Accident Reporting and Investigation LESSONS LEARNED BiWeekly Safety

Accident Reporting and Investigation LESSONS LEARNED Bi-Weekly Safety Meeting March 8, 2012

Accident Investigation • The purpose of any investigation procedure is to attempt to establish the facts surrounding a reportable occurrence (referred to as ‘event’) so that corrective action, if necessary, can be taken to prevent its re-occurrence. An investigation will involve: – Collecting data concerning the accident – Identifying injuries, property damage, and losses that resulted from the accident – Putting in place measures for preventing the event from re-occurring

Accident Investigation A reportable occurrence or ‘event’ can include: First Aid Recordable Injury Near Miss Chemical Exposure Equipment Damage Production Interruption/Loss Vehicle Citations Vehicle Accidents Theft Vandalism

Accident Investigation • The focus is to filter through the information surrounding the event to determine why it occurred. • Pertinent facts are gathered: date, time, circumstances, environmental conditions, and other factors. • Individuals associated with the event under investigation are interviewed. Who, When, Where, How and Why, and only the facts

Safety ‘Flash’ Report • The method for reporting an occurrence is Mangan’s Flash Report, mi-2105, Safety (Flash) Report • The form is located on the ADP Portal under Safety Forms.

Safety ‘Flash’ Report • The report is ‘flashed’ (forwarded) to your: – – Supervisor or Project Manager Operations Manager Regional Director and Safety at safetytraining@manganinc. com • Management can determine any actions that are in the best interest of the employee(s), clients, or others involved. Most of our clients have requirements for reporting any of these situations and it is our contractual obligation to adhere to their policies.

Lessons Learned • Incidents can then be shared as a “lessons learned” to inform and educate others • The goal is to prevent the incident from occurring again in the future. Following are some Mangan “Lessons Learned” from 2011…

Mis-communication of Live Electrical Exposure • During HCU Turnaround / Cutover execution there was potential for a hazardous (live electrical circuits) situation that was not communicated to the cutover field lead or the cutover lead until well after the fact.

Miscommunication of Live Electrical Exposure • The Mangan engineer who was working with client contractor electrician did not specifically inform the electrician of the potential for live power. • The Mangan engineer was not at the panel when the electrician became aware that there was live electrical in the panel.

Miscommunication of Live Electrical Exposure • The Mangan PM heard from the night shift that the potential hazard had occurred and may require a client incident formally filed just prior to the 6 AM meeting. • The Mangan PM on his way to the meeting took this information as fact and made an incorrect assumption. • There was no formal report or corrective action created but rather a communication breakdown.

Miscommunication of Live Electrical Exposure • Determined Cause / Lessons Learned – Failure to follow cutover communication steps and incomplete communication of roles/responsibilities/communication steps.

Miscommunication of Live Electrical Exposure • Follow Through - the following was communicated to all field personnel: • All safety issues, near misses, incidents, or otherwise will be communicated to the field lead and/or the cutover lead in order to insure proper reporting. This also ensures all parties are aware of potential harmful situations. • In addition, it is advised to refrain from such conversations until all facts are known and confirmed. All suspected incidents that are related to safety or risk should be fully investigated in a timely fashion.

H 2 S Monitor Alarm Event • During HCU Turnaround a client electrical contractor instrument tech was working to install an instrument on the V-997 tower (High Pressure Separator) when his H 2 S monitor went off.

H 2 S Monitor Alarm Event • He exited the tower and spoke to his foreman who notified the client Field Operator and Mangan engineer. • The Mangan engineer radioed to the Mangan console lead who informed the console operator of the occurrence.

H 2 S Monitor Alarm Event • The area H 2 S monitor screen showed a 0 ppm reading on the sensor at the base of the HP Separator. • The field operator climbed the tower to inspect and cleared the tower for re-entry. • The electrical instrument tech chose not to re-climb the tower until he was debriefed by his supervisor.

H 2 S Monitor Alarm Event • Determined Cause – Probable H 2 S puff caused when the tech was working on the new instrument. • Follow Through – Proper preventative action was taken. H 2 S monitor was worn and the tech followed proper procedure to exit the location to a safe area and notify operations and the cutover team. – Reinforce need for H 2 S monitors and good communication during shift change meeting.

Forklift Boom Hits Wall • Solar employees were working in the receiving area of the client facility with a 40’ boom lift during installation of the inverter. • While rotating the boom lift to the left it came in contact with the wall.

Forklift Boom Hits Wall • Determined Cause – There was a 4” conduit over mezzanine. The area was tight and when boom lift was rotating left it was too close to the wall. • Lessons Learned – Pay better attention to obstacles – Move slow in tight spaces – Utilize spotter

Crane Work Overhead • The Mangan employee wanted to enter client building 8 to connect to the PA 10 PLC. • It was noted that there was presence of the crane in the alley near the entrance (truck and boom), and the area was taped off. • The employee was informed that they could use the door on the other side of the building.

Crane Work Overhead • The sign on the east PA 9 door said do not enter because of the crane work. The sign on the east PA 10 door said entry was available through PA 6. • The employee was aware of previous crane and recent floor work in PA 6, so entered through PA 10 11: 00 am. • The employee left the building around 11: 15 am.

Crane Work Overhead • When the employee attempted to re-enter around 11: 30 am, they were stopped and warned that the whole building had been evacuated for the crane work.

Crane Work Overhead • The employee was not aware that the east PA 10 door should not be used for entry, until they were told so around 11: 30 am as they were about to re-enter. • The employee then waited to re-enter until after the crane had departed.

Crane Work Overhead • Determined Cause / Lesson Learned – The employee had insufficient information, and didn't seek clarification of the signage. – The sign on the door only warned them away from entering PA 9, but not PA 10, because of the crane work. • Follow Through – The client determined the following follow through steps: • Post a sign at the front

Crane Work Overhead • Client Follow Through – Post a sign at the front desk when a crane is on site notifying visitors and contractors which areas are restricted access – Add a line item in expectations during crane lift checklist to remind the crane operator to put a sign at front desk – Take a look at SOP’s and determine whether or not verbiage is sufficient to prevent a re-occurrence – Formulate a contractor orientation plan – Request better signage for building access door to PA -10.