Meraux Refinery

TITLE:

INCIDENT REPORTING ANDINVESTIGATION PROCEDURE

PURPOSE:

Establish requirements for identifying, reporting,and investigating incidents, or potential incidents, in or near the refinery.This procedure will be utilized by employees and/or contractorsand apply to circumstances resulting from, or with the potential for; releases, injury, equipment or property damage, security breaches, health exposures, environmental episodes and community complaints.

GOALS:

The goal of this policy is to provide a common procedure for reporting an incident or accident and tracking the investigation so the causes of the incident are accurately established and communicated to the organization. Importantly, the findings shall be available as a learning tool forthe organization to minimize the possibility of reoccurrence of an event in the future. It is also the goal of this document to ensure that the plant’s incident investigations are in compliance with the OSHA PSM regulation, 29 CFR 1910.119 (Attachment “A”).

DEFINITIONS:

Incident-An unplanned, undesired event that resulted in, and/or has the potential to result in:

  • aphysical injury
  • an environmental episode, exposure or release
  • community complaint orsecurity compromise
  • damage to equipment, vehicles or facilities.

Near Miss - A potential situation which could lead to an incident.

Severity -Incidents/near misses will be categorized asone of threeLevelseverities, as described inAttachment “B”. The type of investigation required will vary with the incident’s Severity Level, which in summary are:

Level 1.An incident or near miss with consequences which led to or could have caused a first aid injury,minor process equipment damage, or a non-serious and non-reportable release of materials from process equipment.

Level 2.An incident which resulted in a recordable injury, a reportable or significantrelease of material, equipment damage, or exposure to personnel and/or the community

Level 3.An incident or near miss caused by the process or process equipment which did or could have caused severe personnel injury / death or extensive equipment damage, or an incident which involves the release of a highly hazardous chemical which resulted, or could have resulted, in catastrophic consequences.

PROCEDURE:

I. Initial Reporting Guidelines:

A.An employee or contractor observing or involved in an incident, no matter how small, has the responsibility to perform the following steps:

1. Immediately take appropriate corrective action to secure their personal and co-workers safety in accordance with their training.

  1. Immediately initiate medical attention if needed.
  1. Promptly report the incident to immediate Murphy supervisorand provide accurate information from the scene.

4. Initiate and complete theincidentreport with

assistance from their supervisor. Refer to Attachment “D”Near Miss / Incident Report form.

Note: This initial incident report must be completed as soon as possible after the occurrence, and preferably no later than the end of the shift, or work day, on which it occurred.

B. The immediate supervisor has the responsibility

to take thefollowing steps for every incident, regardless of Severity Level:

1.Immediately take action to mitigate or prevent recurrence of the situation. This includes securing medical attention as required.

Promptly notify the appropriate support Department (i.e.Safety, Operations, Environmental, etc.)foradditional assistance ifneeded. Any incident involving a personal injury requires Safety Department notification. Any incident involving an environmental release requires Environmental department notification. Security incidents are reportable directly to the security supervisor on shift.

2. Complete a Level 1 incident investigation before leaving work. This should be conducted jointly with the employee (or contractor). This may requireovertime!

Note: If it is not possible to complete a Level 1 incident investigation on-shift, then it is the responsibility of the relevant departmental next level of supervision (Superintendent) to schedule the affected personnel to conduct the Level 1 investigation as soon as it is practical.

3. Forward the report to the relevant departmental next level of supervision no later than the end of the shift or work day.

II.Incident Investigation Guidelines:

  1. The objective of any investigation is to identify the consequences, secure the immediate and future safety of personnel, discover the causes and contributing factors, document emergency response actions, and recommended actions that will minimize the probability a reoccurrence of the event.
  1. Themethodologies for an investigation are established by the incident’s Severity. Specifics of the methodologies for the three Severity Levels are itemized in Attachment “C”.

Level 1:For all incidents(all levels), regardless of Severity, the immediate supervisor has the responsibility to complete a Severity Level 1 investigation with the individuals involved in the event, using Level 1 investigation methods on the same work day as the event. Severity Level 1 incidents require subsequent approval by the Superintendent level (or equivalent) in the respective department. On off-hours and holidays, the immediate supervisor is the shift supervisor.

Level 1 incidents are reportable using SSP-0032 Attachment "D", Near Miss / Incident Report. The immediate supervisor is responsible for insuring that Sections 1 through 3 of the Near Miss / Incident Report have been completed on-shift, for signing approval in Section 4 and listing the team members, and for submitting the form to the Superintendent (or equivalent) when completed. The Superintendent (or equivalent) will review the report and recommendations, determine if additional investigation is necessary, sign approval, and then forward the report to the PSM Manager (preferably the same day) so that the report can be placed on the intranet and communicated to employees. The Superintendent (or equivalent) is responsible for insuring that the recommendations resulting from the investigation are promptly addressed and resolved. The PSM Manager is responsible for tracking the recommendations to completion.

Level 2: These investigations require the Superintendent (or equivalent) to complete a Level 2 investigation, using Severity Level 2-3 investigation methods, in addition to the Level 1 investigation conducted by the on-shift personnel. The subsequent Level 2 incident investigation must commence within 48 hours of occurrence.Investigations are to be conducted by a team assigned by the Superintendent (or equivalent) which may include, but not be limited to, the immediate supervisor(s) of the employee(s) involved, and representatives from the Maintenance,

Safety and/or PSM Departments. The investigation team will include a union employeetrained in incident investigation. If contractors are involved, the contract employee, the contractor safety representative, and/or the contractor’s management shall participate.

Level 2 incidents are reportable using SSP-0032 Attachment "E", Level 2-3 Incident Investigation Report, in addition to the Level 1 report completed on-shift. When complete, the Superintendent (or equivalent) will notify the PSM Manager, who will schedule an Incident Review Committee Meeting, where the Superintendent (or designee) will present the results of the investigation to the Plant Leadership Team.

Level 2 incidents require approval by the Operations Area Superintendent, the Maintenance Area Superintendent, Department Manager (or equivalent) in the respective department, as well as the Refinery Manager. Upon approval, the PSM Manager will post the investigation report on the intranet for access by employees.

The Superintendent (or equivalent) is responsible for insuring that the recommendations resulting from the investigation are promptly addressed and resolved. The PSM Manager is responsible for tracking the recommendations to completion.

Level 3: The Refinery Manager will assign an investigation team leader to conduct a Level 3 investigation, using Severity Level 2-3 investigation methods, in addition to the Level 1 investigation conducted by the on-shift personnel. The subsequent Level 3 incident investigation must commence within 48 hours of occurrence.

The investigation team leader will assemble an investigation team which may include, but not be limited to, the immediate supervisor(s) of the employee(s) involved, and representatives from the Maintenance, Safety and/or PSM Departments. The

investigation team will include a union employeetrained in incident investigation. If contractors are involved, the contract employee, the contractor safety representative, and/or the contractor’s management shall participate. The assembled team will have members who have the appropriate knowledge and experience to thoroughly analyze the incident or near miss. This includes knowledge and experience in conducting an incident investigation as well as knowledge and experience in the process unit and its associated equipment.

Level 3 incidents are reportable using SSP-0032 Attachment "E", Level 2-3 Incident Investigation Report, in addition to the Level 1 report completed on-shift. When complete, the investigation team leader will notify the PSM Manager, who will schedule an Incident Review Committee Meeting, where the investigation team leader will present the results of the investigation to the Plant Leadership Team.

Level 3 incidents require approval by the Operations Area Superintendent, the Maintenance Area Superintendent, Department Manager (or equivalent) in the respective department, as well as the Refinery Manager. Upon approval, the PSM Manager will post the investigation report on the intranet for access by employees.

The Superintendent (or equivalent) of the affected area is responsible for insuring that the recommendations resulting from the investigation are promptly addressed and resolved. The PSM Manager is responsible for tracking the recommendations to completion.

  1. Investigation Team responsibilities:
  1. When any incident or near miss occurs the involved employees shall initiate the Near Miss / Incident Report, and participate in an on-shift investigation.
  1. Secure the incident or near miss site to allow proper collection of facts, samples, site conditions data, and other pertinent information until the root causes and conclusions of the investigation are completed.
  1. Conduct interviews as soon as possible after the incident.
  1. Photograph the incident site and evidence, if applicable(camera permit required). (This will be valuable if information is needed at a later date)
  1. Analyze the event(s) to determine:
  1. The time line, if deemed necessary by the team leader, defines events leading up to incident or near miss, and subsequent actions taken after the occurrence.
  1. Contributing factors tothe incident.
  1. The Root Cause of the incident.Incident investigations shall be aimed at fact-finding using standardized methodologies. Initial findings may only be symptoms of other underlying factors.

  1. Recommend the most effective long term corrective action and provide direction for short term actions toeliminate repetition of similar incidents or near misses. Assignment of responsibilities for resolving recommendations will be done by the appropriate Department Manager.
  1. Submitthe final report detailing the findings of the team based on the above activities.
  1. The Corporate office may elect to participate, assist or lead any investigation.
  1. Finalizing Incident Investigations and Communication of Findings:
  1. Every incident investigation, regardless of Severity Level, will conclude its investigation with a report gatheringthe conclusions of the investigation. The Severity Level will dictate the methodology and content of the report. Investigation reports shall be retained for 5 years.
  1. Department Managers have specific responsibilities depending on the incident Severity:

Level 1; periodically audit findings, reports and investigation methods to assure the investigation standards are maintained for those personnel participating in incident investigations.

Level 2; review and approve the Investigation report(s) submitted to them for approval. Participate as required in the incident investigation.

Level 3; lead or participate in the incident investigation as assigned by the Refinery Manager.

  1. Communication:

Each Department Manager shall assure the findings and lessons learned are effectively communicated via E-mail to their department staff and utilized contractors. The findings will also be posted on Intranet web forother refinery employees. The Department Manager is responsible to allocate authorized resources and follow-up on recommendations arising from incident investigations.

Issued by:Doug Frueh

PSM Manager

Approved by: Bill Turnage

Safety & Security Manager

Approved by:Lynn Bourgeois

Refinery Manager

Revisions made to:

  1. Attachment “D” – Near Miss / Incident Report