Subcontractor HSSE Prequalification

Questionnaire – Minor Scope

PEC-HS-FRM-X-16150 Rev 0

SUBCONTRACTOR DETAILS
Subcontractor Name

Address

HSSE Focal Point Name

HSSE Focal Point Contact Number
HSSE Focal Point Email id

1. HSSE policy: Does your company have a documented HSSE Policy? If YES, please attach a signed
and dated copy

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

2. HSSE leadership Commitment: Is Senior management involvement in HSSE management visible?

If YES, provide evidence such as (MOM of HSSE meetings, Site walkthrough etc.)

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

3. Hazards and risk assessment: Do you have a process to assess risks specific to your scope of
work? If YES, provide Task Risk Assessments relevant to the scope of work and Risk Register

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

4. Training and Competency: Do you provide new employee induction/ orientation, Job specific
training relevant to the scope of work? If YES, please provide your HSSE Training Matrix

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

5. Organisation: Please provide your corporate HSSE organisation chart and CV of the HSSE focal point
YES NO ATTACHED REMARKS
(YES/ NO) (IF ANY)

6. HSSE Documentation/ Management System: Do you have a Project HSSE Plan for a similar
scope of work? If YES, please provide a copy

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

Controlling Document: PEC-HS-PRO-X-13858 Page 1 of 6

Subcontractor HSSE Prequalification
Questionnaire – Minor Scope
PEC-HS-FRM-X-16150 Rev 0

7. Operational Control Procedures: do you have HSSE operational control procedures or HSSE work
instructions specific to your activities (i.e. security arrangements, lifting procedure, chemical handling,
loading and unloading of material, blasting, welding, etc.); if yes provide copies:

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

8. HSSE Management System Certification: Is your Company’s HSSE Management system certified
to an international standard (ISO / OHSAS)? If YES, please provide a copy of certificate

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

9. Handling of chemicals: Do you have a process to identify assess, control, and mitigation of hazards
encountered form Chemicals/ Hazardous substances relevant to the scope of work? If YES, provide
sample COSHH assessment and Chemical Hazards register.
YES NO NA ATTACHED REMARKS
(YES/ NO) (IF ANY)

10. Personal protective equipment: Do you maintain the list of the PPE relevant to the scope of work?
If YES, please submit

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

11. Equipment control and maintenance: Do you ensure plant and equipment are correctly registered,
controlled, and maintained in a safe work condition? If YES, please submit your Equipment inspection/
maintenance log, third party inspection log and sample certificate copies

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

12. Lower Tier Subcontractor Management: Do you have a process for lower tier subcontractors
HSSE capabilities assessment and management? If YES, provide sample records of prequalification
assessments and performance evaluation

YES NO NA ATTACHED REMARKS

(YES/ NO) (IF ANY)

Controlling Document: PEC-HS-PRO-X-13858 Page 2 of 6

Subcontractor HSSE Prequalification
Questionnaire – Minor Scope
PEC-HS-FRM-X-16150 Rev 0

13. Road Safety Management: Do you implement a risk based approach to identify the need of In-
Vehicular Monitoring System (IVMS) on your vehicles and defensive driving training?? If YES, provide
details of the process also sample IVMS report and DDT certificate

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

14. Inspections: Does your company schedule and conduct HSSE inspections? If YES, provide a sample
inspection schedule for all tasks, areas, components, plant, equipment etc.,

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

15. Environmental Management: Do you have an Environmental Aspect/ Impact register,

environmental management plan and a waste management plan specific to the scope of work? If YES,
please provide samples from a previous project

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

16. Health & Welfare Management: Does your company assure the health, fitness and welfare of your
employees? If YES, provide sample copies of pre-employment medical, fitness to work and sample
inspection records on water, catering, hygiene, and accommodation

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

17. Statutory notifiable incidents, Improvement requirements and prohibition notices: Has
your company suffered any statutory notifiable incidents, improvement requirement / prohibition notices
by the relevant national regulatory body for HSSE / other enforcing authority? If YES, provide details of it
and follow-up preventative measures taken

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

18. HSSE performance achievement awards: Has your company received any award for HSSE
performance achievement? Please provide certificates and/or photographs as evidence

YES NO ATTACHED REMARKS

(YES/ NO) (IF ANY)

Controlling Document: PEC-HS-PRO-X-13858 Page 3 of 6

Subcontractor HSSE Prequalification
Questionnaire – Minor Scope
PEC-HS-FRM-X-16150 Rev 0

19. HSSE performance records: Have you maintained your HSSE records of your last five years? If
YES, please complete below table*:

Year
Description
Man Hours1
Number of Fatalities2
Number of Lost Time
Incidents
Number of Restricted
Workday Cases
Number of Medical
Treatment Cases
Number of First Aid
Cases
Number of HiPo
Incidents
Number of Near Misses
LTIFR per 200,000
manhours
RIFR per 200,000
manhours
Occupational Health
illness ( work related)
Environmental Incidents
(Major)
Environmental Incidents
(Serious)
Environmental Incidents
(Medium)
Environmental Incidents
(Minor)
Security Incidents
(Major)
Security Incidents
(Serious )
Security Incidents
(Medium)
Security Incidents
(Minor)
*Please refer to Appendix I (below) for definitions

1Include exposure hours and HSSE statistics expended by subcontractors performing work subcontracted by you.
2 For each Fatality, provide a description of the incident, the root / contributing causes, and the action plans to
prevent reoccurrence.

Controlling Document: PEC-HS-PRO-X-13858 Page 4 of 6

Subcontractor HSSE Prequalification
Questionnaire – Minor Scope
PEC-HS-FRM-X-16150 Rev 0

Appendix I - Definitions

Fatality: Any work-related injury or illness that resulted in death. Fatalities arising from suicide,
inexplicable personal behaviour or natural causes shall be excluded.

Lost Time Incidents: Any work related fatality, injury or illness which prevents that person from
doing any work for any day excluding the day of the incident.

Restricted Workday Cases: A work-related injury or illness is RWC if it results in restriction of

work or motion, or transfer to another job.

Restricted work means after an injury or illness:

 The employee is kept by you from performing one or more of the routine functions of their
job or from working the full workday that they have been supposed to work otherwise; or
 The employee is recommended by a physician or other licensed health care professional
not to perform one or more of the routine functions of their job, or not work the full workday
that they have been supposed to work otherwise

Transfer to another job means after an injury or illness (not the day of the injury or illness) the
employee is assigned to a job by you other than their regular job for part of the day

Medical Treatment Cases: MTC is a work-related injury or illness that results in medical treatment
beyond first aid. MTC excludes death, one or more days away from work and one or more days of
restricted work. In order a work-related injury or illness to be a MTC, the employee must receive
medical treatment remaining at work while not being restricted. ‘Medical treatment’ is defined as
combating disease or disorder by management and care of a patient. It does not include:

 Visiting a physician or other licensed health care professional only for observation or
counselling
 Conducting diagnostic procedures (X-rays and blood tests, administering prescription
medications only for diagnostic purposes such as using eye drops in order to dilate pupils)
 First aid

First Aid Case: First Aid Case is a work-related injury or illness that requires the person
receiving treatment from a qualified First Aid Attendant and is not an injury/illness that is
categorised as ‘Recordable’. The following types of treatment are considered as first aid:

 To use medications that are non-prescription at non-prescription strength

 To administer tetanus immunisations (other immunisations, Hepatitis B vaccine, rabies
vaccine, etc. are considered medical treatment)
 To clean, flush, or soak wound that are on the surface of the skin
 To use wound coverings (bandages, BandAids TM, gauze pads, etc.), or to use SteriStrips
TM or butterfly bandages
 To use hot or cold therapy
 To use totally non-rigid means of support (elastic bandages, wraps, non-rigid bask belts,
etc.)
 To use temporary immobilisation devices (splints, slings, neck collars, or back boards)
during transportation of an accident victim
 To drill a fingernail or toenail for relieving pressure, or to drain fluids from blisters
 To use eye patches
 To use simple irrigation or a cotton swab for removing foreign bodies that are not
embedded in or adhered to the eye

Controlling Document: PEC-HS-PRO-X-13858 Page 5 of 6

Subcontractor HSSE Prequalification
Questionnaire – Minor Scope
PEC-HS-FRM-X-16150 Rev 0

 To use simple means (irrigation, tweezers, cotton swab, etc.) for removing splinters or
foreign material from all areas but eyes
 To use finger guards
 To use massages
 To drink fluids for relieving heat stress

HiPo Incident: Any incident that could, in other circumstances, have realistically resulted in a
major consequence as defined in the Petrofac Incident Potential Severity Matrix including:

 Potential of one or more fatalities

 Potential of Major pollution event leading to long-term widespread damage or Statutory
Notices, extensive clean up requiring national/ international support to contain and/or
clean up
 Potential of property or equipment loss /damage or total loss of operations. E.g. >$1M
 Potential of regulatory prosecution and heavy fine. Damage to company’s standing with
stakeholders. Averse intentional media attention

Near Misses: An incident that under slightly different circumstances, could have caused harm to
people, environment, assets or company reputation, but did not.

Lost Time Injury Frequency Rate (LTIFR): The frequency of lost time injuries per 200,000 hours
worked/at risk.

Recordable Case: Recordable Cases are the sum of the number of Fatalities, Lost Time
Injuries/Illnesses, Restricted Workday Cases and Medical Treatment Cases

Recordable Injuries Frequency Rate (RIFR): The frequency of recordable injuries per 200,000
hours worked/at risk.

Environmental Incidents (Major severity): Major pollution event leading to long-term widespread
damage or Statutory Notices, extensive clean up requiring national/ international support to contain
and/ or clean up

Environmental Incidents (Serious severity): Substantial pollution event leading to large-scale

regional damage or Statutory Notices, clean up may require national support and result in delays
to schedule

Environmental Incidents (Medium severity): Moderate pollution event leading to local damage,
Statutory Notices, clean up and corrective action

Environmental Incidents (Minor Severity): A low or contained pollution event, slight or no effect,
no offsite impact, minor breach requiring corrective action e.g. few litres of liquid spill

Security Incident (Major severity): One or more fatalities resulting from a security incident,
property or equipment damage/theft in excess of $1M, kidnap or bomb threat
Security Incident (Serious severity): Life changing injuries resulting from a security incident,
property or equipment damage/theft ($100k - $1M), sexual assault, extortion/blackmail, missing
person
Security Incident (Medium severity): LTI, medical treatment or RWC resulting from a security
incident, possession of illegal items or property or equipment damage/theft ($10k - $100k)
Security Incident (Minor severity): Non-recordable injuries/FAC resulting from a security
incident, minor criminal acts or attempts or property or equipment damage/theft (<$10k)

Controlling Document: PEC-HS-PRO-X-13858 Page 6 of 6