AZN Procedure Doc. No.

: L3-005-HSE-02
Rev. Date: 25-Dec-2018
Issue
Issue Date Revalidation
No. HS & E Incidents and Observations Page 2 of 10
3 28-Jun-2015 24-Dec-2020

Distribution List
Department/Section Recipient Department/Section Recipient
Management GM Stores All staff
Operations All staff Chemistry All staff
H.R. & Administration All staff Electrical All staff
I.T. All staff Mechanical All staff
Finance All staff Instrumentation & Control All staff
Procurement All staff Engineering All staff
H.S.E. All staff Performance All staff
Security All staff

Revision Record
Revision
Issue No. Description of Change Effective date
No.
1 0 First issue 28/06/2015
Routine review; clarification of
2 1 incident definitions, removal of 22/03/2018
‘workarounds’ until relevant
3 Removal of references to Intelex
2 31/12/2018
and format change
 AZN Procedure Doc. No.: L3-005-HSE-02
Rev. Date: 25-Dec-2018
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No. HS & E Incidents and Observations Page 3 of 10
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Contents
1.0 PURPOSE.................................................................................................................. 4
2.0 PRINCIPLE ................................................................................................................ 4
3.0 SCOPE....................................................................................................................... 4
4.0 RESPONSIBILITY ..................................................................................................... 4
5.0 DEFINITIONS/ ABBREVIATIONS ............................................................................. 4
6.0 REFERENCES ........................................................................................................... 5
7.0 HSE AND BUSINESS RISK....................................................................................... 5
8.0 PROCEDURE ............................................................................................................ 5
8.1 Investigation of Incidents or complaints ............................................................................. 5
8.2 Incident Details ...................................................................................................................... 5
8.3 Investigation .......................................................................................................................... 5
8.4 Investigation .......................................................................................................................... 5
8.5 Corrective Action .................................................................................................................. 6
8.6 Monthly Reporting ................................................................................................................. 6
9.0 AUDIT / REVIEWS ..................................................................................................... 6
10.0 ATTACHMENTS ........................................................................................................ 6
Appendix 1 Definition of Incidents ........................................................................................7
Appendix 2 Guidance on Incident Investigation...................................................................8
 AZN Procedure Doc. No.: L3-005-HSE-02
Rev. Date: 25-Dec-2018
Issue
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No. HS & E Incidents and Observations Page 4 of 10
3 28-Jun-2015 24-Dec-2020

1.0 PURPOSE
This procedure defines the responsibilities for ensuring that all incidents (i.e. departures from
normal methods of working) and communications of an environmental nature are recorded,
reported to off-site authorities as necessary and investigated. To aid meeting this objective,
Incidents, Near Misses, HSE Observations and Unsafe Acts/Conditions are defined.

2.0 PRINCIPLE
The main objective is to learn from an incident to avoid a repeat or trend, communicate the
findings and gain improvement from review.

3.0 SCOPE
For the purposes of this procedure, an incident is any departure from normal that could have an
adverse effect on health, safety, environmental, financial, productivity, morale or other factors at
AZN. Environmental complaints should be considered incidents and managed in the same way.
In addition to actual events, it is particularly important that "near misses" and Unsafe
Acts/Conditions are recorded so that lessons can be learnt and communicated on and off site
and that systems and methods of working improved to avoid the actual losses that would arise
if the near miss became a direct hit.

The Incident Communications procedure must be followed to ensure the appropriate people
external to AZN are informed of a serious incident.

4.0 RESPONSIBILITY
General Manager Ensure external reporting is carried out in accordance with the AZN
O&M Incident Communications and in accordance with owner
procedures
Ensure a Panel of Enquiry is convened if required by the seriousness
of an incident

HSE Manager Ensure all incidents, near misses and UACs are investigated
appropriately and reported as required

HR & Admin Report injuries to the Kuwaiti Labour Department as required by Labour
Manager Law No. 6 of 2010, article 90

All members of Initiate an investigation via IMS when experiencing, witness or being
staff informed about an incident, near miss or UAC

5.0 DEFINITIONS/ ABBREVIATIONS

IMS Incident Management System
UAC Unsafe Act or Condition
Incident, Near Miss,
UAC etc see Appendix 1
 AZN Procedure Doc. No.: L3-005-HSE-02
Rev. Date: 25-Dec-2018
Issue
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No. HS & E Incidents and Observations Page 5 of 10
3 28-Jun-2015 24-Dec-2020

6.0 REFERENCES
Incident Management System
State of Kuwait Labour Law No. 6 of 2010

7.0 HSE AND BUSINESS RISK

All incidents must be investigated and any lessons learned communicated to all relevant staff.
Near misses and UACs must be investigated to ensure any trends are noted and the chances
of a similar event becoming an incident.

8.0 PROCEDURE
8.1 Investigation of Incidents or complaints
All incidents should be recorded on the IMS to allow for investigation, recording of
consequences and assigning of corrective and preventive actions.

8.2 Incident Details

A person experiencing an incident or near miss should report to HSE via the IMS. This system
allows all UACs, near misses and incidents to be reported on the same application. The fields
for each are labelled to show the information required; when sufficient information has been
entered to allow an initial investigation to take place the name of the duty shift engineer or line
manager should be entered, the form must be saved and then submitted. Note that when the
form is submitted for assessment notification is sent automatically to the HSE Department
giving brief details of the incident.

8.3 Investigation
If an investigation is required the Incident Manager creates and investigation form and adds
any appropriate comments and assigns an Incident Investigator from staff members.

NOTE: The State of Kuwait Labour Law No. 6 of 2010, article 90 requires that:

“If the worker is injured due to reason and in the course of or on his way to and from the work,
the employer shall report the accident immediately upon its occurrence or promptly upon
having knowledge thereof, as the case may be, to each of the following:
a) The Police Station of the area under whose jurisdiction the place of work is situated
b) The Labour Department under whose jurisdiction the place of work is situated
c) The Public Institution for Social Security or the insurance company in which the workers are
insured against the work injuries”.

The law is intended as protection for workers but does not appear to differentiate between
levels of injury, and all accidents where a worker is significantly injured should be reported.

8.4 Investigation
The Incident Investigator nominated to investigate the incident completes the investigation
and saves and submits the form when complete. During the investigation, a Root Cause
Analysis should be made and recorded on the form.
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8.5 Corrective Action

When the investigation is complete a Corrective Action form should be initiated and actions
assigned.

8.6 Monthly Reporting

Incidents, near misses and unsafe acts/conditions are reported each month to the
management team by the HSE Manager using data collected from the IMS, along with Fresh
Eyes statistics, safety walks data and other information as required.

9.0 AUDIT / REVIEWS

This document will be reviewed every 2 years or as a result of audit findings.

10.0 ATTACHMENTS
AZN O&M procedure Incident Communications
Appendices
 AZN Procedure Doc. No.: L3-005-HSE-02
Rev. Date: 25-Dec-2018
Issue no. Issue Date Revalidation
HS & E Incidents and Observations Page 7 of 10
3 28-Jun-2015 24-Dec-2020

Appendix 1 Definition of Incidents

Incidents
An Incident is any departure from normal that has an adverse effect on health, safety, the
environment, or finances of the station or company.

For example:
Any injury to staff, visitors or contractors,
A spillage of oil or chemicals of more than approx 2 litres,
Any damage to plant, buildings or grounds,
Any dangerous occurrence or disease,
A breach of the site Environmental Licence,
Any work carried out without a PTW where one is required.
An item of waste disposed of off-site incorrectly that may cause significant harm

A Near Miss is a dangerous occurrence that could have caused injury if circumstances or timing had
been different.

For example:
A potential breach of the site Environmental Permit
A piece of scrap metal falling from a HRSG gantry that would have caused injury had it fallen onto a
passer-by,
A spillage of oil or chemicals of less than approx 2 litres that could have become more serious,
A loose handrail that moved when a person leaned on it, but it did not fail altogether,

An Unsafe Act is when a person allows or causes something to be left in a position that could cause
injury or damage in the future.

For example:
When a person leaves a piece of equipment or debris in a position from where it could fall or be
knocked onto someone below,
A hot pipe is left with some lagging missing,
A handrail is left loose that could cause someone to fall if they were to lean on it,
A person is observed working unsafely.
A person is observed working on a chemical system without specified PPE, but without sustaining
injury
An item of waste disposed of incorrectly but not leaving site.

An Unsafe Condition is similar to an unsafe act, but the person is not seen causing the condition

An HSE Observation is when a fault is noted that could eventually lead to harm, such as an area with
one or two lamps not working but the area is still safe to work in. Where many lamps have failed and
visibility is impaired, an Unsafe Condition.
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Rev. Date: 25-Dec-2018
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Appendix 2 Guidance on Incident Investigation

This appendix is intended to give guidance to staff that have been assigned an incident form for
which they are to conduct an investigation. The purpose is to ensure a consistent approach to the
information gathered after an incident and how it is analysed. This in turn should enable risks to be
identified and adequately controlled in future.

The steps of the overall process are outlined below.

Incidents to be investigated will usually be of a “minor” nature; however the “worst potential
outcome” of some incidents could overlap into the serious or major class. Minor is low level
investigation carried out by the relevant line manager, HSE Manager, relevant suitable nominee, or
small team made up from these people. “Serious” and “Major” investigations are carried out in
accordance with site emergency procedures.

Likelihood of recurrence Potential worst outcome of adverse event

Minor Serious Major
Certain
Likely
Possible
Unlikely
Rare

Steps required to conduct the Investigation

Step 1 – Gather detailed information including: Who, what, where, when, work procedures, risk
assessments and control measures in place, workplace, work tools & materials used, competence,
supervision and work planning (enough time allowed, sequence of actions to complete task).
Sketches or photographs of the incident scene may also be used to record information prior to the
incident scene being “returned to normal”.

Answer the questions below if deemed relevant

Investigation Information Gathering Questions

Who was injured / suffered ill health or was otherwise involved with the adverse event? What was
the actual damage to the plant and/or environment?
How did the adverse event happen? (Note any equipment involved)
What activities were being carried out at the time?
Was there anything unusual or different about the working conditions?
Were there adequate safe working procedures and were they followed? Was action taken to limit
any injuries or losses to plant? Was an environmental risk assessment in place?
What injuries or ill health effects, if any, were caused? Was treatment given as promptly as was
required?
If there was an injury, how did it occur and what caused it?
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Was the risk known? If so, why wasn’t it controlled? If not, why not?
Did the organisation and arrangement of the work influence the adverse event?
Was maintenance and cleaning sufficient? If not, explain why not.
Were the people involved competent and suitable?
Did the workplace layout influence the adverse event?
Did the nature or shape of the materials influence the adverse event?
Did difficulties using the plant and equipment influence the adverse event?
Was the safety and/or spillage equipment sufficient?
Did other conditions influence the adverse event?
What were the immediate and underlying root causes?

Step 2 – Analysis of Information: Analyse the facts to establish what happened and why. What
were the immediate, underlying and root causes? These could include Human factors,
Organisational factors, Plant and Equipment or Environmental factors. Compare the causes with
previous incidents, both on site and at other locations – is there a trend developing? Use of graphs
may assist with the data analysis.

Asking the question “WHY” until you come to a logical answer, or until the answers are no longer
meaningful will get you to the causes of the “incident” or “event”. Below is a flow diagram, which
shows the answers to the question “WHY”. On asking why after, “John breaks his leg” the three
answers “John is on a ladder”, “falls due to gravity”, and “John falls off” explain why John breaks
his leg. The question “WHY” is then asked from each previous answer to find the next answers and
so on, until the root causes are identified.

John breaks his leg

WHY WHY WHY

John is on ladder Falls due to gravity John falls off

WHY WHY

Access to the roof The ladder slips

WHY

The ladder is not

tied

WHY

Step 3 – Identifying suitable Risk Control Measures: Once the “underlying” and “root” causes have
been identified the control measures, which are required, should be recommended or put in place.
Judgement can also be made (involving your line manager or HSE Manager) on whether or not
 AZN Procedure Doc. No.: L3-005-HSE-02
Rev. Date: 25-Dec-2018
Issue no. Issue Date Revalidation
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similar risks occur elsewhere in the business (other departments or possibly worldwide). It should
also be determined if similar events have happened in the past and why have they reoccurred.

Step 4 – Risk Control Action Plan: If required a “SMART” Plan should be implemented to enable
the appropriate control measures to be put in place. This could include short and or longer-term
fixes, modifications, training, procedure and risk assessment reviews. These recommendations
and or actions should be recorded on the actual incident form.