..

INCIDENT INVESTIGATION
AND REPORTING

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 TABLE OF CONTENTS

1. INTRODUCTION....:.......................................................................................................... 3
2. ABBREVIATIONS ............................................................................................................. 3
3. DEFINITIONS.................................................................................................................... 3

0 4.
5.
RESPONSIBILITES......................................................................................................... 10
INCIDENT REPORTING AND INVESTIGATION............................................................. 13
6. INCIDENT INVESTIGATION ........................................................................................... 15
7. INCIDENT DATA BASE .................................................................................................. 22
8. MEDICAL REPORT......................................................................................................... 22
9. REFERENCES................................................................................................................
10. 23

10.1. ATTACHMENTS ............................................................................................................. 23

10.2. Attachment 1: Incident Preliminary Report Form ............................................................. 24
10.3. Attachment 2: Near Miss Report Form............................................................................. 25
Attachment 3: Emergency Contact List............................................................................ 26
10.4. Attachment 4: Investigation Format ................................................................................. 27
10.5. Attachment 5: Incident Reporting Flow Chart................................................................... 28
CONCURRENCE........................................................................................................................ 29
0
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Page 3 of29
 1. INTRODUCTION

1.1. Purpose

The purpose of this procedure is to identify;

1.1.1. Incidents and report in a logical manner through and including all relevant
information.

1.1.2. Establish effective immediate/basic and underlying causes.

1.1.3. Establish means to prevent recurrence.

0
1.2. Scope

This procedure covers the reporting, investigation, follow-up and close out of all type of
incidents related to RIIPED. It details what happened, the key lessons learned, the
recommendations and corrective action taken. It gives the guidelines on the methods
of analysing statistics. An HSE Incident Alert or HSE Incident Information will be raised
as appropriate.

2. ABBREVIATIONS

LTI Lost Time Incident

RWC Restricted Work Case
MTC Medical Treatment Case
FAC First Aid Case
MVA Motor Vehicle Accident
LTIR Lost Time Injury Rate
TRIR Total Recordable Incident Rate
0 SR Severity Rate

3. DEFINITIONS

Company Aramco Overseas Company B.V. and

Sumitomo Chemical Co. Ltd.

Petro Rabigh Company Rabigh Refining and Petrochemical Company

who is the owner of the existing facilities in
the Rabigh referenced as PRC.

Rabigh Phase II Petrochemical Project The Overall Expansion Development Project

in Rabigh which is managed by the Company,
referenced as Rabigh Phase II Project or the
Project.

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Project Procedure
 Incident Investigation and Reporting

Company Representative Aramco Overseas Company B.V. and

Sumitomo Chemical Co. Ltd. Representative
coordinating with different departments of
Petro Rabigh Company.

RIIPED Rabigh-11 Program Execution Department that

manages Rabigh Phase II Petrochemical
Project.

RIIPED HSE Team The team consists of RIIPED HSE Manager,

HSE Engineers and HSE Advisors who are

0 working in RIIPED HSE Office.

PMT Project Management Team

EPC Engineering, Procurement and Construction

HSE Health, Safety and Environment

Contractor(s) The Organization whom is awarded and

contracted to perform the work under this
Project.

Subcontractor(s) Organization(s) that provides services to

Company or Contractor.

3.1. Incident

An event or event sequence, whether it results in loss, injury, illness, disease or none of
these including food poisoning and communicable disease.
0 The following incident types are distinguished:

3.1.1 On-job fatality (FAT)

An on-job injury that results in fatality

3.1.2 Lost Time Incident (LTl)

An on-job injury that involves one or more days away from work beyond the day
the injury occurred.

3.1.3 Restricted Duty Injury Case (RDI)

An on-job injury that results in restricted work or job transfer. The employee cannot
perform an activity he/she regularly performs at least once a week (example: a
Page 5 of 29
 sprained ankle resulting in a reassignment from a field to a desk job for 5 days).
Does not include restricted work activity limited to the day of injury. Examples of
how to determine a restricted work case are:

3.1.3.1 Employee is kept from performing one or more of the routine functions
(work activities the employee regularly performs at least once a week) of
his/her job, or from working the full work day that he/she would otherwise
have been scheduled to work..

3.1.3.2 A physician or other licensed health care professional recommended that

the employee not perform one or more of the routine functions of his/her
0 job, or not work the full workday that he/she would otherwise have been
scheduled to work.

3.1.4 Medical Treatment Injury Case (MTI)

An on-job injury that is more serious than on-job First Aid Injury (FAI) (examples:
treatment requiring sutures, use of tweezers to remove splinters from eye, rigid
means to immobilize part of body).
MTI's include all case involving:

3.1.4.1. Using wound closing devices such as sutures, staples, etc.

3.1.4.2. Using devices with rigid stays or other systems designed to immobilize
parts of the body (does not include any non-rigid means of support).

3.1.4.3. Removing splinters from the eye with tweezers and other complex means.

3.1.5 First Aid Injury Case (FAI)

0 Minor on-job injury requiring one-time treatment and subsequent observations. The
treatment, even if administrated by physician, doesn't require medical or surgical
follow-up intervention {examples: Diagnostic procedures such as x-rays and blood
test. Treatments such as tetanus shots, bandaging, using eye patches, hot or cold
compression therapy). Below is the complete list of all treatments considered as
First Aid. Any minor treatment that is not on the list should be considered as a
Medical Treatment Injury case.

3.1.5.1. Using a nonprescription medication at nonprescription strength.

3.1.5.2. Administering tetanus immunizations.

3.1.5.3. Cleaning, flushing or soaking wounds on the surface skin.

3.1.5.4. Using wound coverings such as bandages, band-aids, gauze pads, etc.,
or using butterfly bandages or steri-strips.
0

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Page 7 of 29
 Using hot or cold therapy or treatments.

Using any non-rigid means of support, such as elastic bandages, wraps, non-
rigid back belts, etc.

Using temporary immobilization devices while transporting an accident victim

(e.g., splints, slings, neck collars, back boards, etc)

Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister.

Using eye patches.

Removing foreign bodies from the eye using only irrigation or cotton swab.

Removing splinters or foreign material from areas other than eye by irrigation,
tweezers, cotton swabs or other simple means.

3.1.6 Off job Disabling Injury Case (ODI)

Any injury suffered by an employee that does not arise out of and in the course of
employment and which results in death or day(s) away from work.

3.1.7 Near Miss Case

A near miss is defined as an event which did not result in injury or loss, but which
had the potential for injury or loss if circumstances had been slightly different. Near
miss incidents include, events where injury or property damage could have
occurred but did not, events where a manor safety system failed to perform as
0 designed, e.g., fire pump auto stat malfunction, events where potential
environmental damage could result. Note that unsafe conditions and unsafe acts in
themselves are not near misses but may be part of a near miss occurrence.

3.1.8 Motor Vehicle Accident (MVA)

Motor Vehicle Accident is an Incident which has involved a vehicle and which has
resulted in injury. Illnesses and/or damage (loss) to people, assets, the
environment or the company reputation. This term shall be used as a secondary
classification of an incident.

3.1.9 Environmentallncident

Any work related incident that can harm to environment such as spill (oil,
chemical or any other hazardous material/waste), unauthorized discharge of
wastewater, or breach of environmental regulations.

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 3.1.10 Fire Incident

Any burning of property or equipment that belongs to the project.

3.1.11 Heavy Equipment Incident

Heavy Equipment Incident is an event where unintentional contact is made by

equipment, or its load, with personnel, structures or other equipment causing injury
or damage.

0 3.1.12 Property Damage

Property damage to property of the Client, project property or Subcontractor

resulting from an incident during construction activities, which the loss of damage
is more than 500 dollars.

3.1.13 Security Related Incident

Any incident related to threat, robbery kidnapping, sabotage which involves

company property or personnel working in the project. This term shall be used as a
secondary classification of an incident.

3.1.14 Category of Incidents

Category Incident lnjury/illn Environment Property lnvestigati Investigation

ess Damage on Team Team
Formed by
(1) Minor Could have Medical Reportable oil spill less $1000- Package EPC Project
3
resulted in First Aid than 8m (50 barrels); $100,00 (EPC) Manager
minor injury/ chemical spill/leak that 0 Manager
0 environmental
spill/property
can be controlled by the
affected area personnel,
damage within their internal
resources.
(2) High Recorda Reportable oil spill reater $100,00 PMT - EPC Project
Moderate Potentiai(Hi- ble or than or equal to Bm (50 0- Manager Manager
Po) Could restricte barrels) but less than 800 $100,00 in - EPC HSE
3
have resulted d duty m (5000 barrels), 00 consultatio Adviser
in moderate(or case, irrespective of the nwith - PMT Manager
more sever) single proportion recovered; RIIPED - RIIPED HSE
injury/ LTI chemical spill/leak that HSE Advisor
environmental leads to total evacuation Manager
spill/ property of non-essential on-site
damage personnel.
 (3) Major Multiple Reportable oil spill of 800 $100, 0 - RIIPED
3
LTI or m (5000 barrels) or more, 000 and Project
Fatality irrespective of the more manager
proportion recovered; - RIIPED HSE
chemical spiiVIeak that Manager
leads to emergency - PRC
N/A evacuation of the site. Representative
- Saudi Govt.
authorities (as
necessary)
-Others (see
NOTE-1 below)

0 NOTE-1:

In case of incidents occurring in RIIPED Packages (EPCs) working within the PRC High Security
Areas, representatives from concerned PRC organizations (such as CSFD, EHD, ISO, P&GA etc.)
shall be invited by RIIPED HSE Manager to take part in the investigation.

3.2. Incident Statistics

The collection and interpretation of number of incident and the use of probability theory to
analyze the incident trends in the project and the company as a whole. Statistics are
analyzed annually as a minimum, causes are determined and corrective actions are
monitored properly. It is also the guide for us (we use) to compare Company's HSE
performance against other company or other related institution.

The followings definitions and formulas will be used to measure the Rate on Incidence
Recordable for the project;

0 3.2.1. Lost Time Injury Rate:LTIR

This Incident rate is based upon the total number of Lost Time Injury cases which
resulted iin death plus the number of Lost Time Incident per 200,000 man-hours
worked (which is equivalent to 100 persons working in a calendar year- per
OSHA), but exclude Restricted Work Day Case (RWC) and Medical Treatment
Case (MTC);

LTIR = (Fatality+ No. of Lost Time Incidents) x 200.000

Total Man-Hours

3.2.2. TotalRecordable Incident Rate: TRIR

This Incidence rate is based upon the total number of Recordable cases per
200,000 man-hour, any work-related injury and illness case requiring more than
first aid that fall into any one of the following:

3.2.2.1. Fatality
 3.2.2.2. Lost Time Incident
3.2.2.3. Restricted Workday Case
3.2.2.4. Medical treatment (other than first aid);

Total Recordable Cases are the sum of Lost Time Incident (LTI), Restricted Work
Case (RWC), Medical Treatment Case (MTC) and Occupational Illnesses but
excluding First Aid Case and Near miss Case:

TRIR = (Fatality + LTl + RWC + MTC) x 200.000

Total Man-Hours

The type of Recordable Incident will be decided by joint agreement between Site
HSE Manager and the Physician who administered the victim.

3.2.3. Severity Rate: SR

This Incident rate is based upon the total number of Lost Workdays per 200,000
man-hours:

SR = Total number of Lost Workdays x 200.000

Total Man-hours

3.3. Statistics Terms

3.3.1. Total Man-Hours

Total man-hours are the total numbers of hours worked, including overtime and
training, but excluding leave, sickness and absence.

3.3.2. Lost Work Days (Days Away from Work)

0 Lost Work Days are those work days regardless, consecutive or not, on
which the employee would have worked but could not because of
occupational injury or illness, excluding the day of injury or onset of illness.

The maximum number of days can be given to a single incident or event is

180 lost work days.

A lost days' work can only be charge to a single year where the incident took
place.

Example: LTl case happened 2006.12.15 the Doctor advised him to rest
for 30 days, he can return to work on 2007.01.15, 30 lost days' work will be
charged to the year 2006 and not anymore to 2007.
 Lost Workdays of Death: Each Death resulting from occupational injury or illness is
automatically given a schedule charge of 7,500 days.

RESPONSIBILITES

RIIPED Managing Director

Ensure that all major incidents are reported immediately to the Client (Company
Representative), Head Office and where applicable, to the statutory authorities.

Ensure all incident reports are reviewed and where necessary, promptly instigate
additional investigations

In the case of a Major incident or fatality, organize an Investigation Team and appoint
a Team Leader.

Regularly review incident reports and implement any changes required to improve site
HSE performance. (i.e., EHS plan update, work practices revision, additional
training etc.)

Review the Monthly HSE Performance report and issue to Head Office and the
Company Representative.

4.2. RIIPED HSE Manager

Participate with the Investigation Team for all Major Incidents

Coordinate with the investigation group regarding all the necessary data needed
for easy determination of the root causes of the incident.

Review the incident reports and implement any recommendation stipulated in the
report.

Closely monitor the implementation of the action to be taken, making sure that his
subordinates are following the HSE procedures.

Nominate members from RIIPED HSE organization to take part in incident

investigation (of Moderate and Major incidents)

Share & communicate Lessons Learnt from incidents with all Package PMT
Managers and EPC Managers (Refer the Procedure for Dissemination of HSE
Communication, RIIPED -PP- DHAC- 001).

4.3. PMT Project Manager

4.3.1. Ensure that an initial Incident Report is completed within 24 hours of any incident.
 Review all Incident Reports and monitor incident trends and ensure that
recommendations are followed up through Line engagement.

Where appropriate, recommend to the Project Manager that an Investigation Team be

instigated.

On receipt of an initial verbal major incident report, immediately send out SMS
notification to Emergency Contact person for Project.

Submit site Weekly, Monthly & Annual HSE report and review the information to
identify trends.
EPC Construction/Site Manager

Ensure that all incidents that occur in his area of responsibility are properly
investigated if requested, participate with the Investigation Team.

Coordinate with the investigation group regarding all the necessary data needed for easy
determination of the root causes of the incident.

Review the incident reports and implement any recommendation stipulated in the report.

Closely monitor the implementation of the action to be taken, making sure that his
subordinates are following the HSE procedures.

Injured Person/ Others

It is the responsibility of all workers to report all and any injuries, near misses or
incidents.
It is the responsibility of an injured person to listen and tell the truth to the best of his
knowledge how an injury occurred.

It is the responsibility of an injured person to take his medication responsibly and take the
recommended rest period prescribed by Physician for recovery.

Supervisor of Injured Person

It is the responsibility of the injured person's supervisor to inform according to the emergency
response procedure, the injured person's supervisor must contact the person
responsible for calling and implementing the stages of the emergency procedure (Refer
Emergency Response Plan, RIIPED- PP- ERP- 001).

The supervisor must make sure the injured person is in no immediate danger.
 The supervisor is also responsible to make sure the injured person is not overwhelmed by
spectators.

The supervisor shall be taking notes oftimes and any relevant information.

The supervisor should also escort the injured person if there is no medic for some unforeseen
circumstances to medical center for identification of EPC, injured persons personal
information until higher level person in the EPC arrives to relieve the supervisor.
Medic on Site

The medic on site is responsible for the best medical first aid care he can supply when faced
with an injured person.

The medic once on the scene must evaluate condition and administer first aid only, the medic
shell relieve the supervisor of all personal documents belonging to the injured person if
need be for medical center or hospital delivery.

All medical reports must go through the clinic and the medic.

RIIPED HSE Engineer I Advisor

Upon receipt of incident report, carefully analyze the causes and action to be taken to prevent
recurrence of the incident.

If the investigation report is not clear, request for a more thorough investigation report and
other supporting·evidence needed (photos, medical report, witness statement etc.)

If it is a moderate I major incident, conduct a site visit and participate in the

investigation process.

Immediately report the moderate I major incidents to the RIIPEO HSE Manager and the
concerned PMT Manager all the details of the incidents and the action to be taken to
prevent recurrence.

Analyze all the statistics in project sites. Incident trends, Leading indicators and
Lagging indicators shall be reviewed.

Compile all the summary records and statistics of the project sites.

After analyzing the entire incident and the recommendation, a feedback system shall be
implemented. Lessons learned from any incident shall be distributed to all sites for
information and reference to prevent the recurrence of the said incident.
 NCIDENT REPORTING AND INVESTIGATION

It should be understood by all Management that:

• The incidents that downgrade our business are caused: they do not just happen;
• The causes of loss can be determined and controlled

In order to better understand the circumstances, which lead to the causes of incidents, the
Project Manager has a prime responsibility for organizing an Investigation Team, and shall
appoint the members of the Investigation Team.

Incident Initial Reporting

All incidents will be immediately reported to all relevant people on the Emergency contact list
(see- Attachment No. 3), via SMS notification from the EPC HSE Manager. This
measure will be utilized up until a fully functional Emergency Call center is operating
with a one call emergency number.
Note: In PRC Restricted Areas, use of mobile phones is not permitted

If incident occurs in the EPC Projects within PRC High Security areas, EPC supervisor shall
inform immediately by calling Bravo Radio #1 or 911 and then inform their PMT Focal
Point by phone or SMS. They will submit incident report format within 24 hours of the
incidents occurrence. This should include brief facts relating to the incident. The
Attachment No. 1 shall be used.

PMT focal point immediately inform RIIPED HSE Manager, who will in turn inform concerned
PRC Organizations (for incidents within PRC High Security areas)

All near miss incidents shall be reported in the form shown in Attachment-4 (Near Miss
Reporting Format). Certain Near Miss incidents could be classified as HIPO (High
Potential) depending of its severity by RIIPED HSE Manager- in which case, such near
miss incidents will be investigated further, as described in Section 6.1 below.

Reporting to RIIPED Office

In the event of an occurrence of an incident like fatality or multiple hospitalizations (more than 3
people) or injuries requiring medical attention which results in lost time or above, the
incident shall be immediately notified to the head office with an initial written report within
24 hours by RIIPED HSE Manager.

Actions Immediately After an Incident

Supervisors shall take the following Initial Actions whenever any incident has occurred
because the success of an investigation often comes in the first few moments.

Supervisor's initial actions vary for every incident. The person on the scene must be the judge
of what is critical. These steps are guidelines to apply as appropriate.

Take Control at the Scene

Incidents make people act differently. People are curious and they want to help, but
often they are irrational and do more harm than good.

Unless a Senior Manager is present, a supervisor needs to take charge.

Ensure first aid and call for emergency services. People's lives and their wellbeing come first.
Have someone raise the alarm for medical assistance. Control potential secondary incidents
Secondary incidents are usually even more serious because the normal controls over
loss exposures have been weakened by the incidents. Positive temporary actions
need to be taken after quick, but careful, thought of the consequences.

Identify sources of evidence at the scene. Things can change quickly and information lost
forever. Items can be moved during emergency response or attempt at rescue work.
Supervisors need to notice these things while taking other initial actions.

Preserve Evidence from Alteration or Removal

If there seems to be significant Joss potential, good investigation is more important

than getting back to work. Supervisors have authority to keep things from
being moved. They should also keep people away from the incident site so
nothing is disturbed before they get to look it over.

Incident sites shall not be changed or cleaned up unless a release letter has been
issued by the Leader of the Investigation Team (where one has been formed)
after the consent of all members of the Investigation Team.

The relevant Area Manager is responsible to ensure that no changes or clean-up of

incident sites will occur prior to a written release of the incident site by the
Investigation Team.

Investigate to determine the loss potential. What could happen is vital to future loss
prevention. Supervisors should make a prompt appraisal of how the incident
could have happened and how likely it is to occur again.
INCIDENT INVESTIGATION

Investigation of Near Miss Incident

All Near Miss cases should be reported in Near miss reporting form (Attachment-2).

Potential consequences shall be highlighted for effective preventive measures against

recurrence to be taken.

HIPO (high potential) near miss incidents will be investigated by the PMTManagement,
involving the concerned EPC Management and RIIPED HSE Advisor
-as necessary.

All near miss incidents shall be recorded in the Incident Database for tracking.

Investigation of Moderate Incidents

All Moderate Incidents shall be investigated by a team, formed by the PMT Manager, in
consultation with RIIPED HSE Manager (See Table under Section3.1.13). The
nominated Team Leader shall be conversant in the incidentinvestigation process
including identification of Direct Causes and the Root Causes

The investigation process shall follow the broad guidelines mentioned below in Section 6.3
(investigation of major incidents) and arrive at the root cause(s) and the related
recommendations.

The Investigation Report shall cover (among others) description of the facility, description of
incident, details of the damages /loss, findings and analysis covering direct causes and
root causes, recommendations, identification of Action Party for implementation of
recommendations and the ETC date.
Investigation Report shall be submitted to the PMT Manager, who will approve and send further
to RIIPED HSE Manager.

RIIPED HSE Manager shall review the root causes and the recommendations.
Details of the incident and the recommendations shall be recorded in the RIIPED
Incident Database for tracking.

Investigation of Major Incidents

Organizing an Investigation Team

An Incident Investigation Team to be facilitated by the RIIPED HSE Manager in

consultation with the concerned PMT Manager

Investigations should be carried out as soon as possible after the incident, because the
quality of evidence can deteriorate rapidly with time.

In principle, the Investigation Team should consist of the following:

a) EPC Construction Manager, responsible for the area where the

incident happened.
b) EPC Construction Engineer/Supervisor responsible for the work that
was carried out.
c) EPC HSE Manager responsible for the area.
d) Subcontractor Project Manager. e)
Subcontractor HSE Manager.
f) PMT Project Manager g)
RIIPED HSE Manager
h) Invitees from PRC organizations (for incidents inside PRC High
 Security areas- such as, CSFD, EHD, lSD, P&GA etc.)
i) Government representatives, as required by the regulations
j) Witness of the event, if any.
k) Others, as decided by the Investigation Team Leader

RIIPED HSE Manager, in consultation with RIIPED Management & PMT shall nominate
a Team Leader for the investigation (either from within the above list or others-
as appropriate). The nominated Team Leader shall be conversant in the
incident investigation process including identification of Direct Causes and the
Root Causes

Preparation for the Investigation

Factual information relating to the event should be collected for effective

investigation. It shall include the following:

• Drawings showing the location of the scene of the event

• Work Procedures/ Method of Statement/Risk Assessment relating to the event
• Job EHS Analysis
• Records of instructions/briefings given at Toolbox Meetings, etc
• Records of Work Permits, if applicabble
• Work Organization (command structure and persons involved)
• Personal Data of the victim etc.

Fact Findings

Incidents and other problems are seldom,if ever, the result of a single cause; thus
collecting information as much as possible is required to establish causes
which are assumed to have contributed to the events.

The investigators should inquire into five main areas:

 Environment
• Equipment
• People
• Materials
• Method Statement/Risk Assessment/Job EHS Analysis

In each of these areas, conditions, actions or omissions should be identified which

could be factors contributing to the incident or damage or loss.

The initial stages of an investigation normally focus on conditions and activities

immediately relating to the incident and only immediate causes may be
identified at first.

However, the conditions underlying these causes also need to be identified.

The Principal Fact Finding sources are:

• Examining the scene of the accident

• Interviewing personnel concerned and witnesses if available
• Reviewing Written instructions and procedures
• Records; and information should be carefully examined and
systematically analyzed, particularly discrepancies in statements
made by different witnesses should be verified by supporting
evidence to help deduce the real course of what and how the event
happened.

After fact finding it should be possible to:

• Give a precise description of the incident, its background and the

events leading up to it
• Describe working environment
• Identify the equipment in use, its capabilities and any failures
• Describe the locations of key personnel and their actions im
mediately before the incident
• List all pertinent instructions
• Level of response to the incident (rescue, shutdown, fire fighting,
etc.)
• Make an inventory of all the consequences of the accident (injury,
damage; and loss).

Inspection of the Scene of the Incident

It is mandatory to look over the scene and the environment around the incident. This
gives a mental picture to seek and discuss information.
 The big picture is an orientation to the elements involved,such as people, equipment,
materials and environment.

The scene of the incident must be preserved 'as is' until at least a preliminary
examination has been completed to collect physical evidences that can help
to collect factual aids, especially when witnesses are not available.

Photographs and/or video film used (before obtained PRC authorisation to do photos)
should be effectively to assist the investigation and to provide visual aids
and records.

Furthermore, physical evidence can help victims and witnesses to clearly

recall what happened.

Items to Check include:

• The position of equipment/vehicle in relation to other equipment and

facilities
• The condition of tools/equipment/facilities relating to the incident
• Other activities ongoing in proximity at the time of the incident
• Activity of the victim or equipment/vehicle etc. At the time of the
incident
• State of congestion and accessibility.
• Illumination of the location/site.
• State of housekeeping
• Presence or absence of warning signs/notices
• Effect of weather
• Presence of witnesses
• Presence of unauthorized people
Where no incident team has been established the incident scene shall only be
released upon written instruction from the RIIPED HSE Manager.

Interviews

A Witness is anyone who knows something related to what happened.

Some witnesses are eye witnesses to the incident as it happend while others
are people involved. It is best to start with eye witnesses and the people
involved because they are the most likely to know the details of what
happened. They are also the most likely to forget these details if not
questioned promptly.

The first details from these witnesses give the investigation team the symptoms of the
problem. They are the starting point on the path to basic
 causes. Peoples memories as well as their willingness to talk can be
affected by the way they are questioned.

Victims, witnesses, and colleagues may have different impressions of what

happened, therefore interviews shall be conducted as privately as possible
so that witnesses are not influenced by each other's memories.

Witnesses' interviews should be conducted step by step, sequentially based on

the facts available.

When there are significant differences of opinion, follow-up interviews may be

needed.

Avoid interviewer comments, leading questions; accusations shall be avoided.

The interview information should be recorded, without any modification by the

interviewer's preconceptions.

Records, Drawings, Written Instructions and Procedures can help witnesses

sort out relevant facts in their minds.

Records, such as inspection and maintenance records of equipment and facilities,

EHS training records, work permits, and measurements of environmental
conditions may provide information relevant to the investigation.

Written instructions and procedures provide evidence of pre-planning and individual

responsibilities.

The investigation should try to establish the extent to which written procedures and
instructions were understood and acted upon, as these can indicate the
effectiveness of training and supervision. Experience shows that
procedures are frequently not fully applied in practice.

Analysis of Findings

The Incident Investigation Team shall have meetings to analyze and identify the
sequence of critical events, underlying causes of the incident, scrutinizing
findings collected, the survey records of the scene of the incident, outputs
through the interviews with all witnesses, documents concerned, etc., and
establish the root causes and summarize recommendations to prevent
recurrence of similar accidents.

The causes of incidents consist of immediate causes which could have contributed
directly to the incident, and underlying root causes such as
 the lack of management, and human factors and job factors, and/or a
combination of these thus, the cause of an incident is usually complicated
even when the cause seems to be obvious, the investigator should
remain skeptical until all possibilities have been investigated.

First, look for any immediate causes which could have contributed directly to the
incident. The immediate causes consist of usually substandard actions and
substandard conditions.

In addition to the immediate causes above, the basic/ underlying root causes which
are "causes behind the causes" also shall be investigated.The
basic/underlying causes are classified as personal factors such as
inadequate capability, lack of knowledge, etc., and job factors such as
lack of management, inadequate leadership and/or supervision,
inadequate engineering, maintenance system, inadequate procedure,
etc...

Any assumptions made during the analysis should be clearly identified in the report.

The progress and results of the meetings shall be recorded.

Root Cause Analysis

Conclusions shall contain bot immediate causes and root causes. An immediate
cause (also known as a "causal factor'') is a human error or equipment failure that
directly led to the incident or made the incidents consequence worse. A root cause
(also known as a "basic cause") is underlying reason why an immediate cause
occurred and is virtually always a specific deficiency in a management system.

Typical management system include procedures, standards, planning, design,

personnel selection, supervision, safety/hazard reviews, emergency planning, work
permitting, training, communication, maintenance, inspection, etc. the investigation
committee shall determine root cause using a structured root cause analysis technique.
An immediate cause can be expected to have more than one root cause.

Recommendations

Recommendations shall be made to identify actions to prevent recurrence

All recommendations shall be in the form of a practical Action Plan which clearly
indicate the party responsible for action so that effective follow-up can be
achieved. Deadlines for actions should be specified for subsequent
endorsement by the action party.
 The following SMART factors shall be kept in mind when preparing rec
ommendations:
• Specific
• Measurable
• Achievable
• Relevant
• Time Bound

The recommendations to eliminate basic and immediate causes and to improve

HSE management shall also be included in the report.
Each recommendation shall have the Action Party identified (for
implementation) and the ETC Date for completion.

Upon receiving permission I investigation report, recommendations for remedial

actions shall be implemented.

Detailed execution procedures for recommendations shall be explained to, and fully
understood by all the employees concerned.

Report Distribution

The final report shall typically cover all details, under various Sections, as indicated in
Attachment - 4.

The Incident records are consolidated into the HSE Section of the
Monthly Construction Report for wider distribution.

The incident investigation report will be introduced at the Monthly HSE Committee
Meeting as a lesson learned.

The detailed Incident Investigation report shall be submitted to Head

Office immediately. Copy of the Report shall be provided to the Company
Representative.

Once all action items are closed out on the final incident report, CONTRACTOR and
COMPANY HSE Manager will sign the report off as complete, and then
submit officially through the Rabigh Phase II Project document control
system for record keeping.

Follow-Up

The Leader of the Investigation Team should organize follow-up inspections and the
progress in implementation of the recommendations shall be periodically monitored
by the Investigation Team Members until all items are completed.
INCIDENT DATA BASE

Details of the incident (near miss, minor, moderate and major) and the recommendations
shall be recorded in the RIIPED Incident Database for tracking. An electronic data base
shall be used to register incidents to track the status of follow ups.

The data shall be compiled systematically and sequentially.

Records shall include, but may not limited to

• First Information (informer, date, time, receiver)

• First Actions Taken
• Members of the Incident Investigation Team
• Minutes of incident investigation meeting
• Recommendations for rectification
• Approval of recommendation
• Comments by the Client and/or Authorities if any
• Implementation of recommendations/closer
• Follow-up results

Every recorded recommendation shall be followed up for adequate implemetation by the

identified Action Party. Satisfactory Closure of such recommendations shall follow the
guidelines provided in the Procedure: Closure of HSE Recommendations
RIIPED-PP-CHR-001.

The RIIPED HSE Manager shall be retain the Database until the completion of the
Project and transfer data to Head Office and to the Company, if requested.

MEDICAL REPORT

A Completed Medical Report shall be recorded for all incidents on site resulting in injury. Medical
Report shall be updated, as soon as any further or new treatment is given by the physician and
shall be issued to the site HSE Manager complying with medical confidentiality guide lines.

The HSE Manager is responsible for submitting an updated Medical Report to Company
without delay.

A Medical Report comprises of 3 sections:

Personal Details Supervisor shall complete personal details.

 The immediate Supervisor of the injured party or other individuals who
may be assigned the work shall complete the incident details. Details
Accident Details
shall include all items specified on the Form including date and time of
incident, weather conditions and location.

The EPC Site Doctor shall complete details, confirm injury type, body part
Injury Details
and details of any medical treatment given.

REFERENCES

o OSHA Regulations (Standards - 29 CFR Part 1904)

o Applicable KSA laws I Ministry of Health Food Poisoning Manual
o ARAMCO procedures (Notification requirements for incidents including fire Gl-6.003)
o PRC Incident Reporting and investigation procedures
o (PRC Sanitary Regulation, PRC-EHD-G1-501)

Applicability shall be for the most stringent amongst local laws I regulations, codes and
standards of the company control procedures.

ATTACHMENTS

Attachment 1: Incident Report Format

Attachment 2: Near Miss Report Form
Attachment 3: Emergency Contact list RIIPED Project
Attachment 4: Investigation Format
Attachment 5: Incident Reporting Flow chart

Attachment 4: Investigation Format

The Investigation Report shall include the following:

(a) Face sheet and title

(b) Executive Summary
(c) Index or Table of Contents
(d) Letter of appointment of the chairman
(e) List of members with concurring signatures
(f) Definitions of terms (if required)

(g) Description of facilities and operations prior to the incident

(h) Description of the incident
(i) Findings and analysis
(j) Conclusions t
(k) Recommendations
(I) Sequence of events prior to, during, and immediately after the
incident (particularly those events which may have contributed to the
incident)
(m) Evaluation of emergency response
(n) Appendices (organized as Appendix 1, 2, 3... or Appendix A, B, C... ),
to include copies of pertinent corporate or departmental documents, sketches
 and photographs, cost estimates of repairs, witness statements
and transcripts of interview notes, advisor and consultant technical
reports, distribution list, letters to actionable parties (see

paragraph 4.6), etc.

the Conclusions shall contain both immediate causes and root causes. An immediate cause (also
known as a "causal factor") is a human error or equipment failure that directly led to the
incident or made the incident's consequences worse. A root cause (also known as a "basic
cause") is an underlying reason why an immediate cause occurred and is virtually always a
specific deficiency in a management system. Typical management systems include
procedures, standards, planning, design, personnel selection, supervision, safety/hazard
reviews, emergency planning, work permitting, training, communications, maintenance, inspection,
etc. The investigation committee shall determine root causes using a structured root cause analysis
technique; refer to the Corporate Safety & Fire Protection Department for methodology. Any
immediate cause can be expected to have more than one root cause.