Incident Classification, Investigation, and Reporting Manual

Reporting of Incidents
INCIDENT CLASSIFICATION,
INVESTIGATION AND REPORTING
Version 311207
The companies belonging to the Royal Dutch/Shell Group of companies are separate and distinct entities, but in this document the collective
expressions “Shell” and “Group” are sometimes used for convenience in contexts where reference is made to the companies of the Royal
Dutch/Shell Group in general. These expressions are also used where no useful purpose is served by identifying the particular company or companies.
This document is prepared by Shell International B.V. (SI) as a service under arrangements in existence with companies of the Royal Dutch/Shell
Group; it is issued for the guidance of these companies and they may wish to consider using it in their operations. Other interested parties may receive
a copy of this document for their information. SI is not aware of any inaccuracy or omission from this document and no responsibility is accepted by
SI or by any person or company concerned with furnishing information or data used in these guidelines, for the accuracy of any information or advise
given in the guidelines or for any omission from the guidelines or for any consequences whatsoever resulting directly or indirectly from compliance
with or adoption of guidance contained in the guideline even if caused by a failure to exercise reasonable care.
The copyright of this document is vested in Shell International B.V., The Hague, Netherlands.
All rights reserved.
DECEMBER 2007
HEALTH, SAFETY AND ENVIRONMENT PANEL
Incident Classification, Investigation and Reporting
1 Management Summary 4
1.1 Purpose and Scope 4
1.2 Group Standards 5
2 Recording of Incidents 6
3 Investigation of Incidents 7
3.1 Responsibilities and Competence 7
3.2 Extent of Investigation 7
3.3 Investigation Process 7
3.4 Establishing the Sequence of Events 8
3.5 Analysis of Underlying Causes and Weaknesses in Management System 8
3.6 Incident Report and Follow up 9
4 Learning from Incidents 10
5 Classification of Incidents 11
5.1 Work Related Activities 11
5.2 Injuries 12
5.3 Illnesses 12
5.4 Incidents Resulting in Asset Damage, Environmental Impact and/or Impact on Company Reputation 12
5.5 Near Misses 12
5.6 Potential Incidents 13
5.7 High Risk Incidents 13
6 Reporting of Incidents 14
6.1 Reporting Company 14
6.2 Reporting of Significant Incidents 15
Appendix 1 Definitions and Explanation of Terms 17
Appendix 2 Incident Classification and Reporting Flow Chart 26
Appendix 3 Medical Treatment Cases and First Aid Cases 27
Appendix 4 Distinguishing between Injuries and Illnesses, and Determining whether Illnesses are
Occupational 30
Musculo-skeletal Conditions including Back Problems 30
Repetitive Strain Injury (RSI) 32
Work Related Stress 32
Burns 32
Dermatitis 33
Animal Bites and Insect Stings 33
Heart Attacks 34
Infectious Diseases 34
Common Subjective Symptoms 34
Food Poisoning 34
Noise Induced Hearing Loss 35
Eye Problems 35
Aggravation of an Existing Physical Deficiency 36
Pre-existing Conditions 36
Infected Laceration 36
Reaction to Medical Treatment 36
Recurrence of Symptoms 36
Medical Verification by a Medically Qualified Person 37
Individual Susceptibility 37
Permanent or Temporary Transfers 37
Overexposure to Health Hazards 37
Appendix 5 Classification of Occupational Illness 38
Appendix 6 Asset Damage - Examples 39
Appendix 7 Environmental Impact - Examples 40

Atmospheric Emissions 40
Oil and Chemical Spills 40
Complaints 41
Non-compliances 41
Appendix 8 Reputation Impact - Examples 43
Appendix 9 Incident Investigation Guidance 44

Conducting Interviews 44
Inspecting the Location 44
Collecting Background Information 45
Fact Finding 45
Records and Procedures 46
Special Studies 46
Conflicting evidence 46
Appendix 10 Sequentially Timed Event Plot - Example 48
Appendix 11 Incident Report Layout for a Significant Incident 49
Appendix 12 Work Related Activities – Guidance and Examples 51

Transportation of Personnel 51
Working from Home 51
Working Away From Home 52
Transportation of Goods and Equipment 52
Transportation of Product 53
Injuries during Training 54
Meal Period Illnesses 54
Fitness Centre 54
Entertainment of or by Customer, Supplier or other Business Contacts 54
Recreation and Social Events 55
Acts of God and Wilful Acts 55
Horseplay 55
Appendix 13 Procedure for Reporting and Review of Significant Incidents 56
Appendix 14 Exposure Hours - Examples 58

Management Summary
1 MANAGEMENT SUMMARY
1.1 Purpose and scope (most of this section will be removed when the Manual is released)
The Shell Group HSE policy requires that every Shell Company “has a systematic approach to HSE
management designed to ensure compliance with the law and to achieve continuous performance
improvement” and “sets targets for improvement and measures, appraises and reports
performance”. An essential feature of the systematic approach and continuous performance
improvement is the reporting of incidents, so that they can be investigated, lessons learned, and
performance monitored.
The guiding principles for incident reporting, investigation and learning will be set out in
the new Incident Investigation and Learning Manual. The following is provided as an
interim and will be removed from this document when the Manual is released.
The guiding principles for incident reporting, investigation and learning are that:
 management controls should be in place for activities and operations having the
potential for incidents with a significant impact on the company
 we will investigate all incidents where management controls should have been in place
(even if the incidents are not formally work related (see definitions)) and take action to
measure the effectiveness of these management controls. It is all about learning.
The guiding principles for classification and recording are that:
 we will classify our injury incidents (using the OSHA definitions and OGP scope) and
include these cases in the statistics as a means of benchmarking our performance.
This document provides guidance on the recording, investigation, learning, classification, and
reporting of incidents which result in injury or illness, and in damage to assets, the environment or
company reputation. It also addresses incidents that had no adverse outcome, i.e. near misses. It sets
out the rules for the reporting of incidents by Shell companies and joint ventures. This revision
replaces the Group Incident Classification and Reporting Guide (2002).
The reasons for revising this guide are:
 To incorporate a section on Learning from Incidents
 To align the guidance on classification of illnesses and injuries more closely with the US
Occupational Safety and Health Administration (OSHA) and the International Association of
Oil and Gas Producers (OGP) system for scope;
 To incorporate findings from audits and reviews;
This is a transition document. The high level mandatory requirements will be moved to the new
Incident Investigation and Learning Manual in 2008 under the HSE Control Framework
Project. The majority of the contents will be retained in a supporting document to the new Manual.
The extensive OSHA documentation can also be used as guidance except where this document
specifically excludes its use i.e. Stress. Differences between this document and OSHA should be
4 Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

Management Summary
brought to the attention of the team responsible for the maintenance of this document via your
Business / organization HSE Data Reporting focal point. The suspected differences will then be
reviewed and either corrected in the next revision or specifically retained.
1.2 Purpose and scope
The Group procedure for an HSE Management System applies to all companies that are under
Shell’s operational control. This procedure requires that “all incidents and near misses with
significant actual or potential consequences shall be thoroughly investigated and reported”.
This section details the standards and procedures that are mandatory for all Companies:
 Companies shall implement processes for identifying and logging all incidents that occur in
their activities. They shall classify the incidents in terms of actual consequences and risk rating,
applying the Risk Assessment Matrix (RAM);
 Companies shall investigate all significant incidents, i.e. those with actual consequences to the
company which rate 4 or 5 on the RAM, to establish both immediate and underlying causes and
weaknesses in the HSE management system. The investigation shall include Tripod or causal
learning methodologies. They shall recommend actions to prevent recurrence and to improve
effectiveness of the HSE management system. They shall report the findings of their
investigation and their action plan to the business. The Procedure for Reporting and Review of
Significant Incidents is detailed in Appendix 13;
 Companies shall investigate all high-risk incidents that have a high risk rating on the RAM, to
establish the immediate and underlying causes and weaknesses in the HSE management system.
They shall recommend actions to prevent recurrence and to improve effectiveness of the HSE
management system. When the investigation reveals significant learning potential (see section 4)
they shall report the findings and learning to the business.

2 RECORDING OF INCIDENTS
(will be rewritten when Manual is released)
The Group is moving towards a common recording system known as Fountain Incident
Management (FIM) that satisfies the requirements for recording incidents. Alternate systems can be
used in the interim. In order to facilitate learning, all RAM 3+ incidents shall be recorded in English.
Details of incidents need to be recorded (logged) before investigations commence. The initial
incident recording will require an initial RAM classification in order to determine the level of
investigation.
All incidents where management controls have failed or should have been in place, or where
learning can be extracted, need to be reported and entered into FIM or equivalent interim system –
even if they are not work related. The primary objective is to learn from the established facts and
prevent recurrence. We will record, investigate and learn from incidents that are not formally work
related under the classification system.
The recording or reporting of a (potentially) work-related injury, illness, or fatality does not mean
that the recording organization was at fault, that a rule or regulation has been violated, or that the
effected party is eligible for workers’ compensation or other benefits. The details recorded in the
system and the classification may change as additional information becomes available as part of the
investigation or subsequent to the investigation.
The FIM system may be used to record and circulate details of accidents that have occurred in other
organizations or industries.
Reporing of Incidents
3 INVESTIGATION OF INCIDENTS
3.1 Responsibilities and Competence
Investigation of incidents is a line responsibility. All investigations should be led by or sponsored by

a line manager or supervisor. HSE and other specialists should be employed as required in a support
or facilitating role.
When conducting a detailed investigation and Tripod or Causal learning analysis, it is recommended
that the investigation team should include a competent facilitator. Each business should develop
competence criteria for facilitators, e.g. a person who has attended a Tripod facilitator training
course or has experience in applying the Tripod methodology to the analysis of incidents.
Incidents occurring during activities controlled by contractors should be investigated by the
contractor, supported where necessary by company HSE and other specialist advisers. The incident
investigation report submitted by the contractor should be reviewed and agreed by the company.
3.2 Extent of Investigation
The extent of investigation of incidents should be based on a consideration of:

 Actual consequences. Significant incidents should be thoroughly investigated and the findings
analysed by the Tripod methodology or causal learning method. In addition, local legislation
may prescribe the level of investigation and reporting of fatalities;
 Risk rating as determined by the RAM Risk Assessment Matrix (2006).
3.3 Investigation Process

The investigation should be carried out as soon as possible after an incident. The quality of evidence
will deteriorate rapidly with time, therefore delayed investigations are usually not as conclusive as
those performed promptly.
The investigation should include the following activities:
 Conducting interviews;
 Inspecting the location and gathering physical evidence;
 Collecting background information;
 Fact finding;
 Reviewing records and procedures;
 Conducting specialist studies;
 Resolving conflicts in evidence.
Guidance on these activities is provided in Appendix 9. The checklists can be used as a ready
reference before starting on an investigation.

3.4 Establishing the Sequence of Events

Documenting the sequence of events is a crucial step that provides the starting point for analysis of
underlying causes. A number of techniques are available to help visualise the sequence of events.
3.4.1 Timeline
A timeline is simply a list of the events in chronological order. For straightforward incidents a
timeline and narrative will suffice as a description of the sequence of events.
3.4.2 Hazard-Event-Target (HET) trios
The Tripod Beta methodology applies linked HET trios to describe the sequence of events before
and after an incident. It is described in detail in EP 95-0321 Tripod Beta, which is available on the
Exploration and Production web site at:
http://sww.siep.shell.com/hse/index.htm?target=/hse/safe/tripod.htm.
3.4.3 Sequentially Timed Event Plot (STEP)
A STEP identifies the actions of key “actors” in the incident and plots them against time. The
“actors” can be people, vehicles, items of process equipment, process conditions etc. The scale of
the time axis is normally not linear, but varies to suit the interval between events. Each event is
described in terms of date, time, actor and action.
The value of a STEP is that it enables a visual representation of the sequence of events to be shared
by investigation team members and witnesses. It focuses the investigators on agreeing the sequence
of events before starting to analyse the causes. A STEP is amenable to a white board and post-it
technique. STEP is particularly powerful in providing an overview of complex process incidents.
An example of a STEP diagram is shown in Appendix 10.
3.5 Analysis of Underlying Causes and Weaknesses in Management System

The purpose of this analysis is to establish the underlying causes of the incident, so that actions can
be taken to prevent recurrence, and also to understand the failures and weaknesses in management
systems that led to the incident. Although this analysis is a separate activity from investigation of the
incident, it is recommended to carry out the investigation and analysis concurrently, so that they can
support and build on each other.
Many methods are available for analysing the underlying causes of incidents, but some of these do
not recognise the concepts of latent (management) failures. The method recommended in the Shell
Group for analysis of HSE incidents is the Tripod or causal learning methodology.

3.5.1 Tripod for Understanding Incidents

This variation combines one of the techniques outlined above for documenting the sequence of
events, together with the Tripod theory of incident causation, including “caused by” and “leads to“
guides, to establish the latent failures. The Tripod tree is normally built using a white board and
post-it technique, and the final tree is documented in a spreadsheet.
Details of this method are available from Shell Global Solutions, GSGH/1.
3.5.2 Tripod Beta
This variation applies the HET trios to represent the sequence of events, and the Tripod theory of
incident causation, including “caused by” and “leads to “ guides, to establish the latent failures. The
Tripod Beta computer tool includes a number of wizards to facilitate the several stages in building a
Tripod tree. It also enables a report to be generated in a standard format.
This method is described in detail in EP 95-0321 Tripod Beta, which is available on the Exploration
and Production web site at:
http://sww.siep.shell.com/hse/index.htm?target=/hse/safe/tripod.htm.
3.5.3 Other methods
The investigation and analysis of less serious incidents, where a Tripod methodology or causal
learning methodology analysis is not being undertaken, should include an analysis of factors such as
type of incident, type of injury, phase of operation or activity, cause of incident. This type of analysis
of all the incidents occurring over a period of time can provide valuable input to an incident
prevention programme.
3.6 Incident Report and Follow up
3.6.1 Incident Report
The incident report presents the investigation findings, analysis and action plan. Recommended
actions arising from the incident investigation should be entered in Fountain Incident Management
or equivalent system for tracking and close out.
Appendix 11 shows the recommended report format for an investigation of a significant incident. If
Tripod Beta is used for the analysis, the report can be generated automatically in a standard format.
The incident report should be reviewed at the appropriate management level as a check on the
completeness and quality of the investigation and to obtain agreement to the proposed actions.
3.6.2 Legal advice
When compiling incident reports that may be required by authorities and other third parties outside
the company, it is recommended to seek legal advice before commencing the reports. Requests for
copies of incident reports should be considered individually taking into consideration the potential
risks and exposures for the company, its directors and employees and the possibility of criminal or
civil liability.

4 LEARNING FROM INCIDENTS
The text below has been provided by the cross Business LFI Working Group for inclusion in the
new Incident Investigation and Learning Manual. This section will be removed from here
when the Manual is in place.
Learning needs to be extracted and disseminated for all incidents where management
controls have failed or should have been in place, and all incidents where learning can
be extracted; even if the incidents are not classified as work related.
All businesses, support functions and other organisations shall:

 have a designated LFI coordinator who:
o upon receiving the initial notification of a Significant Incident in their part
of Shell, communicates the facts known so far in their part of Shell as well
as to other businesses, support functions and organisations in Shell, where
there is a need to take immediate mitigating action to prevent a similar
incident
o for incidents with key learning, ensures Action, Awareness and where
relevant Leadership LFIs are produced for sharing and/or for identifying
actions to be taken to prevent similar incidents from recurring.
o involves appropriate legal review for LFIs
o disseminates LFIs to targeted people in the business, support function or
other organisation (down to contractor level), across to other businesses
and support functions and to industry in general
 for staff who receive the learning, assign accountabilities to verify applicability,
assign actions and track actions to completion.
In addition, businesses shall:
 identify incidents from outside Shell
 get line management endorsement for actions prior to issuing Action LFIs to the
relevant entities
 tracks follow up on Action LFIs
 includes learning in Shell Group Standards, and Manuals as well as local or regional
standards, procedures and work instructions.
 assess effectiveness of the LFI process.
Click here for more information

5 CLASSIFICATION OF INCIDENTS
Incidents are unplanned events or chains of events that have, or could have, resulted in injury or
illness or damage to assets, the environment or company reputation. This section describes how to
determine if an incident is work related and then goes on to describe the various types of impact of
incidents. Definitions and explanations of the terms used are presented in Appendix 1 and a
flowchart of the process of classifying incidents is given in Appendix 2. Examples of the different
types of impact of incidents are given in Appendices 3 to 8.
Where there is any doubt, decisions on work relatedness and other classification matters should be
made after the investigation is completed.
5.1 Potential Work Related Activities
Work Related incidents shall be recorded and included in performance statistics. The following
activities should be considered as potentially work related until shown otherwise, as they are
susceptible to incidents with significant impact, for which company controls should be in place:
 All work by company personnel;
 All work by contractor personnel on company premises;
 All work by contractor personnel on non-company premises for which it is concluded on the
basis of risk considerations that company and contractor management controls are required.
For company personnel work includes overtime, attending courses, conferences and company
organised events, business travel, field visits, or any other activity where the employee’s presence is
expected by the employer. Participation in voluntary programs is not considered work related but
high potential incidents arising at such events will be recorded and investigated for their learning
potential.
For contractor personnel, the same activities are included when they are executed under a contract
on behalf of the company. Contractor includes all sub-contracted activities.
Where it is impossible or inappropriate for the company to seek to apply management control on a
contractor, exceptions may be justifiable. Examples may be found in areas where contractor services
are not dedicated to the company, for example:
 Manufacturing of components in a factory together with the manufacture of components for
other customers;
 Construction at a contractor's fabrication site shared by other customers;
 Delivery of goods or products to company locations by a contractor who is also employed to
deliver goods or products to other companies during the same journey;
 Customer collection of company products, where the vehicle and drivers are under the control
of the customer.
For these exceptional situations the company should make a conscious, risk based and documented
decision whether or not to maintain management controls and include incidents in performance
reports.
Appendix 12 provides further guidance and a number of examples to illustrate what are work related
activities, see also the definition of Work Related.
5.2 Injuries
The various terms are defined in Appendix 1 and guidance on the types of Medical Treatment Cases
(MTC) and First Aid Cases (FAC) is given in Appendix 3.
The potential consequences of injuries should be assessed on the RAM.
5.3 Illnesses
The procedure to determine whether or not an illness is occupational (work-related) is detailed in

Appendix 4. Examples to clarify the boundaries between occupational and non-occupational
illnesses, and also between injuries and illnesses, are also given in Appendix 4. Having determined
that an illness is occupational it can then be categorised into type of disorder or disease according to
the classification in Appendix 5.
For internal and external benchmarking purposes, work related illnesses should be recorded both
according to OGP definition and OSHA definition. The difference is that OGP classifies an illness
as work-related if caused by work (probability 50% or more), while OSHA defines an illness as
work-related if an event in the work environment either caused or contributed to the resulting
condition or illness.
Records should be kept on the outcome of an occupational illness in terms of fatality, lost work,
restricted work, medical treatment or first aid/no treatment provided. These records should be
entered in FIM. All identified occupational illnesses meeting OGP definitions are included in total
recordable occupational illness data.. The key performance indicator for occupational illness is Total
Recordable Employee Occupational Illness Frequency (TROIF). Contractor occupational illnesses,
when known, should be recorded and investigated for learnings. The number of case will be
reported, however the cases are not to be included in the TROIF calculation. OSHA recordable
occupational illnesses are extracted from the data base to use for external benchmarking purposes.
The actual and potential consequences of an occupational illness should be assessed on the RAM.
See Appendix 4 - Overexposure to Health Hazards.
5.4 Incidents Resulting in Asset Damage, Environmental Impact and/or

Impact on Company Reputation
Incidents resulting in asset damage, environmental impact and/or impact on company reputation are
not normally classified into severity classes in the same way as injuries. However, the actual
consequences and the (potential) risk rating should be assessed using the RAM, so as to decide the
level of investigation, follow up and reporting. Many incidents have impacts in more than one
category, e.g. asset damage and company reputation, in which case the highest RAM rating
determines the extent of investigation and follow up.
5.5 Near Misses

Near misses are incidents that under slightly different circumstances could have caused illness, injury
or damage to assets, the environment or company reputation, but did not (incident has occurred).

Overexposure to hazardous chemicals, noise and other health hazards should be considered as near
misses when the exposure did not result in an identified illness.
Companies should encourage the reporting and analysis of near misses as they provide a valuable
source of learning that can be applied to prevent future incidents.
5.6 Potential Incidents
Potential incidents are unsafe practices or hazardous situations that could result in an incident
(incident has not occurred).
Potential incident data is frequently collected in the course of work-site inspections, unsafe act
auditing, management walks and through incident or near miss reporting systems.
Companies should encourage the reporting and analysis of potential incidents as they provide a
valuable source of learning that can be applied to prevent future incidents.
5.7 High Risk Incidents

High Risk Incidents (HRIs) are incidents for which the combination of potential consequences and
probability are assessed to be in the high risk (red shaded) area of the RAM. HRIs can be incidents
that result in injuries, illnesses or damage to assets, the environment or company reputation, or they
can be near misses.
HRIs should be thoroughly investigated and the lessons learned applied to prevent future significant
incidents. See also Section 4.

6 REPORTING OF INCIDENTS
6.1 Reporting Company
The companies that are required to report incidents in accordance with this guide are Shell
companies and Joint Ventures that are under Shell’s operational control (JVs-uoc), i.e. entities over
which a Shell company has the full authority to impose the adoption and implementation of the
Group HSE Policy and Procedure.
For Joint Ventures not under operational control (JVs-nuoc), Shell companies are required to use
their influence to promote the Group HSE policy and to encourage JVs-nuoc to report their HSE
performance and incident data. Refer to Appendix 9 of Group HSE Management System (1999) for
details of the management of JVs-nuoc.
For shipping activities operational control applies to Group owned and demise (bare boat) chartered
vessels but excludes time or voyage chartered vessels. Trading is only operationally responsible for
the Trading managed fleet. The other fleets that are included in the shipping sector, whilst reporting
to Trading, are the operational responsibility of other operating companies, i.e. Shell UK, Norske
Shell, Shell CAPSA, ALSOC and SCOA.
The data included in the Shell Group external reports will draw on data reported by Shell companies
and JVs-uoc under this guidance and may be subjected to independent verification.
For internal reporting purposes, HSE data is to be reported to Group (CAE) via the Business and
Organization lines. The existing reporting entities as of 2007 are Exploration and Production,
Downstream, Gas & Power, Trading, Shell Global Solutions and Central Functions. This may
change with time. The Shell People Organization Online Unit hierarchy can be used to determine
which organisation unit is responsible for reporting each employee’s incidents and exposure hours to
Group (CAE).
In the case of Contractors, the reporting entity managing and directing the contractor’s activities are
responsible for reporting the contractor’s incidents and exposure hours, wherever they are working.
In some exceptional situations there may be reasons for a unit to establish incident reporting
responsibilities that differ from those stated above. If so, both units HSE Management Systems
must have documented the arrangements prior to any incidents.
When a company employee or contractor/consultant is visiting or on assignment in a Group
company other than his employing company the responsibility for reporting any incidents associated
with that employee lies with the employing company that also records the employee’s exposure
hours. The company being visited is responsible for investigating the incident and for implementing
resulting recommendations. This rule also applies to employees of Group Functions and Shell
Global Solutions International despite the fact that these service providers will have a contractual
arrangement with the company being visited. The presumption is that because they are Shell
companies these consultants will be working to Shell Group standards.
In the case that exposure hours are not calculated, e.g. for third party injuries and environmental
incidents, the company responsible for operating the equipment or facilities involved is responsible
for reporting.
6.2 Reporting of Significant Incidents
All significant incidents, having actual consequences rated 4 or 5 on the RAM, shall be notified to
the business director within 24 hours. Final classification on the basis of the investigation report is
the responsibility of the business HSE adviser.
Refer to Appendix 13 for the details of the Procedure for Reporting and Review of Significant
Incidents.
Third Party Fatalities

All third party fatalities that are suspected to have resulted from work related activities, shall be
notified to the business, investigated and reported in line with the Procedure for Reporting and
Review of Significant Incidents in Appendix 13. Two types of third party fatality are recognised:
A. If the investigation reveals that failures of company or contractor management controls that
should have been in place contributed to the incident causation, the incident shall be recorded.
B. If the investigation reveals that the incident was caused wholly by the action of the third party
the incident will not be recorded.
Any lessons that result from the investigations should be entered into FIM or equivalent interim
system and tracked to closure.
All work related third party fatalities resulting from assault, sabotage and theft should be included in
the statistics.
Non-accidental Death
In case of a Non-accidental Death (NAD), there is a requirement to identify whether the incident
may be work related or involve a failure(s) of company or contractor management controls that
should have been in place. This applies also to non-accidental deaths in company premises and
non-company premises including company and contractor accommodation where there is reason
to suspect a relationship between the death and events or exposures related to work.
The NAD shall be notified to the business within 24 hours in all cases where the death occurred
at the company premises and investigated to:
 Decide whether there is a causal relationship between work and the death, in which case
the death should be classified as work related and recorded in statistics using definitions
of work-relatedness as defined in this document.
 Determine if the company medical emergency response procedures, including first aid,
medical treatment and medical evacuation were suitable and complied with Shell
standards?
If the NAD occurred outside the company premises and/or outside normal working hours, the
NAD shall be notified to the business within 24 hours if and when any of the following questions
is answered by “yes”:
 Were there any work related exposures, e.g. contacts with hazardous substances or
working conditions that could have caused or contributed to the death?
 Were there any pre-existing medical conditions relevant to the job of the individual?
 Has the individual been declared unfit to carry out his normal duties in compliance with
company standards or not had a relevant fitness to work assessment?
 Did the individual exhibit any signs or symptoms associated with the cause of death

before or during his recent work period?

 Was the individual recently referred to a doctor or hospital in relation to a possible work
related condition?
All NAD cases that occurred at the workplace or involved a failure(s) of company or contractor
management controls should be investigated to:
 Identify work related causes or contributing factors that may provide the grounds for
corrective action and improvement;
 Establish whether there were weaknesses or failures regarding management controls that
should have been in place.
The investigation report should
a) provide a proposal whether the case is work-related or not
b) and whether there were failures in management controls with recommendations for
improvement.
The investigation should be conducted in a way that respects medical confidentiality, and focus on
those aspects related to the incident that are under management control.
Deliberate Death
Suicides and homicides should be notified to the business as soon as practicable. If the initial
investigation indicates a work-relationship, they should be investigated in the same way as an
accidental death and included in statistics.

Appendix 1: Definitions and Explanation of Terms
Appendix 1 Definitions and Explanation of Terms
Asset Damage
A direct loss of or damage to plant, equipment, tools or materials resulting from an incident. (Refer
to guidance and examples in Appendix 6).
Business
One of the global Shell businesses, i.e. Exploration and Production, Downstream or Gas and Power.
Business Travel
For a Shell employee, Business Travel is any travel undertaken for the purposes of work activities in
which that person is engaged in the interests of his or her employer, to the following extent:
 It includes the period from the time that person leaves their residence or their normal place
of work until they return or until the time they arrive at their destination and check into
temporary accommodation (‘home away from home’).
 It includes, on the return trip, the period from when the person checks out of their
temporary accommodation until they arrive at their residence or their normal place of work.
 It includes the whole spectrum of travel, from international travel through to simple acts like
crossing a public road on foot between two company buildings.
 It excludes a person’s normal commute to work.
 It includes travel to the airport for a business trip from the time an employee leaves home
even if that travel follows the same route as their normal commute. If the employee stops in
the office first to work, then the period of employee’s business travel starts from the office
and not their home.
 It excludes that person’s commute from their home away from home to their temporary
place of work or a significant detour made for personal reasons.
 Any injury or illness occurring during the business trip is considered to be work related for
recording, investigation and learning purposes; but not all injuries and illnesses will be
recordable for statistical purposes.
Business Travel - Contractor

For a Shell contractor, Business Travel is any travel undertaken for the purposes of work activities in
which the contractor is engaged in supplying Shell or one of its subsidiary companies with goods
and / or services, to the following extent:
 It includes day-to-day travel undertaken by a Shell contractor in the course of carrying out Shell
work-related activities.
 It excludes day-to-day travel undertaken by the Shell contractor when that person is not engaged
in Shell work related activities (such as their normal commute, or any travel undertaken in the
interest of their own employer).
 It includes contractor mobilization and demobilization when performed under contract with
Shell.

Business Unit
Activities in one of the Group businesses that are operated as a single economic entity. A business
unit can coincide with a Group company or straddle part or all of several companies.
Consequential Business Loss

The indirect loss associated with incidents resulting in asset damage, environmental impact or
impact on company reputation. It comprises elements such as loss of production (expressed as
profit margin), process unit downtime, product quality costs, cost of environmental clean up, cost of
recovery/disposal of waste and cost of reprocessing off-grade material.
The intention is to estimate the order of magnitude of the loss so that the incident can be assessed
on the RAM and the appropriate resources put into investigation. It should not be necessary to
conduct a detailed accounting of the full range of indirect costs. Consequential business loss should
be estimated on a 100% equity basis.
When consequential business loss results from an incident with impact on the environment or
company reputation, the consequences should be assessed under both asset damage and the
environmental/reputation categories of the RAM and the highest rating used to determine the
extent of investigation and follow up.
Company
Company or Group company means a Shell company, a Joint Venture under operational control
(JV-uoc), or a Joint Venture not under operational control (JV-nuoc) that has agreed to report its
HSE performance and incident data to Group following the reporting methodology detailed in this
guide.
Contractor
All parties working for the company either as direct contractors or as subcontractors.
Environmental Impact
The negative impact on the environment resulting from an incident. (Refer to guidance and
examples in Appendix 7).
Exposure Hours
The total number of hours of employment including recorded overtime and training but excluding
leave, sickness and unrecorded overtime hours. Exposure hours should be calculated separately for
company and contractor personnel.
Time off duty, even if this time is spent on company premises, is not included in the calculation of
exposure hours, but incidents during this time should be recorded and investigated. When they meet
the work related definition, they should be included in the statistics as recordable incidents.
(Refer to guidance and examples in Appendix 14).
In many company sites the number of exposure hours can be calculated from computer controlled
access or time keeping records. In the absence of more accurate methods exposure hours can also
be calculated from a headcount and nominal working hours per person or time writing systems.
In order to meet reporting schedules, exposure hours can be estimated on the basis of the previous
data. Corrections can be made at the end of the reporting year when more time is available.
OSHA now requires 24 hrs man-hour counting for Off shore (off shore ruling). Will include text.

Fatality
A death resulting from a work related injury or occupational illness, regardless of the time
intervening between the incident causing the injury or exposure or causing illness and the death.
FAR
The number of fatalities per hundred million exposure hours.
FIM
Fountain Incident Management (FIM) is the Group system for recording incident details, the
investigation, classification and action items. It can also issue notifications and reports. Other
systems can be used in the interim; but all Businesses and Functions are expected to be using FIM
by end 2009. FIM should be used for all potentially work related incidents including those that occur
while in “home away from home status”.
Fires and Explosions

Normally taken to mean all fires that necessitated the use of a fire extinguisher or other
extinguishing means, e.g. snuffing steam, shut off fuel or switch off electricity supply. Fires with no
visible flame, e.g. oil soaked insulation, should also be included. All flammable explosions or
overpressure explosions should be included, irrespective of the extent of containment.
First Aid
An incident is classified as a First Aid if the treatment of the resultant injury or illness is limited to
one or more of the 14 specific treatments. These are:
1. Using a non-prescription medication at non-prescription strength (2);
2. Administering tetanus immunizations;
3. Cleaning, flushing or soaking wounds on the surface of the skin;
4. Using wound coverings such as bandages, Band-AidsTM, gauze pads, etc.; or using butterfly
bandages or Steri-StripsTM.
5. Using hot or cold therapy;
6. Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts,
etc;
7. Using temporary immobilization devices while transporting an accident victim (e.g., splints,
slings, neck collars, back boards, etc.).
8. Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister;
9. Using eye patches;
10. Removing foreign bodies from the eye using only irrigation or a cotton swab;
11. Removing splinters or foreign material from areas other than the eye by irrigation, tweezers,
cotton swabs or other simple means;
12. Using finger guards;
13. Using massages; or
14. Drinking fluids for relief of heat stress.
Note: When determining whether a prescription medicine was used the normal practise is to
apply the definitions used in the country where the incident occurred. However, when making

this classification it should be remembered that the intent is to distinguish those more severe
situations that require a medical practitioner to use strong antibiotics and painkillers from those
that only require first aid. The definition of Prescription Medication may be used as guidance
in making decisions between those that are strong antibiotics and painkillers from those that
only require first aid.
For medications available in both prescription and non-prescription form, a recommendation

(2)
by a physician or other licensed health care professional to use a non-prescription medication at

prescription strength is considered medical treatment. The definition of Prescription
Medication may be used to determine when the prescription strength threshold has been
crossed.
First Aid Case (FAC)

Any work related injury that involves neither lost workdays, restricted workdays or medical
treatment but which receives First Aid treatment. (Refer to relevant definitions in Appendix 3).
High Risk Incident (HRI)

An incident for which the combination of potential consequences and probability are assessed to be
in the high risk (red shaded) area of the RAM. HRIs can be incidents that result in injuries, illnesses
or damage to assets, the environment or company reputation, or they can be near misses.
Incident
An unplanned event or chain of events that has, or could have, resulted in injury or illness or
damage to assets, the environment or company reputation.
Incidents do not include operations, maintenance, quality or reliability incidents which had no HSE
consequence or potential. Incidents do not include degradation or failure of plant or equipment
resulting solely from normal wear and tear.
Injury
Any injury such as a cut, fracture, sprain, amputation etc. that results from a single instantaneous
exposure.
Lost Time Injuries (LTI)

The sum of injuries resulting in fatalities, permanent total disabilities and lost workday cases, but
excluding restricted work cases and medical treatment cases.
Lost Time Injury Frequency (LTIF)

The number of lost time injuries per million exposure hours.
Lost Workday Case (LWC)

Any work related injury that renders the injured person temporarily unable to perform their normal
work or restricted work on any day after the day on which the injury occurred. Any day includes rest
day, weekend day, scheduled holiday, public holiday or subsequent day after ceasing employment.
A single incident can give rise to several lost workday cases, depending on the number of people
injured as a result of that incident.
Lost Workdays (LWD)

The total number of calendar days on which the injured person was temporarily unable to work as a
result of a lost workday case.
In the case of a fatality or permanent total disability no lost workdays are recorded.

Medical Treatment (MT)

An incident is classified as Medical Treatment (MT) when the management and care of the patient
to address the injury or illness is above and beyond First Aid(i).
Medical Treatment does not include: -
 The conduct of diagnostic procedures, such as x-rays and blood tests, including the
administration of prescription medications used solely for diagnostic purposes (e.g., eye
drops to dilate pupils);
 Visits to a physician or other licensed health care professional solely for observation or
counselling;
The following may not involve any treatment but for purposes of severity classification, will be
recorded as Medical Treatment.
 Any loss of consciousness
 Significant injury or illness diagnosed by a physician or other licensed health care
professional for which no treatment is given or recommended at the time of diagnosis.
Examples include punctured eardrums, fractured ribs or toes, byssinosis and some types
of occupational cancer.
 Needle stick injuries and cuts from sharp objects that are contaminated with another
person’s blood or other potentially infectious material.
 Occupational hearing loss.
 Medical removal under a government standard (use the Shell Health Guidelines where
no government standard exists).
Note: First Aid carries a very specific meaning for this purpose. Please refer to the definition of
(i)
First Aid.
Medical Treatment Case (MTC)
Any work related injury that involves neither lost workdays or restricted workdays, but which
receives Medical Treatment. (Refer to relevant definitions in Appendix 3).
Near Miss
An incident that could have caused illness, injury or damage to assets, the environment or company
reputation, or consequential business loss, but did not.
Non Accidental Death

A death from any cause other than from a work related incident.
Occupational Illness
Any abnormal condition or disorder of an employee, other than one resulting from an occupational
injury, caused by exposure to environmental factors associated with employment. An illness is
work-related if the balance of probability is 50% or more that the case was caused by exposures at
work.
Occupational illnesses include acute and chronic illness or diseases that may be caused by inhalation,
absorption, ingestion or direct contact with the hazard, as well as exposure to physical and
psychological hazards. (Refer to guidance and examples in Appendix 4).
OSHA occupational illness cases will be captured for benchmarking purposes in FIM (and other
systems where possible).

Operational Control
See “Instructions on Determining Operational Control” – Appendix 5 of the PMR
Permanent Total Disability (PTD)

Any work related injury that permanently incapacitates an employee and results in termination of
employment.
Prescription Medication
1. All antibiotics, including those dispensed as prophylaxis where injury or illness has occurred to
the subject individual.
Exceptions: Dermal applications of Bacitracin, Neosporin, Polysporin, Polymyxin, Iodine or
similar preparation.
2. Diphenhydramine (Benadryl) greater than 50 milligrams( mg.) in a single application.
3. All analgesic and nonsteroidal anti-inflammatory medication (NSAID) including:
 Ibuprofen (such as AdvilTM) - Greater than 467 mg. in a single dose.
 Naproxen Sodium( such as AleveTM-) Greater than 220 mg. in a single dose.
 Ketoprofen (such as Orudis KTTM) - Greater than 25mg. in a single doge.
 Codeine analgesics (Cocodamol, Panadeine, etc.) – Greater than 16 mg. in a single dose.
Exceptions: acetylsalicylic acid (Aspirin) and acetaminophen (paracetamol) are not considered
medical treatment.
4. All dermally applied steroid applications.
Exceptions: hydrocortisone preparations in strengths of 1% or less.
5. All vaccinations used for work-related exposure
Exceptions: Tetanus
6. All narcotic analgesics (except codeine as listed above)
7. All bronchodilators
Exceptions: Epinephrine aerosol 5.5 mg./ml or less
8. All muscle relaxants (e.g. benzodiazepines, methocarbamol and cyclobenzaprine).
9. All other medications (not listed above) that legally require a prescription for purchase or use in
the state or country where the injury or illness occurred.
Note: Where there are apparent contradictions, advice should be sought from a Company physician
and reasoning documented.
Potential Incident
An unsafe practice or a hazardous situation that could result in an incident (incident has not
occurred).
Reputation Impact
The negative impact on company reputation resulting from an incident. The negative impact can be
in the form of adverse attention from media, politicians or action groups, or in public concern about
company activities. (Refer to guidance and examples in Appendix 8).

Restricted Work
Any work related injury or illness that keeps the employee from performing one or more of the
routine functions associated with their job or a physician recommends that the employee not
perform one or more of their job's routine duties.
Restricted Work Case (RWC)

Any work related injury which results in Restricted Work.
Restricted Workdays (RWD)

The total number of calendar days counting from the day of starting restricted work (not counting
the day of injury / illness) until the person returns to his normal work.
When restricted workdays follow a period of lost workdays, the restricted workdays are recorded in
addition to the lost workdays, but the injury is recorded as a lost workday case only.
Risk Assessment Matrix (RAM)

A tool that standardises qualitative risk assessment and facilitates the categorisation of risk from
threats to people, assets, environment and company reputation. The tool is described in detail in the
Risk Assessment Matrix (2006).
Road Transport Incident

An incident involving a vehicle driven by a company or contractor employee, whether on or off the
road, that has resulted in injury, illness or damage to assets, the environment or the company's
reputation, irrespective of the cost of repair or responsibility for cause.
A vehicle is defined as a car, van, light vehicle, heavy goods vehicle, road tanker, bus, motorcycle or
any unit under tow, e.g. trailers, caravans, mobile generators.
This definition does not include:
 Incidents involving vehicles operating on aprons of public airfields;
 Damage as a result of normal wear and tear, e.g. minor paint scratches, stone chips, and
mechanical wear and tear;
 Incidents which occur when the vehicle was unattended, e.g. vandalism or other damage whilst
the vehicle was parked. These would be considered as incidents rather than transport incidents.
Significant Incidents
Incidents with actual consequences that rate 4 or 5 on the RAM. (people, environment, damage or
reputation).
Third Parties
Persons or organisations that are not employed by or contracted to a company or contractor.
Total Sickness Absence

Absence from work on grounds of incapacity to work due to any sickness and injury, work related
or not, expressed as percentage of total workdays available. All other cases of absence such as
pregnancy, childbirth, leave, training and seminars, are not included in the definition of absence.
Total Recordable Cases (TRC)

The sum of injuries resulting in fatalities, permanent total disabilities, lost workday cases, restricted
work cases and medical treatment cases.

Total Recordable Case Frequency (TRCF)

The number of Total Recordable Cases per million exposure hours.
Total Recordable Occupational Illness (TROI)

The sum of all recordable occupational illnesses. Cases involving no lost or restricted workdays and
no medical treatment or first aid are included. A single exposure can give rise to several occupational
illness cases. Contractor occupational illness cases are to be reported when known, but are not to be
included in the TROIF.
Total Recordable Occupational Illness Frequency (TROIF)

The number of employee occupational illnesses per million exposure hours.
Vehicle Kilometres Driven

The number of vehicle kilometres travelled during work related activities whilst being driven by a
company or contractor employee.
Work Related
An injury or illness must be considered work related if an event or exposure in the work
environment caused or contributed to the resulting condition or significantly aggravated a pre-
existing injury or illness. Work relatedness is presumed for injuries and illnesses resulting from
events or exposures occurring in the work environment unless one of the following exceptions
applies in its entirety:
 Occurs when an employee or contractor is present in the work environment as a member of

the general public. In this case it will be included in the 3rd party statistics.
 Results solely from voluntary participation in a wellness program or in a medical, fitness, or
recreational activity such as blood donation, physical examination, flu shot, exercise class,
racquetball, or baseball. On the other hand, if the employee was injured by a trip or fall
hazard present in the employer’s lunchroom, the case would be considered work-related.
 Involves signs or symptoms that surface at work but result solely from a non-work related
event or exposure.
 Is solely the result of eating, drinking, or preparing food or drink for personal consumption
(whether bought on the employer’s premises or brought in). For example, if the employee is
injured by choking on a sandwich while in the employer’s establishment, the case would not
be considered work-related. Note: If the employee is made ill by ingesting food
contaminated by workplace contaminants (such as lead), or gets food poisoning from food
supplied by the employer, the case would be considered work-related.
 Is solely the result of doing personal tasks at the establishment outside of the employee’s
assigned working hours
 Is solely the result of personal grooming, self medication for a non-work-related condition.
Or is intentionally self-inflicted
 Is caused by a vehicle accident and it occurs on a company owned parking lot or road while
the employee is commuting
 Is the common cold or flu (Note: contagious diseases such as tuberculosis, brucellosis,
hepatitis A, or plague are considered work-related if the employee is infected at work).
 Is not a Shell occupational stress case.
Shell uses a wider definition of stress than does OSHA.

The OSHA definition of work relatedness excludes a mental illness (unless it is post-traumatic stress
syndrome where it can be tied to a specific workplace incident, or are incidents where the employee
voluntary provides an opinion from a physician or other licensed health care professional stating the
employee’s mental illness is work-related).

Appendix 2: Incident Classification and Reporting Flow Chart
Appendix 2 Incident Classification and Reporting Flow Chart
Incident occurs
N Actual loss? Y
Near miss Work N Not recordable

Related?
N Injury/
illness?
Asset, Y
N High risk environment
on RAM? or reputation
incident
Y
Fatality N
or PDT?
Y Illness? N
N Learning
for others?
Y Lost N
Y Workdays?
Y Restricted N
N Consequence work?
4 or 5? Medical
Y N
treatment?
Y
Y
TROI LWC RWC MTC FAC
Report Voluntary Immediate Routine reporting to Business Report

within reporting notification within
Company to to Business Company
Business
Severity classifications will be applied to occupational illness cases.
OSHA occupational illness cases will be captured for benchmarking purposes in FIM (and other
systems where possible).

Appendix 4: Distinguishing between Injuries and Illnesses, and Determining whether Illnesses are Occupational
Appendix 3 Medical Treatment and First Aid
Medical Treatment (MT)

An incident is classified as Medical Treatment (MT) when the management and care of the patient
to address the injury or illness is above and beyond First Aid(i).
Medical Treatment does not include: -
 The conduct of diagnostic procedures, such as x-rays and blood tests, including the
administration of prescription medications used solely for diagnostic purposes (e.g., eye
drops to dilate pupils);
 Visits to a physician or other licensed health care professional solely for observation or
counselling;
The following may not involve any treatment but for purposes of severity classification, will be
recorded as Medical Treatment
 Any loss of consciousness
 Significant injury or illness diagnosed by a physician or other licensed health care
professional for which no treatment is given or recommended at the time of diagnosis.
Examples include punctured ear drums, fractured ribs or toes, byssinosis and some types
of occupational cancer.
 Needle stick injuries and cuts from sharp objects that are contaminated with another
person’s blood or other potentially infectious material.
 Occupational hearing loss.
 Medical removal under a government standard (use the Shell Health Guidelines where
no government standard exists).
Note: First Aid carries a very specific meaning for this purpose. Please refer to the definition of
(i)
First Aid.
First Aid
An incident is classified as a First Aid if the treatment of the resultant injury or illness is limited to
one or more of the 14 specific treatments. These are:
1. Using a non-prescription medication at non-prescription strength (2);
2. Administering tetanus immunizations;
3. Cleaning, flushing or soaking wounds on the surface of the skin;
4. Using wound coverings such as bandages, Band-AidsTM, gauze pads, etc.; or using
butterfly bandages or Steri-StripsTM.
5. Using hot or cold therapy;
6. Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid
back belts, etc;
7. Using temporary immobilization devices while transporting an accident victim (e.g.,
splints, slings, neck collars, back boards, etc.).

8. Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister;

9. Using eye patches;
10. Removing foreign bodies from the eye using only irrigation or a cotton swab;
11. Removing splinters or foreign material from areas other than the eye by irrigation,
tweezers, cotton swabs or other simple means;
12. Using finger guards;
13. Using massages; or
14. Drinking fluids for relief of heat stress.
Note: When determining whether a prescription medicine was used the normal practise is to
apply the definitions used in the country where the incident occurred. However, when making
this classification it should be remembered that the intent is to distinguish those more severe
situations that require a medical practitioner to use strong antibiotics and painkillers from those
that only require first aid. The definition of Prescription Medication may be used as guidance
in making decisions between those that are strong antibiotics and pain killers from those that
only require first aid.
For medications available in both prescription and non-prescription form, a recommendation

(2)
by a physician or other licensed health care professional to use a non-prescription medication at

prescription strength is considered medical treatment. The definition of Prescription
Medication may be used to determine when the prescription strength threshold has been
crossed.
Prescription Medication
1. All antibiotics, including those dispensed as prophylaxis where injury or illness has occurred to
the subject individual.
Exceptions: Dermal applications of Bacitracin, Neosporin, Polysporin, Polymyxin, Iodine or
similar preparation.
2. Diphenhydramine (Benadryl) greater than 50 milligrams( mg.) in a single application.
3. All analgesic and nonsteroidal anti-inflammatory medication (NSAID) including:
 Ibuprofen (such as AdvilTM) - Greater than 467 mg. in a single dose.
 Naproxen Sodium( such as AleveTM-) Greater than 220 mg. in a single dose.
 Ketoprofen (such as Orudis KTTM) - Greater than 25mg. in a single doge.
 Codeine analgesics (Cocodamol, Panadeine, etc.) – Greater than 16 mg. in a single dose.
Exceptions: acetylsalicylic acid (Aspirin) and acetaminophen (paracetamol) are not considered
medical treatment.
4. All dermally applied steroid applications.
Exceptions: hydrocortisone preparations in strengths of 1% or less.
5. All vaccinations used for work-related exposure
Exceptions: Tetanus
6. All narcotic analgesics (except codeine as listed above)

7. All bronchodilators
Exceptions: Epinephrine aerosol 5.5 mg./ml or less
8. All muscle relaxants (e.g. benzodiazepines, methocarbamol and cyclobenzaprine).
9. All other medications (not listed above) that legally require a prescription for purchase or use in
the state or country where the injury or illness occurred.
Note: Where there are apparent contradictions, advice should be sought from a Company physician
and reasoning documented.
Further guidance on distinction between Medical Treatment and First Aid

1. All immunizations given in the absence of an injury or illness are excluded from either medical
treatment or first aid classification. Examples include Business travel and protective
immunizations to first aiders and emergency responders. Immunizations (with the exception of
tetanus) given after an injury or illness are medical treatment.
2. A physician or other licensed health care professional recommends medical treatment but the
employee does not follow the recommendation. If a physician or other licensed health care
professional recommends medical treatment including the issuing of prescription medication,
the person should be encourage to follow that recommendation. The case would be considered
Medical Treatment, even if the person does not follow the physician or other licensed health
care professional’s recommendation.
3. Organizations should not distinguish between first aid and medical treatment cases on the basis
of number of treatments administered.
4. Use of devices with rigid stays or other systems designed to immobilize parts of the body are
considered medical treatment.
5. Physical therapy or chiropractic treatment are considered medical treatment if they go beyond
the definition of first aid.
6. Wound closing devices such as sutures, staples, glue etc., are considered medical treatment.

Appendix 4 Distinguishing between Injuries and Illnesses, and

Determining whether Illnesses are Occupational
Occupational illness is any abnormal condition or disorder of an employee, other than one resulting
from an occupational injury, caused by exposure to environmental factors associated with
employment. An illness is work-related if the balance of probability is 50% or more that the case
was caused by exposures at work.
Occupational illnesses include acute and chronic illness or diseases that may be caused by inhalation,
absorption, ingestion or direct contact with the hazard, as well as exposure to physical and
psychological hazards. Whether a case involves a work related injury or an occupational illness is
determined by the nature of the original event or exposure that caused the case, not by the resulting
condition of the affected employee. In order to determine whether an employee's illness is work-
related, the following questions should be addressed:
 Has an illness clearly been identified?
 Does it appear that the illness is caused by, or mainly caused by, suspected agents or other
conditions at work?
 Does it appear that an event or exposure in the work environment contributed to the resulting
condition or illness?
 Are these suspected agents present, or have they been present, in the work environment?
 Was the affected employee exposed to these agents in the work environment?
 Was the exposure to a sufficient degree and duration to result in the illness condition?
 Was the illness attributable mainly to a non-occupational exposure?
The material safety data sheets for those substances suspected of causing employee illnesses should
be checked to verify the relationship between the exposure and the resulting symptoms.
Musculo-skeletal Conditions including Back Problems

A medical condition involving the musculo-skeletal system may be a work related injury, an
occupational illness, or a non-work related injury or illness.
Work Related Injury Guidance

A musculo-skeletal problem is considered to be a work related injury if the affected person was
engaged in a work related activity and there is a clear record of an incident, i.e. an identifiable
unplanned event, such as a sudden effort or over exertion, blow to the back, slip, trip, or fall.
Generally the employee reports sharp and sudden pain during or shortly after the event. The pain
may come and go over a period of time or may not become a significant problem for 24-48 hours
after the activity.
Examples
1. A worker was installing a window mounted air conditioning unit. As the worker was sliding it
into place, it tilted and started to fall. The worker caught it and forced it into place, but in doing
so felt a sharp pain in the back. This would be considered work related injury, since the
condition resulted from the sudden effort required to prevent the unit from falling.
2. A worker’s foot slipped in the process of swinging a hammer and a back pain developed
immediately. This would be considered a work related injury, since the onset of symptoms was
directly associated with the slip that occurred in the course of and arose out of employment.

Appendix 1
3. An employee with a known back problem experienced a recurrence of back pain whilst lifting a
drum of lubricating oil. This would only be considered a work related injury if the original
condition was aggravated as a consequence of a lifting action which was outside the normal
limits of the task, i.e. over exertion.
4. A clerk who is usually involved in work that is not physically demanding was asked to assist in
unloading a large shipment of heavy items by hand. The clerk felt no discomfort that day but
the following morning the his right shoulder and back muscles are so sore that he was unable to
perform the normal job effectively and had to be given specially selected duties. The injury was
consistent with the type of work performed on the previous day and the case would be
considered a work related injury.
Occupational Illness Guidance

A musculo-skeletal problem is considered to be an occupational illness if it is caused by prolonged
or continued exposure to over exertion in the performance of the employee’s duties. The recurrence
of symptoms from previous cases need not be reported as a separate occupational illness unless they
have recurred as a result of new exposures that differ from the original exposure.
Examples
1. An employee reported severe back pain that gradually developed towards the end of each
workday, but could not attribute the condition to any specific event or activity. After reviewing
the employee's work assignments, it was concluded that the condition resulted from continuous
over exertion in the performance of the employee's duties. The case would be considered an
occupational illness.
2. A seismologist was engaged routinely in the use of a standard mouse in manipulation of on-
screen data. Over a period of some weeks he noted gradual onset of pain, stiffness and local
tenderness over the wrist and forearm that improved following a break from work. After
clinical assessment of the case, it was concluded that the condition primarily resulted from
continuous over exertion and would be considered an occupational illness. See the section on
Repetitive Strain Injury for further guidance on reportability.
Non Work Related Injuries and Illnesses Guidance

A musculo-skeletal problem would not be considered to be a work related injury or an occupational
illness if the condition merely surfaced at work spontaneously and without provocation from an
external force, work activity or an incident in the workplace, but arose solely out of a pre-existing
condition.
Note: A pre-existing condition does not affect the reportability of a subsequently contracted work
related injury or occupational illness. If an injury or illness is caused or mainly caused by exposures
at work it must be reported without regard to the employee’s pre-existing condition.
Examples
1. An employee sprained lower back muscles in a minor road traffic accident whilst on leave. The
pain eased and the employee was able to return to work a few days later. A recurrence of the
pain was felt when the employee got up from his chair. There is no evidence of a prior incident
at work causing or contributing to the condition. This condition is attributed solely to the
employee’s pre-existing physical condition and therefore would not be considered a work
related injury.
2. An employee reached up without overreaching to pick up a hard hat from the top of a locker
and experienced back pain. There was no evidence of a prior incident, the trigger for the
condition was within normal job limits, the employee had no previous history of work related
back problems, and therefore the condition would not be considered as work related.
Appendix 1
3. Conditions occurring spontaneously at work without provocation from an external force or

work activity, e.g.:
 An employee turns his or her head to answer a question or gets up from a chair and
experiences sudden pain onset;
 An employee kneels to tie his or her shoelaces and experiences back pain;
 An employee coughs and complains that his or her back has “gone”.
 These events would not be considered as work related.
Repetitive Strain Injury (RSI)

RSI is a medical syndrome caused by repetitive movements affecting the neck, upper back,
shoulders, upper and lower arm, elbow, wrist or hand, or a combination of these areas. It is
considered to be RSI if the effects are restrictive or lead to participation problems.
RSI is sometimes referred to as Cumulative Trauma Disorder (CTD), Occupational Cervico brachial
Disease (OCD), Occupational Overuse Syndrome (OOS) and others. RSI is always caused by a
combination of factors. These include excessive use of force, working in awkward positions,
working continuously in the same position and repeated and continued movements. For further
guidance refer to the HSE Advisers’ Panel guide, RSI in the Office Environment (2001).
When an RSI is classified as an occupational illness, it is classified as per Appendix 5 as a musculo-
skeletal disorder of the upper limbs.
Work Related Stress
A stress case is considered to be work related when there is an identifiable organisational and/or
interpersonal factor in relation to work and the working environment which has contributed to a
stress related disorder. requiring significant intervention, such as specific counselling or treatment,
modification of duties or loss of time from work.
This is a deviation from OSHA. The Shell definition shall be applied
Stress reactions caused by traumatic events at work, such as being involved in an armed robbery, a
major explosion or fire in the work environment, are also considered to be work related.
Burns
Contact with heat, cold, electricity, intense radiation or a caustic chemical that produces a burn in a
single contact, is a work related injury. Sunburn or welding flash burns that result from prolonged or
repeated exposure are considered occupational illnesses.
Burns should be treated just as other types of injury are, i.e., minor burn injuries will be first aid,
while more serious burns will be at least a medical treatment case because they will involve medical
treatment. For example, a small second degree burn to the forearm that is treated with nothing more
than a bandage is first aid. A larger or more severe second degree burn that is treated with
prescription creams or antibiotics, or results in restricted work, job transfer, or days away from work
is a Recordable Case. The vast majority of first degree burns and minor second degree burns will not
be a Medical Treatment Case because they will not meet the medical treatment criteria. However,
more serious first and second degree burns (e.g. burns to the palm of the hand or face) that receive
medical treatment will usually be recordable, and third degree burns should always be recordable
because they require medical treatment as a minimum.
First Degree Burns

Only the outer layer of skin is damaged, characterised by reddening of skin, pain and sometimes
swelling.
Second Degree Burns

Injury to the epidermis and damage to the superficial underlying tissues. The injury is characterised
in similar way to first degree burns but blistering of skin may also occur. Intense pain, reddening and
a mottled skin appearance are common.
Third Degree Burns:

Most serious category of burns where the entire skin thickness is affected, with blackened or
blanched grey-white skin. Treatment includes debridement (removal of burned skin) and skin grafts.
Dermatitis
Example:
A chemical worker contracted a mild case of dermatitis on both hands while working with a solution
for several hours. The employee was sent to the doctor, who recommended application of a topical
lotion (a commercial, non-prescription remedy). The employee bought a bottle of the lotion and
treated the rash for a few days until it disappeared. There were no subsequent visits to the doctor.
The rash did not prevent the employee from performing all the duties of the job. If considered an
injury, the case would not be recordable since no medical treatment was provided. However, since
the case almost certainly did not involve a single instantaneous exposure, it should be classified as an
occupational illness. A dermatitis or pulmonary condition caused by or aggravated by exposure to a
chemical skin or pulmonary sensitizer is always recordable as an occupational illness. Consequently,
the kind of treatment given by the doctor (even if no treatment is given) is immaterial, since all
occupational illnesses are recordable.
Animal Bites and Insect Stings
Animal bites and insect stings are normally considered as work related injuries if they occur in the
course of employment. However, repeated exposure may result in disorders that are considered
occupational illnesses.
Example 1:
A snake bit a lineman engaged in routine work. The case would be considered a work related injury.
Example 2:
Insects carrying the disease leishmaniasis bit a member of a party clearing jungle for seismic work.
The resulting sickness would be considered an occupational illness.
Example 3:
Malaria or other diseases that result from mosquito bites or insect stings are classified as
occupational illnesses (see Infectious Diseases).

Heart Attacks
Heart attacks are not normally classified as work related injuries because they normally do not result
from single instantaneous incidents in the work environment. When heart attacks do occur, they
should be assessed against the criteria for occupational illnesses. This means that heart attacks
occurring in the working environment should only be classified as occupational illnesses if they
result or mainly result from exposures at work.
Infectious Diseases
Infectious diseases such as malaria and Chagas disease are only recordable if they have been
confirmed by clinical testing or by a doctor. If the illness is endemic to an area or the country and
employees indigenous to that area are diagnosed with the illness on a regular basis cases should not
be reported. If the illness occurs among employees from an area where the illness is not endemic,
the illness should be classified as an occupational illness. Diseases caused by insect stings, such as
malaria, are normally considered as work related if they occur in the course of employment even if
the mosquito bite may have occurred outside the company premises.
Common Subjective Symptoms

Complaints of such common subjective symptoms as general malaise, headache, nausea, stomach
upset are not occupational if they are not caused or mainly caused by exposures at work. In
evaluating these cases one should be aware that many subjective complaints, including feelings of
malaise, headache, nausea, etc., may be symptomatic of a wide range of diseases, a number of which
are occupational in origin. One should pay attention to the distribution of such subjective
complaints in time and place, particularly when such complaints are observed to occur among one
or more groups of employees.
Food Poisoning
Food poisoning should be treated as an illness and will normally impact a group of individuals.
See the definition of Work Related - point 4 Appendix 1 and Meal Period Illnesses in Appendix 12.
If the food poisoning arises from food provided in a hotel or restaurant not under control of the
employer or provided in an airplane, it is potentially recordable as an occupational illness if the
person is involved in a work related activity at the time and it can be demonstrated that multiple
people have been impacted. It is recognized that this is going to be difficult to establish in many
cases.
Non work related cases should be recorded for learning purposes.
Deep Vein Thrombosis
Deep Vein Thrombosis (DVT) is a medical condition where a blood clot causes a blockage in a deep
vein - usually in the legs, thighs and pelvis. Complications from DVT can result e.g. when a clot
breaks off and lodges in the lungs, causing Pulmonary Embolism (PE). This is life threatening. DVT
is recordable as an occupational illness if caused by or mainly caused by exposures at the work place,
including business travel. Factors to include to determine reportability as work related include

genetic factors, previous DVT/PE, recent surgery, cancer, pregnancy, contraceptive

medication, hormone replacement therapy, a leg cast, obesity, smoking, extensive varicose veins,
dehydration, and lack of mobility for longer periods, e.g. when travelling.
Medical Removal
If an employee is medically removed under the Company medical surveillance requirements the case
must be reported as an occupational illness. See for criteria Medical Surveillance Guidelines (URL
link to Web).
Noise Induced Hearing Loss
Noise induced hearing loss should be classified on criteria described in the section below. This is a
deviation from the criteria contained in the SHC Noise Guide (1991) that will be corrected when the
Noise Guide is next updated
If an employee's hearing test (audiogram) reveals that the employee has experienced a work-related
Standard Threshold Shift (STS) in hearing in one or both ears, and the employer's total hearing loss
is 10 decibels (dB) or more in comparison the employee's baseline audiogram (averaged at 2000,
3000, and 4000 Hz) in the same ear as the STS, the case is recordable as occupational illness.
Consult Shell Health Services for additional guidance.
Respiratory conditions - application of oxygen
The individual must have sustained an injury or illness before the administration of oxygen, or any
other medical treatment, makes the case recordable.
Example:
If an employee is exposed to chlorine or some other substance at work and oxygen is administered
as a precautionary measure, is the case recordable? If oxygen is administered as a purely
precautionary measure to an employee who does not exhibit any symptoms of an injury or illness,
the case is not recordable. If the employee exposed to a substance exhibits symptoms of an injury or
illness, the administration of oxygen makes the case recordable.
Eye Problems
Example:
An employee goes to a doctor and is informed that she should wear prescription glasses because of
work related eye deterioration caused by the nature of the job. If it can be established that the
disorder was caused or mainly caused by exposures at work this case would be classified as an
occupational illness. However, the company should distinguish work related eye problems from
those due to ageing or hereditary factors unrelated to the job.

Aggravation of an Existing Physical Deficiency
If aggravation of an existing physical deficiency arises out of an incident in the course of

employment, any resulting increased disability should be considered a work related injury and
classified according to the ultimate extent of the disability.
Example 1:
An employee with a known knee defect wrenched it whilst climbing down a ladder, when the
bottom rung gave way. This aggravation required medical attention and would therefore be
considered a work related injury.
Example 2:
An employee with a known knee defect, but declared fit for duty, suffered a recurrence of the
disability whilst walking up steps. The incident arose solely out of the employee's pre-existing
deficiency and therefore the resulting disability would not be considered a work related injury.
Example 3:
An employee with a blister unrelated to work knocked the top off the blister in the course of the
employee's work activity. The broken blister became infected and resulted in lost time. This would
be considered a work related injury.
Pre-existing Conditions
An employee's physical or mental defect or pre-existing physical or mental condition does not affect
the classification of a subsequently contracted occupational illness. If in such circumstances an
illness is caused or mainly caused by exposures at work, the company must report it without regard
to the employee's pre-existing physical or mental condition.
Infected Laceration
An infection resulting from a laceration should be classified as a work related injury because the
classification is based on the original event, the laceration, not on the subsequent developments.
Reaction to Medical Treatment

The classification of a disorder resulting from medical treatment depends upon whether the
treatment was for work related purposes.
Example:
An employee going on a business visit was vaccinated against yellow fever. Some days later the
employee was taken ill and the illness was linked to the vaccination. This would be considered an
occupational illness.
Recurrence of Symptoms
Companies are required to report each new occupational illness when the illness has been
established for the first time. The recurrence of symptoms from a previous case should not be
reported. Deciding whether the emergence of illness symptoms constitutes a new event or the

Appendix 4
recurrence of a previous illness may be complex. Generally, each occupational illness should be
reported with a separate entry. However, certain illnesses such as silicosis may have prolonged
effects that recur over time. The recurrence of these symptoms should not be reported as a new
case, unless the occupational illness results in an escalation of severity, e.g. to death or permanent
total disability.
Some occupational illnesses such as certain skin or respiratory conditions may recur as the result of
new exposures to sensitising or other hazardous agents. They should be reported as new cases.
Medical Verification by a Medically Qualified Person

A medically qualified person, appointed as such by Shell Health, should verify all occupational illness
cases where possible.
Individual Susceptibility
Variations in the characteristics of particular employees of their susceptibility to various illnesses

should not affect the classification of an injury or illness.
Permanent or Temporary Transfers

Permanent or temporary transfers to another job to remove employees from further exposure to
health hazards are preventive in nature. If no occupational illness has occurred they are not
considered recordable events.
Overexposure to Health Hazards

Exposure of workers to hazardous chemicals at concentrations above the Occupational Exposure
Limit (OEL), or to other health hazards above their respective control limits, should be considered
as incidents. When the overexposure do not result in occupational illnesses they should be
considered as either near misses or potential incidents, depending on whether incidents actually
occurred.
Examples of exposures are:

 Working in a noisy area without hearing protection or other measures to reduce noise levels;
 Inhalation of a toxic chemical following a spillage without taking precautions;
 Working with hazardous materials such as asbestos containing products without taking
precautions;
 High results from routine exposure measurement;
 High legionella count in water systems that could generate an aerosol and be inhaled.

Appendix 5: Classification of Occupational Illness
Appendix 5 Classification of Occupational Illness
Infectious and parasitic diseases:

malaria, food poisoning, infectious hepatitis, dysentery, lambliasis, legionnaire's disease.
Skin diseases and disorders:

contact dermatitis, allergic dermatitis, rash caused by primary irritants, sensitizers or poisonous
plants, oil acne or chrome ulcers.
Respiratory conditions due to dust or toxic agents:

silicosis, asbestosis, pneumoconiosis, pneumonitis, (allergic) bronchitis, alveolitis, asthma,
pharyngitis, rhinitis or acute congestion due to chemicals, dusts, gases, or fumes.
Poisoning (systemic effects of toxic materials):

poisoning by lead, mercury, arsenic, cadmium, or other metals; poisoning by carbon
monoxide, hydrogen sulphide, or other gases; poisoning by solvents; poisoning by pesticides;
poisoning by other chemicals such as benzene, epichlorhydrin and formaldehyde.
Acute exposures are recordable as illness (or injury) if signs / symptoms and / or treatment
has been provided including oxygen.
Upper limb and neck disorders:

synovitis, tenosynovitis, and bursitis; Raynaud's phenomenon; other disorders of the musculo-
skeletal system and connective tissue associated with repeated trauma, including RSI.
Back problems and lower limb disorders:

synovitis, tenosynovitis, and bursitis; Raynaud's phenomenon; other disorders of the musculo-
skeletal system and connective tissue associated with repeated trauma, including chronic back
disorders caused by exposures at work.
Cancers and malignant blood diseases:

mesothelioma; bladder cancer; leukaemia and other malignant diseases of blood and blood
forming organs.
Disorders due to mental stress:

depression, neurosis, stress, functional disorders of the gastrointestinal tract and recurring
tension headaches.
Noise induced hearing loss:

Refer to Appendix 4. We no longer use the SHC Noise Guide 1991.
Other Illnesses and disorders:

Physical disorders such as heatstroke, sunstroke, heat exhaustion and other effects of heat
stress; freezing, frostbite and other effects of exposure to low temperatures; caisson disease;
effects of ionising (alpha, beta and gamma rays, radium) and non-ionising (welding flash,
ultraviolet rays, microwaves, sunburn) radiation; vibration (white finger).
This category also includes benign tumours; eye conditions due to dust and toxic agents; other
(non-malignant) diseases of blood and blood-forming organs.

Appendix 6: Asset Damage - Examples
Appendix 6 Asset Damage - Examples

Asset damage is a direct loss of, or damage to, plant, equipment, tools or materials resulting from an
incident. The consequences of the incident may include both direct loss or damage or consequential
business loss. The consequences should be assessed on the RAM.
Example 1
Whilst a crane was lifting a heat exchanger on a crude oil production module, it was dropped onto
an instrument airline that ruptured. Instrument air supply was lost and the module was shutdown
safely without further damage or leakage. It took 6 hours to repair the instrument airline and a
further 6 hours to re-commission the module and re-establish crude oil production.
As the event posed a threat to people in the vicinity and the instrument air loss could have led to
further plant emergencies this event would be considered an (HSE) incident. The asset damage
resulting from this incident was the cost of repairing or replacing the instrument airline. The
consequential business loss was the cost of lost crude oil production. In assessing the cost of lost
production no account should be taken of the possibility of making up the lost production using
spare capacity in the production programme. The cost should be based on the design or
programmed capacity of the module and the downtime.
If the falling heat exchanger had been damaged its repair or replacement cost would be included in
the asset damage. If the repair or replacement of the heat exchanger caused delays in achieving
improved throughput, heat saving or product quality the associated costs would be included in the
consequential business loss.
Example 2
A gasoline process pump was allowed to run dry, the pump vibrated and the bearing failed. The seal
held and there was no leakage of gasoline.
This event resulted in damage to the assets but there was no harm to people, the environment or
company reputation. The event would not be classified as an (HSE) incident. However, it might be
reported as an operational disturbance, a maintenance item or a quality incident.

Appendix 7: Environmental Impact - Examples
Appendix 7 Environmental Impact - Examples

Environmental impact is the negative impact on the environment resulting from an incident. This
section illustrates with examples the main types of environmental impact. Note that many of the
examples also have an impact on company reputation.
Atmospheric Emissions
Example 1: Emission of hydrogen sulphide

A refinery sour water pump seal failed and released hydrogen sulphide into the plant area, triggering
the toxic gas detection and alarm system. The pump was quickly switched off and isolated. There
were no external complaints and it was estimated that the hydrogen sulphide in air concentration at
the fence was below the odour threshold.
Although the assessment revealed that there were unlikely to be off-site complaints, there was a
potential safety problem on-site, therefore the incident should be considered as a near miss and
investigated.
Example 2: Emission of hydrogen sulphide from a flare stack

The refinery flare extinguished whilst waste gas containing hydrogen sulphide was being flared.
There was a rotten eggs smell in the neighbouring village 1 km away that led to a number of
complaints being made by residents.
As hydrogen sulphide went offsite in concentrations above the odour threshold, and resulted in
complaints, this should be considered as an incident with environmental and reputation impact.
Example 3: Halocarbons
All accidental releases of halocarbons, i.e. CFCs and halon, should be considered as incidents
regardless of size of emission.
Oil and Chemical Spills

When a spill is not contained within the site or within the process system it should be considered as
an incident having environmental impact.
Example 1: Fuel oil spill during work on pipeline

A large diameter fuel oil pipeline in the tankage area of a refinery was being opened up for
maintenance. Because the line had not been adequately cleaned beforehand, around 1 tonne of fuel
oil spilled into the pipe track. The majority ran off into the site drains but was collected in the
interceptor system and recovered. None of the oil passed through the interceptor outfall to the river.
As the spill was contained within the site, and did not pose a risk to groundwater systems because it
was contained within impervious drainage channels, it was not considered an incident with
environmental impact. However, it should be reported as a near miss and investigated to prevent
recurrence.

If the same spill occurred under conditions of high rainfall and some of the oil was discharged
through the outfall and recovered from the river (controlled water), then the spill clearly had an
environmental impact. If the incident was serious enough to draw the attention of the
environmental authorities and the media, the impact on company reputation should also be taken
into account.
The cost of lost fuel oil and the cost of clearing up and disposing of the oily water are consequential
business loss that should be assessed against the asset damage criteria on the RAM.
Example 2: Diesel oil spill from ship

A vessel was berthed in port. Diesel oil was being transferred internally from the wing tanks to fuel
settling tanks. The settling tank overflowed spilling diesel onto the deck of the vessel. Approximately
200 litres went into the harbour. The vessel’s Shipboard Oil Pollution Emergency Plan was put into
operation and the oil was dispersed within an hour. The Authorities were notified. The master of the
vessel was subsequently charged under section 12-2 of MARPOL for illegally discharging oil.
This was clearly an incident with environmental impact. The fact that the Authorities were involved,
and the incident attracted local media attention, means that it should also be considered as an
incident with reputation impact. The incident should be classified and reported on basis of the
highest RAM rating.
Complaints
Example 1: Noise complaint from local resident

A resident of the community close to a refinery complained of a high noise intermittently overnight.
The complaint was investigated and the source of noise tracked down to a compressor local alarm
siren that was faulty. Even though there were no prescribed maximum noise limits in the local
community, the complaint should be considered as an incident.
Example 2: Smoky flare

A call was received from the pollution inspector that a member of the public had complained that
the ground flare at a natural gas plant was exceptionally smoky over a weekend. The public living
near the plant have always taken an interest in HSE issues at the plant, and the incident was
discussed at the local community council meeting. This would be considered as an incident with
impact on company reputation.
Non-compliances
Example 1: Disposal of waste paint tins

Three partly full 5 litre tins of liquid paint were found in a general waste skip that had been returned
from an offshore installation to a landfill site. The waste was detected by the landfill operator and
constituted a "waste non-compliance". If it had gone into the landfill this would have breached
statutory criteria and could have led to prosecution.
Although it was spotted before it went in to the landfill this incident should be considered as a
minor breach of statutory criteria, and therefore as an incident. As there had been previous non-
compliances on that landfill location which had come to the attention of the local press, the impact
on reputation should also be taken into account.

Example 2: Construction waste

A LNG plant was being constructed on a green-field site. The conditions of the permit for
construction and operation of the plant specified that disposal of hazardous waste should be
reported to the environmental authority. Oil and chemical waste was found in the local landfill site
and was traced back to unauthorised tipping by the construction contractor.
This was a clear non-compliance with the permit conditions and should be reported as an incident.

Appendix 8 Reputation Impact - Examples

Reputation impact is the negative impact on company reputation resulting from an incident. The
negative impact can be in the form of adverse attention from media, politicians or action groups, or
in public concern about company activities.
The consequences of reputation incidents should be assessed using the RAM taking into account the
specific local circumstances and sensitivities.
A number of the environmental examples in Appendix 7 also demonstrate how various types of
incident can damage company reputation.
Further examples of incidents inside and outside Shell that damaged the company’s reputation can
be found in the Group crisis management web-site at: http://sww.shell.com/crisismanagement/.

Appendix 9: Incident Investigation Guidance
Appendix 9 Incident Investigation Guidance

This appendix provides a checklist of subjects to be addressed during the investigation of incidents.
Conducting Interviews
Interviews with witnesses should be carried out as soon as possible after the incident, as intervening
time and discussions with others can influence a person’s recollection of events. The value of a
witness's input can be greatly influenced by the style of the interviewer, whose main task is to listen
to the witness's story and not to influence it by making comments or asking leading questions. This
requires patience and understanding. An investigation team is often seen in a prosecuting role, and
witnesses may be reluctant to talk freely if they think they may incriminate themselves or their
colleagues. An investigator is not in a position to give immunity in return for information, but must
try to convince interviewees of the purpose of the investigation and the need for frankness. The
following are some points of good practice when conducting an interview:
 Prepare the questions you need answered beforehand;
 Avoid interviews by the whole investigation team that may intimidate the witness. The
optimum is two interviewers and a single witness. Also avoid interviews by immediate
supervisors;
 Allow the witness to be accompanied by a colleague or friend or a safety representative;
 Conduct the interview in private and start off with a general discussion to put the witness at
ease before asking questions about the incident;
 Make sure that the witness understands that he or she will not be required to sign a statement;
 Ask the witness to go step by step through the events surrounding the incident, describing both
own actions and the actions of others. Do not ask leading questions;
 Separate facts from opinions. Ask further questions to confirm the facts, and note the opinions;
 Summarise the discussion at the end of the interview to make sure that there is no
misunderstanding. Afterwards, prepare notes of the discussion and agree them with the witness.
Clarify any anomalies and any conflicts with other evidence;
 Assess the need for the witness to receive counselling.
Inspecting the Location

Important facts and data can be gained from observations made at the scene of the incident,
particularly if the location is kept undisturbed until the preliminary investigation has taken place.
Rescue operations or the presence of residual hazards may necessitate moving some of the
equipment, but this should be kept to a minimum.
Before disturbing the incident location photographs and/or video film should be taken. Sketches
can be used to document the physical relationship and distance between people, tools and
equipment. All relevant equipment, tools, clothing, PPE and other material evidence should be
identified and labelled. If critical equipment or tools have been damaged or have failed they should
be kept in a secure place pending more detailed analysis.
Local legislation may prescribe that for certain classes of incident, e.g. fatality or motor vehicle
accident, nothing may be moved without prior permission from the relevant authorities.

Investigators should look for any conditions or factors at the location that could have contributed to
the incident. Factors to check include:
 Position of all equipment in relation to other equipment and people;
 Position of valves, spades, set points, recorders, override switches, etc.;
 Samples of process materials, products of reaction/combustion, drain water etc.;
 Process control and safeguarding instrument status. Check that records are retained beyond 24
hours;
 Procedures, vehicle tachographs, training records, log books, process logs and test records;
 Condition of the load-bearing surface;
 Accessibility and evidence of congestion;
 Lighting, visibility and audibility at the location;
 State of housekeeping;
 Condition of all plant, vehicles, equipment and tools;
 Effects of weather;
 Presence of witnesses;
 Evidence of spills or release;
 Odours, discoloration, tyre marks;
 Presence of unauthorised people;
 Evidence of excessive forces;
 Presence of warning signs and notices.
Collecting Background Information
Background information will include:

 Process design and operating manuals;
 Procedures for the type of operation involved;
 Records of instructions and briefings given on the particular job being investigated;
 Location plans;
 Organisation and persons involved;
 Product information and MSDS.
Fact Finding
During the initial stages of every investigation, investigators should collect and record all the facts
that may add to the understanding of the incident and the events surrounding it. They should be
aware of the danger of reaching conclusions too early and of failing to keep an open mind to the full
range of possibilities. They should ask the questions who?, what?, when?, where?, why? and how?
about the circumstances of the incident. Here is a checklist of specific questions that should be
answered during the fact-finding process:
 What operations were in progress?
 What equipment was in use? Had any of the equipment failed?
 Where were the key personnel and what were their actions immediately before the incident?
 What instructions were given that are related to the incident?
 What energy sources and flows were not controlled?
 Were there any operational deviations, equipment defects or inappropriate use of resources and
equipment?

 Were there any changes of personnel, procedures, processes or equipment that could have
contributed to the incident?
 What were the weather conditions?
 What action did any third parties take that contributed to the incident?
 Were the individuals involved physically fit and competent to perform the job?
 Could alcohol or drugs have been a contributory factor? Should tests be done?
 Could the effect of fatigue, work cycles and stress be contributory factors?
 Could social or domestic pressure have had an impact on an individual’s behaviour?
 Could time of day, age of people involved, length of service, training received etc. be
contributory factors?
After a first round of fact finding it should be possible to give a precise description, supported by
the documented facts, of the events leading to the incident, the incident itself and the initial
response to the incident. It should be possible to:
 Describe the consequences of the incident in terms of injury, damage and loss, environmental
and reputation impact;
 Identify what defences (controls and recovery measures) were in place to prevent the incident;
 Identify the substandard acts which breached these defences;
 Identify the preconditions which led to the substandard acts;
 Identify what additional information and specialist resources are needed to confirm the
immediate causes and to establish the underlying causes (Tripod latent failures);
 Comment on response to the incident, including first aid, emergency medical treatment, rescue,
shutdown of the process and fire fighting.
Records and Procedures
Documentation such as as-built drawings, inspection records, instrument and tachograph records,
printouts, log sheets/books, maintenance records, work permits and load/time sheets may provide
information relevant to the investigation.
Written instructions and procedures may provide evidence of pre-planning and individual
responsibilities. The investigation should try to establish the extent to which these procedures and
instructions were understood and acted upon, as this can indicate the effectiveness of training and
supervision. The relevance and extent of application of procedures should be assessed during the
investigation.
Special Studies
Incidents of a technical or complex nature often require specialist input and further studies to
determine causes of failure. Aircraft crashes, crane failures and plant explosions are examples of
incidents where specialist advice may be required. This should be rapidly identified and the
specialists involved early in the site assessment.
Conflicting Evidence
It is not unusual for witnesses to give differing accounts of an incident. Human memory can be
unreliable and, even if not motivated by self-protection or other subjective arguments; one person's
recollection of an incident can differ from another person's in important details. Investigators should
note any significant differences in accounts of an event. Faced with conflicting witness statements,

investigators should look for the similarities between the statements and commonality with other
evidence. The objective is to use the evidence to understand the incident and not to prove the
accuracy of individual statements, nor to apportion blame.

48
Time
Actor 28/5 7/6 7/6 pm 10/6 13/6 am 14/6

Appendix 10
On-line
P9101 A
On-line Minor Seal repair Seal repair Reinstalled

P9101 B leak on priority 3 delayed & started
On-line Hot & noisy Bearing Tripped,

Appendix 10: Sequentially Timed Event Plot – Example
Taken re-sleeved Reinstalled bearing

P9101 C of-line incorrectly & started seized
Electrical Young &

technician inexperienced
Rotating Did not

equipment advise
section
Plant Not
manager informed
of problem
Boiler
Reduced
Sequentially Timed Event Plot – Example
feed water
flow flow
Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

Appendix 11: Incident Report Layout for a Significant Incident
Appendix 11 Incident Report Layout for a Significant Incident
This appendix lists the headings and provides guidance on the content of a report of a significant
incident. When the Tripod Beta tool is used to analyse the incident the report can be generated
automatically from the data inputted to the Beta Tool software.
Summary
A brief summary of the report, giving the background of the incident, a description of the incident,
description of injuries, damage and loss, and outlining the causes established and the agreed actions.
Place, time and date of incident
Consequences
Details of persons injured, and the injuries in a form understandable to non-medical readers.
Description of the damage and loss, including an estimate of the cost of direct and consequential
losses.
Events leading up to the incident

A short narrative that sets the scene of the incident:
 Description of the operation in progress;
 Preparations made for the work, including work procedures, instructions, permits and
supervision;
 Personnel involved including work and shift patterns;
 Equipment involved;
 Environmental and weather conditions;
 Activities taking place at the scene of the incident;
 Activities of key persons prior to the day of the incident that could have affected their actions.
Description of the Incident

A statement of the facts immediately surrounding the incident, covering the period from the
initiating events until the situation was under control. The statement should include photographs,
drawings or maps to illustrate the narrative. It should also include a presentation of the sequence of
events, using one of the methods described in Section 3.4 of this document.
Results of the investigation

This section should demonstrate that the investigation was carried out in sufficient depth to support
the conclusions that follow. Where relevant, it should include references to:
 Environmental conditions;
 Condition of equipment and facilities, including inspection and maintenance history, operating
mode;
 Procedures relating to the operation;
 Information about the training and experience of persons involved;
 Work instructions and communications;

Appendix 11: Incident Report Layout for a Significant Incident
 Records and documentation;

 Information derived from the nature of the damage;
 Witness statements;
 Medical records;
 Factors affecting alertness or judgement, e.g. fatigue, social pressures, alcohol, medication or
drugs;
 Working conditions;
 Survival aspects;
 Results of special investigations and tests;
 Rescue and damage containment activities;
 Emergency response and recovery activities.
Results of analysis
This section should include the results of the analysis of the findings, identifying the immediate and
underlying causes and weaknesses in the management system. The results are normally presented as
a Tripod tree.
When certain conclusions have not been fully established by the available evidence these should be
highlighted as tentative conclusions.
Action items
This section should include corrective actions for immediate causes (Tripod breached defences) and
improvement actions addressing the underlying causes and management system weaknesses (Tripod
latent failures). Action items should be achievable and measurable, and should specify action parties
and implementation times.
Appendices
Sequence of events.
Tripod tree and GFTs .
Other data needed to supplement the report, including photographs, and drawings.

Appendix 12: Work Related Activities – Guidance and Examples
Appendix 12 Work Related Activities – Guidance and Examples
Transportation of Personnel
See definitions of Business Travel.
Example 1:
An employee on a business trip travelled by taxi from an airport to the hotel where he would stay.
He was injured in a road incident during the taxi journey. The injury is work related.
Example 2:
An employee, who has a company vehicle for unrestricted personal use, was due to attend a business
meeting some distance away on a Monday morning. He decides to leave on the Friday and break the
journey by visiting friends. An incident occurred during the diversion from the normal route. The
resultant injury is not work related.
Example 3:
A ship’s crewmember was travelling ashore by launch for an authorised recreational trip. He was
expected to arrange safe transport. An incident occurred when the launch collided with another ship
and the crewmember was injured. The injury is work related.
When an incident occurs during travel in non company arranged transport and subsequent
investigation shows that company transport should have been provided, for example if incidents
during this activity could create a negative impact on the company, then the incident should be
considered work related.
Example 4:
An employee had to travel from home to the local airport for a weekly shift at a location upcountry.
The roads were known to be dangerous because of frequent armed robberies. If no company
transport was provided then a robbery involving an employee in private transport would be
Note: Example 4 is not work related under OSHA. Other situations involving company supplied
transport are still being clarified. Examples will be added when the information is available.
Working from Home
Injuries and illnesses that occur while an employee is working at home, including work in a home
office, will be considered work-related if the injury or illness occurs while the employee is
performing work for pay or compensation in the home, and the injury or illness is directly related to
the performance of work rather than to the general home environment or setting. For example, if an
employee drops a box of work documents and injures his or her foot, the case is considered work-
related.
If the injury or illness is related to non-work activities or to the general home environment, the case
is not considered workrelated. If an employee is injured because he or she trips on the family dog
while rushing to answer a work phone call, the case is not considered work-related. If an employee
working at home is electrocuted because of faulty home wiring, the injury is not considered work-

related.
If an employee voluntarily takes work home and is injured while working at home, is the case
recordable? No. Injuries and illnesses occurring in the home environment are only considered work-
related if the employee is being paid or compensated for working at home and the injury or illness is
directly related to the performance of the work rather than to the general home environment.
Working Away From Home

When an employee is travelling on company business the total period away from regular place of
work, including normal life activities, e.g. in a hotel and travelling by taxi to a meeting, are
considered to be part of employment. Any injury or illness occurring during the business trip is
considered to be work related for recording, investigation and learning purposes but not all injuries
and illnesses will be recordable for statistical purposes. The “home away from home” concept
applies – see definition of Business Travel.
Company or contractor employees may be required to live on board tankers, fixed or floating
platforms, supply vessels, standby boats, construction workers camps or other accommodation
provided by the employer as part of their normal work assignment. Injuries occurring during normal
life activities are assumed to result from the employee’s presence at the location, as required by the
company or contractor, and therefore to be work related. If investigation of an incident reveals that
it was caused wholly by the action of the employee and failures of management controls did not
contribute, the incident is not work related.
In case of illnesses that materialise during business travel the normal criterion for occupational
illness should be applied, i.e. was the illness caused by or mainly caused by exposures in the
workplace?
Example 1:
An employee sustained an injury in an offshore gymnasium during off duty time. If management
controls were not breached the injury is not work related. If the injury resulted from a failure of one
of the pieces of equipment it would be work related.
Example 2:
An outbreak of food poisoning occurred in a contractor’s construction workers’ camp. As the
outbreak clearly resulted from a failure in hygiene standards of food provided by the contractor the
illnesses would be occupational.
Example 3:
An employee sustained an injury or illness after checking into a hotel during off duty time. The
incident should be recorded and investigated for learning purposes but is not recordable for
statistical purposes.
Transportation of Goods and Equipment
Considered to be Work Related

 Transportation of goods and equipment within company managed locations;

 Transportation of goods and equipment on company owned or contracted transport, including

subcontractors and spot hire transport;
 Transportation of goods and equipment that is readily identifiable as related to the company
operations, e.g. seismic vehicles and land drilling rigs, or process equipment for a new plant
construction.
Not considered to be Work Related

 Transport activities which are not dedicated to the supply of goods and equipment for the
company or its contractors that are not readily identifiable as related to company or its
contractors and do not present a high risk to the company, e.g. delivery of mail, use of road, air
and sea freight, contractors engaged on multi deliveries.
Transportation of Product
Considered to be Work Related

 All incidents involving company or contractors’ employees on company premises or working
under the company's management control.
Example 1:
A road haulier was working under a term contract to deliver product on the company's behalf. The
haulier worked for a number of other companies. An incident occurred during the time the haulier
was delivering product exclusively for the company. The injury should be included in the company
statistics, as should the associated exposure hours and the kilometres driven.
 All incidents occurring within company managed locations or alongside company managed
pipelines.
 Incidents which occur when company or contractor vehicles, including sub contractor or spot-
hire vehicles, are undertaking the following journeys, whilst subject to company management
control:
 To a terminal or depot to load products;
 From a terminal or depot to deliver products to a customer;
 From a customer to a terminal or depot or to a contractor base or other predefined base,
to complete the journey;
 To or from a workshop or garage for vehicle service or maintenance.
 Incidents occurring in vehicle parking areas or other off-road situations, e.g. customer premises,
whilst subject to company management control.
Not considered to be Work Related

 Incidents to contractors not subject to company management control, for example:
 Delivery of products to company locations by a contractor who is also employed by other
companies to deliver their products to other locations during the same journey. However,
when such vehicles are within the company location both the vehicle and driver must
comply with the company standards and requirements, and the activities will be considered
as under operational control;
 Customer collection of company products where the vehicle is under the management
control of the customer, e.g. freight on board sales of products to dealers or distributors
not under operational control ex-depot. As in the previous example the vehicle is
considered to be under operational control when at the company location;
 Back-haul journeys where the contractor vehicle carries products for other companies or
has been re-routed by the contractor on behalf of another company, or for his own benefit;

 Contractor assigned by a local authority to an activity when the company is unable to

impose management control.
Injuries during Training
Example:
An employee attended a course at a training school and sustained an injury. As the injury occurred
during the training sessions it is a work related injury. Had the injury occurred in the employee's
recreational time, and was not caused by a failure of management controls of the training centre, it
would not be work related.
The injury and the exposure hours should be included in the statistics of the company employing the
injured person. The training centre should investigate and follow up the incident and report the
findings to the employing company.
Meal Period Illnesses
Illness caused or mainly caused by exposures occurring during the employee's meal period or other
off duty periods are not considered as occupational unless they result from exposures to hazards in
the work area.
Example 1:
An employee suffered food poisoning resulting from food provided by the employer. This case
would be considered an occupational illness.
Example 2:
An employee was sitting in the canteen and eating food that he had brought to work. He suffered
food poisoning. The case would not be considered an occupational illness.
Fitness Centre
Incidents involving employees at company physical fitness centres are not normally work related,
even though the company encourages participation in fitness programs and subsidises the costs of
participation. If participation is required as part of employment, then any resulting incidents are
work related. If an injury results from a failure of one of the pieces of equipment or other
management controls it would be work related.
Entertainment of or by Customer, Supplier or other Business Contacts

An injury or illness caused or mainly caused by exposures which occur while an employee is
entertaining a customer, supplier or other business contact, or while the employee is being
entertained by a customer, supplier or other business contact, for the purpose of transacting,
discussing, or promoting business, would be considered a work related injury or an occupational
illness.

Appendix 4
Recreation and Social Events
Company premises include all employer controlled sports fields, tennis courts, golf courses, parks,
swimming pools, gyms, social clubs and other similar recreational facilities which are used by
employees on a voluntary basis primarily during off-work hours. The Company should maintain
management controls appropriate to the facilities, activities and participants. Injuries to employees,
their families or others should be recorded and investigated if they result from failures in the
management controls or to the absence of management controls which should have been in place.
The work related test is to be applied in determining recordability as either an employee or 3rd party
for statistical purposes.
Example 1:
The 3 year old child of an employee drowned in the swimming pool at a Company social club. The
requirement not to leave young children unsupervised had not been specified or applied in this case.
This would be considered a 3rd party work related fatality.
Injuries to employees participating in social events outside company premises are work related if the
events are organised by the company and the injuries result from a failure of management controls.
If injuries result wholly from the actions of the employees, e.g. falling from a bar stool, they are not
Acts of God and Wilful Acts

Injuries from "acts of God" such as being struck by lightning while at work are considered work
related.
Incidents occurring during the course of employment that are due to someone’s wilful act are
recordable, whether or not they occur on company premises.
Example 1:
An employee on a business trip was mugged after leaving a taxicab on the way to check-in to a
hotel. The injuries sustained are work related.
Example 2:
Two workers had a fight at the worksite. Any injuries sustained are work related.
Horseplay
Injuries arising out of horseplay during work are work related.
Example 1:
An employee was showing off by operating a forklift truck that he was not familiar with or
authorised to use. He lost control of the truck and struck a fellow employee. Although the employee
was engaged in a prohibited activity his injury and that of the fellow employee are considered to be
work related.
Appendix 13: Procedure for Reporting and Review of Significant Incidents
Appendix 13 Procedure for Reporting and Review of Significant

Incidents
All significant incidents, i.e. incidents with actual consequences to the company rating 4 or 5 on the
Risk Assessment Matrix, shall be reported according to the procedure detailed below. This
procedure applies to illnesses and injuries, including third party fatalities, non-accidental deaths and
deliberate deaths, and to incidents involving damage to assets, the environment or company
reputation.
Steps Action Party Timing
Notify the business Reporting company Within 24
To: business HSE adviser and relevant business director. hours of
Copies to: managing director for business, business chief incident
executive and Group HSE adviser.
Prepare investigation report Reporting company Within one

According to Group guidelines, including Tripod or causal month of
learning methodology analysis. Send to business HSE incident
adviser (copy to Group HSE adviser on request only).
Review investigation report Business HSE adviser Within two

Review report for completeness and quality of months of
investigation, identification of underlying causes and incident
improvement actions. If necessary request reporting
company to improve the report.
Advise classification Business HSE adviser At end of

Advise classification of incident to the reporting company review
and Group HSE adviser. As process owner the Group
HSE adviser may review the classifications.
Significant incident review meeting Meeting participants: Within three

A review meeting led by the business chief executive will be - Group managing months of
held for all incidents resulting in a company or contractor director incident
employee fatality, selected third party fatalities and all other - Business chief executive
HSE incidents with a significant impact. - Relevant bus. director
The review will consider the causes of the incident and - Business HSE adviser
actions taken and planned. (plus other expertise)
- Others decided by
business chief executive
Debrief Business HSE adviser Within one
Prepare action items and lessons learned and copy to week of
participants and Group HSE adviser. review
meeting
Follow up report Reporting company Within one
This report will review implementation of action items Business HSE adviser year of review
from the investigation report and the significant incident should remind company meeting
review meeting. Send copy of report to participants (to if necessary
Group HSE adviser on request only).

Appendix 13: Procedure for Reporting and Review of Significant Incidents
Review of follow up report Business HSE adviser Within two

Confirm receipt and ask further questions as required. weeks

Appendix 14: Exposure Hours - Examples
Appendix 14 Exposure Hours - Examples

The following examples are intended to clarify the definition and calculation of exposure hours, to
achieve a consistent approach in the calculation of injury and illness frequencies.
Example 1:
An office worker lives in a suburban area and travels to work by public transport. This person's
exposure hours would be the time spent at the office.
Example 2:
An office worker lives in a suburban area and travels to work in transport arranged by the company.
This person's exposure hours would be the time spent at the office. However, an injury occurring to
the employee in transport arranged by the company would be considered a work related injury.
Example 3:
An employee travels on company business but in own time outside normal working hours. This
person's exposure hours would be calculated on the basis of the normal working week.
Example 4:
An employee is working scheduled and recorded overtime. This person's exposure hours would
include all overtime periods. Any unrecorded overtime would be excluded.
Example 5:
An office employee is working unscheduled extra hours. Whilst in theory such working time should
be treated as in Example 4, it is generally not justified to keep records of such working time for
safety performance reporting. Hence, this person's exposure hours would be calculated on the basis
of the normal working week.
Example 6:
A company employee or contractor works on an oilrig or supply boat. Only the on duty hours are
included in the calculation of exposure hours.
Example 7:
A company or contractor organizational unit is not able to provide the actual exposure hours for a
month by the time required. Estimated exposure hours can be used. An acceptable method is to
report March, April and May exposure hours as Quarter 2 etc. A correction can be applied (if
available) before the final annual exposure hours are submitted.
Note:
On company owned or time charter tankers exposure hours are calculated on the basis of 24 hours
per day, rather than the usual hours on duty. This is in-line with maritime industry practice.

Incident Classification, Investigation, and Reporting Manual

Uploaded by

Copyright:

Available Formats

Incident Classification, Investigation, and Reporting Manual

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Incident Classification, Investigation, and Reporting Manual

Uploaded by

Copyright:

Available Formats

Reporting of Incidents

INVESTIGATION AND REPORTING

4 Learning from Incidents 10

Appendix 1 Definitions and Explanation of Terms 17

Appendix 2 Incident Classification and Reporting Flow Chart 26

Appendix 3 Medical Treatment Cases and First Aid Cases 27

Appendix 5 Classification of Occupational Illness 38

Appendix 6 Asset Damage - Examples 39

Appendix 7 Environmental Impact - Examples 40

Appendix 8 Reputation Impact - Examples 43

Appendix 9 Incident Investigation Guidance 44

Appendix 10 Sequentially Timed Event Plot - Example 48

Appendix 11 Incident Report Layout for a Significant Incident 49

Appendix 12 Work Related Activities – Guidance and Examples 51

Appendix 13 Procedure for Reporting and Review of Significant Incidents 56

Appendix 14 Exposure Hours - Examples 58

4 Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

1.2 Purpose and scope

5 Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

3.1 Responsibilities and Competence

Investigation of incidents is a line responsibility. All investigations should be led by or sponsored by

3.2 Extent of Investigation

The extent of investigation of incidents should be based on a consideration of:

3.3 Investigation Process

7 Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

3.4 Establishing the Sequence of Events

3.4.2 Hazard-Event-Target (HET) trios

3.4.3 Sequentially Timed Event Plot (STEP)

3.5 Analysis of Underlying Causes and Weaknesses in Management System

8 Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

3.5.1 Tripod for Understanding Incidents

3.5.2 Tripod Beta

3.5.3 Other methods

3.6 Incident Report and Follow up

3.6.1 Incident Report

3.6.2 Legal advice

9 Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

4 LEARNING FROM INCIDENTS

All businesses, support functions and other organisations shall:

10 Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

5.1 Potential Work Related Activities

The procedure to determine whether or not an illness is occupational (work-related) is detailed in

5.4 Incidents Resulting in Asset Damage, Environmental Impact and/or

5.5 Near Misses

12 Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

5.6 Potential Incidents

5.7 High Risk Incidents

13 Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

6.1 Reporting Company

6.2 Reporting of Significant Incidents

Third Party Fatalities

15 Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

before or during his recent work period?

16 Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

Appendix 1 Definitions and Explanation of Terms

Business Travel - Contractor

17 Incident Classification, Investigation and Reporting, Issue 3.0, December 2007

Consequential Business Loss