INCIDENT REPORTING AND INVESTIGATION PROCEDURE

Transcription

1 INCIDENT REPORTING AND INVESTIGATION PROCEDURE Document No: PGM HSE PRO B Revision: A B Prepared by: Reviewed by: B Sowden M Matthews/ W Astill J Bromley/ C Ellam/ B Morrow/ N Taylor/ S Bidois Approved by: J Bromley/S Bidois C McAuley T Moylan C Winn SUMMARY OF DOCUMENT REVISIONS Rev. No. Date Revised Section Revised Revision Description 1 20/11/2012 All Yearly review: clarified environmental incidents; included investigation requirement matrix, improved cross referencing. Uncontrolled if printed, retrieve current version from STEMS Page 1 of 19

2 TABLE OF CONTENTS 1. PURPOSE 3 2. SCOPE 3 3. DEFINITIONS AND ACRONYMS Definitions 3 4. ROLES AND RESPONSIBILITIES 6 All Personnel 6 Area Supervisor 6 Line Manager 6 Health, Safety and Environment Manager 7 Health, Safety and Environment Superintendent 7 General Manager 7 5. TRAINING 7 6. PROCEDURE Immediate Action and Reporting Investigation Level Determination Collection of Information Investigation Corrective Actions Communication of Lessons Learnt 9 7. RECORD KEEPING 9 8. REVIEW LEGISLATION AND STANDARDS RELEVANT DOCUMENTATION APPENDICES 10 APPENDIX A 11 Paddington Operations Risk Ranking Matrix 11 APPENDIX B 13 Investigation/Injury Reporting and Investigation Matrix 13 APPENDIX C 15 Medical Treatment Examples 15 APPENDIX D 17 5 Whys Analysis Form 17 Uncontrolled if printed, retrieve current version from STEMS Page 2 of 19

3 1. PURPOSE This document sets out the requirements for effective reporting and investigation of incidents and hazards occurring at Norton Gold Fields (NGF) Paddington Operations. It is important that consistent, quality information is obtained about incidents and their causes, to develop appropriate corrective actions to prevent their recurrence. 2. SCOPE This Procedure applies to all sites within the NGF Paddington Operations. 3. DEFINITIONS AND ACRONYMS 3.1 Definitions Incident Classifications Hazard A hazard is anything which has the potential to cause harm (ill he alth, injury or damage to plant, property, the environment or community assets). Incident An incident is an unplanned or unwanted event that has or could have resulted in harm. Near Miss A near miss is an incident that has not resulted in harm - that is there were no consequences from the incident. However, under slightly different circumstances there could have been. Serious Potential Incident A Serious Potential Incident (SPI) is any: Incident where the potential consequences have been risk ranked as Catastrophic, regardless of the actual consequences of the incident. Incidents in which actual injury/illness, property loss/damage or environmental damage has occurred as well as incidents which are near misses may be classified as SPIs. NB. Estimation of potential severity must be realistic and should consider the outcome of the incident under slightly different circumstances. Uncontrolled if printed, retrieve current version from STEMS Page 3 of 19

4 Reportable Incident A Reportable incident is an occurrence required to be reported to the District Inspector of Mines as set out in: Section 78 of the Western Australian Mines Safety and Inspection Act 1994; the Mining Act 1978 via tenement conditions; or to the Department of Environment and Conservation: the Environmental Protection Act 1986 (Section 72);or the Contaminated Sites Act 2003 if an incident creates a suspected or known contaminated site. Reporting of damage to community assets (cultural heritage) can be required under the Aboriginal Heritage Act There are other Acts relating to incidents that may need to be considered on a case by case basis for unique incident types. Injury Classifications Work Related Fatality A work related fatality is a death resulting from a work related injury or illness. Lost Time Injury (LTI) A Lost Time Injury is any work-related injury that results in the injured person being absent from work, as a direct result of the severity and nature of the injury, for one full shift or longer. Shifts lost as a direct consequence of the time taken to obtain a confirmation on diagnosis or treatment do not cause an injury to be classified as a Lost Time Injury (e.g. due to remote location). Modified Work Injury (MWI) A Modified Work Injury is a work-related injury or illness, where a doctor or other licensed health care professional considers it necessary to keep the employee from performing one or more of the routine functions of their job or from working a full shift. Medical Treatment Injury (MTI) A Medical Treatment Injury (MTI) is any work-related injury that: is outside the scope and capability of a first aider requires treatment by, or under the specific order of a medical practitioner or any injury that could be considered as being one that would normally be treated by a medical practitioner; and is not a lost time injury or a modified work injury In simple terms, an MTI is more serious than a First Aid Injury, but less serious (a s determined by the degree of incapacitation or in terms of time lost) than an LTI or MWI. Examples of MTIs are contained in Appendix C. Uncontrolled if printed, retrieve current version from STEMS Page 4 of 19

5 First Aid Injury (FAI) A First Aid Injury is any work-related injury/illness that is managed by first-aid treatment only, regardless of who administers the first aid treatment. Disabling Injury This is a statutory classification that applies only in WA. (Reference: WA DMPR Guideline: Occurrence, Accident and Occupational Disease Legislative Reporting Requirements, May 2001) An injury that results in the injured person being disabled so that they are unable to return to their ordinary occupation the following day, regardless of whether the person is rostered to work the following day or not. This includes disabled persons assigned to alternate duties Total Recordable Injury (TRI) Total Recordable Injuries (TRIs) is an indicator developed by the minerals industry and includes all injuries except first aid cases. This includes lost time injuries, medically treated injuries and modified work Injuries Routine Functions Routine functions are those work activities the employee usually performs at least once per week. Work Related Injury An injury or illness is work related if an event or an exposure in the work environment either caused or contributed to the resulting condition or significantly aggravated a pre-existing injury or illness. Injuries and illnesses resulting from events or exposures occurring in the work environment are presumed to be work related, unless listed in the exceptions described below: Exceptions for where injuries are not considered work related An injury or illness occurring in the work environment that falls under one of the following exceptions is not work related The injury or illness involves signs or symptoms that surface at work but result solely from a non-work related event or exposure that occurs outside the work environment The injury or illness results solely from voluntary participation in a wellness program, a medical, fitness, sporting or recreational activity. The injury or illness is solely the result of an employee eating, drinking or preparing food or drink for personal consumption The injury or illness is solely the result of an employee doing personal tasks (unrelated to their employment) at the establishment outside the employee s assigned working hours The injury or illness is caused by a motor vehicle incident and occurs in a company car park or company access road while the employee is commuting to or from work The injury or illness occurs whilst the employee is at a home away from home, e.g. a hotel, motel or other temporary residence, even though they are there in the course of their work Uncontrolled if printed, retrieve current version from STEMS Page 5 of 19

6 The illness is the common cold or flu. (Note: contagious diseases such as infective gastroenteritis, brucellosis, hepatitis A, tuberculosis are considered work-related if the employee is infected at work). Environmental Incident Classifications Level 1 Incident A Level 1 incident is one that results in negligible damage to the environment or heritage feature. Level 2 Incident A Level 2 incident is any other environmental incident including causing minor, shortterm or long-term damage. 4. ROLES AND RESPONSIBILITIES All Personnel Report any incidents or near misses that they have observed or been involved in to their supervisor. Area Supervisor - Make the area safe. - If required, seek first aid attention for either self or person(s) involved in event. - Isolate the area if required. - Ensure that the area involved with an incident is not disturbed. Make preliminary assessment of incident and preserve conditions where practicable. In conjunction with the person/s involved enter the incident information into STEMS. Assess/determine incident classification as defined above in Section 3. Determine level of investigation in conjunction with Line Manager. Report incidents to senior personnel in accordance with the Incident/Injury Reporting and Investigation Matrix. Prepare or assist in preparation of incident reports to external authorities in the format required by the relevant Act(s). Line Manager Liaise with supervisor to assess incident classification Notify relevant parties (internal/external) Confirm the level of investigation (using Incident/Injury Reporting and Investigation Matrix. Uncontrolled if printed, retrieve current version from STEMS Page 6 of 19

7 If deemed necessary based on the risk ranking of the incident, appoint an ICAM investigation team. Review investigation report findings and recommendations. Health, Safety and Environment Superintendent Participate in the investigation process as required. Ensure that information is collected and presented to the investigation team where an ICAM is the required investigation method. Prepare or assist in the preparation of reports to external authorities in the formats required by the relevant Acts. Health, Safety and Environment Manager Ensure this procedure is implemented at all sites under the control of NGF Paddington Operations. Monitor the extent and level of investigation to ensure it is consistent with the Risk Ranking Matrix and recommend any upgrade or down grade of level. Participate in the investigation process as required. Monitor the database to ensure that the corrective actions have been implemented by their due date. Review the quality of reporting and investigations and make recommendations to management as required. Ensure that a sufficient number of key employees are trained in the application of the ICAM investigation process. Responsible for periodic review of this Procedure. General Manager Responsible for ensuring sufficient resources are available to implement this Procedure. Responsible for signing off incident reports to external authorities. 5. TRAINING All personnel shall be informed of their responsibilities regarding the reporting and investigation of incidents and near misses during the General Site Induction. Those personnel required to facilitate ICAM investigations shall undergo ICAM training. 6. PROCEDURE 6.1 Immediate Action and Reporting When an incident occurs, immediate action is required to prevent escalation and further injury/damage. In the case of injury the first action involves treatment and assessment by an appropriately trained first aider. Uncontrolled if printed, retrieve current version from STEMS Page 7 of 19

8 Where possible the site should be left undisturbed until the investigation team has inspected it. Where this is not possible, photographs should be taken or sketches made of the scene. The Area Supervisor must be advised of the incident and an assessment of the problem should be made to identify the extent of injury and/or damage. All incidents shall be notified immediately to the Line Manager, HSE Manager and Mine Manager in accordance with the NGF Paddington Operations Incident/Injury Reporting and Investigation Matrix. Notification should contain details of: Time, place and nature of the incident Persons injured, equipment damage Nature of injury/damage and estimate of severity Immediate corrective action being taken Activity in progress at the time 6.2 Investigation Level Determination The Area Supervisor determines the level of investigation based on the classification of the incident. The HSE Manager may recommend to Management upgrade or downgrade of the level after consideration of all circumstances associated with the incident. The level of investigation shall be based on a risk assessment of the incident with the risk determined by consideration of the worst-case realistic scenario (potential consequence). The Risk Ranking Matrix shall determine the level of investigation required. The level of investigation can range from: Direct entry into STEMS Written Report (5 Whys) ICAM Investigation The Investigation shall be conducted in accordance with the training provided for each level of investigation. 6.3 Collection of Information The facilitator of the investigation shall, where required, request the HSE Superintendent to collect information required for the investigation and present it to the investigation team. The HSE Superintendent shall ensure that in the event of an ICAM being required, all relevant information pertaining to the incident is collected, collated and presented to the investigation team in a clear and concise manner. Uncontrolled if printed, retrieve current version from STEMS Page 8 of 19

9 6.4 Investigation An investigation is to: Document and describe the incident or near miss in detail, Establish the contributing factors and root causes leading to it; and Identify the corrective actions required to eliminate or prevent a recurrence. The timing of the investigation shall be dependent on completion of the collection of information and the nature of the incident. The investigation shall be scheduled by the facilitator. The personnel required to participate in investigations and the type of investigation shall depend on the risk ranking of the incident. The investigation requirements matrix shall provide guidance on the type of investigation required and the personnel who should participate in the investigation process. Upon completion of the investigation, documentation shall be forwarded to the HSE Superintendent for entry into STEMS. 6.5 Corrective Actions The principal objective of an investigation is to take action to prevent further incidents of this kind. There should be at least one recommendation addressed to each identified cause. Recommendations should be: S Specific M Measurable A Accountable R Reasonable T - Timely E - Effective R Reviewed Corrective actions shall be entered into STEMS and tracked to completion. 6.6 Communication of Lessons Learnt The lessons learnt must be communicated to the wider organisation so that all employees can benefit from an investigation. After the investigation and findings are reported, the relevant line manager will send the incident investigation details to the HSE Superintendent. The HSE Superintendent, in consultation with the Line Manager, will prepare and distribute an Incident Alert. A short presentation about the investigation and its findings and recommendations should be given to the workforce. 7. RECORD KEEPING Incident reports, Incident Alerts and ICAM investigation reports are retained on STEMS. Uncontrolled if printed, retrieve current version from STEMS Page 9 of 19

10 8. REVIEW A review shall be carried out to ensure the content of this procedure is still applicable, current and practicable. A review should take place: a. Whenever the process/equipment changes b. At a periodic frequency (every two years) c. At incident investigation. 9. LEGISLATION AND STANDARDS Mines Safety and Inspection Act Mines Safety and Inspection Regulations Australian Standard As Recording and Measuring Work Injury Mining Act 1978 Environmental Protection Act 1986 (Section 72) Contaminated Sites Act 2003 Aboriginal Heritage Act RELEVANT DOCUMENTATION The following documentation may be utilised or referenced to comply with the requirements of this procedure: Paddington Gold 5 Whys Analysis Form ICAM Incident Investigation Reference Guide 11. APPENDICES Appendix A Paddington Gold Risk Ranking Matrix Appendix B Incident/Injury Reporting and Investigation Matrix Appendix C Medical Treatment Examples Appendix D 5 Whys Analysis Form (Word version on STEMS PGM-HSE- FRM ) Uncontrolled if printed, retrieve current version from STEMS Page 10 of 19

11 Appendix A PADDINGTON OPERATIONS RISK RANKING MATRIX Uncontrolled if printed, retrieve current version from STEMS Page 11 of 19

12 Combine the results from Table A and B to calculate the risk ranking on Table C TABLE A. CONSEQUENCE OF EVENT (Actual and Potential) Level Descriptor Injuries Environment Corporate liability Cost 1 Insignificant Minor injuries 2 Minor First aid treatment 3 Moderate Minor medical treatment 4 Major Serious extensive injuries No permanent damage to the environment or heritage feature Spillage immediately contained; Minor short-term damage to the environment or heritage feature; Spillage contained with some difficulty; Significant short-term or minor long-term damage to the environment or heritage feature. Major short-term or significant longterm damage to the environment or heritage feature. 5 Catastrophic Fatality Major long-term damage to the environment or heritage feature TABLE B. LIKELIHOOD OF EVENT OCCURRING Level Descriptor Description No corporate liability <$10,000 Low corporate liability Moderate level of corporate liability High level of corporate liability. Very high level of corporate liability A Almost Certain Is expected to occur in most circumstances (ie > once per day) $10,000 - $50,000 $50,000 - $750,000 $750,000 - $3,000,000 >$3,000,000 B Likely Will probably occur in most circumstances (ie > once per month but < once per day) C Possible Should occur at some time (ie > once per year but < once per month) D Unlikely Could occur at some time (ie < once per year) E Rare May occur only in exceptional circumstances (ie unlikely to ever occur) TABLE C. Likelihood RISK RANKING Consequences A B C D E RISK LEVEL TYPE RANKING ACTION Extreme risk 1 5 Cease all affected work immediately. In the event of an incident an ICAM is required. Immediate action required. High risk 9 12 Consider ceasing all affected work. In the event of an incident an ICAM is to be considered. Action/s & responsibilities to be assigned by end of the shift. Moderate risk In the event of an incident an ICAM is to be considered. Manage by routine procedures. Low risk Manage by routine procedures. Uncontrolled if printed, retrieve current version from STEMS Page 12 of 19

13 Appendix B INVESTIGATION/INJURY REPORTING AND INVESTIGATION MATRIX Uncontrolled if printed, retrieve current version from STEMS Page 13 of 19

14 Incident/Injury Reporting and Investigation Matrix Injury/Incident Classification Investigation Level Basic 5 - Whys ICAM Shift Supervisor Superintendent Dept Manager Safety Coordinator HSE Superintendent Manager General Manager Managing Director *An Injury where immediate medical treatment is required I I I I NC NC IMMEDIATELY First Aid Yes No NC NC NC NC NC NC Medical Treatment Injury Yes D I NC I I NC NC Modified Work Injury Yes D I NC I I NC NC Lost Time Injury Yes D I I I I NC NC Fatality No Yes I I I I I I Serious Potential Incident No Yes I I I I NC NC Reportable Incident Yes D I I I I NC NC Environmental Incident Level 1 Yes No NC NC NC NC NC NC Environmental Incident Level 2 No Yes I I NC I NC NC Notes I = Immediately - means as soon as practicable after the incident has occurred - no matter what time of day or night. Priority shall be given to stabilising the injured and rendering the scene safe. NC = Normal Communication during business hours. Incident is to be reported upward verbally during normal business hours and entered into STEMS by the end of shift. D = Department Manager's Discretion - At the very least the incident is to be investigated by the Supervisor/Superintendent. Using the 5 Whys method is preferable. It is at the Department Manager's discretion whether an ICAM is to be carried out. * This refers to an injury where, in the opinion of the Supervisor/Superintendent on advice of trained first aider, the injured person needs immediate medical assessment or treatment beyond what can be provided by a trained first aider. Uncontrolled if printed, retrieve current version from STEMS Page 14 of 19

15 Appendix C MEDICAL TREATMENT EXAMPLES Uncontrolled if printed, retrieve current version from STEMS Page 15 of 19

16 A Medical Treatment Injury Does include: Use of prescription medications (except a single dose administered on the first visit for minor injury or discomfort) Use of sutures or staples to close a wound Treatment of partial or full thickness burns. Removal of embedded objects or corrosive chemicals from eyes by medical staff Injuries which result in loss of consciousness Surgical debridement (removal of burned or damaged tissue) Removal of foreign bodies from a wound if the procedure is complicated by the depth of embedment, size or location (does not include the removal of small splinters). Treatment of bruises by drainage Treatment of extensive abrasions at greater than full skin depth Series (more than two occasions) of physiotherapy or chiropractic treatment under the direction of a medical practitioner. Admission to hospital or equivalent for observation after head injury, injury to chest or abdomen or inhalation of gases or fumes. Note: the admission has to be based on severity of incident and/or symptoms, not on a hospital s automatic admission protocols. Use of non-prescription medication at prescription-equivalent dose/strength. Any fracture ECG after electric shock that shows abnormal rhythm of the heartbeat. These treatments are considered to be Medical Treatments regardless of the professional status of the person providing the treatment. The following Does Not constitute a Medical Treatment Injury: Diagnostic procedures such as X-rays (unless the result is positive), ECGs (see above), laboratory analysis, blood tests, administration of prescription medication used for diagnostic purposes, e.g. eye drops to dilate pupils unless they lead to further medical treatment. Tetanus shots or boosters. Visit to a doctor solely for observation, counselling or confirmation of diagnosis without any further medical treatment or treatment that could have otherwise been provided by a trained first aider. Uncontrolled if printed, retrieve current version from STEMS Page 16 of 19

17 Appendix D 5 WHYS ANALYSIS FORM (Word version on STEMS PGM-HSE-FRM ) Uncontrolled if printed, retrieve current version from STEMS Page 17 of 19

18 STEMS Incident Number: 5 WHYS ANALYSIS FORM Incident Location: Incident date: Type of Process: Type of Equipment: Team Members: Incident Description: FIVE WHY s 1. Why did the incident happen? What caused it? Verification /Reason 2. Why did 1 happen? Dig deeper a) b) c) 3. Why did 2 happen? Dig deeper a) b) c) 4. Why did 3 happen? a) b) c) 5. Why did 4 happen? a) Uncontrolled if printed, retrieve current version from STEMS Page 18 of 19

19 Identify the Causes of the incident: Description of Root Cause: Root Cause Categories: Action Items: Corrective Actions Action to Control Causes Assigned to Target Date 1. Specific Measurable Actionable Relevant Timely Facilitator Supervisor Superintendent Department Manager Investigation Sign Off Name Signature Date Name Signature Date Name Signature Date Name Signature Date Uncontrolled if printed, retrieve current version from STEMS Page 19 of 19

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