Main contractor name – LTI# - Date of incident
Incident details
Contractor name/number :
(subcontractor-contractor-PDO)/CXXXXXX
Incident owner
:
Name / Ref Ind
Location
:
Area / unit - (road/yard/station/rig/hoist/plant etc)
Incident date & time
:
(d/m/yr) / (24 hour clock) – advise if estimated
Incident type
:
Fatal, LWC, high potential, significant incident etc
Actual severity rating
:
Number (1-5) / letter (P, E, A,R) – from RAM
Potential risk rating
:
Letter (A-E), Number (1-5)/letter (P, E, A,R) from RAM
Description of Injuries
:
Worst injuries (fractures, head injury, amputation etc)
FIM ID No
:
Number assigned in FIM
Immediate cause
:
Short description of what caused harm
Key underlying cause
:
Main learning from investigation
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Main contractor name – LTI# - Date of incident
Description of the incident:
This should include the relevant facts explaining what happened including all relevant parties
• Leading up to the incident
• Immediately before the incident
• During the incident
• Immediately after the incident
• In the emergency escalation of the incident
Important Note:
This should be in sufficient detail to allow a person who does not know anything about the incident to
imagine it. It should only be about what happened and not why it happened. Do not include investigation
findings here, simply describe the incident as the investigation has shown it happened.
For complex incidents involving the interaction of several different parties, a timeline can be added on a
separate slide immediately after this one.
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Main contractor name – LTI# - Date of incident
Photographs, diagrams & sketches
Rules
• Only include photos or sketches if they add value explaining the incident or causes.
• Each photo/sketch must be labeled to explain what it is and why it has been shown.
• Ensure photos are labeled to explain context (e.g. road looking in direction of; historical photo
of plant before fire etc).
• Ensure all photos are evidenced to the investigation. (have formed part of the investigation)
• Ensure all photos are of suitable clarity.
• Include a maximum of four photographs/sketches per page.
• Do not exceed three pages of photographs, diagrams and sketches
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Main contractor name – LTI# - Date of incident
Key investigation findings:
The findings should be listed in terms of subject and importance – (list below is non-exhaustive)
1. People,
training, age, experience, nationality, medical conditions, disciplinary record etc
2. Equipment,
type, serial number, maintenance, inspection, failings, appropriate for use etc
3. Activities at the time of the incident,
lifting, driving, commuting, drilling, POOH etc
4. Relevant environment,
workplace conditions, weather, lighting, floor surface, dust, cramped etc
5. Operational management ,
supervision, TBTs, SJPs, SWPs, STOP, availability on site etc
6. Contractual management,
audits, CH involvement, defaults, inspections, visits, issues, sub contractor management
7. HEMP,
review, appropriateness to the incident, is it used, how is it translated into action
8. Previous relevant incidents/learnings,
what, where, were they aware of it, were controls introduced
9. Emergency response,
how effective was it, did it impact on the severity?
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Main contractor name – LTI# - Date of incident
Conclusions:
Active causational failures:
The acts or conditions precipitating the incident. They usually involve the front-line staff, the
consequences are immediate and can often be prevented by design, training or operating systems.
Latent causational conditions:
Managerial influences and social pressures that make up the ‘way we do things around here’,
influence the design of equipment or systems and define supervisory inadequacies. They tend to be
hidden until triggered by an event. Latent conditions lead to human errors or violations.
Latent causational management failures (underlying causes):
Latent failures are due to people removed in time and space from the operation, e.g.
designers, decision makers and managers. Latent failures are typically failures in the HSEMS (design, implementation or monitoring). e.g: poor design of plant/equipment;
ineffective training or communications; inadequate supervision or resources; uncertainties
in roles and responsibilities. Latent failures are usually hidden until they are triggered by
an event likely to have serious consequences. Did the HSE–MS identify these hazards and
place barriers for mitigation? If not, then it is a latent management failure
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Main contractor name – LTI# - Date of incident
• Directorate IRC Minutes:
Date held:
(d/m/yr)
Feedback to Incident Owner:
(Depth, accuracy, quality, robustness, feasibility and appropriateness of investigation findings
and recommendations)
1. …
2. …
3. …
Query raised:
(raise questions which have not been adequately answered in the investigation or presentation)
1. ...
2. …
3. …
Additional recommendations:
(Including, revisiting the investigation to improve quality, adding any key recommendations
that are requested by the directorate management but have been missed in the investigation, or
removing inappropriate recommendations)
1. …
2. …
3. …
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Main contractor name – LTI# - Date of incident
Non-causational findings but worthy of note:
(Investigations can often identify issues which although not directly linked to the cause of the
incident are important to report, correct and communicate for wider learning. List these here in
bulleted format.)
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Main contractor name – LTI# - Date of incident
Tripod Tree
(include copy of the Tripod tree flow diagram for all
4/5 incidents or High Potential)
Investigation reports requiring a Tripod must confirm that the findings and recommendations match the
Tripod findings
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Main contractor name – LTI# - Date of incident
Immediate actions:
(Report all remedial measures actions taken and completed within one week of the incident)
1.
...
2.
...
Redline recommendations:
Report the five most important actions to prevent a reoccurrence in the future.
Causations
Recommendations
Target
Date
Action Party
(Contractor)
Action Party
(PDO /CH)
Status
Brief
Description of
Action Taken
Date
Completed
Causation 1
Causation 2
Causation 3
Causation 4
Causation 5
a)
b)
c)
d)
e)
a)
b)
c)
d)
e)
a)
b)
c)
d)
e)
a)
b)
c)
d)
e)
a)
b)
c)
d)
e)
a)
b)
c)
d)
e)
a)
b)
c)
d)
e)
Note:
1.
Causations to be linked with the recommendations, noting that one causation may have one or more recommendations
2.
Recommendations to include title of Action Party and not just PDO or Contractor Company. These must be under separate columns –
one each for PDO and for Contractor
3.
Actions to be given to PDO and or direct contractors only. The sub-contractor to be indicated as action party in brackets
4.
Where an action is with a contractor the corresponding PDO action party is the Contract Holder to ensure it is completed & in FIM
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Main contractor name – LTI# - Date of incident
Additional Recommendations:
(include the less urgent actions required to improve the management and for other contractors to learn from)
Causations
Recommendations
Target
Date
Action Party
(Contractor)
Action Party
(PDO staff)
Status
Brief
Description of
Action Taken
Date
Completed
Causation 1
Causation 2
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
Note:
1.
Causations to be linked with the recommendations, noting that one causation may have one or more recommendations
2.
Recommendations to include title of Action Party and not just PDO or Contractor Company. These must be under separate columns –
one each for PDO and for Contractor
3.
Actions to be given to PDO and or direct contractors only. The sub-contractor to be indicated as action party in brackets
4.
Where an action is with a contractor the corresponding PDO action party is the Contract Holder to ensure it is completed & in FIM
Contact CEO & PDO Director joint statement
_________________________
Contractor CEO
(RESPONSIBLE)
_____________________
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PDO Director
(ACCOUNTABLE)
PDO safety advice
Date:
Incident title
What happened?
Very short description of what happened
Photo explaining what
was done wrong
Your learning from this incident..
( This must relate to the people at risk of harm or people at risk of causing
the harm)
Title (e.g. Drivers)
• Learning points for them from the investigation
Photo explaining how it
should be done right
Strap line – (keep short and punchy
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Management learnings
As a learning from this incident and ensure continual improvement all contract
managers are to review their HSE HEMP against the questions asked below
Confirm the following:
• Make a list of closed questions (only ‘yes’ or ‘no’ as an answer) to ask other contractors if they have
the same issues based on the management or HSE-MS failings or shortfalls identified in the
investigation. Pretend you have to audit other companies to see if they could have the same issues.
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