shell ai2.pdf

8/10/2019 SHELL AI2.pdf

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The Main reason for Reporting and Investigating Incidents is to Le arn from them.

If there has been an Inci dent, something went wrong!

We need to fi nd out exactly what went wrong and why.

Once we understand this we can prevent it happening a gain!

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Accident/ Incid ent Inves tigation

Incident Notification,Incident Notification,Investigation and ReportingInvestigation and Reporting

Why do we Report and InvestigateAccidents and Incidents?


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Incident Reports and InvestigationFindings provide the means to Learn

from Unplanned Events and helpPrevent Recurrence

An Accident is described as an Unplanned Event or an Undesired Event.

We need to understand the reason why this event occurred. Not just the actualimmediate cause, but also any und erlying reasons, perhaps not i mm ediatel yobviou s.

The easi est way to determine the causes, is an Inve stigatio n.


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The procedure covers the following categories:

Occupational Illness Near Misses Accident with Injury Environmental Release/Dischar ge Loss of Containment

Security Incident Asset Dam age External Complaints Non Conformance

The foll owing Categ ories are covered by the procedur e;

Occupational Illness Any illness caused by work or the workplace .

Near Misses Where something has gone wrong but no-one got hurt.

Accident with Inju ry As above but with Injury or dam age to equi pment.

Environm ental Release /Discharge Where something went wrong andpollution occurred.

Loss of Containment A Leak of dangerous gases or fluids.

Security Incident Any situation where a breach of Security can affect thewell-being of the organization.

Asset Damage Any Incident which results i n Loss or Damage to Pl ant andEquipment.

External Complaints From the Regulators, Government, The Public andIndependent Organizations.

Non Conformance Usually against an Internal or External Audi t.


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Purpose: To Ensure that,

All Incidents are promptly Reported All Incidents are Thoroughly Investigated and Root

Causes are identified so that suitable action can betaken to prevent recurrence

All Conditions with the Potential to Cause Harm arereported so that Remedial A ction Can be taken

SBEP meet all Statutory and Group requirem ents On Incident Reporting

We must ensure that;

We Report all Incidents promptly, however minor th ey may appear.

We Investigate a ll Incidents thoroughl y and Iden tify Imm ediate and RootCauses and specify the sui table a ctions to be taken to prevent recurrence .

We Report a ll Conditions with the Potential to Ca use Harm so that we can fixthem imm ediatel y.

We (SBEP) must com ply with all Statutory and Group requ irements onIncident Reporting .


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The Shell Risk Assessment Matrix (RAM)

This procedure uses RAM to asse ss the potentialoutcome of an incident in a Standardized,Qualitative manner. (See pages 32-35)


Turn to Page 32 to see a copy o f the SBEP Risk Assessment Matrix (RAM)

This Matrix is used to quantify the severity of the Incident to allow decisi ons tobe made regarding the selection of the Investigation Team and the Reportin gSpeed.


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The Shell Risk Assessment Matrix (RAM)

The Vertical Axis displays the Potential Consequence

The Horizontal Axis displays the Likelihood of theConsequence happening

The combination of Potential Consequence andLikelihood defines the Risk Classification

We use the Matrix to determine the level of severity of the Incident - I.e. Low,Medium or High.

This al lows us to better select the level of personnel involved in theInvestigation and the Urgency of Reporting.

When using the Matrix AFTER and Incident, we are looking at the historicaleviden ce for a simila r incident with the SAME Consequen ces or outcome.

This i s well explained in the Procedur e.


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Using RAM :

The RA M Risk Classification will be used to determinethe seniority level of personnel involved in theinvestigation and the method and speed of reporting.



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Incident Notification,Incident Notification,

Investigation and ReportingInvestigation and Reporting

RAM Actual

Consequence/Severity Level 4/5

RAM Risk Classification

Classification Significant High Medium Low

InvestigationSponsor

Director accountable forthe activity (VP)

Director accountable for theactivity (VP)

Senior Manageraccountabl e for the activity(e.g. Department Manager)Functional Team Leader

Manager accountable forthe activity (e.g. OIM, SiteManager)

Owner Senior Manageraccountabl e for the activity(e.g. Department Manager)Functional Team Leader

Senior Manageraccountabl e for the activity(e.g. Department Manager)Functional Team Leader

Person who is accountablefor the activity (e.g. OIM,Site Manager)

Person who is accountablefor the activity (e.g. O psSupervisor)

Investigation TeamLeader

Independent SeniorManager


Owner or Head ofDepartment not associatedwith the work

Owner or Supervisor ofthe work

Responsibility Table

The Respon sibility tabl e all ows you to select the appropriate level ofManagement or Staff to Sponsor, Own or Lead the Investigatio n Team.

It is a simple a nd easy to use syste m, and if used correctly in conjuncti on withthe RAM, can be very effecti ve.

Using this method takes the pressure off anyone involved in making th esedecisi ons.


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The Investigation Process

This can be broken down in to 10 Stages

Initial Actions 2. Organization3. Investigation 4. Review

Communicate 6. Actions Compile Report 8. Present Report9 . Report to IRP 10. Approve Report


The 10 Stages in the Investigation Process we are looking at does NOT invol vethe detai led instruction on how to Investigate and Inci dent.

This i s a separate issue and involves d etailed traini ng and assessment.

Only Trained, Competent Investigators can conduct Investigations.


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Step 1 - Initial Actions Incident is reported to Supervisor

Supervisor makes site safe and records any changes, protectssite

Supervisor Notifies Location Manager

Loc . Manager notifies EC if appropriate

Loc . Manager notifies Relevant Managers & SBEP HSE Dept.

EC will be cal led out for Medivac/ Medrescue , Incidents which arenot stabilising or are escalating, Incidents with a sever ity of 4 or 5.

EC will notify senior management as appropriate

It is important that Supervisors are aware of their responsi bilities in Makingthe Site Safe and recording any Changes they have made in doing so.

The Emergency Co-ord inator should be notifie d as a matter of routine as theInciden t may escalate and req uire further attention. It helps if he is prepared.


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Step 2 Organise the InvestigationResponsibility Level Table

RAM ActualConsequence/Severity Level 4/5

RAM Risk Classification

Classification Significant High Medium Low

InvestigationSponsor

Director accountable forthe activity (VP)

Director accou ntable for theactivity (VP)

Seni or Manageraccountabl e for the activity(eg Department Manager)Functional Team Leader

Manager accountable forthe activity ( eg OIM, SiteManager)

Owner Seni or Manageraccountabl e for the activity(eg Department Manager)Functional Team Leader

Seni or Manageraccountabl e for the activity(eg Department Manager)Functional Team Leader

Person who is accountablefor the activity ( eg OIM, SiteManager)

Person who is accountablefor the activity (e.g. O psSupervisor)

Investigation TeamLeader



Owner or Head ofDepartment not associ atedwith the work

Owner or Supervi sor of t hework

This i s the same table as see n earli er and helps to make the decision easier.

Don t forget to use the RAM for classification. Do nt Guess!


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Step 2 Organise the Investigation

Depending u pon the n ature of the in cident and its potentialfor wider learning, the Owner sh ould consider wheth er toinclude a Tripod Beta analysis in the investigation.

Investigations of Significant or High Risk Incidents shou ldinclude a Tripod Beta analysis. For medium risk i ncidentswith wider potential learning, it i s recommended th at a Tripod

Beta analysis be performed. Owners shou ld apply to the HSE Manager wh o will assign a

facilitator to support the investigation team in using theTripod Beta technique.

TRIPOD BETA is a Root Cause Analysis Prog ramm e designed to hel p youunderstand the Underlying or Latent Causes of Incidents.

If the Incident Owner decides that the nature of the incident is one of thefollowing,

Significant - Always use TRIPOD BETA

High Risk - Always use TRIPOD BETA

Medium Risk - TRIPOD BETA Recommended

Wider Learning Potential - TRIPOD BETA Recommended

Owners who wish to use this technique should apply to the HSE Manager whowill assign a faci litator to support th e investi gation team in using the TRIPODBETA technique .


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Step 3 Issue Terms of Refere nce

The Owner initiates the investigation by appointing the InvestigationTeam Leader and team members, and issuing Terms of Reference .(See Appendix 3)

The Terms of Reference are given to the Investigat ion Team Leader andto the Line Manager controlling the location. For a low risk incident theTerms of Reference can be verbal.

The Terms of Reference will define the scope of work, list the teammembers, provide object ives/guidance, specify a target date forpresentation of the investigation report to the Owner and any interimrequirements.

TERMS OF REFERENCE are issued, in writing, to co mm unicate theinstructions to the Investigation Team in order to avoid confusion.

For Minor o r Low Risk Incidents, the Terms of Reference can be Verbal .


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Step 4 Prepare the Investigation Team

The responsibility for appointing the team is with the IncidentOwner.

All incidents mu st be investigated by at least two people andRoles may be combined, but the following requirements mu stbe met:

As per the Procedure and the Selection Table, the Incident Owner appointsthe Team Leader a nd Members.

The Team Leader does NOT pick h is own team!

Team mem bers, who must be trained and competent in Inciden t

Investigation techniques, are appointed on the basis of their Knowledge ofthe Area or Process or their Specialist Skills.

TEAM m eans more than one person!


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A competent person must be designated as the Investigation Team Leaderand at least one person must be knowledgeable in the activity beingundertaken at the time of the incident.

Ideally, the team should include the employee safety representat ive fromthe location involved in the incident. For environmental incidents, t hiscould be the location environmental representative.

If the incident involved the work of a contractor, then a contract employee,manager or HSE representative must be included.

The team can include other persons, as required, with appropriateknowledge, experience and independence to thoroughly investigate andanalyse the incident. (i.e. other Asset Teams or external tec hnicalspecialists)

The Owner should always try to involve any interested parties in theinvestigation, such as local staff, Contractor s safety reps etc.

He can call in Experts as required for their sp ecial ist knowledge and experti se.


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When th e Team is notified and assembled, they shou ld bebriefed on the background to the incident and on wh at isalready known from th e prelimi nary report. An ysketches/photographs/plans shou ld be made available to

them.The Team Leader will all ocate tasks and deadlines betweenthe members; for example:

Always try to get as much information as possib le, includi ng documentation ,as this will save the team time during the investigati on.


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Step 4 Prepare the Investigation Tea m

Research into available technical information, procedures,standards, specifications, records, etc.

Interviewing witnesses (interviewing of injured person(s) mayrequire a hospital visit).

Arranging equipment examination, test, reconstructions , etc.

Completing the incident report and d etailed i nvestigationreport as applicable.

In allocating Tasks to the team, the Team Leader should try to use thestrengths of the team.

For example, a good talker should carry out the inter views and someonewith an eye for d etail should r eview the documentati on.

Outside independent help can be used as required, such as test housesand experts.

The Incident Investigation Report should be as complete and as detail ed aspossible, always anticipating what questions may be asked at revi ew.


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Step 5 Conduct the Investigation

Commence the in vestigation as soon as possible after theincident. Evidence quality deteriorates with time.

Appendix 9 of the Shell Group Guide provides a checklist ofsubjects to be addressed during th e investigation of theincident.

As per SHELL Corporate Guidelines, the Investigation must be conducte dby Trained, Competent Investigators using Tried and Tested Universal lyAcceptable Investigation techni ques.


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Step 6 Establish Findings and Make Recommendations Establish findings and identify actions to prevent recurrenc e by

identifying and correcting the latent failures (underlying causes) of theincident.

The Tripod Beta analysis tool can help determine the Active failures(immediate causes) and Latent failures (underlying causes)

The Investigat ion Team Leader may consult technical expert s asnecessary to determine possible corrective actions. However, t he

Investigation Team Leader is responsible for deciding which of thepossible corrective actions should be recommended to the Owner.

Corrective actions will focus on reducing the risk to as low asreasonably practic able (ALARP).

The Investigation Team can actuall y Recomm end actions to preventrecurrence by identifying and correcting the latent failures (unde rlyingcauses) of the incide nt.

The Tri pod Beta anal ysis tool can hel p determine the Acti ve fail ures(immediate causes) an d Latent failures (underlyi ng causes) and shoul dnot be di scounted as too complicated. Hel p will be provi ded.

The Team Leader is responsible for de ciding which of the possiblecorrective actions should be r ecomm ended to th e Owner.

Corrective actions will focus on reducing the risk to a s low as reasona blypractica ble (ALARP).


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Step 7 Compile Report and Review with Line ManagersCompile Report and Review with Line Managers

Before the incident report is submitted to the Owner, it is reviewed withthe line management of the area to confirm that the technical aspectsare correct and to agree the actions and assign Action Parties.

If the incident involves contractor employees, equipment, or contractor-owned/operated worksites, agree on the report content with both SBEP

and contract or line management. For a significant or high-risk incident, a more formal detailed

investigation report is also required for submission to the Shell Group(see Appendix 5 for layout of report to be used).

It is considered a common courtesy to discuss your findings with the LineManagement of the area. This allows him to confirm that the tech nicalaspects are correct and to agree the actions and assign Action Parties.

Do this be fore submitting the Report to the Owner. Line Manage rsappreci ate this courtesy and they wil l not object to critici sm if they areaware it i s coming.

Likewise with Contractors, inform and agree on the report content with bothSBEP and contractor l ine management.

For a significant or high-risk in cident, a more formal de tailed investigationreport is also required for submission to the Shell Gro up (see Appe ndix 5for layou t of report to be used).


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Step 8Step 8 Present Report to OwnerPresent Report to Owner

The incident report should be formally presented to the Owner who mayThe incident report should be formally presented to the Owner who maywish to include other interested parties at this stage.wish to include other interested parties at this stage.

The Owner should review the investigation, satisfy himself that t heThe Owner should review the investigation, satisfy himself that t hefindings and recommendations for the investigation have been done,findings and recommendations for the investigation have been done,discuss and agree the correc tive actions, the pers on accountable f or thediscuss and agree the corrective actions, the person accountable f or theaction, and the target date for c ompletion.action, and the target date for c ompletion.

The Owner is then responsible for communicating actions to the personsThe Owner is then responsible for communicating actions to the personsresponsible for them, and agreeing a timely completion date.responsible for t hem, and agreeing a timely completion date.

The Owner may wish to incl ude other i nterested par ties at thi s stage, such asHeads of Departments, Lead Hands etc. Anyone that he feel s may benefitfrom hearing th e Findi ngs of the Investigatio n..

The Owner shoul d revie w the investig ation, and if he i s happy with i t, agree thecorrective actions, the person accountable for the action, and the targe t datefor completio n.

The respo nsibil ity for communicatin g actions to th e persons re sponsibl e forthem, and agreeing a timely completion date, i s the owner.


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Accident/ Incid ent Investigation


Step 9Step 9 Present Report to the Incident Review PanelPresent Report to the Incident Review Panel

All High Risk and Significant incidents should be presented to an IRP.All High Risk and Significant incidents should be presented to an IRP.Medium risk incidents are at the discretion of the investigation sponsor.Medium risk incidents are at the discretion of the investigation sponsor.Low risk incidents with little potential for lateral learning do not needLow risk incidents with little potential for lateral learning do not needpresenting to an IRP.presenting to an IRP.

The investigation findings and report should be formally present ed byThe investigation findings and report should be formally present ed bythe Owner, supported by the Investigation Team Leader. The IRP willthe Owner, supported by the Investigation Team Leader. The IRP willreview and endorse the findings of the investigation (see 3.1.4).review and endorse the findings of the investigation (see 3.1.4).

An Incident Review Panel (IRP) comprises Senior Management Personnel ,An Incident Review Panel (IRP) comprises Senior Management Personnel ,possibly from EPW In Houston or the Hague .possibl y from EPW In Houston or the Hague .

All High Risk and Significant incidents shoul d be presented to an IRP.All High Risk and Significant incidents should be presented to an IRP.

An IRP would not normally be conven ed for Medium risk incidents unlessAn IRP would not normally be convened for Medium risk incidents unlessrequested at the discretion of the investigation spo nsor.requested at the discretion of the investigation spo nsor.

Low risk incidents with l ittle potential for late ral learnin g do not needLow risk incidents with little potential for late ral learning do not needpresenting to an IRP.presenting to an IRP.

The inve stigation findi ngs and report should be formally presented b y theThe investigation findings and report should be formally presented b y theOwner, supported by the Investigation Team Leader. The IRP will reviewOwner, supported by the Investigation Team Leader. The IRP will reviewand endorse the findings of the investigation (see 3.1.4).and endorse the findings of the investigation (see 3.1.4).


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Step 10 Approv e the Report

Following an IRP, the Owner ensures that any changes orrecommendations arising from the meeting are included in the report.

The Incident Report Editor carries out a quality assurance check on thedata and recommends to the Owner to Approve the report .

Any written investigation report should be attached to the incident record.

If the report is classified as confidential, then it should be sent to t he HSEManager for secure filing.

The investigation phase is now finished, but further action is required tocommunicate the learning (Section 5) and to follow-up and close out thecorrective actions (Sect ion 6).

Following an IRP, the Owner ensures that any changes or re comm endatio nsarisi ng from the meeting are included in the report.

The Incident Report Editor (Probably the Health and Safety Manag er)carries out a quality assurance check on the da ta and recommends to theOwner to Approve the report.

Any written investigation report should be attached to the incident record.

If the report is classi fied as con fidential, then it should be sent to the HSEManager for se cure filing.

The investigation phase is now finish ed.


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Responsibilities

SUPERVISOR Initiates Investigation after receiving notification Ensures that the scene of the Incident is made safe and

protected from disturbance

Records any disturbances to the scene when making itsafe Notifies the Location Manager, OIM, Site Manager,

Vessel Master etc

The Supervi sor Kicks off the process when he receive s initial noti ficationof an inci dent.

He initiates investigation after receiving notification.

Makes t he scene of the incident safe and protected from disturb ance.

He records any disturbances to the scene when making it safe.

He n otifies the Location Manager, OIM, Site Manager, Vessel Master etc.


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Responsibilities

LOCATION MANA GER Will notify relevant Field/Departm ent/Site Managers &

the SBEP HSE Department of the Incident. Such notification will be given ASA P and no later that

24 hours Where appropriate, will notify the Emergency

Coordinator (EC) to initiate any emergency responseand to make any statutory notifications

Notifies the relevant Fiel d/Department/Site Manag ers & the SBEP HSEDepartment of the Inci dent, no later that 2 4 hours

Where appr opriate, he will n otify the Emergency Coor dinator (EC) to initiateany emergency response and to make any statuto ry notifi cations


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Responsibilities

INCIDENT OWNER Formally requests the Inv estigation to be

performed Appoints the Investigation Team Leader and

Members Draws up Investigation Terms of Reference Ensures that Action Item s are assigned to those

with the skills and expertise to carry them out Approv es the Incident and Investigation Reports

The Incident Owner formally requests the Investigation to be performed

He Appoin ts the Investigation Tea m Leader and Members and draws upInvestigation Terms of Referen ce

He ensures that Action Items are assigned to those with the skill s andexpertise to carry them out and monitors the progress.

He approves the Incident and Investigation Re ports if i n agreement.


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Investigation and ReportingInvestigation and ReportingResponsibilities

INCIDENT OWNER (Continued) Ensures all Action Item s are entered into the

Database and HSE Action Tracking System Reviews progress reports to ensure all

outstanding action items are closed out

Take action with the action party if items notbeing closed out within the specified deadlines Present the Investigation Findings and

Recomme ndations to the Incident Review Panel(IRP)

The Owner ensures all Action Items are entered into the Databa se andHSE Action Tracki ng System

He reviews progress reports to ensure all ou tstanding action i tems areclosed o ut

He can take action with the action party if items not being closed out withinhis specified de adlines

He will present the Investigation Findings and Re comm endations to theIncident Review Panel ( IRP)


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Investigation and ReportingInvestigation and ReportingResponsibilities

INCIDENT SPONSOR The Incident Sponsor is the Owner s Supervisor Ensures that Owners have the necessary Competency

to fulfill their responsibilities Convenes an Incident Review Panel (IRP) to review

Significant or Medium/High Risk incidents Conducts an Annual rev iew of the Incident

Investigation Process within their sphere of influenceand implements improvements

The Incid ent Sponsor i s the Owner s Supervisor or Manager

He must select Owners who have the necessary Competency to fulfi ll theirresponsi bilities

The Sponsor convenes the Incident Review Panel (IRP) to re viewSigni ficant or Medium/High Risk incidents

He must conduct an Ann ual revi ew of the Incident Investigation Processwithin his operation and identify a ny improvements


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Responsibilities

INVESTIG AT ION TEA M LEADER Investigates the Incident along with appointed Team

Members Establishes the situation before the incident Determines what happened during the incident Determines the Active and Latent Failures Determines the Actions required to prevent recurrence

The Investigation Team leader is a highly responsible position a nd he mustensure the followin g:

He must be Trained and Competent in this rol e.

He will control the actual Inve stigatio n and appo inted Te am Mem bers.

He must establish the situati on before the inci dent and de termine what

happene d during the inci dent.

He should determine the Active and Laten t Failures and the actionsrequired to prevent recurrence .


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Responsibilities

INVESTIGATION TEAM LEADER (Continued) Ensures that the Incident Report Form is accurately

completed Produces a more detailed report for Significant and High

Risk Incidents Helps present the findings and recommendations at the

IRP Prepare material for communicating lessons learned to

others

The Team Leader also:

Makes sure the Report Form is accurately completed on time.

He will produce a more deta iled report for Significant and High RiskIncidents. This will have to go to the IRP.

Help the Incident Owner present the fin dings an d recommendations at the

IRP.

Prepare methods and materials for co mm unica ting le ssons learned to othersin the organisati on.


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Responsibilities

LINE MANA GERS

Ensures Contractor compliance to this procedure

Ensures the incident is investigated and reportedwithin a defined time Follows up and closes out actions

The Line Manager has the responsi bility to see that a ll per sons, whetherstaff or contractor, follows this procedure for reporting and investigatingincidents.

He is also responsible for making sure that al l dead lines and timescales areadhered to within thi s procedur e.

The Line Manager will see that a ll reco mm ended action points are correctl yclosed out within the specifie d timescale.


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Responsibilities

HSE MANA GER Ensures awareness of reporting requirements for the

Group and Government A uthorities Responsible for Formal Reporting to Shell Group Facilitates the IRP meeting Ensures all legal reporting requirements are met Assists in dealing with the Authorities

The SBEP HSES Manager makes sure that everyon e is aware of thereporting requi rements for the Group and Government Authori ties.

He is al so responsi ble for Formal Reporting to the Shell Group a ndFacil itates IRP meetings

He will also ensu re that all legal reporti ng requirements are met and willassist in deali ng with the Authorities where requir ed.


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Responsibilities

HSE MANA GER (Continued) Assists the line in carrying out the investigation Conducts Initial Reviews and Reports and confirms the

consequence rating Ensures that root causes are properly identified and

remedial actions appropriate Maintains Incident Report and Investigation Database.

The HSES Manager will also assist the li ne, where required, in carrying outthe incident investigati on.

He will conduct Initial Revie ws and Reports and confirm the conseque ncerating .

He will also ensu re that the Root Cause or Causes are properly identified andappropriate remedial actions are put in place.

He maintains the Incident Report and Investigation Databa se.


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Responsibilities

VICE PRESIDENT

Oversees Inve stigations with high actualconsequence rating (4&5)

Chairs the Incident Review Panel Meeting

The Vice President oversees a ll Investigations with a high actual conseque ncerating ( 4&5).

The Vice President will Chair the Incident Review Panel Meeti ng.


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Responsibilities

INCIDENT REVIEW PA NEL (IRP)

Ensures that Incidents are properly Investigated andPrimary and Contributory causes identified.

Identifies opportunities for Lateral Learning and Actions Gets agreements on follow-up Actions, Responsibilities& Deadlines

Effectively Cas cades Information to prevent recurrence


The IRP ensure s that Incidents are correctly Investigated and that thePrimary and Contributory causes are also identified.

The IRP can Identify opportu nities for Lateral Learni ng and Actions acrossthe company.

The IRP looks for agreements on follow-up Actions, Responsi bilities and

deadlines and tries to effectively cascade information to prevent recurrence.


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Shell Internal Incident Reporting

All incidents are reported in th e Incident Re porting database.The database con tains:

Details of the incident (including a full description, date, time,place and actual/potential consequences).

Details of the consequences (including injuries/ill ness;hydrocarbon releases; fires; asset damage; environmen talemissions / discharges; reputation impact).

The causes of th e incident (both active and latent failures).

Actions to prevent or reduce recurrence.

All reported incidents must be recorded in the Incident Reporting Database sothat relevant information can be easi ly retrieved.

The database contain s the foll owing:

All details of the incident, including a full description, the date, ti me, place ofthe incident, and any actual and potential conseq uences.

Detail s of the consequ ences, including any injuries or illnesses; h ydrocarbonrelea ses; fires; asset damage; environmental emissions and d ischarge s; andthe impact on our reputatio n.

Where identifiable, the Active and Latent Failures/Causes of the incident andActions to prevent or reduce recurren ce.


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Classification Of Incidents

Now we will descri be how to determine th e classifi cation of theincident.

We will address wheth er an incident is work related and thengo on to describe the classification of incidents, injuries andoccupational illnesses.This is shown in Figure 3.1 (Classification of Incidents);

All incidents need to be Classified, to help us decide h ow and when torespond to each classi fication.

The first decision is to establ ish whether the incident is work related or no t. Itis possible that a n Injury could have been suffe red at home, for example.

We have a cla ssificati on Guide to assist you in this decision.


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Investigation and ReportingInvestigation and Reporting

This Cha rt will assi st you in classifying an Inci dent.

It helps you to select the appropriate reporting route and speed.

It also helps you decide if the incident is work rel ated.


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1. Establish a Work Relationship

Is the incident work related ?

An incident is work related if it occurs in an area in w hich SBEP controlsare in place, or should have been in place.

The following activities are considered to be work related where companycontrols should be in place:

All work by SBEP personnel.

All work by contractor personnel on SBEP premises/facilities .

All work by contractor personnel on non-company premises whereboth SBEP and contractor management controls are required.

This i s where a decision must be made regardi ng the term Work Relate d.

Is the inci dent work relate d?

An incident would be conside red work relate d if it occurs in an area in whichSBEP has control or should have control .

The following activities are conside red to be work related where companycontrols should be in place:

All work by SBEP personnel.

All work by contractor personnel on SBEP premises/facili ties.

All work by contractor personnel on n on-company premises where bothSBEP and contractor management contro ls are required.


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1. Establish a Work Relationship

For company personnel, work includes overtime, attending cours es,conferences and company organised events, business travel, field visits, orany other activity where t he employee s presence is expected by theemployer.

For contractor personnel, the same activities are included when they areexecuted under a contract on behalf of the company. Contractor includes

all sub-contracted activit ies.

For SBEP Company personnel, and contractors working on our behal f.

Work incl udes any work and o vertime, attending courses, conferences andcompany organi sed events, business travel , field visits, or any other acti vitywhere the employee s presence i s expected by the emplo yer.

For contractor personnel, the same activities are included when they areexecuted under a contract on behalf of the Company. Contractor includesall sub-contracted activities.


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2. Determine the Ty pe of Incident

An Incident is an unplanned event or chain of events that has, or couldhave, resulted in injury or illness or damage to as sets, t he environment orcompany reputation.

Incidents do not include operations, maintenance, quality or reliabilityincidents which had no HSE consequence or pot ential.

The initial phase is to determine which of the following 3 cat egories theincident falls into:

An Incident is an unplanned event or chain of events that has, or couldhave, resulted in injury or illness or damage to assets, the envi ronment orCompany reputati on.

Incidents do not include nor mal, routine o peration s, maintenance, qua lity orreliability inci dents which had no HSES consequen ce or potenti al.

The initial ph ase is to determine which of the following 3 categori es theincident falls into:


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1. Potential Incident

A Potential Incident is an unsafe practice or hazardous situation thatcould result in an incident (incident has not oc curred).

Usually identified during work-site inspections, management walks, andthrough incident or near miss reporting systems.

Companies should encourage the reporting and analysis of potential

incidents because they provide a valuable source of learning that can beapplied to prevent future incident s.

Potential incidents are reported and recorded in the HSE dat abase whenthere are significant learning opportunities .

A Potential Incident

A Potential Incident is any unsafe practice or hazardous situation that couldresult in an incident ( incident has not yet occurred ).

Usuall y identified during work-site inspe ctions, management walks, and

through incident or near miss repo rting systems.

We must encourage the reporting and analysis of pote ntial incide ntsbecause they provide a valuable source of learning that can be ap plied toprevent future inci dents.

Potential incidents are reported and recorded in the HSE database whenthere are significant learning opp ortuniti es.


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2. Near Miss Incident

A Near Miss is an incident that, under different circumstances, couldhave caused illness, injury or damage to assets , the env ironment orcompany reputation, but did not (incident has oc curred).

Over exposure to hazardous chemicals, noise and other health hazardsshould be considered as near misses when exposure did not result in anidentified illness.

A Near Miss Incident

A Near Miss Incident is where, had there been differen t circumstances,could h ave caused an illness, injury or damage to assets, the envi ronmentor Company reputati on, but di d not

(incident has occurred ).

Any over exposure to hazardous chemicals, noise and other h ealth ha zardswill be considered as near misses where exposure did not result in anidenti fied illness.


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3. Injury / Damage Incident

An incident with an actual outcome leading to an injury, illnessor damage to assets, the environment or company reputation.

An I njury or Damage In cident

Any incident with an actual outcome leading to an injury, illness ordamage to assets, the environment or Company repu tation.

The Incident HAS Happened.


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Plant and Equipment Damage Incident

a) Asset Damage

A direct loss of or damage to plant, equipment, tools or

materials resulting from an incident

Asset Damage

An Asset Damage Incident i s where there is an actual loss i n terms ofPersonnel / Man Hours or Hard ware.

Actual loss can be described as a Co st to the Company.


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Plant and Equipment Damage Incident

b) Fires and Explosions

Normally taken to mean any fire that necessitated the use of afire extinguisher or other extinguishing means, e.g. snu ffing

system, shut off fu el or switch off electri city supply.A fire with no visible flame, e.g. oil soaked i nsulation, sh ouldalso be included.

All flammable explosions or physical explosions shou ld also beincluded, irrespective of the extent of containment.

Fires and Explosions

Fire and Explosion losses include any type of fire and do not necessaril yinvolve naked fl ames.

I do not agree with this de finition of a fir e.

A fire may not require the use of a fire extinguisher, b ut must always bereported and investigated as a fire.


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Investigation and ReportingInvestigation and Reportingc) Environmental Im pact

The negative impact on the environment res ulting from an incident including:

Spills of oil or chemical, or other pollutant, to sea, water or ground,regardless of size, exc ept when a spill is contained within the site, where itshould be considered a Near Miss with potential to cause damage to theenvironment.

Any excursion of oil in water from a produced water discharge in exces s of100ppm oil in water.

Accidental releases of halocarbons , i.e. CFCs, Halon (excluding routinemaintenance top ups) .

Breaches of waste disposal procedures which have, or may cause,damage to the environment and/or damage to the company s reputat ion.

Environm ental Impact

Spills of any pollutant, to the sea, fresh water or ground, regardless of size,must be reported an d investi gated.

The exception to this rule is when a sp ill is contained within the site, say

within a purpose bui lt bund . In this case it should be considered a Near Mi sswith Potential to cause damage to the enviro nment.

Any oil in produced water in excess of the limit set at 100ppm oil in watermust also be reported and Investi gated, as must any acci dental release s ofhaloca rbons , i.e. CFCs.

Breaches of waste disposal procedures whi ch have, or may cause, damage

to the environment and/or damage to th e Company s reputati on.


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d) Impact on Reputation

The negative impact on company reputation resu lting from anincident.

The negative impact can be in the form of adverse attentionfrom media, polit icians or action groups, or in pu blic concernregarding company activities.

Impact on Reputation

Where there is a negative impact on our Company s reputation resultingfrom an incident, it must be reporte d and Investi gated.

The negative impact can be in the form of adverse attention fr om m edia,

politician s or action groups, or in public concern regardi ng companyactivities.


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3. Class of Injury or Illness

FATALITY

A death resulting from a work related injury or occu pationalillness, regardless of the time intervening between theexposure o r incident causing the in jury or illness and th edeath.

PERMANENT TOTAL DISABILITY (PTD)

Any work related injury that perman ently incapacitates anemployee and results in termination of employment.

Class of Injury or I llness

These Classifications are a guide to help you to accurately report thephysical outcome of an Incid ent.

Remember the cause must be Work Related .


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OCCUPAT IONAL ILLNESS

Any work related condition that is caused by or mainly caused by exposuresat work (50% or more probability that the illness was caused by exposuresat work).

Includes acute and chronic illness or diseases that may be caused byinhalation, absorption, ingestion or direc t contact .

The reporting and investigation of any occupational illness will be subject t o

the consent of the injured party. Where this is withheld, the illness will bereported as an SBEP occurrence (location and direct orate not dis closed).

Details of the illness should be sent to the Group Head of OccupationalHealth. The `incident owner should only investigate under instruction fromthe Head of Occupational Health.

We have to make difficult decisions on whether an Illness is work rel ated, wewill use a benchmark proba bility of more than 50%.


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LOST WORKDAY CASE (LWC )

Any work related injury that renders the injured persontemporarily unable to perform their normal work or restrictedwork on any day after the day on which the injury occurred. Inthis case any day includes rest day, weekend day, schedu ledholiday, public holiday or subsequent day after ceasingemployment.

The Shell definition is different from the OSHA definition, whichconsiders restricted work as a lost workday case. The Shelldefinition is consistent with OGP. (formerly e&p forum).

A single incident can give rise to several lost workday cases,depending on the nu mber of people injured as a result of thatincident.

Note that the offi cial absence from work begins on the Day AFTER theIncident occurred and includes days off and weeke nds.


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Restricted Work Case (RWC)

Any work related injury which renders the injured persontemporarily unable to perform all, but stil l some, of their normalwork on any day after the day on which the injury occu rred.

It is not unheard of in the Oil and Gas Industry for Companies orInstallations to keep their personnel on light duties to avoid d eclari ng theIncident official ly.

It is important to n ote the an i njured party must be able to carry out SOME oftheir no rmal duties.


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Medical Treatme nt Case (MTC)

Any work related injury that involves neith er lost workdays norrestricted workdays, but which requ ires treatment by aphysician or other medical specialist (i ncluding a den tist orphysiotherapist).

Medical treatment does not include first aid even if a doctorprovides this.

The procedu re outlines some examples.

This Shel l rule differentiates between treatment by a physician and aMedic.

The offshore FPSO Fluminen se has a Physician in the Medic Rol e andtherefore he will b e treated as a Med ic in thi s case.


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Incident Notification, Investigation and Repo rtingIncident Notification, Investigation and Repo rtingReporting of Significant Incidents to Group (RAM 4 or 5)

ACTIONS TO BE TAKEN ACTION PARTY TIMING

Notify the business (EP)To: EP HSE adv iser and relevant EP Regional Business Director.Copies to: EP Chief Executive an d Group HS E adviser.

SBEP(HSE Dept)

Within 24 hrs of in cident

Prepare investig ation repo rt an d Level 3 NotificationAccor ding to Group gu idelines, includ ing Tripod analysis.Send to EP HS E adviser (co py to Group HSE adviser on requ est only).

SBEP(Investigation Team)

Within one month of incident

Review invest igatio n reportReview r eport for completeness and quality of investigation, identification of und erlying caus es and impro vement actions.If necessary request repor ting compan y to impro ve th e repo rt.

SBEP HSE adviser Within two mon ths of incident

Adv ise classificationAdv ise classification of in cident to the EP and Group HSE ad viser. As p rocess own erthe Gr oup HSE ad viser m ay rev iew the classifications.

SBEP HSE adviser At end of review

Significant incident review meetingA rev iew meeting led by the EP Chief Executive will be held for all incidents resultingin a compan y or con tractor employee fatality, selected th ird p arty fatalities and all otherHSE incidents with a significant impact.The review will consider the cau ses of the incid ent and actions taken an d planned

Meeting p articipants:Group Managin g DirectorEP Chief Executive OfficerRelevant EP DirectorBusiness HSE adviser

Within three m onths of incident

Debrief Prepare action items and lessons learned and copy to participants an d Group HS Eadviser.

EP HSE adviserWithin one week of rev iewmeeting

Follow up reportThis r epor t will review implementation of action items from the investigation report andthe significant incident review meeting. Sen d copy of r eport to participants (to Gro upHSE adviser on requ est only).

SBEP (HSE Dept)(EP HSE adviser shou ld remind compan y if necessary)

Within one year of reviewmeeting

Review of follow up reportConfirm receipt and ask fu rther questions as requir ed.

EP HSE adviser Within two weeks o f receiving follo w up rep ort

This simple table sho ws the Timescale for Reporting to Grou p andsubsequent Actions after a SIGNIFICANT Incident. (RAM classi fication 4&5)


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Investigation and ReportingInvestigation and ReportingDistribution of Lessons Learned

As the main object ive of c arrying out an investigation is to identify the causesof incidents and to prevent recurrence, the biggest benefit from theinvestigation is to distribute the lessons learned to other sites where a similarincident might occ ur.

There are several ways of communicating less ons to ot hers.


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Incident DatabaseThe HSE Manager will transfer the initial incident findings and lessonslearned to target groups in the most appropriate means.

Safety Comm unicationsOne of the key roles of an Incident Review Panel is to identify signific antlearning points arising from incidents and to disseminate t hem within theCompany.If the IRP deem it important to share the incident information and lessonswith other parts of the organization or with the industry as a whole, then theHSE Department will issue the most appropriate form of safet ycommunication/alert.


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Corrective Action Tracking

Approval of Corrective Actions

The Owner of th e incident report is responsible for agreeingcorrective actions with the Investigation Team and for en suringthey are entered into the HSE Database.

If the Owner is not satisfied that the actions re commended fullyaddress the active and latent failures of the inciden t, then th eOwner should instruct the Investigation Team to seek furtherevidence and formulate further actions before th e incidentreport and actions are approved.

The Incident Owner must satisfy himself that the actions will actual ly make apositive contribution to preventing this incident reoccurring .

If he is not happy in a ny way, then he is qu ite entitled to ask th einvestigating te am to reconsider th eir findings.


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Investigation and ReportingInvestigation and ReportingCorrective Action Tracking

Notificati on of Action Parties

Once the Owner approves the incident report an d correctiveactions, actions will be emai led to the Action Parties by the HSEManager. Where this is not possible (e.g. due to the ActionParty not having email access), then the Owner sh all ensurethat the Action Party is notified by sending th em a paper copy ofthe action item.

The Incident Owner must specify not just the action items to be addr essedbut also a time table for completion.

The target timescale for close out of the actio ns must be reali stic andachieva ble, and wher e at all possibl e, measurable.


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Corrective Action Tracking

Corrective Action Implementation and Closeout

The Action Party implements the action through to completion. The ActionParty may also be required to update the Owner of progress. Oncompletion, the Action Party will inform the HSE Manager so that the ac tioncan be marked as complete in the action trac king syst em.

Closeout MonitoringThe Owner monitors the progres s of ac tions against their incident report sand ensures that corrective actions are completed. Each Department shouldestablish a proc ess for the periodic review of action status.

It is helpful if the person monitoring the Action Tracki ng System issuesbulletins to all departments with outstanding action i tems to make them awareand remind them of their deadlines.

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