Incident Reporting & Investigationfor better emergency response & disaster management

A presentation

By

Rajnath RamJoint Adviser (I), PNGRB

Contents DefinitionsIncident type/ classificationsCause of incident/disastersIncident reportingInvestigating incidentDeveloping action planCommunicating the incident

statisticsManaging documentation

DefinitionsFollow common definitions across your organization

(refer PNGRB(Codes of practices for Emergency Response and disaster Management Plan) Regulations, 2010 and any other applicable statutory documents)

Incident Emergency Risk analysis, risk assessment, risk management Degree of Emergency (L-I, L-II, L-III) Onsite emergency Offsite emergency Disaster management Plan (DMP)

Encourage to use common definitions across your organization and among your contractors/third party agency through the written procedures, review and updation on continuous basis

Incident Type/ ClassificationsAs per PNGRB regulations Level-I

◦which can be effectively and safely managed within the site by the available resources;

◦no impact outside the site, location or installation.

Incident Type/ ClassificationsLevel-II :Which cannot be effectively and

safely managed with available resources

additional support is alerted or required;

has the potential to effect beyond the site

May require mutual aid;

Incident Type/ ClassificationsLevel-III: an incident with off-site impact could be catastrophic and is likely to

affect the population, property and environment inside and outside the installation,

management and control is done by District Disaster Management Authority (DDMA)

Incident Type/ ClassificationsNote: Level-I & Level-2 :onsite

emergency Level-3: off-site emergency

For Level-III, till the District Authority step in, it should be the responsibility of the installations/units incharge to manage the emergency

Cause of incident/disasters

Man Made Natural Calamities Extraneous

Heavy Leakage

Fire Explosion Failure of

Critical Control system

Design deficiency

Unsafe acts In-adequate

maintenance

Flood Earth Quake Cyclone Outbreak of

Disease Excessive Rains Tsunami

Riots/Civil Disorder/ Mob Attack

Terrorism Sabotage Bomb Threat War / Hit by

missiles Abduction Food

Poisoning/ Water Poisoning

Sector –Wise fire incidents

50%

22%

15%13%

E&PRef & ProcessMarketingPipeline

Source: OISD

Causes of incidents

60%

6%

18%

16%

Human FactorElectricalEquip. failureothers

Source: OISD

Consequences of Incident The consequences of an Incident are fire

explosion, blast waves, fast spreading flames, BLEVE, UVCE resulting in direct effects like damage to buildings/property, burns, fatalities.

The consequences of an Incident may be confined within the premises or may spill off-site triggering cascading effects.

An Incident in the neighborhood may sometimes cascade into an on-site emergency. It should be prevented or managed to avoid major emergency.

Incident reporting As per PNGRB (Technical Standards and Specifications

Including Safety Standards for City or Local Natural Gas Distribution Networks), Regulations 2008:◦ Incident reporting as per Enclosure-I of SCHEDULE-IE. ◦ It must be read in conjunction with the PNGRB (Codes of

practices for ERDMP) Regulations, 2010.

As per PNGRB (Codes of practices for ERDMP)Regulations, 2010◦ Any incident of L-II and L-III shall be reported◦ Preliminary report as per Schedule VI must reach within 48

hours to PNGRB◦ Detailed investigation report within a month PNGRB can invoke penalty provision on Non-Compliance

Also report near miss incidents

Why Focus on Near Misses? Establish Causes

Provide learning to prevent recurrences before they become Serious

Establish corrective actions

Improve our companies safety culture

Statistical safety data base

Nothing is learned from unreported incidents and the causes are left uncorrected!

Why Minor Incidents Go Unreported Fear of:

◦ Supervisor/Manager Disapproval◦ Getting a Bad Reputation◦ Being terminated or disciplined

Not Wanting To:◦ Lose time from the job◦ Have a incident on their work record◦ Be the subject of or involved in an investigation

Not knowing why minor incidents should be reported or what near misses are.

Lack of Management follow-through in the past. Fear of having a poor or blemished safety record.

Encourage Reporting Incidents

Ensuring all employees are told to report near miss incidents also.

Positively reinforcing each other when reporting near miss incidents.◦ Put penalty provision for not reporting

Reminding ourselves of its importanceSharing successes—improve the work

environment across the entire company.Using the Emergency-O-Gram for

initiation of the investigation and reporting of document

Make the incident reporting format readily available to all the employees.

INCIDENT INVESTIGATIONS WHY?

* Prevent Reoccurrence * Valuable Asset to Management * Improve the Company's

performance and Profitability

?

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The ultimate purpose of investigations is to prevent future incidents.

Incident Investigation an example

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As a rule of thumb, use the “5-W” principle! Simply ask “Why” five (5) times.

1. Why did you slip and Fall in the hall by the water cooler ? <answer> Because the floor was wet.

2. Why was the floor wet? <answer> Because there was water on it.3. Why was their water on the floor? <answer>I don’t know. It was coming out from underneath the water cooler.4. Why was water coming out from under the

water cooler? <answer> I don’t know. Let’s look. There is a hole in the drain pipe.

5. Why is there a hole in the drain pipe? <answer>It appears as if it rusted out.Was this an UNSAFE ACTIVITY or UNSAFE CONDITION?

Incident Investigation an example

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It was an Unsafe Condition, caused by an Unsafe Activity.

The rusted pipe was caused by lack of preventative maintenance, which was an unsafe activity. If there is “blame” where does it lie? Was there a preventative maintenance program?, Who was in charge of it. Why was it not checked? Should this be subject to disciplinary actions?

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Steps to Incident Investigation

• Manage the Incident Site • Collect factual Information• Record witness statements• Analyze the Facts• Investigations must produce factual

information • Recommend Corrective Action • implement Corrective Action Follow-up

Investigating IncidentEssential Actions (planning) Prepare a written procedure for investigations (also refer

statutory requirements) Develop an investigation report form that guides

investigators Define the company’s responsibilities in assisting

investigations conducted by contractors on incident sites.

Make investigation procedures and forms available to employees and contractors.

Bring in external investigators to collect and verify data for incidents.

External investigators are third-party investigators/independent experts

Investigating IncidentEssential Actions (verifying data and

investigations) At the beginning of an investigation, hold a

meeting of all parties involved to:◦ review investigation goals and procedures◦ Fix specific roles and responsibilities of all

participants◦ describe the types of data to be collected and

how it will be verified and handled◦ Ensure all relevant documents available

including statutory documents◦ Review and verify data reported on

preliminary incident report ◦ physically inspect the incident site and take

photographs for inclusion in investigation report

◦ Review the circumstances that led up to the incident

Investigating IncidentEssential Actions (verifying data and

investigations) review operating conditions Review all documents prepared as a part of the incident report interview witnesses and other people who were involved in

the incident or preparation of incident reports compare new data to historical data to identify new problems

and trends Conduct root-cause analysis to further verify collected data

and determine why the incident occurred. Record all findings Collect, if possible, incident data documented by government

and insurance investigators for comparison purpose Treat incident data confidential.

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Employee responsibilitiesRESPONSIBILITY to comply with all policies and procedures

RESPONSIBILITY to report all unsafe acts and conditions

RESPONSIBILITY to be a team member - to assist others in compliance

RESPONSIBILITY to offer suggestions that may have a positive impact on safety

Steps to Develop Action Plan

(based on Recommendation by the third party

independent investigation) 1. Identify corrective actions

2. Assigning responsibility

3. Establish deadline for actions and follow-up

4. Obtain management approval

5. Communicate results

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Communicating the incident statisticsTo the employees of the

organizations to the controlling authorities (full

report) ◦Organizational head◦Statutory organizations

Managing Documentation

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Conclusion Encourage incident

reporting Investigate accidents

immediately Provide the investigation

report within 48 hours of accident

Take leadership Provide safety training Conduct safety meeting Mock drills exercise Provide written rules Assess Personal Protective

Equipment

Follow technical, Safety & Health Regulations

Emergency Preparedness

Always go for Incident Investigations

Safety Consultations

Time based mitigation/action plan

Review & Revise Safety Program- Management of change

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Thank You