Incident Reporting, Recording and Investigation Procedure. Issue Date: 20/03/2013 Review Date: 20/03/2014

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1 Incident Reporting, Recording and Investigation Procedure Issue Date: 20/03/2013 Review Date: 20/03/2014 FORM: REV: 7 STATUS: Issued for Use DOC OWNER: HSE Risk Manager Purpose This procedure establishes minimum HSE standards which are mandatory for reporting, recording, classifying, notification and investigating of incidents. It is recognised that implementation of this procedure may require additional local or departmental forms, checklists, registers and/or completion of government forms. Scope This procedure is applicable to all types of incidents, near misses and unsafe act observations which involve personnel (including contractors) and/or equipment involved in Arrow Energy controlled work. It is the responsibility of the Line Manager to ensure where required, additional documents are developed which meet and/or exceed the requirements set within this procedure. Deviation from these requirements must be managed in accordance with the HSE Document Deviation Procedure 1. Responsibilities Title Department Managers Line Managers Departmental HSE Managers Responsibilities Provide adequate resources to fulfil the requirements of this procedure. Ensure incidents are reported and investigated internally and where required externally, as per the requirements of this procedure. Act as or assign an appropriate team leader for incident investigations with a consequence severity of major. Ensure incident sites and other affected areas are made safe and that all necessary actions to prevent escalation of an incident are administered. Assign classifications to incidents and agree on actual and potential consequence severities. Ensure all necessary incident related paperwork is completed and submitted within agreed time frames. Act as or assign an appropriate team leader for incident investigations with a consequence severity of serious. Determine completion dates and provide adequate resources for the timely completion of corrective and preventative actions. Provide or facilitate necessary training to all relevant personnel on the requirements of this procedure and approved Arrow Energy investigation processes. Be familiar with all country and state specific HSE regulatory reporting and investigation requirements relevant to Arrow Energy operations. Authorise the issue of external notifications of HSE incidents to regulatory bodies. Act as or assign an appropriate team leader for incident investigations with a consequence severity of catastrophic. Disseminate relevant investigation reports. Ensure incident reports and key incident statistics are analysed for trends and act accordingly to introduce relevant actions designed to reduce the potential for loss. This document is UNCONTROLLED when printed 1/2 3

2 Title Supervisors Corporate HSE Advisors HSE Representatives All Personnel Responsibilities Ensure incident sites and other affected areas are made safe and all necessary actions to prevent escalation of an incident are administered. Act as team leader for investigations on incidents with a consequence severity of insignificant (as required) and minor. Communicate incident causal factors and actions to relevant personnel. Support Department Managers, Line Managers and Supervisors in the implementation and interpretation of the requirements of this procedure. Take part in investigations for incidents with a consequence severity of major or catastrophic. Support Line Managers and Supervisors in the implementation and interpretation of the requirements of this procedure. Take part in investigations for incidents with a consequence severity of serious. Administer a location specific incident register and/or recording system (or equivalent). Maintain training records for incident reporting, recording and investigation training. Report incidents openly and provide support to all incident investigations. Complete and submit all incident related paperwork in a timely manner. This document is UNCONTROLLED when printed 2

3 and Summary of INCIDENT OCCURS CRISIS & EMERGENCY MANAGEMENT INCIDENT MANAGEMENT CARE OF PEOPLE EMERGENCY RESPONSE EMERGENCY MANAGEMENT 1) INTERNAL REPORTING REHABILITATION CRISIS MANAGEMENT STABLE/SAFE ENVIRONMENT RETART OPERATIONS 2) INITIAL CLASSIFICATION RETURN TO WORK PLAN 3) EXTERNAL NOTIFICATION 4) INVESTIGATE 5) FINAL CLASSIFICATION 6) RECORDING/PERFORMANCE MEASURING 7) CORRECTIVE ACTIONS 8) REVIEW 9) COMMUNICATE 10) CLOSE OUT Figure 1 Incident Management This document is UNCONTROLLED when printed 3

4 Initial Response Internal Reporting When an incident has occurred, initial response actions to make personnel and the area safe must only be carried out if an individual feels comfortable and safe doing so. PERSONNEL SHOULD NOT PUT THEMSELVES IN DANGER WHEN RESPONDING TO AN INCIDENT Initial response actions may include: Isolating energy sources where safe to do so - work associated with the incident may need to be suspended to prevent further consequences; Removing personnel from danger and, if required, render first aid; Shutting down plant and/or equipment (where safe to do so); Raising the alarm through various means including: Telephone; Radio; Contacting the nearest Arrow Energy employee or Supervisor; and/or Initiating a Manual Alarm Call Point. Calling for emergency services, if required. If the incident has initiated an emergency situation, notification will be managed using the relevant Emergency Management Plan. Surat Basin Emergency Management Plan (19-CEM-PL-0001) Bowen Basin Emergency Management Plan (18-CEM-PL-0001) Brisbane Emergency Management Plan (99-CEM-PL-0002) Other Crisis & Emergency Plans and Procedures can be found on the Reservoir- Corporate HSE - Crisis & Emergency Management Section Supervisors must be consulted to ensure all necessary actions to prevent escalation of the incident are administered. Line Managers must ensure the incident site and other affected areas are made safe and where practicable, access to the location should be limited to authorised personnel only. The incident location should be secured using barricades and equipment covered to ensure additional damage is minimised. Photographs should be taken to record the scene and witness statements recorded as soon as practicable. All personnel are encouraged to report without penalty. Arrow Energy empowers and supports personnel when they notify their Supervisor of an incident or if they stop an activity because they believe there is, or has been potential for an incident to occur. Incident involving Arrow Personnel; When an incident occurs which involves Arrow Personnel or Arrow Activities it is important that Arrow Line Management are made aware of the incident immediately after initial emergency response actions are in place. The initial method of communication should be a phone call from the senior member of the party involved in the incident (or delegate) to their Line Manager/Supervisor followed by entering a written report in the Incident Management Database (Fountain). This document is UNCONTROLLED when printed 4

5 The Line Manager with the support of HSE Representative and/or Environmental Representatives notify the relevant Arrow Departmental Managers / SSM / SSSM within timeframes that allow assignment of an appropriate Incident Owner and time constrained external notifications be made as detailed in Statutory Notification Guideline (99-H-GDL-0029). If in doubt, report internally to SSSM level immediately after initial emergency response actions are in place. Incidents with potential to attract Government or Media attention must be reported without delay by SSSM to Arrow VP C&SD to allow timely Parent Company notification. Is the Incident a Significant Incident? A significant incident is an incident which is notifiable to external bodies (Regulators), or Recordable by Industry Statistics or the Arrow Scorecard. Note; The Arrow Scorecard content changes on an annual basis depending on the focus applied by the company. If the incident is classified as a Significant Incident, the Incident Owner must complete the Incident One Page Summary Form (99-H- FM-0062) and send it to the Arrow Energy Leadership Team as soon as possible after the incident occurs (no later than 24 hours) Completion of necessary Incident One Page Summary Form (99-H- FM-0062) should be prioritized after the completion of necessary actions required to manage the emergency situation. Departmental HSE Managers and Environment Managers should support the Incident Owner with this process. The purpose of the Incident One Page Summary Form is to make critical information and a situational update available to the Leadership Team wherever they may be. Incident Entry into the Incident Management Database The Incident Owner is responsible for ensuring that the incident is entered into the Incident Management Database (Fountain). When entered the incident will be assigned a unique incident number and an automatic incident notification is generated and distributed to internal stakeholders. If the persons reporting the incident don t have access to the Incident Management Database they should use the Incident Notification & Reporting Form (99-H-FM-0010) to provide a written report of the incident as backup to the initial phone call. The Incident Owner is responsible for ensuring that the information on the form is entered into the Incident Management Database. Access to the Incident Management Database can be arranged by contacting a Fountain Gatekeeper. The Incident Notification & Reporting Form should only be used when the persons involved don t have access to Incident Management Database. Information on the Incident Management Database is available on the Corporate HSE page of the Reservoir. This document is UNCONTROLLED when printed 5

6 Contractor Reporting Classification of Work Related Incidents Communication to Arrow Energy All Contractors are required to immediately report all health, safety, security and environmental incidents that occur at Arrow Energy controlled workplaces. (Including unplanned events resulting in, or having the potential for, injury or ill health to a person, damage to plant, equipment, Arrow Energy reputation or the environment, or a combination of these) The Contractor must report these incidents to the Arrow Supervisor, Contract Holder and Arrow HSE Representatives immediately after initial emergency response actions are in place. Is the Incident a Significant Incident? If the incident is classified as a Significant Incident, the Arrow Supervisor/Contract Holder must work with the Contractor to complete the Incident One Page Summary For. The Arrow Supervisor/Contract Holder must then send the One Page summary to The Leadership Team providing them with a situational update as soon as possible after the incident occurs (no later than 24 hours) Group HSE Managers and/or Environment Manager should support this process. Enter incident into Incident Management Database (Fountain) Contractors do not have access to the Incident Management System (Fountain). It is the responsibility of the Arrow Responsible Supervisor to enter the incident into the Incident Management System. Once the incident is entered into the Incident Management System, an incident notification will be generated and sent to internal stakeholders within Arrow informing them of the incident occurrence. Responsibility for classification Determine the work relatedness of the incident. What are the Legislative Jurisdictions that apply to the location and the activity? What are the actual Consequence Severity/Impact and Potential Risk Rating of the incident in each category of Occupational Health, Safety, Security, Environment, Reputation/Legal and financial. Determine the HSE Jurisdiction of the incident location including identification of: Mode of Contract Controlling Safety Management Plan Environmental Authority incident reporting conditions Site Safety Manager/Senior Site Safety Manager with responsibility to notify regulatory authorities. Other entities specified in legislation, coordination agreements and principal hazard management plans who must be notified of the incident or participate in its management (overlapping tenure) Work Relatedness An injury or illness will be considered work related if an event of exposure in the work environment either caused or contributed to the resulting condition This document is UNCONTROLLED when printed 6

7 or significantly aggravated a pre-existing injury or illness. Work relatedness is presumed for injuries or illnesses resulting from events or exposure occurring in the work environment; unless an exception specifically applies. Work Environment is defined as the establishment and other locations where one or more employees are working or are present as a condition of their employment. The work environment includes not only physical locations, but also the equipment or materials used by the employee during the course of work Work Related Exceptions include; Employee was present at the work environment as a member of the general public rather than as an employee. Signs or symptoms that surface at work but result solely from a non work related event or exposure that occurs outside of the work environment. Injury or illness results solely from voluntary participation in a wellness program or in a medical, fitness, or recreational activity such as blood donation, physical examination, flu shot, exercise class, racquetball, or baseball. Injury or illness solely the result of employee eating, drinking or preparing food for personal consumption at employers establishment (does not include illness caused by food contaminated by workplace contaminants or contaminated food supplied by the employer) Employee doing personal tasks (unrelated to their employment) at the establishment outside of work hours. Employee engaged in personal grooming, self medication for non-workrelated condition, or the injury was self inflicted. Injury or illness caused by an incident while employee is commuting to and from work or which occurs on a company parking lot or access road when the employee is commuting to or from work. Illness is the common cold or flu (see OSHA Guide for transmission of contagious diseases that are considered work related) Illness is a mental illness (not caused by the work environment) Travelling when the employee has established a home away from home by checking into a hotel, motel, company supplied housing or accommodation camp for one or more days. Travelling when the employee has taken a detour for personal reasons from a reasonably direct route. Note: The examples of work related exceptions above are condensed from the OSHA Record Keeping Handbook- Section Please refer to this publication for detailed guidance on interpretation of the Occupational Safety and Health Act of OSHA Record Keeping Handbook ( If the incident does not satisfy the work related definition/interpretation it should still be entered into the Incident Management System. The incident will still be classified for consequence but is not subject to escalation to This document is UNCONTROLLED when printed 7

8 Notifiable or Recordable Status. Arrow Incident Classifications Line Managers, with assistance from HSE Representatives and/or Environmental Representatives, shall classify work related incidents as per the OSHA Record Keeping Handbook definitions described below. The classifications are based on OSHA and comply with the following acts and regulations: Workplace Health and Safety Regulation; Petroleum and Gas (Production and Safety) Regulation; Petroleum (Submerged Lands) (Management of Environment) Regulations (or revised legislation as applicable); Environmental Protection Act; and Electrical Safety Act. All Arrow Energy locations shall use the classification definitions (listed below) for corporate reporting. This ensures common terms are used and allows for internal comparison. Local country or state specific terms may differ slightly and can be used at a site level, and with regulatory bodies, as required. The Arrow Energy work related incidents are classified as 1 (or more) of the following: Fatality; Lost Time Injury or Occupational Disease/Illness; Restrictive Injury; Medical Treatment Injury; First Aid Injury; High Potential Near miss Dangerous Event; Equipment Damage; Significant Environmental Incident Environmental Incident; Near Miss; and/or Unsafe Act or Condition. If an event occurs which does not involve harm or loss, it is defined as a Near Miss. This is defined as a work related incident where there has been a release of energy which, in slightly different circumstances could have injured or caused ill health to a person, damaged plant, equipment, company reputation or the environment. In the case of a Near Miss, energy has been dissipated elsewhere into the environment resulting in no loss or harm. Significant Incident A significant incident is an incident which is notifiable to external bodies (REGULATORS), or Recordable by Industry Statistics or the Arrow Scorecard. Note; The Arrow Scorecard content changes on an annual basis depending on the focus applied by the company. This document is UNCONTROLLED when printed 8

9 Fatality (FTL) Fatal injury to a person caused by a workplace, a relevant workplace area, a work activity, or plant or substances for use at an Arrow Energy controlled work site. NOTE: A fatality may occur at an Arrow Energy workplace due to a non-work related injury, illness or disease. In these circumstances, internal and external regulatory reporting requirements must still be followed. Lost Time Injury/Case or Occupational Disease/Illness (LTC) When the injured or ill employee experiences days away from the work beyond the day of injury or onset of illness, or days away are prescribed by a physician or licensed health care practitioner. (This applies even if the day after the injury/illness is not a rostered day of work) When a work related injury or illness that results in days away from work you must: Begin counting the days away from work on the day after the injury occurred or the illness began. Days away from work must be recorded whether the injured or ill employee follows the physician or licensed healthcare professional s recommendation or not. How do I count weekends, holidays or other days the employee would not have worked anyway? You must count the number of calendar days the employee was unable to work as a result of the illness or injury, regardless of whether the employee was scheduled to work or not. Weekend days, holidays, vacation days or other days off are included in the total number of days recorded if the employee would not have been able to work on those days because of a work related injury. How do I record a case in which a worker is injured or becomes ill on a Friday and reports to work on a Monday, and was not scheduled to work on the weekend? You need to record this case only if you receive information from a physician or other licensed health care professional indicating that the employee should not have worked, or should have performed only restricted work during the weekend. If a medical examination reveals that the person can work unrestricted on the next day but is prevented from doing so (for example by having a rostered day off or weekend) this would not be classified as an LTI. When the person has received clearance by a Medical Practitioner or Registered Professional to return to work and conduct normal duties, the person will resume the duties that were assigned to them prior to the LTI event. Restricted Work Case (RWC) When the employee is kept from performing one or more routine job functions (activities the employee performs at least once per week; or is kept from working a full workday- Not including the day of injury/illness onset or This document is UNCONTROLLED when printed 9

10 Permanent Total Disability Routine functions-work activities the employee regularly performs at least once per week. Permanent Total Disability- Permanent Total Disability is a work related injury where there is an inability for the employee to continue working. A physician or other licensed health care professional recommends that the employee not perform one or more functions of his or her job, or not work the full workday that he or she would otherwise have been scheduled to work. Do I have to record restricted work or job transfer if it applies only to the day on which the injury occurred or the illness began? No, you do not have to record restricted work or job transfers if you, the physician or other licensed health care professional, impose the restriction or transfer only for the day on which the injury occurred or the illness began. How do I record a case where the worker works only for a partial work shift because of a work related injury or illness? A partial day of work is recorded as a day of job transfer or restricted duties except for the day on which the injury occurred or illness began. When the person has received clearance by a Medical Practitioner or Registered Professional to return to normal duties the person will resume their normal duties as assigned to them prior to the Restrictive Injury event. Medical Treatment Injury/Case (MTC) Is a work related injury or illness that results in the employee requiring management and care as a patient to combat disease or disorder. Medical Treatment Cases do not include; Visits to Physicians or other licensed health care professionals solely for observation or counselling. The conduct of diagnostic procedures, such as x-rays and blood tests, including the administration of prescription medications used solely for diagnostic purposes (e.g. eye drops to dilate pupils) First Aid Cases( See definition below) What if a physician or other licensed health care professional recommends medical treatment but the employee does not follow the recommendation? You should encourage the injured or ill employee to follow that recommendation. The case must be recorded as medically treated regardless of whether the employee follows the recommendation. This document is UNCONTROLLED when printed 10

11 First Aid Case (FAC) A First Aid Case is recorded when first aid treatment is required as a result of a work related injury or illness/disease. First aid can include one or more of the following: Using a non-prescription medication at non-prescription strength (for medications available in both prescription and non-prescription form, a recommendation by a physician or other licensed health care professional to use a non-prescription medication at prescription strength is considered medical treatment); Administering tetanus immunisations (other immunizations, such as Hepatitis B vaccine or rabies vaccine, are considered medical treatment when given in the context of an injury); Cleaning, flushing or soaking wounds on the surface of the skin; Using wound coverings such as bandages, band-aids, gauze pads, butterfly bandages or steri-strips etc.); Using hot or cold therapy; Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts etc, (devices with rigid stays or other systems designed to immobilize parts of the body are considered medical treatment for record keeping purposes; Using temporary immobilizing devices such as splints, slings, collars or back boards while transporting an accident victim; Drilling a fingernail or toenail to relieve pressure, or draining fluid form a blister where an underlying fracture has been excluded; Using eye patches; Removing foreign bodies from the eye using only irrigation or a cotton swab; Removing splinters or foreign material from areas other than the eye by irrigation, tweezers, cotton swabs or other simple means; Using finger guards; Using massages (physical therapy or chiropractic treatment are considered medical treatment); Drinking fluid for relief of heat stress. No Treatment Case (NTC) Where an injury does not meet any of the other severity criteria (as outlined above) and does not require First Aid treatment, it can be classified as a No Treatment Case. Near Miss (NM) Is an incident that could have caused illness or an injury to people, or damage to Assets, the Environment or Reputation, but did not. (e.g. energy was released bur there were no actual consequences) High Potential Near Miss (HPNM) An incident that could reasonably have resulted in a serious injury or death except for One barrier, or what-if scenario This document is UNCONTROLLED when printed 11

12 Environmental Incident All consequences in which there was an effect on the environment (even if contained). This includes: Loss of Primary Containment (LOPC) with or without secondary containment, LOPC of any material including non toxic and non flammable materials from a process, or an undesired event or condition that =, under slightly different circumstances could have resulted in a COPC of a material. Significant Environmental Incidents (SEI) Are those incidents considered Significant and include those that have the potential for environmental harm, and also non- compliances/breaches to be reported to the regulator. Judgment of environmental harm includes spill volume, chemical type, receiving environmental sensitivity. Incidents beyond spills can be included e.g. Vegetation clearance. All incidents reported to the regulator are not necessarily Significant Property Loss/Damage (PLD) This is defined as an event that causes significant damage to plant, equipment or machinery owned or leased by Arrow Energy. Significant damage is defined as the result of an incident having the potential to cause damage over and above AUD $5,000. Unsafe Act or Condition (UAC) This is defined as a person s behaviour or act which can introduce or leave an unsafe condition in the workplace, with a wilful disregard for the safety of themselves or others, including but not limited to: Horseplay; Not wearing a seat belt or not driving to the speed limit; Not taking preventative action to a visible hazard, such as incorrectly stored Dangerous Goods; Non compliance with site procedures provided for safety, operations or maintenance; or Knowingly placing oneself or others in danger. Life Saving Rule Breach (LSR Breach) Is a breach of any of the twelve Life Saving Rules as listed below; 1. Work with a valid work permit when required. 2. Conduct Gas Tests when required. 3. Verify isolation before work begins and use the specified life protecting equipment. 4. Obtain authorisation before entering a confined space. 5. Obtain authorisation before overriding or disabling safety critical equipment. 6. Protect yourself against a fall when working at height. 7. Do not walk under a Suspended Load. 8. Do not smoke outside designated areas. 9. No alcohol or drugs while working or driving. 10. While driving, do not use your mobile phone and do not exceed speed This document is UNCONTROLLED when printed 12

13 External Notification limits. 11. Wear your seat belt 12. Follow prescribed Journey Management Plan. A breach of any Life Saving Rule will result in Life Saving Rule Consequence Management refer to the Life Saving Rules Consequence Management Procedure (99-H-PR-0035) Land Access Rule Breach (LAR Breach) Is a breach of any of the following Land Access Rules 1. Only enter the property with the approval of your supervisor, who has cleared access with the landholder/ 2. Only conduct activities that are approved within the access conditions. 3. Follow the directions of the Landholders Report any directions that are not within the access conditions. 4. Report landholder discussions, complaints or incidents to your supervisor or Land Liaison Officer. 5. Carry personal and vehicle identification showing that you are an employee or contractor of Arrow. 6. Keep sites tidy; ensure all rubbish is removed from site. 7. Do not interfere with the landholder s property, equipment or operations. Use approved tracks and lay down areas. Drive at less than 10kph within 200 meters of buildings. Leave gates as signed or found. 8. Do not take firearms, weapons, animals, illicit drugs or alcohol onto the property. 9. Do not light fires unless authorized. Smoking is only permitted in the designated locations. 10. Do not enter a site during or after wet weather without consent of the Land Liaison Officer (who has cleared access with the Landholder) except in the case of a declared emergency. 11. Do not negotiate with landholders. Only Land Liaison Officers are permitted to negotiate activities and access conditions. 12. Do not threaten or pressure landholders or other people on the property. Some incidents require external notification to regulatory bodies. It is vital that incidents which require notification to the regulator or other external parties are notified to the correct person within the correct timeframe, using the correct methodology. Notifiable Incidents require initial Notification as outlined above but there may also be a requirement for progress reports and close out report notification. The Statutory Notification Guideline (99-H-GDL-0029) provides guidance as to whether an incident is notifiable, who the notification must be made to, timeframe for notification and methodology for notification. For incidents which involve a contractor is the responsibility of the contractor to report any regulatory notifiable incident to the relevant regulatory body. See Attachment B Contractor Incident Guidelines Flowchart. This document is UNCONTROLLED when printed 13

14 Incident Investigation Internal Investigation Requirements The objective of all incident investigations is to determine and analyse causal factors and root causes and to develop and implement effective corrective/preventative actions which address the root causes and prevent such an incident from re-occurring. Investigation findings for all incidents are to be uploaded to the Incident Management System as a method of communicating the outcomes. Level of Investigation The level of investigation detail and formality is dictated by the consequence severity assigned to the incident. The investigation levels, Investigation Sponsor, Investigation Team makeup and Investigation Timelines are defined in Investigation Levels Guideline (99-H-GDL-0027) Any incident that is required to be reported to a regulatory body or of Severity Level 2 and above shall be investigated and analysed for Root Cause using the TapRooT or similar cause analysis technique. Contractors may use TapRoot or a similar investigation methodology. Insignificant and Minor Actual Consequence Severity 1-2 Investigation of incidents with a consequence severity of insignificant, minor and serious will include the following steps: Observations made from a site review and gathering of witness accounts (as required); Root cause analysis to an appropriate level (if reportable it must be a TapRooT ); Provision and recording of recommendations to prevent recurrence on the Incident Notification and Reporting Form9; and identified are completed to control any hazards. Moderate, Major and Catastrophic Consequence Severity 2-5 Incidents with a consequence severity of major or catastrophic must have a formal TapRooT investigation. The relevant Manager (as detailed in Investigation Levels Guideline (99-H-GDL-0027) will determine an appropriate investigation team leader. Formal investigation team leaders must be appropriately trained and competent in Arrow Energy approved TapRooT investigation techniques (see guidance notes for further details) and the requirements of this procedure. Note: The investigation team must include a relevant member of the Central Engineering Team for incidents of Severity Level 2 to 5 involving Loss of Containment, Safety, Asset Integrity, Equipment Damage / Failure, Serious or Dangerous Electrical Events, Ionisation Hazards. Incident Investigation The first stage of Incident Investigation is to form an investigation team as soon as possible after the incident occurs and establish an investigation team lead. This document is UNCONTROLLED when printed 14

15 Site layout and conditions prior to the incident; Sketches, diagrams, photographs Information about the injury/incident, as detailed in Attachment D Incident Reporting Lists; Procedures, risk assessments, Permits to Work, log book entries and other written instructions relevant to the incident for adequacy and implementation; Training records; Details and history of plant and equipment involved in the incident; Eye witness accounts which should be in the form of written statements; Supervisory structure; Information on previous incidents and similar events; and If the incident resulted in an emergency response, details of the emergency response actions must also be collected. A time line for the incident (and emergency action where relevant) should be developed to provide a basis for identification of the incident causal factors. Causal factors are categorised as follows: Initiating event/immediate cause(s): Circumstances and conditions that immediately precede the incident (such as fuel supply turned on); Underlying cause(s): Reasons why conditions were presented and how they link to the root cause(s). Often the result of personal factors (such as lack of knowledge), equipment failure or job factors (such as inadequate equipment); and Root cause(s): The controlling causes of the incident. Often organisational factors such as inadequate procedures, standards or non compliance with standards. Finalised investigation reports must be uploaded to the Incident Management System. Corrective/Preventative In the course of the investigation, observations and recommendations for corrective and preventative actions must be made and presented in the TapRoot Investigation Report Form or other appropriate investigation form. Line Managers shall be advised of actions which require immediate attention, to reduce the potential for reoccurrence, as soon as possible following discovery by the team. Corrective/Preventative actions should be entered into the Incident Management System and each action should be assigned to an action party. It is the responsibility of the Incident Owner to ensure that all actions assigned to their incident they are responsible for are actioned appropriately and then closed out in the Incident Management system. External Investigation Requirements Some investigations may require involvement from regulatory bodies and/or government agencies. These are stipulated by local, country and/or state legislation. The Group HSE Manager and Environment Manager (or delegate[s]) shall be familiar with all external investigation requirements for all Arrow Energy controlled work locations. This document is UNCONTROLLED when printed 15

16 Record Supervisors must record investigation details for incidents with a consequence severity of insignificant (when completed), minor and serious. This should be completed in Fountain. These must be submitted to the relevant Line Manager and HSE Representative/Environmental Representative for review and approval of corrective and preventative actions. Assigned actions must be entered against the incident in Fountain with an Action Party assigned. Formal investigation reports for incidents with a consequence severity of major or catastrophic are prepared on the TapRoot Investigation Report Form 16 and submitted to the Group HSE Manager or Environment Manager and relevant Department Manager for review, approval and sign-off. All investigation reports must be entered into the Fountain System. NOTE: Completed incident investigations which are to be sent to the relevant regulatory body, shall be forwarded to the Group HSE Manager or Environment Manager for distribution. Formal investigation reports must include the following information: Incident brief including: Facility/plant/area/location affected; Date/time of incident; Date/time of notification; Incident cost (including both financial and down time); Date of final report issue; and Name of investigation team leader and members. Incident summary; Incident conditions; Initiating event/immediate causes; Detailed incident description including: Incident time line; Causal factors; and Root causes. Preventative and corrective actions; Attachments, which may include: A flow chart or Why Tree figure of the incident; Relevant charts, drawings, records and the like; Event logs; Witness statements; and/or Photographs. The HSE Representative/Environmental Representative shall disseminate investigation reports to interested parties (similar departments) in other areas of the business. This facilitates knowledge transfer across the business and allows actions which may be relevant in other areas to be addressed. Alternatively, the Safety Alert Form or Environmental Alert Form may be issued to facilitate knowledge transfer. A Safety or Environmental Alert may also be issued to external bodies to facilitate industry learning. Confidential business or personnel information must be excluded from the Safety or Environmental Alert. The Line Manager, Group HSE Manager or Environment Manager with technical input from relevant personnel, shall authorise the issue of all internal This document is UNCONTROLLED when printed 16

17 Close Out Monitor and Review Training and external Safety Alerts 17 or Environmental Alerts as per the requirements of the Safety Alert Procedure 19 or Environmental Alert Procedure 20. Approved corrective or preventative actions must be recorded and progress to close out monitored. Line Managers shall determine completion dates, provide adequate resources and nominate personnel as responsible for the completion of each action. shall be communicated to those who have been nominated as responsible. The Group HSE Manager or Environment Manager shall ensure all incident reports and key incident statistics are analysed for trends and reported to relevant Department Managers as follows: Number of incidents by classification (such as LTIs, MTIs, Dangerous Events and the like); Frequency per million man hours of Fatalities, LTIs, MTIs and RIs (see guidance notes for how frequency is calculated); and Number of incidents by location. Where areas of commonality or trends occur, the Group HSE Manager shall act accordingly to introduce relevant HSE programs, initiatives, training and/or other actions which work to reduce the potential impact of loss throughout Arrow Energy. Likewise the Environment Manager will introduce the necessary environmental programs, initiatives and training to all Arrow personnel. Department Managers shall provide adequate training to all relevant personnel in accordance with their responsibilities to report, record and investigate incidents. Training records shall be maintained by the HSE Representative/Environmental Representative and refresher training provided as required. This document is UNCONTROLLED when printed 17

18 Guidance Notes Subject Specified High Risk Plant TapRooT Guidance Notes The following items of plant are specified as high risk plant under Schedule 2 of the Workplace Health and Safety Act 11 : Air conditioning units; Amusement devices; Cooling towers; Escalators; LP gas cylinders; and Lifts. The Schedule also provides a detailed definition for each type of high risk plant. For example, an LP gas cylinder is defined as a cylinder with a water capacity of more than 0.1kg that contains liquefied petroleum gas under pressure. TapRooT is an incident investigation system that analyses both human performance and equipment root causes of incidents. TapRooT is based on theory and models of human and equipment performance from a number of experts. It is a systems approach that not only looks at what happened but why it happened. TapRooT sorts the findings of an investigation into a structured framework consisting of 3 main steps and is illustrated in Figure 2 TapRooT Investigation Steps below. Calculating Frequency Figure 2 TapRooT Investigation Steps Investigators gather all relevant incident information and arrange this into a sequence of events. From this chart, causal factors are determined and agreed upon by all persons involved in the investigation. Each causal factor is tracked through the TapRooT Root Cause Tree TM to determine the root cause. The causal factors are grouped into the following basic categories: Procedures; Training; Quality control; Communications; Management systems; Human engineering; and Supervision. Each basic category branches into varying levels of root causes and a series of questions lead the investigators to actual root cause(s) of the incident. A frequency rate is the number of incidents (fatality, LTC, MTC or RWC) for each million hours worked. The number of hours used for the calculation can refer to the total number of hours worked by all personnel or may exclude the hours worked by contractors. This document is UNCONTROLLED when printed 18

19 Subject Department Manager Line Manager HSE Representative Environmental Representative Corporate HSE Advisor Guidance Notes The example below shows how an TRC Frequency Rate (TRCFR) is calculated: Number of TRCs in the period TRCFR = x 1,000,000 Number of hours worked in the period Any Manager/Supervisor position that has budget for and authority over a whole department. Relevant management personnel (i.e. Asset, Drilling or Project etc.) who supervise others but are not the head of the business unit or department. Person responsible at the work location for HSE activities. This role may be full time/part time. This includes field based roles such as HSEC Advisor and Field HSE Advisor. Person responsible for environmental protection and activities at the or for the work location. This role may be full time or part time. This includes Environmental Coordinators reporting to Environment Manager and/or HSE Representative on site. This position reports to the Group HSE Manager and is responsible for providing advice and support on HSE matters across the Arrow Energy organisation (both corporate and to field based assets). References Referenced Documents Reference Document Title 1 99-H-PR-0015 HSE Document Deviation Procedure 2 APPEA Safety Incident Reporting Guidelines, March APPEA Environmental Incident Database Guidelines, November Workplace Health and Safety Regulation Petroleum and Gas (Production and Safety) Regulation Petroleum (Submerged Lands) (Management of Environment) Regulations Environmental Protection Act Electrical Safety Act H-FM-0010 Incident Notification and Reporting Form 10 Surat Basin Emergency Management Plan 19-CEM-PL Bowen Basin Emergency Management Plan 18-CEM-PL Brisbane Emergency Management Plan 99-CEM-PL Workplace Health and Safety Act Electrical Safety Regulation 2002 This document is UNCONTROLLED when printed 19

20 Referenced Documents Reference Document Title H-PR-0026 HSE Regulatory Compliance Procedure V-PR-XXXX Environmental Regulatory Compliance Procedure H-FM-0043 Contractor Incident Investigation Review Form H-FM-0015 TapRoot Investigation Report Form H-FM-0037 Safety Alert Form H-PR-0067 Safety Alert Procedure H-GDL Statutory Notification Guideline H- FM Incident One Page Summary Form H-GDL Investigation Levels Guideline Supplementary Information Sources Document Control Revision Revision Date Reviewer Approver 7 20 Mar 2013 Lisa Mealiff Bernadette Urquhart Alan Gorlick Rachel Palmer This document is UNCONTROLLED when printed 20

21 Attachment A Contractor Incident Guidelines Flowchart Incident/Injury Contractor is aware of incident/injury Contractor contacts Emergency Services Attend to first aid treatment of injured persons, make the scene as safe as possible and apply emergency response procedures Contractor contacts Arrow Staff Non Notifiable Contractor commences investigation and classifies incident Notifiable FAI, Insignificant Injury, unsafe act/condition, minor and insignificant damage to plant/environment Contractor forwards report to Arrow for review and investigation Arrow returns report to contractor, tracks corrective actions until closed. Monitor and review. Arrow forwards report to Regulating Government Body with corrective action listed Contractor contacts Regulatory Government Body as determined by Statutory Notification Guideline (99-H-GDL-0029) MTI/LTI/RI, near miss dangerous event, dangerous act serious to major damage to plant/environment Contractor investigates and forwards report to Arrow Arrow investigates Contractor Management Fatality, life threatening injury, catastrophic damage to plant/ environment Regulating Government Body/Police investigate. Arrow and Contractor assist Contact an Arrow Energy Supervisor/OHS Representative and ask for assistance if in doubt. Contractor to report to Regulating Government Agency and Arrow Energy Staff Reportable Incidents: Immediately by phone. Report ASAP Non Reportable Incidents: Immediately by phone. Report with in 3 days. Staff from Arrow Energy have a duty of care to assist Contractors and to help them fulfil their obligations. Definitions of injuries are to be determined as per the requirements of the Arrow Energy Procedure Incident Reporting, Recording and Investigation (). This document is UNCONTROLLED when printed 21

22 This document is UNCONTROLLED when printed 22