Appendix 1: LSR Violation Investigation Form

Record Number: Location: Main road near MGP

fence.
Involved Person Name/Company/ID: Four personnel from Al Asfar Date & Time of Violation: 03-01-2023
Technical Services, the vehicle supplier to Marmol Integrated, were & 09.45 Hours
involved.
LSR Breached: Working without personal protective equipment (PPE) Contractor: ✓ Yes No
Brief description of the Violation: On January 3rd, 2024, at 09:45 hours, while conducting OQ HSE audit, an
observation was made regarding a crew engaged in repairing a wheel loader belonging to Marmol Integrated's
vehicle supplier, Al Asfar Technical company. The repair activity was observed to be taking place on the main
road near the MGP plant. It was noted with concern that the crew had failed to obtain a valid permit to work
(PTW) and had not completed a Task Risk Assessment (TRA) prior to commencing the repair work.

Sr. Investigation Questionnaire Yes/No Remarks

1 Was the behaviour intended?
Did the individual`s behaviour reflect little
2 regard or intent not to conform to HSE
requirement and / or procedures?
NO A combination of factors such as
negligence, lack of awareness training,
failure to follow OQ requirements and
procedures, inadequate awareness about
OQ life-saving rules and poor
communication, the lack of actions taken by
the involved parties led to the incident.
Therefore, it can be considered
unintentional.
YES it seems that the individuals involved
exhibited lack of regard for HSE
requirements and procedures. Their actions,
such as failing to obtain permits, neglecting
risk assessments, not using basic personal
protective equipment (PPE), and not
attending necessary inductions, indicate a
disregard for safety protocols.

Would another individual with the same
3
training and experience had done the same?
Did the individual’s actions / behaviour
4 indicate an attempt or desire to conform with
applicable procedures and policies?
Was the direction from supervisor or person of
5
higher seniority?
Were the consequences of the behavior
6
intended?
NO individuals who have undergone induction
training and PTW training are familiar with
the project's Permit to Work (PTW) system
would likely adhere to safe work procedures.
This training and knowledge of procedures
ensure that individuals understand and
follow the necessary safety measures.
NO the individual's actions and behavior do not
indicate an attempt or desire to conform with
applicable procedures and policies. Multiple
breaches of safety protocols, such as failing
to obtain permits, neglecting risk
assessments, and not using personal
protective equipment, suggest a lack of
intention to adhere to established
procedures.
NO Marmol management did not receive
advance notice or information regarding the
visit of the supplier's mechanical team.
NO it seems that the consequences of the
behavior were not necessarily intended. The
lack of adherence to safety procedures and
policies may have led to unintended
consequences, such as the incident
involving the repair of the wheel loader. their
actions may have been a result of
 negligence or oversight rather than
deliberate intent to cause harm.
Was information and/or training provided to the NO The individuals participating in the activity
7
individual did not undergo the project-specific Health,
Safety, and Environment (HSE) induction.
Is training or information relating to the non- NO Despite the availability of training programs
8
conformance available and information, the individuals involved in
the incident failed to adhere to safety
protocols and procedures, indicating a lack
of understanding or awareness regarding
the consequences of non-conformance. This
suggests that additional efforts may be
needed to ensure that personnel are
properly trained and informed about the
importance of conforming to established
procedures and policies.
Deficiencies in training, personnel selection YES The individuals involved does not have
9
process and/or inexperience with task received adequate training or guidance
regarding safety protocols and procedures,
leading to a lack of awareness or
understanding of the correct procedures to
follow. Additionally, there may have been
shortcomings in the personnel selection
process, such as insufficient screening for
qualifications or experience relevant to the
task at hand. Furthermore, inexperience with
the specific task being performed, such as
repairing the wheel loader, could have
further exacerbated the likelihood of non-
conformance with safety requirements.
Addressing these deficiencies through
enhanced training, improved personnel
selection processes, and providing more
guidance and supervision for inexperienced
personnel can help prevent similar incidents
in the future.
 System Failure / Blameless Error ✓ Error (Slips, Lapse or Mistake)
Outcome
 Inappropriate behavior  Reckless/Self Interest Violation
 Intentional act to cause harm or disruption
Actual impact of  None
Violation
Consequence Mgt. Reinforce Training: Ensure that all personnel undergo comprehensive training on the
Recommendation OQ life-saving rules.
Accountability: Implement a system of accountability where individuals are held
responsible for adhering to the life-saving rules. This could include regular audits,
assessments, and disciplinary actions for non-compliance.
Continuous Communication: Foster a culture of open communication where
employees feel comfortable raising concerns or reporting instances of non-compliance
with LSR. Encourage regular safety meetings and toolbox talks to reinforce the
importance of these rules.
Supervision and Monitoring: Increase supervision and monitoring of work activities to
ensure that life-saving rules are being followed correctly. This may involve assigning
dedicated safety supervisors or conducting frequent site inspections.
Recognition and Rewards: Recognize and reward individuals and teams who
consistently demonstrate adherence to life-saving rules. This could include incentives
such as bonuses, awards, or public recognition to encourage positive safety behaviors.
Corrective Actions: Implement corrective actions for individuals or teams found to be
in violation of life-saving rules. This may involve retraining, counseling, or temporary
suspension from hazardous tasks until competency is demonstrated.
Continuous Improvement: Regularly review and update the company's life-saving
rules based on feedback, lessons learned from incidents, and changes in industry best
practices. Continuously strive to improve safety standards and procedures.
Investigation Team Investigation Lead Safety Contractor Rep Contract Holder (in
(Direct Supervisor Representative (in case of case of contractor)
/ Line Manager) contractor
Name & Signature

Date

03.02.07-Life_Saving_Rules_Corporate-Procedure | April 2021

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