main contractor name – lti# - date of incident incident details pdo directorate/dept: (e.g. osd...
DESCRIPTION
Main contractor name – LTI# - Date of incident Sequence of events/timeline You can use any format for a time line, or sequence of events, e.g. a list, a diagram or tables, which ever you believe best fits your investigation. Only include events which are key to explaining what happened. 3 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides Guidance NoteTRANSCRIPT
Main contractor name – LTI# - Date of incident
Incident details
PDO directorate/dept : (e.g. OSD _OSO_OSO4)
Contractor name/number: (subcontractor-contractor-PDO)/CXXXXXX
Incident owner : Name / Ref Ind
Location : Area / unit - (road/yard/station/rig/hoist/plant etc)
Incident date & time : (d/m/yr) / (24 hour clock) – advise if estimated
Incident type : Fatal, LWC, high potential, significant incident etc
Actual severity rating : Number (1-5) / letter (P, E, A,R) – from RAM
Potential risk rating : Letter (A-E), Number (1-5)/letter (P, E, A,R) from RAM
Names of any IPs : Names of the injured people (for fatality add marital statues with kids age)
Description of injury/damage: Worst injuries (fractures, head injury, amputation etc)/damage
FIM ID : Number assigned in FIM
Immediate cause : Short description of what caused harm
Key latent mgmt failure : Key latent Mgmt failure from conclusion slide
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Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides
Main contractor name – LTI# - Date of incidentDescription of the incident………………….
This should be free text writing and include the relevant facts explaining what happened to all the relevant parties:
1.Leading up to the incident , 2. Immediately before the incident, 3. During the incident, 4. Immediately after the incident ,
5. In the emergency escalation of the incident.
The description should be in sufficient detail to allow a person who does not know anything about the incident to imagine it. It should only be about what happened and not why it happened. Do not include investigation findings here, simply describe the incident as the investigation has shown it happened.
Delete all Guidance Note text from your presentation – its there to help and once used it should not be included in your presentation.
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Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides
Guidance Note
Main contractor name – LTI# - Date of incident
Sequence of events/timeline
1...2...3...4...
•You can use any format for a time line, or sequence of events, e.g. a list, a diagram or tables, which ever you believe best fits your investigation.
• Only include events which are key to explaining what happened.
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Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides
Guidance Note
Main contractor name – LTI# - Date of incidentPhotographs, diagrams & sketches
• Only include photos or sketches if they add value explaining the incident or causes.
• Each photo/sketch must be labeled to explain what it is and why it has been shown.
• Ensure photos are labeled to explain context (e.g. road looking in direction of; historical photo of plant before fire etc).
• Ensure all photos are evidenced to the investigation. (have formed part of the investigation)
• Ensure all photos are of suitable clarity.
• Include a maximum of four photographs/sketches per page.
• Do not exceed three pages of photographs, diagrams and sketches
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Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides
Guidance Note
Main contractor name – LTI# - Date of incident
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Key findings
Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides
Main contractor name – LTI# - Date of incident
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Immediate Cause:
Underlying Cause:
Latent management system failures:
Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides
Main contractor name – LTI# - Date of incident
Barrier Broken / Missing
Structural Integrity Process
ContainmentIgnition Control Detection
Systems Protection Systems
ShutdownSystems Emergency
Response Life Saving
Structural Integrity Process
ContainmentIgnition Control Detection
Systems Protection Systems
Emergency Response Life
Saving
Structural Integrity Process
ContainmentIgnition Control Detection
Systems Protection Systems
Emergency Response Life
Saving
Structural Integrity Process
ContainmentIgnition Control Detection
Systems Protection Systems
Emergency Response Life
Saving
- Competency Issue- Procedure Adherence
Piping Systems
Manually Overridden
Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides
Main contractor name – LTI# - Date of incidentEssential remedial actions taken:
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Remedial action No: 03 Status Completed/Ongoing
Causation No
Action taken
Action party Reference Ind. Target date
Remedial action No: 04 Status Completed/Ongoing
Causation No
Action taken
Action party Reference Ind. Target date
Remedial action No: 05 Status Completed/Ongoing
Causation No
Action taken
Action party Reference Ind. Target date
Main contractor name – LTI# - Date of incidentRecommendations for MDIRC/IRC endorsement:
.
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Recommendation No 01 Status Endorsed/Not endorsed
Causations NoRecommendation
Action party Reference Ind. Target date
Revised recommendation after IRC review
Recommendation No 02 Status Endorsed/Not endorsed
Causations NoRecommendation
Action party Reference Ind. Target date
Revised recommendation after IRC review
Main contractor name – LTI# - Date of incidentRecommendations for MDRIC endorsement:
.
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Recommendation No 03 Status Endorsed/Not endorsed
Causations No
Recommendation
Action party Reference Ind. Target date
Revised recommendation after IRC review
Recommendation No 04 Status Endorsed/Not endorsed
Causations No
Recommendation
Action party Reference Ind. Target date
Revised recommendation after IRC review
Main contractor name – LTI# - Date of incident
Directorate IRC Minutes: Date held: Feedback to Incident Owner: (Depth, accuracy, quality, robustness, feasibility and appropriateness of investigation findings and recommendations)1.…2.…3.…
Query raised:(raise questions which have not been adequately answered in the investigation or presentation)1....2.…3.…
Additional recommendations:(Including, revisiting the investigation to improve quality, adding any key recommendations that are requested by the directorate management but have been missed in the investigation, or removing inappropriate recommendations)1.…2.…3.…
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Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides
Main contractor name – LTI# - Date of incident
Tripod Tree (include copy of the Tripod tree flow diagram for all
4/5 incidents or High Potential)
Investigation reports requiring a Tripod must confirm that the findings and recommendations match the Tripod findings
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Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides
Main contractor name – LTI# - Date of incident
Supplementary investigation findings:The findings are points to note but were not causational in the incident
1.People, training, age, experience, nationality, medical conditions, disciplinary record etc
2.Equipment, type, serial number, maintenance, inspection, failings, appropriate for use etc
3.Activities at the time of the incident, lifting, driving, commuting, drilling, POOH etc
4.Relevant environment, workplace conditions, weather, lighting, floor surface, dust, cramped etc
5.Operational management ,supervision, TBTs, SJPs, SWPs, STOP, availability on site etc
6.Contractual management,audits, CH involvement, defaults, inspections, visits, issues, sub contractor management
7.HEMP,review, appropriateness to the incident, is it used, how is it translated into action
8.Previous relevant incidents/learnings,what, where, were they aware of it, were controls introduced
9.Emergency response,how effective was it, did it impact on the severity?
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Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides
Main contractor name – LTI# - Date of incident
Date: Incident title
What happened?Very short description of what happened
Your learning from this incident..(This must solely relate to the people at risk of harm or people at risk of causing
the harm)
Title (e.g. Drivers)
• Learning points for them from the investigation
Strap line – (keep short and punchy)
Photo explaining what was done wrong
Photo explaining how it should be done right
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PDO safety advice
Main contractor name – LTI# - Date of incident
As a learning from this incident and ensure continual improvement all contractmanagers are to review their HSE HEMP against the questions asked below
Confirm the following:
•1•2•3•4•5
Make a list of closed questions (only ‘yes’ or ‘no’ as an answer) to ask other contractors if they have the same issues based on the management or HSE-MS failings or shortfalls identified in the investigation. Pretend you have to audit other companies to see if they could have the same issues.
Management actions
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