Document QJoMELMdbV9bpq5yEjbrXbN26

C (,cvW-k-- ORGANIZATION A PROCEDURE MANUAL giMJWWI----llluim. -f--*--^jn-----tjut-- _L'-l^l -- hbL-i? SP-0\4 --- . jThis procedure explains the investigation and reporting of significant juries, near-misses, fires and spills. Investigations and leports of this type are utilized to determine the basic causes of the incident and the corrective action required to prevent recurrence. The report also serves as a means to communicate the circumstances surrounding the incident to all areas of the plant. Areas not involved will then use the report to determine the potential for similar incidents. POLICY :ttAM6> [Accidents which result in significant injuries, near-misses, fires and spills will be thoroughly investigated and reported, with follow-up recommendations. Investigations will be conducted regardless of whether the persons involved are Monsanto employees or contractor employees. Investigation and reporting of other incidents are covered under Procedures D-0904 (Minor Iljury Reporting and Investigation) and D-0905 (Loss Reporting). Ao&fcD 1. The following injury definitions conform to the provisions of the Occupational Safety and Health Act (OSHA) of 1970. They also represent a uniform system for recording, classifing and investigating injuries as outlined in "Guidelines for Recording and Reporting Occupational Injuries and Illnesses", Monsanto Co., Safety and Property Protection, January, 1977. JIAW6M ( RECORDABLE INJURIES will be investigated under this procedure. Recordable injuries are defined as any death or injury that results from a work related accident or from an exposure in the work environment and involves any of the following: a. Medical Treatment (not first aid) b. Inability to Work c. Restriction of Work or Motion d. Loss of Consciousness e. Transfer to Another Job 6113 16981 BG01518 / 4 / . . page: i op ^ UKUANI^AMUN & KKULtUUKt MANUAL D-0903 gVf Jt-L MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AND REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIRES AND SPILLS 2. A NEAR-MISS is any incident where significant injury or property damage could have resulted had circumstances been only slightly different than actual or had the activity been continued. A near-miss will be judged significant by the concerned Superintendent or PT Manager with the recommendation of the Safety Department considered. 3. A FIRE or SPILL will be judged significant by the concerned Superintendent or PT Manager With the recommendation of the Safety Department considered. RESPONSIBILITIES A. The GENERAL SUPERINTENDENTS, CED SUPERINTENDENT, and PT M?HAGER are responsible for: A. Insuring that incidents which are covered in the defiiitions section are reported to him and the Safety Department. B. Initiating an investigation, appointing a committee, and brief--.g the chairman for incidents as follows; (a) Injuries - The Superintendent or Manager of the employee (Monsanto or contractor) injuried. (b) Near-Misses - The Superintendent or Manager of the employee (Monsanto or contractor) or the equipment exposed to the near-miss. (c) Fires or Spills - The Superintendent or Manager of the area in which the incident occurs. C. Assigning responsibility for corrective action in his invoLved areas. D. Reviewing investigation reports for incidents outside their areas, determining application of recommendations^ffassigning responsibilities, and-feefe-CTiing fehe-GafctY Departawont* E. Reporting application and status of the recommendations pertaining to their areas. ORIGINAL ISSUE 1/4/65 6113 16982 REVISED R/5 12/30/76 001519 PAOP2 OF S> ATTACHMENT , ORGANIZATION & PROCEDURE MANUAL SP-o^ MONSANTO COMPANY ( CHOCOLATE BAYOU PLANT INVESTIGATION AND REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIRES AND SPILLS 2. The INVESTIGATION COMMITTEE is responsible for conducting the investigation, recording the facts, and publishing the report. 3. Acoso The DEPARTMENT SUPERINTENDENTS and PT GROUP SUPERVISORS are responsible for reviewing and approving the investigation report, and establishing timing and responsibilities for accomplishing the recommendations. 4. The SAFETY SUPERINTENDENT is responsible for assisting in identi fication of significant incidents, staffing of committees, advis ing committees, and review at the Dept. Superintendent/PT Group Supervisor level. He will appraise Management on status of recommendations and maintain files of reports and pertinent correspondence. PROCEDURE ( IDOCD 1. If an accident occurs which fits into the above general definitions, ! the concerned Superintendent or Manager will appoint an investi gation committee. Normally, the committee will be composed of * four members, but, the size may be varied depending on the nature and complexity of the incident. A representative of the Safety Department will serve as a member of all investigation committees, unless the exception is approved by the Safety Superintendent. The Superintendent or Manager has the option of staffing the can- mittee from within his own department or other departments in the plant. The exception to this is the Safety Department representative. Individuals directly involved in the incident should not be members of the committee. Final review of selected incidents may be held at the Superintendent or Manager level with approval of the Plant Manager. 2. The following criteria should be used in selecting the investigation committee chairman: A. The chairman named should have served as a member of at least one formal investigation committee prior to serving as a chairman. B. The chairman should be skilled in conference leadership. A key function is drawing all members of the committee into parti cipation and contribution to the investigation. C. The chairman should be skilled in Managerial Analytics Problem Solving and Decision Making techniques. : D. 6113 16983 ORGANIZATION & PROCEDURE MANUAL _____ MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AND REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIRES AND SPILLS D. Generally, the more severe the incident, the more experienced person required to act as chairman. Usually, a supervisor/ technical/managerial employee will make the more competent chairman, particularly for more complex incidents. E. The chairman may need to be familiar with technology of an incident when the preliminary indicators show that technology is important to the cause and/or solution. Refer to Attachment #3 for suggested instruction to the chairman of investigation committees. 3. The investigation will be started by the committee within 24 hours of the time o: the incident. The following guidelines should be used: A. Visit scene of accident to investigate physical facilities. Take photographs or make sketches and diagrams to record details of the physical environment. B. Interview witnesses and the injured employee if available. The plant nurse should be contacted to determine extent of injury or disability. Additional concerned personnel may '.je interviewed and should include the concerned line supervision. C. The committee will tentatively agree on the cause of the accident and recommendations and the chairman will prepare a rough draft following the format in Attachment #1. D. A report number will be assigned by the Safety Department. 4 Within three working days following the incident the investigation report will be reviewed <^nd approved by the Department Superintendent or Supervisor involved. The Safety Superintendent will assist in this review. The entire committee may participate if requested by the chairman, Department Superintendent, or Safety Superintendent. 5. mtto The committee then will present the report in person jointly to the Superintendent or Manager involved and the Plant Manager for approval within five working days following the incident. 6. The basic report, with appendix, will be published within ten working days following the incident. Copies will normally be distributed to all Superintendents, Managers, and the Safetv Dent, unless restricted by the Plant Manager. LQ01521 16984 ORGANIZATION & PROCEDURE MANUAL 5P-014 u-uyu-f- MONSANTO COMPANY CHOCOLATE BAYOU PLANT ( INVESTIGATION AND REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIRES AND SPILLS 7. The distribution of the basic report, without appendix, will normally be to all plant supervision, but may be restricted by the Superintendent, Manager, or Plant Manager. 8. The following instructions are applicable to status reporting1 A. Each department will report its response to the recommendations to its Superintendent or Manager,and-' the Safety Doparfemente. A copy of the recommendations sheet from the accident report be used fcr reporting this response, retyping should iot be necessary B. Each department should indicate those recommendations that are applicable to its operations, the date the recommendation is completed, any comments, and the status of the recommendation. ( C. Investigation committee chairmen should circulate the status reports to the other members of the comnuttee. ( 6ll3 16985 BC01522 PARE 5 OP 5 ORGANIZATION ft PROCEDURE MANUAL so-o/^ Attachment #1 MONSANTO COMPANY CHOCOLATE BAYOU PLANT ( INVESTIGATION AND REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIRES AND SPILLS MONSANTO COMPANY CHOCOLATE BAYOU PLANT ALVIN, TEXAS ACCIDENT INVESTIGATION REPORT N0._ NEAR-MISS INVESTIGATION REPORT NO.______ FIRE/SPILL INVESTIGATION REPORT NO.____ PATE s (APPROVED BY PLANT MANAGER) TO: ALL SUPERVISION (Normally) SUBJECT: Investigation of Accident in !HAm40 C Department and Unit DESCRIPTION OF ACCIDENT The opening paragraph should be a summary statement of the incident - itself stating the extent of injuries and/or damage to equipment, who was injured if applicable (functional job descriptions, not names) and the where, when, what and how of the incident. This should be followed by a brief chronological description of the events occurring i and conditions existing just prior to, during and following the accident ^ that are related to the accident or that will assist in giving a clearer (understanding of the nature of the occurrence. This should be givt*n in summary and limited to a statement of facts only; not conclusions c.rawn as a result of unsubstantiated theories. CAUSE The prime cause, as determined by the investigating committee, that was responsible for the accident shoiId be covered in this section. Only those secondary causes, if any, that the committee feels were critically .important should be listed and labeled "secondary causes". (The listing Jof secondary causes tends to dilute emphasis on the prime cause.) RECOMMENDATIONS These recommendations should be the result of the investigation by the committee making this report. Only measures to correct both the direct cause and any contributing causes to the accident should be covered. If corrections are already made or underway, this should be reflected in the report. Completion dates and assignments of responsibility to Superintendents will be included in this section. Assigning of joint responsibility should be avoided for clarity. Recommendations should be specific and realistic and should avoid generalizations such as "be more careful", "pay attention", etc. When recommending "reviewing" of hazards associated with a given task, refer to specific written sources of information and/or list specific recommended precautions recognized by the committee. Recommendations should be listed on the format shown on page 2 of this attachment. APPROVED BY: Superintendent ytarre- Date " Date 611163986LG0__1__5__2__3______ {Signed oy ail members of the Investigating Committee) PAC5FI OP Attachment #1 D-0903 Page 2 of 2 c .j ,- 7 on > 54 *C 6113 16987 OH 0> nt; ft 4 Cd 3t JC 0t o c o pto *4 JQ CJ *urHz k p< rt iH P aa 'cz, <I 3A-/ ^Attachment ?f2 ORGANIZATION & PROCEDURE MANUAL -D "'0003' MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AND REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIRES AND SPILLS REPORT APPENDIX ACCIDENT INVESTIGATION REPORT NO. NEAR-MISS INVESTIGATION REPORT NO. FIRE/SPILL INVESTIGATION REIORT NO.____ ACCIDENT CLASSIFICATION DATE; (Approved by Plant Mgr.) This should be enumerated as follows (where applicable). 1. Name (optional) 2. Department 3. Occupation 4. Experience on the Jcb 5. Equipment Involved 6. Operation Being Performed 7. Type of Accident 8. Mechanical Cause 9. Human Cause 10. Type of Injury 11. Parts of Body Involved 12. Time and Date of Accident 13. Date Investigation Initiated ACCIDENT INVESTIGATION This should cover all pertinent information gathered by the investi gating committee m sufficient detail, it should include statements of witnesses, pas-; history of the injured if it affects the accident, and any other pertinent information gathered during the course of the investigation. PERSONNEL INTERVIEWED AND WITNESSES 6113 16988 Include in this section personnel interviewed and witnefieP.l'J^ ORIGINAL ISSUE 1/4/65 rrw -- REVISEDR/4 12/30/76 j ATTACHMENT#2 MONSANTO COMPANV CHOCOLATE BAYOU PLANT INVESTIGATION AND REPORTING OF SIGNIEICANT INJURIES. NEAR-MISSES. FIRES AND SPILLS Ci INSTRUCTIONS TO THE CHAIRMAN OF INVESTIGATION COMMITTEES 1. Selected chairman will meet with the Superintendent or Manager immediately fallowing the incident requiring investigation to receive a gereral outline of what is expected of him in his job as committee chairman. .2 The chairman should read Ctfp procedure D-0903, 3. MflNeO The chairman should not edict his opinions or allow individuals reviewing/approving the report to do so with the committee members. He should use his conference leadership techniques in guiding the committee in their activities. The interest is in finding consensus judgements of the group. 4. It is important that the committee determine the true facts of ( "what happened" and what can be done to prevent similar or related incidents in the future. 5. Frequently, errors in judgment or failure of individuals to follow established procedures are involved in an incident. These occurrences should not be "whitewashed". They should be recognized by the committee and noted in the report. How ever, it is important to speak to "what" was done and not speak to "who" did it. .6 The key committee function is to identify the prime cause of the incident. This prime cause should be identified in the report. Any other secondary contributing factors which the committee feels critically important should also be listed, but they should be labeled as secondary factors and should be minimized. 7. The committee's "recommendations" should deal with the prime cause of the accident. Secondary contributing factors and any other safety lessons that have been identified may be listed if they are relevant and important. Recommendations should be as specific as possible. It should not be assumed that plant ( supervision knows what "standard procedures" or "safe working practices" are. Make reference to specific procedure numbers, plant safety guides, or any other known documents. BO01526 ORIGINAL ISSUE 5/4/71 i REVISED R/2 12/30/76 |; PAGE_l__Of__2 6113 16989 ORGANIZATION & PROCEDURE MANUAL Attachment #3. D-0903 MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AND REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIFES AND SPILLS INSTRUCTIONS TO THE CHAIRMEN OF INVESTIGATION COMMITTEES Describe the actual "do'3" and "don'ts" the conmittee has identified in the incident. Keep in mind that supervision across the plant will be reading these recommendations and trying to relate them to our overall safety program. Make the recommendations meaningful and applicable. .8 While the value of good procedures is well recognized, the temptation to recommend a procedure for every situation should be avoided. The committee's recommendation should be aimed at achieving a correct balance between "use of procedures" and "use of judgment" for plant activities. 9. .10 mp | When the committee is not confident they know the proper action to be taken in a recommendation, they should feel free to rec ommend that a study or analysis be accomplished to decide what action is necessary. They may want to recommend the involvement of an expert in a given area. Responsibilities and timing for accomplishing each recommendation will be established during the review of the incident with the Department Superintendent or PT Supervisor. I11* DP68 I All members of the committee whould meet with the Superintendent or Manager and the Plant Manager when accomplishing the investi gation review with them. 12. The committee chairman is responsible for obtaining appropriate stenographical help. 13. The chairman should recommend to the Superintendent or Manager and Plant Manager any limitations on distribution of the investigation report if he feels them necessary. 14. The chairman should be informed that the Safety Department representative on his committee is a good source of information regarding how accident investigation committees should function. They serve on many of these committees and have accumulated experience. ___ e /a "------r 6113 16990 w EQG1527 PAGE. .OI_2 Barbara *i i Attached is a copy of the procedure, D-0903, which was revised by D. K. Stephens. Linda Miller issued it to all procedure book holder: last week. Lynda Lairpreeht r c:c <&cre d ( ' 'Gr m 9 *4 H i (;;cijR jD< c< <t rre <* : I i 41 0 0 j.d u cjv (k r_e.0 # 0 e o :O 9 9 g i f rj&0 eiBflr0i>eej 4tr GQ^Q.ej3jy>ejp JF?3rTXT y* 6113 16991 BO01528 ORGANIZATION & PROCEDURE MANUALp-0903 MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AMD REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIRES AND SPILLS PURPOSE ( iThis procedure explains the investigation and reporting of significant ,HAMiED|injuriest near-misses, fires a spill^. Investigations and reports of this type are utilized to de (ermine the basic causes of the incident and the corrective action requi sd t prevent recurrence. The report also serves as a means to commun .cab the circumstances surrounding the incident to all areas of the t. Areas not involved will then use the report to determine the ntial for similar incidents. POLICY [Accidents which result in significant injuries, near-misses, fires and spills will be thoroughly investigated and reported, with follow-up recommendations. Investigations vill be conducted regardless of whether the persons involved are Monsanto employees or contractor employees. Investigation and reporting of other incidents are covered under Procedures D-0904 (Minor In; ury Reporting and Investigation) and D-0905 (Loss Reporting). DEFINITIONS Added The following injury definitions ^sonform to the provisions of the Occupational Safety and Health Act (OSHA) of 1970. They also represent a uniform system for recording, classifing and investigating injuries as outlined in "Guidelines for Recording and Reporting Occupational Injuries and Illnesses", Monsanto Co., Safety and Property Protection, January, 1977. RECORDABLE INJURIES will he investigated under this procedure. Recordable injuries are defined as any death or injury that results from a work related accident or from an exposure in the work environment and involves any of the following: LjJAM&fcD a. Medical Treatment (not first aid) b. Inability to Work c. Restriction of Work or Motion d. Loss of Consciousness e. Transfer to Another Job ORIGINAL ISSUE 1/4/65 REVISEDR/5 12/30/76 6113 . 16992 B001529 PAGE ^,,OF_i & tt a r* u va erwr ORGANIZATION & PROCEDURE MANUAL D_0903 MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AND REPORTING OF SIGNIFICANT TNtTTTRTES. NEAR-MISSES. FIRES AND SPILLS 2. A NEAR-MISS is any incident where significant injury or property damage could have resulted had circumstances been only slightly different than actual qr had the activity been continued. A near-miss will be judged significant by the concerned Superintendent or PT Manager with the recommendation of the Safety Department considered. 3. A FIRE or SPILL will be judged significant by the concerned Superintendent or PT Manager with the recommendation of the Safety Department considered. RESPONSIBILITIES A. The GENERAL SUPERINTENDENTS, CED SUPERINTENDENT, and PT MANAGER are responsible for: A. insuring that incidents which are covered in the definitions section are reported to him and the Safety Department. B. Initiating an investigation, appointing a committee, and briefing the chairman for incidents as follows: (a) Injuries - The Superintendent or Manager of the employee (Monsanto or contractor) injuried. (b) Near-Misses - The Superintendent or Manager of the employee (Monsanto or contractor) or the equipment exposed to the near-miss. (c) Fires or Spills - The Superintendent or Manager of the area in which the incident occurs. C. Assigning responsibility for corrective action in his involved areas. D. Reviewing investigation reports for incidents outside their areas, determining application of recommendations, assigning responsibilities, and informing the Safety Department accordingly. E. Reporting application and status of the recommendations pertaining to their areas. 6113 001530 16993 hdiciwai icciiri /A/CC DC\/iccno/K i i /in fnc. PAGE-2___OF_ ORGANIZATION & PROCEDURE MANUAL D-0903 MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AND REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIRES AND SPIIIS 2. The INVESTIGATION COMMITTEE is responsible for conducting the investigation, recording the facts, and publishing the report. 3. Aooeo The DEPARTMENT SUPERINTENDENTS and PT GROUP SUPERVISORS are responsible for reviewing and approving the investigation report, and establishing timing and responsibilities for accomplishing the recommendations. 4. IHAtf&ED The SAFETY SUPERINTENDENT is responsible for assisting in identi fication of significant incidents, staffing of committees, advis ing committees, and review at the Dept. Superintendent/PT Group Supervisor level. He will appraise Management on status of recommendations and maintain files of reports and pertinent correspondence. PROCEDURE 3D06D 1. If an accident occurs which fits into the above general definitions, the concerned Superintendent or Manager will appoint an investi gation committee. Normally, the committee will be composed of four members, but, the size may be varied depending on the nature and complexity of the incident. A representative of the Safety Department will serve as a member of all investigation committees, unless the exception is approved by the Safety Superintendent. The Superintendent or Manager has the option of staffing the com mittee from within his own department or 'other departments in the plant. The exception to this is the Safety Department representative Individuals directly involved in the incident should not be members of the committee. Final review of selected incidents may be held at the Superintendent or Manager level with approval of the Plant Manager. 2. The following criteriashould be used in selecting the investigation committee chairman: A. The chairman named should have served as a member of at least one formal investigation committee prior to serving as a chairman B. The chairman should be skilled in conference leadership. A key function is drawing all members of the committee into parti cipation and contribution to the investigation. <3* c\ CO O' H VO C*t ^ vO C. The chairman should^be skilled in Managerial Analytics Problem Solving and Decision Making techniques. ]}Q01.53^- ORIGINAL ISSUE 1/4/65 REVISEDR/5 12/30/76 PAGI _OF_ ATTftrUUCKIT ORGANIZAT1QN & PROCEDURE MANUAL MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AMD REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIRES AND SPILLS D. Generally, the more severe the incident, the more experienced person required to act as chairman. Usually, a supervisor/ technical/managerial employee will make the more competent chairman, particularly for more complex incidents. E. The chairman may need to be familiar with technology of an incident when the preliminary indicators show that technology is important to the cause and/or solution. Refer to Attachment #3 for suggested instruction to the chairman of investigation committees. 3. The investigation will be started by the committee within 24 hours of the time of the incident. The following guidelines should be used: A. Visit scene of accident to investigate physical facilities. Take photographs or make sketches and diagrams to record details of the physical environment. B. Interview witnesses and the injured employee if available. The plant nurse should be contacted to determine extent of injury or disability. Additional concerned personnel may be interviewed and should include the concerned line supervision. C. The committee will tentatively agree on the cause of the accident and recommendations and the chairman will prepare a rough draft following the format in Attachment #1. 6113 16995 D. A report number will be assigned by the Safety Department. 4. Within three working days following the incident the investigation report will be reviewed and approved by the Department Superintendent or Supervisor involved. The Safety Superintendent will assist in this review. The entire committee may participate if requested by the chairman. Department Superintendent, or Safety Superintendent. lOAftlteo 5. The committee then wili present the report in person jointly to the Superintendent or Manager involved and the lant Manager for approval within five working days following the incident. .6 The basic report, with appendix, will be published within ten workinc days following the incident. Copies will normally be distributed to all Superintendents, Managers, and the Safety Dept, unlgss restricted by the Plant Manager. BG015o4 ORIGINAL ISSUE 1/4/65 PAGE 4__ OF_i REVISED R/5 12/30/76 a itk' ORGANIZATION & PROCEDURE MANUAL D-0903 MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AND REPORTING OF SIGNIFICANT INJURIES. NEAR-MTSSES. FIRES AND SPILLS 7. The distribution of the basic report, without appendix, will normally be to all plant supervision, but inky be restricted by the Superintendent, Manager, or Plant Manager. .8 The following instructions are applicable to status reporting: A. Each department will report its response to the recommendations to its Superintendent or Manager and the Safety Department. A copy of the recommendations sheet from the accident report will be used for reporting this response, retyping should not be necessary. B. Each department should indicate those recommendations that are applicable to its operations, the date the recommendation is completed, any comments, and the status of the recommendation. GAUGED C. Investigation committee chairmen should circulate the status reports to the other members of the committee. D. On or before the 15th of each month, each Superintendent and Manager will submit a status report for all incidents that have incomplete recommendations. When all recommendations are completed, the final status report will be submitted and noted on the report form.(See Attachment #1, page 2) REVISED ORIGINAL ISSUE 1/4/65 6113 16996 BG01533 A m ft ORGANIZATION & PROCEDURE MANUAL Attachment #1 D-0903 MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AND REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIRES AND SPILLS MONSANTO COMPANY CHOCOLATE BAYOU PLANT ALVIN, TEXAS ACCIDENT INVESTIGATION REPORT NO. NEAR-MISS INVESTIGATION REPORT NO,______ FIRE/SPILL INVESTIGATION REPORT NO.____ DATE: (APPROVED BY PLANT MANAGER) TO: ALL SUPERVISION (Normally) SUBJECT: Investigation of Accident in !i!AM60 fl>D*D Department and Unit DESCRIPTION OF ACCIDENT The opening paragraph should be a summary statement of the incident itself stating the extent of injuries and/or damage to equipment, who was injured if applicable (functional job descriptions, not names) and the where, when, what and how of the incident. This should be followed by a brief chronological description of the events occurring and conditions existing just prior to, during and following the accident that are related to the accident or that will assist in giving a clearer (understanding of the nature of the occurrence. This should be given in : summary and limited to a statement of facts only; not conclusions drawn as a result of unsubstantiated theories. CAUSE The prime cause, as determined by the investigating committee, that was responsible for the accident should be covered in this section. Only those secondary causes, if any, that the committee feels were critically important should be listed and labeled "secondary causes". (The listing of secondary causes tends tp dilute emphasis on the prime cause.) RECOMMENDATIONS These recommendations should be the result of the investigation by the committee making this report. Only measures to correct both the direct cause and any contributing causes to the accident should be covered. If corrections are already made or underway, this should be reflected in the report. Completionjlates and assignments of responsibility to Superintendents will be included in this section. Assigning of joint responsibility should be avoided for clarity. Recommendations should be specific and realistic and should avoid generalizations such as "be more careful", "pay attention", etc. When recommending "reviewing" of hazards associated with a given task, refer to specific Written sources of information and/or list specific recommended precautions recognized by the committee. Recommendations should be listed on the format shown on page 2 of this attachment. APPROVED BY: Superintendent Date Date 6113 16997 BCG1534 {Signea members of the Investigating Committee) ORIGINAL ISSUE 1/4/65 REVISED R/5 12/30/76 PAGE 4:- OR 7" ORGANIZATION & PROCEDURE MANUAL Attachment #,2 . D--0903 MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AM)-REPORTING ~0F`SIGNIFICANT INJURIES. -^NEAR-MISSES. FIRES -AND SPILLS REPORT APPENDIX ACCIDENT INVESTIGATION REPORT NO. NEAR-MISS INVESTIGATION REPORT NO. FIRE/SPILL INVESTIGATION REPORT NO.____ -- ACCIDENT CLASSIFICATION DATE: (Approved by Plant Mar.1 This should be enumerated as follows (where applicable). 1. Name (optional) 2. Department 3. Occupation 4. Experience on the Job 5. Equipment Involved 6. Operation Being Performed 7. Type of Accident 8. Mechanical Cause 9. Human Cause 10. Type of Injury 11. Parts of Body Involved 12. Time and Date of Accident 13. Date Investigation Initiated ACCIDENT INVESTIGATION This should cover all pertinent information gathered by the investi gating committee in sufficient detail, it should include statements of witnesses, past historyjof the injured if it affects the accident, and any other pertinent information gathered during the course of the investigation. PERSONNEL INTERVIEWED AND WITNESSES 6113 16998 . Include in this section personnel interviewed and witnes ORIGINAL ISSUE 1/4/65 PACE 1 of 1 _ REVISEDR/4 12/30/76 ATTACH MENT#2 ORGANIZATION & PROCEDURE MANUAL #3 MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AMD REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIRES AND SPILLS INSTRUCTIONS TO THE"CHAIRMAN OF INVESTIGATION COMMITTEES 1. Selected chairman will meet with the Superintendent or Manager immediately following the incident requiring investigation to receive a general outline of what is expected of him in his job as committee chairman. 2. The chairman should read O&P Procedure D-0903. 3. Changed The chairman should not edict his opinions or_allow individuals reviewing/approving the report to do so with the committee -- members. - He should use, his conference leadership techniques in guiding the committee in their activities. The interest.is infinding consensus judgements of the group. 4. It is important that the committee determine the true facts of "what happened" and what can be done to prevent similar or related incidents in the future. 5. Frequently, errors in judgment or failure of individuals to follow established procedures are involved in an incident. These occurrences should not be "whitewashed". They should be recognized by the committee and noted in the report. How ever, it is important to speak to "what" was done and not speak to "who" did it. 6. The key committee function is to identify the prime cause of the incident. This prime cause should be identified in the report. Any other secondary contributing factors which the committee feels critically important should also be listed, but they should be labeled as secondary factors and should be minimized. The committee's "recommendations" should deal with the prime cause of the accident. Secondary contributing factors and any other safety lessons that have been identified may be listed if they are relevant and important. Recommendations should be as specific as possible. It should not be assumed that plant supervision knows what "standard procedures" or "safe working practices" are. Make reference to specific procedure numbers, plant safety guides, or any other known documents. BG015o6 noiniMAi iccur 5/4/71 or\;iccn R/2 12/30/76 6113 16999 ORGANIZATION & PROCEDURE MANUAL Attachment #3 D-0903 MONSANTO COMPANY CHOCOLATE BAYOU PLANT INVESTIGATION AND REPORTING OF SIGNIFICANT INJURIES. NEAR-MISSES. FIRES AND SPILLS INSTRUCTIONS TO THE CHAIRMEN OF INVESTIGATION COMMITTEES Describe the actual "do's" and "don'ts" the committee has identified in the incident. Keep in mind that supervision across the plant will be reading these recommendations and trying to relate them to our overall safety program. Make the recommendations meaningful and applicable. 8. While the value of good procedures is well recognized, the temptation to recommend a procedure for every situation should be avoided. The committee's recommendation should be aimed at achieving a correct balance between "use of procedures" and "use of judgment" for plant activities. 9. When the committee is not confident they know the proper action to be taken in a recommendation, they should feel free to rec ommend that a study or analysis be accomplished to decide what action is necessary. They may want to recommend the involvement of an expert in a given area. 'ODfcp 10. Responsibilities and timing for accomplishing each recommendation will be established during the review of the incident with the Department Superintendent or PT Supervisor. DO0 11. All members of the committee whould meet with the Superintendent or Manager and the Plant Manager when accomplishing the investi gation review with them. 12. The committee chairman is responsible for obtaining appropriate stenographical help. 13. The chairman should recommend to the Superintendent or Manager and Plant Manager any limitations on distribution of the investigation report if he feels them necessary. 14. The chairman should be informed that the Safety Department representative on his committee is a good source of information regarding how accident investigation committees should function. They serve on many of these committees and have accumulated experience. 6ii3 B001537 17000 ORlftlWAl IRSIIF 5/4/72 I orvicc-nR/2 12/30/76 1 SAFETY .PROCEDURE MANUAL MONSANTO COMPANY _ _ _ _ _ _ _SP_-0_1_5 _ _ CHOCOLATE BAYOU PLANT PLANT-WIDE USE OF WATER ON CHEMICAL SPILLS PURPOSE: The purpose of this procedure is to acquaint all Maintenance per sonnel with the safety of using water on chemical spills. SCOPE: This procedure covers the use of water on all chemicals within the plant. RESPONSIBILITY: In the event of a chemical spill, the primary function of the Main tenance personnel is to notify production personnel immediately. Assistance may be requested of Maintenance personnel from production to regain control of the situation. It is the responsibility of the Maintenance foreman to insure that all technicians receive this information. As new chemicals are brought into the plant, information must be gathered on the use of water. This can be obtained from the Safety Department. PROCEDURE 1. Water can be safely applied on all chemical spills in the plant. 2. In any emergency, except Hor equipment operating at extreme high temperatures, such as HDA in Hydrocarbons, there would be no problems. In some cases, water will upset operating conditions, but this is to be expected in emergency cases. 3. Fog streams, in most cases, is the most effective application of water to hydrocarbon spills. Large quantities of air are pulled in with the fog spray, causing the vapor to become too lean to burn. Also, many chemicals are soluble in water. The more water applied, the faster the hazard of fire of explosion is reduced. Spilled material should be flushed to sewer as soon as possible. 4. Spills of low temperature material will vaporize much faster when large amounts of water fog is applied, due to the difference in temperature of the chemicals and the water. The vapors will also be dispersed faster so there will no longer be a flammable mixture. 6113 17001 BG01553 ORIGINAL KSIIF As A 7 BvK.B.Owen REVISED / / By RFVlFWFn* /l h-t Qw n r* PAGE 1 OF 2 ATT APHMFNT