Document No.

IMSP -10/03

Revision No. 00

Section INTEGRATED MANAGEMENT SYSTEM Effective Date 01/08/2017

Subject SHERQ INCIDENT INVETSIGATION REPORT Page No. Page 1 of 7

SHERQ INCIDENT INVESTIGATION REPORT

SITE/POWER STATION: MUNYATI POWER STATION

DEPARTMENT: MMD

CLASSIFICATION:

DATE OF INCIDENT: 17 JUNE 2019

DATE OF INVESTIGATION: 5 JULY 2019

Distribution List:
Managing Director
ZPC Exco
Technical Compliance Manager
Power Plant Manager
Section Heads
Departmental Forepersons
Risk and Quality Practitioners

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Revision 00 Date printed:2021/10/01 Page 1 of 7

1. INCIDENT SUMMARY

1.1 Details of Involved/Injured Persons

Name: Tinashe Manga

EC number:
Age:
Gender: Male
Dept./Sect MMD
Occupation: Attaché
Witnesses: N/A
Supervisor in Charge: Zenasi

1.2 Incident Details

Date of incident: 17 June 2019

Time of incident: 10:00
Place of incident: Boiler House
Activity Undertaken: Maintenance of the alarm chamber
Nature: Coal particles fell into his left eye
Date of Report 18 June 2019

1.3 Incident Description

T Manga was working on boiler 8 alarm chamber with artisan A Akimu. At around 10:00 Manga
was instructed to go and collect pieceas of mutton clothes for cleaning as they were working
on a dusty area. He disembarked the stairs using the right hand side of the boiler. The
employee proceeded to the firing floor and he then decided to check the readings on the final
steam pressure gauges as a routine to their work, as he looked up to check the pressures on
the gauges a coal particle fell into hi9s left eyes . Manga immediately went to the nearby tap
and splashed tap water into the eye and proceeded back to work without any difficulties and
hence he did not inform his workmates of the incident. The following morning on waking up he
felt an irritation in the eye, he then reported for duty and requested for permission to go to the
clinic from the foreperson. He went to the clinic and was assessed with the RGN. The nurse
identified a foreign body in the eye, The eye was bandaged and Manga was referred to Stanley
House Kwekwe to see the doctor. Upon arrival at Stanley House the doctor removed the
bandage and the particle was no longer in the eye but instead they spotted it on the bandage,
he was told to go back to work.

2. INVESTIGATION DETAILS
2.1 INVESTIGATION TEAM

Name Title Signature

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Revision 00 Date printed:2021/10/01 Page 1 of 7

 M Kwenda SHO
J Miranzi EMD Artisan
K Mpaya GT Maintenance
A Makaza Sherqc Rep Attachee
T Chiutanyi Lab Attachee

2.2 INVESTIGATION TIME (MANHOURS): 1hr 15minutes.

2.3 STATEMENTS TAKEN BY:

Name Title

A Makaza SHERQC ATTACHEE

3. INCIDENT CLASSIFICATION
3.1. DAMAGE INCIDENT

Damage/Incident classification Major Minor X Near Miss

Nature of damage (Describe extent of damage):

Laceration and haematoma formation on the middle finger of the left hand.

3.2 ENVIRONMENTAL INCIDENT

Env Incident Classification Level 3 Level 2 Level 1 Complaint

Nature of Environmental impact (Describe ):
N/A

4. BACKGROUND TO THE INCIDENT

 The injured was tasked to collect cotton waste cloth from the boiler storeroom.
 Manga disembarked the stairs and as he was now walking on the firing floor he decided to check
the gauge class reading as a routine of their work
 Upon checking the readings coal particles fell into his left eye..
 The cotton waste was used for cleaning and dusting as they were working on a dusty area
 The employee did not conduct a pre-task risk assessment as evidenced by subsequent failure to
detect the dangers of checking the gauge class without goggles.
 He did not report the injury as he just splashed water in the eye and he continued with his duties
without any difficulties
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Revision 00 Date printed:2021/10/01 Page 2 of 7

 He work up the following day with an irritation in the eye and he reported for duty, he then
requested to visit the clinic and was referred to Stanley House

SUMMARY OF FINDINGS
 The Investigation committee went on to review the following document which correlate the purported job

1. MMD G87 for the day of the incident (attached Appendix 1)

2. Work order for the job (attached Appendix 2)
3. Pre-task risk assessment form (missing)

 The G87 showed that there was work planned for boiler 8 alarm chamber but however the work delayed to
commence to the 22nd of June and yet the incident occurred on the 17 th of June.
 It further shows that T Manga was not part of the work as his name does not appear on the work order.
 The risk assessment form is missing. If checking of the pressure gauge was part of the job as purported ,a
risk of falling particles was supposed to be noted and a mitigation action of ensuring that one is wearing
goggles and a hard hat had to be put in place
 .However from the findings it can be deduced that T Manga was not part of the job but the incident occurred
due to a coal particle falling into his eye
 The actual sequence of events before the occurrence of the incident cannot br therefore established from
above

5. INCIDENT ANALYSES
6.1 INCIDENT COSTS

Medical & compensation $27.00 Generation Loss $

Labour rent/replacement $ Fines $

Investigation cost $ Others: $

Equipment Replacement/renting $ Total incident costs: $27.00

6.2 DIRECT CAUSES OF THE INCIDENT

Substandard Practices/Unsafe Act Substandard Conditions/Unsafe conditions

 Inadequate Risk Assessment.  Manual handling.

 Lone working.

6.3 BASIC CAUSES

Personal Factors Job Factors

 At risk behaviour by the injured as he did not  Perforations on coal chutes which causes
follow standard procedure of pre-task risk random falling of particles.
assessment by:
o Not wearing proper gear to the tasked
job i.e. goggles

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6.4 PREVENTATIVE ACTION RECOMMENDED

Addressing Personal Factors Addressing Job Factors

 Employee need to be reprimanded by  Providing an accessible and suitably constructed

line management for at risk behaviour.
 Line supervisors need to check systems
for safety and compliance to attaches.
facility for checking the readings other than looking
upwards..
 Maintaining of coal chutes to avoid falling of coal..
 Line supervisors need to be actively involved in
ensuring safe work methods are being used.

6.5 CONCLUSIONS

Immediate Cause:
Not wearing proper PPE
Basic Cause:
Failure to do pre-task risk assessment
Contributing factors:
Perforations of coal chutes which causes random falling of coal particles.

6. CORRECTIVE ACTION PLAN

No Action Responsibility Target Completion Signature

Date date at Closure

1 Maintaining of coal chutes to avoid random SEM

falling of coal

2 To establish a proper way of checking the SEM

gauge class reading and avoid looking
upwards.

7. INCIDENT REPORT APPROVAL

Shift Charge Zenasi Signature Date

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 SHEQ practitioner
E Ndanga Signature Date
(Risk Engineer)

Section Head F Sabvukutwa Signature Date

Power Plant Manager L K Shumba Signature Date

8. EVALUATION OF EFFECTIVENESS OF CORRECTIVE ACTIONS

9.1 Comments by the Assessor

Incident
Name Signature Date
Assessor

9.2 Closure of incident

I _______________________________ am satisfied that the corrective action plan as
(Sectional Head)

described has been fully implemented and has proven effective on controlling the associated risks,
and as far as practicable will prevent the occurrence / recurrence of undesirable events.

Signature:______________________ Date:________________
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