WMC Environment, Health & Safety Management System
© WMC Resources Ltd
WMC has developed this document for internal use, specific to circumstances and conditions within its operations. It is
Learning From Incidents Standard
WMC-EHS-STD-007
Owner: Peter Plavina
Champion: Gary Sutherland
DocsOpen Ref: 83595
Uncontrolled copy – check web for latest revision
Revision Reviewed Description of Changes Date Approved
0 P Plavina / K Ashby
Standard – Learning From Incidents
CONTENTS
1 PURPOSE AND SCOPE ... 3
2 DETAILS... 3
2.1 Incident Classification... 3
2.2 Incident Reporting ... 4
2.3 Incident Investigation... 5
2.4 Management of Corrective and Preventative Actions ... 5
2.5 Communication of Lessons Learned ... 6
2.6 Management and Use of the EHS Data Management System ... 7
3 RESPONSIBILITIES ... 9
4 APPENDICES... 11
General Approach to Incident Classifications... 12
Injury and Illness Incident Classification Details... 14
Classification of Environmental Incidents ... 21
Incident Investigation – Generic Process ... 32
Standard List of Contributory Factors... 36
Template for Hard Copy Investigation Report for incidents with H or E severity... 37
Flowchart and Template for EHS Lessons Learned Bulletin ... 38
Standard – Learning From Incidents
1
PURPOSE AND SCOPE
This Standard provides an overview of the key processes associated with managing the information derived from environmental, health and safety (EHS) incidents. Effective learning from incidents is an important element in the continuous improvement process for EHS.
The key processes are: Incident classification Incident reporting Incident investigation
Management of corrective and preventive actions Communication of lessons learned
The tool used to support these processes is the EHS Data Management System (DMS), which is linked to the WMC email system (Microsoft Outlook).
Because the business processes used for EHS incidents are similar to the business processes used for other “loss events” (e.g. production loss, property damage, community impacts, security breaches, etc.) these non-EHS incidents are included where appropriate in this standard. However, they are not covered comprehensively.
2 DETAILS
2.1 Incident Classification
2.1.1 Types of Incidents
EHS Incidents:
This Standard comprehensively covers the following types of incidents: Personal injury or illness
Environmental harm
Legal or WMC non-compliances for EHS issues EHS near-misses
EHS Hazards Other Incidents:
This Standard and the EHS DMS also caters for the following types of non-EHS incidents: Property/equipment damage
Production loss Community impact
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Security breaches
Non-EHS near-misses or hazards
2.1.2 Classification of Incidents According to Severity
For the sake of simplicity and uniformity, most of the incidents covered by this Standard are classified into four broad categories, according to their ACTUAL and their POTENTIAL severity. The four severity levels are:
E (Extreme) H (High) M (Medium) L (Low)
These severity levels determine the reporting and investigation processes as detailed in other sections of this standard.
The definitions of severity for the various types of incidents are contained in the Appendices. In addition to classification according to severity, EHS incidents are classified according to other criteria and definitions such as those prescribed by mining safety and environmental regulations and those used historically within WMC (eg. Lost Time Injuries, Medically Treated Injuries and Environmental Non-compliances).
Thus, a single incident will be classified according to a range of different requirements. All of these are detailed in the respective Appendices and are also built into the EHS DMS
Details on classification of incidents (EHS and others) are found in the following Appendices:
Appendix A1 General Approach to Incident classifications
Appendix A2 Injury / Illness Incident Classification - Details
Appendix A3 Environmental Incident Classification - Details
2.2 Incident Reporting
All EHS incidents must be reported to the appropriate parties and recorded in the EHS DMS so that corrective and preventive actions can be implemented.
Internal (within a site) Reporting
Sites are responsible for ensuring that the relevant line managers and site support personnel are notified of incidents in a timely fashion. These requirements must be defined in a site Procedure. The DMS is configured to provide notification of incidents to defined roles within the site.
Off-site (but within WMC) Reporting
Off-site reporting (within WMC) requirements are detailed in Table 1. For “Extreme” and “High” severity incidents, the target is 24 hours for the report and 14 days for the investigation. Immediate
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verbal communication to the relevant General Manager Operations and Executive General Manager, as well as the General Manager - EHS, is required for all “Extreme” severity incidents. Off-site (outside WMC) Reporting
Sites are responsible for ensuring that all legal reporting requirements are complied with. These requirements must be documented in a site procedure, which includes roles, responsibilities, timeframes, forms / paperwork and training arrangements. Further guidance on external communication is found in the External Communications Guideline (WMC-EHS-GUI-010).
2.3 Incident Investigation
2.3.1 Objectives
All EHS incidents shall be investigated to determine what happened and why, so that corrective actions can be taken.
For “Low” potential incidents, an informal investigation needs to be carried out (i.e. the Investigation section of the incident report in the DMS does not have to be completed).
For all higher potential severity levels, a formal investigation must be conducted so that the contributing factors can be identified and addressed (see Appendix B2 for the standard list of contributing factors found in the DMS.
Incident investigation focuses on system failures, not on apportioning blame to individuals. Generic Investigation Process
The Generic Investigation Process is shown in Figure 1. The number and types of people involved and the degree of thoroughness of investigation changes according to the potential severity of the incident – Extreme, High, Medium or Low; see Table 2 (the Potential Severity will always be equal to, or higher than the Actual Severity).
2.4 Management of Corrective and Preventative Actions
2.4.1 Actions from Incidents
The DMS provides the ability for all agreed actions arising from an incident to be recorded, monitored and closed out. Specific times and responsibilities are designated for all actions. For Low potential incidents, the actions are documented in the incident report. For all other incidents the actions are documented in the investigation report.
Actions must be discussed with the responsible person and timeframes agreed before the actions are allocated in the DMS.
When an agreed action is not implemented, or an action different from the agreed action is implemented, the reasons for the change must be included in the close out documentation within the DMS
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Table 1 – Incident Reporting Off-site (but within WMC)
INCIDENT ACTUAL OR POTENTIAL SEVERITY
(whichever is the higher)
TIME-FRAME FOR INCIDENT REPORT
REPORTED TO
Immediately (verbally) Operations General Manager Executive General Manager The General Manager - EHS
E-Extreme
24 hours using DMS incident report
As above, but including Group EHS Data Administrator
H-High
And LTIs, MTIs and all
Environmental Non-compliances
24 hours using DMS incident report
One up from site General Manager
Relevant support Group Manager (E, H or S)
EHS Data Administrator
M-Medium and L-Low
No requirement for off-site (but within WMC) notification.
Not applicable.
2.4.2 Actions from Other Sources
The functionality of the DMS should be used to track actions from other sources (audits, inspections, reviews etc.)
2.5 Communication of Lessons Learned
“EHS Lessons” are lessons from incidents which, if communicated and acted upon in other parts of the organisation, would improve EHS management or reduce the risk of occurrence of similar incidents.
It is the responsibility of Investigation Team Leaders, in conjunction with the Clients for investigations and the respective site EHS professionals, to identify worthwhile lessons learned opportunities.
A Lessons Learned Bulletin (see Appendix C for the template) is completed by the relevant site EHS professional, authorised for release by the site General Manager or their designate, if required, and sent to the Group EHS Data Administrator who arranges distribution in consultation with the relevant Group Manager.
All sites must have a designated Lessons Learned Coordinator to: review all Lessons Learned Bulletins received by the site
forward or otherwise communicate the Bulletin to people within their site who they believe need to take action in response to the Bulletin
document, in the EHS Lessons Learned Public Folder in Outlook:
- the people to whom the Bulletin was communicated
- the specific actions taken at the site in response to the Bulletin (including decisions
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Lessons Learned Bulletins should also be used to communicate advice and alerts from other companies, industry bodies, regulatory agencies and suppliers.
All site actions in response to Lessons Learned Bulletins must be managed using the action tracking functionality of the DMS.
2.6 Management and Use of the EHS Data Management System
The EHS DMS is the primary tool for collecting and managing information arising from EHS incidents. It resides on the WMC computer network, and is accessible from any networked personal computer.
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Figure 1 – Generic Investigation Process for E, H and M Potential Severity Incidents (further details can be found in Appendix B1)
REPORTING AND CLASSIFICATION Incident occurs and is reported
Incident is classified according to potential severity
INVESTIGATION STEP 1
Identify Client
STEP 2
Client appoints Team Leader
STEP 3
Team Leader appoints Team
STEP 4 Define Scope Getting Started STEP 5 Gather Information Gather Information Analyse STEP 6
Summarise and Analyse Information
STEP 7
Determine immediate and underlying contributory factors
Produce Report
STEP 8 Develop Recommendations
STEP 9 Peer Review (if applicable)
STEP 10 Develop actions
STEP 11
Client signs off on report and actions
Make Improvements STEP 12 Implement Actions
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Table 2 - Investigation Requirements Based on Potential Severity of Incident
**Further details on investigation of selected E category incidents is contained in the guideline - “Critical Incident Management” (not yet written). Details for each of the steps in the generic investigation process shown in Fig 1 are contained in Appendix B1
Data Collection
The primary responsibility for entering EHS incidents into the DMS, then using the action tracking and reporting functionality lies with front line supervisors. EHS Professionals and EHS Data Administrators have specific functions within the system, and are categorised as expert users or trainers.
Superintendents, Department Managers and General Managers have specific roles in reviewing and “signing off” incidents in the DMS.
Data Management
Overall responsibility for management of the DMS lies with the Corporate EHS Data Administrator in the Corporate EHS Group. The responsibility at each site lies with the site champion for the DMS, who supports the Site EHS Data Administrator. Sites are responsible for ensuring they have appointed trained and competent personnel to the data administrator role, and that there is adequate back-up.
3 RESPONSIBILITIES
General Managers
Ensure there are site procedures which reflect all relevant requirements of the WMC Learning from Incidents Standard.
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Ensure there is appropriate training of all personnel on site in the roles and requirements of the Learning from Incidents business process.
Ensure that people are appointed to the roles of Lessons Learned Coordinator and EHS Data Administrator.
Ensure that the DMS is supported and used to its full extent by EHS specialists and all supervisors, superintendents and managers.
All Supervisors
Adhere to the site’s Learning from Incidents procedures. Use the DMS.
EHS Specialists
Be fully conversant with the detailed aspects of the Learning from Incidents business process, incident classifications and use of the DMS.
Coach and support others in the above.
Actively monitor the quality of the processes and outputs from the Learning from Incidents business processes.
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4 APPENDICES
Appendix A1 General Approach to Incident Classification
Appendix A2 Injury / Illness Incident Classification Details
Appendix A3 Environmental Incident Classification Details
Appendix B1 Incident Investigation – Generic Process
Appendix B2 Standard List of Contributory Factors
Appendix B3 Template for Hard Copy Investigation Report for Incidents with E or H Severity
Appendix C Template for EHS Lessons Learned Bulletin
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APPENDIX A1
General Approach to Incident Classifications
For any EHS incident where an actual loss has occurred, the incident is described in the following ways:
The general type of asset which has suffered a loss (for EHS incidents, the assets are either “people” or “the environment”)
The specific part of the asset involved (eg arm, groundwater) The nature of the loss (eg cut, contamination)
The mechanism of the loss (eg person falling, hydrocarbon leak)
Actual severity (Extreme, High, Medium or Low – E, H, M, L – as per Table 1) Potential severity (E, H, M, L – as per Table 1)
Other measures
- Traditional or historical measures such as for injury / illness – LTI, MTI, MI and for
Environmental - Non-Compliance Levels 1 to 5.
- Additional measures such as degree of restriction on ability to work (restricted
duties)
Contributory factors – as listed in Appendix B2
A similar approach has been used in describing plant / equipment damage, production loss and community / heritage incidents.
Full details of these different ways of describing and classifying EHS (and other) incidents are built into the DMS “pick-lists”, and are listed on the hard-copy Incident Report form.
Specific detailed information (what, when, where, how) is gathered for all incidents in addition to the broader categories described above.
Severity Classifications
Severity classification definitions for EHS incidents are summarised in Table 1 and are detailed further in Table 4 (for injury / illness) and Figures 2 to 9 for environmental incidents (decision flowcharts).
The severity classifications have been designed to provide effective measures of EHS performance.
The injury / illness severities are based broadly on the extent of damage or harm to the injured person. Implicit in the definitions is that a recoverable injury is less severe than an injury which leaves permanent disability or disfigurement.
The environmental severities are based on the scale, extent and permanency of damage to the natural environment.
Historical measures of EHS performance (LTI, MTI, Environmental Non-Compliance) also broadly reflect severity levels, are included for historical continuity and to allow industry comparability.
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Table 1 - Incident Severity Classifications Summary
EXTREME HIGH MEDIUM LOW
Incident Type Personal Injury / Illness Fatality or major permanent physical disability Major recoverable injury / illness. Minor permanent physical disability Medical treatment injury / illness Minor injury / illness (first aid)
Environmental Harm Extreme permanent impacts High level permanent damage Medium level permanent damage Minor and recoverable damage Plant / Equipment Damage >$1.0 million $0.5 - $1.0 million $0.15 – $0.5 million <$0 - $0.15 million
Production Loss >$1.0 million $0.5 - $1.0 million $0.15 – $0.5
million
<$0 - $0.15 million
Community Impact Not Yet Determined
Near miss / Hazard (in relation to one of the incident types above) Refer to relevant severity level above Refer to relevant severity level above Refer to relevant severity level above Refer to relevant severity level above
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APPENDIX A2
Injury and Illness Incident Classification Details
Lost Time Injury (LTI)
A Lost Time Injury is any work-related injury that results in the injured person being absent from work, as a direct result of the severity and nature of the injury, for one full shift or longer. Shifts lost as a direct consequence of the time taken to obtain confirmatory diagnosis or treatment (eg due to remote location) do not cause an injury to be classified as a Lost Time Injury.
Medical Treatment Injury (MTI)
A Medical Treatment Injury (MTI) is any work-related injury that:
Requires treatment by, or under the specific order of a medical practitioner or any injury that could be considered as being one that would normally be treated by a medical practitioner; and
Results in less than a full shift being lost from work
In simple terms, an MTI is more serious than a Minor Injury (MI), but less serious (as determined by the degree of incapacitation in terms of time lost) than an LTI.
Illustrative examples of MTIs are contained in Table 1 below. Minor Injury
A Minor Injury (MI) is any work-related injury / illness that is managed by first-aid treatment only, regardless of who administers the first aid treatment.
Illustrative examples of MIs are contained in Table 2 below. Serious Potential Incident
A Serious Potential Incident (SPI) is defined as any incident which had potential to be of E (Extreme) severity, as defined in Tables 3 and 4 below. Note that incidents in which actual injury / illness occurred as well as incidents which are near-misses or hazards can be classified as SPIs. Estimation of potential severity must be realistic, and should consider the outcome of the incident if one, or at most two aspects were different by a small degree.
Some examples:
If time of day was different
- Eg 10 minutes earlier, a person was standing at the spot where the scaffold plank
fell
If location of person was different
- Eg if the person had been standing 0.5 metres closer to the valve, they would have
been sprayed in the face with sulphuric acid If location of injury was different
- Eg if the angle grinder had hit the fitter’s leg 5cm to the right, it would have sliced his
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Estimation of the potential severity of hazards is more difficult, because no event has yet occurred. The estimation therefore has to involve a consideration of probability, exposure and consequences.
In summary, estimation of potential severity for EHS incidents involves a mixture of subjectivity and good judgement. It is best resolved by discussion between involved parties, EHS specialists and, for H and E potential severity, sign-off by at least a Department Manager if not the General Manager . (The DMS does not have an incident category labelled as SPI. An incident becomes an SPI once it is classified as having potential severity of “Extreme”. SPIs can be reported from DMS using its reporting functions).
Table 1 – Medical Treatment Injuries – Illustrative Examples
Does include:
Use of prescription medications (except a single dose administered on the first visit for minor injury or discomfort)
Use of sutures or staples or other techniques designed to close an open wound Treatment of partial or full thickness burns.
Removal of embedded objects from eyes Injuries which result in loss of consciousness
Surgical debridement (removal of burned or damaged tissue)
Removal of foreign bodies from a wound if the procedure is complicated by the depth of embedment, size or location.
Treatment of bruises by drainage
Treatment of extensive abrasions at greater than full skin depth
Series (more than two occasions) of physiotherapy or chiropractic treatment under the direction of a medical practitioner.
Admission to hospital or equivalent for observation after head injury, injury to chest or abdomen or inhalation of gases or fumes. Note: the admission has to be based on severity of incident and /or symptoms, not on a hospital’s automatic admission protocols.
Use of non-prescription medication at “prescription-equivalent” dose / strength. Any fracture
The treatments listed above are considered to be Medical Treatments regardless of the professional status of the person providing the treatment
Does not include:
Diagnostic procedures such as X-rays (unless the result is positive), laboratory analysis, blood tests, administration of prescription medication used for diagnostic purposes, eg eye drops to dilate pupils unless they lead to further medical treatment
Tetanus shots or boosters
Visit to a doctor solely for observation, counselling or confirmation of diagnosis without any further medical treatment
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Table 2 – Minor Injuries – Illustrative Examples
An injury that requires first aid treatment only. Such treatment is considered first aid even if it is administered by a doctor.
Minor injuries include:
Treatment of superficial burns
Cleaning abrasions / small wounds with antiseptic and applying a bandage Using wound coverings such as bandages, band-aids, gauze pads, or the like Cleaning, flushing or soaking wounds on the surface of the skin
Use of non-prescription medication and administration of a single-dose treatment using prescription medication on the first visit for a minor injury or discomfort (non-prescription medication can only be used at non-prescription strength)
Removing non-embedded foreign bodies from the eye using only irrigation or a cotton swab Applying hot-cold compresses
Use of elastic bandages on sprains immediately after the injury
Removing splinters or foreign material from areas other than the eye by irrigation, tweezers, cotton swabs or other simple means
Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister Using eye patches
Using finger guards Using massages
Using any non-rigid means of support such as elastic bandages, wraps, non-rigid backbelts, etc Using temporary immobilization devices while transporting the injured person
Disabling Injury
This is a statutory classification that applies only in WA. (Reference: WA DMPR Guideline: Occurrence, Accident and Occupational Disease Legislative Reporting Requirements, May 2001) Definition: “An injury that results in the injured person being disabled so that they are unable to return to their ordinary occupation the following day, regardless of whether the person is rostered to work the following day or not. This includes disabled persons assigned to alternate duties” Note: in the following sections, terms in italics are defined terms.
Restricted Duties
Restricted duties occur when, as a result of work-related injury or illness, the person’s supervisor or a medical practitioner considers it necessary to keep the employee from performing one or more of the routine functions of their job or from working a full shift. Restricted duties do not have to be reported if they apply only on the shift during which the employee was injured / ill.
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Routine Functions
Routine functions are those work activities the employee usually performs at least once per week. Work Relatedness
An injury or illness is work related if an event or an exposure in the work environment either 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 an exception described below in “Exceptions for work relatedness” specifically applies.
Exceptions for work relatedness
An injury or illness occurring in the work environment that falls under one of the following exceptions is not work related
The injury or illness involves signs or symptoms that surface at work but result solely from a non-work related event or exposure that occurs outside the work environment
The injury or illness results solely from voluntary participation in a wellness program, a medical, fitness, sporting or recreational activity.
The injury or illness is solely the result of an employee eating, drinking or preparing food or drink for personal consumption
The injury or illness is solely the result of an employee doing personal tasks (unrelated to their employment) at the establishment outside the employee’s assigned working hours The injury or illness is caused by a motor vehicle incident and occurs in a company car park or company access road while the employee is commuting to or from work
The injury or illness occurs whilst the employee is at a “home away from home”, eg a hotel, motel or other temporary residence, even though they are there in the course of their work The illness is the common cold or flu. (Note: contagious diseases such as infective
gastroenteritis, brucellosis, hepatitis A, tuberculosis are considered work-related if the employee is infected at work)
Work relatedness during travel
Injuries and illnesses that occur while an employee is on travel status are work related if, at the time of the injury or illness, the employee was engaged in work activities “in the interest of the employer”. An employee commuting between their permanent residence or temporary residence and their normal workplace is not considered to be undertaking work-related travel.
Working at home
Injuries and illnesses that occur while an employee is working at home, including work in a home office, will be considered to be work related if the injury or illness occurs while the person 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.
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Significant aggravation
A pre-existing injury or illness has been significantly aggravated when an event or exposure in the work environment results in an injury or illness that would likely not have occurred but for the occupational event or exposure.
New case or recurrence?
An injury or illness is a new case if
The employee has not previously experienced an injury or illness of the same type that affects the same part of the body, or
The employee previously experienced an injury or illness of the same type that affected the same part of the body but had recovered completely (all signs and symptoms had
disappeared) from the previous injury or illness and an event or exposure in the workplace caused the signs or symptoms to reappear.
The above does not apply in the case of occupational illnesses where the signs or symptoms may recur or continue in the absence of an exposure in the work environment. However, in the case of occupational asthma, for example, each occurrence which is caused by an event or exposure in the work environment is a new case.
Work environment.
The work environment” is defined as “the establishment and other locations where one or more employees are working or are present as a condition of their employment. The work environment includes not only physical locations but also the equipment or materials used by the employee during the course of their work.
Days Lost
If an employee leaves WMC’s employment, the number of days lost or days on restricted duties should be based on information gained from the employee or their new employer regarding the condition of their illness or injury. If this approach is not successful in providing reliable information, or if the person is no longer employed (for reasons other than the injury / illness), the days lost should be estimated based on the nature and severity of the illness or injury. This estimate should be made by the site health professional in conjunction with a doctor’s opinion, and authorized by the site General Manager.
The same approach must be used if a contractor completes their contract period prior to the resolution of their injury / illness.
Compensable Injury / Illness
A compensable injury / illness is one which qualifies for financial compensation under the relevant Workers’ Compensation Legislation or Scheme. The fact that an injury is accepted for Workers' Compensation does not, by itself, automatically mean that it should be included in WMC’s injury statistics although this would usually be the case. An injury which is accepted by the relevant authority as being compensable, but which is judged to be not work-related for the purposes of WMC’s classification should have the reasons well documented.
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Medical Practitioners
The judgement of a medical practitioner to allocate time off from work must be considered final even if WMC believes that there are alternative duties that the injured person could have performed. To avoid such circumstances arising, routine liaison with local doctors should be established to ensure they are aware of the range of alternative duties that are available and to ensure they will discuss each case with WMC before deciding to allocate lost time.
Medical Practitioners Advice Required for LTIs
An LTI is not recorded when an injured / ill person decides, of their own volition, to miss a rostered shift unless their absence is supported by documented advice from a medical practitioner.
Meaningful Restricted Duties
Bringing an injured person back to work without assigning any relevant and productive activity, (i.e. other than on a planned Return to Work Programme including meaningful and productive "Restricted Duties") to avoid an LTI being recorded is not an acceptable practice.
Alterations to Rosters
Altering a roster or allocating annual leave, special leave, sick leave, etc. to avoid an injury being classified in the correct manner is an abuse of the system and is not an acceptable practice.
Severity Classifications for Illness / Injury
In addition to all the classifications described above, illness and injury are also classified according to severity as summarised below: Extreme, High, Medium and Low. This scheme is built into the DMS. The four categories (E, H, M, L) are also used, for consistency, to broadly classify environmental incidents, production loss, property damage and other forms of loss (see the Learning From Incidents Standard for further details).
This approach to classification of injury / illness is designed to provide a better measure of severity than is possible using the LTI / MTI system. This approach considers only the severity of injury or harm suffered by the injured person and is not influenced by work rosters. The “Medium” and “Low” categories are identical to MTI and MI definitions.
Table 3 – Summary of Illness / Injury Severity Classifications
INJURY / ILLNESS SEVERITY
EXTREME (E) HIGH (H) MEDIUM (M) LOW (L)
Personal Injury / Illness Fatality or major permanent physical disability Major recoverable injury / illness. Minor permanent physical disability Medical treatment injury / illness Minor injury / illness (first aid)
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Table 4 – Examples of Illness / Injury Severity Classifications
SEVERITY OF ILLNESS / INJURY
EXAMPLES
(Note: These lists are indicative, not exhaustive)
Extreme (E)
Fatality
Major permanent physical disability
Quadriplegic Paraplegic
Amputation of limb including hand or foot Total loss of eyesight from at least one eye Extensive scarring from severe burns Major loss of hearing
Head injury with significant permanent disability to neurological function
Permanent disability resulting from severe chronic pain due to injury
Inhalation injury with permanent loss of lung function and associated disability
High (H)
Minor permanent physical disability
Major recoverable injury / illness
Amputation of part or whole finger, toe, ear
Minor permanent loss of flexibility or range of movement of a joint (>5% loss)
Minor permanent impairment of vision Minor permanent loss of hearing
Moderate permanent disability resulting from chronic pain Moderate permanent disability resulting from an unstable major limb joint (hip, knee, elbow, shoulder)
The injury / illness requires hospitalisation as in-patient (ie includes overnight stay for treatment purposes). Excludes hospitalisation for precautionary and observation purposes. The person recovers fully after the treatment, with no significant permanent disability.
Medium (M)
Medical treatment Definition exactly the same as for MTI -detailed in Table 1
Note that MTI does not include injuries which result only in restricted duties.
Low (L)
Minor injury / illness Definition exactly the same as for MI-detailed in Table 2, ie
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APPENDIX A3
Classification of Environmental Incidents
Environmental incidents are classified in two ways: a) by the significance of their impact, and b) by the significance of the non-compliance.
(A) Significance of the Environmental Impact
The significance of an incident’s environmental impact is classified on the basis of:
- the events proximity to, and / or impact on, ‘sensitive’ components of the
environment
- the estimated duration of the impact
- the size of the area impacted, and
- the proximity to, and/or impact on the community.
In order that these parameters are systematically addressed, the classification of an impact’s significance shall be completed by the use of the accompanying eight flowcharts. Steps to Classifying the Significance of the Impact
If the event being classified is a spill then refer first to the Spill Classification Flowchart. If the event being classified is an emission to air then refer first to the Air Emission Classification Flowchart.
Given that the incident is a spill or an emission, these flowcharts will subsequently direct you to one or more of the other flowcharts.
If the incident is neither a spill nor an emission, you must choose one or more of the following assets that has been impacted upon, consider each of their flowcharts, and any other flowchart that they in turn lead you to:
- Soils
- Groundwater
- Surface Waters
- Biota
If soil has been impacted upon then refer to the Soil Flowchart.
If groundwater has been impacted upon then decide whether or not the groundwater has any surface expression (ie comes to surface via transpiration, vertical leakage, springs or flows in to water courses). If there is surface expression refer to the Groundwater – Surface Expression Flowchart, if not, refer to the Groundwater – No Surface Expression Flowchart.
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Results of Classification Process
The flowcharts will lead you to classify the significance of the incident’s environmental impact in one or more of the following five categories. Where the flowcharts lead you to classify an incident in more than one significance category, the incident shall be assigned the highest of those significance categories. Thus an incident will be assigned one of the following classifications:
- No significant environmental impact
- Low environmental impact
- Medium environmental impact
- High environmental impact
- Extreme environmental impact
(B) Non-Compliances
Non-compliances with the law shall be classified into one of five reporting levels, depending on the location of the impact, and the extent and permanency of the environmental damage.
An environmental incident can only be a non-compliance if we have failed to operate in accordance with the law.
For the purpose of this classification process, the term ‘law’ is used as a general reference to Acts, Regulations, and other legal instruments such as tenement or lease conditions, development consents, and licences.
For the purposes of reporting non-compliances the following interpretations shall be used:
- Level 5 non-compliances are incidents that result in an ‘Extreme Environmental
Impact’.
- Level 4 non-compliances are incidents that result in a ‘High Environmental Impact’.
- Level 3 non-compliances are incidents that result in a ‘Medium Environmental
Impact’ and persist for longer than one month.
- Level 2 non-compliances are incidents that:
a) result in a ‘Medium Environmental Impact’ that persists for less than one month,
or
b) result in a ‘Low Environmental Impact’.
- Level 1 non-compliances are incidents that:
a) result in ‘No Significant Environmental Impact’
b) result in a breach of environmental law without any associated environmental
impact. This is referred to as ‘technical’ non-compliance (for example, the expiry of an operating license, or a technical breach of a tenement or lease condition such as the late lodgment of a Report).
Standard – Learning From Incidents
Publicly contentious non-compliances
In the event that a non-compliance is likely to be contentious in the public domain or is likely to come to the attention of senior regulators or politicians, as assessed by the site GM, the non-compliance shall be upgraded by one level. [eg a Level 2 non-compliance that triggers the authorities to issue notice of a requirement for corrective works shall be upgraded to a Level 3 non-compliance, a Level 3 non-compliance that attracts national media attention shall be up-graded to a Level 4 non-compliance). Guidance in this matter can be sought from Group EHS.
Close-out of non-compliances
Following the report of a non-compliance, it shall be deemed remedied and shall be closed-out on the EHS DMS, once the subsequent actions have been completed:
1. Completion of an incident investigation
2. Identification of corrective actions required to remedy the non-compliance by site
management
3. Approval of corrective actions by the relevant regulator (this includes prearranged
agreements on response actions), and
Standard – Learning From Incidents
N o S ig n if ic a n t E n v iro n m e n t a l Im p a c t u n le s s t h e y a r is e f ro m o t h e r f lo w c h a rt s Is th e s p ill c o n ta in e d w i th in a e x is ti n g e n g in e e r e d b u n d o r h a r d s ta n d a r e a N o A r e th e r e r e s u l ta n t e m is s io n s ? Y e s Is th e r e p o te n tia l fo r im p a c ts o n s o ils a d ja c e n t o r b e n e a th th e a ffe c te d a r e a ? Is th e r e p o te n tia l fo r i m p a c ts o n g r o u n d w a te r b e n e a th th e a ffe c te d a r e a Y e s R e f e r t o a ir e m is s io n s f lo w c h a rt R e fe r to G r o u n d w a te r ( n o s u r fa c e e x p r e s s io n ) flo w c h a r t R e fe r to G r o u n d w a te r ( s u r fa c e e x p r e s s io n ) flo w c h a r t R e fe r to S o il Im p a c t F lo w c h a r t R e fe r to B io ta Im p a c t F lo w c h a r t 1 Y e s N o D o e s th e a ffe c te d g r o u n d w a te r h a v e a s u r fa c e e x p r e s s io n ? Y e s Y e s N o N o S p ill C la s s if ic a tio n F lo w c h a r t N oStandard – Learning From Incidents
Airborne Emissions
Is the emission likely to fall within a
residentiall, or ecologically or socially sensitive
area?
Does the emission exceed licence conditions? Yes High Environment Impact Yes No No Is 'fall-out' likely to impact on water, soil
or biota Refer yo Surface Water Impact Flowchart Refer to Soil Impact Flowchart Refer to Biota Impact Flowchart 1 Yes No Significant Environmental Impact unless they arise from other flowcharts No Air Emission Classification Flowchart Did the 24hr average concentration exceed the Air NEPM or equilavent? Yes No Medium Environment Impact
Has the emission caused the fatality or hospitalisation of one or more members of the public? No Extreme Environment Impact Yes
Standard – Learning From Incidents
Impacts on groundwater -no surface exposure Is stygofauna known to be affected? Yes NoIs the impacted area likely to exceed 1
hectare?
No Significant Environmental Impact unless they arise from other flowcharts
No
Is the impacted area likely to exceed 10 hectares? Yes Low Environmental Impact No
Is the impacted area likely to exceed 100 hectares? Yes Medium Environmental Impact No
Does the affected water impact upon a
residential, or biologically or socially senstitive area? Yes High Environment Impact Yes
Is the impact likely to persist longer than half of the remaining
operation's life or more than 15 years?
Yes No No Groundwater Impact (No surface expression) Classification Flowchart Refer to Biota Flowchart 1
Has the affected water caused the
fatality or hospitalisation of one or more members of the public? Extreme Environment Impact Yes No Is the contaminated water within our
property?
No
Standard – Learning From Incidents
D oe s th e a ffe cted grou nd w a te r co me to the surfa ce a s fre e w ate r? Is fre e w a ter a t th e surface kn o w n o r likely to b e con tam ina ted ?yes Y es R efer to S urfac e W aters D o e s th e grou nd w a te r co me to th e su rfa ce at e vap o ra tio n sin ks,
'd a m p sp o ts' o r sim ilar? N o Y es A re su rfa ce soils/ silts like ly to b e co m e o r a re kn ow n to be con tam ina ted ?
Is th e im p a cte d a re a likely to e xce e d
1 00 m2
N o S ig nific an t E n viro nm en ta l Im p ac t unle ss th ey arise fro m o th er flo w ch arts N o Is th e im p a cte d a re a likely to e xce ed 1 he cta re ? Y es L o w E n viro n m en tal Im p act N o Is th e im p a cte d a re a likely to e xcee d 1 0 he cta res? Y es M ed iu m E n viro n m en tal Im p act N o
D o es the affe cte d w ate r im pa ct u po n a
re sid e ntia l, o r bio log ically or so cially sen stitive
are a? Y es H ig h E n viro n m en t Im p act Is th e im pa ct like ly to pe rsist lon g er th a n h alf of the re m a in in g op e ra tio n 's life o r m o re tha n 1 5 yea rs? N o yes Y es Y es N o Is th e co nta m in atio n
like ly in kill flo ra or fa un a ?
N o
N o S ig nific an t E n viro nm en ta l Im p ac t unle ss th ey arise fro m o th er flo w ch arts N o R e fe r to B iota N o N o N o G roundw ater Im pact
(S urface expression) C la ss ific a tio n F low chart E xtrem e E n viro n m en t Im p act H a s th e a ffected w a ter ca u se d th e fa tality or h osp ita lisatio n o f
o n e o r m o re m e m b e rs o f the pu blic? Y es N o Is the co nta m in a te d w ate r w ithin ou r prop erty? N o Y es
Standard – Learning From Incidents
Is the impacted area likely to exceed 1
hectare?
No Significant Environmental Impact unless they arise from
other flowcharts
No
Is the impacted area likely to exceed 10 hectares? Yes Low Environmental Impact No
Is the impacted area likely to exceed 100 hectares? Yes Medium Environmental Impact No Yes High Environment Impact Yes Is the contaminated soil contained within
our property?
Soil Impact Classification Flowchart
Does the affected soil impact upon a residential, or biologically or socially senstitive areas? No Extreme Environment Impact
Has the affected soil caused the fatality or hospitalisation of one or more members of the public? Yes No No Yes
Standard – Learning From Incidents
Is fauna or flora likely to be
affected?
Yes
Is the affected water 'stock drinking quality' or better?
No
Is the impacted area likely to exceed 1
hectare?
No Significant Environmental Impact unless they arise from other flowcharts
No
Is the impacted area likely to exceed 10 hectares? Yes Low Environmental Impact No
Is the impacted area likely to exceed 100 hectares? Yes Medium Environmental Impact No High Environment Impact
Is the affected water within 1 km of a potential user?
No
Is the impacted area likely to exceed 1 hectare? Low Environmental Impact No
Is the impacted area likely to exceed 10 hectares? Yes Medium Environmental Impact No High No
Is the impact likely to persist longer
than half of the remaining operation's life or more than 15 years? Yes No Yes No Refer to Biota Flowcharts
Does the affected water impact upon a
residential, or biologically or socially senstitive area? Yes Yes yes Surface waters Impact Classification Flowchart Extreme Environment Impact
Has the affected water caused the fatality or hospitalisation of one or more members of the public? Yes No Is the soil contaminated within our property? No
Standard – Learning From Incidents
Is the primary impact likely to be on fauna or flora Is the soil contaminated within our property? No Significant Environmental Impact unless they arise from other flowchartsNo
Is the impacted area likely to exceed 10 hectares? Yes Low Environmental Impact No
Is the impacted area likely to exceed 100 hectares? Yes Medium Environmental Impact No
Is any impact likely to persist longer
than half of the remaining operation's life or more than 15 years? Yes Flora High Environment Impact Yes No Is the impact on a 'listed' or senstive ecosystem or habitat? No Extreme Environment Impact Yes
Does the impact affect a a residential, or biologically or socially senstitive area? No Yes Refer to impacts on Biota Impact Classification Flowchart 1
Has the impact caused a deletarious change to population dynamics of a
significant species,or substantial persistent ecosystem change or loss of
productivity? Yes High Environment Impact No
Has the impact caused the fatality of a significant number of
vertebrates?
No
is the impacted area likely to exceed 1
hectare?
No Yes
Standard – Learning From Incidents
Is the impacted macro-fauna both locally and regionally common? Yes Is the impacted marco fauna locallyrare but regionally common?
No
Is the impacted marco fauna locally and regionally rare?
No Is the local population likely to recover within 1 year? No Significant Environmental Impact unless they arise from other flowcharts
yes
Yes
Is the local population likely to
recover within the longer of either the life of the operation or 15 years? No Is the local population likely to recover within 5 years Yes Medium Environmental Impact No Yes Low Environmental Impact No High Environment Impact High Environment Impact Yes No Biota Impact Classification Flowchart 2
Has the impact caused a deletarious change to population dynamics of a
significant species,or substantial persistent ecosystem change or loss of
productivity? No Extreme Environment Impact Yes
Standard – Learning From Incidents
APPENDIX B1
Incident Investigation – Generic Process
Refer to Figure 1 in the Standard.
Step 1 Identifying Client
The Client is the person who asks for the investigation to be done and who receives and signs off on the report, the recommendations and action plan. Table 2 shows that the Client for all EHS incidents is, as a minimum, the Department Manager (for all severities other than L – Low)
Step 2 Client Appoints Team Leader
Investigation Team Leaders should ideally have been trained using the 4-hour training package - WMC Investigation Team Leader Training.
Figure 1 shows the generic roles of people who may be required to carry out the role of Investigation Team Leader. In some incidents, it may not be appropriate to follow this guidance (e.g. due to the involvement of the suggested Team Leader in the incident) and the selection of Team Leader is then made at the discretion of the Client.
Step 3 Team Leader Appoints Team
Table 2 shows the recommended minimum team membership numbers and roles. Additional team members may be added if it is clear to the Team Leader that this would assist the investigation. The number of team members should not be greater than five. Ensuring the independence of team members becomes increasingly important for incidents ranked H or E.
Step 4 Define Scope
For M category incidents, it is sufficient for the investigation team to discuss and agree what the scope of the investigation is, i.e. what is being investigated and what is not. For H category incidents where the Client is the General Manager, it is recommended that the General Manager provide a written scope for the Investigation Team. This provides the opportunity for the General Manager to request the team to focus on particular aspects of an incident.
For E category incidents, a comprehensive written scope is mandatory.
Step 5 Gather Information
This is done by:
- Interviewing witnesses and other relevant people
- Examining the scene of the incident
Standard – Learning From Incidents
- Examining appropriate documents such as training records, procedures, reports,
log sheets, inspection sheets, handover notes, maintenance records, etc.
Investigation teams must be aware of regulations concerning the disturbance of the scene of a serious incident e.g. a fatality. In most jurisdictions it is a criminal offence to disturb the scene of a fatality without authorisation from the regulator or the Coroner. Restrictions may also be placed on the scene of a non-fatal incident or a serious environmental incident.
Interviewing techniques are important, as is the taking of statements immediately after an incident has occurred.
Step 6 Analyse Information
This is the heart of the whole investigation. There are two aspects to this analysis: 1. Determining what happened, step by step
2. Determining what it was about the steps leading up to the incident that was deficient or less-than-adequate, and therefore may have contributed to the incident
A number of tools are available to assist the analysis process. The recommended tools are:
- Event charting
- Fish-bone diagrams
- Fault-tree analysis
- Events and Conditions Charting
- Gap analysis
For a category M incident it is recommended that the two tools which should be considered for use are:
- Event charting
- Fish-bone diagrams
Event charting leads to a concise summary of what happened.
The Fish-bone diagram facilitates the identification of the immediate and underlying contributory factors.
For category H and E incidents, it is recommended that three tools be considered for use:
- Fault-tree analysis
- Events and conditions charting
- Gap analysis
Fault-tree analysis forces a thorough consideration of all the events and circumstances which, in combination, resulted in the incident. Fault-tree Analysis is particularly useful when it is not immediately apparent what happened, e.g. no witnesses, poor evidence.
Standard – Learning From Incidents
Events and conditions charting is simply a recording of the key steps leading up to the incident in chronological sequence together with identification of sub-standard conditions at each step.
Gap Analysis is the identification of the requirements of:
- The WMC EHS Management System
- The site’s Standards and Procedures
- Any applicable Acts, Regulations, Australian Standards / Codes of Practice
and the circumstances at the time of the incident in relation to these requirements, i.e. what was in place compared with what should have been in place.
For the events and conditions charting, and the fish-bone diagram tools, the suggested model against which the incident should be evaluated is the Nertney Wheel, i.e. a workplace free from EHS incidents requires controls and barriers to be in place in four broad categories:
- People
- Equipment
- Work Environment
- Procedures
Step 7 Determine Immediate and Underlying Contributory Factors
Incidents invariably occur due to a number of contributory factors, seldom just one. It is useful to consider firstly the immediate contributory factors e.g. ladder broke, pipe ruptured, wrench slipped, but then to consider the underlying contributory factors, i.e. the management system deficiencies which allowed the “immediate” events to take place. For each “immediate contributory factor”, there must be a corresponding “underlying contributory factor”.
Note that the word “cause” and “root cause” is not used in this Standard, due to its widespread misuse and misinterpretation.
Appendix 2B contains the WMC standard set of contributory factors which must be used for all EHS incident investigations. It is important to use this standard set of factors so that aggregate analysis of EHS incidents can be carried out across each site and across the company.
Step 8 Develop Recommendations
For each underlying contributory factor, there must be a corresponding recommendation. Recommendations should only be specific and detailed if the Investigation Team has appropriately qualified and experienced people in it, and if the team believes it needs to provide such detailed recommendations to the Client.
It is perfectly acceptable for a recommendation to be quite broad, e.g. “Review the quality of the competency assessment for crane operators.” The action plan (done later) must be specific, and must satisfy the Client.
Standard – Learning From Incidents
Step 9 Peer Review (if applicable)
Peer review is an independent check on the quality of the Investigation Report and must be done for all H and E category incidents, as described in Table 2.
Investigation teams can easily lose direction or objectivity, especially for long and complex investigations. “Fresh eyes” looking over the report can provide valuable input. However, it is the Investigation Team which makes the final decision on the content of the report, taking into account the comments of Peer Reviewers.
Step 10 Develop Actions
The Action Plan is the response to the recommendations. It may consist of simple agreement to the recommendations or it may provide more specific detail on what is going to be done. It is acceptable for an action plan to disagree with a recommendation, so long as this is documented together with the reasons and the Client accepts the action plan.
Action plans must be specific and measurable, with responsibilities and target dates for completion specified.
Step 11 Client Signs off on Report and Actions
This is the final step in the investigation process prior to actions being implemented.
Step 12 Implement Actions
Actions must be recorded in the action-tracking system within the DMS and monitored until they are completed.
Standard – Learning From Incidents
APPENDIX B2
Standard List of Contributory Factors
People Slip / lapse - Lapse of attention, Inadvertent omission. Unintentional. Mistake – Lack of knowledge to select the appropriate course of action, (including no knowledge of requirements). Unintentional
Violation – Intentional deviation from understood and accepted standards for whatever reason
Failure to correctly identify hazards Inadequate training
Inadequate communication Inadequate supervision PPE worn but failed to protect PPE standards not complied with
Equipment Failed
Used incorrectly / outside normal operating range Poorly designed / not suited to the task / poorly installed Inadequate maintenance
Hazards not identified
Work
Environment
Restricted work area Poor housekeeping Adverse weather Poor visibility
Inadequate assessment of conditions
Procedures Do not exist
Exist, but inadequate / inaccurate Exist, but not followed
Exist, but impractical / unrealistic Exist, but not known/not understood Risk assessment inadequate / not done “Management of change” process failure
Standard – Learning From Incidents
APPENDIX B3
Template for Hard Copy Investigation Report for incidents with H or E severity
Cover Page Executive Summary Investigation Scope Investigation Team Investigation Process Description of Incident Other Relevant Information Discussion
Findings
Summary of Immediate and Underlying Contributory Factors Recommendations
Standard – Learning From Incidents
APPENDIX C
Flowchart and Template for EHS Lessons Learned Bulletin
Flowchart for Preparation and Distribution of Lessons Learned Bulletins Using Public Folders
LLC = Lessons Learned Coordinator LLB = Lessons Learned Bulletin
Permissions:
All WMC has permission to read the EHS Lessons Learned Public Folder Only LLCs have permission to write to it
LLB opportunity identified by anyone in WMC and info provided to Site LLC
Site LLC prepares LLB and, if required, gets site approval to send off site
LLB received by Corp LLC. Reviews, edits, etc and prepares it for distribution in liaison with relevant personnel (site and / or corp)
Corp LLC sends LLB to relevant Site LLCs, EHS people and GMs, as well as to Public Folder
Upon receipt, Site LLC sends LLB to relevant people on site, with appropriate instructions & / or requests for response
Site LLC prepares response on findings & / or actions taken (including no actions taken) and sends to Public Folder and to Corp LLC
