Roles and Resp Conducting Investigation

7/27/2019 Roles and Resp Conducting Investigation

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Conducting successful investigations





Task 2: Incident investigation terms of reference

Incident investigations require a term of

reference (ToR) be formalized unless they are

level 2 or below or minor potential



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



Task 4: Conducting the Tripod Beta

(4/5 actual, High Potential or Tier 1)

Require a Tripod Beta analysis to identify the

underlying causes



Task 5: Statement of Fitness for Process Plant or

Equipment

Before restarting a process facility the following criteria

shall be confirmed as having been met

The basic and immediate physical cause(s) of the

incident are understood.

Corrective actions required for restart are completed

and address the incident causes.



Task 5: Statement of Fitness for Process Plant or

Equipment

• 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 this incident.

• Statements of Fitness requirements specified in

SP-2062 have been met where applicable.



Task 6: Incident Review(IRC)/MD Incident Review (MDIRC)

and Serious Incident Review (SIR) process

Local

review

Directorate

IRC

MDIRC SIR

High potential,level 4/5, Tier 1 x x x x

Medium potential or level 3 x x

Unauthorised overdue medium

potential or level 3

x x x

Low potential or level 1/2 x



Task 7: Report writing

For low potential or level 1 or 2 incidents the investigation report

should be no more than one page long.

The report shall contain as a minimum:

Place, time, date, and description of the incident;

Classification of incident (incident type) Actual and Potential Consequences;

Why the incident occurred

Wider management issues identified

Action items to prevent reoccurrence.

The report shall clearly highlight the key findings identified from

the investigation




For more serious incidents compile a more detailed Incident

investigation Report

Include an executive summary

The report shall contain as a minimum:

Place, time, date, and description of the incident;

Key findings

Supplementary findings

Actual and Potential Consequences;

Details of barriers, (Barrier or active??) failures,

underlying causes and latent failures

Action items to prevent reoccurrence.




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 incidentinvestigation report.




SMART - Action items - 5 Redlined Actions

Specific (S) 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?

Time bound (T) By when do you want to achieve the set objectives?



Task 9: Fountain Information Management (FIM)



Task 10: Close out of remedial actions

Discuss



Task 11: Learning from incidents

Poster to educate the people at risk

Management learning’s from the investigation to enable the

management to review their procedures and HEMP to avoid it

happening again



Task 12: Serious Incident Review Committee (SIR)

The Managing Directors is required to present the learning's

from the most serious incidents, including actual 4/5 or high

potential to PDO shareholders on at least an annual basis



Roles and Resp Conducting Investigation

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