Professional Documents
Culture Documents
TRAIN OF KM500
GAS TREATMENT
PLANT
HAV-EXT-HS-PRO-0147
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 2/ 20
1. SCOPE
This procedure explains basic principles and aims of Havatek about Accident/Incident Investigation
system.
2. DESCRIPTION
2.1 Accident / Incident Investigation
The HAVATEK A.Ş Accident/Incident Investigation system places the following obligations on all Project
Director, Site Manager, supervisors and employees of Contractor and any Site Subcontractors.
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 3/ 20
Contractor and any Subcontractor are required to ensure their employees immediately report all accidents
/incidents or hazards to their supervisors. All of the following should be reported:
A hazard, near miss or dangerous event;
Property or equipment damage;
Physical injury or harm to health;
A fire event.
All accidents and incidents shall be reported, investigated and analyzed.
Subcontractors will ensure the accident/incident or hazard is fully investigated by their supervision and
reviewed by the HSE Supervısor to ensure appropriate corrective and preventative actions are identified
and implemented. Supervisor also undertake an independent investigation.
The completed Subcontractor report must be lodged with the respective Contractor Site HSSE Manager
within 24 hours of the accident/incident occurring or hazard being identified.
The respective Contractor Site HSSE Manager, following receipt of the reports from the relevant person on
completion of an appropriate investigation, will document a summary of specific accident/incident or hazard
details. Contractor and Subcontractor Site Manager and Supervisors shall actively encourage their
employees to report all accidents, incidents and hazards.
The HAVATEK A.Ş will ensure the Client Representative advised of the accident/incident as soon as
practical following the occurrence. This may be performed verbally [telephone discussion/ face to face] or
written [e-mail/ facsimile/ etc.]. Upon finalization of the investigation report a copy shall be provided to the
Owner’s Representative.
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 4/ 20
The HSE Supervısor may nominate Contractor HSSE Manager or as appropriate Technical Lead to follow
up on the status of the nominated corrective/preventative actions proposed in the investigation to ensure the
accident/incident or hazard has been properly dealt with and the risk of recurrence minimized or eliminated.
Once all nominated corrective/preventative actions have been implemented, the Accident/ Incident or
Hazard Report will be closed out and filed at the Contractor Project Site Office.
The Site EHS Notice board will be updated periodically and will be located at the site main entrance. The
Site EHS Notice board will display the following Key Performance Indicators:
Project has been running for [number] of days;
Lost Time Injury Frequency Rate [number];
Lost Time Injuries to Date [number];
Environmental Incidents to Date;
Lost Work Days to Date;
All injury Frequency Rate;
Total Project Hours to Date.
Determining and controlling hazard is the most important process of HSE system. So the aim is to
cause the system to gain necessary precautions by determining possible risks and accidents which
can cause work accidents. (The detailed information of this subject can be find in “Hazard
Identification, Risk Assessment and Control “procedure.)
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 5/ 20
Making technical and legal inspections of equipment with a planning system which are used
during activities with personal and group protection equipment
Determining criterions which sets legal and acceptable working conditions and to document
them (job plans, charts etc.)
Making verification inspections (Controlling and chasing timing of inspections which are done
before by check list application)
4.3 Accidents, Events, Inconvenience, Corrective and Preventive Activity
4.4.1 For work accidents; Has made “Documentation of work accidents – Statistic analysis of work
accidents– Evaluation of work accidents performances” procedures and “Root analysis – Accident
development tree analysis” processes. The aim is to abrogate reasons of an accident and to prevent
its repetition.
4.4.2 For Events; Urgen1t operation plans have been prepared related with fire, eruption, earthquake
and malicious acts (anarchism) and these are documented as a process. So the aim is to abolish the
damages of employees or to minimize them.
RCA and WHY TREE technics will be used for incident investigations.
First aid cases shall be reported as preliminary reports with corrective actions identified.
Incident flash report shall be submitted to Exterran and the related parties within 24 hour of the
incident
5. Attachments
1- Incident Flash report
2- Incident flow chart
3- Incident Matrix
4- Incident Report Form
Accident / Incident Investigation System Procedure
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 6/ 20
Attachment 1
Flash Incident Report
Date: Time: am/pm
Site: Location:
HAVATEK Sub-Contractor
Incident:
Classification:
Injury Illness
Spill/Environmental High Potential Near Miss
Property Damage Vehicle Incident
Fire Theft/Security breach
Other
Comments:
Prepared by:
Accident / Incident Investigation System Procedure
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 7/ 20
Attachment 2
Investigation CONSTRUCTION e-mail (within 2 working day from HAVATEK Site HSE
Level 1 SUBCONTRACTOR Site incident occurrence) Manager
Management HAVATEK Site
Management
HAVATEK Site HSE Manager e-mail (within 2 working days from HAVATEK Site
incident occurrence) Management/
EXTERRAN
Representative
HAVATEK Project
Director
HAVATEK Head
Office
HAVATEK Corporate
HSE Manager
Investigation HAVATEK Site HSE Manager e-mail (within 1 week from incident HAVATEK Site HSE
Level 2 occurrence) Manager
HAVATEK Site
Management
HAVATEK Project
Director
Investigation HAVATEK Site HSE Manager e-mail (within 1 week from incident HAVATEK Project
Level 3 occurrence) Director
HAVATEK Site
Management
HAVATEK Head
Office
HAVATEK Corporate
HSE Manager
Accident / Incident Investigation System Procedure
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 8/ 20
Attachment 3
Real Consequences
Incident Scope
Investigation Level as per Real Consequences Incident Classification
Health & Safety Environment Assets & Properties General Community / Media / Reputation
Threatens survival of the
site/company in its current form. Adverse International media.
Level V - catastrophic, irreversible Requires fulltime senior Damaging NGO campaign.
3 Catastrophic Multiple work-related fatalities. impact to environment > 1% of Project Value management
Fundamental attention.
threat to operating License to operate compromised.
Determination of Real Level IV - serious (major) results.
Consequences environmental impact. Between 1% and 0,1% of Project Requires immediate senior Persistent adverse national media /
3 Major Work-related fatality. Major Spill / Leakage Incident Value management attention. public / NGO attention.
Level III - material environmental Significant deterioration in the
Work-related LTIs or occupational impact. Between 0,1% of Project Value and achievement of results. Some national media / public / NGO
2 Moderate diseases with medical leave. Medium Spill / Leakage Incident 100.000 € Requires response fromin the
Material deterioration division. attention for an extended period.
Level II - non-material (minor) achievement of results. Some adverse State/Provincial
Determination of Medical Treatment Cases, Work environmental impact. Requires response from dept media attention for a brief period.
Investigation Level 2 Minor Restricted Cases. Minor Spill / Leakage Incident Between 100.000 and 10.000 € manager. Criticism by NGOs.
according to Real
Requires response from Some community complaints.
Consequences
Level I - unauthorized disposal of departmental staff under routine Adverse local public or media
1 Insignificant First-Aid Cases, Near Misses. benign waste < 10.000 € procedures. attention.
Potential Consequences (considering all the safeguards effectively in place during the occurrence of the event)
Assessment of Potential
Scope Definitions
Consequences
Community / Media / Reputation Adverse International media. Some adverse State/Provincial Some community complaints.
Damaging NGO campaign. Persistent adverse national media / Some national media / public / NGO media attention for a brief period. Adverse local public or media
License to operate compromised. public / NGO attention. attention for an extended period. Criticism by NGOs. attention.
Environment Level IV - serious (major) Level III - material environmental Level II - non-material (minor)
Level V - catastrophic, irreversible environmental impact. impact. environmental impact. Level I - unauthorized disposal of
impact to environment Major Spill / Leakage Incident Medium Spill / Leakage Incident Minor Spill / Leakage Incident benign waste
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 9/ 20
Attachment 4
PROJECT NAME
Notified by:
Notified to:
Incident description
Incident Classification
Accident / Incident Investigation System Procedure
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 10/ 20
Work related
Non work related Injury No injury
Time off No time off Mat. damage Env. damage No damage
Restricted Asset
Fatality ☐ Work Case ☐ Damage Near Miss
☐ (RWC) (AD) ☐
(FAT) (NM) (*)
Non Work Medical Environmental
☐ Related ☐ Treat. Case ☐
Motor Vehicle
☐
Inc. (MVI) Incident (EI)
(NWR) (MTC)
Lost Time Security
☐ ☐
Incident (LTI) Breach (SB)
First Aid Case Fire Incident
☐ ☐
(FAC) (FI)
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 11/ 20
☐ Restricted Work Case (RWC) ☒ Medical Treatment Case (MTC) ☐ First Aid Case (FAC)
Full IP’s name:
No time off
☐ Asset Damage (project) (AD) ☐ Asset damage (3rd party) (AD) ☐ Fire Incident (FI)
Asset: ID:
Owner: Cost (€):
Asset description:
Damage description:
Cause of damage:
With damage
Description:
Quantity of emissions / spill (L):
Description:
Lost assets (Real or Potential):
Estimated Cost (€/$) (real or potential):
Potential Consequences for Health and Safety:
Potential Consequences for the Environment:
2.2 Outcome
Accident / Incident Investigation System Procedure
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 12/ 20
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 13/ 20
Weather
Housekeeping
Location / design of work area
Environment
Visibility
Access / egress
Ground and noise conditions
Fault or failure
Design / quality
Availability
Equipment Modifications
Maintenance
Inspections / pre-starts
Risk assessment on equipment
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 14/ 20
Control Institute (ILCI) Loss Causation Model represents the sequence of events that allow an actual loss to occur. It can be used to understand the various causes leading to incidents and
provides a framework for the subsequent incident investigation.
This model takes a proactive approach to loss prevention and suggests that incidents are symptoms of lack of control in the management system, which is to be identified. The various events
are explained by working backwards from the loss. Please refer to Attachment 2: ILCI Loss Causation Model for the events checklist and refer to Incident Report Guidelines, Section 2.4
for more detailed instructions.
This model can be replaced by other commercial root cause analysis methods such as Taproot, RCA, WHY TREE or similar.
Accident / Incident Investigation System Procedure
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 15/ 20
2.5 Events timeline (can be replaced with any commercial events timeline)
Event 1
Event 2
Event 3
Event 4
Event 5
Event 6
Event 7
Action Description
Action 1
Action 2
Action 3
Action 4
Action 5
Action 6
Action 7
Accident / Incident Investigation System Procedure
Doc. Code: HAV-EXT-HS-PRO-0147 Issue Date:17.06.2021 Rev. No: B Rev.Date: 14.09.2021 Page No: 16/ 20
A1
A2
A3
A4
A5
A6
A7
2.8 Investigation team
Name ID Company Position
Reported by:
Reviewed by:
Approved by:
Potential Consequences
Consequence Matrix (considering all safeguards in place at the moment of the event)
5 4 3 2 1
Catastrophic Major Moderate Minor Insignificant
Work-related LTIs or Medical Treatment
Health & Safety Multiple work-related occupational diseases Cases, Work Restricted First-Aid Cases, Near
fatalities. Work-related fatality. with medical leave. Cases. Misses.
Level IV - serious
(major) Level II - non-material
Level V - environmental Level III - material (minor) environmental
Environment
catastrophic, impact. environmental impact. impact. Level I - unauthorized
irreversible impact to Major Spill / Leakage Medium Spill / Leakage Minor Spill / Leakage disposal of benign
environment Incident Incident Incident waste
Assets & > 1% of Project Between 0,1 and 1% Between 100.000€ and Between 10.000 and
Less than 10.000€
properties Value of Project Value 0,1% of Project value 100.000 €€
Threatens survival of
the site/company in Fundamental threat to Significant Material deterioration in
its current form. operating results. deterioration in the the achievement of Requires response
General
Requires fulltime Requires immediate achievement of results. results. from departmental
senior management senior management Requires response from Requires response from staff under routine
attention. attention. division. dept manager. procedures.
Adverse International
media. Some adverse
Community /
Damaging NGO Persistent adverse State/Provincial media Some community
Media /
campaign. national media / Some national media / attention for a brief complaints.
Reputation
License to operate public / NGO public / NGO attention period. Adverse local public
compromised. attention. for an extended period. Criticism by NGOs. or media attention.
Likelihood Matrix
5 Very Frequent The risk will materialize in the project more than once a year.
4 Frequent The risk will materialize more than once during the entire duration of the project.
3 Rare The risk will sometimes materialize over the entire duration of the project.
2 Possible The risk may materialize over the entire duration of the project.
1 Unlikely The risk is not expected to materialize during project execution, although it may be conceivable.
Matrix for Incident Investigation Level determination based on potential consequences (mark the
applicable investigation level according to the worst potential consequence that could have occurred and its probability of occurrence)
Consequences
5 4 3 2 1
Catastrophic Major Moderate Minor Insignificant
5 Very Frequent 3 3 3 2 1
4 Frequent 3 3 2 2 1
Likelihood
3 Rare 3 2 2 1 1
2 Possible 2 2 1 1 1
1 Remote 1 1 1 1 1
Basic causes
Personal factors Job factors
☐ 1. Inadequate capability / behavioral ☐ 1. Inadequate leadership supervision
☐ 2. Lack of knowledge ☐ 2. Inadequate engineering
☐ 3. Lack of skill ☐ 3. Inadequate purchasing
☐ 4. Stress ☐ 4. Inadequate maintenance
☐ 5. Fatigue ☒ 5. Inadequate tools / equipment
☐ 6. Improper ventilation ☐ 6. Inadequate work standards
☐ 7. Wear and tear
☐ 8. Abuse or misuse
Immediate causes
Acts Conditions
☐ 1. Violation (intentional) ☐ 1. Inadequate/defective guards or protective barriers
☐ 2. Violation (unintentional) ☐ 2. Inadequate/defective PPE
☐ 3. Improper position (in the line of fire) ☐ 3. Inadequate/defective warning systems/safety devices
☐ 4. Overexertion or improper posture ☐ 4. Inadequate security provisions or systems
☐ 5. Work or motion at improper speed ☐ 5. Inadequate design/specification/management of change
☐ 6. Improper lifting or loading ☐ 6. Inadequate/defective tools/equipment/material/products
☒ 7. Improper use/position of tools/equipment/materials/products ☐ 7. Inadequate maintenance/inspection/testing
☐ 8. Servicing of energized equipment / inadequate energy
☐ 8. Congestion, clutter or restricted motion
isolation
☐ 9. Failure to warn of hazard ☐ 9. Inadequate surfaces, floors, walkways or roads
☐ 10. Inadequate use of safety systems ☐ 10. Hazardous atmosphere (explosive/toxic/asphyxiating)
☐ 11. PPE not used or used improperly ☐ 11. Storms or acts of nature
☐ 12. Equipment or materials not secured ☐ 12. Inadequate training/competence
☐ 13. Disabled or removed guards, warning systems or safety
☐ 13. Inadequate work standards/procedures
devices
☐ 14. Improper decision making or lack of judgement ☐ 14. Inadequate hazard identification or risk assessment
☐ 15. Lack of attention/distracted by other concerns/stress ☐ 15. Inadequate communication
☐ 16. Acts of violence ☐ 16. Inadequate supervision
☐ 17. Use of drugs or alcohol ☐ 17. Poor leadership/organisational culture
☐ 18. Fatigue ☐ 18. Failure to report/learn from events
Incident
Type of contact Contact with
☐ 1. Struck against ☐ 1. Electricity
☐ 2. Struck by ☐ 2. Heat
☐ 3. Caught in ☐ 3. Cold
☐ 4. Caught on ☐ 4. Radiation
☐ 5. Caught between ☐ 5. Caustics
☐ 6. Slip ☐ 6. Noise
☐ 7. Fall on same level ☐ 7. Toxic or noxious substances
ACCIDENT/INCIDENT INVESTIGATION
SYSTEM PROCEDURE
Doc. Code:HAV-EXT-HS-PRO-0147 Issue Date: 17.06.2021 Rev Date: 14.09.2021 Revision No: B Page No : 20/20
Loss
☐ 1. People ☐ 4. Material
☐ 2. Property ☐ 5. Quality
☐ 3. Environmental ☐ 6. Safety