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Petroleum Development Oman L.L.C.
Document Title: Incident Notification and Investigation
Document ID
Document Type
Security
Discipline
Owner
Issue Date
Version
PR-1418
Procedure
Un-Restricted
HSE
MSE5
14 November 2013
3.1
AUTHORISED
Keywords: This document is the property of Petroleum Development Oman, LLC. Neither the whole nor
any part of this document may be disclosed to others or reproduced, stored in a retrieval system, or
transmitted in any form by any means (electronic, mechanical, reprographic recording or otherwise)
without prior written consent of the owner.
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i
Document Authorisation
Authorised For Issue
Document Authorisation
Document Authority
Document Custodian
Document Controller
Head HSE Corporate Planning
Lead Incident Investigoter
Lead Incident Investigoter
Younis Hinai
Talib Shaqsi
Talib Shaqsi
Ref. Ind::MSE5
Ref. Ind::MSE54
Ref. Ind: MSE54
Date: 06/01/2014
Date: 06/01/2014
Date: 06/01/2014
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'PR1418 V.3.1' Procedure
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ii Revision History
The following is a brief summary of the 4 most recent revisions to this document. Details of all
revisions prior to these are held on file by the issuing department.
Version No.
Date
3.1
Jan
Author
Chris Evans MSE54
Scope / Remarks
Various
upgrades
including
investigation methodology, timings,
AIPS advice, templates, PIM.
Chris Evand MSE54
Total rewrite
2014
3.0
Nov
2012
2.2
Oct
2009
Nivedita Ram MSE5
Update in AI-PSM definitions
2.1
Sep
2008
Nivedita Ram MSE5
Updated in line with the Yellow Guide –
issue Dec 31, 2007. Inclusion of the RAM,
OSHA Guidelines
2.0
Dec
2003
Ohimai Aikhoje CSM4
Updated in line with new SIEP Standard for
Health,
Safety
and
Environmental
Management Systems – Incident reporting
and Follow up EP 2005-0100-29.
Follows new EP global procedure for
Incident Reporting and Follow Up.
1.0
Jany-03
Andrew Ure MSE4X
Update Procedure to bring it into line with
PIM Incident Management tool, and with
PDO re-organisation
iii Related Business Processes
Code
SP1157
GU612
Business Process (EPBM 4.0)
HSE Training Specification
Incident Investigation, analysis and reporting guideline
iv Related Corporate Management Frame Work (CMF)
Documents
The related CMF Documents can be retrieved from the Corporate Business Control
Documentation Register CMF.
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TABLE OF CONTENTS
i
Document Authorisation ......................................................................................................... 3
ii
Revision History ..................................................................................................................... 4
iii
Related Business Processes ................................................................................................. 4
iv
Related Corporate Management Frame Work (CMF) Documents ........................................ 4
1
Introduction ............................................................................................................................ 7
1.1
Background ...................................................................................................................... 7
1.2
Purpose ............................................................................................................................ 7
1.3
Scope ............................................................................................................................... 7
1.4
Objective .......................................................................................................................... 7
1.5
Distribution/target audience .............................................................................................. 7
1.6
Deliverables ...................................................................................................................... 7
1.7
Performance monitoring ................................................................................................... 8
1.8
Quality assurance ............................................................................................................. 8
1.9
Review and improvement ................................................................................................. 8
1.10
2
Step-out and approval .................................................................................... 9
Roles and Responsibilities ................................................................................................... 10
2.1
Overview:........................................................................................................................ 14
2.2
Immediate action to take following any incident (within 24 hours) ................................. 14
2.2.1
Task 1: Initiate emergency response........................................................... 14
2.2.2
Task 2: Gathering information ...................................................................... 15
2.2.3
Task 3: Organise remedial works, repairs or recovery ................................. 15
2.2.4
Task 4: Communication and escalation of the incident ................................ 16
2.2.5
Task 5: Preliminary assessment of incident severity & potential risk rating . 17
2.2.6
Task 6: Identifying the directorate incident ownership ................................. 18
2.2.7
Task 7: Identifying the Incident Owner ......................................................... 19
2.2.8
Task 8: Determining work relatedness ......................................................... 19
2.2.9
Task 9: Create an initial learning from incident ............................................ 19
2.3
Conducting successful investigations ............................................................................. 20
2.3.1
Task 1: Incident investigation team set up .................................................. 20
2.3.2
Task 2: Incident investigation terms of reference ........................................ 21
2.3.3
Task 3: Conducting the investigation ........................................................... 21
2.3.4
Task 4: Conducting the Tripod Beta (4/5 actual, High Potential or AI-PS) .. 21
2.3.5
Task 5: Statement of Fitness for Process Plant or Equipment.................... 22
2.3.6
Task 6: Local Quality Review, Incident Review (IRC), MD Incident Review
(MDIRC), AI-PS Working Party and Serious Incident Review (SIR) process ...................... 22
2.3.7
Task 7: Report writing.................................................................................. 24
2.3.8
Task 8: Life Saving Rules ............................................................................ 26
2.3.9
Task 9: PDO Information Management (PIM) ............................................. 29
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2.3.10
Task 10: Close out of remedial actions ....................................................... 31
2.3.11
Task 11: Learning from incidents ................................................................ 31
2.3.12
Task 12: Serious Incident Review Committee (SIR) ................................... 32
2.3.14
Task 14: Consequence management for poor quality investigations .......... 32
2.4
Follow up and record keeping......................................................................................... 33
2.4.1
Task 1: Evaluate the adequacy of the incident follow-up process ............... 33
2.4.2
Task 2: MDC PIM review ............................................................................. 33
2.4.3
Task 3: Records from investigations ........................................................... 33
2.5
3
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Training and competence ............................................................................................... 34
Appendices ........................................................................................................................... 35
3.1
Appendix 1, Forms and Reports ..................................................................................... 35
3.2
Appendix 2, Related Business Control Documents and References ............................. 35
3.3
Appendix 3, Change Log ................................................................................................ 36
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1 Introduction
1.1
Background
Learning and applying lessons from incidents to avoid a repeat is essential for continual
improvement of HSE performance. Investigations identify underlying causes and
management shortfalls which PDO and contractor management can learn from.
1.2
Purpose
To ensure:

All incidents including near misses and hazardous situations are reported, investigated
and analyzed to identify where management controls failed and recommendations to
identify new or restore controls are implemented;

Early sharing of lessons to facilitate prompt corrective action where similar situations are
found to prevent a recurrence both locally and at other locations.
1.3 Scope
This procedure sets the minimum requirements in PDO operations for the notification,
classification, investigation, report writing, remedial actions, incident analysis and
dissemination of learning’s from incidents to bring about the continual improvement in the
operations HSE performance.
1.4 Objective
To provide management and contractors a simple process to follow linked to guidance in
GU612 to enable them to take the appropriate action in dealing with any type of HSE
incidents.
1.5 Distribution/target audience
The target audience is HSE Teamleaders, HSE Managers/Advisers, Contract Holders,
Contract Site Reps, Contract Managers, Contractor CEOs, operational management or
indeed anyone who may be called upon to report or investigate an incident
1.6 Deliverables
The following deliverables shall be achieved by adhering to this procedure:
1. Initial notification into PIM within 16 hours including initial RAM assessment and
identification of the appropriate Incident Owner.
2. Director/MD notification for medium/high potential or a 4/5 actual incident shall be issued
within 48 hours of confirmation.
3. The initial PIM notification shall be opened and accepted/rejected by the Incident Owner
within 3 days of the incident.
4. Directorate IRC presentation to take place within 30 days if a medium potential or actual
severity 3 incident.
5. Tripod Beta analysis conducted for all high potential or a fatal work related incidents.
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6.
MDIRC to take place within 42 days (high potential or a fatal incident).
7.
Appropriate and quality investigation reports uploaded into PIM within 50 days.
8.
All relevant fields in PIM to be completed within 50 days.
9.
Action items uploaded into PIM with action parties and deadlines agreed within
50 days.
10. Action items closed out by the deadlines in PIM with evidences uploaded by the
deadlines.
1.7
Performance monitoring
The MSE5 team weekly monitor compliance with incident investigation protocol
conducting a review of incident PIM entries and RAM ratings and correct errors.
The MSE5 team reports PIM non compliance levels to the MDC each month.
The MSE5 team conduct a quarterly review of the PIM incident data identifying trend
analysis for learning and non compliances with PIM and PR1418 protocol.
Key performance indicators utilized:
1.8

Incident investigation timelimits achieved

Incident investigation quality check passed

Incident investigation details available in PIM

Action items closed out by the PIM deadlines with evidences uploaded
Quality assurance
1. A quality review of the PIM incidents is ongoing by the MSE5 team.
2. The MSE5 team review weekly the accuracy of PIM entries and RAM ratings.
3. A quarterly review of the PIM incidents by the MSE5 team analyses trends.
4. The PDO Lead Incident Investigator reviews MDIRC presentations before submission
to the MDIRC secretary.
5. The lateral learning communication is reviewed, translated and distributed by the
MSE5 team following all serious or medium potential incidents.
1.9
Review and improvement
This document shall be reviewed every 3 years and revised if necessary by the document
custodian in line with GU612.
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1.10 Step-out and approval
The requirements of this document are mandatory. Non-compliance shall only be authorised by
the Corporate HSE Manager through a STEP-OUT approval.
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2 Roles and Responsibilities
The following table formalizes the roles and responsibilities of different levels in the incident notification, investigation and reporting process.
R= Responsible:
Responsible for the action being carried out
A= Accountable:
Accountable to ensure the responsible person(s) carries out the action required
S= Support:
Is called upon to provide support the responsible person to achieve the action required
C= Consult:
Is consulted to ensure the correct action, timing or focus is being applied
I= Inform:
Is informed to ensure that they are kept aware of progress on the actions.
C
C
R
5
Notify HSE Team Leader and Senior Operational Management
R
6
Assess initial level of severity and potential classification from RAM
7
Confirm the appropriate Incident Owner
8
Incident owner can re-assign incident owner in PIM one level lower if appropriate
9
Contact and inform the chosen incident owner
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'PR1418 V.3.1' Procedure
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I
I
I
R
R
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A
C
MD
A
Notify the Road Safety Standards Team if motor vehicle incident
R
Director
I
4
R
R
UOM AI-PS Manager
C
S
R
MSE 4 CFDH Tech Safety
S
A
Contact CCR 5555
MSE 4X Tech Safety Eng
C
R
Collect initial facts and eye-witness statements.
3
MSE 5 HSE Corp Planning
MSE 54 Lead investigator
R
2
HSE Teamleader
I
Immediate emergency action
Investigation team
I
1
Incident Owner
I
Supervisor
First on scene
Activity
MSE 52 PIM Data mmgt
STEP 1 NOTIFICATION
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R
10
Create an initial incident notification in PIM
11
Create the Level 1 notification
12
Review Level 1 notification
14
Communicate Level 1 notification in/ outside of PDO.
14
Create an appropriate core investigation team
R
15
Devise initial Terms of reference for the investigation
A
16
Hold initial meeting of the investigation team
17
Make initial assessment if work related and inform MSE5
18
A
R
C
C
I
S
MD
Director
UOM AI-PS Manager
A
A
R
S
S
A
R
S
A
R
S
Identify Tripodian and conduct tripod analysis
A
R
S
19
Design and issue initial incident learning
A
R
20
Check website for relevant information on incident type
A
R
C
21
Complete initial short investigation report & upload in PIM
A
R
S
22
Review learning’s from previous incidents
A
R
S
23
Conclude investigation into the incident, including visits, interviews, inspection of equipment, review of records, HSE
MS, safety cases, HEMP, procedures and specifications
A
R
24
Analyze findings and identify underlying causes.
A
R
S
25
Sign Statement of Fitness prior to restart of a process facility
R
C
C
'PR1418 V.3.1' Procedure
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S
C
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R
I
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MSE 5 HSE Corp Planning
S
A
R
MSE 54 Lead investigator
MSE 52 PIM Data mmgt
MSE 511
HSE Teamleader
Investigation team
Incident Owner
First on scene
Activity
Supervisor
STEP 2 INVESTIGATION
R
C
C
I
S
S
S
A
I
I
C
C
C
I
I
I
C
C
C
S
S
C
I
I
I
S
I
S
I
S
A
R
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UOM AI-PS Manager
I
I
26
Create directorate Incident review (IRC) presentation
A
R
C
I
S
27
Reach agreement on work relatedness with MSE team
A
R
C
C
C
28
Challenge to ensure the action items are SMART and appropriate
A
R
C
C
29
Arrange and hold Directorate IRC
A
C
R
C
S
30
Identify high risk 'ESSENTIAL RECOMMENDATION' actions
A
R
C
C
I
31
Update presentation and investigation report with points raised in Directorate IRC
A
R
I
I
I
32
Upload agreed actions into PIM
A
R
I
I
33
Arrange MDIRC review slot via MSE54, informing all attendees
A
C
R
C
34
Confirm with MSE54 who will be secretary and take minutes
A
R
I
C
35
Review draft report and issue.
A
R
C
36
Attend MDIRC and present minutes to MSE54
A
R
C
37
Create final report and presentation
A
38
Upload final report and presentation into PIM
39
40
41
I
I
I
C
R
I
C
A
R
I
Upload additional agreed actions into PIM
A
C
R
I
Issue final report including outcome of MDIRC
A
R
I
I
I
Process and cascade final ‘learning from Incidents’ communication
I
I
I
I
A
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R
I
I
I
C
I
I
I
I
MD
MSE 4 CFDH Tech Safety
I
Director
MSE 4X Tech Safety Eng
MSE 5 HSE Corp Planning
MSE 54 Lead investigator
MSE 52 PIM Data mmgt
MSE 51
HSE Teamleader
Investigation team
Incident Owner
First on scene
Activity
Supervisor
STEP 3 IRC PROCESS
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I
I
I
R
S
S
I
R
S
S
R
S
S
S
44
Implement remedial actions successfully
A
45
Update PIM to confirm action points are successfully closed
A
46
Check status of action point close outs.
A
47
Confirm the quality and accuracy of action points closed out
48
Challenge any failure to close out action point by deadline
49
Conduct status reports and trend analysis
50
Provide Directorates with monthly 'overdue PIM action item report'
51
Update overdue PIM items into the KPIs dashboard
52
Present dashboard in MDC
53
Process consequence management for sub-standard investigations
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MSE 511
S
I
MD
I
S
Develop Serious Incident Review material for MD.
Director
S
R
43
A
C
C
I
I
A
I
I
A
R
A
R
A
R
A
R
R
S
I
UOM AI-PS Manager
R
R
MSE 4 CFDH Tech Safety
R
A
MSE 4X Tech Safety Eng
MSE 54 Lead investigator
S
Enter MDIRC minutes and report to PIM.
MSE 5 HSE Corp Planning
MSE 52 PIM Data mmgt
C
42
HSE Teamleader
I
Investigation team
I
Incident Owner
First on scene
Activity
Supervisor
STEP 4 ACTION TRACKING
I
I
A
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2.1
Overview:
2.2
Immediate action to take following any incident (within 24 hours)
2.2.1
Task 1: Initiate emergency response
Actions taken immediately following an incident can make a significant difference in reducing its
consequences. It is important to act quickly. All staff should be trained in the following:
1. Ensure help has been requested and management informed. Call 24675555 or
24385555 if it looks like a serious incident. If in doubt…. call.
2. Make the area safe first before dealing with casualties.
3. If you suspect H2S could be a factor go down or across wind.
4. Ensure all equipment is switched off and powered down.
5. Ensure the immediate area is made secure to prevent spectators entering.
6. Treat or arrange first aid treatment for casualties.
7. Liaise with the management and emergency services when they arrive.
Detailed emergency response information can be obtained from PR1065.
Reporting of spills and leaks
Where an oil leak/spill exceeds 10m3 the line management shall immediately report the
incident to the MSE2 team who shall in turn inform MECA as legally required. Where
spills exceed 50 tonnes, the shareholders will be informed by the Managing Director.
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2.2.2
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Task 2: Gathering information
Continue to secure the scene to ensure evidence is not disturbed. Information from an incident
scene is only of value if the scene is properly preserved. Once integrity has been lost then vital
information is compromised.
All relevant staff shall be trained on what to do if they see an incident or attend an incident
scene:
1. Identify who witnessed the incident and obtain their names and contact details
2. Collect and make a note of the initial facts including;
a. What you saw when you arrived?
b. What is the time?
c. What is the weather?
d. What is the lighting – where is the sun?
e. What, if any non work related general clothes were people wearing
f. Who was the person injured?
g. What did the injured person say?
h. What injuries were visible if any?
i. What equipment was involved?
j. What was the phase of operations, process condition, etc,
k. Markings, scratches etc left by equipment involved,
l. Where were relevant people and equipment
3. Ask witnesses what they saw, heard, smelt etc and make notes. Record who says what.
4. Ensure the road safety department is informed if it is a motor vehicle incident.
5. Take measurements, heights, distances etc if applicable.
6. Take photographs and/or video of the scene as quickly as possible if it is safe to do so.
Remember that taking too many photos is much better than not taking enough.
7. Inform the PDO and contractor management as soon as possible.
2.2.3
Task 3: Organise remedial works, repairs or recovery
It is important for the area to be returned to its normal operation as soon as possible once the
investigation team is confident that they have captured all of the necessary data from the
incident scene and ensured there are no legal restrictions in doing so. The following actions
should take place:
1. Confirm the area can be reopened and it is safe to do so.
2. Confirm the hazards that led to the incident are no longer a threat.
3. Confirm there are no other hazards resulting from the incident which must be dealt with
first.
4. Confirm re-opening the plant or area will not result in further loss or exposure.
5. Confirm the necessary repairs are organized and planned.
6. Confirm recovery equipment/spare parts etc have been ordered and delivered.
7. Confirm the immediate remedial actions have been organized and will take place.
8. If it is a process facility, see section GU612 (Page 67 & Page 181) on statement of
fitness to restart.
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2.2.4
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Task 4: Communication and escalation of the incident
It is important to let the appropriate people know an incident has happened as soon as possible.
If the incident is an actual level 4 or 5 or early indications are it is a Lost Time Work Case then
using the template in GU612, page (64) the incident needs escalating via email immediately to
the list below within 16 hours.










Incident Owner,
Director,
HSE Teamleader,
MSE5,
MSE52
MSE54.
MSE2 (Environmental only)
MSE14 (Motor vehicle incident only)
MSE4 (Process safety incident only for Tier 1,2 – see GUI612 page 16)
MSE46 (Process safety incident only for Tier 1,2 – see GUI612 page 16)
The email should only include known facts so avoid any speculation. The MSE5 team will
create a draft notification and after agreement with the operations/project supervisor the
notification will be issued to the appropriate person for publishing as per the table below:
Type
Issued by
Published to
Deadline
Actual 4/5 incident or
High Potential
Managing
Director
Ministry, Shareholders,
Employees
48 hours
Non Accidental Death
Director
Employees,
Shareholders
48 hours
Significant
Environmental Incident
MSE2
Ministry of Environment
and Climate Affairs
24 hours
Director
Employees
48 hours
Loss of primary
containment over 50
tonne
Managing
Director
Shareholders
24 hours
Lost workday case
Director
Employees
48 hours
Radiation exposure
incident
Director
Employees
24 hours
Electrical incident
Director
Employees
24 hours
Employees
All incidents, including near misses, (or unsafe acts and conditions with remedial action not
closable within 24 hours and by local action only) which are or may be related to PDO's business
and which have or could have caused injury or harm to people, assets, the environment or
PDO's reputation, need entering in the PDO Incident Database (PIM) within 24 hours. See Task
9 – PDO Information Management if clarification is needed.
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Before completing the PIM entry, ensure that you have determined the preliminary assessment
of the actual incident severity and potential risk rating. (See 2.2.5). Guidance on inserting a
notification in PIM is included in GU612 (page 120 & page 142)
On being notified of a serious incident (actual severity 3 or medium potential incidents or above )
an investigation team comprising a combination of local, coastal and contractor management as
well as appropriate specialists relative to the incident shall be deployed to the incident scene to
conduct the ‘on-scene’ investigation within 24 hours.
2.2.5
Task 5: Preliminary assessment of incident severity & potential risk rating
Utilise the PDO ‘Risk Assessment Matrix’ (RAM) in GU612 (page 9 & page 16) to make a
preliminary assessment of actual severity and potential risk of the incident. This assessment
can be changed later if circumstances change.
a. Actual severity rating
It is often difficult to calculate the actual severity of an incident straight away, particularly on
asset damage, environment and reputation, however the best guess estimate should be
made with the information available and using the guidance available in GU612.
For ‘people injuries’ a PDO doctor initially classifys any injury other than first aid treatment.
This is done by either a face to face medical examination or where this is not possible, by the
PDO doctor reviewing the case notes provided by an external medical establishment.
Whilst PDO or contractor management can provide information to the PDO doctor for him to
make the classification, it is up to the PDO doctor to make the decision on whether it is a:







Permanent total disability
Permanent partial disability
Lost workday case
Restricted workday case
Medical treatment case
First aid case
Non accidental death
The classification shall be made within 48 hours of the incident.
It is important for the job description of the injured person to be fully understood and taken into
account when the PDO doctor makes the decision whether the injured person reasonably
requires time off work (and for how long), or is able to continue his normal work duties with
restricted conditions or can work without any restrictions. The more manual or risky the work
activity, the more likely an injury is to require time off work. A guide of work activities against
injuries is included in GU612 page (19).
If there is a dispute regarding the classification, then a panel will meet to discuss and decide.
(via meeting or conference call). This panel will include:


Head of Occupational Health
Head Nurse who dealt with the injured person
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
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HSE Team Leader for the relevant Directorate
MSE54
Contractor HSE Manager (where applicable)
Where the Head of Occupational Health does not agree with the majority decision of the above
panel then the final say on classification is to be taken by MSEM.
No person shall return to work until the PDO doctor has signed him back to work or normal
duties if injured to a lost time injury or restricted work case.
b. Potential risk rating
For the assessment of potential risk, one shall review the details from the incident, consider the
worst scenario that is reasonably probable from the incident and then consider how many times
this has historically occurred within the industry, in PDO or more frequently at the same location.
Utilise all available resources to determine the applicable history e.g.
1. PDO HSE web,
2. PDO PIM database search,
3. Previous local incident reports,
4. HSE Advisers and operations.
This will allow you to assign a potential severity and likelihood of such consequences using the
definitions in the matrix.
Note: The initial classification of an incident made by the person entering the data into PIM shall
be confirmed or otherwise by the Incident Owner and sanctioned by MSEM team.
An exception to this rule applies to Rig activities and ‘dropped objects’ where an alternative
mechanism for assessing potential risk is applied by looking at the weight of the object and the
distance the object fell. These alternative rules are embedded in SP-2097 – ‘Prevention of
Dropped Objects’. A summary of the process is contained in GU612, section 2.2.4.2.
2.2.6
Task 6: Identifying the directorate incident ownership
It is important to establish single point responsibility for an incident to ensure the incident is
investigated, reported and followed-up effectively. Ownership is first assigned to a PDO
directorate and then delegated to the appropriate level within that directorate.
See GU612 page (21) for the rules determining line ownership. Where agreement between
two assets or directors cannot be achieved, MSEM must be informed who will adjudicate.
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Task 7: Identifying the Incident Owner
The PDO Incident Owner is the key person who will ensure a successful and efficient incident
investigation. Once the directorate incident ownership is confirmed, the Incident Owner should
be identified and agree to manage the investigation.
See GU612 page (22) for the rules regarding the appropriate level of person to be an incident
owner for each severity of incident.
2.2.8
Task 8: Determining work relatedness
An incident can be classified in several ways:

PDO/PDO contractor work related reportable and recordable

PDO/PDO contractor work related reportable but non recordable

PDO/PDO contractor non work related

Third party incident work related reportable and recordable

Third party incident work related reportable but non recordable

Non accidental death, suicide

Death by natural causes not related to work exposure

Non PDO incident
All incidents are considered as work related until proven otherwise. Where the investigation
team believes an incident is not work related, it is the responsibility of the Incident Owner to
provide the justification to MSEM who will make the final classification.
Guidance and examples for the classification for work relatedness are found in GU612 page
(23)
2.2.9
Task 9: Create an initial learning from incident
It is essential that PDO capitalizes on learning from incidents and communicates lessons as
soon as possible when the incident is still topical .
The HSE Team Leader shall ensure that within 7 days of an incident an initial incident learning is
created by the investigation team for incidents of actual 4/5 or high potential and issued to
MSE54 for review and distribution.
By sharing the lessons quickly from an incident it enables people to connect with the incident
and also to dispel any false rumours.
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2.3
Conducting successful investigations
First ensure all immediate actions have been conducted (section 2.2)
2.3.1
Task 1: Incident investigation team set up
Contractor or PDO?
An investigation into an incident involving a PDO employee shall be led by the PDO line
management.
An investigation into an incident involving a PDO contractor shall be led by the contractor
management with close support from PDO. The PDO Incident Owner must ensure sufficient
Company resource, including the Contract Holder is assigned to liaise with and support the
contractors investigation team. The level of support and resource will be based on the
severity of the incident and the contractor’s ability to conduct an in-house, unbiased,
satisfactory incident investigation.
Investigation team membership
If it is a PDO operational incident, the Incident Owner is himself responsible for setting up an
appropriate investigation team within 24 hours. Guidance is in GU612 page (27)
This means identifying:
4,5 / High /
High value
learning
AI-PS
1,2 / Low
3 / Medium
Resource (actual/potential)
An appropriate Investigation Team Leader with sufficient authority,
time and focus to lead the team.
X
X
X
Sufficient directorate investigation team members locally to the
incident.
X
X
X
Sufficient directorate investigation team members based at the coast.
X
X
Specialist support from other directorates.
X
X
The Directorate HSE Team-leader
X
X
A Tripodian
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Task 2: Incident investigation terms of reference
Incident investigations require a term of reference (ToR) to be formalized unless they are level 2
or below or minor potential. The ToR must be agreed as part of the first meeting of the
investigation team. An example of a ToR is shown in GU612 page (29).
It is important to ensure that the membership of the investigation team, the frequency of
meetings, the scope of the investigation, timetable of key milestones and roles and
responsibilities are formalized at the start within the timeframes stipulated.
For level 2 or below or minor potential, investigations need to commence within 24 hours of
the incident and conclude within 5 days.
2.3.3
Task 3: Conducting the investigation
Incidents for level 3 or above or medium/high potential shall be subject to a detailed investigation
commencing within 24 hours of the incident. (Guidance on conducting the investigation is
contained in GU612, pages (34-46).
2.3.4
Task 4: Conducting the Tripod Beta (4/5 actual, High Potential or AI-PS)
All incidents of 4/5 actual, High Potential or high value learning AI-PS incidents require a Tripod
Beta analysis to identify the underlying causes of the incident. Tripod analysis uses specific
computer software and can only be conducted by a trained Tripodian. MSE4 will determine
which AI-PS incidents provide high value learning and hence require tripod.
It is easy to apportion blame for an incident on the people primarily involved, however it is often
managerial decisions (sometimes years before and often remote from the location) that can be
linked via the causational pathway back to the immediate cause of an incident. The Tripod
analyses and links the immediate causes of an incident to these underlying causes. By tackling
and addressing these managerial issues a repeat of the incident is more likely to be avoided.
Each contractor and PDO Directorate HSE team shall employ or have access to a trained
Tripodian with the Tripod software to enable a Tripod investigation to be conducted.
The Investigation Team Leader should identify an appropriate Tripodian to be a key member of
the investigation team. A list of trained Tripodians is kept by MSE54.
To conduct a successful Tripod analysis, the Tripodian must have access to all information in
the investigation and hence is a key member of the team from the very start of the investigation.
Guidance on Tripod is contained in GU612 page (154)
TRIPOD IS NOT REQUIRED FOR INCIDENTS WHICH ARE NOT WORK RELATED
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2.3.5 Task 5: Statement of Fitness for Process Plant or Equipment
Before restarting a process facility after a ‘significant incident’, uncontrolled shutdown,
conditions outside the operational limits, or environmental conditions beyond the original
design parameters the following criteria shall be confirmed as having been met:-
The basic and immediate physical cause(s) of the incident are understood through
incident investigation or Root Cause Analysis process.
-
Corrective actions required for restart are completed and address the incident
causes. This could include any or all of: repairs, alterations or modifications,
required monitoring, temporary equipment, mitigations.
-
A review has been conducted to assess implications for similar equipment or
barriers on the asset
-
The Hazards and Effects Register has been reviewed as it applies to the incident.
-
Statements of Fitness requirements specified in SP-2062 have been met where
applicable.
See GU612 page (67) for template and GU 612 page (118) for guidance.
A STATEMENT OF FITNESS TO RESTART IS ONLY REQUIRED FOR INCIDENTS
WHICH ARE 4/5, HIGH POTENTIAL OR HIGH VALUE LEARNING AI-PS
2.3.6
Task 6: Local Quality Review, Incident Review (IRC), MD Incident Review
(MDIRC), AI-PS Working Party and Serious Incident Review (SIR) process
SIR
1) MDIRC
party
(If Tier
AI-PS working
IRC
Directorate
review
Local quality
The IRC/MDIRC/SIR process applies as follows:
High potential,level 4/5, High value learning AI-PS
incidents (normally Tier 1)
x
x
Medium potential or level 3
x
x
Unauthorised overdue medium potential or level 3
x
x
x
High value learning medium or level 3 incidents as
determined by MSE team
x
x
x
Low potential or level 1/2
x
x
x
New technology or information to prevent a
reoccurrence of a previous MDIRC incident
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x
x
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x
For low potential or level 1/2 incidents where only a short and concise investigation is required it
is the responsibility in the first instance of PDO site or field supervision, e.g. Contract Site
Representative (CSR), Drilling Supervisor (DSV) to review and ensure the quality and accuracy
of the investigation. The incidents owner (see GU-612, 2.2.7.7) is responsible to ensure that the
investigation is taking place and is appropriate to the incident. The format of the investigation
and incident report must follow the template provided in GU-612, 2.2.17.
Where the incident itself involves a PDO employee or asset, the incident owner in liaison with
the Directorate HSE Team Leader. is responsible for the quality of the investigation and
reporting in PDO.
It is not considered appropriate to expect contractors to create full IRC packs for minor incidents
or conducting local IRCs as this discourages incident reporting; however where contractors are
habitually providing poor quality investigations then this can be introduced on the authority of the
middle and/or senior management.
For medium or high potential or level 3 and above actual, the IRC process must be followed
Middle management (Senior Well Engineers, Contract Holders, HSE Team Leads and Asset
Team Leader) are responsible for arranging periodic quality reviews on the checks made by the
local PDO management to ensure it is taking place and is appropriate. Directorate senior
management teams can determine the set up of low potential investigation quality reviews most
appropriate to their operation.
The media used for IRCs is PowerPoint. Guidance is found in GU612 page (49) and the
template is in GU612 page (111). It shall be written in English and not deviate from the template
without the permission of MSE54 and the Incident Owner.
The IRC process provides senior management opportunity to challenge the investigation scope,
findings, actions taken and recommendations and assure the quality, integrity and area of focus
of the investigation. It ensures the poignant learning’s have been extracted from the incident to
prevent a reoccurrence as far as is reasonably practicable. In addition any Tier 1 AI-PS
incidents must first be reviewed and confirmed as acceptable by the AI-PS Working Group
before going to IRC and can be organised via MSE4.
The MDIRC presentation is the same as the IRC presentation with an additional slide
highlighting the changes and discussions in the Directorate IRC. In addition the IRC presentation
must be updated to reflect the amendments requested in the IRC.
The presentation shall have a maximum of 5 Essential recommendations highlighted. The
actions are the 5 most important actions to prevent a reoccurrence of the incident.
The remaining actions and recommendations shall follow in a separate section.
The presentation shall conclude with the 2 page lateral learning slides which the MSE5 team
shall then communicate to other contractors and PDO to spread learnings and help prevent a
recurrence. The first page is for communication to employees, the second is the management
failures that HSE Managers need to be aware of.
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The Investigation Team Leader shall ensure the IRC presentation is created and agreed by the
investigation team and quality reviewed by the local PDO management team before submission
to the directorate IRC focal point.
Where the MDIRC/IRC endorses remedial actions and deadlines, the Investigation Teamleader
shall ensure their upload into PIM within 5 days of the IRC taking place.
The deadlines for IRC and MDIRCs are as follows:
Directorate IRC
– 30 days after the incident
MDIRC - Fatalities/NAD/HiPos/Permit to Work violations
– 42 days after the incident
MDIRC – Tier 1 AI-PS
(even if not complete)
– two months after the incident
MDIRC slots are booked via MSE54 who shall be informed of the identity of the minute taker
and provided with a copy of the MDIRC presentation and incident investigation report. Bookings
shall be made no later than 6 days before the proposed MDIRC date. Tier 1 AI-PS incidents
shall always be discussed on the last MDIRC of each calendar month.
During the MDIRC, minutes shall be taken by the minute taker and provided to MSE54 with a
revised presentation and report within 4 days of the MDIRC.
The Investigation Team Leader shall upload any additional remedial actions requested from the
MDIRC and the HSE Team Leader shall check this has been done. Support can be requested
from MSE521 but is not guaranteed.
The timeframe of the incident investigation process is shown in GU612 page (155)
2.3.7
Task 7: Report writing
All reports shall be written in English and any statements or records attached in Arabic, shall be
accompanied with an English translation.
For low potential or level 1 or 2 incidents the investigation report should be short, to the point
and be no more than one page long where possible. Detailed analysis or long winded reports
are not required for a low potential incident. The format for the report is contained in GU612
page (70).
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The report shall contain as a minimum:
-
Place, time, date, and description of the incident;
-
Classification of incident (incident type)
-
Actual and Potential Consequences;
-
Critical factors
-
Key causational factors
-
Immediate causes
-
Underlying causes
-
Latent Management failings
-
Action items to prevent reoccurrence.
The report shall clearly highlight the key findings identified from the investigation.
For more serious incidents the Investigation Team Leader shall organise the investigation team
to compile the more detailed Incident investigation Report. The format of this report is contained
in GU612 page (88).
The report shall contain as a minimum:
-
Place, time, date, and description of the incident;
-
Timeline of the incident
-
Photos and diagrams relevant to the incident
-
Classification of incident (incident type)
-
Actual and Potential Consequences;
-
Critical factors
-
Key causational factors
-
Immediate causes
-
Underlying causes
-
Latent Management failings
-
Action items to prevent reoccurrence.
The report shall be efficient and clearly highlight the key findings identified from the investigation
and include an executive summary so a reader can identify the main output from the
investigation without reading the entire report.
Where a Tripod has been conducted the report shall correspond to the Tripod findings and the
Tripod flowchart will be contained as an Appendix.
Recommendations that are not directly related to the incident causes shall be stated in a
separate section of the incident investigation report.
Action items identified from the investigation must be SMART, this means:
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Objectives should specify what they want to
achieve.
Measureable (M)
You should be able to measure whether you
are meeting the objectives or not.
Achievable (A)
Are the objectives you set, achievable and
attainable?
Realistic (R)
Can you realistically achieve the objectives
with the resources you have?
Timed (T)
When do you commit to achieve the set
objectives?
Where the actions are long term they should be broken down into short and long term actions or
instead the action should relate to obtaining the authorization, budget and timetable for the
action to be closed.
e.g.
short term – obtain budget and sign off for replacement pipeline project.
Long term – pipeline replaced
The investigation team shall identify, liaise with and agree an appropriate action party for each
action required. The wording of action points and reasonable deadlines shall be agreed with the
action party before being formalized in the report. Any dispute shall be raised at IRC.
The investigation shall highlight the 5 Essential recommendations which have the greatest
influence on preventing the incident happening again.
Note: Action items are often work in addition to a person’s normal role and so it is important to
build in contingency when determining the deadline.
2.3.8
Task 8: Life Saving Rules
PDO’s 12 Life-Saving Rules are the next step in the Goal Zero Journey. These rules have been
selected because they represent those activities where non-compliance has the highest likelihood
to result in death or serious injury, the Life-Saving Rules apply to everyone and all operations
under PDO’s operational control.
The Life-Saving Rules set out clear and simple “dos” and “don’ts” covering activities with
the highest potential safety risk. Where violation of a Life-Saving rule is suspected, check
whether supervisors /managers have created pre-conditions which may have contributed
to the violation.
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Investigations into why a Life-Saving rule was not followed should include “the failed life
saving rule”, “the human error/violation type” “the precondition” and “the underlying cause”
and the corresponding weaknesses in the HSE-MS.
For all significant and high risk incidents and/or where it is established that a life saving rule
has been violated, the following should at least be recorded by the incident owner in PIM
under “add investigation"/“immediate causes”: accessible in the bottom part of incident
report page by clicking on the "add investigation" icon. You will be able to view the tab
"immediate cause"
Under the "immediate cause" the drop down menu, includes the Life Saving Rules.
1.
2.
o
o
Record if no life saving rule failed in the incident
If concluded that a life saving rule failed
Select the relevant failed Life Saving rule(s)
Select the relevant human error/violation type : slip/lapse, mistake, unintentional
violation, situational violation, etc.
LSR Consequence Matrix
Rule is broken for the
first time
Rule is broken for the
second time or several
rules are broken at the
same time
Rule is broken for the
third time, or rulebreaking caused injury
or death, or was done
recklessly or wilfully
Warning Letter
low potential impact
Final Warning Letter
high potential impact
Final Warning Letter
Final
Warning
Letter
Dismissal
Dismissal
Dismissal
Note on LSR Consequence Matrix:
•
The Company reserves the right to take circumstances of the rule breaking into account
to modify the disciplinary measures.
•
The Breaking of a Life-Saving Rule is considered a Major Misconduct, and the HR
disciplinary process as defined in the Employee Policy Manual will be used to administer
this consequence matrix.
•
ROP speed and alcohol thresholds will be used.
•
Other existing rules and procedures remain valid.
Adding Life Saving Rule Violation incidents into PIM
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All violations should be reported in PDO Incident Management (PIM) whether or not the
violations lead to an incident. There is now a Life Saving Rules box to be completed by the
incident owner, which provides the opportunity for tracking, this is located in the investigation
part of the PIM report.
The process is:
1. Report incident/observation of a (suspected) life saving rule in PDO (as per normal
procedure for actual or potential incident)
2. Investigate the suspected life saving rules violation, the human error type (why was the
rule not followed e.g. to mistake, reckless violation etc), the precondition under which
the rule was violated (e.g.: supervisor interaction) and underlying cause(s)
3. Conclude whether life saving rule was violated, in PIM go to "investigation" tab, click
"add investigation", go to "Immediate Causes" tab, click "+", complete immediate causes
from drop down menu indicating which Life Saving Rule was broken.
For consequence management reporting:
1. For contractor staff, the Life Saving Rules focal point is the Contract Holder, who will,
update PIM with the record of the consequence applied.
2. For PDO employees, the incident owner will update the PIM records.
Please contact PDO Helpdesk at 75599 for any assistance.
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2.3.9
Task 9: PDO Information Management (PIM)
PIM is PDOs Incident Investigation IT Tracking System used to track all incidents and actions
and accessed through the HSE home webpage. A PDO employee’s MU number grants
automatic access and contractor employees with an MUC number can request PIM access from
their Contract Holder.
The PIM database should be used as per the following tables:
Entry into PIM
Deadline for PIM upload
Level 3,4,5 or
medium / high
potential/Tier 1
Level 1,2 incidents
or low potential
1
Initial incident report and photographs
24 hours
24 hours
2
Initial actual severity and potential risk rating
24 hours
24 hours
3
Incident owner
24 hours
24 hours
4
Medical report
when received
when received
5
Initial investigation report/form
5 days
6
MDIRC presentation
36 days
7
Incident investigation report
36 days
7 days
8
Actions and action parties
36 days
10 days
9
Evidences of actions taken
by action
by action
deadline
deadline
10
Close out of incidents with no actions
20 working days
20 working days
11
Close out of actions
by action
by action
deadline
deadline
The MSE52 team are the PIM focal point is available to answer queries about PIM.
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When to use PIM or STOP for unsafe acts or conditions
If the investigation team need to report an unsafe act or condition then this shall be
recorded via the PIM system but only in cases where the unsafe act or condition
requires either remedial action taking more than 24 hours or the involvement of other
non-local parties (e.g. more senior management/other departments) or the procurement
of equipment, goods, stock. The PIM system ensures an assurance process is in place
for the closing out of the remedial actions. In such cases the Incident owner as formally
assigned in the PIM system is responsible for ensuring the action is closed out.
If the unsafe act or condition can be resolved locally with actions closed out within 24
hours by local management then this shall be recorded via the use of a STOP card and
recorded in the STOP system. The observer shall be responsible for the remedial action
and he has to resolve it and/or report it to the local management for immediate
rectification.
Example 1:
An observer or a manager spots a manhole cover which has been taken off a manhole
and laid to the side. He can coach the workers in the immediate area about leaving the
manhole unprotected, investigate why it happened and replace it immediately. This
unsafe condition shall be reported in STOP.
Example 2:
An observer or a manager spots an exposed manhole but the manhole cover which has
been removed cannot be located and the situation has not been reported or the
manhole protected. After the manhole has been protected by a barrier, the situation
must be reported in PIM due to the fact that the new manhole cover needs to be ordered
and this action tracked until it is replaced. The investigation itself will still focus on why
the manhole was not protected by the workers and reported in PIM.” If the manhole
cover has been stolen then it also has to be reported using security incident report form
available for download from the UIC homepage.
Change of PIM Action Party
When an action party changes position or leaves the company, the Incident owner
should update the PIM action with the new action party in order to close out the action.
Change of PIM Incident Owner
When a person takes over a management role, he/she shall contact MSE52 to check if
there are any incident/audit actions or Incident Owner responsibilities open for his/her
new role. MSE52 will transfer the actions and incidents to the new person to avoid them
being lost and having to be reassigned at a later date. The Line Manager of the person
taking on the role should also ensure this process takes place.
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Task 10: Close out of remedial actions
The action party shall be aware of, agree and meet the action close out deadlines.
The action shall be formally closed out in PIM by the action party once the close out can be
evidenced; otherwise PIM will report it as an overdue action. The Incident Owner must
confirm acceptance of the action close out in PIM.
PIM will report the performance of action parties meeting or not meeting deadlines to the
Incident Owner who shall manage instances of non compliance effectively.
On request of the MD, for certain incidents presented to MDIRC, the Incident Owner shall
email an ‘essential recommendation’ close out report to the MSE54 team within 5 days of the
last essential recommendation deadline providing evidence of their completion. If deadlines
have not been met then the reasons why and contingency must be stated. The template is in
GU612 page (110). The MSE54 team will inform the MD of the performance of essential
recommendation close outs who may request the Incident Owner to present the success of
these close outs to MDIRC.
When all actions have been successfully closed out from the investigation, the Incident
Owner shall officially close out the incident in PIM.
2.3.11
Task 11: Learning from incidents
It is essential that the lessons are learnt from incidents. By sharing the lessons from an incident
other parties can learn lessons and identify if they are at risk of it happening to them and by
implementing actions, prevent it happening in the future.
The MSE5 team will communicate a two page lateral learnings from all IRC/MDIRC incidents for
all parties to learn lessons from, page 1 is a poster to educate the people at risk, page 2 is the
management learning’s from the investigation to enable the management to review their
procedures and HEMP to avoid it happening again. The template is found in GU612 page
(104,105) and an example is in GU612 page (106).
The MSE5 team will periodically analyse the statistics from low potential and minor incidents in
PIM and communicate these learnings for all parties to learn lessons from.
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Task 12: Serious Incident Review Committee (SIR)
The Managing Directors is required to present the learnings from the most serious
incidents, including actual 4/5 or high potential to PDO shareholders on at least an annual
basis. The MSE5 team are responsible for collating the information for the Managing
Director presentation and will liaise with the Incident Owners to ensure all the required
evidence for the incidents action close outs are available.
The SIR committee produce minutes from the SIR which will communicate any
additional work which PDO has to conduct resulting from the incident. The MSE5 team
will communicate any additional work requirements to the relevant action parties.
The template for the SIR presentation is found in GU612 page (109-110)
2.3.13
Task 14: Consequence management for poor quality investigations
PDO contractors are required to employ sufficient and competent incident investigators
who have passed the PDO incident investigation course and are able to conduct and
deliver a good quality investigation.
Where an Incident Review Committee meeting has to be reconducted due to a poor
quality investigation, presentation or report, the Contract Holder shall request the
contractor to provide evidence of their competent investigation credentials via training
records.
Where the contractor has not employed an incident investigator to support the
investigation and this is contractually required, or the contractor provides poor quality
investigations on more than one occasion then the Directorate HSE Team Leader shall
ensure the contractor is penalized via the C9 HSE default section of the contract via the
Contract Holder, the penalty to continue until they have employed a competent HSE
incident investigator and improved the quality of the investigations provided.
Poor investigations are those that:
1. Have failed to follow the most up to date PDO IRC template.
2. Do not use the PR1418 v3.1 incident investigation methodology.
3. Do not include a lateral learning in the correct format.
4. Do not clearly identify the critical factors, immediate causes, underlying causes
and latent management system failures.
5. Do not identify SMART actions and recommendations.
6. Do not contain the supplementary information for evidence.
7. Are not presented to IRC within 30 days without a valid justification.
If a IRC needs to be reconvened because of any of these, the consequence management
can apply to both the contractor and PDO investigation team leader.
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2.4
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Follow up and record keeping
All documentation regarding incidents including investigations, statements, records, close
out of actions shall be kept on file for a minimum of 10 years for future review or learning.
2.4.1
Task 1: Evaluate the adequacy of the incident follow-up process
The Incident Owner shall review the quality of the report, timeliness of investigation and
agreed actions. Any outstanding actions which are overdue shall be challenged and
rectified.
2.4.2
Task 2: MDC PIM review
The MSE5 data team shall provide a monthly report on over-due PIM actions to the MDC
who are responsible for ensuring that the responsible action parties in their directorate are
held to account for not meeting the deadline and for assuring the close out of the PIM
actions at the earliest opportunity.
2.4.3
Task 3: Records from investigations
Each Directorate shall retain its incident reports after posting on PIM, connected learning,
and notifications in line with local requirements and for at least 10 years.
Investigation notes and reports shall be posted on PIM and must contain.
-
Notifications,
-
Completed investigation report,
-
Completed IRC/MDIRC presentation,
-
Photographs,
-
Lateral learning documents,
-
Other relevant documents
Note: The medical examination records of workers exposed to hazards must be retained
in the employee’s medical files and retained in a special file dedicated for the reason even
after the end of the employee’s service. In the case of radiation examination reports, the
records must be retained for a minimum of 30 years. Medical records shall be retained
safely and securely and shall not be accessible except to authorized personnel.
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2.5
Training and competence
Management need to ensure suitable and sufficient people are trained and competent in:
Course
Who
Incident Investigation
Supervisors
/
Medium
Course Code
Classroom
SP1157
management / HSE
IAI **
TLs / HSE Advisers /
Contract
CSRs
Holders
/
/
Contract
Managers
PIM training
Supervisors
/
Web
Shell
Open
management / HSE
University
TLs / HSE Advisers*
HSSMGT000767
/ Contract Holders /
CSRs
/
Contract
Managers*
Tripod Beta
HSE Advisers / HSE
TLs
/
persons
designated
Classroom
SP 1157
TPB
as
incident investigators
* Only contractor staff with MUC numbers and access rights to PIM are allowed.
** As of June 2014, PDO has introduced a new investigation course which is in line with the new
concept of incident investigation in this procedure. It is highly recommended that people who
have attend the previous course and who are involved in accident investigation attend the new
course to become familiar with the new concept and to make it easier to be compliant.
Shell Open University accessed via http://sww.shell.com/hse/it/PIM/training/sou_access.html.
Log on your account and enter “PIM’ in the search bar.
It is mandatory that a competent Incident Investigation Team member participate in the
investigation unless it is a low potential or level 1 or 2 actual severity incident.
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3 Appendices
3.1
Appendix 1, Forms and Reports
All forms and reports are found in GU612
All definitions are found in GU612 pages (53-64)
Abbreviations (in alphabetical order)
AI-PS
Asset Integrity, Process Safety
CH
Contract Holder
EPM
Exploration and Production, Middle East
IO
Incident Owner
LFI Team
Learning from Incident Team
MSEM
Corporate S&E Manager
MSE5
Corporate Head of HSE Corporate Planning
MSE51
HSE Communication, & Business Support
MSE511
PIM and lateral learning focal point
MSE52
Corporate HSE Data Management Management
MSE54
Corporate Lead HSE Incident Investigator
3.2
Appendix 2, Related Business Control Documents and References
The following references provide useful information related to this procedure.

Process Safety Performance Indicators for the Refining and Petrochemical Industries (754),
American Petroleum Institute, 2010

Recording and Reporting Occupational Injuries and Illness (1904.7), United States Department
of Labour – click here, current
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Appendix 3, Change Log
The following is the change log for modifications to PR1418 between versions and can be used as a quick
guide to determine the changes which have been made to the document without having to read the whole
document again.
Sr. Date
No
1
09/05/14
Section
Topic
All
Changing the
name of (Red
line actions) to
Essential
Recommendation
2
08/04/14
1.6
3
31/10/14
1.6
4
31/10/14
2.0
5
03/07/14
2.2.4
Reporting
requirements
6
03/07/14
2.2.4
When to use PIM
or STOP
7
03/07/14
2.2.4
8
03/07/14
2.2.5
9
04/07/14
2.2.9
10
04/07/14
2.3.4
Page 36 of 38
Time to enter
incident into PIM
Time for IRC and
MDRIC
Roles and
responsibilities
Remarks and changes
From
To
Redline Action
Essential
recommendation
24 hours
IRC 20 days
MDRIC 28 days
All redline action in
PR1418 replaced with
Essential
recommendation
16 hours
IRC 30 days
MDIRC 42 days
Added consequence
management in the
RASCI chart
Added the
requirement for LOPC
over 50 tonnes to be
reported to
shareholders.
Added a section to
explain when STOP or
PIM should be used to
record an unsafe act
or condition
Added requirement to
inform MSE46 for AIPS incidents
Included the DROPS
calculator for well
engineering in the
determination of
potential severity for
dropped objects.
Expanded
responsibility of HSE
Teamleader to ensure
initial incident learning
is created and issued
to MSE54 for review
and distribution
Added that a list of
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11
04/07/14
2.3.4
12
03/07/14
2.3.4
14
04/07/14
2.3.6
14
03/07/14
2.3.6
Quality review of
incidents
15
03/07/14
2.3.6
Adding quality
check by local
management for
IRC presentations
16
21/04/14
2.3.6
Task 6: Incident
Review (IRC),
MD Incident
Review (MDIRC),
AI-PS Working
Party and Serious
Incident Review
(SIR) process
31/10/14
2.3.6
Types of
incidents
elevated to
MDIRC
17
Page 37 of 38
Revision:3.1
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trained Tripodians is
kept by MSE54
Corrected box
indicating that Tripod
is not required for non
work related
incidents.
Changed Tier 1 AI-PS
incidents to High value
learning AI-PS
incidents for Tripod
investigation
Revised process for
Investigation Team
Leader to upload
MDIRC actions and
HSE Team Leader to
check.
Provided guidance on
quality reviews of
minor incidents and
the process to follow
for checks
The Investigation
Team Leader shall
ensure the IRC
presentation is
created and agreed by
the investigation team
and quality reviewed
by the local PDO
management team
before submission to
the directorate IRC
focal point.
MSE54
MSE54
Incident Owner shall
inform MSE54 on
progress on the close
out of Essential
Actions
Included the specific
ability for a high value
learning LTI to be
raised for MDIRC
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review.
18
03/11/14
2.36
19
04/07/14
2.3.7
20
043/11/14
2.3.10
21
03/07/14
2.3.14
22
31/10/14
2.3.14
23
31/10/14
2.3.14
24
17/12/14
Changed
Fountain
to PIM
25
17/12/14
Included the ability to
attend MDIRC to
present additional
technology/practices
that could have
prevented a previous
fatal or HiPo
Added the two month
requirement for
MDIRC for AI-PS
incidents
Changed the minimum
requirements in an
investigation report
Changed it so the
close out of essential
recommendations is
on request of MD
Introduced the
consequence
management process
for not employing
competent
investigation resource.
Added guidance as to
what constitutes a
poor investigation fo
consequence
management
Added guidance that
consequence mgmt
can apply to the PDO
investigation team
leader
PIM (PDO incident
management
-FIM
2.3.6
Add Permit to
Work violations
to be subject to
the IRC and
MDIRC
investigation
process
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