HS 004 Incident Investigation

SOUTH AFRICA REGION REFERENCE REVISION PAGE
SERVICES H&S 004 11 1 OF 65

HEALTH & SAFETY
SYSTEM OPERATIONAL ORIGINATOR H&S MANAGER
PROCEDURE
INCIDENT INVESTIGATION
DESIGNATION PRINT NAME SIGNATURE DATE
COMPILED BY H&S OFFICER S THERON Original Signed 6/03/2012
REVIEWED BY SNR H&S OFFICER JSD CRONJÉ Original Signed 6/03/2012
AUTHORISED BY H&S MANAGER J SODEN Original Signed 6/03/2012
TABLE OF CONTENTS PAGE ADDENDA PAGE

ANNEXURE 1 – INCIDENT AND DANGEROUS
1. PURPOSE 2 11
OCCURANCE REPORT – SAMRASS 1
2. SCOPE 2 ANNEXURE 2 – INJURY REPORT FORM – SAMRASS 2 12
3. DEFINITIONS AND
2 ANNEXURE 3 – 1 – 13 DAY INJURIES – SAMRASS 4 13
ABBREVIATIONS
ANNEXURE 4 – REPORT ON DATE RESUMED WORK –
4. REFERENCES 2 14
SAMRASS 9
5. RESPONSIBILITY /
2 ANNEXURE 5 – AIIP 15
ACCOUNTABILITY
ANNEXURE 6 – PROPERTY DAMAGE / PRODUCTION
6. INJURY REPORTING STRUCTURE 3 16 -17
LOSS REPORT
7. INCIDENT FLOWCHART &
6 ANNEXURE 7 – SIMPLIFIED INCIDENT REPORT 18
RESPONSIBILITIES
8. ADDITIONAL INSTRUCTIONS 6 ANNEXURE 8 – RM ROAD INCIDENT QUESTIONNAIRE 19 - 20
9 . RM CLAIMS PROCEDURE 7 ANNEXURE 9 – RM SPECTACLE QUESTIONNAIRE 21
10. REPORTING & INVESTIGATING
INCIDENTS OF PROPERTY 9 ANNEXURE 10 – RM DENTURES QUESTIONNAIRE 22
DAMAGE / PRODUCTION LOSS
ANNEXURE 11 – RM ADDENDUM TO INCIDENT REPORT
11. INJURIES TO BE REPORTED TO
9 IN CASE OF INJURIES SUSTAINED DURING SPORTING 23 - 24
DMR
EVENTS
ANNEXURE 12 – NOTIFICATION TO ATTEND AN
12. INCIDENTS RESULTING IN INJURY 10 25
INVESTIGATION
ANNEXURE 13 – HEALTH AND SAFETY HOURS 26
GUIDELINE
13. RECORDS APPLICABLE TO THIS
10 ANNEXURE 14 – INJURY / INCIDENT INVESTIGATION 27 – 41
PROCEDURE
ANNEXURE 15 – POPULATING AN INCIDENT 42 - 58
INVESTIGATION
ANNEXURE “X” – DEFINITIONS AND ABBREVIATIONS 59 - 63
ANNEXURE “XX” - REFERENCES 64
RECORD OF AMENDMENTS 65
REVISION DESCRIPTION OF REVISION DATE
11 CHANGES AS PER RECORD OF AMENDMENTS 1 MARCH 2012
(Original, approved copy filed at the H&S Department)

Uncontrolled if printed. Only up-to-date on the intranet.
Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

H&S 004 11 March 2012 7 March 2012 Page 1 of 65
1. PURPOSE
This procedure is developed to assist with the timely investigation, examination, gathering, and the
analysis of information. For all LTI, SI & Fatals the AGA AIIP will be used. For dressing cases and
incidents to the value of below R50000 the Causation model will be utilized.
2. SCOPE
The guideline deals with the type of Incidents that are required to be investigated and the level of
participation.
3. DEFINITIONS AND ABBREVIATIONS
Refer to Annexure “X”
4. REFERENCES
Refer to Annexure “XX”
5. RESPONSIBILITY / ACCOUNTABILITIES
DESIGNATION RESPONSIBILITIES
H&S Manager • Ensure that a procedure is established, implemented and
maintained dealing with the reporting of actual/potential
nonconformities, injuries and incidents and to ensure that corrective
action and preventive action is taken.
• Develop a system to identify report, assess and record non-
conformances, injuries and incidents and devise actions, to identify
corrective actions and preventive actions.
• Ensure information is distributed to the relevant person where the
affected/responsible persons will analyse the information and take
the appropriate action. Assist & Facilitate all incident where the AIIP
is used.
Snr H&S Officer • Ensure that non conformities, injuries and incidents are
appropriately addressed and investigated.
• Assist with drafting and rectification of action plans to eliminate non-
conformances.
H&S Officer • Follow-up on remedial measures for non-conformances, injuries
and incidents recorded.
• Analyze the information monthly and assist the HOD’s in drafting
action plans addressing the corrective action and/or preventive
action taken. (RMS)
Management • Ensure availability of resources to implement the OH&S programme
Representative • Ensure that analysis is made of information pertinent to OH&S
• Compare information with objectives, evaluate effectiveness of
controls and where targets are not met change controls to achieve
desired results
• Ensure information is distributed and communicated to employees
relevant to the work they perform


• Ensure that personnel are aware of applicable legal and other
requirements
• Ensure H&S Officer (Systems) keep and maintain records
HOD • Ensure implementation and compliance to the system for the proper
reporting and investigation of non-conformances, injuries and
incidents.
• Review analysis of respective risk management system areas as
well as non-conformances, incidents and injuries conducted for the
respective discipline / department.
• Monitor and review compliance to all action plans for the prevention
and correction of issues identified.
• Ensure the reporting of non-conformances, injuries and incidents.
Implement the system to identify, investigate, and participate in
injury/incident investigations, non conformities, and record findings
to correct and prevent a future re-occurrence.
Foreman / • Identify, investigate, and participate in injury / incident
Supervisor investigations, non conformities, and record findings to correct and
prevent a future re-occurrence.
• Comply with rectification/completion of corrected and/or preventive
action plans.
Workplace Health • Identify and communicate Incidents, non conformities and
and Safety participate in injury/incident investigations.
Representative
ATDS • To ensure that incident report communication from the H&S
Department be evaluated with regards to the specific training given
pre the incident and amend lesson plans where required.
6. INJURY REPORTING STRUCTURE
REPORTING AND RECORDING OF INCIDENTS

All incidents required to be investigated in terms of the Mine Health and Safety Act will be reported
and recorded as depicted in Section 23 of the Act.
It is critical that all injuries and incidents be reported immediately to ensure that appropriate
investigation can be launched within 45 minutes to prevent occurrence of similar injuries. It is the
responsibility of every employee in South African Region Services to immediately report all injuries
/ incidents to their relevant supervisors and the H&S Department or before the end of the shift.
INVESTIGATION OF INCIDENT
The investigation process and the identification of the relevant employees that must attend and
assist with the investigation as depicted in this procedure.


ANALYSIS OF INCIDENTS
All incidents required to be reported that is captured in RMS will be analysed and the following
information can be derived from the Web queries:
• Type of incident
• Agency
• Task Performed
• Workplace
• Section
• Time of incident
• Body part injured
• Etc.
The following flow diagram indicates the structure for injury reporting:
Injured
Supervisor
HOD
H&S Officer
Responsible Manager
Incident
H&S Dept initiates Incident


6.1 SOUTH AFRICA REGION SERVICES HEALTH & SAFETY INCIDENT INVENSTIGATION
PROCESS
IDENTIFICATION OF BASIC CAUSES

The basic causes of all incident investigations must be correctly identified. The causation model
could be used as a guide for this process.
The proper personal and job factor must be identified to enable the correct system failure to be
identified and corrected to prevent a reoccurrence of an incident.
Determine underlying OH&S deficiencies and other factors that might be causing or contributing to
the occurrence of incidents as depicted in this procedure.
CORRECTIVE ACTION
Corrective actions are actions taken to eliminate the basic causes of identified nonconformity or
incidents in order to prevent a reoccurrence. This will be recorded on the Incident report form and
captured in RMS or any other means documented to keep track of outstanding and signed off
actions. (Refer to H&S 061 - Nonconformity, corrective action and preventive action)
PREVENTIVE ACTION
Preventive actions are actions taken to eliminate the underlying basic causes of the potential
nonconformity (system failure) in order to prevent an occurrence. (Refer to H&S 061 -
Nonconformity, corrective action and preventive action)
CONTINUAL IMPROVEMENT
Recurring process of enhancing the SARSSS in order to achieve improvements in overall
occupational health and safety performances consistent with South Africa Region Services’ policy.
This will be achieved only when the basic and immediate causes of incidents are correctly identified
and addressed in a timeous manner. Critical trends identified during an investigation process will
be actioned and communicated.
COMMUNICATION OF INVESTIGATION
Communication of information related to the causes and results of incident investigations will be
communicated through the communication process (Refer to H&S 029 – Communication,
Participation & Consultation procedure)
TIME TO PERFORM INVESTIGATION

Incidents must be investigated in a timely manner to ensure witnesses, injured and evidence is
available to ensure a correct account of the events preceding prior during and after the event can be
properly captured.
RESULTS OF INCIDENT INVESTIGATION

Results of incident investigations shall be documented and stored as depicted in H&S -019 - Control
of Records Procedure


7. INCIDENT FLOWCHART & RESPONSIBILITIES
The following flowchart indicates the relevant routes whenever an incident occurs:
Incident Flowchart & Responsibilities
Incident occurring
Legend:
Incident reported to the
SAMRASS 1 = Incident & Dangerous occurrence report form. Supervisor, immediately
SAMRASS 1 = Injury Report form
Notify H&S department
SAMRASS 4 = 1-13 Day Injury report form
SAMRASS 9 = Date resumed work form
Investigation within 45 minutes
of incident being reported.
RM 11 = First Medical Report
RM 12 = Progress Medical Report
H&S dept releases first
RM 13 = Final Medical Report announcement within 24 Hrs
If incident resulted in an injury If only property damage or

near miss
If injured visit his own doctor If injured visit the dressing

H&S Dept update injury log
the doctor will complete station the Comp 1 form to
and distribute to all Formal Investigation
forms RM11, RM12, RM13 Rand Mutual is produced by
concerned
provided by the injured / HOD the dressing station
H&S Dept update daily stats H&S dept releases final

and distribute to all Full Investigation, Causation model for dressings & Incidents announcement within 1 week
<R50000 and the AIIP for LTI’s, Serious, and Incidents >R50000.
H&S Dept to also generate:
Weekly Stats to Corporate Notify DMR using SAMRASS 1
Update Daily Stats H&S dept releases final announcement within 1 week except if injured & 4 for LTI’s and SI’s
Update RMS is still off in which case the announcement will be released at least
1 week after his/her return to work
H&S Statistics monthly Notify DMR using SAMRASS 9
Monthly Graphs when injured return to work
Update Citrix &
Data warehouse. Accident Review with Manager where applicable If it is a Contractor notify the
DOL using SAMRASS 1 & 4
8. ADDITIONAL INSTRUCTIONS
Note: - all incidents to be investigated by the responsible supervisor within 45 minutes using the “45
minute Injury/Incident Investigation form” (Annexure 14).
8.1 A Supervisor must accompany the injured to the medical station / hospital.
8.2 The responsible Manager must liaise with all the Medical Stations on a daily basis to
determine whether any injuries occurred during the previous twenty-four hours.
8.3 Remedial action shall be taken immediately by the supervisor, to remove the cause of the
injury and to prevent a re-occurrence.
8.4 The HOD will notify any person that is required at an investigation by means of the approved
document. (Annexure 12)


8.5 When an injury results in a fatal, the area where it occurred must not be disturbed and it
must be barricaded off for a formal investigation. (Fatal as per the Corporate Fatal
Procedure SAR/OESH/P/A/001.01 available on the H&S Web).
8.6 When an injury results in the death of a person, or where it is likely that the injured person
may die, the Department of Mineral Resources must be informed without delay, by the
responsible Manager / H&S Manager.
8.7 In the case of a fatal injury or when it is likely that the injured may die, a “continuity witness”
is always required.
This witness must preferably be an eyewitness, who must accompany the body to the
dressing station, hospital and government mortuary. He must be informed that he will be
called upon to make a statement and to assist the S.A. Police Services in the formalities to
“identify” the deceased. The primary function of the continuity witness is to give evidence
that the deceased did not incur any further injuries whilst in transit from the scene of the
injury to the mortuary.
Under no circumstances may any employee contact and report the injury to the injured next
of kin. This is the responsibility of the Senior H.R. officer.
8.8 All injuries occurring to outside contractors must be dealt with in the same manner as
described above.
8.9 The supervisor and HOD must monitor the shifts lost by the injured person. They must notify
the H&S Department immediately, should the injured person return to his/her normal duties.
8.10 In cases where injured employees are admitted to hospital, the HOD must also inform the
H.R. Department.
9. RAND MUTUAL CLAIMS PROCEDURE
9.1 Road Incident Questionnaire (Annexure 8)
9.1.1 Report the incident to immediate supervisor, H&S Department and the SAPS.
9.1.2 Supervisor to complete a Road Incident Questionnaire form, attain a MAS Number from
the SAPS and complete all the statements.
9.1.3 If an outside doctor treats the injured, obtain a copy of the First Medical Report.
9.1.4 COIDA: Employees injured or killed in a vehicle Incident
Compensation is paid to employees who are injured or killed in a motor vehicle Incident
if:
• The Incident occurred while the employee was on duty.
• The employee was being driven free of charge to and from work in transport
provided by the employer especially for that purpose and driven by the employer or
one of his / her employees.
• The employee was travelling to work to answer a call out.
• The Incident occurred
o Before the start of a normal or overtime shift, or
o At the end of a normal or overtime shift, and
o On a private road belonging to the employer and which only employees or
people who do business with the employer are allowed to use.
Compensation is not paid to an employee who is injured or killed in an Incident when the employee
has paid someone to transport him / her to or from work e.g. in a mini bus taxi.


9.2 Spectacle Questionnaire (Annexure 9)
9.2.1 Compensation may only be claimed if the spectacles are damaged by a direct blow to the
face.
9.2.2 Report the incident to the immediate supervisor and the H&S Department
9.2.3 Obtain a quote and complete a Spectacle Questionnaire form with statement - must be
signed by the employee.
9.2.4 Submit copies of all documentation to the Compensation Department and get a claim
number.
NOTE:
(A) Liability for the repair or replacement of damaged spectacles can be determined only
upon receipt of the above information, CASES OF URGENCY MAY BE FURNISHED
BY TELEPHONE, FOLLOWED BY THE COMPLETED QUESTIONNAIRE AND
FORM R.M.2.
(B) Upon acceptance of liability for the repair or replacement of spectacles by the Rand
Mutual Assurance Company Limited, the workman may be referred to an optician of
his choice WHO MUST TELEPHONE THIS OFFICE BEFORE AFFECTING
REPAIRS in order that the cost may be discussed with him / her.
(C) If for personal or cosmetic reason the workman wishes to have a more expensive
frame than the standard frame allowed under the Workmen’s Compensation
Commissioner’s tariff, the additional cost must be paid by him / her.
9.3 Dentures Questionnaire (Annexure 10)
9.3.1 Report the incident to the immediate supervisor and the H&S Department
9.3.2 Complete the incident form and statement, to be signed by the employee.
9.3.3 Submit copies of all documentation to the Compensation Department.
NOTE:
(A) Liability for the repair or replacement of damaged dentures can be determined only
upon receipt of the above information, CASES OF URGENCY MAY BE FURNISHED
BY TELEPHONE, FOLLOWED BY THE COMPLETED QUESTIONNAIRE AND
FORM R.M.2.
(B) Upon acceptance of liability for the repair or replacement of dentures by the Rand
Mutual Assurance Company Limited, the employee may be referred to a dentist of his
choice WHO MUST TELEPHONE THIS OFFICE BEFORE AFFECTING REPAIRS in
order that the cost may be discussed with him / her.
(C) In case of serious injury, the employee should be referred to the Klerksdorp medical
Services of the Rand Mutual Assurance Company, Limited.
9.4 Organized Company Sporting Events (Annexure 11)
9.4.1 RMA pays compensation to employees who are injured, or to the dependants of employees
who are killed while playing sport if:
9.4.2 The employee was playing for a team at:
9.4.2.1 Inter-mine level.
9.4.2.2 Inter-mine club level.
9.4.2.3 Inter-group level.
9.4.2.4 External league level in a team made up of members who are mine
employees.


9.4.3 The employee was injured or killed while participating in an individual event and was
representing his/her employer.
9.4.4 The employee was injured or killed when participating as an individual in an inter-mine or
inter-group event.
9.4.5 The employee was injured or killed when practicing for such events.
All Incident forms must be signed and stamped by the Senior H&S Officer, before they are
submitted to the AGAH Compensation Department.
10. REPORTING AND INVESTIGATING INCIDENTS OF PROPERTY DAMAGE / PRODUCTION

LOSS (ANNEXURE 6)
Undesired events resulting in incidents which culminate in loss or which have a potential for loss
must be reported and investigated. As a guideline, losses greater than R50 000-00 in production or
property damage and a down time longer than a full shift (24 Hrs) requires a formal investigation,
using the Causation Model. Losses less than mentioned above to be investigated using Annexure 6.
Production losses can be estimated. All other incidents must be reported for statistical purposes on
the simplified incident reporting form (Annexure 7).
The person submitting the report must endeavour to identify as many causes leading up to the
incident as possible and then make meaningful recommendations to obviate a recurrence of the
incident.
Should the recommendation(s) include changed controls, such controls should be risk assessed as
per the risk assessment process (H&S 014, 018 and 028).
11. INJURIES TO BE REPORTED TO THE D.M.R
The responsible Manager or H&S Manager must report the following injuries immediately to the
Principal Inspector of Mines in terms of Chapter 23 of the Regulations of the Mine Health and Safety
Act (Act 29 of 1996):
12.1 The death of any employee

12.2 An injury, to any employee, likely to be fatal
12.3 Unconsciousness, incapacitation from heat stroke or heat exhaustion, oxygen deficiency, the
inhalation of fumes or poisonous gas, or electric shock or electric burn injuries of or by any
employee.
Should an injury to person result in a lost time (1 – 13 days off sick due to injury) or (13 days or
more off sick due to injury), SAMRASS 4 (Annexure 3) & SAMRASS 1 (Annexure 1) must be
completed by the Snr. H&S Officer authorized by the 4(1) / 3(1)(a) Appointee, and forwarded to the
DMR.
Once the injured resumes his duties, SAMRASS 9 (Annexure 4) must be completed & forwarded to
the DMR by the Snr. H&S Officer.
12. INCIDENTS RESULTING IN INJURY
All incidents resulting in an injury will be fully investigated using the “AngloGold Ashanti AIIP The
information will be captured electronically as per Annexure 15 and Annexure 15A.


13. RECORDS APPLICABLE TO THIS PROCEDURE
RECORDS LOCATION
Full investigation reports H&S Department

SAMRASS documents H&S Department
Property damage / Production loss report H&S Department
Rand Mutual Reports H&S Department


ANNEXURE 1
INCIDENT AND DANGEROUS OCCURRENCE REPORT FORM (SAMRASS 1)
DEPARTMENT OF MINERAL RESOURCES

This form must be completed for reportable Incidents in terms of regulations 23.1(a) (b) (c) and (d) and dangerous
occurrences in terms of regulation 23.4. Sections E and F, need not be completed in the event of a Dangerous
Occurrence. Attach forms SAMRASS 2, 3, 5, 6, 7, and 8, where applicable.
SECTION A: EMPLOYER DETAILS

1. NAME OF MINE
2. DMR MINE CODE
3. MAIN COMMODITY
SECTION B: INCIDENT OR DANGEROUS OCCURRENCE DETAILS
1. Mine Incident or Dangerous Occurrence YEAR ACC /DO REF NO SHAFT
Number Y Y Y Y N N N N S S
2. Number of persons killed
3. Number of persons totally disabled
4. Number of persons injured
5. Date of Incident or dangerous occurrence (use YYYY/MM/DD format) Y Y Y Y M M D D
6. Time of Incident or dangerous occurrence H H M M
7. Location of Incident or dangerous occurrence
8. Name of working place
9. Depth below surface (in metres)
10. Section
11. Description of Incident or dangerous occurrence in words
……………………………………………………………………………………………………………………………………………………………………….
12. Incident classification code
13. Dangerous Occurrence classification code
14. Did Incident or dangerous occurrence occur during normal working hours or overtime? Normal O/Time
15. Did Incident or dangerous occurrence happen at normal workplace? Y N
16. Average number of persons at work during the previous month SURF OPS U\G O/CAST SURF MIN MARINE
Section C: Responsible persons
NAME IDENTITY NUMBER/PASSPORT CERTIFICATE No. OCCUPATION
NUMBER
1ST LEVEL SUPERVISOR
2ND LEVEL SUPERVISOR
3RD LEVEL SUPERVISOR
4TH LEVEL SUPERVISOR
Name of Manager Designation Signature Date
Y Y Y Y M M D D
SECTION D: FOR USE BY THE DEPARTMENT OF MINERALS RESOURCES
1. REGIONAL INCIDENT OR DANGEROUS OCCURRENCE NUMBER Y Y Y Y R N N N I
2. DATE REPORTED Y Y Y Y M M D D
3. TYPE OF INCIDENT OR DANGEROUS OCCURRENCE
4. INCIDENT OR DANGEROUS DATE Y Y Y Y M M D D
OCCURRENCE REGISTERED
BY
5. INQUIRY TYPE
6. PROBABLE CAUSE OF INCIDENT OR DANGEROUS
OCCURRENCE
7. CONTRAVENTION IN INSPECTOR’S OPINION YES NO
8. IF YES, ACT/REGULATION CONTRAVENED
9. ADMINISTRATIVE FINE RECOMMENDED? YES NO
10. DATE EVALUATION FORM COMPLETED Y Y Y Y M M D D
INSPECTORATE DETAILS NAME (IN BLOCK DATE SIGNATURE
LETTERS)
11. INSPECTOR OF MINES
12. SENIOR INSPECTOR OF MINES (MINING)
13. SENIOR INSPECTOR OF MINES (MINING
EQUIPMENT)
14. ARE CRIMINAL PROCEEDINGS ENVISAGED? YES NO


ANNEXURE 2
INJURY REPORT FORM (SAMRASS 2)

NAME OF MINE
Mine Incident or Dangerous Occurrence YEAR ACC /DO REF NO SHAFT
Number Y Y Y Y N N N N S S
Date of Incident or dangerous occurrence (use YYYY/MM/DD format) Y Y Y Y M M D D
REGIONAL INCIDENT OR DANGEROUS OCCURRENCE NUMBER Y Y Y Y R N N N I
SECTION E: EMPLOYEE’S DETAILS

NOTE: THIS SECTION NEED NOT BE COMPLETED FOR A DANGEROUS OCCURRENCE
1. SURNAME
2. FULL FIRST NAMES
3. INDUSTRY NUMBER
4. PF/COMPANY NUMBER
5. IDENTITY/PASSPORT NUMBER
6. DATE OF BIRTH (USE YYYYMMDD FORMAT) Y Y Y Y M M D D
7. COUNTRY OF ORIGIN
8. POPULATION GROUP 01 02 03 04
9. WAS THE INJURED A PERMANENT EMPLOYEE (“E”), A CONTRACTOR (“C”) OR A CASUAL (“T”)? E C T
10. NAME OF CONTRACTING COMPANY (IF APPLICABLE)
11. MALE OR FEMALE M F
12. NORMAL OCCUPATION AT TIME OF INCIDENT
13. TOTAL EXPERIENCE IN CURRENT OCCUPATION Y Y M M
14. WAS INJURED CARRYING OUT NORMAL DUTIES AT TIME OF INCIDENT? Y N
15. DATE FIRST EMPLOYED WITH CURRENT EMPLOYER (USE YYYYMMDD Y Y Y Y M M D D
FORMAT)
16. DATE LAST SHIFT WORKED (USE YYYYMMDD FORMAT) Y Y Y Y M M D D
17. DATE RESUMED WORK (USE YYYYMMDD FORMAT) Y Y Y Y M M D D
18. IF FATAL, DATE OF DEATH (USE YYYYMMDD FORMAT) Y Y Y Y M M D D
Section f: injury details
This section need not be completed for a dangerous occurrence Incident
1. TASK: (PERSON INJURED OR KILLED WHILE PERFORMING)
2. ACTIVITY: (INJURED OR KILLED WHILE….)
3. NATURE OF INJURY
4. PART OF BODY INJURED
5. TYPE OF INCIDENT OF INDIVIDUAL FATAL (F), TOTALLY DISABLING (T), INJURY (I) F T I
6. ALLOCATED DAYS LOST (TO BE COMPLETED BY DMR)


ANNEXURE 3
1-13 DAY INJURIES (SAMRASS 4)
NAME OF MINE: AngloGold Ashanti DMR MINE CODE....................
MONTH:
Codes to be used on this Form are specified in the Code Book
DATE OF MINE NAME OF IDENTITY PASSPORT INDUSTRY DATE RETURNED DAYS INCIDENT OR LOCATION NATURE BODY ACTIVITY
INCIDENT INCIDENT OR INJURED NUMBER NUMBER NUMBER OFF WORK TO WORK ABSENT DANGEROUS OF PART
OR DANGEROUS OCCURRENCE INJURY
DANGEROUS OCCURRENCE CLASSIFICATION
OCCURENCE NO.


ANNEXURE 4
REPORT ON DATE RESUMED WORK (SAMRASS 9)
NAME OF MINE: ………………………….. DMR MINE CODE....................
MONTH: …………………………………..
DATE OF MINE INCIDENT OR NAME OF INJURED IDENTITY NUMBER PASSPORT INDUSTRY DATE DATE
DANGEROUS
INCIDENT OCCURRENCE NO.
NUMBER NUMBER OFF WORK RETURNED TO
WORK
This form is to be completed monthly and forwarded to the regional office of the Inspectorate in respect of all injured
persons who returned to work during that month.


ANNEXURE 5

Incident investigation recording REVISION EFFECTIVE DATE PRINT DATE PAGE

and reporting
ANNEXURE 6
SOUTH AFRICA REGION SERVICES
PROPERTY DAMAGE / PRODUCTION LOSS REPORT

For use on all production losses, or property damage incidents.
DISCIPLINE: ___________________________________________________
DEPARTMENT: ________________________________________________
AREA: _____________________________________ DATE: ________________________
PRODUCTION LOSS PROPERTY DAMAGE

COST OF
COST OF TOTAL UNIT WERE ARTISANS
PROPERTY
PRODUCTION LOSS COST LOSS DOWN TIME CALLED OUT
DAMAGE
R R R HOURS YES NO
Describe briefly how the incident occurred and if applicable, how was the Operator involved?
______________________________________________________________________________
______________________________________________________________________________
Who reported the incident? __________________________ Designation: ___________________
Was the incident reported to the Workplace Safety Representative? Yes No
Do you think this incident could have been prevented? Yes No
If yes, please make your recommendations:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
NB. DEFINE ANY SUBSTANDARD ACTS OR SUBSTANDARD CONDITIONS LEADING TO THE INCIDENT BY
CONSULTING THE RESPECTIVE CODES OVERLEAF AND MARKING THE APPLICABLE CODE/S WITH A
CROSS-’X’.
DEPARTMENT HEAD: _________________ DESIGNATION:_____________________
SIGNATURE: __________________________ DATE: _____________________________


and reporting
ANNEXURE 6 - Continued
To be submitted to: H&S Department
SUBSTANDARD ACT CODE SUBSTANDARD CONDITION CODE

1 Alcohol abuse. 1 Abnormal wear and tear.
2 Deliberate disregard of regulations. 2 Accumulation of water/slime.
3 Drug abuse 3 Congestion or blockage.
4 Failure to get assistance. 4 Defective brakes.
5 Failure to give proper instructions 5 Defective personal protective equipment.
6 Failure to recognise hazards. 6 Defective or slippery floor surfaces.
7 Failure to report unsafe conditions 7 Defective tools and equipment.
8 Failure to secure. 8 Excessive noise.
9 Failure to take preventative action. 9 Fire/explosion hazard.
10 Failure to warn. 10 Dust, fumes, gas.
11 Horseplay. 11 Unhealthy environment.
12 Improper lifting. 12 Inadequate colour coding.
13 Improper loading. 13 Inadequate earth leakage.
14 Improper placement. 14 Inadequate earthing.
15 Careless inattentive behaviour. 15 Inadequate First Aid equipment.
16 Incorrect use of protective equipment. 16 Inadequate guards.
17 Misuse or abuse. 17 Inadequate identification.
18 Non adherence to procedures. 18 Inadequate illumination.
19 Non adherence to rules. 19 Inadequate insulation.
20 Non adherence to standards. 20 Inadequate signs.
21 Operating at unsafe speed. 21 Inadequate storage space.
22 Operating without authority. 22 Inadequate tools/equipment.
23 Removing/making safety devices inoperable. 23 Inadequate space for travel.
24 Servicing equipment whilst in motion. 24 Inadequate ventilation.
25 Substituting substandard equipment. 25 Inadequate warning system.
26 Taking improper position. 26 Inadequate working space.
27 Unauthorised entry. 27 Incorrect installation of equipment.
28 Using defective equipment/tools. 28 No compressed air.
29 Using equipment improperly. 29 No electricity.
30 Using hazardous materials. 30 No spares.
31 Inadequate lifting of materials. 31 No water.
32 Wearing incorrect clothing. 32 Substandard housekeeping.
33 Working in a dangerous situation. 33 Unsafe design and construction.


and reporting
ANNEXURE 7
SIMPLIFIED INCIDENT REPORT

Section: __________________________ DATE: ___________________________
FREQUENT OCCASIONAL RARE

Risk Minor
Ranking Serious
Major
Catastrophic
DESCRIPTION OF INCIDENT INVESTIGATION – SUSPECTED CAUSE(S)
REPORTED BY : ______________________ INVESTIGATOR : _____________________________
DATE : _______________________ DATE : __________________________
SIGNATURE : _________________________ SIGNATURE : _______________________________

RECOMMENDED ACTION TO PREVENT RECURRENCE
RESPONSIBLE PERSON
ESTIMATED COMPLETION DATE
ACTUAL COMPLETION DATE
FOLLOW UP DATE & SIGN OFF
_______________________________________ ____________________________________________
SUPERVISOR HOD
DATE: ____________________ DATE: ________________________


and reporting
ANNEXURE 8
THE RAND MUTUAL ASSURANCE COMPANY LIMITED
ROAD INCIDENT QUESTIONNAIRE

For completion by Employer
1. Name and PF/Co Nº of employee _______________________________________________________________
2. Date of Incident _____________________________________________________________________________
3. Occupation of employee ______________________________________________________________________
4. Did the Incident occur:
4.1 During working hours? ________________________________________________________________
4.2 In the course of employee’s duties? ______________________________________________________
4.3 On mine property? ___________________________________________________________________
5. What was the cause of the Incident?
5.1 If due to mechanical defect of vehicle, details should be given ________________________________
___________________________________________________________________________________
5.2 If due to a collision, was the other party a mine employee on duty or going to or from work?
___________________________________________________________________________________
6. Distance from employee’s place of work _________________________________________________________
7. Was Incident due to some defect in the road or to a locality risk peculiar to mine property? If so give details.
__________________________________________________________________________________________
__________________________________________________________________________________________
8. Was the employee using a normal authorised route to/from place of work? ______________________________
__________________________________________________________________________________________
9. At what time did:
9.1 The Incident occur? __________________________________________________________________
9.2 The employee leaves his home/place of work? _____________________________________________
9.3 His shift commence/end? ______________________________________________________________
10. If Incident occurred outside normal working hours:
10.1 Had the employee been called out for emergency work? ______________________________________
10.2 Was he on stand-by? __________________________________________________________________
10.3 Was he entitled to payment for travelling time? _____________________________________________
11. General or special remarks. (Indicate, of possible, where you consider the blame, if any, for the Incident lies).


and reporting
________________________________________________________________________
12. If the Incident occurred on mine property, please attach a general surface plan of the mine property showing:
12.1 Scene of Incident.
12.2 The employee’s place of work.
12.3 The route used by the employee.
12.4 The employee’s home or residence, if he was resident on mine property.
12.5 Where the road on which the Incident occurred comes from and leads to.
12.6 Other relevant features such as mine workshops, offices, shaft heads, mine dumps, reduction works, railway
lines, residence, sports fields, post office, concession stores, etc.
13.1 Is the road on which the Incident occurred used only by employees, contractors of the mine, persons such as merchants
and representatives coming to the mine to do business, persons visiting employees at work and persons transporting
employees to or from work? __________________________________________________
OR
13.2 Does the general public use the road on which the Incident occurred? __________________________________
14. Was the employee driving his own vehicle or a company vehicle at the time of the Incident? ________________
15. Was the employee being conveyed free of charge to or from his place of work by means of transport controlled and
specially provided by his employer for the purpose of such conveyance? _____________________________
16. Was the Incident reported to the South African Police Services? If so, to which police station?
__________________________________________________________________________________________
17. Please furnish any other available details and statements by witnesses which might assist the Rand Mutual to determine
whether the Incident arose out of an in the course of the employee’s employment.
18. If a third party was involved in the Incident, kindly furnish:
18.1 Name and address ____________________________________________________________________
18.2 Vehicle registration number ____________________________________________________________
18.3 Name of the Company with which he is insured under the Compulsory Motor Vehicle Insurance Act.
___________________________________________________________________________________
For: _________________________ (Name of Employer) Date: ______________________
Signature: ____________________________________________
MANAGER


and reporting
ANNEXURE 9
SPECTACLE QUESTIONNAIRE
For completion by Employer and to be submitted together with Form R.M.2.
WORKMAN: ______________________________________________________________________________
EMPLOYER: ______________________________________________________________________________
DATE OF INCIDENT: ______________________________________________________________________
1. Was the workman wearing the spectacles at the time of the Incident? ____________________________
2. Was there a direct blow to the spectacles? If not, in what manner were they damaged?
____________________________________________________________________________________
3. Description of DAMAGED spectacles –
(a) Type of frame (plastic or metal or combination of plastic and metal) ______________________
(b) Lenses –
i) Bi-focal or not bi-focal ________________________________________________
ii) Clear or tinted ________________________________________________
4. Details of Damage –
(a) Was the frame damaged? If so, give details of damage.
_____________________________________________________________________________
_____________________________________________________________________________
(b) Was one lens only damaged? If so, state left or right, and furnish details of damage.
_____________________________________________________________________________
5. Who supplied the DAMAGED spectacles? _________________________________________________
6. Original cost of DAMAGED frame? ______________________________________________________
7. Was all the damage caused by the abovementioned Incident? If not, give full details.
__________________________________________________________________________________________
For: _______________________________ (Name of Employer)Date: ____________________________________
Signature ______________________________________
MANAGER


and reporting
ANNEXURE 10
DENTURES QUESTIONNAIRE
For completion by Employer and to be submitted together with Form R.M.2.
EMPLOYEE: ____________________________________________________________________________________________
EMPLOYER: ____________________________________________________________________________________________
DATE OF INCIDENT: _______________________________________________________________________
1. (a) Was there a direct blow to the mouth? If not, in what manner were the dentures damaged?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
(b) Did the employee sustain any injury to his mouth or face? If so, give brief description of such injuries.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
2. Details of Damage
(a) Was only the upper denture damaged? ___________________________________________________
(b) Was only the lower denture damaged? ____________________________________________________
(c) Were both upper and lower dentures damaged? ____________________________________________
(d) Description of the damage, i.e. whether upper or lower plates or both, broken in half or cracked; how may teeth
broken, etc.
___________________________________________________________________________________
___________________________________________________________________________________
3. Was all the damage caused by the abovementioned Incident? If not, give full details.
__________________________________________________________________________________________
__________________________________________________________________________________________
For: _______________________________ (Name of Employer) Date: ____________________________________
Signature ______________________________________
MANAGER


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ANNEXURE 11

ADDENDUM TO INCIDENT REPORT IN CASE OF INJURIES SUSTAINED
DURING SPORTING EVENTS

NAME OF INJURED: _____________________________________________________________________________
DATE OF INJURY: _______________________________________________________________________________
DEPARTMENT: __________________________________________________________________________________
NATURE OF SPORTING MATCH: _________________________________________________________________
1. Was the match held with the approval and knowledge of Head of Department? YES / NO *
2. Was he/H&S representing a sports, social or recreational club? YES / NO *
3. For whom and against whom was the match played? _______________________________________________
__________________________________________________________________________________________
4. Who organised the match and what is his designation? ______________________________________________
__________________________________________________________________________________________
5. Was it a league match? YES / NO *
6. Would he/H&S have been expected by Management to take part in the match? YES / NO *
SIGNATURE OF INJURED: _______________________________________________________________________
SIGNATURE OF HEAD OF DEPARTMENT: ________________________________________________________
DESIGNATION: __________________________________________________________________________________
* Delete if not applicable
Definition of a sporting event:

• RMA pays compensation to employees who are injured, or to the dependants of employees who are killed while playing sport
if:
• The employee was playing for a team at:
o Inter-mine level.
o Inter-mine club level.
o Inter-group level
o External league level in a team made up of members who are mine employees.


and reporting
• The employee was injured or killed while participating in an individual event and was representing his/her employer.
• The employee was injured of killed when participating as an individual in an inter-mine or inter-group event.
• The employee was injured or killed when practicing for such events.
VAAL RIVER WEST WITS

WESTERN DEEP LEVELS
PRIVATE BAG X 11
HOSPITAL
ORKNEY P.O.BOX 8004
2620 WESTERN LEVELS
2501
Dear Sir
RAND MUTUAL SPORTS POLICY
NAME OF EMPLOYEE: ___________________________________________________________________________
COMPANY NUMBER: ____________________________________________________________________________
INDUSTRY NUMBER: ____________________________________________________________________________
DATE OF INCIDENT: ____________________________________________________________________________
NAME OF EMPLOYER: __________________________________________________________________________
I confirm that the abovementioned was injured on (date) _______________________________ while:
(Delete whichever is not applicable)
1. Playing in a team event as a member of a team made up of mine employees only.
OR
2. Participating in an individual sporting event, namely ____________________________ (name the event, e.g. athletics,
cycling), which was organised on an inter-mine or inter-group level and/or that there was a clear connection between his
participation in the event and this company, namely ____________________________ (describe the connection, e.g.
employee was sponsored by the company or wearing company colours at the time).
OR
3. Being transported transport specifically authorised by the company for this purpose to or from an event described in (1) or
(2) above.
OR
4. Participating in an authorised practice, rehearsal or preliminary for an event described in (1) or (2) above.
____________________________________ _________________________________
MANAGER DATE:


and reporting
ANNEXURE 12

NOTIFICATION TO ATTEND AN INVESTIGATION
NAME: _________________________________COMPANY NUMBER: ___________________
SECTION: ___________________________________
You are hereby notified to attend:
• Mine Incident Investigation
• Inspector of Mines Inquiry
• Health and Safety Committee Investigation (Departmental Level)

• Health and Safety Committee Investigation (J.H.&S. Level)
To be held: Date: ___________________________
Time: ___________________________
Venue: __________________________
If you want representation and / or witness /es, you will inform your Union Representative and / or your witness /es of the
investigation date, time and venue.
If the witness or representative can not attend ensure that an alternative representative is present.
______________________________________ _______________
SIGNATURE DATE
______________________________________
DESIGNATION


and reporting
ANNEXURE 13
CORPORATE - HEALTH AND SAFETY HOURS GUIDELINES
Source for all labour information will be Labour Costing. All information will be available on the Data Warehouse.
7.1 Calculation of at risk shifts for millionaire shield

Use shift code 000 which is normal shifts.
Add: Number of overtime hours and divide by 8 to get to shifts
- 002 Voluntary Saturday hours worker
- 004 Sunday hours worked 11 shift worker
- 005 Weekday overtime hours
- 007 Sunday hours worked cycle worker
- 018 Weekday quick shift hours cycle worker
- 019 Sunday quick shift hours cycle worker
- 023 Extra Saturday hours worked
- 025 Additional production hours worked
Add: Number of contractor’s shifts
7.2 Calculation of labour at work

Normal shifts 000
Add: Overtime shifts
- 001 Volunteer Saturday shifts worked
- 003 Sunday shifts worked 11 shift worker
- 006 Sunday shifts worked cycle of shift worker
- 009 Non-statutory holiday shift worked
- 013 Paid day off
- 015 Absent medical bureau
- 022 Extra Saturday shifts worked
- 024 Additional production shifts
- 030 Absent day off
- 031 Quick shift Sunday on absent day off
Divide by calendar days.

Add: Number of contractors.
7.3 At risk hours

Take normal shifts (000) and multiply by 9.2 for underground and 9 for surface shifts.
Add: Number of overtime hours
- 002 Voluntary Saturday hours worked
- 004 Sunday hours worked 11 shift worker
- 005 Weekday overtime hours
- 007 Sunday hours worked cycle worker
- 018 Weekday quick shift hours cycle worker
- 019 Sunday quick shift hours cycle worker
- 023 Extra Saturday hours worker
- 025 Additional production hours worked
Add: Number of contractors shifts multiplied by 9.5 for underground and 9 for surface.
7.4 General
Ignore employees working at Business Units, but getting paid at Corporate as well as people costed to
one Business Unit e.g. Business Services and working at another Business Unit. They are immaterial


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ANNEXURE 14
INJURY / INCIDENT
45 MINUTE INVESTIGATION
DISCIPLINE:
DEPARTMENT:
SECTION:
SOUTH
AFRICA
INCIDENT NUMBER:
REGION
SERVICES
DATE REPORT COMPLETED
DESIGNATION NAME DATE RECEIVED SIGNATURE DATE
FORWARDED
INJURED
SUPERVISOR
HOD
H&S OFFICER


and reporting
INFORMATION REGARDING THE INJURED
Date of incident:
Time of incident:
Agency:
Incident:
Surname:
First name:
Occupation:
Company number:
Date of birth:
Identity/ Passport number:
Industry number:
Marital status:
Number of dependants:
Residential address:
Province:
Country:
Employment date:
Discipline:
Main area:
Sub area:
Name of supervisor:
Contact number:
Name of HOD:
Contact number:
Contractor - which company:


and reporting
45 MINUTE INJURY / INCIDENT INVESTIGATION TEAM
Date:
NAME COY NUMBER OCCUPATION DEPARTMENT


and reporting
INCIDENT ANNOUNCEMENT – FIRST / FINAL ANNOUNCEMENT (INJURY / INCIDENT)
VAAL RIVER X WEST WITS

INCIDENT SIGNIFICANCE
INCIDENT CATEGORY
INCIDENT TYPE
INCIDENT NUMBER
DATE AND TIME
DISCIPLINE
WORKING PLACE
NAME
OCCUPATION
INJURY
DESCRIPTION OF INJURY / INCIDENT
CAUSES
REMEDIAL ACTION
___________________ _______________________
Designated Appointee Date of Announcement


and reporting
1. Give a clear description of the LOSS
What activity / task was performed?
Injury
Process Loss
Property Damage
Liability
Threshold Limit Loss

Operational Control
Unsafe Conditions
Injuries
Risk Assessment
System Controls
Unsafe Acts
Incidents
Damage
Ill Health
Property
Loss


and reporting
2. Give a clear description of the INCIDENT
Energy Type:
Potential Chemical Mechanical Thermal Kinetic Gasses Electrical Biological
Description
Loss
Threshold Limit
Operational Control
Unsafe Conditions
Risk Assessment
System Controls
Injuries
Unsafe Acts
Incidents
Damage
Ill Health
Property
Loss
Definitions of Energy
Potential Energy: Energy stored in a body with potential to do work.

E.g. Rubber band, spring, radio-active decay, magnet.
Kinetic Energy: Work required accelerating an object to a given speed (Mass and Speed)
E.g. Moving a cap on a table from Point A to point B, sound, wind.
Mechanical Energy: It is the movement of machine parts.
E.g. Steam Turbine, Electric Motor.
Thermal Energy: It is anything that gives off heat or cold.
E.g. Stove plates, heater, and cold rooms.
Electrical Energy: It is the moving of chargers in an electrical circuit.
E.g. Lightning, generators, turbines, transformers.
Chemical Energy: It is stored energy released by a chemical reaction.
E.g. Matches, different types of chemical mixtures, gasoline.
Gasses: It is the reaction from chemical mixtures.
E.g. Smoke from a fire, gas from a vehicle.


and reporting
3. What UNSAFE CONDITION
contributed towards the incident?
Inadequate warning systems Defective protective devices
Illumination sub standard Inadequate ventilation
Inadequate protective devices Sub standard tools / equipment
Hazardous environmental conditions Congestion / restriction
Natural hazards Fire / explosive hazards
PPE not available / supplied Sub standard material
Excessive emissions Defective surface
OTHER (Specify)- Unsafe work practice
Description
Loss
Threshold Limit
Operational Control
Unsafe Conditions
Injuries
Risk Assessment
System Controls
Unsafe Acts
Incidents
Damage
Ill Health
Property
Loss


and reporting
4. What UNSAFE ACTS contributed?
Disregard of standards / procedures Deviation from standards / procedures /
/ regulations regulations
Failure to comply with instruction Improper handling / lifting
Failure to give proper instruction Improper placing / stacking
Failure to recognize hazard Games / Horse play
Failure to take preventative action / Failure to use safety devices / equipment
secure
Removing or making safety devices Operating equipment without authority
inoperable
Operating at unsafe speed Servicing equipment whilst in motion
Taking up improper / unsafe position Using unsafe equipment / tools
Failure to use PPE OTHER (Specify)
Description
Loss
Threshold Limit
Operational Control
Unsafe Conditions
Injuries
Risk Assessment
System Controls
Unsafe Acts
Incidents
Damage
Ill Health
Property
Loss


and reporting
4.1 What OPERATIONAL CONTROLS
Personal Factors
Physical Ability Physiological Ability
Motivation Mental Ability
Skills Stress
Experience Communication
Abuse / Misuse Attitude
Emotional disturbance OTHER (specify)
Description
Loss
Threshold Limit
Operational Control
Unsafe Conditions
Injuries
Risk Assessment
System Controls
Unsafe Acts
Incidents
Damage
Ill Health
Property
Loss


and reporting
4.2 What OPERATIONAL CONTROLS
Job Factors
Leadership Purchasing
Engineering Quality
Maintenance Tools and Equipment
Permits PPE
Work Standards Operating Procedures
Training / Coaching Induction
Supervision Discipline
Emergency Procedures OTHER (Specify)-
Description
Loss
Threshold Limit
Operational Control
Unsafe Conditions
Injuries
Risk Assessment
System Controls
Unsafe Acts
Incidents
Damage
Ill Health
Property
Loss


and reporting
5. What SYSTEM CONTROLS failed?
Planning and leadership Training Process
Communication Process Risk Assessment Process
Change Management Purchasing System
Legislation Process Inspection Process
Incident Investigation Process Audit & Review Process
Document Control Records Keeping
Corrective / Preventative actions Quality Management
Description
Loss
Threshold Limit
Operational Control
Unsafe Conditions
Injuries
Risk Assessment
System Controls
Unsafe Acts
Incidents
Damage
Ill Health
Property
Loss


and reporting
6. Was this Task / Equipment identified in the
RISK ASSESSMENT process?
Base Line Issue Based CRA
Description
Loss
Threshold Limit
Operational Control
Injuries
Unsafe Conditions
Risk Assessment
System Controls
Unsafe Acts
Damage
Incidents
Ill Health
Property
Loss
Financial
Loss


and reporting
Annexure 1
STATEMENT OF INJURED
Company Number: ____________________________
Occupation: __________________________________
Working Place: ________________________________
Declare: _______________________________________________________________
Signed at ________________________________on the _________day
of ________________________________200____
________________________________________________
SIGNATURE
Statement taken by:
(PRINT NAME): ____________________________________________
Signed: ________________________________________


and reporting
Annexure 2
Photo’s


and reporting
Annexure 3
STATEMENT OF WITNESS
I _______________________________ Coy. No: _____________________
Occupation: ___________________________________________________
Working Place: ______________________________ Declare: ___________________
I declare the above statement to be true and correct and within my personal knowledge. I further declare that this
statement was taken and read back to me.
Signed at _____________________________________ on the ________day
of _________________________200______
______________________________________
SIGNATURE
Statement taken by:
(PRINT NAME): _______________________________________
Signed: ______________________________________________


and reporting
ANNEXURE 15
Populating an Incident /
Investigation (Parent)
Click on link below to jump to the specific section on this page:
• View an Incident
• Add a New Incident
• Edit an Incident
• Delete an Incident
View an Incident
Step 1. Click on "Incidents" on the RMS Home Page
A dropdown menu will open


and reporting
Step 2. Click on "Incidents" on the dropdown menu
Incidents Module will open, displaying the Summary screen with the Filter section
Step 3. In the Filter section, select the following:
- Operation
- Status
Step 4. Click on the "Search" button
Results will display in a grid view below the filter section on the summary screen
Step 5. Click on the relevant Incident in the grid view to select
Step 6. Click on the "Edit" button
The Intermediate screen will open
Step 7. Click on the "Next" button in the Intermediate screen
Incident / Investigation Capture form opens
Step 8. Click on the "Cancel" button to return to the Summary screen


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Add a New Incident


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- Operation
- Status
Step 4. Click on the "Add New" button
The Intermediate screen, will open
Step 5. On the Intermediate screen, select the following:
Capture form
Date Captured
Capturer
Workplace
Discipline
Matter
Step 6. Click on the "Next" button
The Incidents Input Capture form opens
Step 7. Populate all applicable fields
Step 8. Click on the "Save" button to save the information entered into the capture form
Step 9. Proceed by adding an Injury (child) to the Incident (parent) by clicking on the "Create child" button or
click on the "cancel" button to exit
Available buttons at the bottom of the capture form:
• Save
• Save & Finalise
• Cancel
• Print
• Causal Analysis
• Documents
• Generate Report
• Create Child


and reporting
Important when populating an Incident / Investigation:
Remember to save!
- NB: You cannot save an Incident if the minimum required fields for saving have not been populated
(See section below for minimum required fields)
You must finalise the incident as per the month end schedule (approx 21st of each month) Do this by
clicking on the "Save & Finalise" button
- NB: You cannot finalise an Incident (parent) if the Injury (child) has not been finalised first!
- NB: You cannot finalise an Incident if the minimum required fields for finalisation has not been
populated (See section below for minimum required fields)
Different Input field types are used to populate the fields on the Input Capture Form
Required fields are marked with a red icon
Tooltips are displayed when the mouse pointer is hovered over an item / field on the Input Capture
form. A more in-depth description or explanation of what information is required for that specific field
will be displayed in the Tooltip.
Minimum required fields for saving an Incident:
Incident date
Minimum required fields for finalising an Incident:
Incident / Investigation Ref Nr
*Incident date
Type of Accident or Dangerous Occurrence
Incident Time
Shift Involved
MO Section Occurring At
Description of Incident
Important field(s) on the Incident Input Capture Form:
Do Causal Analysis - is an important field as it activates the "Causal Analysis" button


and reporting
How to activate the "Causal Analysis" button:
Edit an Incident
Step 1. Select "Operation" and "Status" in the Filter section on the Summary screen
Results will display in a grid view below the filter section
Step 3. Select the Incident in the grid view
Step 5. On the Intermediate screen, edit the following items where necessary:
Capture Form
Date Captured
Capturer
Workplace
Discipline
Matter


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Step 7. Change / Update the necessary fields in the Incident Input Capture Form
Step 8. Click on the relevant button at the bottom of the Input Capture Form screen to continue E.g. Save /
Save & Finalise / Cancel ...
Remember to Save!
Delete an Incident
Note that you will only be able to delete an Incident if you have access to do so
Results will display in a grid view below the filter section
Step 3. Select the Incident in the grid view
Step 4. Click on the "Delete button" below the Filter section to Delete the selected Incident
- NB: You will not be able to delete an Incident if there is any Injuries (children) linked to the Incident (parent)


and reporting
ANNEXURE 15A
Populating an Injury
Page currently under construction

Click on link below to jump to the specific section on this page:
• View an Injury
• Add a New Injury
• Edit an Injury
• Delete an Injury
View an Injury


and reporting
- Operation
- Status
Resluts will display in a grid view below the filter section on the summary screen
Step 5. Click on the "+" sign next to the Incident (parent) to view all Injuries (children) linked to the Incident
Step 6. Click on the relevant Injury to select


and reporting
The Injury Capture form opens
Step 9. Click on the "Cancel" button to exit and return to the Summary screen
Add a New Injury
An Injury (child) needs to be added / linked to an Incident (parent)
Below are 2 options to create an Injury:
Option 1: From within an Incident (parent) capture form



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- Operation
- Status
Incident / Investigation Capture form opens
Step 8. Click on the "Create Child" button
Step 9. Select the capture form: Injury Monitor


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Step 13. Click on the "Cancel" button to exit and return to the summary screen
• Save
• Save & Finalise
• Cancel
• Print
• Documents
• Generate Report
The following buttons will be visible, but not available:
• Causal Analysis
• Create Child
Click here to learn more about each button's function
Option 2: From the Summary screen



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- Operation
- Status
Step 6. Click on the "Add New" button
The following message will be displayed in a popup window:
Step 7. Click on "OK"


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Step 8. Select the capture form: Injury Monitor
Step 12. Click on the "Cancel" button to exit and return to the summary screen
• Save
• Save & Finalise
• Cancel
• Print
• Documents
• Generate Report
The following buttons will be visible, but not available:
• Causal Analysis
• Create Child
Click here to learn more about each button's function
Important when populating an Injury:
Remember to save!
- NB: You cannot save an Injury if the minimum required fields for saving has not been populated
(See section below for minimum required fields)
You must finalise the Injury as per the month end schedule (approx 21st of each month) Do this by
clicking on the "Save & Finalise" button
- NB: You cannot finalise the injury if the minimum required fields for finalisation has not been
populated (See section below for minimum required fields)
Different Input field types are used to populate the fields on the Input Capture Form
Required fields are marked with a red icon
Tooltips are displayed when the mouse pointer is hovered over an item / field on the Input Capture
form. A more indepth description or explanation of what information is required for that specific field
will be displayed in the Tooltip.


and reporting
Minimum required fields for saving an Injury:
Scenario 1: If Injury Classification is a Dressing case, the required field(s) would be:
Person injured (company number)
Scenario 2: If Injury Classification is LTI or Serious or Fatality, the required fields would be:
Person injured (company number)
Nature of Injury
Body parts Injured
Agent
Minimum required fields for finalising an Injury:
Injury Reference No
*Person Injured (company number)
On the Job (Injured at Work)
*Nature of Injury
*Body parts injured
*Agent
Normal Occupation at time of accident
Organisation Struction Employed At (Auto populate)
Gang (Auto populate)
Competition Classification
Age at Time of Incident (Auto populate)
Important field(s) on the Injury Input Capture Form:
The "Date Off Period" field is important as it calculates the Shifts Lost and establishes the "Injury
Classification"
"Date Off Period" (Whole group) includes:
Date Off Work (The user must select the "Date Off Work" from the calendar provided)
Date Resumed Work (The user must select the "Date Resumed Work" from the calendar provided)
LTI Date (Calculates automatically, but can be edited)
Serious Date (Calculates automatically, but can be edited)
Fatal Date (Calculates automatically, but can be edited)


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Injury Classification (The Injury Classification is a read only field as it calculates automatically)
Incident Date (The Incident Date field on the injury capture form's "Date Off Period" is read only as it
pulls through from the parent incident capture form)
The "Nature of Injury" and "Body parts Injured" fields are important as the "Allocated Days Lost"
fields calculates automatically depending on the selection made in the "Nature of Injury" and "Body
parts Injured" fields.
Edit an Injury
Resluts will display in a grid view below the filter section
Step 6. On the Intermediate screen, edit the following items where necessary:
Capture Form
Date Captured
Capturer
Workplace
Discipline


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Matter
The Injury Capture form opens
Step 8. Change / Update the necessary fields in the Injury Input Capture Form
Step 9. Click on the relevant button at the bottom of the Input Capture Form screen to continue E.g. Save /
Save & Finalise / Cancel ...
Remember to Save!
Delete an Injury
Note that you will only be able to delete an Injury if you have access to do so
Resluts will display in a grid view below the filter section
Step 5. Click on the "Delete button" below the Filter section to Delete the selected Injury


and reporting
Annexure X
DEFINITIONS AND ABBREVIATIONS
DEFINITIONS:
DOCUMENT
Information and its supporting medium (The medium can be paper, magnetic, electronic or optical computer
disc, photograph or master sample, or a combination thereof.)
RECORD
Document stating results achieved or providing evidence of activities performed
CONTROLLED DOCUMENT
Any document that needs to be controlled in terms of its distribution and use, such as the Policy and
documented procedures. These documents are either signed in original ink and/or signed for on a
distribution list. These documents will be signed off after evaluation has been done to determine that they
are adequate for purpose. The document will be signed off by the relevant members as depicted on the
distribution list.
Once copies are printed of the database, they are considered to be “uncontrolled”.
OBSOLETE DOCUMENTS
Documents that have been replaced by later revisions or those that is no longer relevant or valid, and has
been cancelled from the system. These documents will be identified either by crossing them out and writing
obsolete or rubber stamp obsolete document.
UNCONTROLLED DOCUMENTS
Any documents that have not been issued under the circumstances under “controlled documents” are
categorised as uncontrolled. This includes, but may not be limited to:
• Documents that do not need to be controlled such as the monthly safety topic.
• Documents not distributed by the authorised person as per the procedures “authority and
responsibility” table and signed for by the recipient.
• Documents printed from the electronic database. (Watermarked “uncontrolled document)
• Documents duplicated or photocopied from controlled documents.
• Photocopies of the Occupational Health and Safety policy as issued to the public or other
Interested and Affected Parties
It is not possible to judge from an uncontrolled copy whether it is the latest version. It is the responsibility of
the person holding the documentation to ensure that (s) he has the latest version.
INJURY
Physical harm or damage
OCCUPATIONAL HEALTH AND SAFETY

Conditions and factors that affect, or could affect the health and safety of employees or other workers
(including temporary workers and contractor personnel), visitors, or any other person in the workplace
OH&S MANAGEMENT SYSTEM

Part of an organization’s management system used to develop and implement its OH&S policy and manage
its OH&S risks
SEVERITY / CONSEQUENCE
Outcome of an event. There may be one or more consequences from an event. May be expressed
qualitatively or quantitatively may range from positive to negative (Speculative).


and reporting
FREQUENCY
Occurrence per unit time, (May be expressed qualitatively or quantitatively).
EXPOSURE
How often and for how long employees are exposed to a hazard/s.
LIKELIHOOD
Means the chance of an event occurring.
DUE DILIGENCE
Taking reasonable care to protect the health and safety of all employees. Provide equipment, maintain the
equipment, use equipment as prescribed, provide information relating to the equipment, and provide
competent supervision.
INCIDENT
An undesired event which under slightly different circumstances could result in harm to people. Damage to
property or loss to process or an undesired event that could or does result in a loss.
RISK MATRIX
A Risk index can be determined by plotting likelihood and severity indices on the y and x-axis respectively
and then using them to obtain a risk ranking.
HIRA
Process of recognizing that a hazard exists and defining its characteristics
• H = HAZARD
Anything around us that we can see as well as those energy sources we cannot see e.g. Gas and
radiation that can cause harm
• I = IDENTIFICATION
Identify the significant hazards (Process and recognition)
• R = RISK
Risk imagining (Likelihood and consequence if risk materializes)
• A = ASSESSMENT
Determine the magnitude of the risk if materialized
ROUTINE ACTIVITY
An activity which is performed on a regular basis (day to day)
NON ROUTINE
An activity performed on an adhoc basis
ACCOUNTABILITY
Principle that, individuals, organizations, and the community are responsible for their actions and may be
required to explain them to others.
RESPONSIBLE
Liable to be called to respond to a person for issues to be done.
ILL HEALTH
Identifiable adverse physical or mental condition arising from and/or made worse by a work activity and/or
work-related situation.
INTERESTED PARTIES
Person or group, inside or outside the workplace, concerned with or affected by the SARSSS performance.


and reporting
NONCONFORMITY
Non-fulfilment of a requirement – can be any deviation from:
Relevant work standards, practices, procedures, legal requirements.
SARSSS OBJECTIVES
SARSSS goals, in terms of OHS performance, that South Africa Region Services sets itself to achieve.
Objectives are quantified wherever practical.
SARSSS PERFORMANCE
Measurable results of South Africa Region Services management of its risks.
Note: Performance measurement includes measurement the effectiveness of controls.
OHS POLICY
Overall intention and direction which will be followed for the management of health and safety.
RECORD
Document stating results achieved or providing evidence of activities performed
HAZARD
A condition or practice with the potential to cause harm, or exposure to danger. (Immediate Causes,
Substandard Act or Substandard Condition)
RISK ASSESSMENT
Process of evaluating the risk(s) arising from a hazard(s), taking into account the adequacy of any existing
controls, and deciding whether or not the risk(s) is acceptable
PREVENTATIVE ACTION
Action to eliminate the cause of a potential nonconformity or other undesirable potential situation.
CORRECTIVE ACTION
Action taken to rectify a non-conformance or deviation
CONTINUAL IMPROVEMENT
To constantly improve on current Health and Safety standards
PROCEDURE
Specified way to carry out an activity or a process.
RISK ASSESSMENT
Process of evaluating the risk arising from a hazard, taking into account the adequacy of any existing
controls, and deciding whether or not the risk is acceptable.
WORKPLACE
Any physical location in which work related activities are performed under the control of South Africa Region
Services.
AUDIT
Independent and documented process for obtaining “audit evidence” and evaluating it objectively to
determine the extent to which “audit criteria” are fulfilled.
SAFETY MONTH
Period from the 20th of a particular month up to the 19th of the following month.


and reporting
EFFORT BASED OBJECTIVES
Objectives set to improve program related issues
EFFECT BASED OBJECTIVES

Objectives set to improve severity or injury rates
MANCOM
Management Committee
EXCO
Executive Committee
SUPERVISOR
Within South Africa Region Services – One who supervise or has charge and direction of i.e. Foreman,
Clerk of works, Training Officer, Residence Manager, Security Officer etc.
EMPLOYEE
Person working under the control of the organisation and includes contractors.
MANAGEMENT REPRESENTATIVE
A Person appointed in writing ensuring that the OH&S management system is established, implemented
and maintained in accordance with this OHSAS Standard;
and ensuring that reports on the performance of the OH&S management system are presented to top
management for review and used as a basis for improvement of the OH&S management system.
VISITOR
Any person who enters the premises of the mine who is not a full time employee or Contractor paid by the
mine
CONTRACTOR
Any person who perform work for the mine and is paid for his/her service.
ACCEPTABLE RISK
Risk that has been reduced to a level that can be tolerated by the organization having regard to its legal
obligations and its own
HEALTH AND SAFETY COMMITTEE

A committee as required by law M H & S Act Section 25(2)
VERIFICATION
Verification is the act of reviewing, inspecting, testing, etc. to establish and document that a product, service,
or system meets the regulatory, standard, or specification requirements.
VALIDATION
Validation refers to meeting the needs of the intended end-user or customer to
prove the truth or to determine or test the accuracy. Also, validation is the process of checking if something
satisfies a certain criterion.


and reporting
ABBREVIATIONS:
M H & S Act - Mine Health & Safety Act

MA&R - Mineral Act & Regulations
OHASA - Occupational Health and Safety Act
DMR - Department of Mineral Resources
DOL - Department of Labour
SARS - South Africa Region Services
ESW - Engineering Services Workshops
WITW - Wellness in the Workplace
H&S - Health and Safety
LTIFPD - Loss Time Injury Free Production Days
IFPD - Injury Free Production Days
AGAH - AngloGold Ashanti Health
TMM - Trackless Mobile Machinery
COP - Code of Practice
ATDS - AngloGold Ashanti Training and Development Services
CRA - Continuous Risk Assessment
SARSSS - South Africa Region Services Safety System


and reporting
Annexure XX
REFERENCES
• Roles and responsibilities are depicted in each system procedure and updated as and when
required in table format
• OHSAS 18001:2007 (Occupational Health and Assessment Series)
• The Mine Health and Safety Act 29 of 1996
• The Minerals Act 50 of 1991
• Occupational Health and Safety Act (Act 86 of 1993)
• COIDA
• AGA Strategic Objectives
• Implex Legal Register
• ATDS Training Matrix
• AGA RCAT
• Corporate Procedure Directive
• Health and Safety Agreement
• SAR/OESH/P/A/001.01 – AGA Incident reporting
• H&S 004 – Incident investigation
• H&S 006 – Emergency preparedness and response
• H&S 014 – Issue based risk assessment
• H&S 018 – Baseline risk assessment H&S 019 – Control of records
• H&S 023 – Control of documents
• H&S 027 – Competence, training and awareness
• H&S 028 – Continuous risk assessment
• H&S 029 – Communication, participation and consultation
• H&S 030 – Management review
• H&S 031 – Internal audit
• H&S 037 – Management of change
• H&S 055 – South Africa Region Services Scope
• H&S 058 – Legal and other requirements
• H&S 059 – Performance measurement and monitoring
• H&S 060 – Evaluation of compliance
• H&S 061 – Nonconformity, corrective and preventative action
• H&S 065 – Objectives and programme(s)
• H&S 067 – Resources, roles, responsibility, accountability and authority
• H&S 069 – Operational control
• H&S 070 – Documentation
• H&S 071 – H&S Policy


and reporting
RECORDS OF AMENDMENTS
PROCEDURE DATE OF
CHANGES TO PROCEDURE
REVISION NUMBER APPROVAL
H&S 004 – Revision 6 Purpose, Scope, Definitions and 3 June 2009
abbreviations, References, Roles and
responsibilities, Reporting and recording
added,
H&S 004 – Revision 7 “Critical trends identified during an 1 October 2009
investigation process will be actioned and
communicated.” Added to continual
improvement Page 5
45 Minute Injury / Incident Investigation

H&S 004 – Revision 8 Populating RMS 27 January 2010
H&S 004 – Revision 9 Amendment to point 10 (Page 9) 30 August 2011

Amendment to point 7 (page 6) – Incident
H&S 004 – Revision 10 flowchart & Responsibilities 01 November 2011
H&S 004 – Revision 11 Change to annexure 5 Page 14 1 March 2012


and reporting

HS 004 Incident Investigation

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SOUTH AFRICA REGION REFERENCE REVISION PAGE

SERVICES H&S 004 11 1 OF 65

COMPILED BY H&S OFFICER S THERON Original Signed 6/03/2012

REVIEWED BY SNR H&S OFFICER JSD CRONJÉ Original Signed 6/03/2012

AUTHORISED BY H&S MANAGER J SODEN Original Signed 6/03/2012

TABLE OF CONTENTS PAGE ADDENDA PAGE

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

3. DEFINITIONS AND ABBREVIATIONS

Refer to Annexure “X”

Refer to Annexure “XX”

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

6. INJURY REPORTING STRUCTURE

REPORTING AND RECORDING OF INCIDENTS

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

H&S Dept initiates Incident

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

IDENTIFICATION OF BASIC CAUSES

TIME TO PERFORM INVESTIGATION

RESULTS OF INCIDENT INVESTIGATION

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

Incident Flowchart & Responsibilities

If incident resulted in an injury If only property damage or

If injured visit his own doctor If injured visit the dressing

H&S Dept update daily stats H&S dept releases final

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

9. RAND MUTUAL CLAIMS PROCEDURE

9.1 Road Incident Questionnaire (Annexure 8)

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

9.3 Dentures Questionnaire (Annexure 10)

9.4 Organized Company Sporting Events (Annexure 11)

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

10. REPORTING AND INVESTIGATING INCIDENTS OF PROPERTY DAMAGE / PRODUCTION

11. INJURIES TO BE REPORTED TO THE D.M.R

12.1 The death of any employee

12. INCIDENTS RESULTING IN INJURY

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

Full investigation reports H&S Department

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

DEPARTMENT OF MINERAL RESOURCES

SECTION A: EMPLOYER DETAILS

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

INJURY REPORT FORM (SAMRASS 2)

SECTION E: EMPLOYEE’S DETAILS

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

NAME OF MINE: AngloGold Ashanti DMR MINE CODE....................

Codes to be used on this Form are specified in the Code Book

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

NAME OF MINE: ………………………….. DMR MINE CODE....................

(Original, approved copy filed at the H&S Department)

Incident investigation REVISION EFFECTIVE DATE PRINT DATE PAGE

AREA: _____________ DATE:

Who reported the incident? ________ Designation: _

DEPARTMENT HEAD: _ DESIGNATION:_____

SIGNATURE: DATE: ___

REPORTED BY : INVESTIGATOR : _______

DATE : _ DATE : ____

SIGNATURE : _ SIGNATURE : _______

DATE: DATE: ____

For: ___ (Name of Employer) Date:

For: _ (Name of Employer)Date: ______

For: _ (Name of Employer) Date: ______