1、 AFRICAN MINERALS LTDSWI-0431Revision 0Page 1 of 150 24 April 10 Original IssueRev Date Description of Revision Checked ApprovedSAFE WORK INSTRUCTIONSWI-0431ACCIDENT/INCIDENT INVESTIGATIONDocument Custodian : Manager HSEDocument Approved :SAFE WORK INSTRUCTION SWI-0431AFRICAN MINERALS ACCIDENT/ INCI
2、DENT INVESTIGATION Rev 0 Page 2AFRICAN MINERALS LTDFBA18AE8FDECC187214C49EF1349E971.PDFTABLE OF CONTENTS1. SCOPE 32. OBJECTIVES 33. DEFINITIONS 34. PROCEDURE 44.1 General 44.2 Legal Issues 44.2.1 Confidentiality 44.2.2 Statutory Notification 44.2.3 Supply of Documentation 44.3 Responsibilities 44.3.
3、1 Chief Executive Officer (CEO) 44.3.2 Business Line/ Unit Managers 44.3.3 Project Managers 54.3.4 Manager HSE 54.3.5 Supervisors 54.3.6 Technical Advisers and Specialists 54.3.7 HSE Coordinator 54.3.8 Employee Health and Safety Representative/Committee 54.4 Investigation 64.4.1 Purpose of Investiga
4、tion 64.4.2 Communication and Consultation 64.4.3 Consideration of Information 64.4.4 Disciplinary Action 64.4.5 Team Approach 74.4.6 Planned Approach 74.4.7 Detailed Actions 84.4.8 Investigation Interviews 84.5 Causal Factors 94.5.1 Cause Determination 94.6 Findings 94.7 Recommendations 94.8 Correc
5、tive Action 104.9 Accident/Incident Investigation Report Documentation 104.9.1 SWI-F0408B Incident Alert Priority Notification 104.9.2 Form SWI-F0408A Accident/Incident Report 104.9.3 Form SWI-F0408C Supplementary Accident/Incident Report 104.9.4 Distribution 104.9.5 Completion of Report 105. APPEND
6、ICES/FORMS 116. REFERENCES 11SAFE WORK INSTRUCTION SWI-0431AFRICAN MINERALS ACCIDENT/ INCIDENT INVESTIGATION Rev 0 Page 3AFRICAN MINERALS LTDFBA18AE8FDECC187214C49EF1349E971.PDF1. SCOPEThis procedure defines the requirements for the investigation of accidents/incidents for all workplaces within Afri
7、can Minerals Limited Early Cash Flow (AML ECF) to permit collation and detailed analysis.This procedure should be referenced in conjunction with AML ECF Procedures SWI-0408 Accident-Incident Reporting and SWI-0410 Managing HSE Risks.2. OBJECTIVESTo investigate all accidents and incidents, no matter
8、how minor and to investigate sufficiently, to eliminate or mitigate the risk of further injury or harm, to the health of personnel, environment, community and/or plant and equipment.It is required that all of the Root Causes are clearly identified to ensure that the risk control measures applied are
9、 sufficient to meet the objectives of this procedure.There are no restrictions on the distribution of this procedure within the Company.3. DEFINITIONSAccidentAn accident is any unplanned event, which has caused injury or illness. Such an event may also involve damage to the environment, plant or equ
10、ipment, product loss or interruption of work. Incident (Near-Hit)An incident is an unplanned event that occurred at the workplace, which did not result in any damage to the environment, plant or equipment injury or disease, but clearly had the potential to do so.Serious Potential Incident (SPI)Any s
11、erious accident or incident that occurred at the workplace, that had the potential to cause serious injury or fatality resulting from the accident or incident.Contributing FactorsA contributing factor can be any factor relating to the accident or incident including any aspect of the person, task, ma
12、chine and environment that relate to the period before, during, and after the accident.Essential Contributing FactorsEssential factors are those factors that had to be present for the accident or incident to occur. The test for what is an essential factor is simply to ask if the factor was substitut
13、ed would this accident have occurred?FatalityA fatality is a death resulting from a work injury, regardless of the time intervening between injury and death.Lost Time Injury (LTI)A lost time injury is a work injury, which results in the loss of a full normal shift, i.e. the injured person being unab
14、le to perform any regular task or restricted work for any full day or shift following the day, on which the injury occurred.SAFE WORK INSTRUCTION SWI-0431AFRICAN MINERALS ACCIDENT/ INCIDENT INVESTIGATION Rev 0 Page 4AFRICAN MINERALS LTDFBA18AE8FDECC187214C49EF1349E971.PDF4. PROCEDURE4.1 GeneralAn ac
15、cident investigation that is properly, efficiently carried out and is followed by prompt remedial action is required to mitigate the risk of a re-occurrence of an incident.An accident investigation has two purposes: To determine why the accident happened by identifying all work-related facts associa
16、ted with it; To modify work conditions and procedures to prevent a similar occurrence. 4.2 Legal Issues4.2.1 ConfidentialityAccess by external parties to any AML ECF Accident/Incident documents must be authorised by the AML ECF Manager HSE.4.2.2 Statutory NotificationThe Statutory Authority must be
17、notified in accordance with the relevant Statutory Legislation. On a Mine site this shall be via the Registered Manager or Senior Site Executive. At all other locations the responsible Manager or AML ECF Manager HSE shall be responsible for reporting to the relevant Statutory Authority.The AML ECF M
18、anager HSE must be notified immediately of all reportable incidents.Important NoteIn the case of Reportable, Serious Potential Incidents (SPIs) and Fatalities the area must be secured to prevent further harm and is not to be disturbed without the express permission of the relevant Statutory Authorit
19、y.4.2.3 Supply of DocumentationIf after an accident or incident employees are questioned by officers/representatives of external parties (e.g. local inspectorates, police) the following procedures should be followed; Ask to see official identification or authority; Provide the officer/representative
20、 with full cooperation and assistance; Direct the officer/representative to the relevant Senior Manager; Provide the officer/representative with information necessary, but indicate before taking statements that such statements may be incriminatory and that you are claiming privilege in respect of an
21、y answer you give to questions asked; Obtain a receipt for items removed from the work place; Make detailed notes of known facts about the incident for legal representatives, marking them;“PRIVILEGED: PREPARED IN ANTICIPATION OF LEGAL PROCEEDINGS TO ENABLE THE GIVING OF LEGAL ADVICE“.4.3 Responsibil
22、ities4.3.1 Chief Executive Officer (CEO)The CEO is responsible for the allocation of sufficient resources to ensure that all accidents and incidents may be thoroughly investigated and adequate controls implemented in accordance with this procedure.SAFE WORK INSTRUCTION SWI-0431AFRICAN MINERALS ACCID
23、ENT/ INCIDENT INVESTIGATION Rev 0 Page 5AFRICAN MINERALS LTDFBA18AE8FDECC187214C49EF1349E971.PDF4.3.2 Business Line/ Unit ManagersEach Business Line/Unit manager is responsible for ensuring that work accidents occurring within their jurisdiction are thoroughly investigated, all details recorded and
24、reported, the root causes determined and appropriate control measures implemented to prevent further or similar occurrences.4.3.3 Project ManagersProject Managers is responsible for ensuring that work accidents occurring on their projects are thoroughly investigated, all details recorded and reporte
25、d, the root causes determined and appropriate corrective actions and control measures implemented to prevent further or similar occurrences.4.3.4 Manager HSEThe Manager HSE is the custodian of this procedure and is responsible for ensuring all investigations are carried out in accordance with AML EC
26、F and Statutory requirements, for reviewing all submitted accident/incident investigation reports and statistical analysis of all supplied data.4.3.5 SupervisorsBy the nature of their positions and their inherent responsibilities, Supervisors possess a detailed knowledge of the work and the conditio
27、ns under which it is done and are the appropriate persons to undertake the accident investigation. Primary responsibility for investigations shall, therefore, rests with the Supervisor. Acceptance of this responsibility by each supervisor, combined with a personal commitment to the time and effort i
28、nvolved in such investigations, is required if the program is to operate effectively. Their responsibility extends beyond determining the cause of the accident and includes exercising supervisory responsibilities to ensure that proper remedial action is promptly taken.4.3.6 Technical Advisers and Sp
29、ecialistsWhen investigating accidents of a serious nature, or those, which involve highly technical processes, it may be appropriate to engage the services of a technical adviser or other specialist with specialised knowledge of an operation or equipment to assist in the investigation. An “external“
30、 specialist may also provide an additional degree of objectivity to the investigation. When such a person is authorised to conduct or assist in an investigation, it should be carried out in collaboration with the responsible project manager/supervisor.4.3.7 HSE CoordinatorThe HSE Coordinator is the
31、competent person responsible for providing guidance in the coordination of an accident/incident investigation. The HSE Coordinator shall provide technical advice and support, in accordance with qualifications and experience, to the responsible manager/supervisor. The HSE Coordinator is responsible f
32、or assisting with the final determination of the root causes of an accident or incident.4.3.8 Employee Health and Safety Representative/CommitteeWhere a Worker Elected or Appointed Safety and Health Representative is represented at a workplace that has reported an accident or incident, the represent
33、ative or a suitable member of the Health and Safety Committee shall be invited and encouraged to fully participate in the accident/incident investigation. 4.4 InvestigationAll accidents and incidents in the first instance (including First Aid and Near Hits) shall be investigated and documented on fo
34、rm SWI-F0408A Accident-Incident Report and/or SWI-F0406A First Aid Injury Register as required in accordance with this procedure and AML ECF procedure SWI-0408 Accident Incident Reporting.SAFE WORK INSTRUCTION SWI-0431AFRICAN MINERALS ACCIDENT/ INCIDENT INVESTIGATION Rev 0 Page 6AFRICAN MINERALS LTD
35、FBA18AE8FDECC187214C49EF1349E971.PDFAll accidents and incidents that had the potential to cause an MTI or greater shall be reported in the first instance using SWI-0408B Incident Alert Priority Notification and shall be documented on form SWI-F0408A Accident-Incident Report in accordance with AML EC
36、F Procedure SWI-0408 Accident-Incident Reporting.The relevant responsible AML ECF Manager shall have the authority and responsibility for the decision not to submit forms SWI-0408B Incident Alert Priority Notification, SWI-F0408A Accident-Incident Report or to conduct a further detailed supplementar
37、y investigation using form SWI-0408C Supplementary Accident/Incident Report.4.4.1 Purpose of InvestigationThe primary purpose of the accident investigation is to establish the causes as quickly as possible through the identification and examination of all information associated with the accident. Th
38、e objectives of a thorough investigation are to make the required changes in the work conditions and procedures that will ultimately eliminate or mitigate the risk of a similar occurrence.4.4.2 Communication and ConsultationAll investigations shall be carried out without apportioning blame to any on
39、e individual or event. If the existence of an action is to be defined as human error, such actions should be dealt with objectively.It is required that the Consultative Approach is used to encourage participation, ensure clear and concise reporting to all concerned and to source only Factual and Qua
40、ntifiable Evidence. 4.4.3 Consideration of InformationAs soon as possible after the accident, all information relating to the accident should be collated to be considered during the detailed investigation. The investigator should, however, be cautious about accepting incomplete conclusions as the ba
41、sis for establishing the cause. A normal tendency to reinforce preconceived thoughts as to the probable cause should also be resisted. When original factual evidence is not available, conclusions should be based only on substantiated facts or on the best possible logical assumptions. Circumstantial
42、evidence should only be considered, with extreme caution, when no other evidence exists.Subjective statements and information that cannot be substantiated shall not be included in any investigation reporting process.4.4.4 Disciplinary ActionDisciplinary action shall only be considered, as a last res
43、ort, for any action/s that are clearly identified as having a blatant disregard for the health, safety and welfare of; the individual concerned and/or others; or the environment; or the community; or plant and equipment belonging to AML ECF, clients and/or contractors.4.4.5 Team ApproachThe Supervis
44、or directly responsible for the work should carry out the investigation at the time of the accident/incident. Such investigation may be all that is required to establish the causes and to prescribe corrective action for minor incidents.All Serious accidents and incidents (including Near Hits) shall
45、be investigated in detail and documented on the AML ECF Form SWI-F0408A Accident/Incident Investigation Report form in SAFE WORK INSTRUCTION SWI-0431AFRICAN MINERALS ACCIDENT/ INCIDENT INVESTIGATION Rev 0 Page 7AFRICAN MINERALS LTDFBA18AE8FDECC187214C49EF1349E971.PDFaccordance with this procedure an
46、d AML ECF Procedure SWI-0408 Accident/Incident Reporting.All SPIs shall be thoroughly investigated to ensure all contributing factors have been identified. Form SWI-0408C Supplementary Accident/Incident Report shall be used to document the detailed findings and recommendations of the investigation.A
47、n investigation team shall be appointed by the responsible manager and should consist of the following personnel; Supervisor All Person/s involved All Witnesses Worker appointed Health and Safety Representative or Committee Member HSE Coordinator Competent Person/s (expert witness/es) as required.Th
48、e responsible manager is encouraged to participate in all investigations and at minimum shall review the preliminary investigation report and acknowledge the findings and recommendations of the report.All completed SWI-0408C Supplementary Accident/Incident Report forms shall be forwarded on completi
49、on to the AML ECF Manager HSE for review.4.4.6 Planned ApproachAll investigations shall be meticulously planned to ensure all available factual evidence is identified and collated and to implement control measures in an enduring, methodical and practical manner.All investigations shall incorporate the following actions: prevent the removal of evidence or the change of conditions at the work scene of all SPIs and fatalities; determine the specified work procedures in place; all evidence shall be documented e.g. witness re
