Safety Guideline:- Incident Investigation

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Topic : Safety Guideline

INCIDENT INVESTIGATION

Introduction & Purpose 

Incidents occur in the workplace every day for any number of reasons. These incidents can cause injuries and illnesses, property damage, financial loss and sometimes death but even when incidents don’t result in injury or property damage, they are disruptive for workers and operations and may be an indicator of a bigger problem waiting to happen therefore conducting thorough incident investigations is one of the most effective ways to protect your employees from risk of injury or illness.

All workplace incident need to be investigated. Investigators must be a experienced investigators and can assist you in:

• Identify root cause e.g. systems failures, workplace culture, breach of policy/procedure/process, etc.
• Identify control measures to prevent recurrence
• A ‘no blame” approach designed to drive continuous improvement
• Identify opportunities for improvement
• Investigation conducted by highly trained, experiences and qualified investigators
• Formal and accredited training/coaching for your employees with respect to incident investigation techniques.

In this article, i like to share relatively standard process for conducting an incident investigation. While we think you’ll find this article and method helpful, know that you may also want to explore an alternative method of incident investigation that uses a learning team.

An incident investigation is something you (and/or others in your organization) should perform when an incident occurs at the workplace. This can include near-misses, quality problems, accidents, property damage, illnesses, injuries, and fatalities.

There are two primary purposes of an incident investigation. The first purpose is to identify the root cause or causes of the incident. That’s the short-term goal. And the second purpose is to use the information gathered in the incident investigation, and the determination of the root cause, to prevent a similar incident from happening again. That’s the long-term goal.

But not everyone knows how to perform an incident investigation.

• What about you?
• Do you have a plan in place right now?
• Do you know what you’d do if you had an incident at work?

If you have already planned your response and investigation, hats off to you. If not, you can begin planning now. But if you don’t begin planning your investigation until you’ve had an incident at work, you’re much too late and will be behind the proverbial eight-ball.

So in this article, we’ll sketch out what you need to know about performing an incident investigation. And we’ll even give you a list you can use to begin making your incident investigation plan and another list you can use to begin stocking up your incident investigation kit. Hope you find it helpful.

INTRODUCTION TO THE INCIDENT INVESTIGATION PROCESS

Here i am breaking this article down into the following sections:

• Incidents
• Incident Investigations–An Overview
• Incident Investigations–A Closer Look at Each Step 
• Incident Investigation Plans

I recommend you read the entire article, and then use the “incident investigation plans” section at the end to guide you through what to do next.

SECTION 1: INCIDENTS

Before explaining how to perform an incident investigation, let’s start by making sure we know what an incident is and what incidents you should investigate.

What’s an Incident?

“Incident” is an umbrella term that includes the following:

• Fatalities
• Injuries
• Illnesses
• Property damage
• Environmental release or exposure
• Near misses

An incident could even be a quality problem or any unexpected occurrence (even something that turned out better than expected).

But let’s look at the more commonly investigated “negative” incidents a little more closely.

Fatalities : Just what it sounds like. When someone dies at work.

Injuries : A physical injury, such as a bump on the head or a broken arm.

Illnesses : A sickness, such as a respiratory illness suffered from inhaling chemical fumes.

Property damage : Damage to property, such as crashing a forklift into a shelving unit and damaging the forklift and shelving.

Environmental release or exposure : Releasing something into the environment that should not have been released, such as a toxic leak into a stream.

Near misses : Something that could have resulted in a fatality, injury, illness, and/or property damage, but didn’t. For example, a wrench falls from a shelving unit and falls to the ground, barely missing striking a worker on the head.

Should You Investigate All Incidents?

In an ideal world, you’d investigate all incidents, even near misses. But of course, time is limited, so it makes sense to prioritize the most severe incidents and/or the ones that happen/could happen most often.

The more incidents you investigate, the more information you’ll gather, and therefore the better chance you’ll have of avoiding incidents in the future.

Obviously, some incidents will SCREAM for an investigation, such as a fatality (there will be legal requirements to consider as well), while a very minor injury or near miss may not call quite so dramatically for investigation. But again, the more incidents you investigate, the lower your risks will be in the future.

Do All Incidents Merit the Same Type of Investigation?

No.

You’ll use a similar technique for all incident investigations, but you’ll apply more resources while investigating some incidents than you will when investigating others.

For example, it’s logical that more people will play a role in investigating a fatality than in investigating a near miss that would have led to a minor injury.

SECTION 2: HOW TO CONDUCT AN INCIDENT INVESTIGATION: THE BASIC PROCESS, IN ORDER

An incident investigation is a multi-step process. Those steps include:

• Gather the necessary people to perform the investigation
• Get your previously prepared incident investigation kit
• Go to the location of the incident
• Help provide any first aid, medical care, or assistance necessary
• Secure the area where the incident occurred
• Preserve the work area as it is/as it was at the time of the incident
• Identify witnesses to the incident
• Separate witnesses
• Interview the worker(s) involved
• Interview the witnesses
• Document the scene
• Create an incident investigation report
• Distribute the incident investigation report
• Use the findings of the incident investigation report to better identify and control hazards
• Ensure that the corrective actions called for in the report are put into place

Just by skimming the list above, you can understand that you’ll benefit from a lot of planning and consideration in advance.

Knowing what the incident investigation will involve will help you in two ways:

• First, it will help you create a plan for incident investigations that will take place in the future
• Second, it will guide you through the steps of an incident investigation when you’re performing one.

We’ll look at each of these steps in much more detail in the section below.

SECTION 3: HOW TO CONDUCT AN INCIDENT INVESTIGATION: A CLOSER LOOK AT EACH STEP

Gather the Necessary People to Lead and Take Part in the Investigation

Normally, an incident investigation is led by the supervisor of the worker(s) involved in the incident.

In some cases, other people may also help the supervisor or may lead the investigation instead of the supervisor. This can include:

• HSE/SHE/EHS Department 
• A special Incident Investigation team
• The Safety Committee

In addition, the incident investigation will include:

• Workers who were injured or made ill by the incident
• Workers who were present and/or participated but were not injured or made ill
• Other workers who witnessed the incident

In some cases, the worker involved may have the right to request that an employee representative be present during the investigation.

If the incident is especially major, or if a fatality is involved, senior management, engineering, and/or legal personnel may also play a role.

Get Your Previously Prepared Incident Investigation Kit

When going to the site where the incident took place, take with you an incident investigation kit.

You should have prepared the incident investigation kit in advance so it’s ready when needed.

The incident investigation kit should include: 

• Incident investigation forms
• Interview forms
• Markers/tape to barricade the incident area
• High-visibility tape
• Scissors
• Scotch tape
• Warning tags and padlocks to secure the area
• A camera and/or video recorder
• A voice recorder (possibly integrated into video recorder)
• Measuring equipment (measuring tape/ruler)
• Flashlight
• Containers to hold samples
• Personal protective equipment appropriate to your work site
• Atmospheric monitors appropriate to your work site
• First aid kit
• Gloves
• Large envelopes
• Graph paper
• Other paper to write/sketch on

A checklist that lists the steps of the incident investigation and the order in which to complete them
Remember, if you don’t have an incident investigation kit prepared now, you want to do it soon–before you forget. Do it now, or put a reminder on your email calendar to do it tomorrow, or get old-school and put a Post-In note somewhere. But don’t put this off for long.

Go to the Site of the Incident

Once you’ve got the correct people and your incident investigation kit, go to the site of the incident.

As you approach the area, remember to pay close attention and be cautious. Don’t walk into a situation that will harm you, making a bad situation even worse.

Also, make sure you’ve equipped yourself with any PPE that’s necessary to enter the area, either because it’s normally needed in that work area or because the incident has created a need for the PPE.

Help Provide Any First Aid, Medical Care, or Other Assistance Necessary

Remember, there’s been an incident. People may have been hurt, or a hazard may exist.

Do what is necessary to help any sick or injured people, to get people out of harm’s way, and to control the hazard safely before you begin your investigation. Call or otherwise arrange for medical care if necessary.

Secure the Area Where the Incident Occurred

Once people are safe, barricade the area where the incident occurred so that people can’t enter.

Preserve the Area As It Was At the Time of the Incident

With the area barricaded, make sure everything in the area stays as it was when the incident occurred. If things are not removed, moved, or changed, it will make the incident investigation more effective and meaningful.

Identify All People Who Were Involved in or Witnessed the Incident

When you get there, you’ll want to identify the people who were:

• Involved in the incident.
• Witnesses to the incident

Do this as soon as possible, before people go their separate ways and begin to forget key details.

The reason you’re doing this is because you’re going to want to interview all of these people to find out what happened.

But there are two important points to keep in mind at this point.

First, don’t interfere with someone if they have suffered a significant injury or illness and need medical attention. That may be obvious, but it’s worth stating now and keeping in mind during a real incident investigation.

And second, once you begin identifying and talking to the participants and witnesses, it’s important that they know why you want to talk to them and what the purpose of the incident investigation is. And it’s equally important that they know what the purpose is NOT. You want to make it clear that the purpose of holding the interviews and conducting the investigation is to gather information that can be used to help prevent similar incidents in the future. And likewise, you want to make it clear that the purpose is NOT to place blame, assign fault, or punish anyone.

 

Here’s a hint: you’ll have better luck explaining that the purpose of conducting an incident investigation is simply to prevent future incidents and is NOT to place blame or punish if it’s something you’ve already explained to workers in advance. Consider explaining the purpose of incident investigations to your workers as part of the general safety training that they receive, and/or as part of the standard efforts associated with your safety and health management program. Employees are more likely to cooperate fully, and less likely to worry about participation, if you do this.

 

Separate the Witnesses

Separate the people that you’ll interview: sick/injured people, other participants, and witnesses.

You want to hear each person’s wholly unique perspective and thoughts on what happened. If they’ve hung around and discussed events together, you’re less likely to get that raw, unfiltered information and more likely to get people or ideas that have been influenced by other people.

Interview the Workers Affected and/or Involved

• Take the person to a place where you can interview him/her privately. While you’re interviewing the person, keep the conversation informal. Talk to the person as an equal–don’t talk down to the person. Avoid creating an atmosphere that’s accusatory or confrontational.
• Begin the interview by reminding the person that you’re not trying to place blame or penalize, and that you’re just trying to learn what happened so similar incidents won’t happen again.
• Then, ask the person to explain what happened, from beginning to end. Don’t interrupt the person–let the person explain the incident in his or her own words. It’s a good idea to record this conversation as its happening, and you may also want to take notes with paper and pencil as the person talks.
• Once the person has completed his or her story, ask additional questions to fill in any “gaps” or clarify any confusion. Try to use open-ended questions that invite the person to give extended answers based on his or her own thoughts–try to avoid close-ended questions that the person will answer with “Yes” or “No.”
• Once you believe you understand the person’s full story, tell it back to that person. Have them listen to your explanation of their story and ask if you’ve captured what they experienced accurately. If the person explains that you’ve got something wrong, or adds more information, correct your version.
• Next, ask the person why the incident happened and what they think could have been done to prevent the incident from occurring. Have them focus on the conditions and events that led up to the incident.
• Once the person’s finished their explanation, you may find it helpful to lead them through the “5 Whys?” exercise. You may already be familiar with this, but if not, it’s a simple exercise that helps to identify the root cause of an incident. All you do is ask the question “Why?” five times (give or take a few, based on circumstances) to get from superficial explanations to the true root cause(s) of the incident. Here’s an example:
• You: Why did the person get hurt? (Why number 1.)
• Worker: He put his hand on the moving blade.
• You: Why? (Why number 2.)
• Worker: He didn’t know there was a blade there.
• You: Why? (Why number 3.)
• Worker: He wasn’t properly trained about safety aspects of this machine.
• You: Why? (Why number 4.)
• Worker: He doesn’t normally work in this area and was called in as a replacement without receiving the safety training people who work in this area typically receive.
• You: Why? (Why number 5.)
• Worker: There’s no organized way to determine who’s received safety training for this area/that area.

You get the idea. You can also see that the 5 Whys? method could have gone in a different direction above, and that the worker could have suggested that the moving blade should have had been guarded to prevent workers from touching the blade. Remember that your goal is to “dig deep,” moving past superficial explanations of a direct cause (the person’s had was cut by a moving blade), through indirect causes (the person didn’t know there was a moving blade there), to root causes (the person hadn’t received proper safety training to work in the area, there’s no way to know who’s received what safety training, etc.). Remember, there’s nothing “magic” about the number 5. Ask “Why?” until you’ve identified root causes.

Finally, check to see that you’ve got the following information, all of which may prove helpful during your investigation, while making your report, and while trying to put corrective measures into place:

•  Characteristics of all workers involved with the incident, including:
• Age
• Gender
• Department
• Job role/title
• Experience
• Tenure
• Employment status (full time, part, time, seasonal, contractor, consultant)
• Type of injury/illness/incident, including:
• Description
• Body part(s) affected
• Severity
• Task being performed when incident occurred, including:
• General task
• Specific activity within that task
• Location of involved workers
• Body posture of involved workers
• Was person working alone or with others?
• Time factors associated with incident, including:
• Time of day
• Hour within worker’s shift (example: 3rd hour of 8-hour shift)
• Shift (example: day/night)
• Phase of worker’s day (example: entering work, normal work, 15-minute break, mealtime, overtime, leaving work)
• Supervision when incident occurred (example: worker directly supervised, indirectly supervised, or worker not supervised at time of incident)
• Expected supervisor when incident occurred (example: normal/not normal, expected/not expected, feasible/not feasible)

Interview the Witnesses

Use the same technique that you used to interview people involved in the incident (explained immediately above) to interview all other participants and witnesses.

Document the Scene of the Incident

Once everyone who was involved and/or witnessed the incident has been interviewed, turn your attention to the evidence at the site of the incident.

Because you would have already barricaded the area, conditions should be the same as they were immediately after the incident (or as close to that as possible).

The process of documenting the scene may involve:

• ·         Taking photos and/or videos
• ·         Making audio recordings document the scene (perhaps as part of the video)
• ·         Writing notes
• ·         Sketching/drawing the scene
• ·         Making measurements
• ·         Taking samples
• ·         Noting information in equipment operation logs, charts, and records

During this part of the incident, gather the following information:

• ·         Position/status of machines, tools, equipment, supplies, or similar devices
• ·         Information in equipment operation logs, charts, and records
• ·         Characteristics of machines/equipment/tools/supplies associated with incident, including:
• o   Type
• o   Brand
• o   Identification numbers
• o   Size
• o   Distinguishing features
• o   Condition
• o   Specific part(s) involved
• o   Operating settings/status
• o   Entries in logs/charts/records
• ·         Any other materials/subjects involved (example: chemicals)
• ·         Atmospheric/environmental conditions, including:
• o   Temperature
• o   Light
• o   Noise
• o   Weather
• o   Ergonomics
• ·         Preventive measures in place when incident occurred
• ·         How well any preventive measures in place performed

Please note: there’s no reason why documentation of the incident scene can’t be going on at the same time as incident participants and witnesses are being witnessed, and if you have enough people on your incident investigation team, that’s ideal.

 Create an Incident Investigation Report

Once you’ve gathered all the information, it’s time to create a written report.

Your report should:

• ·         Summarize everything you learned during your investigation
• ·         Identify root causes of the incident
• ·         Recommend corrective measures
• ·         List who’s responsible for ensuring each corrective measure is put into place
• ·         State the date by which each corrective measure should be put into place

Distribute the Incident Investigation Report

Once you’ve created the report, it’s time to distribute the report.

Once of the things you should do before an incident occurs is determine who should get a copy of incident investigation reports and how quickly these reports should be created and distributed.

In addition, you should have determined what kind of information gets relayed to managers and general employees, and how that information is made public. You’ll want to follow through accordingly to plan and communicate the appropriate information accordingly.

Communicate Report Findings to the General Work Force

You may not distribute the full incident investigation report in its original form to all workers.

However, you should communicate key findings of the report to the workers at the site.

Use the Findings of the Report to Implement Corrective Measures

• Use the findings and recommendations of the report to put corrective measures into place.
• Make sure anyone who is responsible for putting a corrective measure into place knows:
• What he/she is responsible for doing
• When he/she should have the correct measures in place
• How he/she should communicate any problems experienced while putting the corrective measures in place or how to communicate if he/she could not put the corrective measures in place
• How he/she should communicate that the corrective measures have been put into place so that they can be tracked

Ensure that the Corrective Actions Called For Are Put Into Place

You should have some way to track if and when all corrective actions have been put into place.

Be sure everyone involved in implementing corrective measures knows how to track completion of those measures, and make sure someone has the final responsibility of ensuring that all measures have been implemented by a certain date.

If you don’t track the completion of these corrective measures, it’s easy for one (or several) to never get done.

SECTION 4: INCIDENT INVESTIGATION PLANS

What’s an Incident Investigation Plan?

It’s your plan for preparing to lead incident investigations and for how you’ll actually conduct one.

When Should You Create an Incident Investigation Plan?

Now. Or soon.

The critical thing is, you want to create an incident investigation plan before you need to perform an incident investigation.

And of course, since the future’s uncertain, you don’t know when the next incident is going to occur. So the sooner you create your plan, the better.

Reading the information below will help you create your incident investigation plan.

Why Should You Create an Incident Investigation Plan?

An incident investigation is a multi-step process that requires you to:

• ·         Consider some things in advance
• ·         Make some decisions in advance
• ·         Inform some people in advance
• ·         Provide training in advance
• ·         Gather materials in advance
• ·         Create forms in advance

All this work that’s done in advance will make your incident investigation much more effective. And that should be reason enough to do it now.

Now that you know quite a bit about incidents, and also know what to do during a real incident investigation, it’s time to start creating an incident investigation plan for your workplace.

Do it now, or soon, instead of later. If you’re not going to do it now, go to your calendar, find the next open opportunity, and set an appointment with yourself. Get the time blocked out now, make it a personal action item, and get it done.

What to Include in Your Incident Investigation Plan

Here are some things to include in your incident investigation plan:

Which incidents will be investigated?

Some? All? Just injuries and illnesses? Property damage? What about near misses?

How intensively will different types of incidents be investigated?

It makes sense that some incidents, such as ones that result in a fatality or serious injury, may lead to more intensive incident investigations that other incidents, such as those that lead to a near miss that would have led to only a minor outcome. Give this idea some thought now and come up with a plan to respond/investigate appropriately.

Who should be involved in incident investigations?

Who will be involved in incident investigations? Will it always be the same person/people? Or might it include different people with the same job title (for example, the department manager who supervises the worker involved)?

Will the EHS/Safety manager always be involved? When should management, engineering, and/or legal be included? Is an employee representative to be included? If so, in which cases, and who is that person?

What will be in your incident investigation kit?

Come up with a list (use the recommendations above as a starting point), go get what you need, and put it all together in a single bag or case.

Remember, sooner is better than later for this.

Are policies and procedures in place for contacting outside help in the event of an emergency?

This is a little off-topic, but it’s worth double-checking at this point.

• Are there specific policies in place for employees, managers, and others at the company to summon emergency assistance when necessary after an incident has occurred? Have these methods been explained adequately to all workers?
• Do all workers understand the explanations, and can they do what’s necessary should the need arise?
• Do all methods and systems used to do this (example: emergency phone systems, alarms) work and are they tested regularly?

This is stuff that’s worth checking on.

Has everyone received proper training about incident investigations?

Some people at your workplace may actively play a role in conducting an incident investigation. Before they do, they should know they may be called upon to do this, and they should be trained in the purpose and methods.

In addition, all workers could potentially be included in an incident investigation–being interviewed because they were directly involved or because they were witnesses. As we mentioned earlier, it’s important that they understand the purpose of the incident investigation isn’t to assign blame or punish. Make sure all workers know in advance that incidents will be followed by incident investigations, and make sure they realize the purpose of an incident investigation is to determine root causes and implement preventive measures so similar incidents won’t happen again. And that the purpose isn’t to assign blame or punish.

Create, print, and store interview forms

Create an interview form that can lead interviewers through the process of conducting interviews with the people who were involved in the incident or witnessed the incident. Print out many copies of the form, put them on a clipboard or in a hard-covered binder, and put them into your incident investigation kit. Keep an electronic copy and save it in some logical place on your computer or the work network so you can access this later, print more copies, and/or modify it as necessary.

Create, print, and store investigation forms

Once you’ve finished with the forms to lead investigators through the interview process, create a similar form to lead investigators through the rest of the investigation. Use the section above, where we explain what to look for during the investigation, as a starting point for what to include in your investigation forms.

Print out many copies of the form, put them on a clipboard or in a hard-covered binder, and put them into your incident investigation kit. Keep an electronic copy and save it in some logical place on your computer or the work network so you can access this later, print more copies, and/or modify it as necessary.

Create a template form for your incident investigation reports

You’ll also want to create a form that acts as a template for the person completing the incident investigation report. That form can be used to guide the person writing the report so that he/she is sure to include all the relevant information.

It’s not necessary to print this out, but do save a copy on a computer or the work network so its’ ready when needed.

Determine who will complete the incident investigation

• Who completes the incident investigation report? 
• The same person every time? 
• Or is it someone different each time?

Determine how quickly the incident investigation report should be completed

Will there be a specific deadline for completing incident investigations? No deadline? Or will it vary, depending on the type of incident?

Figure out who will get a full copy of the completed incident investigation report

When the incident report is complete, it should be distributed at the workplace. Determine who will get a full copy of the report and have that list available and ready when needed.

Determine a method for implementing corrective measures

• How will people responsible for implementing the various corrective measures know they’re responsible? 
• How is this communicated?
• How will they note when they’ve successfully implemented the corrective measure? 
• What will they do if they try to implement a corrective measure and can’t? 
• How will they communicate that information?

Determine a method for checking to see if corrective measures have been implemented

Finally, create a method to check back and confirm that all of the correct measures have been implemented. Make sure someone’s responsible for doing this and that it’s done by a specified date.

If that person finds that one or more measure has not been implemented, have the person follow through to find out why and to get the measure implemented as soon as possible.

Conclusion: How to Conduct an Incident Investigation

By performing an incident investigation as described above, you’ve got a better chance of eliminating or reducing the number of incidents at your workplace.

If you explain the process to all the workers at your site, and explain its purpose is to prevent future incidents and not to blame or punish, you’ll have a much better chance of getting their buy-in and of getting full cooperation during an actual investigation.

Remember that the people who will help lead investigations need training in advance about the purpose, methods, and tools used in the investigation, and be sure to get your incident investigation plan and incident investigation kit finished soon, using the tips above as a guide.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Safety Guideline:- Isolation and Lockout

www.safetygoodwe.com

Topic : Safety Guideline

Isolation and Lockout

1. Context:Persons may suffer fatal or serious injury if they are exposed to hazardous energy sources.  One potential exposure occurs while undertaking inspection or maintenance work on plant and equipment.  Therefore it is necessary to ensure that energies are controlled while personnel are working in, or on, plant and equipment.

2. Purpose:

The purpose of this element is to ensure that the installation, construction, inspection and maintenance work performed on plant and equipment where there is potential for hazardous energy release, is only undertaken by competent and authorized persons after the equipment has been safely isolated, and locked such that the risk of fatalities is controlled.

3. Scope:

This element applies to the management of any activity where personnel may be required to interface directly or indirectly with sources of hazardous energy that have the potential to cause fatal or serious injury.  In particular this element applies to both fixed and mobile plant, machinery and equipment.  It applies to all personnel working on  sites and to visitors.

4.0 Element Requirements	Accountability
4.1 Hazard Identification Risk Assessment and Control
A survey must be undertaken to identify hazardous energies associated with plant,machines and equipment.  This survey must record: The plant / equipment / machine Identification name or number / HAC code and location Different types of hazardous energies associated with that plant and equipment. Isolation points for each hazardous energy (these may be local and/or remote)	Company Director
A documented process for undertaking isolation must be developed.  This process must address: Definition of isolation points for each item of plant, machinery or equipment Specification of the lockout mechanism/s to be used Consideration of the particular work to be performed on each item of plant Definition of the steps required to isolate and lockout all energy sources The method of testing (prior to commencement of work) that the energy has been safely controlled Definition of the steps required to remove isolation's and re-energize the plant, machine or equipment.	Company Director
Competent persons must be nominated as Isolation Officers for each type of equipment requiring isolation.	Company Director
All isolation's will be undertaken by means of formal lockout.  Lockout will occur through the application of a lock by the nominated Isolation Officer for the equipment, with subsequent application of locks by each person who will work on the equipment.  The following isolation cases may exist: A single or multiple isolation carried out to protect a single person:  In this case, the single person will apply his/her own lock(s) if he/she is trained as an Isolation Officer.  Otherwise an Isolation Officer must apply the first lock, and then the person requiring the isolation applies their own lock.  A single isolation carried out to protect multiple workers: In this case, the Isolation Officer will apply the first lock.  Other persons will then apply their own lock if they are trained as personal lock holders. A multiple isolation carried out to protect multiple workers: In this case, the Isolation Officer will apply locks and isolate multiple locations as required.  The Isolation Officer will then place the keys of the different isolation locks in a lockout box which he/she will then also lock.  Other persons will then apply their own lock and tag to the lockout box if they are trained as personal lock holders. Visitors must be supplied with a lock which will be attached after the Isolation Officer has applied their lock.	Company Director
The name of each person applying an isolation must recorded at the point of isolation.	Company Director
Where lockout cannot be achieved, then tags may be used for isolation as an interim measure.  However, the ability to lockout will be retrofitted to all plant and equipment.	Company Director
Any risk identified as having a potential to cause fatal incident must be controlled prior to carrying out any tasks.	Company Director
If a documented isolation procedure is not in place, then a job safety analysis must be carried out on tasks prior to commencement of work.  This job safety analysis will address the energy sources present and the nature and the type of isolation required.	Company Director
All documentation and records relating to surveys and risk assessments must be retained for the life of the equipment.	Company Director
When equipment is isolated for more than one shift, a record of the isolation will documented for communication to the incoming shift.	Company Director
Approval must be obtained to remove a lock placed by another person. (Note : such approval will only be sought in exceptional circumstances)	Plant Manager
4.2 Selection, Training, Competency and Authorization
The training and competency assessment system will ensure: Competency standards for persons undertaking surveys to identify hazardous energies associated with plant and equipment.  Competency standards for persons performing the functions of an Isolation Officer. Competency standards for persons performing the functions of personal lock holder. Training and formal competency assessments for the above personnel Authorization of the above personnel to isolate plant and place locks. Recording of all training undertaken and the results of competency assessment. A register of all persons authorized to carry out isolation's.	Company Director
All personnel who undertake surveys, perform JSA’s or any other risk assessments relating to isolation and lockout must be: Competent to undertake isolation and lockout Competent to undertake/facilitate JSA’s or risk assessments	Company Director
Any person responsible for identifying lockout points and applying the primary lock must be formally trained and competent as an Isolation Officer.	Company Director
All persons involved in applying personnel protection locks (personal lock holders) as part of an isolation must be trained in those aspects of the isolation procedure relevant to them.	Company Director
4.3 Communication and Awareness
Isolation and lockout awareness must be a component of general induction for all personnel.  Records of having received awareness training must be maintained.	Company Director
Changes to isolation and lockout safe work procedures must be documented subject to change management and implications communicated to persons who may be affected by the changes.  Copies of written safe work procedures or relevant job safety analysis must be made available in the work place to those persons who perform isolation's.	Company Director
Ongoing awareness information and instruction must be provided on a regular basis to personnel who install, construct, inspect and maintain equipment, and plant with a potential for hazardous energy release.  This awareness must specifically address: Critical aspects of isolation and lockout as summarized below: o    Reasons for isolation o    Types of energies needing to be isolated o    The difference between single isolation's and multiple isolation's o    The rules associated with isolation's Applicable safe work procedures	Company Director
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4.4 Design, Purchase, Fabrication, Installation and Commissioning
Consideration of the ability to lockout and isolate must be addressed as part of the design or purchase processes for new plant and equipment.	Company Director
Design or purchase specifications must be developed for all systems plant and equipment which ensure that hazardous energy sources can be isolated and locked out.	Company Director
Purchasing specifications must ensure that local isolation of plant and equipment is available.	Company Director
Purchasing specifications must address isolation capability for mobile plant and equipment.	Company Director
Purchasing specifications for locks must ensure the master series locks has series keys available.	Company Director
Personal locks are designed so that they can only be unlocked by the key that was issued with the lock.	Company Director
4.5 Work Method and Condition Control
Isolation requirements must be applied to all activities performed on sources of hazardous energy.  This will include application to fixed and mobile plant and equipment.	Company Director
Isolation requirements must also provide guidance on safe working methods for testing plant that has been isolated.	Company Director
Isolation requirements must distinguish between isolation methods and use of “Out of Service” tags.	Company Director
4.6 Maintenance
A maintenance programme must be in place for ensuring that all plant and equipment identified in the survey has lockable isolation points installed or a physical means to prevent a hazardous energy release, and that the location/method of isolation is in a usable state.  .	Company Director
All isolation and lockout equipment must be maintained in a “fit for purpose” condition.  This may include: Isolation points Switches Valves Dampers Flaps Circuit breakers Locks Keys, and Other multiple lockout devices.	Company Director
All isolation and lockout test equipment must be maintained according to manufacturer’s specifications.	Company Director
4.7 Emergency Controls
The site emergency response team and site emergency plan should address potential injuries that may result from failure in isolation systems.	Company Director
4.8 Monitoring, Inspections and Audits
Annual audits must be performed to verify the quality and effectiveness of the requirements set out in this element. As a minimum this will include : Schedules for audits Audit verification of: quality of the risk assessments performed quality of the equipment maintenance programme compliance to training, competency, and awareness requirements compliance to isolation and lockout  procedures Feedback and reporting requirements	Company Director
Inspection of all equipment used for isolation's  must be maintained in accordance with manufacturer’s recommendations and results recorded.	Company Director
Planned Job Observations must be performed by supervisors for the purpose of measuring compliance in regard of: Permit issuing procedures Safe working procedures Status of isolation records	Company Director
4.9 Reporting, Assessment and Corrective Actions
Processes must be in place for the reporting, assessment, and correction of hazards equipment isolation or procedures and must address: Actions required to stand down unsafe equipment, tag it, stop work Recording of actions taken to correct the hazard or defect Actions required to re-start the equipment	Company Director
Processes must also be in place to address actions that may arise from auditing of this particular fatality prevention element.	Company Director

 5. Glossary of Terms

Accountability	The person designated to ensure that the assigned requirement is implemented. This person is held liable and answerable to the level of compliance against the stated requirement.
Authorised	Permission granted by the relevant Manager or nominee to carry out specific tasks.
Competent Person	A person having appropriate knowledge, internal and/or external qualifications, skills, experience and capability to carry out specified tasks.  The combination of such attributes underlies critical aspects of their successful professional performance, and may be assessed against defined competency criteria.
Contractor	A firm or person employed under a contract to provide services in organisation  as distinct from a contract of employment.
Department Manager	The person nominated by organisation as Manager under the organizational structure, also the most senior position with a firm contracting work to organisation.
Hazardous Energy	These energy sources are one or more of; electricity, radiation, pneumatics, hydraulics, gases and liquids, chemical, gravity or any other energy source that has the potential to cause injury or damage.
Isolation	Where a de-energized energy source has been locked in accordance with the Isolation Procedures.  At organisation this is the only form of isolation that is accepted and is other wise known as Positive Isolation.
Must / Shall	Must  / shall is to be interpreted as mandatory.
Non compliance of Isolation	A situation or an occurrence where the organisation  Isolation Regulations or Safe Work Procedure for isolation has not or can not be followed.
Operational Experience	Is a person with a minimum of one years experience relating to the isolation and lockout regulations.
Personal Lock Holder	A person who has received training in the isolation, lockout and tagout procedure.
Isolation Officer	A person who has received advanced training in the isolation, lockout and tagout procedure. The person must have operational experience in the area he/she is working in.
Potential to cause a Fatality/ Risk of a fatality	A hazard that has been identified that if not properly controlled will contribute to a fatal incident.  This can be derived from previous fatal incident experience and / or having being identified by means of risk assessment as having a consequence for fatal injuries.
Risk Assessment	A risk assessment is the estimation of the level of risk associated with and identified hazard to determine the resources needed to control it.  Risk is measured in the terms of consequence and probability.
Safe Work Procedure for Isolation	Is the process of isolating plant or equipment from all energy sources so that work can be carried out on that plant or equipment, without risk of injury from the energy it self.  In the context of this element, a Safe Work Procedure of Isolation is one that has been compiled by the relevant operating department for specific jobs.  The procedures for working on or testing of “live” machinery must be approved by the appropriate Superintendents before implementation.

 

 

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