Accident Investigation Safe work instruction 安全工作指导 非洲矿业有限公司AML HSE安全管理制度 英文版

AFRICAN MINERALS LTD SWI 0431 Revision 0 Page 1 of 15 024 April 10Original Issue Rev DateDescription of RevisionCheckedApproved SAFE WORK INSTRUCTION SWI 0431 ACCIDENT INCIDENT INVESTIGATION Document Custodian Manager HSE Document Approved SAFE WORK INSTRUCTIONSWI 0431 AFRICAN MINERALS ACCIDENT INCIDENT INVESTIGATIONRev 0Page 2 AFRICAN MINERALS LTD 9BF1D21766BB059BA4F47AFD2315BB79 PDF TABLE OF CONTENTS 1 SCOPE3 2 OBJECTIVES3 3 DEFINITIONS3 4 PROCEDURE4 4 1General4 4 2Legal Issues4 4 2 1Confidentiality4 4 2 2Statutory Notification4 4 2 3Supply of Documentation4 4 3Responsibilities4 4 3 1Chief Executive Officer CEO 4 4 3 2Business Line Unit Managers4 4 3 3Project Managers5 4 3 4Manager HSE5 4 3 5Supervisors5 4 3 6Technical Advisers and Specialists5 4 3 7HSE Coordinator5 4 3 8Employee Health and Safety Representative Committee5 4 4Investigation6 4 4 1Purpose of Investigation6 4 4 2Communication and Consultation6 4 4 3Consideration of Information6 4 4 4Disciplinary Action6 4 4 5Team Approach7 4 4 6Planned Approach7 4 4 7Detailed Actions8 4 4 8Investigation Interviews8 4 5Causal Factors9 4 5 1Cause Determination9 4 6Findings9 4 7Recommendations9 4 8Corrective Action10 4 9Accident Incident Investigation Report Documentation10 4 9 1SWI F0408B Incident Alert Priority Notification 10 4 9 2Form SWI F0408A Accident Incident Report 10 4 9 3Form SWI F0408C Supplementary Accident Incident Report 10 4 9 4Distribution10 4 9 5Completion of Report10 5 APPENDICES FORMS11 6 REFERENCES11 SAFE WORK INSTRUCTIONSWI 0431 AFRICAN MINERALS ACCIDENT INCIDENT INVESTIGATIONRev 0Page 3 AFRICAN MINERALS LTD 9BF1D21766BB059BA4F47AFD2315BB79 PDF 1 SCOPE This procedure defines the requirements for the investigation of accidents incidents for all workplaces within African 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 OBJECTIVES To investigate all accidents and incidents no matter 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 sufficient to meet the objectives of this procedure There are no restrictions on the distribution of this procedure within the Company 3 DEFINITIONS Accident An accident is any unplanned event which has caused injury or illness Such an event may also involve damage to the environment plant or equipment 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 serious 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 Factors A contributing factor can be any factor relating to the accident or incident including any aspect of the person task machine and environment that relate to the period before during and after the accident Essential Contributing Factors Essential 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 substituted would this accident have occurred Fatality A 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 unable to perform any regular task or restricted work for any full day or shift following the day on which the injury occurred SAFE WORK INSTRUCTIONSWI 0431 AFRICAN MINERALS ACCIDENT INCIDENT INVESTIGATIONRev 0Page 4 AFRICAN MINERALS LTD 9BF1D21766BB059BA4F47AFD2315BB79 PDF 4 PROCEDURE 4 1General An accident 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 associated with it To modify work conditions and procedures to prevent a similar occurrence 4 2Legal Issues 4 2 1 Confidentiality Access by external parties to any AML ECF Accident Incident documents must be authorised by the AML ECF Manager HSE 4 2 2 Statutory Notification The Statutory Authority must be 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 Manager HSE must be notified immediately of all reportable incidents Important Note In the case of Reportable Serious Potential Incidents SPI s 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 Authority 4 2 3 Supply of Documentation If 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 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 any 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 3Responsibilities 4 3 1Chief 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 INSTRUCTIONSWI 0431 AFRICAN MINERALS ACCIDENT INCIDENT INVESTIGATIONRev 0Page 5 AFRICAN MINERALS LTD 9BF1D21766BB059BA4F47AFD2315BB79 PDF 4 3 2Business Line Unit Managers Each Business Line Unit manager is responsible for ensuring that work accidents occurring within their jurisdiction are thoroughly investigated all details recorded and reported the root causes determined and appropriate control measures implemented to prevent further or similar occurrences 4 3 3Project Managers Project Managers is responsible for ensuring that work accidents occurring on their projects are thoroughly investigated all details recorded and reported the root causes determined and appropriate corrective actions and control measures implemented to prevent further or similar occurrences 4 3 4Manager HSE The Manager HSE is the custodian of this procedure and is responsible for ensuring all investigations are carried out in accordance with AML ECF and Statutory requirements for reviewing all submitted accident incident investigation reports and statistical analysis of all supplied data 4 3 5Supervisors By the nature of their positions and their inherent responsibilities Supervisors possess a detailed knowledge of the work and the conditions 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 involved 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 6Technical Advisers and Specialists When 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 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 7HSE Coordinator The HSE Coordinator is the 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 for assisting with the final determination of the root causes of an accident or incident 4 3 8Employee Health and Safety Representative Committee Where a Worker Elected or Appointed Safety and Health Representative is represented at a workplace that has reported an accident or incident the representative or a suitable member of the Health and Safety Committee shall be invited and encouraged to fully participate in the accident incident investigation 4 4Investigation All accidents and incidents in the first instance including First Aid and Near Hits shall be investigated and documented on form 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 INSTRUCTIONSWI 0431 AFRICAN MINERALS ACCIDENT INCIDENT INVESTIGATIONRev 0Page 6 AFRICAN MINERALS LTD 9BF1D21766BB059BA4F47AFD2315BB79 PDF All 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 ECF 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 supplementary investigation using form SWI 0408C Supplementary Accident Incident Report 4 4 1Purpose of Investigation The 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 The 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 2Communication and Consultation All investigations shall be carried out without apportioning blame to any one 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 Quantifiable Evidence 4 4 3Consideration of Information As 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 basis 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 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 4Disciplinary Action Disciplinary action shall only be considered as a last resort 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 5Team Approach The Supervisor 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 be investigated in detail and documented on the AML ECF Form SWI F0408A Accident Incident Investigation Report form in SAFE WORK INSTRUCTIONSWI 0431 AFRICAN MINERALS ACCIDENT INCIDENT INVESTIGATIONRev 0Page 7 AFRICAN MINERALS LTD 9BF1D21766BB059BA4F47AFD2315BB79 PDF accordance with this procedure and AML ECF Procedure SWI 0408 Accident Incident Reporting All SPI s 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 An 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 The 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 completion to the AML ECF Manager HSE for review 4 4 6Planned Approach All 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 SPI s and fatalities determine the specified work procedures in place all evidence shall be documented e g witness reports diagrams photographs etc verify evidence of the witnesses and if possible the injured person record results of special tests or re enactment s review and select findings and establish causes recommend appropriate changes based on the conclusions and carry out the changes recommended preventing a recurrence of the accident SAFE WORK INSTRUCTIONSWI 0431 AFRICAN MINERALS ACCIDENT INCIDENT INVESTIGATIONRev 0Page 8 AFRICAN MINERALS LTD 9BF1D21766BB059BA4F47AFD2315BB79 PDF 4 4 7Detailed Actions Priority consideration shall at all times be given to any injured personnel to ensure adequate and prompt medical assistance is administered to reduce discomfort aid effective recovery and to facilitate an successful return to work programme Depending on the seriousness of the accident the scene of the accident should be isolated as far as is practicable If there is a possibility that any circumstances surrounding the accident may constitute further danger to anyone action should be taken without awaiting the final outcome of the investigation to remove and or isolate the potential hazard and or to temporarily discontinue the work until the investigation is completed When the exact physical situation cannot be maintained for the investigation a sketch should be prepared and any required photographs taken as soon as possible The names and contact details of all witnesses should be obtained immediately The investigation should proceed as soon as possible after the accident or incident 4 4 8Investigation Interviews Appropriate interview techniques are important to ensure that the interview is based on and conducted utilising only the highest ethical and moral standards At no time shall any conduct be condoned that demoralises and or compromises the welfare of the persons involved or the integrity of the investigation and should never appear hostile nor attempt to coerce or to influence any statements or information supplied Personnel being interviewed should be reminded of the constructive purpose of the investigation Personnel involved in the accident including witnesses and if possible the injured employee shall be interviewed and statements taken as soon as possible following the accident while the events are still clear in their minds and the resulting information and statements should be recorded in writing In many cases the injured employee may be the only principal source of information Before interviews take place the investigation team shall ensure that that they are familiar with the approved procedures in place for the work being performed at the time of the accident Suitable competent persons expert witnesses should be involved as required All persons directly involved should be interviewed first to determine what was task was being performed at the time of the accident or incident This should be followed by interviews with co workers involved or associated in the operation or in the immediate vicinity Each person should be interviewed separately to ensure no collusion or influencing of individual statements occurs Before interviewing the injured employee the investigator should verify that the interview is medically permissible Basic information relative to the