POTENTIALLY SERIOUS INCIDENTS (PSI) A Guideline on Classifying and Reporting in Alberta (Draft)

POTENTIALLY SERIOUS INCIDENTS (PSI) A Guideline on Classifying and Reporting in Alberta (Draft) EDITION» #1.1 REVISED» July 20, 2018 RELEASE DATE» Month Year (TBD) Setting the standard in oil and gas safety

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting in Alberta (Draft) i ABOUT ENERGY SAFETY CANADA Energy Safety Canada is the oil and gas industry s advocate and leading resource for the continuous improvement of safety performance. Our mission is to help companies achieve their safety goals by providing practices, assessment, training, support, metrics and communication. AVAILABILITY This document as well as future revisions and additions, is available from: Energy Safety Canada 5055 11 Street NE Calgary, Alberta T2E 8N4 Phone: 403 516 8000 Toll Free: 1 800 667 5557 Fax: 403 516 8166 ACKNOWLEDGEMENT Energy Safety Canada gratefully acknowledges the many individuals who volunteered their time and effort to complete this document. DISCLAIMER This document is intended to be flexible in application and provide guidance to users rather than act as a prescriptive solution. Recognizing that one solution is not appropriate for all users and situations, it presents generally accepted guidelines that apply to industry situations, as well as recommended practices that may suit a company s particular needs. While we believe that the information contained herein is reliable under the conditions and subject to the limitations set out, Energy Safety Canada does not guarantee its accuracy. The use of this document or any information contained will be at the user s sole risk, regardless of any fault or negligence of Energy Safety Canada and the participating industry associations. COPYRIGHT/RIGHT TO PRODUCE Copyright for this document is held by Energy Safety Canada, 2018. All rights reserved. Energy Safety Canada encourages the copying, reproduction and distribution of this document to promote health and safety in the workplace, provided that Energy Safety Canada is acknowledged. However, no part of this publication may be copied, reproduced or distributed for profit or other commercial enterprise, nor may any part be incorporated into any other publication, without the written permission of Energy Safety Canada.

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting in Alberta (Draft) ii TABLE OF CONTENTS 1.0 Introduction... 1 Purpose and Scope... 1 Alberta Legislation... 1 Defining a Serious Injury... 2 Identification... 3 Life Saving Rules... 5 Process Safety Events... 5 Immediately Dangerous to Life and Health... 5 Flammability... 6 Oxygen Deficiency... 6 Post-Traumatic Stress Disorder... 6 2.0 Roles and Responsibilities... 6 Alberta OH&S Act Named Parties... 6 Employers... 7 Prime Contractor... 7 Workers... 7 Health and Safety Committee and Representatives... 7 3.0 Classification... 7 Definition... 8 Risk Matrices... 8 Controls... 8 Decision Tree... 8 Examples... 10 4.0 Notification... 11 5.0 Investigation... 11 6.0 Reporting... 12 7.0 Corrective and Preventative Actions... 12 8.0 Communication and Learnings... 12 9.0 Education and Training... 12 10.0 Summary... 13 Appendix I Glossary... 14 Appendix II References... 15

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting in Alberta (Draft) 1 1.0 Introduction Purpose and Scope This guideline is intended to assist the oil and gas industry in the classification and reporting of incidents with the potential to cause serious injury to a worker, herein referred to as potentially serious incidents (PSIs). This is now a requirement in the new Occupational Health and Safety Act by Alberta Labour, herein referred to as Alberta OH&S, which came into force June 1, 2018. It is understood that, as part of their internal health and safety programs companies may have more stringent criteria for PSI than indicated in this guideline. This more stringent criteria is not a reporting requirement for Alberta OH&S. Alberta Legislation The requirement for reporting PSIs is in Section 40(5) of the OH&S Act. It states: If any other injury or any other incident that has the potential of causing serious injury to a person occurs at a work site, the prime contractor or, if there is no prime contractor, the employer shall, (a) Report the time, place and nature of the incident to a Director of Inspection, (b) Carry out an investigation into the circumstances surrounding the injury or incident, (c) Prepare a report outlining the circumstances of the injury or incident and the corrective action, if any, undertaken to prevent a reoccurrence of the injury or incident, (d) Ensure that a copy of the report is readily available and provided to an officer on demand, and (e) Provide a copy of the report to a Director of Inspection, the joint work site health and safety committee or health and safety representative, if applicable, or, if there is no committee or representative, make it available to workers once the investigation is complete. The most notable change requires the prime contractor or employer to notify Alberta OH&S with respect to incidents that have the potential to cause serious injury as indicated in subsection (a). It is important to note that Alberta reporting criteria in relation to injury has become admission to the hospital, regardless of duration.

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting in Alberta (Draft) 2 Incidents where no injury has occurred that are already covered in the Alberta OH&S Act include the following: An unplanned or uncontrolled explosion, fire or flood that causes a serious injury or that has the potential of causing a serious injury The collapse or upset of a crane, derrick or hoist The collapse or failure of any component of a building or structure necessary for the structural integrity of the building or structure Any injury or incident or a class of injuries or incidents specified in the regulations There are also additional reporting criteria for mine and mine sites that are covered in Section 40(4) of the Alberta OH&S Act. Defining a Serious Injury Serious injuries are defined as: Fatal injury Life-threatening injury that requires immediate emergency care Life-altering injury that is permanent Examples are provided below in Table 1. This definition and the examples are adapted from the definition provided by Dekra Insight. 1 1 Dekra Insight, D. Martin, A. Black; Preventing Serious Injuries and Fatalities (SIFS): A new study reveals precursors and paradigms

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting in Alberta (Draft) 3 Table 1. Serious Injury and Fatality Categories and Examples Serious Injury Categories Fatal injury Life-threatening injury that requires emergency medical intervention Life-altering injury that is permanent Examples Loss of life Airway obstruction and pulmonary damage, including edema Significant blood loss, internal bleeding and cardiac failure Skull or multiple large bone fractures Chemical poisoning, such as H 2S or carbon monoxide Damage to brain or spinal cord Second or higher degree burns with body surface area >15% Paralysis and central nervous system damage Significant damage to vital organs Loss of large body part (amputation of hand, etc.) Significant burns including the face Post-traumatic stress disorder (PTSD)* *PTSD may be permanent depending on the individual and characteristics of the incident. Any incidents with the potential for these serious injuries would be defined as a potential serious incident (PSI). Identification Potential serious incidents include both injuries that were not serious but had the potential to be serious, as well as near misses where workers were not injured but there was potential for serious injury. For example, a worker is struck on the head with a swinging pipe and receives a minor cut to the side of his head. The potential is there for that worker to be killed by the strike to the head if the worker did not get out of the way in time or had been standing a few inches closer. This is classified as a PSI. Similarly, if the worker described above had stepped out of the way in time and therefore was not injured at all, this would still be a PSI, because a serious injury could have occurred with slight changes to the work site.

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting in Alberta (Draft) 4 A graphic of the various components of serious injury and potential serious injury is presented below in Figure 1. Actual Serious Injuries and Fatalities + Non-Serious Injuries with Potential for Serious Injury (PSI) + Near Misses with Potential for Serious Injury (PSI) = Actual and Potential Serious Injury Exposure Figure 1. Components of actual serious injuries and incidents with the potential for serious injury For the purposes of this guideline and reporting to Alberta OH&S, near misses and injuries with the potential for serious injury or fatality will be considered. An unsafe condition or an unsafe act will not be considered a PSI within this guideline, provided an injury or near miss has not occurred. For an incident to qualify as a near miss, the worker must be exposed to the release of hazardous energy. Hazardous energy may include the following: Pneumatic Hydraulic Chemical Mechanical Thermal Electrical Gravitational Nuclear Any energy that could cause physical or psychological injury If a release or exposure to hazardous energy has not occurred, then, for the purposes of this guideline, this should be considered an unsafe act or an unsafe condition rather than a near miss.

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting in Alberta (Draft) 5 Life Saving Rules Non-compliance with Life Saving Rules (LSR) does not automatically become a PSI; it may be classified as an unsafe act if it does not involve the release or exposure to hazardous energy. Any violation of a Life Saving Rule should be assessed to determine if it is a PSI (i.e., involves the release or exposure to hazardous energy with the worker present [near miss] and/or if an injury has occurred). Process Safety Events Process safety events involve the unintentional release or loss of containment of hazardous materials or energy that may lead to catastrophic consequences. Process safety events are classified into tiers based on criteria defined in the American Petroleum Institute s (API) Recommended Practice 754. Many process safety events are already reportable to a list of regulators that may include Alberta OH&S. Because a process safety event typically involves the release of hazardous energy, if a worker is present or if a worker is injured, it may be a PSI. As such, any process safety event should be assessed to determine if it is a PSI. Immediately Dangerous to Life and Health The Immediately Dangerous to Life and Health (IDLH) concentrations as defined by the National Institute of Occupational Safety and Health (NIOSH) are atmospheres containing harmful substances such as chemicals and other hazardous materials. IDLH values can be found here: https://www.cdc.gov/niosh/idlh/intridl4.html Exceedance of IDLH concentrations represent an immediate threat to life, may affect health irreversibly, may have future adverse effects in health, or may interfere with a worker s ability to escape from a dangerous atmosphere. As a result, IDLH aligns with the definition of a serious injury as identified in Section 1.3 of this guideline with one notable exception: it does not apply to IDLH concentrations based on flammability (10% LEL) as this criterion is more stringent than the Alberta OH&S criterion of 20% LEL. IDLH is notably different than occupational exposure limits (OEL), because OELs vary in what type of health and safety consequences they are trying to prevent such as irritation, organ system toxicity, carcinogenicity, etc. PSI only applies to IDLH concentrations when a worker exceeds or is reasonably likely to exceed these concentrations in the absence of approved respiratory protective equipment such as supplied-air or self-contained breathing apparatus (SCBA). An oil and gas example is the IDLH of H 2 S, which is 100 parts per million (ppm). If a worker was exposed to over 100 ppm of H 2 S without proper respiratory protection, this would constitute a PSI.

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting in Alberta (Draft) 6 Flammability A worker or workers present in flammable work environments represents the potential for serious injury. Flammable work environments are defined as environments at or above the lower explosive limit (LEL) for a flammable substance such as a gas, vapour or combustible dust. This could be indicated by a properly calibrated combustible gas monitor worn in the worker s breathing zone that indicates 100% of the lower explosive limit (LEL) for the flammable substance or mixtures of flammable substances present. Oxygen Deficiency Oxygen deficient atmospheres are defined as atmospheres with oxygen levels below 19.5% at standard temperature and pressure. Workers breathing air that contains less than 19.5% oxygen are at risk for serious injury and, as such, this is defined as a PSI. Post-Traumatic Stress Disorder Post-traumatic stress disorder is a mental health condition that is triggered by a traumatic event or incidents. These incidents may be natural disasters, extreme physical trauma to a person, sexual, physical or psychological assaults, terrorist attacks, etc. If it is reasonable that someone in the work environment could be diagnosed now or in the future based on what has happened, the incident should be considered a PSI. Work site situations can be either an isolated incident or the discovery of an on-going incident. 2.0 Roles and Responsibilities Alberta OH&S Act Named Parties The OH&S Act sets out the obligations of various named parties. The list of parties is more comprehensive than those identified in the previous OH&S Act. For more detailed information about the obligations, please refer to Energy Safety Canada s resources on Alberta Bill 30 at. The named parties are listed below and, where appropriate, specific requirements in relation to PSI are detailed.

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting in Alberta (Draft) 7 Employers Supervisors Owner Prime Contractor Workers Contractors Service Providers Self-Employed Persons Temporary Staffing Agencies Suppliers Health and Safety Committee Health and Safety Representative Employers Copies of the PSI report will need to be shared with the Health and Safety Committee, Health and Safety Representative and made available to Workers. Prime Contractor Working in conjunction with any other named parties, it is the prime contractor s responsibility to notify, investigate and report a PSI to Alberta OH&S. Workers A worker will be designated or selected as the Health and Safety Representative if one is required, and part of the Health and Safety Committee. The PSI investigation reports will need to be made available to Workers. Health and Safety Committee and Representatives Representatives from the Health and Safety Committee or the Health and Safety Representative must participate in the investigation of a PSI. The report of the PSI that is shared with Alberta OH&S must be provided to the Health and Safety Committee, the Health and Safety Representative (if one exists) and be made available to the workers. 3.0 Classification By adopting and using similar terminology and classifications, industry can have more valuable conversations and data sharing around the prevention of serious injuries and fatalities. This can only occur if incidents with the potential for serious injury can be sorted out from other incidents where that potential does not exist. The thinking is that the causal factors which lead to serious injuries and fatalities are different than the causal factors for less significant injuries and, therefore, this differentiation drives different prevention activities. As a result, the classification of injuries and near misses is integral to preventing serious injuries and fatalities.

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting in Alberta (Draft) 8 Definition Evaluate whether potential consequences meet the definition of an incident with the potential to cause serious injury as defined in Section 1.3 of this guideline. One question to ask is, was there enough hazardous energy present to cause a serious injury as per the definition? If yes, then this may have the potential to cause serious injury. Or put another way, what was the worst credible outcome? Risk Matrices For the purposes of establishing more consistency in the classification of PSIs, a focused discussion on risk matrices has not been included because of the variability in the design of various company matrices. However, individual companies can use the severity aspects that are defined in this guideline and determine where these align on their company s risk matrix. As a result, companies should be able to provide company-specific guidance to their personnel on what severity level on their risk matrix equates to a reportable PSI. Controls The use of adequate controls is an important element in the classification of a PSI. If hazardous energy is released, but adequate controls were in placed to prevent a potential serious incident then this is not a PSI. Some examples are provided for reference: Example 1. A worker is wearing a self-contained breathing apparatus (SCBA) when exposed to a harmful substance in concentrations above IDLH limits. This is an adequate control as work in an IDLH atmosphere requires the use of SCBA; therefore, this is not a PSI. Example 2. A suspended load falls and hits the ground within the exclusion zone. No workers are present because everyone is aware of the exclusion zone, adheres to the exclusion zone and the exclusion zone is enforced. This is not a PSI. Decision Tree A decision tree is presented to assist companies in the classification and subsequent reporting of PSIs. This decision tree incorporates the worst credible outcomes as part of the definition of a serious injury; various hazardous energy releases and exposures unique to oil and gas activities; psychological hazards in relation to PTSD; and whether the hazard was adequately controlled. The classification decision tree is presented in Figure 2.

/////////////////////////////////// Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting (Draft) 9 Figure 2. Classification Decision Tree

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting (Draft) 10 Examples A series of PSI and non-psi examples are provided in Table 2. These examples are provided for context only and should not be viewed as a list of all possible incidents that may or may not be a PSI. Table 2. PSI and Non-PSI Examples PSI A worker is working inside a confined space when her personal gas monitor alarms, indicating 100 ppm H 2S, the IDLH for H 2S. The worker is not using SCBA. A worker partially enters an inlet separator by placing his head and upper chest in the vessel so he can see if all the liquid has been sucked from the vessel s boot. His personal gas monitor reads 100% LEL. A worker s gas monitor reads 19% oxygen when process equipment is depressured to atmosphere in the immediate vicinity of the worker. The worker is not using SCBA. A worker is struck on the side of the head with a swinging pipe and receives only a minor cut. A worker is driving to a wellsite when his floor mat becomes stuck on the accelerator pedal and his vehicle collides with a bridge pier. The vehicle hits the pier at 50 kilometers per hour but glances off and the driver is not hurt. A suspended load of pipe is being lifted. The load shifts and the pipe falls to the ground narrowly missing a worker who briefly went under the barricade tape to observe the load. Non-PSI A worker s gas monitor alarms, indicating 5 ppm of H 2S when she walks past a vent connected to a process that has up to 10 ppm of H 2S. A worker partially enters an inlet separator by placing his head and upper chest in the vessel so he can see if all the liquid has been sucked from the vessel s boot. There is no safety watch present, the vessel has been ventilated and gas detection indicates a safe atmosphere. A worker s gas monitor reads 19% oxygen when working outside on a very cold day in an open field when there is no reason for an oxygen deficient atmosphere. A worker drops a pneumatic tool on his steel-toed boot that results in a hairline fracture in one of the bones within the upper part of his foot. A vehicles park break fails, and the vehicle rolls three feet into a parking lot guard rail scratching the front head light. During a lift the load shifts and is observed rocking back and forth. The lift is stopped and the load is lowered to the ground to be reconfigured.

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting (Draft) 11 PSI A worker climbs outside a protected area on an elevated platform and then falls but manages to grab part of the railing, stopping his fall. The worker tears some arm ligaments. A disgruntled former worker pushes through the security gate and fights with security personnel. The individual is taken into custody when a loaded gun is found in his coat pocket. A worker observes a co-worker die in a tragic workplace accident. This worker may develop PTSD. A worker is located inside the guard fence of a beam pump (pump jack) that is not locked out when the counterweight strikes and knocks off his hard hat. Non-PSI A worker slips on an icy sidewalk and pulls muscles in her back resulting in a missed day of work. A heated discussion about health and safety occurs during a budget allocation meeting and the meeting is postponed to allow personnel to calm down. A worker hears that another co-worker has passed away. Slack in the chain used to lockout the beam pump counterweights results in the counterweights moving an inch when a worker is standing outside the guard fence. 4.0 Notification Once a company has identified and confirmed a PSI, they should notify Alberta OH&S. The OH&S Act requires that the prime contractor or, if there is no prime contractor, the employer, report to Alberta OH&S the time, place and nature of the PSI. The Alberta government has developed a PSI notification site that can be accessed here: https://psi.labour.alberta.ca/ 5.0 Investigation Alberta and other jurisdictions require an investigation of a PSI. How companies do this is at their discretion, but it is recommended that they have a consequence-based approach where the type of investigation, the level of training of the investigators, and the formalized nature of the report are based on the potential severity of the incident. A more formalized root cause investigation approach is recommended for PSI such as: TapRoot, 5 Whys, Failure Modes and Effects, Fault Tree Analysis, etc. These examples are provided for reference only and may not be appropriate for all PSIs. Every company needs to build their program and select their investigation processes accordingly.

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting (Draft) 12 6.0 Reporting All PSIs must be investigated, and a report must be prepared that identifies corrective actions to prevent reoccurrence. This report must be provided to Alberta OH&S, the Health and Safety Committee or Health and Safety Representative, and be made available to Workers. A copy of the report must be retained by the Prime Contractor or Employer for at least two years. A PSI Investigation Report template is provided by Alberta OH&S here: https://psi.labour.alberta.ca/home/download?filename=psi_correctiveactionsreport.pdf The report can be submitted to Alberta OH&S by emailing it to: lbr.psi@gov.ab.ca 7.0 Corrective and Preventative Actions In general, the majority of the risks to workers within the industry are known. However, serious injuries and fatalities continue to occur. Often, a failure to implement changes from lessons learned can contribute to ongoing incidents. Therefore, a disciplined approach to communicating these learnings is vital to the prevention of similar injuries. 8.0 Communication and Learnings It is recognized that reportable incidents such as PSIs may result in selective sharing of information in an effort to manage other risks. This is particularly true for actual serious injuries and fatalities where a company s legal department is involved. While this need is recognized and necessary, it is equally important to recognize the need to share these incidents both company and industry-wide to prevent reoccurrence. Companies and industry should take a balanced approach to ensure relevant learnings are shared and prevent reoccurrences. 9.0 Education and Training For companies to successfully prevent serious injuries and fatalities, all named parties must be committed to keeping themselves and their co-workers safe from serious injuries and fatalities. Management should be mindful of how PSIs are communicated within a company; how they respond to the identification of PSI s; how reporting is actively encouraged; and how learnings are translated into preventative action.

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting (Draft) 13 10.0 Summary The classification, management and reporting of PSIs can be part of an effective strategy to prevent and learn from incidents that have the potential for serious injury. By classifying incidents in a manner consistent with this guideline, companies can comply with the new Alberta OH&S requirements, maintain due diligence, and help advance the industry s prevention efforts.

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting (Draft) 14 Appendix I Glossary Term Near Miss Hazardous Energy Immediately Dangerous to Life and Health (IDLH) Lower Explosive Limit (LEL) Process Safety Event PSI PTSD Security Incident SCBA Unsafe Condition Definition An incident that did not result in an injury, but where there was potential for it to do so. Sometimes referred to as a near hit. It must involve the release or exposure to hazardous energy. Energy in the form of pneumatic, nuclear, thermal, mechanical, hydraulic, gravitational, electrical, chemical and any other energy that may result in physical or psychological injury. For additional information on hazardous energy please refer to Alberta OH&S Code s definition of hazardous energy and the CSA Standard, Z460-13 Control of Hazardous Energy. Immediately Dangerous to Life and Health as defined by National Institute of Occupational Safety and Health (NIOSH). IDLH values can be found here: https://www.cdc.gov/niosh/idlh/intridl4.html The lower value of the range of concentrations of a substance, in a mixture with air, at which the substance may ignite (Alberta OH&S Code) A process safety event involves the unintentional release or loss of containment of hazardous materials or energy that may lead to catastrophic consequences. Potentially serious incident that could seriously injure or kill a worker. Post-traumatic stress disorder is a mental health condition triggered by a traumatic event or incidents. These incidents may be natural disasters, extreme physical trauma to a person, sexual, physical or psychological assaults, terrorist attacks, etc. Security incidents involve threats of or criminal activity such as workplace violence, robbery, theft, alcohol and drug abuse or possession, terrorism, etc. Self-contained breathing apparatus A behaviour that is unsafe and contravenes what is expected. Often involves not using personal protection equipment, not adhering to established practices and procedures, bypassing safety controls, etc.

Energy Safety Canada» Potentially Serious Incidents: A Guideline on Classifying and Reporting (Draft) 15 Appendix II References Alberta Labour; Occupational Health and Safety Act, June 1, 2018, http://www.qp.alberta.ca/1266.cfm?page=o02p1.cfm&leg_type=acts&isbncln=978077980049 0&display=html Dekra Insight, Donald Martin, Alison Black; Preventing Serious Injuries and Fatalities (SIFs) A new study reveals precursors and paradigms, 2016 http://dekra-insight.com/images/white-paper-documents/wp_preventing-sif_us_a4.pdf BST (Dekra Company), Don Martin, Scott Stricoff; Determining Serious Injury and Fatality Exposure Potential, 2012 http://www.coresafety.org/wp-content/uploads/2014/12/wp- SIF.Exposure.Potential.October20121.pdf

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