnel. These initial rating is important as different

rating will get different involvement and treatment of investigation reporting.

No. Questions Remark

1 Date and local time of incident

2 Location of incident (i.e. which road, which bound?)

3 Truck number and size

4 Product grade and quantity carried (if laden)

5 Where does the BTO heading to?

6 BTO and company name

7 Nature of incident, i.e., what happened?

8 Number of parties and injuries involved

9 Type of injuries

10 Where does the injured get sent to? (if any)

11 Name of clinic or hospital?

12 Damage to road tanker? Where?

13 Damage to 3rd party vehicle? Where?

14 Type of 3rd party vehicle involved?

15 3rd party vehicle registration number?

16 Any spillage? How many litters (estimated)?

17 Any fire? How severe was it?

18 Any reporters or media coverage?

19 Any authorities at site?

20 Where to lodge police report?

21 Who received the summons?

RT Contractor may also refer to GPS live tracking location report in the website to confirm on the

location and time of the incident. Nevertheless, RT Contractor must also ensure that the road



Aug 2017 01



tanker, BTO, 3rd parties and publics involved at the incident site are not at risk before BTO can

answer all the questions above.

3.2 SMS Notification Template

SMS notification is an initial incident reporting. Thus, it may not need to be contain all the details

to be used in the final report. However, RT Contractors need to verify all details from the GPS live

tracking report on the website prior sending the notification to Engen. The SMS need to reach

Engen within 1 hour of the incident or as soon as RT Contractor get the information. Below is an

SMS notification template for initial reporting to Engen;





4.0 INCIDENT NOTIFICATION

4.1 Engen Notification Process

4.1.1. Immediate Incident Notification

1.

The Incident Owner shall report all Major incidents to Engen Senior Management and PETRONAS

Communication Centre (COMCEN) using the Immediate Notification Form (INF) within 1 hour of the

incident occurring.

2. The Incident Owner shall ensure that the INF is completed and sent through to the Corporate HSEQ

(CHSEQ) HSEQ Business Analyst for vetting.

3. Once the INF has been vetted, the HSEQ Business Analyst sends the form to PETRONAS COMCEN via email.

4. In all cases the relevant people shall be notified as per Annexure 1.

5.

The Incident Owner shall immediately after a Major incident has been contained, update the INF to

include HSE Stand Down information (i.e. Time and Incident status) and send to CHSEQ for Submission

to PETRONAS COMCEN.

6. The CHSEQ Business Analyst shall send the INF updated with the HSE Stand Down details to PETRONAS

COMCEN via email.

4.1.2. Notification to the Authorities

1. All incidents requiring notification to the Authorities shall be approved by the relevant Line Manager.

2. Incidents shall be reported by the Incident Owner to the relevant Authorities as per the prescribed

regulatory timeline requirements.

3.

As a minimum, the following information shall be included:

• Time, location and nature of the incident

• Persons injured

• Equipment damaged

• Any other relevant details



Aug 2017 01



4.1.3. iHSE Reporting

1. The person observing or involved in the incident shall report the incident to the Supervisor/

Responsible person on duty by the end of the shift or within 24 hours of the incident occurring.

The Supervisor/ Responsible person on duty must assign a trained Incident Logger and ensure the incident is captured on the iHSE System by the end of the shift or within 24 hours of the incident occurring.

Note: All incidents are to be managed using the iHSE system

3. A trained Incident Logger shall log the incident details on the iHSE system.

4.

If an Incident occurs at a site not linked to the Engen IT system and server (e.g. Retail or

Commercial site), the incident must be reported to the relevant Engen Manager or Responsible

person to log the incident by the end of the shift or 24 hours of the incident occurring. Where

practicable, the Engen Manager or responsible person will notify an Engen employee who does

have access to the iHSE system to log the incident.

5.

The Incident Owner (i.e. The asset owner) shall review the initial notification for correctness

and where an investigation (i.e. Root Cause Analysis (RCA) is required, shall approve the incident

notification in iHSE with further Investigation.

6.

All Major and/ or potentially Major Incidents shall be reported to relevant Engen Senior Management.

Note: The Engen Senior Management Distribution list shall as a minimum be as per Annexure 1

- Summary of Requirements for Incident Classification and Reporting





4.2 Incident Notification Form

This form will be used to notify Engen of any incidents. The actual form is attached in Annexure 5



Aug 2017 01



4.3 Incident Rating

All incidents shall be rated based on the Incident Rating Descriptors in Annexure 3.

1. The rating shall be based on the highest rating on the impact of the incident to People, Environment

and/or Loss of Primary Containment (LOPC), Asset, Reputation.

2. Incidents with Ratings 1 and 2 identified to have the potential to lead to more severe consequences with

higher Incident Ratings (3, 4 and 5) should be flagged as “High Potential Incident”.

3. Depending on the information and description of the incident, PETRONAS GHSE in consultation with

CHSEQ may review the incident rating.

4.4 HSE Alert

An HSE Alert shall be prepared and disseminated within the Engen Business within 3 working days of the incident

occurring so that other facilities are alerted on similar potential hazards at their sites.

Incident Rating Action by Action Detail

1 Incident Owner Site Manager shall decide how the HSEQ Alert will be shared at

the site (e.g. Via Toolbox Talk, HSEQ Alert Template, etc.).

2 Incident Owner Populate HSEQ Alert Template and ensure that it is shared

across divisions.

3 to 5 Incident Owner Populate HSEQ Alert Template and submit to CHSEQ .

3 to 5 CHSEQ Verify HSEQ Alert content and submit to PETRONAS COMCEN

within 3 working days of the incident occurring.





4.5 Site Preservation

Ideally as little time as possible should be lost between the moment of an incident and the beginning of the investigation. The site (i.e. any plant, substance, structure or thing associated with the incident) should be preserved until at least a preliminary investigation takes place.

It may, however, be necessary to clear the area or rectify problems in order to minimize the

consequences, eliminate the hazards or facilitate emergency response operations. In such cases, the

following should be done by the Site Manager/ responsible designate.

1.

Open a case file with contents as follows:

• iHSE incident details

• GPS Coordinates of incident

• Immediate Notification Form

• Terms of Reference for the incident investigation

• Statements

• Authority and other reports and correspondence

• Photographs and/ or diagrams

• Other relevant information

2. Relevant evidence (e.g. specific data, delivery timesheets, etc.) that might be helpful in the

investigation shall be preserved.

3. Barricading the scene, in the case that local legislation may prescribe that nothing be moved

without prior permission from authorized persons.

5.0 INCIDENT REPORTING

5.1 Incident Investigation Checklist

When conducting an investigation, it is important for the team to identify root cause and

preventive measures to be shared as lesson learnt across the operations in Engen. Below is the

checklist as a guideline. Please refer to Annexure 2 for actual checklist.

Required Actions Description

Evidence/Data Collection Phase Investigation Team


Incident Investigation and Reporting Page Issue Date10 of 35

Revision1 Aug 2017 01



Define ending condition of the incident.

Identify parties involved in the incident.

(People whose actions either caused or contributed to the severity of the incident.)

Record condition of parties involved (latest condition, name of hospital)

Identify witnesses (Name and contact number)

Take photos/video of the incident /accident site.

Photographs/Video should include:

All vehicles involved in incident. (Try and capture coverage of vehicle /equipment / facility damage)

General area around the incident site (Try to highlight hazards/ unfavourable site conditions, anything unusual)

Prepare a detailed sketch of the site (try to highlight all the important items)

Review condition of toad (e.g. Uphill/downhill or bend)



Obtain On-board Trip Computer (OTC) and GPS record

Analyse OTC as soon as possible and provide a report of the findings to the investigation team leader. (Try to get the second by second report)

Check GPS records if there is a sign of overwork or fatigue (Try to capture 7 days before the accident happened)

Other pertinent documentation

For crossovers and spills, obtain loading and delivery documentation (Try to get the relevant form to determine whether it was completed correctly)

Interview other witnesses, if available

Take signed statements if possible.

At a minimum, try and obtain names and contact details.





Review BTO hand phone

Check when was the last call made or received

Evidence of SMS while driving

Obtain the Drug and Alcohol (D&A) test result, if available

• Check if BTO was positive drug and alcohol (Try to bring BTO to the nearest clinic within 4 hours of the incident)

Obtain copies of Police or other government agency reports, if applicable.

• Identify report conclusions/finding of fault, who received summon from police, etc.

• Review training records (Try to get the hardcopy for evidence)

• Determine last relevant training conducted. • Review results of past BOS

• Review results of past Competency evaluations.

Review road tanker Maintenance and Repair Record (Try to get the hardcopy for evidence)

• Check maintenance records of vehicle

• Any major repair for the past few months

• Any repetitive repair or breakdown

• Review defect reporting

• Check related equipment for working condition (e.g. brakes, tyres, physically)



Develop initial assumption

• After asking the How, Where, When, Why, Who? (Should

be manageable items)






Verify assumption

• Plot sequence of events (Try to get 7 days before accident)

• Test for logic of identified event in time and space. • Test for missing or unclear information • Test for technical difference.

Note: Verification must always be compared to Smith System Defensive Driving

If initial assumption holds up, then:

• Identify direct causes of each event leading up to the incident.

(Significant causes that led to the ending state of the incident. If those causes did not happen, the incident would not have occurred).

Prioritize direct causes. (Should start with High, Medium, Low)

For each Factor, ask Why did that event occur?

Ask Why At least 5 times to get the answer

Prioritize Root Causes. (Should start with High, Medium, Low)

Develop recommendations to mitigate or prevent root causes from contributing to other incidents.

• Assign priorities of High, Medium, or Low to recommendations.

6.0 ACCIDENT PRESENTATION TEMPLATE

RT Contractors are required to provide details of the incident in a presentation pack (Microsoft Power

Point format). Engen will call for an investigation session which RT Contractor and BTO are requested

to attend to present their findings. An approved presentation material will then be shared by the

respective RT Contractor during the bi-monthly Fleet Operation Meeting. The presentation reporting

format is as shown below;





Page Number Details

1st Page

Title of Accident

Date and Place of Accident

Date and Venue of Presentation

2nd Page

Name of Fleet Manager

Base of RT and BTO

Number of years working for Engen

Road Tanker Registration Number

Model

Age of RT

BTO Name

Age of BTO

Last Drug & Alcohol Test

Last Medical check up

No of year of experience

Last DDC attended

3rd Page

Incident Description

Date/Time of Accident

Location of Accident

Weather during the Accident

Type of Road

Injury / Damages to BTO and 3rd party

4th Page

Chronology of event 5 days before the accident

Chronology of event during the day of accident

5th Page 7 days working hours

6th Page

OTC/GPS analysis (e.g. Last 60 second, max speed, distance travelled, continuous

driving)

7th Page Re-enactment of the Incident

8th Page Pictures of the Accident

9th Page Incident Findings

Incident Probable Cause






Incident Recommendation

6.1Major Investigation Report

The final report is the tool used to record the relevant information of an incident and to document direct

and root causes, preventive and mitigation recommendations and follow-up and closure action.

Investigator may use the format below in the final reporting.

TABLE OF CONTENTS

No CONTENT REMARKS

1.0 EXECUTIVE SUMMARY

(a) Description

(b) Probable Cause(s)

(c) Immediate Penalty

Action by Hauler

(d) Recommendation(s) &

Investigation team to provide the

description of the incident, what had

caused the incident, immediate action

taken to RT Contractor and

recommendation of the incident.

2.0 PROFILE Profile of road tanker, BTO and RT

Contractor

3.0 DETAIL OF INJURY AND DAMAGE Injuries to the BTO , 3rd parties, and

public (if any) and damages to the road

tanker, 3rd parties vehicles and public

properties

4.0 BACKGROUND OF ACCIDENT Description of the incident

5.0 SEQUENCE OF EVENT Must be 7 days prior to accident. BTO delivery schedule for the past 7 days? Refer to GPS location report.

6.0 INVESTIGATION FINDINGS Findings on the BTO (e.g. working hours

for OTC/GPS analysis), road tanker (e.g.

inspection and M&R reports)and others

findings related to the incident





7.0 PROBABLE CAUSE Most probable cause on how the incident

happened

8.0 RECOMMENDATION TO PREVENT

RECURRENCE AND IMPROVEMENT

Investigation team to recommend items to

prevent the incident and gab for

improvement.

9.0 CONCLUSION Investigation team to conclude the

findings

10.0 ATTACHMENTS

Attachment 1: Incident Notification Form

Attachment 2: Police Report

Attachment 3: Medical Report

Attachment 4: Re-enactment of Incident

Attachment 5: Pictures

Attachment 6: GPS/OTC Movement Report

Attachment 7: Other Related Documents

to attach Incident Notification

Form

- to attach police report

- to attach D&A test result

- the drawing of how the actual incidents happened

- to attach pictures of incident

- to attach all GPS/OTC report

- if any

6.2 Tips to write an investigation report

Below tips shall assist investigation team on how to write a good accident report;

Avoid provocative language

Focus on the manageable areas

Recommendation items should be achievable on time

Mark report " Draft, subject to further review"

Incorporate Legal comments and finalize report

6.3 iHSE

The endorsed investigation report shall be updated into iHSE system by investigation team for filing

and tracking purposes. The action parties shall update iHSE system on action progress or

completion to avoid overdue action. The system will automatically alert the action party, superior

and up to Engen Senior Management through e-mail for prolonged overdue of action items. The

investigation team shall work with Business Lines/Support/Region to assign the responsible party






to implement the recommendations. Recommendations to be discussed on a formal basis with RT

Contractors for agreement on the action required and the time-schedule for implementation and

to be updated in i-HSE by investigation team.

6.4 Below chart shows how the i-HSE process takes place when there is an incident reporting.

6.5 Below is an example of the online i-HSE page in the website.





7 NEAR MISS REPORTING

7.1 Introduction

A Near Miss Event is one that had a likelihood of resulting in injury or property damage but did not

because of luck or some other intervening factor. Near misses are unique because they give us a

second chance to correct dangerous behaviours or conditions before they result in future injury or

property damage. A near miss may also highlight the importance of PPE, safety rules and safety

procedures which has been implemented in RTSMS.

7.2 Reporting Guideline

The BTO should describe the event as accurately as possible. They should include any fact or

observation relevant to the event. If any equipment is involved, the type of equipment is important.

If a process is involved, the employee needs to describe the steps that led up to the event. If the

event is an act of nature or 3rd party, try to list as much relevant information as possible. The

submitting employee is encouraged to recommend a corrective action they feel would eliminate

the hazard or condition to the investigator.

The investigator must complete the corrective action portion of the report. A brief plan or

procedure must address the hazard/condition and the corrective measures that will be taken. The

investigator will sign and date the report to be filled out completely with sufficient information to

allow managers to investigate and address the issues raised.

RT Contractor will include Near Miss Reports on the daily toolbox meeting and in the Incident

Report statistic. The reports will also be summarized for RT Contractor Monthly Safety Committee

Meeting and to be shared during Fleet Operation Meeting with others Road Transporters

7.3 Closure of Near Miss Reporting

RT Contractors need to acknowledge all employees that submit a near miss report. This may

directly encouraged others BTO to report a near miss incident. Every effort should be made to

make near miss reporting, investigation, and follow-up pro-active and positive. It is the objective

of this program to learn from near miss events and to make the appropriate corrections to avoid

future incidents.

8 IMPLEMENTATION OF RECOMMENDATION

8.1 Letter to Road Transport Contractor






Engen will issue an official letter to RT Contractor based on the finalized recommendations by the

higher management of Engen to be implemented per agreed timeline. RT Contractor need to reply

the email together with the implementation plan and status.

8.2 Lessons Learned

Road Transport Contractors are responsible to share the incident with all BTO as lessons learn

during toolbox meetings.





ANNEXURE 1: ROLES, RESPONSIBILITIES & COMPETENCE OF INVESTIGATION TEAM

ROLE RESPONSIBILITIES COMPETENCE

Team Leader

Steer the investigation in line with the Term of Reference

Assign tasks to team members

Identify, discuss and resolve the key

issues as they are raised by the team

Identify required resources e.g.

facilitator, technical specialist

Minor Incident: Trained in incident investigation or at least one

of the investigation tools (e.g. RCAT)

Major incident:

• Trained in incident investigation (i.e. Taproot)

• Experience participating in an

investigation for a major incident (at

least as a team member)

Team Member

Obtain evidence and reference to support the investigation

Conduct site inspection

Carry out interviews

Analyse findings and provide

recommendation

Trained in incident investigation or at least one

of the investigation tools (e.g. RCAT, Taproot,

etc.)

Scribe

(may be from

one of the team

members)

Assists investigation team in

consolidating interview statements,

preparing reports and presentation

Familiar with the requirements of this

Procedure and PTS 18.06.01

Facilitator

(as required )

Guide the investigation process

Facilitate discussions

• Trained as a facilitator or trainer for

incident investigation • Experience participating in incident

investigations (at least as a team

member )






ANNEXURE 2: INCIDENT CLASSIFICATION CRITERIA HARM TO PEOPLE

Class Rating Description

Minor

1

“No Treatment” Case or First Aid Case.

Occupational Illnesses that result in noticeable discomfort, minor irritation or transient

effects after exposure stops.

2

Medical Treatment Case.

Lost Workday Case or Restricted Work Case, where the duration equals or less than 4

calendar days.

Occupational Illnesses with reversible health effects such as food poisoning and acute

dermatitis

Positive biological/biological effect monitoring result without permanent effect to health.

Major

3

Lost Workday Case or Restricted Work Case, where the duration exceeds 4 calendar

days.

Injury which result in Permanent Partial Disability.

Occupational illnesses with irreversible health effects which result in Permanent Partial

Disability such as occupational noise induced hearing loss, chronic back disorder or

repetitive strain injury.

4

Fatality due to injury or occupational illness.

Injury which result in Permanent Total Disability.

Occupational illness including cancer with irreversible health effect which result in

Permanent Total Disability such as asbestosis, silicosis and heart or kidney failure due

to chemical exposure.





5

Fatalities due to injury or occupational illness. Occupational illnesses (including cancer to affected workers exposed to similar hazard

in the same Operating Unit) with irreversible health effect which result in Permanent

Total Disability such as asbestosis, silicosis and heart or kidney failure due to chemical

exposure.

ANNEXURE 2: INCIDENT CLASSIFICATION CRITERIA (cont’d)

ASSET DAMAGE


Minor

1 Direct damage cost less than USD 25,000

2 Direct damage cost from USD25,000 to USD 99,999

Major 3 Direct damage cost from USD 100,000 to USD 999,999

4 Direct damage cost from USD 1,000,000 to USD 9,999,999

5 Direct damage cost is equal or greater than USD 10,000,000

Direct Cost: Cost directly attributed to the incident, such as the replacement value of equipment lost, product loss,

and cost of repairs, clean up, material disposal, emergency response and/or fines.

Direct cost does not include indirect costs, such as business opportunity losses, loss of profits due to equipment

outages, cost of obtaining or operating temporary facilities or cost of obtaining replacement products to meet

customer demand.

Direct damage cost does not include the cost of the failed component leading to the incident, if the component is not

further damaged by the fire or explosion






ANNEXURE 2: INCIDENT CLASSIFICATION CRITERIA (cont’d) ENVIRONMENTAL

EFFECT

CLASS RATING ENVIRONMENTAL IMPACT

Minor

1

Slight Impact Release that comes into contact with soil or water, still confined to the area of the source

of the release and with insignificant adverse effects to the environment.

Examples: Oil/chemical leakage within an unpaved ground in the process area that result in limited

staining on the ground with no stress vegetation observed. There is also no evidence of

access to the groundwater. The leakage has not gone into the storm water drains.

2

Minor Impact

• Release that comes into contact with soil or water, no longer confined to the area

of source of the release but still confined to the company site, resulting in limited

and transient effects to the environment. The effect does not impair the beneficial

use of the environment for the other users.

• Emission or discharge from regulated/permitted source, with a single breach of a

company/other standards but does not exceed any regulatory standards.

Examples:

• Oil/chemical leakage that is not only on unpaved ground in the process area, but

it has gone into the storm water drains, but still contained within the company site.

There is also no evidence of access to the groundwater.

• Produced water quality has exceeded the internal limit for oil and grease. • Treated effluent quality from the Industrial Effluent Treatment System (IETS) has

exceeded the internal limit for COD, if any.

Major 3

Localised Impact

• Release that is no longer confined to the company site, resulting in disruption with

transient effects to the beneficial use of the environment. Evidence of off-site

environmental effect or damage (e.g. vegetation damage, fish kill, groundwater

contamination) but over a limited area.

• Emission or discharge from regulated/permitted source, exceeding regulatory

standard.

Examples:





• Oil leakage resulting in soil and groundwater contamination that migrate to

neighbouring property but does not affect beneficial uses of soil and groundwater

such as potable water supply.

• Spill of oil/chemicals into public drain or adjacent stream resulting in fish kill, but no

significant disruption or loss of beneficial uses of the stream, or loss of sensitive or

protected species.

• Produced water quality has exceeded the regulated limit for oil and grease. • Treated effluent quality from the Industrial Effluent Treatment System (IETS) has

exceeded the regulated limit of COD.

• Stack emission quality for NOx has exceeded the regulated limit.

4

Major Impact

• Release reaching the environment which results in significant disruption of or

impairment to beneficial uses of the environment and/or to public receptors.

Evidence of severe environmental damage such as:

• it is widespread and detectable for some distance beyond the company site; or • becomes sub-standard or unfit for one or more purposes including

supporting normal wildlife populations; or

• interference with other users causing loss of earnings, public health impact or

claims

• Require extensive measures or larger scale effort to restore the contaminated

environment to its original state or risk based approach acceptable level.

• Emission or discharge from regulated/permitted source, with extended or repetitive

breach of regulatory standard with possible legal penalty or prosecution.

Example:

• Oil spill beyond the company site causing significant disruption to commercial fish

farming, or port operations, or other water recreational activities.

• Surface water contamination causing domestic and commercial water supply

disruption to regional population and business activities over several days.

• Groundwater contamination from an underground tank of a petrol station affecting

adjacent community drinking water well.

• Treated effluent quality from the Industrial Effluent Treatment System (IETS) has

exceeded the regulated limit of COD for several days and Department of

Environment (DOE) has issued out the compound.

5 Massive Impact

• Release reaching the environment over designated areas of ecological

importance or an extensive area which results in:

• Significant loss of beneficial uses of the environment and/or loss of public

receptors; or






• Loss of rare, endangered, threatened and endemic species. • Irreparable/long term damage/ widespread environmental effects. • Emission or discharge from regulated/permitted source, with extended or

repetitive breach of regulatory standard resulting in legal penalty/prosecution with

possible total shutdown of facility.

Examples:

• Crude oil spill affecting a large area of sensitive mangrove estuarine with loss of

protected species or critical habitat in that area.

• Contamination of surface water causing loss of sole water supply source for

community and business activity over extended period or inability to sustain

beneficial use of environment.

• Treated effluent quality from the Industrial Effluent Treatment System (IETS) has

exceeded the regulated limit of COD for several weeks and Department of

Environment (DOE) has taken up the noncompliance as a court case for fine.

ANNEXURE 2: INCIDENT CLASSIFICATION CRITERIA (cont’d) IMPACT ON REPUTATION

CLASS RATING DESCRIPTION

Minor

1

Slight Consequence

• Public awareness may exist, but there is no public concern

• Trust questioned – but recoverable speedily

2

Limited Consequence

• Local public concern or complaints • Local media and/ or local political attention with potentially negative

consequence for company operations

• Trust dented – recoverable with time and good Public Relations

Major 3

Considerable Consequence

• Regional public concern. Extensive adverse attention in local media • National media and/ or regional political attention resulting in negative

consequence on company operations.

• Adverse stance of local government and/ or action groups • Trust diminished – recoverable at considerable cost





4

National Consequence

• National public concern. Extensive adverse attention in the national media • Regional/national policies with potentially restrictive measures and/or

consequence on grant of licences.

• Mobilisation of pressure or action groups

5

International Consequence

• International public attention. Extensive adverse attention in international media • National/international policies with potentially severe consequence on access to

new areas, grants of licences and/ or tax legislation

• Trust completely lost – not recoverable

ANNEXURE 2: INCIDENT CLASSIFICATION CRITERIA (cont’d) LOSS OF PRIMARY CONTAINMENT (LOPC)


Minor

1

Slight Release Release below Tier 2 threshold quantity as per API 754 (i.e. R1 < Tier 2 threshold

quantity)

2

Minor Release

Release equal to or above Tier 2 threshold quantity, but below Tier 1 threshold quantity as

per API 754 (i.e. Tier 2 threshold quantity ≤ R2 < Tier 1 threshold quantity)

Major

3

Local Release Release equal to or above Tier 1 threshold quantity as per API 754, but below 10 times the

threshold quantity (i.e. Tier 1 threshold quantity ≤ R3 < 10 x Tier 1 threshold quantity)

4

Major Release Release equal to or above 10 times the Tier 1 threshold quantity as per API 754, but below

100 times the threshold quantity (i.e. 10 x Tier 1 threshold quantity ≤ R4 < 100 x Tier 1

threshold quantity)

5

Extensive Release Release equal to or above 100 times the Tier 1 threshold quantity as per API 754 (i.e. R5 ≥ 100 x Tier 1 threshold quantity)






ANNEXURE 2: INCIDENT CLASSIFICATION CRITERIA (cont’d)

Threshold Release Category

Source: Process Safety Performance Indicators for the Refining and Petrochemical Industries, ANSI/API

Recommended Practice 754, First Edition, April 2010





ANNEXURE 2: INCIDENT CLASSIFICATION CRITERIA (cont’d) PRODUCT CONTAMINATION INCIDENTS

Table 1 – Internal Incident (Occurring at Engen Premises)


Minor

1

Small Contamination

Net volumes of Contaminated product Below volumes of 12000 litres

2

Medium Contaminations

Net volumes of Contaminated Product Between volumes of 12000 and

50000 litres

Major

3 Large Contaminations

Volumes between 50000 litres and 500 000litres

4 Volumes Exceeding 500 000 litres.

5 Included in 4

Table 2 – External Incident (Occurring at Customer Premises


MINOR 1 Small Contamination

Net Contamination incident value < R 100 000

2 Small/Medium Contamination

Net Contamination incident value between R 100 000 and R 1 000 000

MAJOR

3 Medium Contamination

Net Contamination incident value > R 1 000 000 - R 10 000 000

4 Large Contamination

Net Contamination incident value > R 10 000 000

5 N/A






Table 3- Special Cases


INCLUSIONS

Contamination or Non

Conformance Jet A1

3 Any contamination or non-conformance related to handling, transport and

documentation of Jet A1 within Engen control should be investigated

due the high risk of non-compliance

Contamination of

Kerosene with gasoline

3 – Due to the potential for reputational harm and injuries to public this should

be treated as at least a major

Legal non-compliance 3 Dosing of IK related products, /complaints relating to Product not meeting

specification. Highlighted by a Notice served by Government.

Water Table Water which is present in product that is not as a result of process – e.g.

Washings and flushing’s shall be considered a contamination and the

contamination rating based on the values given in Table 1 and or Table 2

EXCLUSIONS

Water None Where water is present as an inherent part of the process, it is not

considered a contamination (e.g. from condensation)





ANNEXURE 3: HSE ALERT

APPENDIX 6: HSE ALERT TEMPLATE

REF: CLICK HERE TO TYPE REFERENCE NUMBER

CLICK HERE TO TYPE TITLE

• BRIEF DESCRIPTION OF THE INCIDENT

Click here to begin typing

• RECOMMENDATIONS


• CONTACT

Click here to type Name

Click here to type Designation, Group HSE

Click here to type Email





REVIEW STATUS AND APPROVALS

CLICK HERE TO TYPE TITLE


Name/Designation Date Sign-off

Preparer Click here to type Name Click here to type Designation ,Group

HSE

Click here to

select date

Communications Review

Completed Adam Syeed Sultan Head, Communications/KM, Group HSE

Click here to

select date

HOD/SME Review

Completed Click here to type Name Click here to type Designation ,Group

HSE

Click here to

select date

Legal Review


Legal

Click here to

select date

Approved for Release Dr. Bea Ponnudurai

Head, Group HSE Click here to

select date

Published and Closed Adam Syeed Sultan Head, Communications/KM, Group HSE

Click here to

select date





ANNEXURE 4: HSE LESSONS LEARNED TEMPLATE

REF: CLICK HERE TO TYPE REFERENCE NUMBER TYPE OF INCIDENT : Click here to begin typing LOCATION OF INCIDENT : Click here to begin

typing DATE OF INCIDENT : Click here to select date

• BRIEF DESCRIPTION OF INCIDENT


• OUTCOME


• ACTIVE FAILURES


• KEY FINDINGS

1. Click here to begin typing

LESSONS LEARNT

1. Click here to begin typing 2.





Click here to type photo caption

CONTACT

Click here to type Name Click here to type Designation, Group HSE Click here to type Email





REVIEW STATUS AND APPROVALS

HSE LESSONS LEARNT

CLICK HERE TO BEGIN TYPING


Name/Designation Date Sign-off

Preparer Click here to type Name Click here to type Designation ,Group

HSE

Click here to select date

Communications Review

Completed Adam Syeed Sultan Head, Communications/KM, Group HSE

Click here to

select date

HOD/SME Review


HSE

Click here to

select date

Legal Review


Legal

Click here to

select date

Approved for Release Dr. Bea Ponnudurai

Head, Group HSE Click here to

select date

Published and Closed Adam Syeed Sultan Head, Communications/KM, Group HSE

Click here to

select date





ANNEXURE 5:

Incident Date: Reported by:

Incident Time: Incident: Process: Non-Process

Nature of Incident : Near Miss/Near Hit Lost Profit Opportunity Fire/Explosion Non Work-related Injury/Illness Injury/Illness Quality Asset Damage or Loss Security Breach Community Complaint Transportation

LOPC/Environment (incl Emission/spill)

Direct Cause Sub Direct Cause

Asphyxiation Oxygen Deprivation Drowning Confined Space Other

Biological Poisoning Animal Attack/Insect Bite Infection Disease Others

Caught Caught on Caught Between Caught In Others

Crime Trespassing Theft Burglary Threat Sabotage Hijack Others

Energy Electrical Fire Explosion Lightning Water Others

Ergonomic Exertion Bodily Reaction Others

Exposure/Contact Exposure to Substance/Sources of Energy Exposure to {Contact} by Substance/Sources of Energy Exposure to {Contact} with Substance/Sources of Energy Others

Fall Fall from Height/Fall to Below Fall to Surface/Slip & Fall/Trip & Fall

Others Illness Sudden Collapse Others

Integrity Failure Equipment failure Structural Failure Others

Loss of Containment Overflow Spill Leak Others

Nature Flood Earthquake Tsunami Landslide Strong Wind/Tornado/Hurricane Others

Quality/Non-conformance Customer Internal Product Service Supplier Others

Struck Struck/Hit By Struck/Hit Against Punch Through/Nip Others

Transportation Land Accident Aviation Accident Marine Accident Others

Other Sub Direct Cause

Incident Notification





Party Involved Contractor PETRONAS Group Third Party

Contracting Company if

Applicable

Activity Involved

Air Transportation Assemble/Dissemble Chemical Handling Confined Space Entry Diving Electrical Work Excavation Hydro jet Cleaning Hydro testing Land Transportation Lifting Loading/Unloading Manual Handling Other Radiography Routine Maintenance Routine Operations Scaffolding Sea Transportation Sports/Recreation Start-up/Shutdown Welding/Cutting/Sawing

Working at Height

Other Activity

Area where Incident

Occurred

Exact Location

Department Responsible

Title of Incident

Detailed Description (Who,

What, Consequences)

Immediate action taken:

Incident Owner or

Responsible Party

Is this a

Confidential

Incident?

1.0

yes

2.0

no

Reason: