hss 01 052 incident investigation - uk power...

UK Power Networks HSS 01 052v13.0

Incident InvestigationsOwner

Name Suleman AlliTitle Director of Safety, Strategy & Support Services

Signature

Date 19 September 2018

Authoriser

Name Peter VujanicTitle Head of Safety, Health and Environment

Signature

Date 14 September 2018

This document forms part of the UK Power Networks Integrated Management System and compliance with its requirements is mandatory. Departure from these requirements may only be taken with the written approval of the above authoriser.

Revision RecordVersion number 13.0 What has changed?

Deleted reference to EMP 00-0006. 6.4 added reference to HSS 41 004 withdrawal/ reinstatement of competencies. 7.0 added record of withdrawal of certificates. 8.4 added flow diagram for contractor incidents.HSS 01 052a v3.0 reviewed (now v4.0) – no changesHSS 01 052aa v2.0 reviewed (now v3.0) – no changesHSS 01 052ab v2.0 reviewed (now v3.0) – no changesHSS 01 052b v3.0 reviewed (now v4.0) – no changesHSS 01 052d v1.0 reviewed – no changes

Why has it changed?Additional Contractor requirements. EMP 00-0006 has been withdrawn.

Date published 26/09/2018

Next review date 01/11/2020

Prepared by R. MacKinnon

Version number 12.0 What has changed?Definitions added Incident Leadership Team (ILT).Inclusion of responsibilities for Head of SHE.Added flow chart for ILT appendix 2, now also a requirement to report fatalities to Ofgem.

Why has it changed?ILT now required for certain criteria.

Date published 13/07/2017


Prepared by R. MacKinnon & C. Shackell

Version number 11.0 What has changed?Timescales for VSI and SI investigation completion extended. All Investigations are now loaded to the AIRLine system by the Investigator. Date published 27/04/2016

This printed document is valid at 20/05/23, check after this date for validity. of 17


Requirement to complete a short executive summary for each investigation. Reference to accident book removed as process now on line. The terms iCASS changed to AIRLine and HSS&TT changed to SSSS throughout. New Owner/Authoriser. HSS 01 052a Added summary box. HSS 01 052aa, ab, b, & d no changes. HSS 01 052c and h withdrawn.

Why has it changed?Launch of the AIRLine System for incident reporting and investigation.


Prepared by S. Wigfull

Circulation

☒ All UK Power Networks Staff☐ Asset Management☐ Capital Programme & Procurement☐ Connections☐ Contractors☐ Customer Services☐ Finance☐ G81 External website☐ HR & Communications☐ ICPs (Independent Connection Providers)☐ IDNOs (Independent Distribution Network Operators)☐ Information Systems☐ Legal☐ Meter Operators☐ SHE&TTA

☐ In Business safety team☐ Safety Reps

☐ Network Operations☐ EPN☐ LPN☐ SPN☐ Connection Services☐ Distribution Capital Delivery☐ Highway Services☐ Logistics☐ Network Control☐ Powercare☐ Transport Services

☐ Strategy and Regulation☐ UK Power Networks Services

☐ Airports☐ Rail☐ Strategic projects☐ HS1, DLR & Commercial buildings☐ MUJV / Allenby☐ Business Development

☐ Others (specify)



Contents

1.0 Introduction and Purpose................................................................................................42.0 Scope.................................................................................................................................43.0 Objective............................................................................................................................44.0 References........................................................................................................................45.0 Definitions.........................................................................................................................46.0 Responsibilities................................................................................................................57.0 Records.............................................................................................................................78.0 Investigation Process.......................................................................................................79.0 Incident Recommendations...........................................................................................1310.0 Reporting and Communication.....................................................................................1411.0 Lost Time Incident (LTI) Return to Work Interviews...................................................1712.0 Training and Competence..............................................................................................17



1.0 Introduction and PurposeThis procedure defines the process for the investigation of health, safety, environmental and UK Power Networks related incidents to prevent reoccurrence and thereby minimise human, environment and economic loss.

2.0ScopeThis procedure applies to incidents involving employees and contractors working on behalf of UK Power Networks and UK Power Networks Services and any incident involving assets owned by UK Power Networks.

3.0ObjectiveThe objectives for this procedure are to ensure that:

Investigations are undertaken to a consistent standard and in appropriate detail to identify root causes and identify and implement appropriate preventative controls;

Lessons are learnt and are communicated to all relevant parts of UK Power Networks and its contractors; and

Regular review of reports and trends are analysed to identify weaknesses in tasks or processes.

4.0References

HSS 01 051 Incident Reporting

HSS 01 052a SI & I Level Investigation Report Template

HSS 01 052aa VSI Investigation Report Template

HSS 01 052ab VSI Investigation Template

HSS 01 052b Incident Reporting Root Cause Analysis Guide

HSS 01 052d Investigator's Guide for AIRLine+

COP 00 009a Incident Escalation Matrix

HSS 41 004 Managing Authorisations Following an Operational Incident

HSS 01 061 Task Risk Assessment

HSS 01 094 Specific Action Teams (SATs)

5.0Definitions

Incident (I) Incidents with a Classification matrix rating of 1 to 12 (Green).

Serious Incident (SI) Incidents with a Classification matrix rating of 13 to 20 (Amber).

Very Serious Incident (VSI)

Incidents with a Classification matrix rating of 21 to 25 (Red).

ILT Incident leadership Team

Legally Privileged This protects all communications between a professional legal adviser (a solicitor, barrister or attorney) and his or her clients from being disclosed without the permission of the client. The privilege is that of the client and not that of the lawyer.



6.0Responsibilities6.1 UK Power Networks Director of SS&SS is responsible for:

Providing sufficient resources for competent SHE advice to ensure compliance with the requirements of this procedure;

Determining who will be in attendance at the Major Incident Review; and Ensuring that recommendations are closed on time and in full and that incidents

trends are fully discussed and actioned as necessary on a regular basis.

6.2 Head of Safety, Health & Environment is responsible for: Confirming the incident rating for VSIs and when an Incident Leadership Team (ILT)

is required; Advising of the incident rating to the Director of SS&SS and the Company Secretary; Appointing the Lead Investigator for VSI investigations (Lead In-Business

HSS/Environment Advisors will assist in identifying an appropriate Investigator); and Ensuring that recommendations are closed on time and in full and that incidents

trends are fully discussed and actioned as necessary on a regular basis.

6.3 UK Power Networks Directors are responsible for:

Providing sufficient resources to ensure compliance with the requirements of this procedure including making themselves available as Lead Investigators and Approvers for VSI investigations where appropriate;

Leading an investigation which falls within the VSI investigation category where asked to do so by either the Legal Department or the Director of SS&SS;

Leading the investigation team when an investigation falls within the required criteria where asked to do so by either the Legal Department, the Director of SS&SS or the Head of SHE;

Appointing the Lead Investigator for SI investigations where appropriate (Lead In-Business HSS/Environment Advisors will assist in identifying an appropriate Investigator);Attending the Major Incident Review Committee where required to discuss and review SI and all VSI investigation reports; and

Ensuring that recommendations are closed on time and in full and that incidents trends are fully discussed and actioned as necessary on a regular basis.

6.4 Managers are responsible for ensuring:

Employees are aware of this process and those likely to be part of investigation process have received appropriate training;

Withdrawal / reinstating of competencies if applicable in accordance with HSS 41 004 Managing Authorisations Following an Operational Incident and notifying relevant managers or teams;

Employees are suitably briefed on the use and function of the on-line investigation portal;

Employees and Trade Union appointed safety representatives are released to undertake training and participate in investigations as required;

Investigations of Incident (I) events arising out of the work activities under their control are conducted promptly;

Co-operation with the Investigator and feedback on draft recommendations to ensure they are appropriate, allocated to the correct person and timescale;



Briefings on lessons learnt and actions to the local Health, Safety & Environment Committee (HSEC) and team meetings;

Recommendations are implemented in full and on time and outcomes and evidence recorded on AIRLine; and

They review all overdue action reports within their area of responsibility and encourage their teams to complete overdue actions.

6.5 Lead Investigators are responsible for:

Appointing relevant specialists to assist with the investigation; Ensuring the investigation timescales are adhered to and informing the ILT, Major

Incident Review Committee (VSI), relevant Director (SI) or Senior Manager (I) when this is not achievable;

Contacting AIRLine should there be a justification to amend the agreed incident classification;

Completion of the interim and final reports, agreeing recommendations with action owners prior to issue and obtaining approval for issue;

Briefing the Major Incident Review Committee as requested; and Ensuring the Investigation questionnaire is completed including an Executive

Summary and that the report and evidence are loaded into the AIRLine.

6.6 H&S Engagement Manager shall ensure that the HSS Co-ordination team:

Amend the incident category, type, severity status subject to written instruction from the Investigator, Lead HSS in-business/Environment Advisor or Director;

Notify Major Incident Review Committee and relevant Directors of any significant changes to the incident classification as a result of the investigation;

Issue the action to undertake the investigation to the Investigator and provide them with all available information;

Provide support to investigators, reviewers, approvers and action owners on the use of the on-line system;

Offer briefings to new managers and HSS Advisors re the use of AIRLine; and Prepare the monthly and weekly statistics showing overdue actions and trends.

6.7 Lead/In Business HSS/Environment Advisors are responsible for:

Reviewing and agreeing the level of classification of all VSI and SI Providing expertise and technical support to the Investigator including training and

mentoring where required; Assisting Line Managers in identifying the level of incident classification and who to

undertake the investigation and notifying AIRLine; Undertaking reviews of incident reports where requested; Ensuring overdue recommendations and incident trends are discussed at directorate

management meetings; Chasing overdue action owners associated with investigations; and Ensuring that learning points from incidents are documented clearly, signed off by

the Head of SHE and distributed in the business through the appropriate means (e.g. Team Brief, 1st 15).

6.8 Contract and Project Managers are responsible for:

Ensuring that contractor incidents are investigated and findings are inputted into AIRLine;



Ensuring that health and safety information, including learning points from incidents, are shared with the relevant contract organisations that they are managing; and

Participating in investigations and undertaking actions as a result of UKPN led investigations as requested by the Investigator.

6.9 Employees and contractors will co-operate with the Incident Investigator and attend a return to work interview where applicable.

6.10 Trade Union appointed Safety Representatives will be:

Invited to be part of the investigation; Provided with training in the requirements of this procedure and the skills required to

undertake incident investigation; Provided with copies of completed investigations where requested; Requested to provide relevant details (on request) of any additional independent

safety representative investigation that may have been carried out which may assist the investigation; and

Through the joint consultative HSEC forums, monitoring incident statistics and trends, including sickness and ill health data and reviewing the effectiveness and implementation of recommendations and actions detailed in investigations.

6.11 Specific Action Teams (HSS 01 094) are responsible for reviewing and revising risk assessments where risks are missing or controls lacking in accordance with HSS 01 061.

7.0RecordsReports and all associated documents (e.g. witness statements), recommendations /actions, evidence to close actions will be stored in AIRLine for a minimum of 20 years.

The withdrawal of operational certificates shall also be recorded in the relevant Control Room log, and SAP.

8.0 Investigation Process8.1 Investigation Team

The Investigator will appoint specialists to assist with the investigation if required.

Type Investigator and Specialists

VSI Investigator: Director.Selected by: Head of SHE with advice from LegalSpecialists: Head of Safety, Health & Environment or Lead In Business HSS \ E Advisor, Relevant Safety Representative(s) \ operational \ equipment \ or craft experts.

SI** Investigator: Senior Manager - external to the departmentSelected by: Director.Specialists: HSS\E Advisor, Relevant Safety Representative(s) \ operational \ equipment or craft experts.

I Investigator: Line Manager.Selected by: Senior Management Team member.Specialists: Advice from Relevant Safety Representative \ HSS\E Advisor or craft experts

** For environmental incidents the Lead Environment Manager selects the investigator.



8.2 Incident Investigation

HSS Reporting Co-ordinator will issue the Investigator with a request to complete an Investigation via the AIRLine system.

The investigation will commence in-line with figure 1, 2 and 3 to ensure evidence is secured. Depending on the incident this may require an immediate visit to site to take photographs and obtain witness statements. Evidence to be collated and examined will normally include work instructions, drawings, safety documents, switching schedules and logs, network control room voice recordings, photographs of the work area/equipment, procedures, equipment test certificates etc.

The Root Cause Analysis Reference Guide (HSS 01 052b) is designed to help the trained Investigator to describe what happened during a particular incident, to determine how it happened and to understand why it happened.

Using this guide, the Investigator will ensure that all root cause(s) are thoroughly investigated before deciding on recommendations for corrective action. This is done by taking each immediate and underlying cause and analysing the reasons for its occurrence.

Each recommendation from the incident investigation should relate directly to a root cause. It is only once the root cause(s) of the incident have been identified that the Investigator can determine recommendations that will genuinely prevent reoccurrence of the incident.

As part of the investigation, the Investigator will also review the Task Risk Assessments to understand what part of the system failed. The Investigator will identify whether the Task assessment was never carried out, inadequate assessment or controls or simply not followed.

Where there is a justification as a result of findings to amend the Incident type or category the Investigator must justify the reasons for the change in the investigation report.

Each investigation shall be loaded into AIRLine via the Investigation Questionnaire which confirms the incident type, category and investigation level undertaken, the investigation team and requires a short Executive Summary to be provided which will be made available to employees so it must not contain any names only factual findings and learning in relation to the incident.

8.3 Implementation of an ILT

The appointment of an ILT will be determined by the Head of SHE and must meet the criteria Figure 2 below following the escalation of an incident:

Safety (Actual or Potential of); Permanent Disability or Fatality to UKPN Staff/Contractor/Member of the public;

Notification or Intervention requiring urgent attention; Health Significant Long term effects or Terminal ill health condition; Environmental High impact or Catastrophic impact as defined in HSS 01 051b; and Major Event as defined in COP 00 009a.



8.4 Contractor Incidents

For I level investigations, the contractor will be deemed responsible for conducting the investigation in line with their company procedures. For SI and VSI investigations, the Contract Manager/Project Manager shall ensure that the investigation is in line with this procedure. Where it is a contractor led investigation the Contract Manager/Project Manager is responsible for completing the Investigation questionnaire and loading a copy of the investigation into AIRLine. See figure 3

Where it is deemed appropriate by the Director of SS&SS or the Head of Safety, Health & Environment, such as where it is an operational incident, a UK Power Networks Investigator will be part of the investigation or a UK Power Networks led investigation will be undertaken.



8.5 Independent Connection Provider (ICP) Incidents

Incidents involving the distribution network will be subject to the investigation classification set out in the matrix in Table 2 in HSS 01 051. For I level investigations, the ICP will be deemed responsible to conducting their own investigation in line with their company procedures and once complete the ICP will meet with UK Power Networks to analyse the facts of the incident and consider and agree recommendations to avoid re-occurrence.

For SI and VSI investigations UK Power Networks will, where it is deemed appropriate by the Director of Connections or SS&SS or the Head of Safety, Health & Environment, conduct its own investigation. Subject to the outcome of this investigation a decision to withdraw the Letter of Acceptance (LOA) for an individual of the ICP may be implemented by the UK Power Networks contract manager responsible for the ICP.

9.0 Incident RecommendationsThe Investigator will evaluate the recommendations using the Recommendations Prioritisation Matrix. Each recommendation is evaluated to identify the:

Unmitigated Risk Rating - which is the level that would remain if the recommendation is not implemented – this is the one used to prioritise the recommendations; and

Mitigated risk – which is the level after the recommendation has been completed.

Both ratings are recorded on the Investigation Report. It is possible in some cases that both the unmitigated and mitigated risk ratings are the same e.g. where a recommendation develops a document or where further investigation is needed.

Incident Recommendations Prioritisation MatrixConsequence Investigation Level

Fatality Terminal ill health condition Long Term widespread damage or loss Major fire-explosion / gas-vapour leak (poisonous) Catastrophic Environmental Impact

E E110

E214

E321

E423

E525

Permanent disability Significant long term health effects Major damage or loss Fire / minor gas – poisonous component release High Environmental Impact

D D19

D213

D318

D422

D524

Lost Time Injury (LTI) Health issue requiring time off work, significant pain Significant property/ plant damage or loss RIDDOR Reportable (Major Injury) Medium Environmental Impact

C C14

C27

C317

C419

C520

Medical Treatment Injury Health issue needs physiotherapy or counselling (no time off) Short Term local damage or loss Minor fire / non-poisonous component release Low Environmental Impact

B B12

B25

B38

B415

B516

First Aid Treatment Very minor health issue slight pain (no time off work) Very limited property/ plant damage or loss Negligible Environmental Impact

A A11

A23

A36

A411

A512

VSIVery Serious Incident

SISerious Incident

IIncident

1 Very Unlikely

2 Unlikely

3 Possible

4 Likely

5 Very Likely

Likelihood of Re-OccurrenceIntolerable Risk: 25 – 21 = Eliminate; 20 – 13 = Manage; 12 – 11= Procedural Solutions. Tolerable Risk 10 – 9 = Contingency Procedures; 8 – 1 = Review Periodically

The Unmitigated Risk Rating ensures that recommendations to address high risk issues are implemented quickly and that resources are allocated to the most appropriate risk reduction measures.

The Investigator will agree the scope and timescale and the value of the Unmitigated and Mitigated Risk rating of the recommendation with the owner prior to the issue of the report. The recommendation owner must confirm in writing or by email to the Investigator that they have accepted the recommendation.



10.0Reporting and Communication HSS 01 052a and HSS 01 052aa/ab are the templates for the investigation reports and VSI level Recommendations. Individual’s names or addresses should be treated as confidential and must not be referred to in the investigation report. For certain VSIs and at the request of Legal, the investigation may be conducted under legal privilege.

For VSI and SI investigation reports all sections of the report templates must be completed and any supporting documentation included as part of this report.

However, for I level reports where it is judged that there is a very low likelihood of recurrence of an inconsequential harm, the report will be filled in only to the extent that it describes the incident and explains why no further investigation is required. For RTC 3 & 4 only the Motor Incident Report Form should be completed and sent to Transport.

10.1 Timescales

The indicative timescales for reporting and communication are given below. It is expected that investigations will be concluded earlier than these timescales where practicable with an urgency that reflects the nature of the incident and risk to staff, contractors and members of the public.

Report/Communication Type TimescaleSignificant Notification (SIN report) Within 1 working day of confirmation of VSI or LTIInterim Report (VSI investigations) Within 5 working days from incident occurrenceFinal Report

- VSI investigations- SI investigations

I investigations

From appointing investigator via the systemWithin 8 weeksWithin 4 weeksWithin 2 weeks

Where these timescales cannot be achieved the Lead Investigator will seek approval for additional time from Director for (SI) and Major Incident Review Committee for (VSI).

10.2 Review and Approval

The table below lists who should complete the review.

Type Review and Approved by VSI Reviewed by: Director of SS&SS, Head of Safety, Health & Environment or Company Medical

Officer (for work related ill health cases). Approved by: Director (other than SS&SS), member of the Major Incident Review Committee

SI Reviewed by: Lead In Business HSS/Environment Advisor and Senior OH Advisor (for work related ill health cases). Approved by: Director or relevant SMT member

I Reviewed by: In Business HSS/Environment Advisor or OH Advisor (for work related ill health cases). Approved by: Senior Manager

The Major Incident Review Committee will meet monthly to review VSI reports to identify trends and ensure timely action of recommendations. SI reports will also be considered where appropriate.



10.3 Lost Time Incidents (additional guidance)

When an employee is not immediately absent from work but subsequently becomes absent as a result of a work related incident a judgement may need to be made whether the incident constitutes a lost time incident. This judgement may require information beyond that immediately available and an investigation should be completed. Any changes made to the incident classification will be made by the Major Incident Review Committee.

In these circumstances, and until investigation is complete it is acceptable to delay reporting under RIDDOR until classification is confirmed.

10.4 Reinstatement of Authorisation

A return to normal working will normally occur providing any recommendations set by the investigation have been satisfied. Only in cases where the investigation determines serious negligence or a deliberate and careless breach of procedures, will the withdrawal remain in force until the outcome of the consequential disciplinary procedure is given.

10.5 Communication

Learning points will be communicated via HSS Bulletins, In the Know, Know How, Team Brief, toolbox talks etc. as shown in figure 4.

Under NO circumstances should copies of incident reports to be made available to parties external to UK Power Networks. Any request by a third party for a copy of an internal incident report must be directed in writing to the Head of Safety, Health & Environment and in the case of UKPN Services incidents to the Director of UKPNS.



11.0Lost Time Incident (LTI) Return to Work InterviewsWhere an employee loses a day or shift as the result of an accident at work, he/she shall be interviewed by his/her Business Manager, after returning to work and normally within 5 working days using form (HR 01 008a). In such situations the individual’s immediate supervisor and/or Safety Representative shall be given the opportunity to attend the interview.

12.0Training and CompetenceIncident Investigators will be trained in undertaking investigations, root cause analysis and recommendation prioritisation as required by this procedure (course ref HSE087). To develop competence, first time Investigators will be accompanied by a competent Investigator.


hss 01 052 incident investigation - uk power...

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