VALERO – KROTZ SPRINGS
S.H.G. # 9
Page 1 of 18
Revised 01/14/04
Effective 02/01/04
INCIDENT INVESTIGATION AND REPORTING GUIDELINE
1.0
PURPOSE
The purpose of this document is to provide guidance for effectively reporting, investigating
and analyzing all incidents and near misses to determine the cause(s) and associated
corrective actions to prevent recurrence.
2.0
SCOPE
This guideline applies to all Valero employees and contract personnel for all types of
incidents, including work related employee injuries and illnesses, while on duty inside or
outside the facility, process related equipment failures, fires, environmental incidents,
production/ product loss or contamination and near misses, and the defeating of
emergency shut down device (except as outlined in Section 8.0).
This S.H.G. will apply to all Valero and contract personnel. All contractors will be
required to report all incidents to their Valero representative immediately. If the incident
involved the contractor's work, a contractor might be required to provide a
representative to participate on and/or support any investigation team. As required by
the OSHA regulations and as required to assist in the investigation, such representative
may need to have expertise with contractor's work which is involved in the incident.
This procedure also applies to unexpected or major repairs that are required during
turnarounds or shutdowns, or when the inspection group discovers unusual equipment
deterioration.
3.0
DEFINITIONS
Emergency Shutdown Device – Any device designed specifically to shut down, bypass,
or remove a piece of equipment from service when operating conditions or operator inputs
dictate.
Minor Incident – Minor impact on life, property or environment. Economic impact and
media exposure is insignificant. Corrective action to prevent recurrence is obvious and can
be quickly implemented.
Moderate Incident - moderate impact on life, property or environment. Moderate
economic impact and liability exposure to the company. Some limited media interest
and/or community involvement. Incident may require full or partial activation of the
Corporate Emergency Operations Center. Corrective actions are not immediately obvious
therefore an incident investigation is required.
VALERO – KROTZ SPRINGS
S.H.G. # 9
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Effective 02/01/04
Major Incident - Major incident resulting in serious impact on life, property or
environment. Substantial economic impact and/or excessive liability exposure for the
company. Adverse media coverage, lawsuits or negative community relations. Incident
likely requires activation of the Corporate Emergency Operations Center and possible
deployment of Corporate Field Support Teams. Corrective actions are not immediately
obvious. Formal investigation utilizing a systematic method for identifying root causes is
required and could involve corporate resources.
Incident Investigation Team - A team that will investigate a particular incident. This team
may be comprised of supervisors, hourly employees, safety personnel, environmental
personnel, technical personnel, and others as needed. Team will not normally consist of
any personnel directly involved in the incident. Teams will usually contain members from
multiple departments in the refinery. At least one member of the team must be trained in
and competent at Root Cause method investigations.
Investigation Team Leader - A member of the investigation team who will be responsible
for conducting the investigation and overseeing the incident report preparation and
issuance.
Near Miss - An undesired event that, under slightly different circumstances, could result in
physical harm to personnel, equipment damage, hazardous material release or product
loss.
4.0
REPORTING REQUIREMENTS

Employees will make initial reports to their immediate supervisor as soon as an
incident/injury occurs or is noticed. In almost all cases, this report will be made
during the work shift that the incident/injury occurs. If an injury is noticed after the
employee leaves work, he/she should notify their supervisor by phone as soon as
possible.

The immediate supervisor or designee will complete items 1 through 12 on the
First Report of Incident Form included in Attachment 1.

The preparer of the report or designee shall start collecting statements and
gathering data within 24 hours of the incident. This constitutes the initial phases of
the investigation.

If it is determined that a formal team investigation is required, the investigation
team will be selected as soon as possible, but not later than 72 hours following this
determination (see attachment 2). If the incident is clearly Moderate or Major or if
there is any doubt, the Supervisor should notify the Department Director, Safety
Manager, and Plant Manager.
VALERO – KROTZ SPRINGS
S.H.G. # 9
Page 3 of 18
Revised 01/14/04
Effective 02/01/04
5.0
RESPONSIBILITIES
Individual/Group
Assigned Responsibilities
Immediate
 Complete items 1-12 on the First Report of Incident Form (Attachment 1).
Supervisor
 If necessary, complete the Environmental Notification Supplement and
Or Designee
make notifications to Environmental and/or I&E Department as needed.

Notify the Owning Area Supervisor and/or Shift Supervisor.
Owning Area
For Incidents requiring a formal team investigation:
Supervisor
 Once the area is made safe, maintain the area as found to preserve
Or
evidence until the investigation team leader releases the area. (As required,
Shift Supervisor
pictures may be taken of the area before changes are made. A camera is
available in the Shift Supervisor's Office, Safety or Training Office and for
this purpose.)
 Immediately begin collecting written statements from all persons involved in
the incident or those who may have information concerning the incident. All
statements will be dated and signed by the individual before they leave the
facility.

Collect any other pertinent information that may be needed in the
investigation. (See Attachment 2 Incident Investigation Pre-meeting
Checklist.)
 Inform affected employees and contractors of the possibility of being alcohol
and/or drug tested within eight hours of the incident.
Operations

Determine whether a Team or Owning Area incident investigation is
Director or
required.
Designee

If a team investigation is required, designate an investigation team
consisting of three or more of the following: (one or more of which should
be an impartial person from a department not involved in the area in
which the incident occurred)
∙ The Immediate Supervisor or Lead Technician(s) of the area where the
incident occurred
∙ Shift Supervisor
∙ A Maintenance representative
∙ A Safety Department representative
∙ A Technical Service representative
∙ An Environmental Department representative
∙ Other hourly and/or salaried employee(s), if necessary, who are
knowledgeable of the process involved
∙ Specialized expertise if needed (e.g. process safety, inspector, etc.)

Review and approve the final incident investigation reports.

Follow-up on open recommendations in their area.
VALERO – KROTZ SPRINGS
Owning Area
Director or
Designee
Investigation
Team

Review and approve Owning Area Investigation Report (First Report of
Incident, Section 14)

Once the team membership is set, all members should be present for each
meeting.
Subsets of the full committee may convene to work on specialized aspects of
more involved incident investigations.
Meet to initiate the investigation as soon as possible but no later than 72
hours after the incident has been determined to require a formal team
investigation (including weekends and holidays).
Set the time and place for the meetings to begin and notify all members.
State the reason for the meeting.
Ask the involved individuals (employees and/or contractor) to tell what
happened.
Request outside resources, if required.
Lead the discussion at the formal investigation, utilizing a formal root cause
analysis system.
Lead the team in completing the incident investigation. The team leader will
conduct the investigation until the team can:
∙ Describe the incident
∙ List the results of the investigation
∙ List the direct and contributing causes
∙ Develop recommendations which, when implemented, will help assure
that the incident will not recur and for each recommendation indicate the
person responsible for the follow-up and estimated date of completion
Note: If an involved employee cannot be present, management should have
two investigation team members talk with the employee as soon as possible.
Maintain and update the Incident Investigation Recommendations
Tracking records.
Maintain records of all completed incident investigations and
documentation of closure of all recommendations.
Prepare Safety Bulletins whenever it is appropriate to circulate safety
information about a minor incident.
As soon as Valero or the contractor determines that there is a
substantial likelihood that an incident that is being or will be investigated
under this S.H.G. is likely to lead to a legal proceeding involving the
contractor or the contractor's personnel, then it shall notify the other's
representative of such determination.
Distribute final report.
Report incidents to their immediate supervisor immediately.
Be available and provide information to the investigation team.
Do not leave the facility until released by the Owning Area or Shift
Supervisor.
Cooperate with request for drug or alcohol screening.


Team Leader







Environmental &
Safety Affairs




Individual(s)
involved in an
Incident
S.H.G. # 9
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Effective 02/01/04





VALERO – KROTZ SPRINGS
6.0
FIRST REPORT OF INCIDENT
6.1


S.H.G. # 9
Page 5 of 18
Revised 01/14/04
Effective 02/01/04
First Report Preparer
The First Report of Incident Form (yellow sheet) is used for any Safety or Environmental
incidents or any near miss. This form is to be completed before the end of the shift
whenever possible. Additional instructions to the reporting Supervisor are located on the
back of the form. Additionally, a green sheet must be filled out for environmental incidents
and attached to the First Report of Incident.
After items 1 through 12 on the form are completed, a copy should be sent to the Safety
Department (and another copy sent to the Environmental Department if the incident has
environmental impact), and the original should be sent to the Operations Director (or a
copy of the entire form should be sent if an environmental incident remains open at the
end of the shift). A copy must also be sent to the Owning Area Director/Manager if
Operations is not the Owning Area.
6.2






Operations Director
The Operations Director will determine whether a Formal Team Investigation or an
Owning Area Investigation is required.
Monitor status of the incident reports and investigations.
6.2.1 Formal Team Investigation
If a Formal Team Investigation is required, the Operations Director will, in
consultation with other departments, assign the Investigation Team leader and
members.
Forward the original form to Safety Department, with a copy to the Owning Area.
Review the draft Investigation Reports.
6.2.2 Owning Area Investigation
Forward the original form to the Owning Area Manager or Director, with a copy to
Safety Department.
6.3

Safety Department
Enter the incident information from the First Report of Incident, including any action
items identified, into the incident tracking system. Enter investigation reports and
action items into the Incident Tracking System.
6.4



Owning Area Manager or Director (Owning Area Investigations)
Determine the appropriate investigation methodology.
Ensure that the investigation is conducted by appropriate personnel.
Review the Owning Area Investigation (First Report of Incident, Section 14) for
accuracy and to ensure that the report does not contain the names of personnel
involved in the incident, and the incident description includes facts only (no
inferences or speculations).
Ensure that action items address the incident causes.
Within ten calendar days of the incident, the Owning Area Investigation information
(Section 14 of the First Report of Incident form) must be completed, reviewed and
signed by Owning Area Management, and forwarded to the Safety Department.


VALERO – KROTZ SPRINGS
S.H.G. # 9
Page 6 of 18
Revised 01/14/04
Effective 02/01/04
7.0
FORMAL TEAM INCIDENT INVESTIGATION REPORT COMPLETION AND
DSTRIBUTION

The Team Leader will coordinate the completion of the incident investigation report using
the Root Cause analysis software report format (alternately, Attachment 4 format may be
used). The report will not contain the names of personnel involved in the incident, and the
incident description will include facts only (no inferences or speculations). A draft report will
be completed electronically, printed, reviewed and approved by all team members.
Incident numbers are obtained by calling the Safety Office.
NOTE: If a root cause cannot be determined based on the information available, the
Incident Investigation Report will be based on the known information. Recommendations
will be crafted to help prevent future similar incidents.





Members of the incident investigation team will initial a copy of the draft report.
A hard copy and electronic copy (on a diskette) of the draft report is sent to the Director of
Operations for review and circulation to appropriate Managers/Directors for signatures.
Changes by the Directors/Managers will be sent back to the investigation team for initialing
prior to issuance.
The Department Director/Manager will submit the incident investigation report to the Plant
Manager, HS&E Director, and other Directors/Managers as specified for review and final
approval.
The final approved report will be sent to the Safety Department for distribution and
electronic filing. Distribution will include:
∙
∙
∙
∙
∙
∙

Plant Manager and all Department Directors/Managers
All bulletin boards
Investigation team members (including a contractor if represented on the
investigation team)
Personnel who have been assigned responsibility for recommendations
Appropriate personnel at other refineries
Personnel in corporate loss control & executive management.
All follow-up documentation will be kept on file in the HS&E Department for at least five (5)
years from the date of the incident along with copies of information, statements, permits
and other data collected during the investigation.
VALERO – KROTZ SPRINGS
S.H.G. # 9
Page 7 of 18
Revised 01/14/04
Effective 02/01/04
8.0
Defeat an emergency shut down device

The First Report of Incident Form (yellow sheet) may be required to report the defeating of
an emergency shut down device. The table below provides guidance on when a First
Report is to be generated.
IS FIRST REPORT REQUIRED?
METHOD USED TO DEFEAT SHUTDOWN
Operational Status
Of Equipment
Mechanical
Software
Electronic
Scheduled Startup
Yes
Yes, Unless Recurring
Audible Alarm
Yes, Unless Momentary
Switch is used
Scheduled Shutdown
Yes
Yes, Unless Recurring
Audible Alarm
Yes, Unless Momentary
Switch is used
Normal Operations
Yes
Yes
Yes, Unless Momentary
Switch is used
Yes, Unless Recurring
Yes, Unless Momentary
Audible Alarm
Switch is used
The First Report is to be completed as soon as possible but no later than the end of the shift.
Additional instructions to the reporting Supervisor are located on the back of the form.
After items 1 through 12 on the form are completed, the form should be routed as directed on the
form for all incidents.
Scheduled PM Work
Yes
9.0
SAFETY BULLETIN

The bulletin will contain general and specific safety information and lessons learned
from incidents and/or near misses. Typically these are written for incidents with easily
identified causes and when there are minimal follow-up actions.
A Safety Bulletin can be initiated by any individual or group and submitted to HS&E
Department.
The Safety Bulletin will be reviewed, sent to affected Directors/Managers for approval
and distributed by the HS&E Department.
See Attachment 5 for one possible format of a Safety Bulletin. The distribution of the
Safety Bulletin will be as follows:



∙
∙
∙
∙
∙
Plant Manager and Department Managers
All bulletin boards
Appropriate contractor representatives
Appropriate personnel at other refineries
Personnel in corporate loss control & executive management
VALERO – KROTZ SPRINGS
S.H.G. # 9
Page 8 of 18
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Effective 02/01/04
10.0
FOLLOW-UP

Supervisors will determine which Safety Bulletins and Incident Investigation Reports are
appropriate to review with their personnel.
Formal Team Incident Investigation Reports will either be circulated or posted within
appropriate areas.
Once a recommendation has been completed, the responsible person will notify the Safety
Office Clerk in writing or E-mail that the item has been addressed. Appropriate
documentation/evidence of closure will be maintained in the HS&E files for each
recommendation.
A log of the incomplete recommendations is maintained by the Safety Office. A report is
reviewed monthly at a Managers/Directors Staff Meeting.



VALERO – KROTZ SPRINGS
S.H.G. # 9
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Revised 12/17/03
Effective 02/01/04
Attachment 1
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S.H.G. # 9
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S.H.G. # 9
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(Attachment 2)
INCIDENT INVESTIGATION PRE-MEETING CHECKLIST
(IF FORMAL ROOT CAUSE ANALYSIS SYSTEM IS NOT USED)
1.
Initiate the Investigation
A.
B.
C.
D.
E.
2.
Date: ___________
Time: __________
Obtain incident investigation number from Safety Department.______
Set a meeting time
_______
Arrange for a meeting place
_______
Notify appropriate managers
_______
Notify team members
_______
Information Collection - Collect information pertinent to the investigation (indicate N/A if not
applicable).
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
Copies of the First Report of Incident
Photos of the area and equipment involved
Statements from those involved and/or eyewitnesses
Copies of any permits issued
Applicable procedures
Applicable safety rules
Unit operating logs, chart recorders information
Maintenance records on equipment
Previous process Hazard Analysis file
Piping and instrument diagram
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
3.
Review incident - be prepared to describe details.
_______
4.
Start to prepare Incident Report.
_______
5.
Use Attachment 3 for guidance on information gathering, analysis and determination of
corrective actions.
_____
VALERO – KROTZ SPRINGS
S.H.G. # 9
Page 14 of 18
Revised 12/17/03
Effective 02/01/04
(Attachment 3)
ADDITIONAL GUIDANCE ON INFORMATION GATHERING, ANALYSIS
AND DETERMINATION OF CORRECTIVE ACTIONS
(IF FORMAL ROOT CAUSE ANALYSIS SYSTEM IS NOT USED)
I.
Additional Guidance on Information Gathering
The following considerations may also be useful in determining direct and contributing causes of
an incident:
A.
Positions
1.
2.
3.
4.
5.
B.
Results of energy contact (e.g., marks, debris, distortions)
Did existing controls work or were they adequate? (Look at equipment guards and
access, automatic safety controls, safe work procedures, personal protective
equipment, materials of construction, etc.)
Witness locations
Location/orientation/condition of debris or original equipment
Sources of distraction
Parts Evidence
1.
Equipment that may have
a.
b.
c.
d.
e.
f.
g.
2.
3.
4.
5.
C.
Malfunctioned
Been misfitted/poorly installed
Been overstressed
Been poorly maintained
Been faulty in design
Been substandard for the application
Been improperly operated or used
Contamination
Improper, defective tools
Control system records or charts
Material spills/signs of leakage
Factors Potentially Affecting Individuals
1.
2.
3.
4.
5.
6.
Level of training/job experience/lack of supervision
Judgement factors/understanding of training or procedures and clarity & availability
of training or procedures
Routine or non-routine work
Emotional factors/state
Overall job satisfaction
Medications/drugs
VALERO – KROTZ SPRINGS
II.
INFORMATION ANALYSIS
A.
Define Sequence of Events
1.
2.
3.
4.
B.
S.H.G. # 9
Page 15 of 18
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Effective 02/01/04
Initiating event
Intermediate responses/actions (man and machine)
Final step resulting in perceived incident
Sequence of events in response to the incident
Analyze Each Event
1.
Initiating Event
a.
Why did it occur?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
b.
2.
Human error or unsafe act?
Mechanical failure?
Miscommunication or poor information?
Poor design?
Program failure?
Poor procedure?
Failure to follow procedure?
Inadequate training or equipment
Unsafe conditions?
Unrecognized hazard?
What could have been done to prevent its occurrence?
Subsequent Events
a.
b.
c.
Examine each subsequent step for action and response
Determine whether each step was appropriate or inappropriate
For each inappropriate action/response, determine:
1.
2.
d.
Why it occurred?
What could be or have been done to assure an appropriate
response or more minimal impact if the event recurs
Look for omissions or failures of programs and corrective actions required
to prevent similar occurrences
VALERO – KROTZ SPRINGS
III.
CORRECTIVE ACTIONS DETERMINATIONS
A.
Human Error Prevention
1.
2.
3.
4.
5.
6.
7.
B.
Improve Training of Designer or Provide Better Data
Revise to Meet Design Codes/Standards
Determine Appropriate Design Codes/Standards
Process Hazards Analysis (PHA) Considerations
1.
2.
F.
Training
Improved Recordkeeping
Change in Method of Information Presentation
Change in Procedure
Poor Design
1.
2.
3.
E.
Preventive Maintenance Change
Change in Design/Specification
Change in Material
Change in Installation Procedures
Miscommunication/Poor Information
1.
2.
3.
4.
D.
Training
Change in Procedure
Change in Design
Change in Information Presentation
Elimination of Distractions
Change in Program
Disciplinary Actions if Deliberate
Mechanical Failure
1.
2.
3.
4.
C.
S.H.G. # 9
Page 16 of 18
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Effective 02/01/04
Is a formal PHA study needed of this system?
Revise PHA Protocols/Procedures to Better Anticipate in Future
Program Failure
1.
2.
3.
Revise Facility Procedures
Improve Routine Internal Assessments of Program (where appropriate)
Training
VALERO – KROTZ SPRINGS
S.H.G. # 9
Page 17 of 18
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Attachment 4: Alternate Report Format
VALERO REFINING
INCIDENT INVESTIGATION REPORT
No. KS-XX-XX
(Number Obtained From Safety Department)
To:
Distribution
From: Investigation Team Leader
Date: Date of Report
DESCRIPTION OF INCIDENT (Accident date, place, time)
Describe the incident clearly and precisely. Use photos or sketches where appropriate.
Description should be concise, chronological and understandable to anyone.
RESULTS OF INVESTIGATION
Indicate the date and time that the incident investigation was initiated. List, in logical
order, pertinent facts uncovered in the investigation. Again, the results should be concise
and universally understandable.
DIRECT AND CONTRIBUTING CAUSES OF THE INCIDENT
Specify the causes of the incident and explain:
Personal protective equipment
Position of people
Actions of people
Tools and equipment
Procedures
Training
Etc.
RECOMMENDATIONS AND CORRECTIVE ACTIONS TO PREVENT RECURRENCE
Recommendations made by the investigation team to prevent a recurrence of the
incident. Concisely list immediate and long-term actions. For each action, indicate the
person responsible for the follow-up and estimated date of completion.
INVESTIGATED AND APPROVED BY
List of the investigation team members. Team members must initial the final report prior to
issuance.
APPROVED BY
Includes the Plant Manager and other Department Managers as needed. This will normally
include the Directors of Operations, Maintenance and HS&E. However, if a person is assigned
responsibility for a corrective action, that person’s Manager/Director will also be listed as a signee.
VALERO – KROTZ SPRINGS
S.H.G. # 9
Page 18 of 18
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Effective 02/01/04
Attachment 5
Valero SAFETY BULLETIN
Krotz Springs Refinery
WHAT OCCURRED:
WHAT RESULTED:
SIGNIFICANT CAUSES:
PRECAUTIONS TO PREVENT RECURRENCE:
AREA REPORTING:
DATE:
COMPLETED BY:
APPROVED BY:
Plant Manager
DATE POSTED:
DATE TO BE REMOVED: