Doc. No. 4.5.3.

P-SLEI001

Busbar Revision: 0

Amalgamated Dept.: JHB

INCIDENT AND ACCIDENT INVESTIGATION PROCEDURE

PURPOSE

The purpose of this procedure is to describe how Busbar Amalgamated will report, record, manage,
investigate and implement corrective or preventative action for Safety, Health and Environmental (SHE)
non-conformances and incidents to ensure the continual improvement of the SHE Management System

BRIEF DESCRIPTION OF CHANGE

This document has been amended to make it site specific and to include the requirement of Clients

APPROVAL SIGNATURE RECORD

Reviewer Role Title Signature
Document Owner Busbar Amalgamated

Reviewed by: G. Stanley

Document Administrator M. Ferreira- Netto

Approved by Proconic

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Document Administrator
1.0. Scope:
It is applicable to all SHE Non-Conformances that occur on the Busbar Amalgamated site including
those relating to permanent, temporary employees and contractors.

2.0. References
3.1. Occupational Health & Safety Act Section 24(1)(2), 25, 31(1)(b) and 32(2)
3.2. GAR 9
3.3. COID Act Sec. 22, 25, 38 and 39.
3.4. General Machinery Regulations 7
3.5. Group Directive 15.1.1: Reporting fatal accident and serious incidents.
3.6. ISO 14001: 2004 Clause 4.5 (Checking and corrective action) Requirement 4.5.1 (Monitoring
and Measurement)
3.7. OHSAS 18001: 1999 Clause 4.5 (Checking and corrective action) Requirement 4.5.2
(Accidents, incidents, non-conformance and corrective and preventative action).

3.0. Definitions:
4.1. Fatal Incident

The death of an employee or contractor who dies as a result of an injury suffered in a work
related Incident.
4.2. Lost Time Accident
An injury, suffered in a work related incident, resulting in the employee being unable to report
for work on any scheduled shift or workday beyond the day or shift on which the incident
occurred.
4.3. Restricted Work Case Incident
This is an incident that causes injury, which while not resulting in time off work, does result in
the employee having to undertake light duties (restricted work or alternative duties) for at least
one shift following the incident prior to them returning to their normal job. Office workers cannot
be classed as RWC due to the fact that their work is already classed as light duties.
4.4. Disabling Incident
For record purposes a “disabling incident” will be defined as any incident which arises out of
and in the course of duty, resulting in any occupational illness, injury or disease; and giving rise
to any related temporary or permanent disablement as determined by a medical practitioner.
Such an incident shall furthermore be classified as a “disabling” where one or more of the
following criteria are applicable:
- The loss of one or more days or shifts following the shift during which the incident
occurred.
- All fractures and amputations, irrespective of whether or not any days were lost
- Occupational illness which necessitate medical treatment resulting in days off work.
4.5. Occupational Disease / Illness
Is a disease caused by environmental factors, the exposure to which is peculiar to a particular
process, trade or occupation, and to which an employee is not ordinarily subjected to or
exposed outside of or away from such employment.
4.6. Irreversible Occupational Incident
An occupational disease with irreversible health effects. (e.g. Noise Induced Hearing Loss)
4.7. Reversible Occupational Incident
An occupational disease with reversible health effects. (e.g. Dermatitis)
4.8. Environmental Incident
An environmental incident is any incident which causes harm or has the potential to cause harm
to the environment.
4.9. Major Environmental Incident
Any environmental incident which is reportable by law or impacts on the external environment.
4.10 Minor Environmental Incident
Any environmental incident which occurs within the factory boundaries and does not impact on
the external environment and is not reportable by law.
4.11 Incidents
An incident is an unplanned event which causes, or can cause, a degree of damage or harm to
persons, plant, materials, equipment or the environment.
4.12 Environment
Surroundings in which an organisation operates, including air, water, land, natural resources,
flora, fauna, humans, and their interrelation

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 4.13 Safety, Health and Environmental Management System
The part of the overall management system that includes organisational structure, planning
activities, responsibilities, practices, procedures, processes and resources for developing,
implementing, achieving, reviewing and maintaining the safety and health policy and
environmental care policy.
4.14 Non-conformance
Non conformances are when Spacelabs Employees do not conform to the following:
Legislation
Objectives and Targets
Key Performance Indicators
4.15 Serious Incidents:
4.6.1. Incidents involving any of the following:

    Serious injuries (as defined below)

    High potential incidents, such as large fires, explosions, escapes of gas or
hazardous substances, the collapse of scaffolding, cranes, or other large
structures including buildings, falling dangerous objects, all occurring in an area
normally occupied or used by personnel, or any other incidents having the
potential of causing Fatal Accidents or Serious Incidents whether resulting in
the individual case or not.
    amputation.
    serious or multiple fractures.
    loss of sight in one or both eyes.
    serious burns
    any other injury or incident resulting in unconsciousness requiring resuscitation
or admission to hospital than 24 hours.
4.16 CSC:
Country Sustainability Controller

4.0. Responsibility
4.1. The SHE Specialist is responsible for establishing, implementing and maintaining this
procedure
4.2. The SHE Specialist is responsible for ensuring that all qualified investigators understand and
adhere to this procedure.
4.3. All employees are responsible for reporting safety, health and environmental non-conformances
to the Emergency Co-ordinator.
4.4. The Regional Managers/Station Manager in conjunction with their SHE Representatives and
Supervisors are responsible for compiling accident investigation forms
4.5. The Regional Managers/Station Managers are to ensure that the necessary corrective action is
implemented.
4.6. The Regional Managers/Station Manager are responsible to the Country Sustainability
controller for ensuring compliance with the Group Directive 15.1.1; - Reporting fatal accidents
and serious incidents.
4.7. The Regional Managers /Station Manager shall be responsible for reporting any accident or
incident as promulgated in terms of Section 24 & the GMR 7 OF THE Occupational Health and
Safety Act, Act 85 of 1993. This shall include non-employees accidents as per General
Administrative Regulations 8.
4.8. The SHE Specialist is responsible for implementing and recording any changes in the
documented procedures resulting from preventive and corrective action.
4.9. The Emergency Co-ordinator shall within 14 days of the treatment of a person for diseases as
listed below or disease, which arose out of that person's employment, report such incident to
the Chief Inspector using WCL 22 form.

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5.0. Procedure
5.1. Internal SHE Incident/Accident Investigation Procedure:
5.1.1 All incidents requiring more than first aid treatment shall be documented on an
Annexure 1 form, the Regional Manager/Station Manager in conjunction with the
SHE representatives shall be responsible for the completion of these forms.
5.1.2. The Regional Managers/Station Manager along with the Emergency Co-ordinator must
complete a W.C.L 2(E) Form (Employer’s report of an accident), on the day of the
incident/accident. This report must accompany the injured person when he goes for
medical treatment outside the factory.
5.1.3. The completed form together with the First Medical Report (W.CL.4) must be forwarded
to the Head Office in Sunning Hill who is responsible for submitting the documentation
to the correct department so that the additional information can be completed and
forwarded to Alexander Forbes for registration with the Commissioner.
5.1.4. Copies of all WCL records shall be kept by the Emergency Co-ordinator for auditing
purposes. (This includes, First Medical reports, Progress Medical Reports and Final
Medicals.)
5.1.5. The Regional Managers/Station Managers in conjunction with the appointed Incident
Investigator, Supervisor and the injured employee shall form an investigation committee
and investigate the incident / accident or occurrence.
5.1.6. The preliminary investigation of an incident is to be conducted within 24 hours of the
incident occurring and the full investigation is to completed within seven days. The
proposed actions that are to be implemented as per the investigation are to be
completed within 3 months. In the case of the contractors, such investigations must be
completed within the contracted period.
5.1.7. All proposed preventive and corrective actions should be reviewed through a risk
assessment prior to implementation.
5.1.8. It is the responsibility of all Regional Managers/Station Manager to record all incidents
e.g. occupational injuries, illness, environmental damage or damage to property,
material and equipment loss within their area of concern and forward the records to the
Administrator who shall be responsible for the filling of these incidents and updating of
the incident Data base.
5.1.9. All of the above mentioned shall be summarized by the SHE Specialist on a monthly
basis for discussion during monthly Safety Committee.
5.1.10. The Regional Managers/Station Manager shall be responsible for reporting any
accident / incident as promulgated in terms of Section 24 & the GMR 7 of the
Occupational Health and Safety Act, Act 85 of 1993.
5.1.11 The risk Assessments are to be reviewed after every serious injury to ensure that it is
correctly rated and additional controls are not required.

5.2. The following incidents within BA shall be investigated, pending the severity, probability
of re-occurrence and financial impact.

5.2.1. Safety
o Fatalities
o Total Permanent Impairment
o Lost Work Day
o Medical Treatment

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 SPECIAL NOTE FOR REPORTING INCIDENTS.

Reporting of incident in connection with machinery: (GMR 7).

The following incidents are to be reported to the Department of Labour:- ( Provincial

Inspector, Enforcement and Inspection Services )

* The fracture or failure of any part of machinery resulted in a falling or flying

object
* Machinery ran out of control as a result of the failure of a control or safety
equipment and could have caused an injury to a person who had been
conveyed on or in such machinery or had been in the vicinity thereof ; or
* The fracture or failure of any part of machinery in which gas is under pressure
resulted in the sudden release of such gas, shall be reported forthwith to an
inspector by the employer or user of machinery concerned.

Section 24:

The following incidents are to reported to the Compensation commissioner,

Provincial Inspector, Enforcement and Inspection Services

* Any person dies, becomes unconscious, suffers the loss of a limb or part of a
limb or is otherwise injured or becomes ill to such a degree that he is likely
either to die or to suffer a permanent physical defect or likely to be unable for a
period of 14 days either to work or to continue with the activity for which he was
employed or is usually employed;
* A major incident occurred; or
* The health or safety of any person was endangered and where-
- A dangerous substance was spilled.
- The uncontrolled release of any substance under pressure took place.
- Machinery or any part thereof fractured or failed resulting in flying, falling or
uncontrolled moving objects;or
- Machinery ran out of control, shall, with in the prescribed period and in the
prescribed manner, be reported to an inspector by the employer or the user of
the plant or machinery concerned, as the case may be
* In the event of a incident in which a person died, or was injured to such an
extent that he is likely to die, or suffered the loss of a limb or part of a limb, no
person shall without the consent of an inspector disturb the site at which the
incident occurred or remove any article or substance involved at which the
incident occurred or remove any article or substance involved in the incident
there from: Provided that such action may be taken as is necessary to prevent
a further incident, to remove the injured or dead, or to rescue persons from
danger.

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 5.2.2. Health
The following is the list of diseases to be reported to the Inspector and to

DISEASES
W1. Pneumoconisis-fibrosis of the parenchyma of the lung pleural thickening causing
o significant impairment of function.
r 2. Bronchopulmonary disease
k 3. Byssinosis
m4. Occupational asthma.
e 5. Extrinsic allergic alveolitis
n 6. Any disease or pathological manifestations
’ 7. Erosion of the tissue of the oral cavity or nasal cavity
s 8. Dysbarism, including decompression sickness barotrauma or osteonercrosis
9. Any disease: allergic or irritant contact dermatitis
C 10. Mesothelioma of the pleura or peritoneum or other malignancy of the lung
o 11. Malignancy of the lung, skin, larynx, mouth cavity or bladder
m12. Malignancy of the lung, mucous membrane or the nose or associated air sinuses
p 13. Malignancy of the lung angiosarcoma of the bladder
e 14. Leukaemia
n 15. Tuberculosis of the lung
s 16. Brucellosis
a 17. Anthrax
t 18. Q-fever
i 19. Bovine tuberculosis
o 20. Post traumatic Stress
n 21. Hearing impairment
22. Hand-arm vibration syndrome (Raynaud’s phenomenon)
C 23. Any disease due to overstraining of muscular tendonous insertions.
ommission in case of treatment:

5.2.3. Environment

Any incident that involves the following needs to be reported to the City Council or
department of Solid Waste and Water Pollution and Department of water affairs

Major Environmental Incident

o Major emission
o Fire or Explosion leading to danger to the public or potentially serious pollution or
detriment to the environment (immediate or delayed)
o Pollution of or potential to pollute a water resource
o Has or is likely to have a detrimental effect on a water resource

There are various classification of of environmental incidents.

o Major Environment Incident
o Reportable environmental Incident
o Minor Environment Incidents.

The Environmental Management System includes procedures to identify and control several
types of non conformance:
o internal incidents
o external complaints
o emergencies
o legal non-compliance

The above incidents could include any of the following:

o Spillage of chemical/product/other substance
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 o Waste of Resource (e.g. Water/Electricity)
o Incorrect Waste Separation
o Contamination of road/stormwater system
o Major dust problem
o Obnoxious odour/smell
o Poor housekeeping

5.3. The Investigation Process.

5.3.1. Introduction:
Incident investigation should be seen as a systematic and pre-planned exercise. To
ensure this, a systematic process must be followed.
5.3.2 Process:
o Phase 1 – Situation analysis:
The investigator (s) must arrive at the scene as soon as possible after the
incident has taken place and establish what should have happened and what
actually happened.
o Phase 2 – Collect Information:
Ask questions; observe the general scene and activities and view
documentation. Take pictures where possible.
o Phase 3 – Analyze data:
Root and basic causes must be established from the data analysis.
o Phase 4 – Remedial Action Plans.
Final conclusion and recommendations must be drafted and submitted to the
appropriate person(s). When evaluated and agreed upon, action plans must be
implemented.
o Phase 5 – Follow up.
The recommendations made must be assessed and reviewed to ensure that
they are appropriate and that they address the risk factors agreed on as
acceptable.

5.4. Group Directive 15.1.1: Reporting fatal accidents and serious incidents:

5.4.1 If a fatal accident or serious incident occurs, the SHE specialist must immediately
inform the CSC by telephone (or the responsible Country Manager /
Regional Manager and GF-SA if the CSC cannot be reached). The CSC must then
immediately inform the Country Manager / Regional Manager and GF-SA by telephone.
On site where there is no SHE Specialist, (e.g. construction, project, customer, field or
maintenance sites), the project manager, or sustainability controller, or OHS Officer
appointed by the project manager, must immediately inform the CSC by telephone (or
the responsible Country Manager / Regional Manager and GF-SA if the CSC cannot be
reached or has not been appointed).

5.4.2. Within 24 hours of the fatal accident or serious incident, the CSC (or LSO or appointed
person, if the CSC cannot be reached or has not been appointed) must send the
completed Form F1 by Lotus Notes to the Group CEO, GF-SA, GF-CC, and the
responsible Country Manager / Regional Manager of the country concerned.

5.4.3 Within one week of the fatal accident or serious incident, the CSC (or LSO appointed
person, if the CSC cannot be reached or has not been appointed) must provide GF-SA
with photographs, sketches and relevant documents to indicate the scope of existing
controls before the accident or incident, such as training records, risk assessment,
method statement, standards operating procedure, maintenance records, etc. Where
necessary GF-SA will liaise with Group Function - Risk Management & Insurance (GF-
RI) to ensure co-ordination of Group -level investigations.

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 5.5. Group Directive 15.1.1. Reporting fatal accidents and serious incidents: - Investigation
Requirements:

5.5.1. Immediately following the occurrence of a fatal accident or serious incident, the
responsible Country Manager / Regional Manager must initiate a local investigation to
include the following actions:

    Appoint and brief an investigation team, which must include appropriate

technical experts, headed by a senior chairperson independent of the site or
project concerned.
    Issue terms of reference for the investigation team.
    Consider at what point legal advice may be needed.
    Specify timescales for the delivery of the team's report.
    Decide whether an interim report would be appropriate to provide immediate
recommendations to avoid a repeat of the accident or incident.
    Produce a final report including a technical analysis of the accident or incident
with long term, as well as any short term, recommendations.

Prior to release of the report the responsible Country Manager / Regional

Manager must review the findings and recommendations and agree on appropriate
courses of incident. The final report must contain management responses to all
recommendations and a responsible person assigned to each action. Each action must
have a target time for completion. Regular progress reviews must be conducted to
ensure all actions are implemented fully and on time.

5.5.2. The responsible Country Manager / Regional Manager, in consultation with GF-SA,
must decide on the distribution of the report and which findings and "lessons learned"
are to be shared with other businesses.

6.0. Records:

Doc No. Document Name Kept by/at Retention Period

Employers Report of an Accident
(WCL2)
8.2. Recording and Investigation of
Incidents (Annexure 1)
8.3. Incident Accident Investigators
Appointment Letters.
8.4. Group Instruction 15.1.1: -
Notification Form.
8.5. Statistics.

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