Incident Investigation Reporting Rev.1.03

Procedure 2.32.2.1.02.
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QATAR STEEL COMPANY Established 01-Jan-2002
Effective date 01-Mar-2021
(QPSC) Revision 1.03
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PROCEDURE
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Incident Investigation and

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Reporting
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Prepared by:
Incident Investigation and Reporting HSE Department
Page 1 of 32 Issued by:
HSE Department
Procedure 2.32.2.1.02.01
REVISION HISTORY
Revision Date Date to be

Issue Date Amendment Description
No. Effective Revalidated
00 01-Jan-2002 First Issue 01-Jan-2002 14-Oct-2003
01 14-Oct-2003 Re-Issue 14-Oct-2003 01-Nov-2005
02 01-Nov-2005 Re-Issue 01-Nov-2005 01-Apr-2008
03 01-Apr-2008 Qatar Steel Logo change 01-Apr-2008 01-Apr-2011
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01-Apr-2011 Checked & found OK 01-Apr-2011 10-Sep-2013
Revised as per OHSAS 18001 & Online incident-
04 10-Sep-2013 10-Sep-2013 28-Jun-2015
tracking system included.
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Section 4.2.13 & 4.2.14 added in Employees
05 28-Jun-2015 28-Jun-2015 17-Aug-2016
responsibilities.
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Section 4.2.2.3a added in Area In-Charge
1.00 17-Aug-2016 17-Aug-2016 16-Aug-2019
responsibilities
1.01 16-Jan-2018 Full revision of procedure
ED 16-Jan-2018 11-Nov-2019
1.02 01-Jan-2020 Update of template and company acronym 01-Jan-2020 31-Dec-2022

Full revision of the procedure
1.03 01-Mar-2021 Section 7.2 Requirements of a Team leader. 01-Mar-2021 28-Feb-2024
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Section 7.8 Mothballing plant - Incidents reports status
categorized as ‘Closed’ due to mothballing
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Procedure 2.32.2.1.02.01
TABLE OF CONTENT
REVISION HISTORY
TABLE OF CONTENTS
1 INTERNAL CONTROLS ............................................................................................................. 5

1.1 Review of Procedure…………………………………………………………………………...4
1.2 Employee Responsibilities……………………………………………………………………..4
1.3 Approval…………………………………………………………………………………….….4
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2 PURPOSE… .................................................................................................................................. 6
3 SCOPE……. .................................................................................................................................. 6
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4 PROCEDURE ................................................................................................................................ 7
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4.1 Introduction ............................................................................................................................. 7
4.2 Abbreviations .......................................................................................................................... 7
4.3
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Definitions ............................................................................................................................... 8
5 CLASSIFICATION ..................................................................................................................... 13
5.1 Type of Event / Observation ................................................................................................. 13
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5.2 Type of Outcome ................................................................................................................... 13

5.3 Severity of Event ................................................................................................................... 13
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5.3.1 Actual Severity Level .................................................................................................... 13

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5.3.2 Potential Severity Level ................................................................................................. 13

5.4 Risk Ranking ......................................................................................................................... 14
6 ROLES AND RESPONSIBILTIES ............................................................................................ 15
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7 INCIDENT INVESTIGATION AND REPORTING PROCESS FLOW ................................... 20

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7.1 Step 1 – Initial Response ....................................................................................................... 20

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7.1.1 Initial Response .............................................................................................................. 20

7.1.2 Notification .................................................................................................................... 21
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7.1.3 Communication of learnings .......................................................................................... 22

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7.1.4 Classification of Incident ............................................................................................... 22

7.2 Step 2 – Form Investigation Team ........................................................................................ 23
7.3 Step 3 – Determine the Facts................................................................................................. 24
7.4 Step 4 – Determining Key Factors ........................................................................................ 28
7.5 Step 5 – Determining Systems to be strengthened ................................................................ 28
7.6 Step 6 – Recommending Corrective and Preventive Actions ............................................... 28
7.7 Step 7 – Document & Communicate Findings...................................................................... 29
7.8 Step 8 – Follow up ................................................................................................................ 30
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Procedure 2.32.2.1.02.01
8 CONTINUOUS IMPROVEMENT ............................................................................................. 31

9 REFERENCES ............................................................................................................................ 31
10 MANAGEMENT OF CHANGE ................................................................................................. 31
11 APPENDICES ............................................................................................................................. 32
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Procedure 2.32.2.1.02.01
1 INTERNAL CONTROLS
1.1. Review of Procedure
To assure Managements, Shareholders and External agencies confidence in the company's policies &
practices, QATAR STEEL Internal Audit may verify compliance with this procedure. [Department
Owner] shall review this procedure every three years to ensure that it continues to serve the purpose
intended.
1.2. Employee Responsibilities
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All employees of the company are required to observe and abide with this procedure.
1.3. Approval
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This procedure and any amendments made thereto; require the following approvals.
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Procedure 2.32.2.1.02.01
2 PURPOSE
The purpose of this procedure is to describe the reporting and investigation of incidents in Qatar
Steel with the aim of preventing incidents occurring and continuous improvement of HSE systems
by:
 Identifying and implementing actions to prevent incident recurrence,
 Promoting an atmosphere of openness by improving communications and understanding
about the incident,
 Identifying conditions that could potentially contribute to the occurrence of future incidents
and providing an opportunity to share this information broadly within Qatar Steel.
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 Providing input to the development and improvement of HSE policies, procedures,
guidelines, and standards.
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3 SCOPE
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This procedure outlines the process for investigating, reporting and communicating incidents for
Qatar Steel employees, contractors and visitors. It is applicable to all incidents occurring at Qatar
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Steel facilities and Doha offices, including:
a) Personal Injury (Occupational Health and Safety injuries and illnesses to Qatar Steel
employees, contractors and visitors at Qatar Steel premises)
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b) Environmental release
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c) Near miss
d) Unsafe conditions
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e) Explosion / Fire
f) Property Damage
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g) Unsafe act
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h) Vehicle incidents (Employee / visitor transportation provided by Qatar Steel i.e. Qatar Steel
Buses, Qatar Steel contractor vehicles within Qatar Steel premises)
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i) Other violations (e.g. security incidents)

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HSE Department
Procedure 2.32.2.1.02.01
4 PROCEDURE
4.1 Introduction
Incident investigation is the process of identifying the underlying causes of incidents and remedial
steps to be taken to prevent similar events from occurring again. The objective of an incident
investigation is for employees to learn from experiences and thus avoid repeating past mistakes.
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4.2 Abbreviations
COD Change of Design
ERP Emergency Response Plan
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HSE Health Safety & Environment
ITS Incident Tracking System
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LTI Loss Time Injury
MD & CEO Managing Director & Chief Executive Officer
MIC Mesaieed Industrial City
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MME Ministry of Municipality and Environment
MTC Medical Treatment Case
CO Chief Officer
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PHA Process Hazard Analysis
PPE Personal Protective Equipment
PSSR Pre-startup Safety Reviews
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PSM Process Safety Management

QAR Qatari Riyal
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RCA Root Cause Analysis

RWC Restricted Workday Case
TA Test Authorization
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YTD Year to Date

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HSE Department
Procedure 2.32.2.1.02.01
4.3 Definitions
Table 1: Definitions of terms used throughout the procedure
Term Definition
Incident An unplanned or unusual event and circumstances that result in, or

have the potential to result in, an undesirable consequence
An incident may be categorized as either an “accident” or a “near

miss”.
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Accident Any event that has resulted in injury or damage to a person, property
or equipment such as the following that result in undesirable
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consequences:
 Injuries/illnesses that have a serious adverse effect on
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employee health or safety
 Significant environmental impact
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 Unfavorable impact on the public
 Significant property damage including all fires/explosions
An unplanned or uncontrolled event or chain of events that has not

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Near Miss
resulted in recordable injury, illness, asset damage or environmental
damage but had the potential to do so in other circumstances
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(incident has occurred).

 A person trips over an object and falls to the ground but did
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not get injured

 A person has to dive or jump out of the way to avoid a
collision with a motorized vehicle, a moving object like a
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suspended part on a conveyor or from an uncontrolled

suspended load
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 A person has to jump from a falling ladder

 Any emergency equipment (fire extinguisher, Air Pack,
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Oxygen sensor, eye wash, etc.) fails to operate properly

when called on in an emergency.
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Unsafe Act Any act or omission by an individual that poses a risk of injury or
damage, such as breaching a safety procedure, or the failure to act
upon an unsafe condition. Examples may include:
 Not reporting an unsafe condition and leaving a hazard for
someone else,
 Failure to follow health and safety procedures or failure to
wear the specified PPE.
Unsafe Any situation that could result in injury or damage to people,
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Term Definition
Condition property or equipment. Examples may include:
 Dangerous item left as an obstruction or a confusing or

misleading procedure/works instruction.
Recordable All work-related incidents resulting in a fatality, an injury requiring

injury time off work (LTI), a restriction in the work performed (RWC), or
an injury requiring medical treatment (MTC) or a First Aid Case.
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Personal Any injury such as a cut, fracture, sprain, amputation, which results
Injury from a work-related activity or from an exposure involving a single
incident in the work environment, such as deafness from explosion,
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one-time chemical exposure, back disorder from a slip/trip.
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Fatality Cases that involve one or more people who died as a result of a
work-related incident or occupational illness. ‘Delayed’ deaths that
occur after the incident are to be included if the deaths were a direct
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result of the incident. For example, if a fire killed one person
outright, and a second died three weeks later from lung damage
caused by the fire, both shall be reported.
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Lost Time Non-fatal cases that involve a person being unfit to perform any
Injury (LTI) work on any day after the occurrence of the injury or occupational
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illness. ‘Any day’ includes rest days, weekend days, leave days,
public holidays or days after ceasing employment.
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Restricted Cases that do not result in a fatality or a LTI but do result in a person
Workday Case being unfit for full performance of the regular job on any day after
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(RWC) the injury or occupational illness e.g. punctured ear drums, fractured
ribs or toes. Work performed might be:
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 Assignment to a temporary job

 Part-time work at the regular job
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 Working full-time in the regular job but not performing all

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the usual duties of the job.

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Medical Cases not severe enough to be reported as fatalities, LTI or RWC

Treatment but when the management and care of the patient to address the
Case (MTC) injury or illness is above and beyond first aid treatment.
MTC includes treatment of injuries administered by physicians,

registered professional personnel, or lay persons (i.e. non-medical
personnel).
Examples of MTC:
 Any loss of consciousness
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HSE Department
Procedure 2.32.2.1.02.01
Term Definition
 Needle stick injuries and cuts from sharp objects that are
contaminated with another person’s blood or other
potentially infectious material
Examples of non-MTC:
 First aid treatment (one-time treatment and subsequent
observation of minor scratches, cuts, bumps, splinters, and
so forth, which do not ordinarily require medical care)
even though provided by a physician or registered
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professional personnel.
First Aid Cases not sufficiently serious to be reported as MTC or more
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Accident serious, but nevertheless requiring first aid treatment, including the
following:
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 Using a non-prescription medication at non-prescription
strength
 Cleaning, flushing or soaking wounds on the surface of the
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skin
 Using wound coverings such as bandages, Band-Aids,
gauze pads (other wound closing devices such as sutures,
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staples, surgical glue, are considered medical treatment)

 Using hot or cold therapy
 Using any non-rigid means of support, such as elastic
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bandages, wraps, non-rigid back belts (devices with rigid

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stays or other systems designed to immobilize parts of the

body are considered medical treatment for recordkeeping
purposes)
 Using temporary immobilization devices while transporting
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an accident victim (e.g. splints, slings, neck collars, back

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boards)
 Drilling of a fingernail or toenail to relieve pressure, or
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draining fluid from a blister

 Using eye patches
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 Removing foreign bodies from the eye using only irrigation

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or a cotton swab
 Removing splinters or foreign material from areas other than
the eye by irrigation, tweezers, cotton swabs or other simple
means (needles, pins or small tools to extract splinters would
generally be included)
 Using finger guards
 Using massages (physical therapy or chiropractic treatment
are considered medical treatment for recordkeeping
purposes)
 Drinking fluids for relief of heat stress.
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HSE Department
Procedure 2.32.2.1.02.01
Term Definition
Explosion/ Any combustion, regardless of the presence of flame. This includes

Fire electrical arcs that involve a subsequent fire or evidence of
combustion. Evidence of combustion includes flames, smoke,
charring or carbonizing that are uncontrolled and not part of the
process.
Security Any event that threatens or actually impacts the security of Qatar
Incidents Steel staff, assets, confidential information or business continuity
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arising from sabotage, political or social upset, organized crime.
Examples include:
 Unauthorized access or intruder on a Qatar Steel site
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 Theft from a Qatar Steel site or personnel engaged in
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controlled activities
 Criminal damage to Company property
 Physical harm / Receipt of threats (verbal or written)
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 Significant protest or demonstration at a controlled or
monitored site
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Environmental Any unplanned event that has an adverse impact upon the quality of
Release air, land, water, wildlife for example:
 Sudden and uncontrolled liquid / gaseous release
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 Exceedance / breach of permit or external reporting

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requirement
 Waste management (escape or improper storage/disposal).
Controlled release of gases or liquid through maintenance shall not

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be considered incidents, and are thus not reportable provided they

are within regulatory permit conditions. If outside regulations, the
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release shall be recorded as an environmental incident.

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Property An event which results in damage to equipment, building,

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Damage structures, vehicles etc.

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Any crash involving a Qatar Steel Employee or visitor transportation

Vehicle
provided by Qatar Steel i.e. Qatar Steel Buses, Qatar Steel Contractor
Incidents
vehicles within Qatar Steel premises.
Other Other events not covered by the definitions provided above e.g.
Violations Process Safety incidents
Non-industrial Any potential or actual harm or damage (including death) to the

Incident body resulting from external causes that does not arise on Qatar
Steel premises.
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HSE Department
Procedure 2.32.2.1.02.01
Term Definition
Risk The Risk Assessment Matrix is a tool that standardizes qualitative

Assessment risk assessment, facilitates the Qualitative categorization of HSE
Matrix risks and, where appropriate, used for prioritization of activities and
resources. The matrix axes, consistent with definition of risk, are
Consequences (Impacts) and Probability (Likelihood).
Root Cause The most basic causes that can reasonably be identified, for which
effective corrective actions for preventing recurrence can be
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generated. These causes are most often imbedded in the systems of
the organization.
Repeat incidents are defined as events that meet the following
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Repeat criteria:
Incidents  Previously occurred at the same site/operation and was
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investigated and,
 Involved the same activity and,
 Occurred as a result of exposure to a similar hazard and,
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 Occurred as a result of a similar immediate or root cause.
Note that all 4 criteria must be satisfied for a repeat incident

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classification.
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Procedure 2.32.2.1.02.01
5 CLASSIFICATION
Accidents and near misses are classified according to the following criteria.
5.1 Type of Event / Observation

1) Accident
2) Near Miss
3) Unsafe Act
4) Unsafe Condition
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5.2 Type of Outcome
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a. Personal Injury
b. Environmental Release
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c. Explosion / Fire
d. Property Damage
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e. Vehicle Incident
f. Other (e.g. Security)
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5.3 Severity of Event

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The actual and potential severity of each accident and near miss is classified in alignment with the
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level of consequence to People, Assets and Production, Environment and Reputation as outlined
in the Qatar Steel Risk Matrix.
The severity level determines the level of response with respect to the investigation methodology,
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who investigates and reports, who is informed, and who reviews/approves investigations.
In instances where an accident/near miss has multiple potential effects, the most severe shall
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prevail and injury to personnel has priority over other effects when other severities are equal.
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5.3.1 Actual Severity Level

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Assess the actual severity in each of the categories in Tables 2 - 5 and record the highest level. For
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near miss events, potential severity is used.
5.3.2 Potential Severity Level
The potential severity level is classified by determining the most realistic outcome had the
circumstances been different.
Where a change in circumstances or removal/absence of barriers could have led to a different
outcome, it is necessary to look at the actual circumstances and consider “what might have been”.
In determining the most realistic outcome, effective barriers and protective measures in place
should be considered. Discounting the effectiveness of reliable barriers could cause an over-
estimation of the potential consequence of an incident.
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HSE Department
Procedure 2.32.2.1.02.01
5.4 Risk Ranking

Table 2: People
Potential
Severity People Description
0 No injury No injury or health effect.

1 Slight injury or health First Aid cases or minor discomfort cases e.g. Headache, dust / fumes
effect / gases having irritation in the nose when inhaled - a person can return
back to work after a rest.
2 Minor injury or health Reversible injuries or illnesses requiring Medical Treatment (MTC) or
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effect Restricted Workday Cases (RWC) for 5 days or less but not LTI's. E.g.
loss of consciousness from medical reasons only (e.g. diabetes,
epilepsy, narcolepsy etc.), needle stick injuries and cuts from sharp
objects.
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3 Major injury or health Reversible injuries or illnesses resulting in RWCs for more than 5 days
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effect or LTIs e.g. punctured ear drums, fractured ribs or toes, chronic back
injuries, loss of consciousness from work-related activities e.g. blow
to the head, heat induced.
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4 Single Fatality or Single fatality, permanent disability or irreversible illness such as
permanent total corrosive burns, amputation.
disability
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5 Multiple fatalities Multiple fatalities or multiple irreversible illnesses. A near miss with
potential for multiple fatalities.
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Table 3: Asset damage, Loss of Production

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Potential Asset damage,

Severity Loss of Production Description
0 No damage No financial impact.

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1 Slight damage, No disruption to operation, estimated cost less than QAR 50,000.
(< QAR 50,000)
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2 Minor damage Brief disruption to operation, estimated cost of QAR 50,000 to

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(QAR 50,000 to 500,000

500,000)
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3 Local damage Partial shutdown of operation, estimated cost of QAR 500,000 to

(QAR 0.5M to 5,000,000.
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5,000,000)
4 Major damage Partial loss of operation; estimated cost between QAR 5M to
(QAR 5M to 25,000,000.
25,000,000)
5 Extensive damage Substantial or total loss of operation with estimated cost in excess of
(>QAR 25,000,000) QAR 25,000,000.
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Procedure 2.32.2.1.02.01
Table 4: Environment
Potential
Severity Environment Description
0 No effect No impact to the environment.

1 Slight effect No lasting effect.
Low-level impacts on biological or physical environment, local
environmental risk within the fence and within the system.
Clean up within days.
2 Minor effect Minor short-medium term damage to small area of limited significance.
Single exceeding of statutory or prescribed limits; single complaint; no
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permanent effect on the environment.
Clean up within weeks.
3 Local effect Moderate short-medium term widespread impacts, repeated exceeding
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of statutory or prescribed limits and beyond fence or neighborhood.
Clean up within months.
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4 Major effect Severe environmental damage; Qatar Steel is required to take extensive
measures to restore the contaminated environment to its original state;
extended exceeding of statutory or prescribed limits. Clean up within
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months – years.
5 Massive effect Persistent severe environmental damage or severe nuisance extending
over a large area; in terms of commercial or recreational use or nature
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conservancy, a major economic loss for Qatar Steel; constant high

exceeding of statutory or prescribed limits. Long term clean up required.
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Table 5: Reputation
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Potential
Severity Reputation Description
0 No impact No reputational impact.

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1 Slight impact Public awareness may exist but there is no public concern.
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2 Limited impact Some local public concern; some local media or local political attention
with potentially adverse aspects for Qatar Steel operations.
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3 National impact National public concern; extensive adverse attention in the national
media. Significant difficulties in gaining approvals.
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4 Regional impact Extensive adverse attention in the regional media; regional public and
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political concern. May lose consent to operate or not gain approval.

Management credentials are significantly tarnished.
5 International impact Extensive adverse attention in international media; international public

attention. Consent to operate threatened.
Reputation severely tarnished.
6 ROLES AND RESPONSIBILTIES

All Qatar Steel employees are responsible for obeying the incident reporting guidelines contained
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HSE Department
Procedure 2.32.2.1.02.01
within this procedure. A failure to obey and practice these responsibilities could lead to disciplinary
action. Functional responsibilities are assigned to key personnel as follows:
HSE Manager
 Provides appropriate notification of incidents to external stakeholders (MIC) in the timing

defined in this procedure (after consultation with MD & CEO)
 Reviews Initial Incident Report form for the sufficiency and quality of the information
provided and decides whether a Detailed Incident Investigation with Root-Cause Analysis
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is required for incidents, based on the guidelines provided in this procedure.
 Informs the MD & CEO and CO of any serious incident (as identified in the notification
flow).
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 Approves the Incident investigation task team composition
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 Reviews all Detailed investigation reports for the sufficiency and quality of the information
provided and provides feedback to incident investigation team leader as necessary

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Provides any kind of assistance / expertise throughout incident investigations, as requested
by the Incident Investigation Team Leader
 Support communication of Lessons Learned across Qatar Steel
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 Issues bi-monthly reports to Department Managers and MD & CEO for summary of all
incidents, including bimonthly progress status reports of open action items. Reports are
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issued to the owning Department Manager.

 Reviews the justification for a proposed new action / deadline
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 Ensures that all incidents and corrective actions are maintained in the central database (ITS
system)
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 Supports Line Management in communication of learnings and findings from incidents

with a severity (actual or potential) classified as S3, S4 or S5 as per this procedure
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 In case of personal injury, HSE Manager / Dept. shall follow up that necessary reports to
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Insurance & Human Capital Department have been sent and received by responsible
personnel.
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 Frequently inspects the incidents corrective actions across different departments for
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effectiveness (utilizing the inspection checklist provided in this procedure)

 Formally appoints the Incident Investigation Team Leader and defines the deadline, when
a Detailed Investigation and Root Cause Analysis is to be performed
 Supports the arrangement of adequate resources to support investigations of S4 or S5
severity. This can be in the form of 3rd party support if required.
 Reviews and approves the Detailed Incident Investigation Reports.
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HSE Department
Procedure 2.32.2.1.02.01
HSE Coordinator
 Ensure the shift supervisor secures the incident scene.
 Initiate evidence collection process (statements, measurements, document collection and
photos).
 Receives notification and supports Shift Supervisor in the initial classification of the
incidents
 Coordinates the initial response based on the initial classification of the Incident
 Review initial incident form for the quality/sufficiency of the information and data
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provided.
 Issue the initial incident form through ITS system (if the actual and potential severity is S1
or S2)
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 Participate in incident investigations, providing any kind of assistance / expertise and
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ensure that they are completed within the prescribed time limits.
 Ensure that the incident procedure is adhered to

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Follow-up on implementation of corrective and/or preventive actions.
 Compile a Safety Alert regarding the incident and distribute to Department Managers, as
per instruction.
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 Provides support to HSE Manager in preparation of periodic reports


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Notifies HSE Manager immediately of any serious incidents (classified as actual S3 or

actual & potential S4 or S5)
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Chief Officer
 Reviews and validates a proposed new action / deadline
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 Arranges a routine meeting with all involved parties at regular intervals to discuss the
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progress of incidents action plans and status.

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Managing Director & Chief Executive Officer

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 Notifies the Board of Directors of incidents resulting in a fatality / multiple fatalities.

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 Provides support in the form of reviews and resources in the case that there is an actual S4
or S5.
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HSE Department
Procedure 2.32.2.1.02.01
Department Manager
 Encourages employees and contractors working under him to promptly notify all incidents
and near misses
 Ensures availability of department personnel and appropriate resources for investigations,
as required (is also consulted for alignment on task team membership within his
department)
 Contributes to the detailed incident investigation process if/when required by the Incident
Investigation Team Leader
 Reviews Detailed Incident Reports for the sufficiency and quality of the information
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provided and provide feedback to Incident Investigation Team Leader, as necessary.
 Ensures implementation of all actions related to his area of responsibility and routinely
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monitors and follow up to ensure timely completion as per defined deadlines
 Shares incident reports with all the personnel in his area of responsibilities and actively
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communicate key findings and learnings
 Ensures incidents corrective actions in his area of responsibility are periodically inspected
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for effectiveness
 Reviews the justification for a proposed new action / deadline
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Shift Supervisor
 Upon receipt of initial notification by the Incident Notifier, evaluates and classifies the
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incident, according to the requirements set in this procedure

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 Encourages employees and contractors working under him to promptly notify all incidents
and near misses.
 Secures the incident scene and prevent potential escalation of hazards (e.g. barricaded) and
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preserve the scene to avoid destruction of evidence / reoccurrence of incident and potential
escalation of hazard.
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 Identify initial action to be implemented and assigns actioners

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 Shares incident reports with all the personnel in his area of responsibilities and actively
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communicate key findings and learnings.

 Contributes to the detailed incident investigation process if/when required by the Incident
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Incident Investigation Team

 Actively participate and contribute to the incident investigation process by completing the
tasks assigned by the Incident Investigation Team Leader. For example:
 Attend the meetings and participate to all investigation activities
 Support collection of evidence / facts as agreed with the Team Leader
 Contribute to and/or write the incident investigation report as agreed with the Team Leader
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HSE Department
Procedure 2.32.2.1.02.01
 Complete all actions arising from the investigation that are required to move the
investigation forward as requested by the team leader.
 Ensure confidentiality is maintained during the course of the investigation
 Each Team Member formally represents his function/department in the course of the
investigation process
Incident Investigation Team Leader

 Identifies, together with HSE Manager and in alignment with relevant
department/functions, the necessary Incident Investigation Team Members
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 Plan and lead the detailed incident investigation (and Root-Cause Analysis) as per the
present procedure
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 Ensures systematic identification of root-causes through application of suitable root-cause
analysis methodologies
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 Ensure that appropriate corrective / preventative actions (recommendations) are identified
and agreed with respective functions / departments
ED
 Ensures that the Detailed Incident Investigation Report is completed within defined
timeline and meets the minimum requirements as specified in current procedure

LL
Present the result of the Detailed Incident Investigation to Qatar Steel Management, when
required
Note - Investigation Team Leader is normally a Qatar Steel employee. In specific circumstances,
O
the CO may indicate the need to appoint an external Team Leader to facilitate and lead the
TR
investigation.
Action Owner

N
Ensure that the action is completed and implemented by the due date.
 Inform the Department Manager and HSE Manager when an action is completed and
O
provide evidence and a full description of exactly what was done to fulfil the requirements
of the recommendation. Evidence could be minutes of a meeting an updated procedure, a
C
work order for some engineering work, etc.

N
 Define the action as completed and attach or reference the relevant evidence wherever
possible.
U
Medic / Nurse
 To provide medical care in the case of personal injuries
 Support and advise with incident investigation, including classification of injuries / medical
conditions
 Monitor status of injured persons and liaise with outside hospitals
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
7 INCIDENT INVESTIGATION AND REPORTING PROCESS FLOW

The steps in the process of incident investigation are described as follows:
PY
O
C
ED
LL
O
TR
Figure 1: 8 Step Incident Investigation Process

N
7.1 Step 1 – Initial Response

O
7.1.1 Initial Response

C
 When an incident occurs, it is the responsibility of either an eyewitness, the affected person,
or any other appropriate person with adequate information to notify the Shift Supervisor so
N
that an appropriate and timely response is made.

U
 An initial evaluation is conducted, and classification is made. The initial notification shall
also be provided to the HSE Co-ordinator who will assist the Shift Supervisor in the initial
classification of the incident.
 Immediate actions shall be taken to eliminate or control hazards when an incident occurs.
Depending on the incident, the Emergency Response Plan might be activated, if necessary,
following specific guidelines provided in Qatar Steel ERP procedure.
 The safety of personnel and the surrounding community is the first consideration; however,
in addition to activating the appropriate emergency response to the event, area supervision
must take steps to preserve physical items, computer data, and other relevant information
until the investigation begins.
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
 Preservation of the scene and all potentially relevant physical items, computer data, and
other information is especially critical if the event is serious enough to warrant investigation
by external agencies or the local country authority having legal jurisdiction.
 Steps that should be taken to prevent the disturbance of or tampering with potential
evidence include the following:
o Barricading and securing of the scene, including protecting it from the weather
o Collecting, identifying, and properly storing (i.e., preserving) physical items and
data records
o Photographing the incident scene and equipment, as necessary
PY
o Documenting interviews of key personnel
O
7.1.2 Notification
 Actual S3, actual and potential S4 & S5 incidents are immediately communicated to the
C
HSE Manager, affected Department Managers, MD & CEO and Chief Officers via phone
(SMS or call). ED
 A short email (which generates also an SMS) within two (2) hours from the incident
occurrence. Shift supervisor & HSE coordinator outline the nature and severity of the
incident, including the number of personnel/ contractors injured, extent of injuries and
LL
whether hospitalization was required.
 Actual S1, S2 and potential S3 incidents are notified within 24 hrs. to HSE Manager and
O
Department Manager via email/ SMS

 All incidents are investigated and documented via ITS.
TR
 Once the Initial Incident Report is generated in ITS, in the case of actual and potential S1
and S2, then the report is formally issued
N
 Initial Incident Report is issued within 48 hours from the time of the incident occurrence.

O
HSE Manager shall review the report to ensure completeness, accuracy and quality of
reported information.
C
 If the severity of the incident is potentially S3, then the Initial Incident Report is reviewed
N
by the HSE Manager and the decision to undertake a detailed investigation is at the
discretion of the HSE Manager, with consultation from relevant Department managers
U
(decision to be made within 48 hours of the incident occurrence).

 External notification of incidents is aimed to share substantial information with the Board
of Directors of Qatar Steel, concerning HSE incidents resulting in a fatality / multiple
fatalities.
 HSE Manager will notify the relevant authority for any HSE incidents with actual severity
classified as S3, S4 or S5 incidents.
 The notification will be in the form of fax or email and should take place within 24hrs from
the incident occurrence. This notification excludes emergency case incidents, which are
handled under the "Emergency Response Procedure.
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
7.1.3 Communication of learnings

 Communicating the learnings from an initial investigation is a vital component in the effort
to prevent recurrence and to leverage learning more broadly.
 HSE Manager & Department Managers shall ensure an active and timely communication
and review of relevant learnings to appropriate personnel, including employees and
contractors from the affected area, and those whose job tasks are related to the incident
findings.
 HSE Department may assist Department Managers in the preparation of a support
document to facilitate the communication of the learnings across the organization.
PY
7.1.4 Classification of Incident
 A detailed (formal) investigation - with Root Cause Analysis - might be required,
O
depending on the classification of the incident severity, considering both actual or potential
C
consequence of the incident (see Risk Ranking Section 7.4).
 Incidents with an actual S3 or actual and potential S4 or S5 require a formal and detailed
ED
investigation. The investigation of incidents with potential S3 consequences are at the
discretion of the HSE Manager (in consultation with relevant Department Managers). See
Table 6 below.

LL
Incidents with an actual or potential consequence classified as S1 or S2 are not subject to a
mandatory Detailed Investigation (Management can request a detailed investigation).
 HSE Manager provides the Chief Officer with written indication on the need to conduct a
O
detailed incident investigation, based on the criteria outlined in table below.

TR
 Any deviation from these requirements will need formal justification from the
Management.
N
Table 6: Detailed Incident investigation requirements

S1 or S2 Potential S3 Actual S3 &
O
Actual & Potential S4 or S5

C
Detailed Investigation / RCA requirements

N
Detailed A detailed RCA may be conducted for Detailed Investigation / RCA is

U
Investigation / potential S3 or if there is recurrence of required

RCA is not accident / near miss.
required This is at the discretion of the HSE
Manager (in consultation with relevant
Department Managers)
Note - Disciplinary action would be taken against any employee who conceals an injury or incident
and/or evidence.
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
7.2 Step 2 – Form Investigation Team

The composition of the investigation team is critical as it could affect quality of investigation. The
incident investigation team leader shall be appointed by the HSE Manager.
In determining the composition of the investigating team, the following guidelines need to be
considered depending on the nature, severity and complexity of the incident:
 The HSE Manager shall sponsor the investigation and shall nominate the incident
investigation team leader:
PY
 The Investigation Team Leader will always be the highest position in terms of the
O
companies hierarchy, e.g. Department manager will not be a member of the investigation
team but rather the Team Leader of the investigation team,
C
 The Investigation Team Leader shall be trained and competent in the Incident Investigation
and Reporting process, including Root-Cause Analysis techniques. He must have
ED
successfully completed Incident Investigation training and be competent, as a minimum, in
the following:
o Collecting and preserving evidence
LL
o Conducting effective interviews

o Establishing event chronologies
O
o Application of root cause analysis (RCA) techniques

TR
o Writing recommendations
o Creating incident investigation report
N
 The Investigation Team Leader should also have participated in several investigations
before leading the Investigation Team for the first time.
O
 Investigation team leader shall be independent of the affected area

C
 Investigation team leader shall assign one of the team members as a scribe for duration the
investigation
N
 Selection of Investigation team leader shall be as follows:

U
o In the case of Actual & Potential S3, the chair shall be at Section Head level and
above.
o In the case of Actual & potential S4 or S5, the chair shall be at Manager level
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
Team Members
 Incident investigation team should consist a minimum of five and maximum seven core
members
o HSE Manager / HSE Engineer / Department Manager
o Subject Matter Experts from different disciplines as required e.g.
 Operations,
 Maintenance,
 Medical / Nurse, in case of injuries or illnesses
PY
 Representative from the affected department
 Learning and Development / HSE Trainer
O
o Incident controller in case the incident was handled as an emergency
o As appropriate, and where the incident involved contract work, contractor
C
management and employees
o At least one member of the investigation team shall be knowledgeable of the
ED
process, where the incident occurred.
o For security related incidents, security personnel must be consulted and be part of
LL
investigation team member.
The following people may NOT form part of the investigation team
O
 Injured employee(s)
TR
 Witnesses to the incident.

 Direct supervisor
N
Initial on boarding of the Incident Investigation Team members represents a key step to ensure
O
adequate alignment of the different members. Soon after the identification of the team members by the
Incident Investigation Team Leader, the Team Leader shall:
C
 Formally notify the Team Members of the inclusion within the Incident Investigation Team
N
 Organize a formal onboarding meeting with all team members to align on objectives, scope,
working method, plan of activities
U
7.3 Step 3 – Determine the Facts

All information and evidence relating to the incident, as well as to the events and conditions leading
up to the incident, should be gathered.
In order to determine what happened to cause the incident and how it happened, the Incident
Investigation Team needs to establish answers to the following: WHO, WHAT, WHEN, WHERE and
WHY. When questioning people, be aware of comments like “that area isn’t important” or “don’t go
there” and these may lead to important aspects of the contributing factors.
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
Effective evidence preservation is the key to answering these questions and achieving a successful
investigation. The four types of evidence, known as the Four P’s, are Position, People, Parts and Paper.
PY
O
Figure 2: Four types of evidence (Position, People, Parts and Paper)
C
Position
ED
This is the most fragile form of evidence so should be gathered as soon as possible after the incident
has occurred.
Conduct a physical examination of the area around the incident location. Sketches, diagrams, position
maps and photographs all assist in determining where people and equipment were before, during and
LL
after the incident. Look for evidence of movement e.g. scrapes, skid marks, etc. In the event of a
fatality, take photographs tactfully showing the position of the body, and if the body can be removed,
O
photograph the area again after removal.
Note: Due to the fragile nature of the ‘position’ evidence, there is local responsibility of first responders
TR
to capture this information.
People
N
The primary method to be used for gathering people evidence, the second most fragile type of evidence,
is personal interviews. As people’s recollection of details will be affected over time, it is imperative
O
that witnesses are interviewed as quickly as possible. Relevant information is not restricted to the
C
incident itself, but includes standards and practices of the work group, normal operating conditions
and any past incident of a similar nature. Interviews and witness statements need to be taken from
N
those people both directly and indirectly involved in the incident.

U
Best practice is to undertake the interview, then have the interviewer complete the witness statement
afterwards, then review with the interviewee who should then sign as correct. Collecting witness
statements without an interview can lead to omission of important information.
The willingness of witnesses to disclose information can be affected by the way they are questioned.
When interviewing witnesses the following points should be used where appropriate:
Interviews Questioning techniques to use:

 Ensure that while one person makes his/her statement, other witnesses are not present
 Interview at an appropriate place
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
 Use an interpreter if necessary

 Put the person at ease
 Get the individual's version
 Use the questioning technique of starting with open questions. Further clarity must then be
obtained by general questions followed by specific (yes/no) questions
o Use CLOSED questions only to establish facts
o Avoid hypothetical questions e.g. "So what do you think happened?"
o Avoid leading questions e.g. "So in your opinion he did it?
PY
 Ask necessary questions at the right time
 Statements must be read back to the persons to ensure they reflect the true events and only
O
once agreed to, should be signed by the person who gave the statement
 Give the witness some feedback
C
 Record critical information quickly
 Use visual aids
ED
 End on a positive note

LL
Give the witness the opportunity to come back to the investigation team if they remember
further information.
O
A demonstration may assist to visualize the incident, but incident re-enactment should be used only:
 When the information cannot be gained in another way
TR
 When it is vital to the development of remedial actions, or

 When it is absolutely necessary to verify critical facts about the incident.
N
When using re-enactments, have the witness describe each step carefully before acting the part. Stop
O
the action before the critical (accidental) step.

After all statements have been taken and other relevant evidence collected, the investigation team must
C
have a discussion to ensure that they have a full understanding of the sequence of events.
N
Parts
Parts, tools, equipment, PPE (personal protective equipment) must be retrieved, labelled (what it is
U
and where it was found) and protected against damage for later analysis. An examination of physical
items involved in the incident must be carried out to determine what role they played in the incident
and to identify the possible causes of the incident.
The following questions may be asked when examining a piece of plant/equipment:
 Where is it damaged?
 What caused the part to fail?
 Was the part being used fit for purpose?
 Did the part conform to the design specification?
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
 What was the extent of the wear and tear?

 Is there any evidence of “tampering” (seek expert advice)?
Paper
Paper evidence is the least fragile of all types of evidence, and will be available for analysis days or
weeks after the incident. Review documents and records that are relevant e.g.:
 Equipment maintenance records,
 Procedures,
 Risk assessments,
PY
 Permits,
 Test certificates,
O
 Toolbox talks,
C
 Registers,
 Training certificates, ED
 Competence certificates and qualifications.
Such documents are used to confirm facts and verify conditions which will assist with establishing the
LL
potential causes.
Develop a Chronology/Timeline
O
Once all sources of information and evidence have been gathered it is important to analyze it in such
a way as to establish the sequence of events and conditions that led to the incident. This is most
TR
effectively done by establishing a timeline for the events and conditions which is described in the
following steps.
1. Identify the main event or “incident”. This should be a single line statement usually describing
the point in time when the incident occurred. The main “incident” event would not normally
N
have associated conditions.

O
2. Progressing backward in time identifies the pre-incident sequence of events from the
C
information collected through interviews and document reviews. Branches can be constructed
where a parallel event sequence occurred. The branches should join the main time sequence at
N
the appropriate point.

U
3. Progress forward in time from the incident and identify the post-incident event sequence.
4. For each event, detail relevant conditions at the time of that event.
5. Ensure each event and condition is discretely numbered so that the timeline can be
reconstructed. An Excel spreadsheet is recommended to record the Timeline.
6. Any events or conditions that are assumed or that require further investigation should be clearly
marked so this information can be acquired.
Once the Incident Investigation Team has agreed upon the timeline, those personnel directly involved
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
with the incident, including contractors and temporary staff, should be consulted to verify that the
timeline is correct. This step is extremely important to ensure the Team’s findings are accurate and
credible.
7.4 Step 4 – Determining Key Factors
Once all evidences and facts have been determined a systematic analysis of root-causes can be initiated.
Root Cause Analysis is a method whereby immediate causes are further analyzed to identify
underlying causes, and underlying causes are further analyzed to identify root causes.
Identification of root causes allows identification of an effective set of preventative/ correct actions, in
PY
particular to address the systemic root-causes which have led to the incident and that could lead to
future re-occurrences if not properly addressed.
O
Specific Root-Causes Analysis techniques may be adopted, such as those listed in the table below (list
not exhaustive):
C
Table 7: RCA Techniques
Technique Brief overview
ED
5 Why Five Whys typically refers to the practice of asking five times why the event/failure
Analysis has occurred in order to get to the root cause of the problem
LL
Fishbone / Ishikawa diagram (also known as Fishbone diagram) is simple structured graphical
Ishikawa tool perform cause and effect analysis and identify the root causes of
O
Diagrams events/problems
TR
Why Tree Pre-defined logic tree is a structured/sequenced diagram tools which helps to
visualize the causal relationships among different causes (from direct/immediate
causes down to potential root-causes) in a logical sequence
N
There is no “right” or “wrong” technique. The Incident Investigation Team Leader is responsible for
O
selecting the technique that better fits to the specific situation, taking into consideration:
 Complexity of the event and its dynamic nature
C
 Personal experience in application of the technique

N
 Competencies / confidence of the team members in the applicability of the technique

U
7.5 Step 5 – Determining Systems to be strengthened

Investigations shall also identify Management System elements that need to be strengthened to help
prevent recurrence and enable trend analysis and continuous improvement.
These areas for improvement flow from the key factors already identified and shall be noted on the
investigation report.
7.6 Step 6 – Recommending Corrective and Preventive Actions
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
An important step of the investigation process is to propose effective actions (preventive / corrective)
to prevent recurrence. The following is vital:
 Proposed corrective and/or preventive action arising out of the Incident Investigation must
address all of the identified root causes.
1. Elimination
2. Substitution
3. Engineering control
4. Procedures & Training
PY
5. PPE
O
Include identification, for each action, of responsible individual (Action Owner) and
estimated completion dates
C
 Ensuring that proposed actions are agreed with relevant stakeholders (e.g. affected
departments)
ED
In particular, the Incident Investigation Team should identify the need to:
 Review/update any Hazard Identification & Risk Assessment studies
LL
 Review/update any operating procedures / safe work practice

 Review/update the Emergency Response Plan
O
 Re-train relevant personnel

TR
Note: Recommendations that need to be completed before operations resume should be clearly
identified. Other recommendations (e.g., longer-term system- related improvements or evaluations)
N
often require a completion date that extends beyond startup.

O
7.7 Step 7 – Document & Communicate Findings

C
Communicating the results of incident investigations is a vital component in the effort to prevent
recurrence and to leverage learning’s more broadly.
N
A Safety Report should be distributed as soon as possible after an incident occurred, the following
need to be communicated to all employees:
U
 What happened (do not communicate the name(s) of any injured or parties involved)
 In which area
 Immediate actions taken to prevent recurrence
 Immediate and contributing causes
A Detailed Incident Investigation report should be written so that personnel not directly involved in
the affected area can understand them - Site or area specific terminology should be minimized.
Once the draft of the Detailed Incident Investigation report is generated by the investigation team, line
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
management and HSE Manager shall review the draft report for completeness and quality prior to
approval and issuance.
Each review step shall help ensuring that the following items have been addressed and providing
feedback to the investigation team concerning additional work to be done prior to finalization:
 Accuracy of incident classification
 Completeness and thoroughness of applicable facts, chronology, and root-cause analysis
 Adequacy and specificity of recommendations and timing to address all physical, human, and
operating or managing system key factors (including the need for interim controls for
recommendations involving long-term implementation). For any incident recommendation
PY
requiring funding, authorization at the appropriate level of the organization need to be obtained.
 Accuracy of items listed for system elements needing strengthening

O
Accuracy and completeness of linkages between facts, root-causes, recommendations, and
system elements needing strengthening
C
The Detailed Incident Investigation reports should be finally approved within maximum thirty (30)
calendar days from the incident occurrence date, or within the timeframe defined by the Chief Officer.
ED
Upon final approval, the Detailed Incident Investigation Report is shared with relevant stakeholders.
In particular, copies of the Detailed Incident Investigation Report shall be sent by the HSE Manager
LL
to:
 Manager of the affected department
 Legal Department
O
 Environment Engineer, in the case of spills or releases and require further reporting to MME
TR
A case study will be shared with all.
7.8 Step 8 – Follow up

N
To ensure prompt follow-up and closure of recommendations from an incident investigation report, a
O
system must be developed for periodic status reports by HSE Manager until all recommendations are
implemented and closed out.
C
Additionally, it must be ensured that the system includes a verification of the implementation and
effectiveness of the corrective action.
N
If a recommendation is to be declined, the Action Owner shall document, in writing and obtain the
U
approval of Department Manager and HSE Manager on adequate evidence, that one or more of the
following conditions is true:
 The analysis on which the recommendation is based contains material factual errors.
 The recommendation is not necessary to protect the health and safety of the employer’s own
employees, the employees of contractors, or the health and safety of the community, wildlife,
or environment.
 An alternative measure would prevent recurrence of a similar incident.
 The recommendation is not feasible (note that an alternative recommendation should be
provided to address the key factor).
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
 Mothballing Plant: All incidents reports status categorized as ‘Closed due to mothballing’
the same incident reports will be reviewed and ensure all the recommended corrective
actions are closed before the mothballing plants are planned to operate again.
The investigation report can be finally closed only by the Chief Officer after due verification that all
recommendations have been implemented.
The HSE Manager ensures periodic (weekly) report for Qatar Steel Management to support
management monitoring of incident and action plans. The following leading performance indicators
should be considered in the HSE Dashboard for Qatar Steel:
PY
 Number of open detailed investigations
 Number and % of detailed investigation report finally approved within defined deadline
(defined by Qatar Steel Chief Officer as per procedure)
O
 Number and % of open recommendations
C
 Number and % of overdue recommendations
 Number and % of recommendations completed within expected deadline (YTD and by
ED
year)
 Trend and analysis on system elements identified to be strengthened by investigations
LL
Subsequent preventive/corrective action plans are reviewed on a bi-monthly basis for their progress in
a meeting with participation of HSE, Production and Maintenance delegates.
Close out rate for relevant action plans is reviewed by each Department Mgr. in regular meetings and
O
forms part of Department's performance dashboard.

TR
A tracking system is available in Incident Tracking System to monitor the completion of the corrective
actions.
Qatar Steel MD & CEO in consultation with the Chief Officers and HSE Manager shall decide which
N
reports will be shared during Board of Directors Meetings.

O
8 CONTINUOUS IMPROVEMENT
C
This procedure must be inspected in order to ensure continuous improvement. The Audit checklist
N
must be used when inspecting the performance of Qatar Steel against the incident investigation and
reporting procedure on a quarterly basis by the HSE Dept.
U
9 REFERENCES
1) Qatar Steel, Incident Reporting, Investigation and Handling of Safety Suggestion Procedure
10 MANAGEMENT OF CHANGE
No changes shall be made to this procedure without approval from the Qatar Steel HSE Manager. Any
suggestions or recommendations for updates or improvements to this procedure should be submitted
in writing to the HSE Manager. Each submission should give details of the proposed amendment and
the reason why it is considered necessary.
Prepared by:
HSE Department
Procedure 2.32.2.1.02.01
The HSE Manager will keep a log of all change requests, prioritize them for action and, subject to his
approval, schedule them for inclusion in the next relevant update of the document. The latest version
of this procedure shall be made available via the QSC computer network. Earlier versions shall be
retained for a minimum of three years in accordance with the Qatar Steel document management
system.
11 APPENDICES
PY
Appendix 13.1 Qatar Steel Risk Matrix
Appendix 13.2 Table of Contents for Detailed Investigation Report
Appendix 13.3 Incident Tracking System
O
Appendix 13.4 Overall incident investigation and reporting flow chart detailed flow
Appendix 13.5 Notification flow
C
Appendix 13.6 Guidance on selecting system elements to strengthen
Appendix 13.7 Illustrations of definitions
Appendix 13.8
Appendix 13.9
ED
Investigation Audit Checklist
Incident Case Study
Appendix 13.10 World Steel Association Incident Notification Form
LL
O
TR
N
O
C
N
U
Prepared by:
HSE Department

Incident Investigation Reporting Rev.1.03

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Procedure 2.32.2.1.02.

Incident Investigation and

Revision Date Date to be

00 01-Jan-2002 First Issue 01-Jan-2002 14-Oct-2003

01 14-Oct-2003 Re-Issue 14-Oct-2003 01-Nov-2005

02 01-Nov-2005 Re-Issue 01-Nov-2005 01-Apr-2008

03 01-Apr-2008 Qatar Steel Logo change 01-Apr-2008 01-Apr-2011

1.02 01-Jan-2020 Update of template and company acronym 01-Jan-2020 31-Dec-2022

1 INTERNAL CONTROLS ............................................................................................................. 5

5.2 Type of Outcome ................................................................................................................... 13

5.3.1 Actual Severity Level .................................................................................................... 13

5.3.2 Potential Severity Level ................................................................................................. 13

7 INCIDENT INVESTIGATION AND REPORTING PROCESS FLOW ................................... 20

7.1 Step 1 – Initial Response ....................................................................................................... 20

7.1.1 Initial Response .............................................................................................................. 20

7.1.3 Communication of learnings .......................................................................................... 22

7.1.4 Classification of Incident ............................................................................................... 22

8 CONTINUOUS IMPROVEMENT ............................................................................................. 31

1.1. Review of Procedure

1.2. Employee Responsibilities

i) Other violations (e.g. security incidents)

PSM Process Safety Management

RCA Root Cause Analysis

YTD Year to Date

Table 1: Definitions of terms used throughout the procedure

Incident An unplanned or unusual event and circumstances that result in, or

An incident may be categorized as either an “accident” or a “near

An unplanned or uncontrolled event or chain of events that has not

(incident has occurred).

not get injured

suspended part on a conveyor or from an uncontrolled

 A person has to jump from a falling ladder

Oxygen sensor, eye wash, etc.) fails to operate properly

Unsafe Any situation that could result in injury or damage to people,

 Dangerous item left as an obstruction or a confusing or

Recordable All work-related incidents resulting in a fatality, an injury requiring

 Assignment to a temporary job

 Working full-time in the regular job but not performing all

the usual duties of the job.

Medical Cases not severe enough to be reported as fatalities, LTI or RWC

MTC includes treatment of injuries administered by physicians,

First Aid Cases not sufficiently serious to be reported as MTC or more

staples, surgical glue, are considered medical treatment)

bandages, wraps, non-rigid back belts (devices with rigid

stays or other systems designed to immobilize parts of the

an accident victim (e.g. splints, slings, neck collars, back

draining fluid from a blister

 Removing foreign bodies from the eye using only irrigation

Explosion/ Any combustion, regardless of the presence of flame. This includes

 Exceedance / breach of permit or external reporting

Controlled release of gases or liquid through maintenance shall not

be considered incidents, and are thus not reportable provided they

release shall be recorded as an environmental incident.

Property An event which results in damage to equipment, building,

Damage structures, vehicles etc.

Any crash involving a Qatar Steel Employee or visitor transportation

Non-industrial Any potential or actual harm or damage (including death) to the

Risk The Risk Assessment Matrix is a tool that standardizes qualitative

Note that all 4 criteria must be satisfied for a repeat incident