eohsms-05_procedure for incident investigation and analysis

Procedure for Incident Investigation & Analysis Ryobi Kiso (S) Pte Ltd EOHSMS-05

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Procedure for Incident Investigation &

Analysis


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1.0 Purpose

Incidents, implying accidents, industrial diseases and dangerous occurrences, may result in personnel injury and/ or damage to property. This system is established so that all incidents are investigated and analysed to ascertain the cause(s) and to initiate necessary preventive measures to prevent future recurrence.

2.0 Scope

This Procedure applies to : All employees, visitors and sub-contractors

3.0 Definition

3.1 Workplace Accident

A workplace accident is any accident occurring in the course of a persons work, except any accident which occurs while a person is commuting to and from his

workplace; any traffic accident on a public road; any accident which occurs in the course of work of a domestic worker.

3.2 Dangerous occurrence

A dangerous occurrence is a serious workplace incident which does not involve the death or injury of any person at work.

3.3 Occupational disease

A reportable occupational disease includes any of those listed in Annex B under WSH (Incident Reporting) Regulations.

4.0 References

4.1 Workplace Safety & Health Act 4.2 WSH ( Incident Reporting ) Regulations 4.3 MOM Guidelines on Safety & Health Management System

5.0 Form Used

5.1 EOHSMS-05-F01 Incident Report Form ( for companys employees, contractor, vendor & visitor) 5.2 EOHSMS-05-F02 Incident Statistics


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6.0 Procedure

6.1 Incident Reporting Procedure

Injured reports to Superior on his

condition, period of MC or

hospitalization

Department manager In-charge / Supervisor (serious incidents) investigate the incident by: Interview with the injured/ witness(s) Fill up Incident Report Form, and submit

within 24 hrs of the incident to Group Safety & Health Committee & HR.

Additional detailed incident report shall also be submitted within 72 hrs after fatal incident by Investigation Team.

HR submits report to MOM Commissioner within 10 days using the iReport system (http://www.mom.gov.sg/iReport)

Where no MC issued, staff may report

back to work

Seek first aid. Send to clinic or call ambulance at

995, where required.

Inform Direct Supervisor /Department manager In-

charge

Minor Injury/ Near Miss Injury (MC 1 day and above; hospitalization without permanent

disability)

Incident Occurred (Employee)

Fatal/ Serious / Minor Injury Near Miss / Dangerous

Occurrences (DO)

Group EOHS Committee Chairman/ designate notifies

MOM at 63171 111(Tel) 63171446

(Fax), during office hr

Fatal/ Amputation/ Permanent Disability

Notify Group EOHS Committee Chairman & HR Manager

Group EOHS Committee Chairman/ designate notifies

MOM at 63171 111(Tel) 63171446

(Fax), during office hr

Fatal/ Need Hospital Treatment

Incident Occurred (Member of public)

Seek first aid. Send to clinic or call ambulance at

995, where required.


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a) For serious incidents such as fatal accident, amputation case or dangerous

occurrences, Group EOHS Committee Chairman shall form an Incident Investigation Team to investigate the accident. The Incident Investigation Team shall consist of the following personnel:

Chairman of EOHS Committee Department manager concerned Supervisor concerned Group EOHS Committee Members Other personnel as determined by Management/ EOHS Committee Chairman/

Department Manager such as technical specialist

(b) The Incident Investigation Team/ Manager/ Supervisor concerned shall identify the root cause(s) to the incident tracing to the weakness of the EHSMS, propose and implement effective preventive and corrective measures to prevent the recurrence of the incident.

(c) In the event that an incident occurs to contractors/sub-contractors, the representative of that

company shall fill in the necessary particulars in the Incident Report Form and submit to the Yard / Project Manager within 24 hours. Yard / Project Manager will then furnish the report to the Group EOHS Committee and HR.

6.2 Report of Incidents to Authorities a) HR Manager shall ensure that work related accidents of the following category are reported to

the Commissioner of Workplace Safety & Health, MOM (Ministry of Manpower).

The report must be within 10 days using the iReport system on the Internet at the (http://www.mom.gov.sg/iReport).

b) Reportable Incidents include:

Death of an Employee Accident results in the injury of an employee who is given more than 3

consecutive days of medical leave or hospitalized for at least 24 hours

Accident causing injury to a self employed person or member of public and results in death or treatment in hospital for injury

Dangerous Occurrence Occupational Disease

c) Reportable Dangerous Occurrences include : i) Explosion or Fire a. Explosion or fire causing damage to the structure of any room/ place in which persons are employed, or to any machine/ plant contained therein, and resulting in the complete suspension of ordinary work in the room/ place or the stoppage of machinery/ plant for not less than 5 hours, where the explosion or fire is due to the ignition of dust, gas or vapour, or the ignition of celluloid or substance composed wholly or in part of celluloid.

b. Electrical short circuit or failure of electrical machinery, plant or apparatus, which results in an explosion, fire or structural damage, and involves its stoppage or disuse for at least 5 hours.


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c. Explosion or fire affecting any site in which persons are at work and causing complete suspension of ordinary work in the site for at least 24 hours. ii) Collapse of Structures or Equipment a. Failure or collapse of formwork or its supports

b. Whole or partial collapse of a scaffold exceeding 15 meters in height, or a suspended or hanging scaffold from which any person may fall more than 2 meters

c. Collapse or failure of lifting equipment (crane, derrick, winch, hoist, piling frame or any appliance used in raising or lowering persons or goods, or failure of any load-bearing part of lifting equipment, except the breakage of the chain or rope slings), also includes instances in which it is overturned

iii) Machinery Damage a. Bursting of a revolving vessel, wheel, grindstone or grinding wheel moved by mechanical power

b. Explosion or failure of the structure of a steam boiler, receiver or container used for the storage at a pressure greater than atmospheric pressure of any gas or gases (including air) or any liquid or solid resulting from the compression of gas iv) Flooding a. Accidental seepage or entry of seawater into a dry dock or floating dock causing flooding of the dry dock or floating dock.

d) Reportable Occupational Disease include:

HR Manager shall ensure that reportable occupational disease case is reported to the MOM (Ministry of Manpower) within 10 days through iReport system. The Designated Factory Doctor (DFD) who diagnosed the disease shall submit the diagnosis report within 10 days to MOM through iReport system.

Reportable Occupational Disease include:

1. Aniline Poisoning 11. Chrome Ulceration 21. Mercurial Poisoning 2. Anthrax 12. Chronic Benzene Poisoning 22. Mesothelioma 3. Arsenical Poisoning 13. Compressed Air Illness 23. Noise Induced Deafness 4. Asbestosis 14. Cyanide Poisoning 24. Occupational Asthma 5. Barotrauma 15. Epitheliomatous Ulceration 25. Organophosphate Poisoning 6. Beryllium Poisoning 16. Hydrogen Sulphide Poisoning 26. Phosphorus Poisoning 7 Byssinosis 17. Industrial Dermatitis 27. Poisoning From Halogen Derivatives of Hydrocarbons 8. Cadmium Poisoning 18. Lead Poisoning 28. Repetitive Strain Disorder Of Upper Limb 9. Carbamate Poisoning 19. Liver Angiosarcoma 29. Silicosis 10. Carbon Bisulphide

Poisoning 20. Manganese Poisoning 30. Toxic Anaemia

31. Toxic Hepatitis


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Summary table below lists the situations in which an incident report should be made to the Commissioner of Workplace Safety and Health:

6.3 Investigation & Analysis of Incident

(a) Incident investigations are necessary for the following purposes :-

Legal requirements Work Injury Compensation Act - WICA Identifying root causes and contributing factors, and tracing to weaknesses in the

EOHS Management System Preventing similar incident from happening in the future Managements interest in EOHS Establishing the cost of an accident

It is encouraged that incident investigation shall be carried out in a no blame culture. It is therefore considered imperative that any accident investigation considers all preceding factors leading to the accident, and to identify the root cause(s) of the accident in order to prevent a recurrence and eliminate unsafe acts and conditions.

Incident Who should report What to do

A workplace accident that causes the death of an employee.

The employer of the deceased worker.

Notify the Commissioner immediately; and

Submit the incident report within 10 days of the accident.

A workplace accident that causes injury to an employee, who is then: Given more than three

consecutive days of medical leave; or

Hospitalised for at least 24 hours.

The employer of the injured worker.


If the employee subsequently dies from the injury, the employer must notify the Commissioner as soon as he/she knows of the employee's death.

A workplace accident that involves a self-employed person or member of public, causing him/her to: Die; or Sent to hospital for

treatment of injury.

The workplace occupier Notify the Commissioner immediately; and


A dangerous occurrence The workplace occupier Notify the Commissioner immediately; and

Submit the incident report within 10 days of the incident.

An occupational disease The doctor who diagnosed the disease; and The employer of the person with the disease.

Submit the incident report within 10 days of diagnosis (Doctor).

Submit the incident report within 10 days of receiving the written diagnosis (Employer).


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Staffs who are interviewed following an accident must be assured that the interview is carried out to identify root cause(s) and to implement measures to prevent recurrence, and not to apportion blame.

(b) The following are the procedures for incident investigation:

Questions asked during investigation can include:-

1. Was the injured worker(s) / contractor (s) aware of the hazard(s) associated with the activity?

2. Was he instructed in the safe working procedure?

3. Why was he permitted to carry out the work in the manner in which it was undertaken?

4. What training had been received?

5. What maintenance, inspection and examination of associated equipment had been carried out?

From answering the questions and many other contributory factors, management will be able to evolve and implement an action plan including the briefing of staff on safe systems of work and may also include retraining and implementing more rigorous maintenance regimes. Upon analysing the case by the Incident Investigation Team, the Department manager-in charge shall ensure that recommendations are implemented. These recommendations shall be subjected to inspection and audit by the EOHS Committee to ensure implementation of corrective actions has been carried out and has been effective.

All incidents happened and lessons learnt shall be communicated to employees by individual

Dept. Manger /Supervisor during workplace EOHS talk / briefing to inculcate awareness among employees.

(c) Maintenance & Review of Incident Records & Statistics

Incident records such as Incident Notification or report made shall be kept for 3 years from the date of notification or report. Human Resource Manager/ Document Controller shall also maintain the Incident Statistics EOHSMS-05-F02. Group EOHS Committee shall use the statistics to identify type, frequency, severity and causes of incidents so that appropriate measures for improvements can be proposed and implemented. The analysis of incident trends and statistics will also facilitate the planning of EOHS strategic plans, promotional programs and training courses at the workplace.

Obtain initial info. for investigation

Facts Gathering

Facts Analysis & Conclusion

Stop operation and seal off area, for fatal or serious incident

Ask when, where, what, who

Note down happening of incident briefly

Take photographs

Examine the scene eg. broken parts

Interview injured and witness

Take samples for analysis

Check records e.g. servicing, training, instructions

Consider contributing factors, causes

Refer to recognized standards, legislations, past experience, general accepted practices

Implement corrective & preventive measures

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