Process Work Instruction
Doosan Turbomachinery Services
QH&S Investigation
Form #:
DTS-PRO1031
Approved By:
GDT
Revision #:
2
Approval Date:
11/6/17
1
This Form and it's contents are
intellectual property of Doosan
Turbomachinery Services, Inc. This form,
reproductions nor information derived
from it shall be used or distributed
without express written consent of DTS
Sr. management.
Purpose
This procedure has been established to:
a) Implement and maintain a system to identify and prevent incidents resulting in OH&S nonconformities.
b) To provide for a method to address nonconformities and taking actions to mitigate their health and safety impacts.
c) To provide for a method for investigating incidents, determining their causes, and taking remedial actions to avoid
their recurrence, evaluating the need for actions to prevent nonconformities and implementing appropriate actions
designed to avoid their occurrence.
2
Scope
The scope of this procedure includes all occupational innless, injury, and near miss reports within the company.
3
Responsibility
a)
QHSE Management Representative – to head all investigations and train personnel yearly or as needed in their
responsibilities and incident investigation techniques. Training requirements relative to incident investigation and
reporting:
1. Awareness
2. First Responder
3. Investigation
b) Shop Supervisor/Forman – to participate in the investigation and to help determine the root cause
c) Affected Employee – to report all occupational illness, injuries, and incidents to their direct supervisor as soon as
possible
4
Definitions
a)
5
Nonconformity - a non-fulfillment of a requirement and includes the incidents of complaints from the public,
reportable incidents (such as injuries), health and safety alerts, emergency events, and failures to comply with
OH&S policy or procedures.
References and Forms
5.1 References
a) DTS-PRO1041 OH&S Reporting and Recordkeeping
b) DTS-PRO1004 Control of Nonconforming Products and Process
c) DTS-PRO1006 Corrective and Preventative Action
5.2 Forms
a) DTS-GEN1028 OH&S Investigation
b) DTS-GEN1009 Nonconformance Report
c) DTS-GEN1018 Corrective and Preventative Action Report
6
Procedures
•
•
In the event of an Occupational Illness, Injury, Near Miss, or other significant incident the affected employee is to
immediately notify their direct supervisor, if they are not available, they are to notify anyone in a leadership position.
It is the job of the direct supervisor to assess the situation and determine if medical care is necessary. The QHSE
Management Representative is to be notified for all reports of OH& incidents.
Page:
1 of 3
Process Work Instruction
Doosan Turbomachinery Services
QH&S Investigation
Form #:
DTS-PRO1031
Approved By:
GDT
Revision #:
2
Approval Date:
11/6/17
•
•
This Form and it's contents are
intellectual property of Doosan
Turbomachinery Services, Inc. This form,
reproductions nor information derived
from it shall be used or distributed
without express written consent of DTS
Sr. management.
Responsibilities for incident investigations are assigned prior to the occurrence of any incident and QHSE
Management Rep will head all investigation with the help from shop supervisors and employees as needed.
All OH&S incidents merit investigation to the appropriate level with regards to incident severity. While all incidents
should be investigated, the extent of such investigation shall reflect the seriousness of the incident utilizing a root
cause analysis process or other similar method. The OH&S Investigation form, DTS-GEN1028, shall be used for every
investigation.
6.1 Completing the Investigation
6.1.1
Investigation Kit
QHSE Manager has and always will have a kit containing the following items to help assist with the investigation:
• Pens/Paper
• Measurement Equipment (Tape Measures and Rulers)
• Camera
• Small Tools
• Audio Recorder
• PPE
• Marking Devices (Flags or Tape)
• Equipment Manuals
6.1.2
•
•
•
•
6.1.3
First Report of Injury or Illness
The first Report of Injury or Illness shall be completed and submitted to HR as soon as possible within a maximum of
three days from the date of the onset of the injury or illness.
Required incidents must be reported to OSHA or other applicable regulatory agency(s) within 8 hours of their
discovery. Incidents must also be reported to the client as soon as possible, or in a timely manner (within 24 hours
of incident).
Immediately look for and take note of initial identification of evidence following the incident which may include a
listing of people, equipment, and materials involved and a recording of environmental factors such as weather,
illumination, temperature, noise, ventilation, and physical factors such as fatigue, age, and medical conditions.
Evidence such as people, positions of equipment, parts, and papers must be preserved, secured, and collected
through notes, photographs, witness statements, flagging, and impoundment of documents and equipment.
Summary Sheet
The summary sheet is completed after the investigation has been completed, and is the top page of the investigation folder.
6.1.4
•
•
HSE/Management Investigation Sheet
This page is to be completed by either the QHSE Management Representative or a member of management. Page
2 of this section contains OSHA REQUIRED questions and must be completed. Ensure that specific yet concise detail
is given. Page 3 of the investigation is a tool used to identify OH&S Nonconformance’s and Corrective Actions (submit
corresponding NCR’s on form DTS-GEN1009, and CAR’s DTS-GEN1018). The attached cause and effect diagram may
be used to investigate further, but is not required.
Witness interviews and statements must be collected. Locating witnesses, ensuring unbiased testimony, obtaining
appropriate interview locations, and use of trained interviewers should be detailed. The need for follow-up
interviews should also be addressed.
Page:
2 of 3
This Form and it's contents are
intellectual property of Doosan
Turbomachinery Services, Inc. This form,
reproductions nor information derived
from it shall be used or distributed
without express written consent of DTS
Sr. management.
Process Work Instruction
Doosan Turbomachinery Services
QH&S Investigation
Form #:
DTS-PRO1031
Approved By:
GDT
Revision #:
2
Approval Date:
11/6/17
6.1.5
Department Supervisor Investigation Sheet
This sheet shall be completed by the immediate supervisor of the affected employee.
6.1.6
Statement Sheets
Employee statements and witness statements are available to be completed, but not required.
6.2 Lessons Learned
•
•
Lessons learned will be reviewed and communicated.
Changes to processes must be placed into effect to prevent reoccurrence or similar events.
Page:
3 of 3