INCIDENT REPORTING

AND

INVESTIGATION PROCEDURE
 Form#: MR0-03 Rev.# : 00 (12103/07)

DOCUMENT CHANGE REQUEST FORM MR OFFICE

Document Reference: ~~S_A~F_-W:.c...:...P--l~M_S_-0_0_7_(Lln_c_i_d_e_nt_R_eLp_o_rt_in~g~a_n~d:.;,....,;.ln~v~e~s~tig~a~t~io~n~P~ro~c~e~d~u~r~e)L-_

Revision#: 02

Unit I Section: Safety Department : HSE

Description of Page # 12 and 17 of 24, Section 4.18 (addition) and 5.8.2 (editing)
Requested Change : shown in bold and italic

Expected Improvement in Incident Investigation Team's formation

Improvement:

ROUTE INITIATED BY REVIEWED BY APPROVED BY

Name Syed Kamal Shah Mati ur Rab Siddiqui

Date 21-07-14 ....__2_1_-0_1-_14---' ~(J. 21-07-14

Desig./Sign. Sub Engr. UM HSE /Jx GM (M)

Action By MR :

Closed On:

Feedback Sent to Initiator: Yes I No On:

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Signature of MR: ·~·
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E:\Safety 03\Procedures\Revised Procedures\7 - Incident Investigation Procedure\03-Document change request form.doc

 WORK PROCEDURE I SAFETY UNITI

TITLE: INCIDENT REPORTING AND INVESTIGATION

This procedure has been duly reviewed and approved by following review committee.

REVIEW COMMITTEE MEMBERS SIGNATURE

Qadeer Ahmed Khan Director Operations

Mohammad Saleem Zafar General Manager Projects

Brig. Rtd. Mohammad Asif Ali Sirhindi General Manager Administration

Mohammad Munir Ahmed Sr. Production Manager

Mohammad Tariq Javed Training Manager

f----------------1------·-------

Abdul Nasir Maintenance Manager

Farrukh Iqbal Qureshi Technical Services Manager

t
Abdul Majeed Zia Manager Civil Housing Colony Projects
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1,

Tariq Qasim Khan E& I Manager

Abdul Rauf Asstt. Production Manager

 WORK PROCEDURE I SAFETY UNIT I

PROCEDURE REVISION AND CHANGE HISTORY

REVISION NUMBER DA TE REVISED ON NEXT REVISION ON

Revision 00

Revision 01
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Revision 02
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Revision 03
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Revision 04

Revision 05

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CHANGE IN SECTION CHANGE AT PAGE NO. CHANGE MADE ON

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 TABLE OF CONTENTS

SECTIONS PAGE

1.0 POLICY & REQUIREMENT 1

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2.0 SCOPE 1
1,;~m1mm~~rr1
3.0 DEFINITIONS 2
3.1 First Aid Case 2
3.2 Medical Treatment Case (MTC) 2
3.3 Restricted Work Case (RWC) 2
3.4 Lost Time Injury (LTl) 2
3.5 Lost Work Days 2
3.6 Occupational Injury 2
3.7 Occupational Illness 2
3.8 Off the Job Incidents I Injuries 2
3.9 On the Job Incidents I Injuries 2
3.10 Non-work Incidents I Injuries 3
3.11 Fatality 3
3.12 Recordable Injuries 3
3.13 Total Recordable Incidence Rate 3
3.14 Incident 3
3.15 Nearmiss 3
3.16 Fire 3
3.17 Smoldering 3
3.18 Process Fire 3
3.19 Process Safety Incident 3
3.20 Process Release 3
3.21 Operational Upset 4
3.22 Vehicle Incident 4
3.23 Human Factors 4
3.24 Incident Report 4
3.25 Process Safety and Risk Management 4
3.26 Recommendations 4

4.0 CLASSIFICATION OF ON-THE-JOB INJURY AND INCIDENT 5

4.1 Definition of an Incident 5
4.2 Injuries 5
4.3 Fatality 5
 4.4 Lost Time Injury (LTl)
I 5
4.4.1 Lost Workdays 5
4.5 Restricted Work Case (RWC) 6
4.6 Medical Treatment Case (MTC) 6
4.7 First-Aid Case (FAC) 6
4.8 Reportable Injuries 6
4.9 Occupational Illness 7
4.10 Process Safety Incidents 8
4.10.1 Process Release 8
4.10.2 Fires 9
4.10.3 Inoperable Safety Equipment 9
4.11 Operational Upset 10
4.11.1 Human Error 10
4.11.2 Violation of Process Safety and Risk Management Systems 10
4.12 Violation of Safety Procedures I Practices 10
4.13 Vehicle Incidents 11
4.14 Equipment Failure 11
4.15 Others 11
4.16 Ambiguous Cases 12
4.17 Repeat Incidents 12
l'll!(lfijf:I~§
5.0 INCIDENT REPORTING AND INVESTIGATION 13
5.1 Reporting On-the-Job Incidents 13
5.2 Responsibility for Reporting an Incident 13
5.3 Reporting an Incident 13
5.4 Recoding of Incidents 14
5.4.1 Numbering Format 14
5.5 Investigation for Major Injuries I Fatalities I Accidents 15
5.6 Procedure for Investigation Incidents 15
5.7 Calculation of Incident Severity & Level of Investigation 15
5.7.1 Process Safety Incidents 15
5.7.2 Vehicle Accidents 16
5.7.3 Incidents except Process Safety Incident and Vehicle Accident 16
5.8 Investigation Team Leadership 17
5.9 Status of Pending Incident Reports I Recommendations 17
5.10 Distribution of Reports 17
5.11 Quality of Investigation Reports 18
1:1111111rs!ir(§
6.0 OFF-THE-JOB INCIDENTS 19
6.1 Purpose 19
6.2 Reporting 19
 6.2.1 Nearmiss 19
6.2.2 Lost Workday Injuries 19
6.2.3 Traffic Accidents 19
6.2.4 Fire Incidents 19
6.3 Reporting and Recording off-the-job incidents 19
6.4 Approval of Detailed Report I Recommendations and Follow-up 19
§l~~Ml:~' N:lll~
7.0 INCIDENT REPORTS AND RECOMMENDATIONS 20
7 .1 Incident Report Records 20
7.2 Status of Pending Incident Reports I Recommendations 20
7.3 Types of Recommendations and Completion Target Date 20
7.3.1 Timeline of Different Categories 20
7.4 Waiver Requirement 20

8.0 COMMUNICATION 21
8.1 Site Communication 21
8.1.1 Morning Meeting 21
8.1.2 Safety Incident Initial Communication (Flash Report) 21
8.2 Final Report (B Report) 21
8.3 Communication to Management 21
8.3.1 Reporting to CEO 21
8.4 Mode of Communication 22
8.4.1 Safety Management Information System (SMIS) 22
8.4.2 Electronic Mails 22
8.4.3 Hard Form of Documentation 22

9.0 INCIDENT ANALYSIS 23

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10.0 TRAINING 24

11.0 RELATED DOCUMENTS 24

Attachment# 01 Initial Incident Report Form (A) 25
Attachment # 02 Detailed Investigation Report Form (B) 26
Attachment# 03 Incident Recommendation Closure Form (C) 28
Attachment# 04 Off-the-job Incident Report Form 29
Attachment# 05 Process Safety Incident Classification Scoresheet 30
Attachment # 06 Flash Report Sample 32
Attachment# 07 Risk Based Incident Classification Matrix 33
Attachment # 08 SOC Waiver Form 34
Attachment # 09 Debits Due to Incidents 35
 DOCUMENT CODE SAF-WP-IMS-007 I REV. # I 01 I REV. DATE I 20/10/11 PAGE 1 of 24

WORK PROCEDURE
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TITLE: INCIDENT REPORTING AND INVESTIGATI 1N~.iva.Ud. !)ala. ~.j&. ;JJ.,;:.~-;. !'!L
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1.0 POLICY & REQUIREMENT \1.a,.;:~.:. ,. \~'s·
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PFL has strong belief that reporting and analysis of inci ent;'/fr-b~m i~mense~f~~1u~~l~D
opportunities to learn the weaknesses and deficiencies i ~~~~~~emb,bi~ eikd. 1~"'--wbb'obJ
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dire need and requirement of this procedure lies in the philosophy that an incident can be a
major and ample source of valuable learnings for future accident prevention.
Incidents such as unabling injury, a reportable loss (fire I explosion etc.) or a
condition or action that could have resulted in personal injury or damage to the plant I
environment (nearmiss) all can be prevented by adopting proactive approach.
All incidents must be reported, investigated and analyzed for system deficiencies to
prevent recurrences.
The purpose of this procedure is to provide guidelines for investigating incidents that
occur on the plant or off-the-job in a way that:
• Promotes thorough and efficient investigation in a timely manner
• Promotes uniform, accurate, clear, and concise documentation and reporting
• Identifies and implements recommendations to prevent incident recurrence
• Involves the right people to get the information
• Ensures a clear understanding of key factors and key learnings
• Participating personnel obtain a positive learning experience

2.0 SCOPE I
This procedure is applicable to ~II the activities, operations, employees, Contractors,
visitors within the jurisdiction of Pakarab Fertilizers Ltd. Plant site and off-the-job
recordable events pertaining to PFL employees and contractors.
This procedure documents the rules and guidelines for the process to be used to
investigate all safety incidents on the plant. It also captures procedure to be followed for
reporting of Off-the-job incidents. The basic approach is to:
• Define organizational responsibility for filing incident reports within the Company.
• Involve appropriate people, to conduct a purposeful and thorough investigation with
amount of effort being directly related to seriousness of the potential consequences.
• Prompt communication of key factors and key learnings.
• Orderly and timely implementation of recommendations for prevention of future
occurrences.
• Analysis of incidents to highlight trends and detection of significant changes to
prevent recurrence.
ROUTE PREPARED BY f'HEVIEWED BY APPROVED BY REFERENCE

Name Abdul Karim Noon I Fahad lshfaq Fai~1 kh Iqbal Qureshi Qadeer Ahmed Khan
IMS, HSE 4.5.3
Date z 7· ft. ·2511 ' /I z1-1cua.. I
Desig./Sign. UM I Sr. Engr. l\,f (fr "
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 DOCUMENT CODE SAF-WP-IMS-007 REV.# 01

3.0 DEFINITIONS
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3.1 First Aid Case: First aid is limited to any one-time t fi!!!~k~~~]nw.,:: up").11s1.t;fo1·
the purpose of observation of minor scratches, cuts, urns, splinters and so forth, which
do not ordinarily required medical care. First aid can be provided by a physician 01·
nurse. Surveillance or observation, including overnight observation, which reveals no
injury or illness shall be considered first-aid if the employee reports to his next regular
schedule.

3.2 Medical Treatment Case (MTC): Any work related injury in which treatment (other than
first-aid) is administered by a physician or by registered professional personnel
under the standing orders of a physician. Medical treatment does not include first-aid
treatment, even though provided by a physician or registered professional personnel.

3.3 Restricted Work Case (RWC): Any work related injury that results in restricting the
employee to perform all or any part of his normal assignment during all or any part of
the work day or shift. Recordablility of restricted duty at times will be dependent upon
the nature of the work performed by the employee. For example, a sprained ankle may
not be 'Lost workday' for an office assistant working at a desk since he can perform all
his duties but it probably would be for an operator, mechanic or warehouse 1T1an.

3.4 Lost Time Injury (LTl): Any injury or illness which prevents the employee from
performing all the duties of his regularly assigned job on any workday following the
incident on which the employee has been scheduled to work.

3.5 Lost Work Days: All days (whether consecutive or not) on which an employee is
scheduled to work, but is either absent on restricted duty or unable to perform all the
duties of his job because of injury or illness. Days away from work should include only
those full days or shifts that are missed by the employee I contractor on which he I she
was supposed to be on duty. No lost workdays are charged for fatalities.

3.6 Occupational Injury: Death and I or injury or occupational disease suffered by a

person which arises out of and in the course of his employment, on or off the
employee's premises i.e., resulting from work activity or environment of employment

3. 7 Occupational Illness: Any abnormal condition or disorder such as dermatitis,

rash, respiratory problem, poisoning, heat exhaustion and hearing loss, caused by an
exposure to environmental factors associated with employment. Exposure may be
caused by inhalation, absorption, ingestion or direct contract with dust, fumes, vapors or
mists.

3.8 Off the Job Incidents I Injuries: "Off-the-job" Incidents I injuries are that involve
company employed people when they are not working inside plant premises. Fo1·
example, a plant operator cuts his hand by a screw driver while trying to fix a water
hose at home or a technician who slides off a road while riding his bike to work, hits a
tree, and suffers a sprained wrist.

3.9 On the Job Incidents/ Injuries: If similar incidents I injuries had occurred while on the
plant or riding a bike inside plant, they would have been on-the-job incidents.
ROUTE PREPARED BY APPROVED BY REFERENCE

Name h Iqbal Qureshi Qadeer Ahmed Khan

IMS, HSE 4.5.3
Date

Desig./Sign.
DOCUMENT CODE SAF-WP-IMS-007 I REV.# I 01 I REV. DATE I 20/10/11 I PAGE I 3 of24 I
3.10 Non-work Incidents I Injuries: If the incident I injury involves non-employed persons
(family members of employees etc.), then the incident injury would have been neither
on-the-job nor off-the-job because the people were not emplryea. l liey woUlcrrra·ve~~-~~-
been classified as non-work incidents I injuries. No in

3.11 Fatality: Death resulting from a work injury or occupational illne ~alid Q
""'
3.12 Recordable Injuries: All the injuries including Fatalities, Lost Time Injury (LTl),
Restricted Workday Case (RWC) and Medical Treatment Case (MTC) to PFL or
contractor employees will be considered as recordable injuries.

3.13 Total Recordable Incidence Rate: Annualized injuries per 200, 000 man-hours (i.e.
per 100 employees). TRIR is calculated as follows:
TRIR = No. of recordable injuries x 200, 000
Man-hours

3.14 Incident: An incident is an unexpected I unplanned occurrence that interferes with the
orderly progress of work.

3.15 Nearmiss: Any incident which, if it had proceeded to a more serious level or
development, would have the potential of personnel injuries, property damage or liability
claims.

3.16 Fire: A fire is an "unplanned combustion". An "unplanned combustion" is an event

where there is unplanned visible smoke, visible flame or evidence of combustion (e.q.
charring, soot, etc.) which is not part of a design basis (e.g. flare, hot vents etc.) and is
not covered by a valid work permit. Exception is given for fires at the fire training facility,
controlled bush burning in outlying areas and hot vents. Visible vapors due to
evaporation of liquids e.g., lube oil from oil console (designed for), penetrating oil
sprayed on nuts I bolts during shutdown which evaporates as the surface gets hot in
startup, fading of paint from hot lines with aging etc. are exceptions to fire classification.

3.17 Smoldering: Combustion without flame, usually with incandescence and smoke or Self-
sustaining combustion of a material without any flame evident.

3.18 Process Fire: A fire arising from any activity involving a highly hazardous chemical
including use, storage, manufacturing, handling, or the on-site movement of such
chemicals, or combination of these activities.

3.19 Process Safety Incident: An incident that directly involves (or could involve) process
equipment and materials including on-site storage and handling of process materials.
Additionally, incidents that result in any of the following off-site impacts are
automatically classified as Process Safety Incidents: evacuation, shelter-in-place, injury
I illness or major media coverage, e.g. Overflow, over-pressurization, uncontrolled
release of hazardous gas I material.

3.20 Process Release: Any incident of substantial release (in significant amount) of toxic
gas or liquid to the environment form manufacturing facilities (leaks, relief valves
discharges etc.) which may have adverse effect on environment.
ROUTE PREPARED BY RE)folEWED BY APPROVED BY REFERENCE
Name Abdul Karim Noon I Fahad lshfaq Farrukh \Qbal Qureshi Qadeer Ahmed Khan
Date

Desig./Sign.
2.l·J(l•?-<Oll
UM I Sr. Engr.
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DOCUMENT CODE SAF-WP-IMS-007 REV.# 01 REV.DATE 20/10/11 PAGE 4 of 24

3.21 Operational Upset: Any incident due to mal-operation or human error which has
adverse effect on the plant operating conditions e.g. Temperature runaways, carry-
overs or loss of normal operating conditions during routine operation, startup, shutdown,
preventive maintenance, repair jobs, house keeping etc.

3.22 Vehicle Incident: An incident involving moving vehicles including cars, vans, trucks and
bicycles.

3.23 Human Factors: A discipline concerned with the design of machines, processes,
operations and work environments so that they do not exceed human capabilities and
limitations on the job I off the job.

3.24 Incident Report: Documentation of the results of a process incident investigation,

including description of the incident, details I learnings of the investigation, key factors,
system elements that need to be strengthened and recommendations to prevent future
occurrences. Work permits are valid only for the job for which they are issued; one
permit covers only one job.

3.25 Process Safety and Risk Management: Application of management systems and
controls (programs, procedures, audits, evaluations) to a manufacturing or chemical
process in a way that process hazards are identified, understood and controlled so that
process related injuries and incidents (which might affect plant personnel, contractors or
off-site communities) are prevented.

3.26 Recommendations: Proposed modifications to equipment, facilities, operating and I or

maintenance procedures, engineering controls, or administrative controls deemed
necessary by RCA Team, process hazards analysis (PHA) study team or any audit
team, etc. to reduce risk and permit safe operation.

ROUTE PREPARED BY APPROVEDBY REFERENCE

Name Abdul Karim Noon I Fahad lshfaq Qadeer Ahmed Khan
IMS, HSE 4.5.3
Date :Z.7•\~·'l--tHI 1#-111 l.. l 1
Desig./Sign. UM I Sr. Engr. ~ cfr T.S.M D.O