1

KHANBOOLI ELECTROMECHANICAL
CONTRACTING LLC

Incident investigation &

Reporting Procedure

Role Name Designation Date Rev

Prepared By Jawad Ali HSE ENIGINEER 01-08-2023
Reviewed By Shankara GENERAL 04-08-2023
Narayanan MANAGER
Approved BY H. Parkar EXECUTIVE 06-08-2023
DRIECTOR
Approved By Engr. Fadhil MANAGING 06-08-2023
DIRECTOR
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TABLE OF CONTENTS
1 Abbreviation & Definitions 3
2 Purpose 5
3 Scope 5
4 References 5
5 Responsibilities 5
6 Procedure / incident classification Type of 8
Incident
7 Incident Notification 8
8 Incident Investigation 9
9 Level of Incident and Level of Investigation 9
10 Preserving Incident site and evidence 11
11 HSE Incident investigation Process 12
12 Incident Investigation Flow chart 14
13 Incident Reporting 15
14 Record Keeping 18
15 Appendix A incident Action Protocol 19
16 Appendix B Incident Notification Form 20
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1. Acronyms/Abbreviations and Definitions

PD Project Director
PM Project Manager
HSEM Health, Safety and Environment Manager
CD Construction Director
CM Construction Manager
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2. Definitions
Incident An event or chain of events which has caused or could have caused fatality, injury,
illness and/or damage (loss) to assets, the environment, Contractor reputation or
third parties.

Accident It is an unplanned event or chain of events, which has caused injury or illness,
and/or damage (loss) to assets, the environment, Contractor reputation or third
parties.

Where the damage is an injury, then further classification takes place which
describes the impact of the injury. These are:

Lost Time Injury (LTI)

Restricted Work Case (RWC)

Medical Treatment Case (MTC)

First Aid Case (FAC)

Restricted Work A work-related injury, which renders the injured person unable to perform his
Case (RWC) regular duties but results in a Restricted Work assignment on any day after the day
on which the Incident occurred. The Restricted Work assignment must be
meaningful and pre-established, or a substantial part of a regular job.

Medical Treatment A work-related injury, which results in neither lost time nor restricted work, but
Case (MTC) which requires treatment by, or under the supervision of, or from the specific
order of, a medical doctor.

First Aid Case (FAC) Term to define any one-time treatment of minor injuries that usually do not
require medical care by a physician (i.e. scratches, cuts, burns, splinters, not
embedded foreign bodies in the eyes, etc.) and its eventual subsequent visits. Such
treatment is considered FAC even if provided by a physician

Fatality An Incident that results in the loss of life or an injury which culminates in the death
of the injured, regardless of the time intervening between injury and death.

Injury Physical harm or damage to a person resulting from traumatic contact between
the body of the person and an outside agency, or from exposure to environmental
factors.

Near Miss An event or chain of events that could have resulted in fatality, injury, illness and
/ or damage (loss) to assets, the environment, contractor reputation or third
parties.

Serious/Major A generic category which includes all incidents with actual or potential
Incidents consequences of catastrophic, severe and critical nature.
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3. Purpose
The purpose of this procedure is to provide guidance in all incidents are notified, investigated if necessary
and reported in a logical and consistent manner. It will form the basic document to regarding capturing
information necessary to identify the causation factors of the incident related to Project.
This procedure will prescribe suitable actions to prevent re-occurrence of similar incidents and how to
implement such actions and follow up procedures Incident reporting procedures also forms integral part of
this document.
All incidents must be immediately reported to the HSE Department of Contractor.

4. SCOPE
This procedure covers all incidents occurring at any of the project area or facilities of defined as the part of
this project including that happens during activities undertaken by sub-contractors.

5. REFRENCES
• UAE Ministry of Labour and Social Affairs, Federal Law No 8, Year 1980
• Ministerial Order No 32 – 1982.
• OSHAD SF -Occupational Safety and Health Abu Dhabi System Framework
• OSHAD-SF-Mechanisim-11.0-Incident notification, investigation and reporting
• KEMCO HSE Plan.

6. RESPONSIBILITIES
Project Director / Project Manager
• Initiate the appropriate level of investigation with a nominated investigation lead, and adequate
resources are available.
• Notifying the Engineer/Client counterparts as required.
• Allocating adequate human, financial and physical resources to the projects to ensure compliance with
this procedure.
• Responsible for managing the crisis/emergency to minimize the loss and has overall authority.
• If required responsible for inviting Engineer/Client representatives for a collaborated investigation.
• Ensure that all Supervisory staff and Employees are effectively trained, and adequate information is
available on the ‘Incident/Accident Reporting and Investigation Procedure.
• Responsible for official ‘Spokesman’ from the Project and all communications and information to and
from external parties / higher authorities must be through him only or by the representative nominated
by him.
• Responsible for initiating an investigative team in the case of fatal or catastrophic accidents.
• Responsible for reporting all incidents (except First Aid) to Engineer and the specialised department on
a timely basis.
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Project Managers / Construction Managers / Technical

Managers / Department Managers
• Be a lead investigator when appointed by the Project Director.
• Responsible for implementing and administering this procedure.
• Responsible for providing the personnel, facilities, documentation and other resources necessary to
effectively carry out this procedure and provision of a report.
• Ensure that adequate arrangements are made to deal with reporting and investigating all the incidents
and accidents and to ensure that staff and supervisors receive appropriate information and instructions
learnt from those incidents in order to prevent recurrence.
• Analyse all the events on a periodical basis to check for trends in performance and the prevalence of
types of incident or injury.
• Monitor the implementation of the ‘Action Plan’ derived from the investigation and make sure that it is
working satisfactorily.
• Attended all accident/incident review meetings.

HSE ENGINEER
• If nominated by the Project HSE ENGINEER will conduct investigation in collaboration with an
appropriate member of the project. All investigations requiring immediate notification to ADM will be
attended by the appropriate management personnel.
• Responsible for reporting of all incidents (except first aid) as per the reporting protocol mentioned
• Supporting the crisis/emergency to aid in minimize the loss.
• HSE Engineer may be involved immediately following an incident to assist with steps required to make
the area safe, to protect the health and safety of all persons.
• HSE Engineer may be involved to assist with incident investigation team and development of
appropriate risk control measures.
• In their capacity as HSE Committee members, HSE Engineer monitor incident trends and make
recommendations regarding preventative action.
• HSE Engineer will ensure that risk assessments are undertaken, and risks are minimized in those areas
of work/circumstance where there is a predictable risk to minimize accident/incidents on site.
• Collate appropriate Accident Incident Reports and ensure submitted via the proper reporting channels
(including confirmation of immediate medical assistance and further treatments of any injured parties).
• HSE Engineer will review all incident/accident statistics, identify trends and act to reduce accidents to a
minimum.
• HSE Engineer to attend all accident/incident review meetings.
• Cooperate fully with the accident/incident investigation by the local authorities.

Engineers/ Supervisor Personnel

• Implementing and maintaining the Incident/Accident Action Protocol in accordance with this procedure
on site.
• Ensure all accident/incidents/near miss are immediately reported to HSE Department.
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• Ensure that personnel under his/her control are properly trained and made aware of the
Incident/Accident Action Protocol and ensure that they follow safe Work practices.
• Prepare and submit the initial Incident/Accident Report in time and actively participate in investigation
of incidents to reveal all possible causes of the incident, including provision of witness statements.
• Secure the site of incident and to ensure that the incident spot is not disturbed till the completion of
the full investigation.
• Encourage the workforce in reporting of all the incidents/Accidents and near misses and to take
corrective measures to prevent recurrence.
• Share the knowledge/lesson learnt with the employees and other supervisors /departments
• Engineers/Supervisory Personnel to take panoramic photographs of the scene immediately to aid the
investigation team.
• Cooperate and support emergency service as and when involved.

Subcontractor
• Shall perform investigation through the trained personnel/ Team appointed
• Analyse the incidents and bring out root causes.
• Find the trend to take preventive measures.
• Update the records and submit to HSEM.

Individuals
• Be familiar with the KEMCO Safety Procedures for reporting of incidents/accidents.
• Understand the Accident/ Incident Action Protocol and follow the instructions
• Make sure that the first aid assistance is called immediately.
• Report forthwith to their supervisor any situation which they believe could present a risk, and which
they cannot properly deal with themselves.
• Report all the Accident/ Incident and near misses occurring in the workplace immediately to their
supervisor or to the Security/Safety Department either through phone or by person.
• Ensure that in the case of Moderate/Severe personal injury that the accident site is left undisturbed by
securing it until clearance is given by the Supervisor.
Assist the Investigation Team by giving the information of what they witness and what they know about
the incident which may help them in revealing all the possible causes.
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7. Procedure
Incident Classification
Types of Incidents
CSCEC-SK E&C management shall be notified, reported, and recorded the listed below incidents:
1. Lost Time Injuries (LTI)
- Fatality
- Permanent total disability
- Permanent partial disability
- Lost workday cases
2. Serious injuries
3. Serious occupational illness/disease
4. Danger occurrence
5. Restricted work case
6. Medical treatment case
7. First aid injuries
8. Equipment/Property damage
9. Near Miss
For more detail, please refer to OSHAD-SF-Mechanism 11.0 – Incident notification, Investigation, and
Reporting Section 3.1

Recordable Incident
All incidents shall be recorded weather reportable or not, by KEMCO HSE Department. Refer to federal law
No. 8 schedule 1 & 2.

Reportable Incident
All fatal incident, serious injuries and serious occupational illnesses/diseases and danger occurrence shall
be reported by KEMCO management. Refer to federal law No 8 and OSHAD-SF-Mechanism 11.0 – Incident
notification, Investigation, and Reporting schedule A, B & C.

8. Incident Notification
All incident either reportable or recordable shall be reported to KEMCO HSE Department by KEMCO site
and office management.
KEMCO HSE ENGINEER shall notify all incidents to KEMCO top management and at the same time to PMC
HSE ENGINEER. Please refer appendix D for KEMCO emergency call flow chart.
KEMCO HSE Department shall notify the following incident to SRA:
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1. Fatality;
2. Serious Injuries – Refer to OSHAD-SF-Mechanism 11.0 – Incident notification, Investigation, and
Reporting schedule B.
3. Serious Occupational Illnesses; Refer to OSHAD-SF-Mechanism 11.0 – Incident notification,
Investigation, and Reporting schedule C.
4. Serious Danger Occurrence. Refer to OSHAD-SF-Mechanism 11.0 – Incident notification,
Investigation, and Reporting schedule A.
For more detail, please refer to OSHAD-SF-Mechanism 11.0 – Incident notification, Investigation, and
Reporting Section 2 Part (iii).
KEMCO HSE ENGINEER shall notify the concern SRA for fatal incident within 24 hours from the time of an
incident occurring at the workplace.
Serious injuries shall be notified to concern SRA within maximum of 3 working days from the date of an
incident occurring at the workplace.
Serious injuries shall be notified by KEMCO management to Abu Dhabi police and other concern
authorities as per their stipulated reporting requirements such as ministry of labour etc…
For more detail, please refer to OSHAD-SF-Mechanism 11.0 – Incident notification, Investigation, and
Reporting Section 4.

9.Incident Investigation
KEMCO HSE management shall ensure that all incidents including near misses shall be recorded and
investigated to identify the root causes to prevent the reoccurrence of the same.

Internal Investigation Team

KEMCO HSE management shall ensure that the person (s) designated to undertake the internal
investigation are competent in the application of techniques applied in the investigation.
KEMCO management shall provide the additional technical expertise if required.
For more information, please refer to OSHAD-SF-Mechanism 11.0 – Incident notification, Investigation, and
Reporting Section 5.

10. Level of incidents and level of investigation

The level and detail of investigation required for each incident shall be followed OSHAD-SF-Mechanism 11.0
– Incident notification, Investigation, and Reporting Section 5. The investigation must take into consideration
not only the actual severity of the incident, but also the potential outcome.

First Aid - Level 1

• A first aid injury is any one-time treatment of a worker and subsequent observation of an injury, which
does not ordinarily require medical treatment. Such treatment is considered first aid, whether provided
by a first aid provider or a medical professional. First Aid includes;
• Using a non-prescription medication at nonprescription strength (for medications available in both
prescription and non-prescription form, a recommendation by a physician or other licensed health care
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professional to use a non-prescription medication at prescription strength is considered medical

treatment beyond First Aid);
• Administering tetanus immunizations (other immunizations, such as Hepatitis B vaccine or rabies
vaccine, are considered medical treatment beyond First Aid);
5. Cleaning, flushing or soaking wounds on the surface of the skin;
• Using wound coverings such as bandages, Band-Aids™, gauze pads, etc.; or using butterfly bandages or
STERIS-Strips™ (other wound closing devices such as sutures, staples, etc., are considered medical
treatment beyond First Aid);
• Using hot or cold therapy;
• Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc. (devices
with rigid stays or other systems designed to immobilize parts of the body are considered medical
treatment beyond First Aid);
• Using temporary immobilization devices while transporting an accident victim (such as, - splints, slings,
neck collars, back boards, etc.).
• Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister;
• Using eye patches;
• Removing foreign bodies from the eye using only irrigation or a cotton swab;
• Removing splinters or foreign material from areas other than the eye by irrigation, tweezers, cotton
swabs or other simple means;
• Using finger guards;
• Using massages (physical therapy or chiropractic treatment are considered medical treatment beyond
First Aid); or
• Drinking fluids for relief of heat stress.
Medical treatments that are not specifically listed above are not considered as First Aid.
Injury or illness evaluations and observations that do not result in a treatment listed above, such as a
negative x-ray, may also be classified as First Aid cases.

Medical Treatment beyond First Aid - Level 2

An injury that receives medical treatment by a doctor or other health care professional which is more
severe than First Aid treatment but does not result in restricted days or days away from work. (Work-
related cases that require medical treatment Beyond First Aid are Recordable.) Medical treatment includes:
• Closing wounds using sutures, surgical glue etc.
• Provision and/or use of prescribed medication
• Removal of foreign bodies requiring skilled services due to the depth of embodiment, size or shape
• Application of a cast to immobile an injured part of the body

Restricted Workday Case (RWDC) – Level 3

An injury or illness is considered Restricted Work/duty if it results in one or more days of restricted work or
job transfer, beyond the day of the injury/illness as recommended by the employer or health care
professional. (Work-related Restricted Work cases are Recordable).
Restricted Work activity exists if the employee is:
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• Unable to work the full workday he or she would otherwise have been scheduled to work;
• Unable to perform one or more routine job functions
“Routine job functions” are those activities the employee regularly performs at least once per week.

Lost Work Day Case (LWDC) – Level 4

• Days Away from Work occur when, as the result of an injury or illness, a doctor or company manager
determines an employee is unable to be present in the workplace during the full workday even if the
employee was not scheduled to work before the injury or illness occurred, excluding the day of the
incident. (Work-related Day Away from Work cases are Recordable).
• Any fracture, other than to the finger, thumb or toe
• Any amputation
• Dislocation of the shoulder, hip, knee or spine
• Serious Head Injury
• Serious laceration
• Loss of sight (whether temporary or permanent)
• A chemical or hot metal burn to the eye or penetrating injury to the eye
• Any injury resulting from an electric shock or electric burn, leading to unconsciousness or requiring
resuscitation, or admittance to hospital for more than 24 hours
• Entrapment of a body part in machinery/equipment/plant
• Any other injury:
– Leading to hypothermia, head induced illness or to unconsciousness
– Requiring resuscitation
– Requiring admittance to hospital for more than 24 hours
– Loss of consciousness caused by asphyxia or by exposure to a harmful substance or biological agent
– Acute illness or loss of consciousness resulting from absorption of any substance by inhalation,
ingestion or through the skin
– Acute illness which requires medical treatment where there is reason to believe that this resulted
from exposure to a biological agent or its toxins or infected material

Fatality – Level 5
Death, regardless of the time between the injury and the death or length of the illness resulting in
death. (Work-related Fatalities are Recordable).

Preserving Incident Site and Evidence

• KEMCO HSE/site management shall, as far as reasonably practicable, preserve and not disturb the site
where a “Reportable Incident” has occurred until the relevant authorities (Police, Civil Defense, HSE
Inspector/Investigator Etihad/PMC Rail HSE ENGINEER, KEMCO HSE ENGINEER etc.) arrives on site or
directs the employee to take other action;
• KEMCO HSE/site management shall be responsible for preserving all evidence associated with the
incident until such time as the relevant authorities (Police, Civil Defense, Etihad/PMC HSE ENGINEER,
KEMCO HSE ENGINEER etc.) deems necessary to ensure that all relevant evidence is collected;
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• Notwithstanding these requirements, KEMCO may take such steps as reasonably necessary to preserve
the life or safety of any person, or prevent further damage to property or the environment.

12. HSE Incident Investigation Process

• All work-related incidents, including near misses and dangerous occurrences, shall be investigated by
KEMCO. The focus of investigation shall be to identify root causes, prevent future incidents and injuries
and not to assign blame for the incident;
• KEMCO HSE team shall initiate an investigation of all incidents immediately: the level of investigation
shall be proportional to the magnitude of the occurrence;
11. KEMCO HSE team shall use methods, processes and techniques sufficient to identify the root
cause(s) of the occurrence as detailed below:
• Define the scope of the investigation;
• Select the investigators. Assign specific tasks to each (preferably in writing);
• Present a preliminary briefing to the investigating team, including:
– Description of the accident, with damage estimates.
– Normal operating procedures.
– Maps (local and general).
– Location of the accident site.
– List of witnesses.
– Events that preceded the accident.
• Gather information;
– People (person involved in the task and interviewing witness (s)); also interview those who were
present before the accident and those who arrived at the site shortly after the accident. Keep
accurate records of each interview. Use a tape recorder if desired and if approved.
– The interview should determine:
▪ What was not normal before the accident;
▪ Where the abnormality occurred;
▪ When it was first noted;
▪ How it occurred;
– Equipment (identify and verify the work equipment, substances or material related factors);
– Environment (Physical inspection of work environment i.e. weather condition, ground condition
etc.);
– Procedure (failure with applicable safe work system, operational control procedure etc.).
Additionally, documents like equipment manual, available permit to work procedure, training
records etc. to be collected;
– Organizational (Failure to comply with employer’s responsibilities);
• Analyze the data obtained above. Repeat any of the prior steps, if necessary;
• Determine:
– Why the accident occurred;
– A likely sequence of events and probable causes (direct, indirect, basic);
– Alternative sequences.
• Determine the most likely sequence of events and the most probable causes;
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• Conduct a post-investigation briefing.

• KEMCO shall utilize the findings of investigations to improve the control of hazards or significant impacts
on other operations within the entity; and
• Depending on the significance of HSE incidents, it may be deemed appropriate and/or necessary to
utilize the services of professional investigators to assist in investigation of the root causes of the
incident;
• The person(s) conducting the investigation shall be competent in the application of techniques
employed in the investigation;
• On completion of the investigation, or sooner where warranted, the findings of the investigation, along
with corrective actions or other necessary steps identified by the employer, shall be communicated to
relevant members of the workforce;
12. An incident investigation report shall include information such as, but not limited to:
– Type of HSE incident;
– Details of the injured person (e.g. gender, occupation, experience, training, etc.);
– Details of the location;
– Details of the event;
– Evidence collected (e.g. arrangements and location for witness interviews, the statements of the
interviewees, photographs of the scene);
– Actual consequences (e.g. people, environment, assets, reputation) and potential consequences of
the incident;
– Details of the investigation outcome (e.g. equipment maintenance records; risk assessments /
registers; the status of the implementation of the emergency plan and procedures, where
appropriate);
– Recommendations on preventing the recurrence of a similar incident (the recommendations shall
priorities the actions with target completion dates and stipulate the action parties and
responsibilities);
– The person(s) responsible for the investigation, their authority and competency requirements; And
– The root causes of the incident.
KEMCO management shall ensure that the findings of the all investigations are reviewed and analysed to
identify the following as a minimum:
• Reoccurring incidents;
• Common incident contributors: and
• Common trends.
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13. Incident investigation flow chart.

Incident Investigation Process

Incident Investigation Process

Incident Occurred Trained Investigation Team Members

Investigation Team Activated

Conduct Incident Investigation

• Develop Investigation Plan

• Gather Analysis Evidence
• Determine Root Causes
• Develop Recommendations

Generate incident Report

Management Review

• Decide Actions
• Restart Criteria

Implement Action

Communicate Learnings
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14. Incident Reporting

KEMCO HSEM will ensure that an immediate oral (telephone) and SMS report is made to the Employer /
Jacobs (Engineer) Representative followed by a preliminary report within 24 hours for the following cases
using incident notification for attached as Appendix B.
• Fatal Injuries;
• Injuries requiring medical attention;
• Lost time injuries;
• Damage to equipment or property;
• Fires;
• Damage and High Potential Near misses to cranes and heavy equipment.
It’s the duty of Subcontractor Management / HSE Officer to report the incident immediately to Contractor
KEMCO HSEM who will activate the communication line / actions.
For Incidents involving KEMCO or Subcontractor employees / equipment or property, a Preliminary
Incident Notification will be submitted within 24 hours to Employer/Engineer, followed by a full
investigation report within 7 days or as agreed with Employer/Engineer on case to case basis.
For all serious injuries/LTIs or high potential incidences, Project Director shall assign a Team involving
HSEM, EM, PM, CD/CM and any other specialists if required.
KEMCO and subcontractor shall maintain, in a format approved by the Employer/Engineer, a current record
showing all:
• Work Injuries.
• Fires.
• Motor vehicle Incident.
• Incidents involving damage to equipment and property.
• Damage and near misses
• This record shall be reflected in the Monthly report to Employer / JACOBS (Engineer) and Corporate
Offices.

Fatal Incidents
All fatal Incidents on site must be reported immediately to the Contractor HSE ENGINEER who in turn will
report the case to the Project Director and Project Manager and contractor Corporate HSE office. HSEM
shall also report the same to Clinic and Administration / PRO, in turn they will contact Police or other
relevant external agencies.
For more detail refer to OSHAD-SF-Mechanism 11.0 – Incident notification, Investigation, and Reporting
Section 2

Serious / Major Incidents & Dangerous Occurrences

KEMCO and Subcontractor Supervisors shall report any Serious / Major Incident or Dangerous Occurrence
to the Contractor Site HSE ENGINEER / Coordinator immediately, who shall in turn notify the same to
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Construction Director / Project Manager. For more detail refer to OSHAD-SF-Mechanism 11.0 – Incident
notification, Investigation, and Reporting Section 2.

Lost Time Incidents

A Lost Time Incident is an Incident resulting in a person missing at least the next shift from work.
The Contractor and Subcontractor supervisor is required to report the incident to their department head
and HSE ENGINEER / Coordinator immediately. For more detail refer to OSHAD-SF-Mechanism 11.0 –
Incident notification, Investigation, and Reporting Section 2

First Aid Incidents

A First Aid Incident is an Incident where only first aid treatment is given to an injured person (even if given
by a Doctor) who resumes work after such treatment is administered. All First Aid cases on site should also
be reported to site in-charge and HSEM. For more detail refer to OSHAD-SF-Mechanism 11.0 – Incident
notification, Investigation, and Reporting Section 2

Disease
KEMCO Site Medical staff must be informed as soon as a problem becomes obvious.
The Contractor Site Medical staff shall inform the same to HSE ENGINEER / Coordinator as soon as
practicable. For more detail refer to OSHAD-SF-Mechanism 11.0 – Incident notification, Investigation, and
Reporting Section 2

Unsafe Conditions
Working conditions that contravene HSE Rules, Codes of practices and good common sense are not
acceptable in any KEMCO and Subcontractor premises or site, and if exist, are to be rectified by the
immediate Supervisor at the earliest practicable opportunity. The unsafe conditions to be reported to site
HSE Engineers / Officers and HSE Supervisors

Unsafe Acts
Acts that could endanger oneself or endanger others, including the act of horseplay, is prohibited in any
KEMCO and Subcontractor premises or site, and if observed should be reported to the relevant supervisor
and filed HSE officers.

Traffic Vehicle Incident

All traffic related incidences to be reported to KEMCO HSE / Coordinator immediately.

Near-Miss
Any incident in which nobody is hurt or no damage to property is done, such as a piece of equipment
falling from height, somebody slipping or tripping, etc. shall be considered as a ‘near miss’.
Near Miss Incidents are to be reported as soon as reasonably practicable.
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Monthly HSE reporting

Monthly HSE performance and incident shall be reported to JACOBS (Engineer) by KEMCO on Monthly HSE
report.

Lessons learnt
All lessons learnt will be communicated to KEMCO staff and workers via start of shift briefings, tool box
talks, safety alerts.

Media Activities
All media reporting or contact with the media is not permitted by KEMCO employees.
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15. Record keeping

All records pertaining to incident reporting and investigation shall be maintained until end of the project
completion.

• Accident reports
• Supporting documents
• Lesson learnt
• Corrective action
• Training and competency
• Audit of process
• Near misses reports etc

16. Appendix A incident Action Protocol

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Immediate PROJECT EMERGENCY HOTLINE Site HSE

Supervisor
Personnel
Project / Site 0524133904
Engineer

Project Manager

Immediate
Supervisor HSE ENGINEER Site HSE
Personnel
Project / Site
Engineer

– Ensure First First Aid Center / First

– Ensure first
Aid/Medical Aider aid/medical
Assistance. assistance
– Ensure safety of Site HSE Officer &
immediately.
coworker / other Security Personnel – Ensure safety of co-
personal and secure worker / other
the area. personal and secure
– Gather incident Site nominated First the area.
witnesses Information – Assist in investigation
from supervisor/ process.
coworker. – Assist supervisory
– Prepare accident staff in preparing
/incident notification EMERGENCY TELEPHONE accident report.
within 24 Hrs. – Review risk
– Assist the Ambulance Tel. # 998
assessment.
Investigation process – Train and create
Police Department Tel. # 999
and reveal all possible awareness.
Causes. Fire Department Tel. # 997 – Monitor the
– Submission of Implementation of
investigation report by the action plan.
7 days. – Submit independent
– Ensure effective report to Project
implementation of Manager/HSE
action plan. ENGINEER
– Review MS & RA
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17. Appendix B Initial (24 Hour) incident notification Format

INCIDENT TITLE

INCIDENT REFERENCE NO.

Employee Worker Type:

Date of Incident: Time:
ER PMC Contractor 3RD Party

Incident Workplace Address:

Incident Location:

Police Report Number: Authorized Contact Person:

(If applicable) Mobile Number:

Injured Person’s Personal Details: (If applicable)

Name: Occupation:

Gender:
Male Female Date of Birth:

Contact Address: Phone Number:

Employer Details:

Name:

Address:

Phone Number:

Contact Person:

Serious Fatal

Reportable Dangerous Occurrence

Health and Safety Incident: (May Reportable Serious Injury Client Owned Property
select more than one)
Emergency Response Notified Reportable Occupational Fatality

Evacuation Required Illness/Disease

Environmental Incident: Environment – Moderate Environment - Major

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(May select more than one)

Spills/Releases/Discharges to Land
Spills/Releases/Discharges to Water, including groundwater
Harm to Animal Species
Damage to Heritage
Vegetation Removal/Harm
Other:___________________________________________________________

Minor / No Injury / Slight Moderate

Health and Safety Incident: (May Near Miss Lost Time Injury
select more than one)
First Aid Injury Medical Treatment Case

Equipment /Property Damage Restricted Workday Case

Environment – Moderate Environment - Major

Spills/Releases/Discharges to Land
Spills/Releases/Discharges to Water, including groundwater
Environmental Incident:
(May select more than one) Harm to Animal Species
Damage to Heritage
Vegetation Removal/Harm
Other: ___________________________________________________________

Description of Incident (use extra pages if necessary):

By Whom:
Date:
Signature:

Describe Actions taken (use extra pages if necessary):

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By Whom:
Date:
Signature: