AIPS event name
Date
PIM #XXXXXXX
(20XX Tier X #XX)
PHOTO OF FACILITY
OR EVENT
Investigation Team
A
B
C
D
E
Peer Review
A
AIPS Event Summary
PDO directorate/asset
Directorate/Asset
Event owner
Name director or other event (incident) owner
Location
Name location
Event date & time
Date, time
Event type
AIPS Tier 1/Tier 2/LOPC/HiPo/HVL
Actual risk rating
RAM (only for applicable categories and only consequence, not likelihood)
Potential risk rating
RAM (rating for ALL 4 PEAR categories)
Description of Event
One liner of the event
Injury/Damage/Loss
List injury type
List quantity of product lost
List all direct associated cost and damage (including clean-up cost)
List indirect cost (e.g. deferment)
PIM ID
XXXXXXX
Immediate cause
Description (to be taken from “Causation”sheet)
Key latent mgmt failures • List no more than 4 failures (to be taken from “Causation” sheet)
2
Description of the Event
Short to the point description of the event (incident)
Include picture if/where relevant
Overview
photo/drawing of
EVENT
3
Overview of Damage/Impact
ADD
PHOTOS/DRAWINGS or
FLOWCHARTS
(include any further photos in back-up)
4
Sequence of Events
Date & Time
Events
INCLUDE summary sequence of events
Detailed descriptions to be captured in BACK-UP
5
Loss of Barrier Assessment
Which control/recovery barriers failed or were missing?
Include barrier picture if/where relevant
Include a bowtie representation if relevant
6
Key Findings
ANY KEY findings relevant to the event (divide these over design/operational/technical, emergency response and supplemental findings)
Design Integrity
•
ANY finding
Technical Integrity
•
ANY finding
Operating integrity
•
ANY finding
Emergency response
•
ANY finding
Supplemental Findings (any finding that is not directly related to the event, but was encountered during the event)
•
ANY finding
7
Causation
Immediate Cause
• Loss of containment .......
Underlying Causes
• Max 4 to 5 underlying causes
Latent Management Failures
• Max 4 to 5 Latent MGT failures
8
AIPS Pattern Check
(Populate below matrix with the key findings where applicable)
Pattern
DESIGN INTEGRITY
TECHNICAL INTEGRITY
OPERATIONAL INTEGRITY
#1 Drive for
production
#2 Training and
Development
#3 Learning
from Incidents
#4 Creating Error
conditions
9
Recommendations
Recommendation
Action
Party
Target
Date
Status
1
2
3
(Verify that:
- Recommendations address root causes and a clear action to do
- Recommendations are agreed by the action party as well as target date)
10
Recommendations (from MDIRC/IRC)
Recommendation
Action
Party
Target
Date
Status
1
2
3
(Verify that:
- Recommendations address root causes and a clear action to do
- Recommendations are agreed by the action party as well as target date)
11
PDO-LFI AIPS-20XX0X
PROCESS SAFETY EVENT:
Title of the event (Date of event)
KEY WORDS:
Add relevant key words, e.g. Design Integrity, Tier 1, Materials Corrosion & Inspection, Pipelines
WHAT HAPPENED:
Description of the event
ACTUAL CONSEQUENCE(S):
Description of the actual consequence and RAM rating [A3]
POTENTIAL CONSEQUENCE(S):
Description of potential consequence and RAM rating for all categories if applicable [A3C, P4B]
KEY LEARNING(S):
List and number all individual learnings and add integrity category (e.g. [DI]) and ensure learnings are endorsed by appropriate CFDH, e.g.
1. Formation water with low resistivity (<100 ohm.cm) can conduct CP (stray) currents. If in any doubt about the potential for water production assume it will occur at
some time in the operational life and design for it [DI]
2. Cross-bond of existing Isolation Joints can only be a temporary measure, and needs to be followed by replacement or installation of SSD for earthing [TI]
KEY DISCIPLINES:
KEY STANDARDS:
Add relevant key disciplines, e.g.
Add relevant standards, e.g.
Process Engineering (UEP1P),
PR-1418 Incident Notification and Investigation
Material Corrosion & Inspection (UEC)
DEP 80.45.10.10 Design of Pressure Relief, Flare and Vent
Add relevant
photos/drawings of
EVENT
20XX-Tier X #XX, PIM XXXXXXX 12
Back Up
13
20XX-Tier 1 #XX Process Safety Event MDIRC Initial Update
Status on DD MM YYYY
PROCESS SAFETY EVENT:
Directorate – Title of event (DD MM YYYY)
WHAT HAPPENED:
Provide short description of the event
IMMEDIATE CAUSE:
Description of immediate cause
PRELIMINARY UNDERLYING ROOT CAUSES:
List and describe potential underlying causes of the event, e.g.
 Stopping the incoming feed by third party supplier happened too late

PRELIMINARY LATENT MANAGEMENT FAILURES:
List and describe potential management failures of the event, e.g.
 Inappropriate quality control systems for maintenance and inspection

Add relevant
photos/drawings
of EVENT
PRELIMINARY LEARNINGS (not CFDH approved yet):
List all immediate learnings (note that these learnings are not necessarily complete nor will be approved at this stage), and add integrity category (DI, OI, TI), e.g.
 Enforce third party communication protocol in the event of an emergency [OI]
 Monitor the flare KOD level at all times and treat the HH level trip/alarm with the highest priority, even if the unit or plant is down and closed in [OI]

INVESTIGATION TEAM:
List all investigation team members
NEXT MDIRC SCHEDULED UPDATE: DD MM YYYY (within 60 days date of event)
(Provide a copy of the MDIRC Initial Update (Tier 1 only),
required within 10 days after notification)
20XX-Tier 1 #XX, PIM XXXXXXX 14
Recommendations – Asset specific
Recommendation
1
Action
Party
Target
Date
Status
Add any immediate and/or further asset specific actions
2
3
15
Overview of Damage
(More pictures and description if applicable)
16
Witness Statements
(Refer to witness statements where applicable)
17
TRIPOD
Ianadequate process
implemenation for
working plant, S/D,
S/U
Inadequate
Management of
Change
implementation
Inappropriate quality
control system
Inadequate
implemenation of
Standards
Project initiated to
replace pumps
Pre-start up check
list not available for
Ops
Work instrcutons not
clearly
communicated ???
Design/ construction
flaw
Operations check
prior to pump start
not done
Not following
communication
procedure by
Technician
Preventive
maintenance
discontinued in 2013
Modular skid design
without draining
facility
Ignition by heat of
friction between
pump-house and
shaft
Piping stress action
on pump nozzle
Fire at the Hot Oil
pump B
Pump skid draining
facilities
Piping stress
elimination
Pump bolts loosen
and release
Pump Vibration
Condition monitoring
Maintenance
Loss of shaft center
line damage the
pump seal
Hot Oil LOPC from
damaged seal
Both Hot Oil pump
damaged due to fire
Operations
Pump seal B
Hot Oil pumps
Pump nozzle
Pump bolts
Bearing pump B
(Provide Tripod diagram if Tripod has been used in the investigation)
(If other method has been used, provide any representation that may come with it)
18
ICAM Causation description
Findings: Immediate Causes
Unsafe Actions
IC Ref #
ICAM Causation description
Justification
(Provide ICAM tables if ICAM has been used in the investigation)
19
ICAM Causation description
Findings: Immediate Causes
Unsafe Conditions
IC Ref #
ICAM Causation description
Justification
(Provide ICAM tables if ICAM has been used in the investigation)
20
ICAM Causation description
Findings: Underlying Causes (Human and Workplace)
IC Ref #
UC Ref #
ICAM Causation Description
Justification
(Provide ICAM tables if ICAM has been used in the investigation)
21
ICAM Causation description
Findings: Management System failures (MSF)
UC Ref #
MSF Ref #
ICAM MSF Description
Justification for management system failure cited
Life Saving Rules - Were LSR breached related to the event?
Yes/No
(Provide: description which rule was breached,
did the breach caused the event,
was it a violation or negligent error)
22