Shell Ai2 PDF

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The Main reason for Reporting and Investigating Incidents is to Learn from them.
If there has been an Incident, something went wrong!
We need to find out exactly what went wrong and why.
Once we understand this we can prevent it happening again!
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Accident/Incident Investigation
Incident Notification, Incident Notification,
Investigation and Reporting Investigation and Reporting
Why do we Report and Investigate
Accidents and Incidents?
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Incident Reports and Investigation
Findings provide the means to Learn
from Unplanned Events and help
Prevent Recurrence
An Accident is described as an Unplanned Event or an Undesired Event.
We need to understand the reason why this event occurred. Not just the actual
immediate cause, but also any underlying reasons, perhaps not immediately
obvious.
The easiest way to determine the causes, is an Investigation.
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The procedure covers the following categories:
Occupational Illness
Near Misses
Accident with Injury
Environmental Release/Discharge
Loss of Containment
Security Incident
Asset Damage
External Complaints
Non Conformance
The following Categories are covered by the procedure;
Occupational Illness Any illness caused by work or the workplace.
Near Misses Where something has gone wrong but no-one got hurt.
Accident with Injury As above but with Injury or damage to equipment.
Environmental Release/Discharge Where something went wrong and
pollution occurred.
Loss of Containment A Leak of dangerous gases or fluids.
Security Incident Any situation where a breach of Security can affect the
well-being of the organization.
Asset Damage Any Incident which results in Loss or Damage to Plant and
Equipment.
External Complaints From the Regulators, Government, The Public and
Independent Organizations.
Non Conformance Usually against an Internal or External Audit.
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Purpose: To Ensure that,
All Incidents are promptly Reported
All Incidents are Thoroughly Investigated and Root
Causes are identified so that suitable action can be
taken to prevent recurrence
All Conditions with the Potential to Cause Harm are
reported so that Remedial Action Can be taken
SBEP meet all Statutory and Group requirements
On Incident Reporting
We must ensure that;
We Report all Incidents promptly, however minor they may appear.
We Investigate all Incidents thoroughly and Identify Immediate and Root
Causes and specify the suitable actions to be taken to prevent recurrence.
We Report all Conditions with the Potential to Cause Harm so that we can fix
them immediately.
We (SBEP) must comply with all Statutory and Group requirements on
Incident Reporting.
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The Shell Risk Assessment Matrix (RAM)
This procedure uses RAM to assess the potential
outcome of an incident in a Standardized,
Qualitative manner. (See pages 32-35)
Turn to Page 32 to see a copy of the SBEP Risk Assessment Matrix (RAM)
This Matrix is used to quantify the severity of the Incident to allow decisions to
be made regarding the selection of the Investigation Team and the Reporting
Speed.
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Increasing likelihood of estimated potential consequences occurring
Potential Consequences : A B C D E
Harm to People
P
Environmental
Effect
E
Asset Damage
A
Reputation impact
R
Never heard
of in the
industry
Heard of in
the industry
Incident has
occurred in
SBEP or a
comparable
E&P company
Happens
several times
per year in
SBEP or a
comparable
E&P company
Happens
several times
per year at
location
No injury or damage to
health Zero effect Zero damage No impact 0 Low Low Low Low Low
Slight injury or health
effects (including FAC
and MTC), not
affecting work
performance, or
causing disability
Slight effect; local
environmental
damage within
fence &
subsystems
Slight damage:
no disruption to
process (costs less
than US$10,000 to
repair)
Slight impact: Public
awareness but no
public concern
1 Low Low Low Low Low
Minor injury or health
affects affecting work
performance (eg RWC
or minor LTI < a few
days, reversible health
effects)
Minor effect:
Contamination,
single complaint,
no permanent
effect
Minor damage: Brief
process disruption
(costs less than
US$100,000 to
repair)
Limited impact:
Local public concern
(eg may include
media/political)
2 Low Low Low Medium Medium
Major injury or health
effects (eg prolonged
work absence,
irreversible health
damage)
Local effect:
Limited loss of
discharges of
known toxicity,
beyond fence
Localised damage:
Partial shutdown
(costs up to
US$500,000 to
repair)
Considerable
impact: Regional
public or slight
national media/
political attention
3 Low Low Medium Medium High
1 to 3 fatalities or
Permanent Total
Disability from injury or
occupational illness
Major effect:
Severe
environmental
damage
Major damage:
Partial operation
loss, eg 2 weeks
shutdown (costs up
to US$10,000.000)
National impact:
National public
concern.
Mobilisation of
action groups
4 Low Medium Medium High High
Multiple fatalities from
injury or occupational
illness
Massive effect:
Persistent severe
environmental
damage
Extensive damage:
Substantial or total
loss of operation
(costs in excess of
US$10,000,000)
International impact;
extensive negative
attention in
international media
5 Medium Medium High High High
Harm to People
P
Environmental
Effect
E
Asset Damage
A
Reputation impact
R
Never heard
of in the
industry
Heard of in
the industry
Incident has
occurred in
SBEP or a
comparable
E&P company
Happens
several times
per year in
SBEP or a
comparable
E&P company
Happens
several times
per year at
location
and MTC), not
affecting work
performance, or
causing disability
environmental
damage within
fence &
subsystems
Slight damage:
no disruption to
process (costs less
than US$10,000 to
repair)
awareness but no
public concern
performance (eg RWC
effects)
Minor effect:
Contamination,
single complaint,
no permanent
effect
Minor damage: Brief
process disruption
(costs less than
US$100,000 to
repair)
Limited impact:
(eg may include
media/political)
work absence,
irreversible health
damage)
Local effect:
Limited loss of
discharges of
known toxicity,
beyond fence
Localised damage:
Partial shutdown
(costs up to
US$500,000 to
repair)
Considerable
impact: Regional
public or slight
national media/
political attention
Permanent Total
Major effect:
Severe
environmental
damage
Major damage:
Partial operation
loss, eg 2 weeks
shutdown (costs up
to US$10,000.000)
National impact:
National public
concern.
Mobilisation of
action groups
illness
Massive effect:
Persistent severe
environmental
damage
Extensive damage:
loss of operation
(costs in excess of
US$10,000,000)
extensive negative
attention in
international media
Harm to People
P
Environmental
Effect
E
Asset Damage
A
Reputation impact
R
Never heard
of in the
industry
Heard of in
the industry
Incident has
occurred in
SBEP or a
comparable
E&P company
Happens
several times
per year in
SBEP or a
comparable
E&P company
Happens
several times
per year at
location
and MTC), not
affecting work
performance, or
causing disability
environmental
damage within
fence &
subsystems
Slight damage:
no disruption to
process (costs less
than US$10,000 to
repair)
awareness but no
public concern
Harm to People
P
Environmental
Effect
E
Asset Damage
A
Reputation impact
R
Never heard
of in the
industry
Heard of in
the industry
Incident has
occurred in
SBEP or a
comparable
E&P company
Happens
several times
per year in
SBEP or a
comparable
E&P company
Happens
several times
per year at
location
and MTC), not
affecting work
performance, or
causing disability
environmental
damage within
fence &
subsystems
Slight damage:
no disruption to
process (costs less
than US$10,000 to
repair)
awareness but no
public concern
performance (eg RWC
effects)
Minor effect:
Contamination,
single complaint,
no permanent
effect
Minor damage: Brief
process disruption
(costs less than
US$100,000 to
repair)
Limited impact:
(eg may include
media/political)
work absence,
irreversible health
damage)
Local effect:
Limited loss of
discharges of
known toxicity,
beyond fence
Localised damage:
Partial shutdown
(costs up to
US$500,000 to
repair)
Considerable
impact: Regional
public or slight
national media/
political attention
performance (eg RWC
effects)
Minor effect:
Contamination,
single complaint,
no permanent
effect
Minor damage: Brief
process disruption
(costs less than
US$100,000 to
repair)
Limited impact:
(eg may include
media/political)
work absence,
irreversible health
damage)
Local effect:
Limited loss of
discharges of
known toxicity,
beyond fence
Localised damage:
Partial shutdown
(costs up to
US$500,000 to
repair)
Considerable
impact: Regional
public or slight
national media/
political attention
Permanent Total
Major effect:
Severe
environmental
damage
Major damage:
Partial operation
loss, eg 2 weeks
shutdown (costs up
to US$10,000.000)
National impact:
National public
concern.
Mobilisation of
action groups
illness
Massive effect:
Persistent severe
environmental
damage
Extensive damage:
loss of operation
(costs in excess of
US$10,000,000)
extensive negative
attention in
international media
The SBEP Risk Assessment Matrix asks for an assessment to be considered
in one or more of the four categories, People, Environmental, Asset Damage
and Reputation.
By looking at all the potential consequences we avoid overlooking other
issues.
For example, if we investigate a car crash, we will be looking at the Safety
Issues mainly, without thinking of the Environmental damage or the Costs
involved in damage to the vehicle, or indeed anything else.
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The Vertical Axis displays the Potential Consequence
The Horizontal Axis displays the Likelihood of the
Consequence happening
The combination of Potential Consequence and
Likelihood defines the Risk Classification
We use the Matrix to determine the level of severity of the Incident - I.e. Low,
Medium or High.
This allows us to better select the level of personnel involved in the
Investigation and the Urgency of Reporting.
When using the Matrix AFTER and Incident, we are looking at the historical
evidence for a similar incident with the SAME Consequences or outcome.
This is well explained in the Procedure.
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Using RAM :
The RAM Risk Classification will be used to determine
the seniority level of personnel involved in the
investigation and the method and speed of reporting.
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RAM Actual
Consequence/
Severity Level 4/5
RAM Risk Classification
Classification Significant High Medium Low
Investigation
Sponsor
Director accountable for
the activity (VP)
Director accountable for the
activity (VP)
Senior Manager
accountable for the activity
(e.g. Department Manager)
Functional Team Leader
Manager accountabl e for
the activity (e.g. OIM, Site
Manager)
Owner
Senior Manager
Senior Manager
Person who is accountable
for the activity (e.g. OIM,
Site Manager)
Person who is accountable
for the activity (e.g. Ops
Supervisor)
Investigation Team
Leader
Independent Senior
Manager
Independent Senior
Manager
Owner or Head of
Department not associated
with the work
Owner or Supervisor of
the work
Responsibility Table
The Responsibility table allows you to select the appropriate level of
Management or Staff to Sponsor, Own or Lead the Investigation Team.
It is a simple and easy to use system, and if used correctly in conjunction with
the RAM, can be very effective.
Using this method takes the pressure off anyone involved in making these
decisions.
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The Investigation Process
This can be broken down in to 10 Stages
Initial Actions 2. Organization
3. Investigation 4. Review
Communicate 6. Actions
Compile Report 8. Present Report
9. Report to IRP 10. Approve Report
The 10 Stages in the Investigation Process we are looking at does NOT involve
the detailed instruction on how to Investigate and Incident.
This is a separate issue and involves detailed training and assessment.
Only Trained, Competent Investigators can conduct Investigations.
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Step 1 - Initial Actions
Incident is reported to Supervisor
Supervisor makes site safe and records any changes, protects
site
Supervisor Notifies Location Manager
Loc. Manager notifies EC if appropriate
Loc. Manager notifies Relevant Managers & SBEP HSE Dept.
EC will be called out for Medivac/Medrescue, Incidents which are
not stabilising or are escalating, Incidents with a severity of 4 or 5.
EC will notify senior management as appropriate
It is important that Supervisors are aware of their responsibilities in Making
the Site Safe and recording any Changes they have made in doing so.
The Emergency Co-ordinator should be notified as a matter of routine as the
Incident may escalate and require further attention. It helps if he is prepared.
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Step 2 Organise the Investigation
Supervisor (with the Location Manager) determines level of
investigation using the RAM for risk classification.
The Incident Owner (and Incident Sponsor) must be a
manager or supervisor within the team in which the incident
has occurred. The seniority of the person must be decided
using a Classification/Seniority Table.
This task is normally carried out by the Supervisor for the area where the
Incident occurred and the Location Manager.
If there is any doubt about who the Location Manager is, go to the most
Senior Person on Site or in the Department.
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Responsibility Level Table
RAM Actual
Consequence/
Severity Level 4/5
RAM Risk Classification
Classification Significant High Medium Low
Investigation
Sponsor
Director accountable for
the activity (VP)
Director accountable for the
activity (VP)
Seni or Manager
(eg Department Manager)
Manager accountable for
the activity (eg OIM, Site
Manager)
Owner
Seni or Manager
Seni or Manager
Person who is accountabl e
for the activity (eg OIM, Site
Manager)
Person who is accountabl e
for the activity (e.g. Ops
Supervisor)
Investigation Team
Leader
Independent Senior
Manager
Independent Senior
Manager
Owner or Head of
Department not associ ated
with the work
Owner or Supervi sor of the
work
This is the same table as seen earlier and helps to make the decision easier.
Dont forget to use the RAM for classification. Dont Guess!
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Depending upon the nature of the incident and its potential
for wider learning, the Owner should consider whether to
include a Tripod Beta analysis in the investigation.
Investigations of Significant or High Risk Incidents should
include a Tripod Beta analysis. For medium risk incidents
with wider potential learning, it is recommended that a Tripod
Beta analysis be performed.
Owners should apply to the HSE Manager who will assign a
facilitator to support the investigation team in using the
Tripod Beta technique.
TRIPOD BETA is a Root Cause Analysis Programme designed to help you
understand the Underlying or Latent Causes of Incidents.
If the Incident Owner decides that the nature of the incident is one of the
following,
Significant - Always use TRIPOD BETA
High Risk - Always use TRIPOD BETA
Medium Risk - TRIPOD BETA Recommended
Wider Learning Potential - TRIPOD BETA Recommended
Owners who wish to use this technique should apply to the HSE Manager who
will assign a facilitator to support the investigation team in using the TRIPOD
BETA technique.
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Step 3 Issue Terms of Reference
The Owner initiates the investigation by appointing the Investigation
Team Leader and team members, and issuing Terms of Reference.
(See Appendix 3)
The Terms of Reference are given to the Investigation Team Leader and
to the Line Manager controlling the location. For a low risk incident the
Terms of Reference can be verbal.
The Terms of Reference will define the scope of work, list the team
members, provide objectives/guidance, specify a target date for
presentation of the investigation report to the Owner and any interim
requirements.
TERMS OF REFERENCE are issued, in writing, to communicate the
instructions to the Investigation Team in order to avoid confusion.
For Minor or Low Risk Incidents, the Terms of Reference can be Verbal.
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Step 4 Prepare the Investigation Team
The responsibility for appointing the team is with the Incident
Owner.
All incidents must be investigated by at least two people and
Roles may be combined, but the following requirements must
be met:
As per the Procedure and the Selection Table, the Incident Owner appoints
the Team Leader and Members.
The Team Leader does NOT pick his own team!
Team members, who must be trained and competent in Incident
Investigation techniques, are appointed on the basis of their Knowledge of
the Area or Process or their Specialist Skills.
TEAM means more than one person!
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A competent person must be designated as the Investigation Team Leader
and at least one person must be knowledgeable in the activity being
undertaken at the time of the incident.
Ideally, the team should include the employee safety representative from
the location involved in the incident. For environmental incidents, this
could be the location environmental representative.
If the incident involved the work of a contractor, then a contract employee,
manager or HSE representative must be included.
The team can include other persons, as required, with appropriate
knowledge, experience and independence to thoroughly investigate and
analyse the incident. (i.e. other Asset Teams or external technical
specialists)
The Owner should always try to involve any interested parties in the
investigation, such as local staff, Contractors safety reps etc.
He can call in Experts as required for their specialist knowledge and expertise.
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When the Team is notified and assembled, they should be
briefed on the background to the incident and on what is
already known from the preliminary report. Any
sketches/photographs/plans should be made available to
them.
The Team Leader will allocate tasks and deadlines between
the members; for example:
Always try to get as much information as possible, including documentation,
as this will save the team time during the investigation.
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Research into available technical information, procedures,
standards, specifications, records, etc.
Interviewing witnesses (interviewing of injured person(s) may
require a hospital visit).
Arranging equipment examination, test, reconstructions, etc.
Completing the incident report and detailed investigation
report as applicable.
In allocating Tasks to the team, the Team Leader should try to use the
strengths of the team.
For example, a good talker should carry out the interviews and someone
with an eye for detail should review the documentation.
Outside independent help can be used as required, such as test houses
and experts.
The Incident Investigation Report should be as complete and as detailed as
possible, always anticipating what questions may be asked at review.
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Step 5 Conduct the Investigation
Commence the investigation as soon as possible after the
incident. Evidence quality deteriorates with time.
Appendix 9 of the Shell Group Guide provides a checklist of
subjects to be addressed during the investigation of the
incident.
As per SHELL Corporate Guidelines, the Investigation must be conducted

by Trained, Competent Investigators using Tried and Tested Universally
Acceptable Investigation techniques.
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Step 6 Establish Findings and Make Recommendations
Establish findings and identify actions to prevent recurrence by
identifying and correcting the latent failures (underlying causes) of the
incident.
The Tripod Beta analysis tool can help determine the Active failures
(immediate causes) and Latent failures (underlying causes)
The Investigation Team Leader may consult technical experts as
necessary to determine possible corrective actions. However, the
Investigation Team Leader is responsible for deciding which of the
possible corrective actions should be recommended to the Owner.
Corrective actions will focus on reducing the risk to as low as
reasonably practicable (ALARP).
The Investigation Team can actually Recommend actions to prevent
recurrence by identifying and correcting the latent failures (underlying
causes) of the incident.
The Tripod Beta analysis tool can help determine the Active failures
(immediate causes) and Latent failures (underlying causes) and should
not be discounted as too complicated. Help will be provided.
The Team Leader is responsible for deciding which of the possible
corrective actions should be recommended to the Owner.
Corrective actions will focus on reducing the risk to as low as reasonably
practicable (ALARP).
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Step 7 Compile Report and Review with Line Managers Compile Report and Review with Line Managers
Before the incident report is submitted to the Owner, it is reviewed with
the line management of the area to confirm that the technical aspects
are correct and to agree the actions and assign Action Parties.
If the incident involves contractor employees, equipment, or contractor-
owned/operated worksites, agree on the report content with both SBEP
and contractor line management.
For a significant or high-risk incident, a more formal detailed
investigation report is also required for submission to the Shell Group
(see Appendix 5 for layout of report to be used).
It is considered a common courtesy to discuss your findings with the Line
Management of the area. This allows him to confirm that the technical
aspects are correct and to agree the actions and assign Action Parties.
Do this before submitting the Report to the Owner. Line Managers
appreciate this courtesy and they will not object to criticism if they are
aware it is coming.
Likewise with Contractors, inform and agree on the report content with both
SBEP and contractor line management.
For a significant or high-risk incident, a more formal detailed investigation
report is also required for submission to the Shell Group (see Appendix 5
for layout of report to be used).
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Step 8 Step 8 Present Report to Owner Present Report to Owner
The incident report should be formally presented to the Owner who may The incident report should be formally presented to the Owner who may
wish to include other interested parties at this stage. wish to include other interested parties at this stage.
The Owner should review the investigation, satisfy himself that the The Owner should review the investigation, satisfy himself that the
findings and recommendations for the investigation have been done, findings and recommendations for the investigation have been done,
discuss and agree the corrective actions, the person accountable for the discuss and agree the corrective actions, the person accountable for the
action, and the target date for completion. action, and the target date for completion.
The Owner is then responsible for communicating actions to the persons The Owner is then responsible for communicating actions to the persons
responsible for them, and agreeing a timely completion date. responsible for them, and agreeing a timely completion date.
The Owner may wish to include other interested parties at this stage, such as
Heads of Departments, Lead Hands etc. Anyone that he feels may benefit
from hearing the Findings of the Investigation..
The Owner should review the investigation, and if he is happy with it, agree the
corrective actions, the person accountable for the action, and the target date
for completion.
The responsibility for communicating actions to the persons responsible for
them, and agreeing a timely completion date, is the owner.
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Step 9 Step 9 Present Report to the Incident Review Panel Present Report to the Incident Review Panel
All High Risk and Significant incidents should be presented to an IRP. All High Risk and Significant incidents should be presented to an IRP.
Medium risk incidents are at the discretion of the investigation sponsor. Medium risk incidents are at the discretion of the investigation sponsor.
Low risk incidents with little potential for lateral learning do not need Low risk incidents with little potential for lateral learning do not need
presenting to an IRP. presenting to an IRP.
The investigation findings and report should be formally presented by The investigation findings and report should be formally presented by
the Owner, supported by the Investigation Team Leader. The IRP will the Owner, supported by the Investigation Team Leader. The IRP will
review and endorse the findings of the investigation (see 3.1.4). review and endorse the findings of the investigation (see 3.1.4).
An Incident Review Panel (IRP) comprises Senior Management Personnel, An Incident Review Panel (IRP) comprises Senior Management Personnel,
possibly from EPW In Houston or the Hague. possibly from EPW In Houston or the Hague.
All High Risk and Significant incidents should be presented to an IRP. All High Risk and Significant incidents should be presented to an IRP.
An IRP would not normally be convened for Medium risk incidents unless An IRP would not normally be convened for Medium risk incidents unless
requested at the discretion of the investigation sponsor. requested at the discretion of the investigation sponsor.
Low risk incidents with little potential for lateral learning do not need Low risk incidents with little potential for lateral learning do not need
presenting to an IRP. presenting to an IRP.
The investigation findings and report should be formally presented by the The investigation findings and report should be formally presented by the
Owner, supported by the Investigation Team Leader. The IRP will review Owner, supported by the Investigation Team Leader. The IRP will review
and endorse the findings of the investigation (see 3.1.4). and endorse the findings of the investigation (see 3.1.4).
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Step 10 Approve the Report
Following an IRP, the Owner ensures that any changes or
recommendations arising from the meeting are included in the report.
The Incident Report Editor carries out a quality assurance check on the
data and recommends to the Owner to Approve the report.
Any written investigation report should be attached to the incident record.
If the report is classified as confidential, then it should be sent to the HSE
Manager for secure filing.
The investigation phase is now finished, but further action is required to
communicate the learning (Section 5) and to follow-up and close out the
corrective actions (Section 6).
Following an IRP, the Owner ensures that any changes or recommendations
arising from the meeting are included in the report.
The Incident Report Editor (Probably the Health and Safety Manager)
carries out a quality assurance check on the data and recommends to the
Owner to Approve the report.
Any written investigation report should be attached to the incident record.
If the report is classified as confidential, then it should be sent to the HSE
Manager for secure filing.
The investigation phase is now finished.
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Responsibilities
SUPERVISOR
Initiates Investigation after receiving notification
Ensures that the scene of the Incident is made safe and
protected from disturbance
Records any disturbances to the scene when making it
safe
Notifies the Location Manager, OIM, Site Manager,
Vessel Master etc
The Supervisor Kicks off the process when he receives initial notification
of an incident.
He initiates investigation after receiving notification.
Makes the scene of the incident safe and protected from disturbance.
He records any disturbances to the scene when making it safe.
He notifies the Location Manager, OIM, Site Manager, Vessel Master etc.
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Responsibilities
LOCATION MANAGER
Will notify relevant Field/Department/Site Managers &
the SBEP HSE Department of the Incident.
Such notification will be given ASAP and no later that
24 hours
Where appropriate, will notify the Emergency
Coordinator (EC) to initiate any emergency response
and to make any statutory notifications
Notifies the relevant Field/Department/Site Managers & the SBEP HSE
Department of the Incident, no later that 24 hours
Where appropriate, he will notify the Emergency Coordinator (EC) to initiate
any emergency response and to make any statutory notifications
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Responsibilities
INCIDENT OWNER
Formally requests the Investigation to be
performed
Appoints the Investigation Team Leader and
Members
Draws up Investigation Terms of Reference
Ensures that Action Items are assigned to those
with the skills and expertise to carry them out
Approves the Incident and Investigation Reports
The Incident Owner formally requests the Investigation to be performed
He Appoints the Investigation Team Leader and Members and draws up
Investigation Terms of Reference
He ensures that Action Items are assigned to those with the skills and
expertise to carry them out and monitors the progress.
He approves the Incident and Investigation Reports if in agreement.
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Responsibilities
INCIDENT OWNER (Continued)
Ensures all Action Items are entered into the
Database and HSE Action Tracking System
Reviews progress reports to ensure all
outstanding action items are closed out
Take action with the action party if items not
being closed out within the specified deadlines
Present the Investigation Findings and
Recommendations to the Incident Review Panel
(IRP)
The Owner ensures all Action Items are entered into the Database and
HSE Action Tracking System
He reviews progress reports to ensure all outstanding action items are
closed out
He can take action with the action party if items not being closed out within
his specified deadlines
He will present the Investigation Findings and Recommendations to the
Incident Review Panel (IRP)
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Responsibilities
INCIDENT SPONSOR
The Incident Sponsor is the Owners Supervisor
Ensures that Owners have the necessary Competency
to fulfill their responsibilities
Convenes an Incident Review Panel (IRP) to review
Significant or Medium/High Risk incidents
Conducts an Annual review of the Incident
Investigation Process within their sphere of influence
and implements improvements
The Incident Sponsor is the Owners Supervisor or Manager
He must select Owners who have the necessary Competency to fulfill their
responsibilities
The Sponsor convenes the Incident Review Panel (IRP) to review
Significant or Medium/High Risk incidents
He must conduct an Annual review of the Incident Investigation Process
within his operation and identify any improvements
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Responsibilities
INVESTIGATION TEAM LEADER
Investigates the Incident along with appointed Team
Members
Establishes the situation before the incident
Determines what happened during the incident
Determines the Active and Latent Failures
Determines the Actions required to prevent recurrence
The Investigation Team leader is a highly responsible position and he must
ensure the following:
He must be Trained and Competent in this role.
He will control the actual Investigation and appointed Team Members.
He must establish the situation before the incident and determine what
happened during the incident.
He should determine the Active and Latent Failures and the actions
required to prevent recurrence.
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Responsibilities
INVESTIGATION TEAM LEADER (Continued)
Ensures that the Incident Report Form is accurately
completed
Produces a more detailed report for Significant and High
Risk Incidents
Helps present the findings and recommendations at the
IRP
Prepare material for communicating lessons learned to
others
The Team Leader also:
Makes sure the Report Form is accurately completed on time.
He will produce a more detailed report for Significant and High Risk
Incidents. This will have to go to the IRP.
Help the Incident Owner present the findings and recommendations at the
IRP.
Prepare methods and materials for communicating lessons learned to others
in the organisation.
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Responsibilities
LINE MANAGERS
Ensures Contractor compliance to this procedure
Ensures the incident is investigated and reported
within a defined time
Follows up and closes out actions
The Line Manager has the responsibility to see that all persons, whether
staff or contractor, follows this procedure for reporting and investigating
incidents.
He is also responsible for making sure that all deadlines and timescales are
adhered to within this procedure.
The Line Manager will see that all recommended action points are correctly
closed out within the specified timescale.
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Responsibilities
HSE MANAGER
Ensures awareness of reporting requirements for the
Group and Government Authorities
Responsible for Formal Reporting to Shell Group
Facilitates the IRP meeting
Ensures all legal reporting requirements are met
Assists in dealing with the Authorities
The SBEP HSES Manager makes sure that everyone is aware of the
reporting requirements for the Group and Government Authorities.
He is also responsible for Formal Reporting to the Shell Group and
Facilitates IRP meetings
He will also ensure that all legal reporting requirements are met and will
assist in dealing with the Authorities where required.
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Responsibilities
HSE MANAGER (Continued)
Assists the line in carrying out the investigation
Conducts Initial Reviews and Reports and confirms the
consequence rating
Ensures that root causes are properly identified and
remedial actions appropriate
Maintains Incident Report and Investigation Database.
The HSES Manager will also assist the line, where required, in carrying out
the incident investigation.
He will conduct Initial Reviews and Reports and confirm the consequence
rating.
He will also ensure that the Root Cause or Causes are properly identified and
appropriate remedial actions are put in place.
He maintains the Incident Report and Investigation Database.
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Responsibilities
VICE PRESIDENT
Oversees Investigations with high actual
consequence rating (4&5)
Chairs the Incident Review Panel Meeting
The Vice President oversees all Investigations with a high actual consequence
rating (4&5).
The Vice President will Chair the Incident Review Panel Meeting.
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Responsibilities
INCIDENT REVIEW PANEL (IRP)
Ensures that Incidents are properly Investigated and
Primary and Contributory causes identified.
Identifies opportunities for Lateral Learning and Actions
Gets agreements on follow-up Actions, Responsibilities
& Deadlines
Effectively Cascades Information to prevent recurrence
The IRP ensures that Incidents are correctly Investigated and that the
Primary and Contributory causes are also identified.
The IRP can Identify opportunities for Lateral Learning and Actions across
the company.
The IRP looks for agreements on follow-up Actions, Responsibilities and
deadlines and tries to effectively cascade information to prevent recurrence.
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Shell Internal Incident Reporting
All incidents are reported in the Incident Reporting database.
The database contains:
Details of the incident (including a full description, date, time,
place and actual/potential consequences).
Details of the consequences (including injuries/illness;
hydrocarbon releases; fires; asset damage; environmental
emissions / discharges; reputation impact).
The causes of the incident (both active and latent failures).
Actions to prevent or reduce recurrence.
All reported incidents must be recorded in the Incident Reporting Database so

that relevant information can be easily retrieved.
The database contains the following:
All details of the incident, including a full description, the date, time, place of
the incident, and any actual and potential consequences.
Details of the consequences, including any injuries or illnesses; hydrocarbon
releases; fires; asset damage; environmental emissions and discharges; and
the impact on our reputation.
Where identifiable, the Active and Latent Failures/Causes of the incident and
Actions to prevent or reduce recurrence.
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Classification Of Incidents
Now we will describe how to determine the classification of the
incident.
We will address whether an incident is work related and then
go on to describe the classification of incidents, injuries and
occupational illnesses.
This is shown in Figure 3.1 (Classification of Incidents);
All incidents need to be Classified, to help us decide how and when to

respond to each classification.
The first decision is to establish whether the incident is work related or not. It
is possible that an Injury could have been suffered at home, for example.
We have a classification Guide to assist you in this decision.
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This Chart will assist you in classifying an Incident.
It helps you to select the appropriate reporting route and speed.
It also helps you decide if the incident is work related.
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1. Establish a Work Relationship
Is the incident work related?
An incident is work related if it occurs in an area in which SBEP controls
are in place, or should have been in place.
The following activities are considered to be work related where company
controls should be in place:
All work by SBEP personnel.
All work by contractor personnel on SBEP premises/facilities.
All work by contractor personnel on non-company premises where
both SBEP and contractor management controls are required.
This is where a decision must be made regarding the term Work Related.
Is the incident work related?
An incident would be considered work related if it occurs in an area in which
SBEP has control or should have control.
The following activities are considered to be work related where company
controls should be in place:
All work by SBEP personnel.
All work by contractor personnel on SBEP premises/facilities.
All work by contractor personnel on non-company premises where both
SBEP and contractor management controls are required.
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1. Establish a Work Relationship
For company personnel, work includes overtime, attending courses,
conferences and company organised events, business travel, field visits, or
any other activity where the employees presence is expected by the
employer.
For contractor personnel, the same activities are included when they are
executed under a contract on behalf of the company. Contractor includes
all sub-contracted activities.
For SBEP Company personnel, and contractors working on our behalf.
Work includes any work and overtime, attending courses, conferences and
company organised events, business travel, field visits, or any other activity
where the employees presence is expected by the employer.
For contractor personnel, the same activities are included when they are
executed under a contract on behalf of the Company. Contractor includes
all sub-contracted activities.
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2. Determine the Type of Incident
An Incident is an unplanned event or chain of events that has, or could
have, resulted in injury or illness or damage to assets, the environment or
company reputation.
Incidents do not include operations, maintenance, quality or reliability
incidents which had no HSE consequence or potential.
The initial phase is to determine which of the following 3 categories the
incident falls into:
An Incident is an unplanned event or chain of events that has, or could
have, resulted in injury or illness or damage to assets, the environment or
Company reputation.
Incidents do not include normal, routine operations, maintenance, quality or
reliability incidents which had no HSES consequence or potential.
The initial phase is to determine which of the following 3 categories the
incident falls into:
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1. Potential Incident
A Potential Incident is an unsafe practice or hazardous situation that
could result in an incident (incident has not occurred).
Usually identified during work-site inspections, management walks, and
through incident or near miss reporting systems.
Companies should encourage the reporting and analysis of potential
incidents because they provide a valuable source of learning that can be
applied to prevent future incidents.
Potential incidents are reported and recorded in the HSE database when
there are significant learning opportunities.
A Potential Incident
A Potential Incident is any unsafe practice or hazardous situation that could
result in an incident (incident has not yet occurred).
Usually identified during work-site inspections, management walks, and
through incident or near miss reporting systems.
We must encourage the reporting and analysis of potential incidents
because they provide a valuable source of learning that can be applied to
prevent future incidents.
Potential incidents are reported and recorded in the HSE database when
there are significant learning opportunities.
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2. Near Miss Incident
A Near Miss is an incident that, under different circumstances, could
have caused illness, injury or damage to assets, the environment or
company reputation, but did not (incident has occurred).
Over exposure to hazardous chemicals, noise and other health hazards
should be considered as near misses when exposure did not result in an
identified illness.
A Near Miss Incident
A Near Miss Incident is where, had there been different circumstances,
could have caused an illness, injury or damage to assets, the environment
or Company reputation, but did not
(incident has occurred).
Any over exposure to hazardous chemicals, noise and other health hazards
will be considered as near misses where exposure did not result in an
identified illness.
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3. Injury / Damage Incident
An incident with an actual outcome leading to an injury, illness
or damage to assets, the environment or company reputation.
An Injury or Damage Incident
Any incident with an actual outcome leading to an injury, illness or
damage to assets, the environment or Company reputation.
The Incident HAS Happened.
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Plant and Equipment Damage Incident
a) Asset Damage
A direct loss of or damage to plant, equipment, tools or
materials resulting from an incident
Asset Damage
An Asset Damage Incident is where there is an actual loss in terms of
Personnel / Man Hours or Hardware.
Actual loss can be described as a Cost to the Company.
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Plant and Equipment Damage Incident
b) Fires and Explosions
Normally taken to mean any fire that necessitated the use of a
fire extinguisher or other extinguishing means, e.g. snuffing
system, shut off fuel or switch off electricity supply.
A fire with no visible flame, e.g. oil soaked insulation, should
also be included.
All flammable explosions or physical explosions should also be
included, irrespective of the extent of containment.
Fires and Explosions
Fire and Explosion losses include any type of fire and do not necessarily
involve naked flames.
I do not agree with this definition of a fire.
A fire may not require the use of a fire extinguisher, but must always be
reported and investigated as a fire.
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c) Environmental Impact
The negative impact on the environment resulting from an incident including:
Spills of oil or chemical, or other pollutant, to sea, water or ground,
regardless of size, except when a spill is contained within the site, where it
should be considered a Near Miss with potential to cause damage to the
environment.
Any excursion of oil in water from a produced water discharge in excess of
100ppm oil in water.
Accidental releases of halocarbons, i.e. CFCs, Halon (excluding routine
maintenance top ups).
Breaches of waste disposal procedures which have, or may cause,
damage to the environment and/or damage to the companys reputation.
Environmental Impact
Spills of any pollutant, to the sea, fresh water or ground, regardless of size,
must be reported and investigated.
The exception to this rule is when a spill is contained within the site, say
within a purpose built bund. In this case it should be considered a Near Miss
with Potential to cause damage to the environment.
Any oil in produced water in excess of the limit set at 100ppm oil in water
must also be reported and Investigated, as must any accidental releases of
halocarbons, i.e. CFCs.
Breaches of waste disposal procedures which have, or may cause, damage
to the environment and/or damage to the Companys reputation.
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d) Impact on Reputation
The negative impact on company reputation resulting from an
incident.
The negative impact can be in the form of adverse attention
from media, politicians or action groups, or in public concern
regarding company activities.
Impact on Reputation
Where there is a negative impact on our Companys reputation resulting
from an incident, it must be reported and Investigated.
The negative impact can be in the form of adverse attention from media,
politicians or action groups, or in public concern regarding company
activities.
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3. Class of Injury or Illness
FATALITY
A death resulting from a work related injury or occupational
illness, regardless of the time intervening between the
exposure or incident causing the injury or illness and the
death.
PERMANENT TOTAL DISABILITY (PTD)
Any work related injury that permanently incapacitates an
employee and results in termination of employment.
Class of Injury or Illness
These Classifications are a guide to help you to accurately report the
physical outcome of an Incident.
Remember the cause must be Work Related.
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OCCUPATIONAL ILLNESS
Any work related condition that is caused by or mainly caused by exposures
at work (50% or more probability that the illness was caused by exposures
at work).
Includes acute and chronic illness or diseases that may be caused by
inhalation, absorption, ingestion or direct contact.
The reporting and investigation of any occupational illness will be subject to
the consent of the injured party. Where this is withheld, the illness will be
reported as an SBEP occurrence (location and directorate not disclosed).
Details of the illness should be sent to the Group Head of Occupational
Health. The `incident owner should only investigate under instruction from
the Head of Occupational Health.
We have to make difficult decisions on whether an Illness is work related, we
will use a benchmark probability of more than 50%.
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LOST WORKDAY CASE (LWC)
Any work related injury that renders the injured person
temporarily unable to perform their normal work or restricted
work on any day after the day on which the injury occurred. In
this case any day includes rest day, weekend day, scheduled
holiday, public holiday or subsequent day after ceasing
employment.
The Shell definition is different from the OSHA definition, which
considers restricted work as a lost workday case. The Shell
definition is consistent with OGP. (formerly e&p forum).
A single incident can give rise to several lost workday cases,
depending on the number of people injured as a result of that
incident.
Note that the official absence from work begins on the Day AFTER the
Incident occurred and includes days off and weekends.
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Restricted Work Case (RWC)
Any work related injury which renders the injured person
temporarily unable to perform all, but still some, of their normal
work on any day after the day on which the injury occurred.
It is not unheard of in the Oil and Gas Industry for Companies or
Installations to keep their personnel on light duties to avoid declaring the
Incident officially.
It is important to note the an injured party must be able to carry out SOME of
their normal duties.
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Medical Treatment Case (MTC)
Any work related injury that involves neither lost workdays nor
restricted workdays, but which requires treatment by a
physician or other medical specialist (including a dentist or
physiotherapist).
Medical treatment does not include first aid even if a doctor
provides this.
The procedure outlines some examples.
This Shell rule differentiates between treatment by a physician and a
Medic.
The offshore FPSO Fluminense has a Physician in the Medic Role and
therefore he will be treated as a Medic in this case.
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First Aid Cases (FAC)
Any single treatment and subsequent observation of minor
scratches, cuts, burns, splinters, etc. that do not normally
require medical care by a physician. Such treatment and
observation is considered a first aid case even if provided by a
physician or registered professional personnel.
The procedure details some examples of first aid treatment, i.e.
one-off treatment and subsequent observation of minor injuries:
This can include any pain killing treatment or injection immediately after the
injury.
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Incident Notification, Investigation and Reporting Incident Notification, Investigation and Reporting
Reporting of Significant Incidents to Group (RAM 4 or 5)
ACTIONS TO BE TAKEN ACTION PARTY TIMING
Notify the business (EP)
To: EP HSE adviser and relevant EP Regional Business Director.
Copies to: EP Chief Executive and Group HSE adviser.
SBEP
(HSE Dept)
Within 24 hrs of incident
Prepare investigation report and Level 3 Notification
According to Group guidelines, including Tripod analysis.
Send to EP HSE adviser (copy to Group HSE adviser on request only).
SBEP
(Investigation Team)
Within one month of
incident
Review investigation report
Review report for completeness and quality of investigation, identification of
underlying causes and improvement actions.
If necessary request reporting company to improve the report.
SBEP HSE adviser Within two months of
incident
Advise classification
Advise classification of incident to the EP and Group HSE adviser. As process owner
the Group HSE adviser may review the classifications.
SBEP HSE adviser At end of review
Significant incident review meeting
A review meeting led by the EP Chief Executive will be held for all incidents resulting
in a company or contractor employee fatality, selected third party fatalities and all other
HSE incidents with a significant impact.
The review will consider the causes of the incident and actions taken and planned
Meeting participants:
Group Managing Director
EP Chief Executive Officer
Relevant EP Director
Business HSE adviser
Within three months of
incident
Debrief
Prepare action items and lessons learned and copy to participants and Group HSE
adviser.
EP HSE adviser
Within one week of review
meeting
Follow up report
This report will review implementation of action items from the investigation report and
the significant incident review meeting. Send copy of report to participants (to Group
HSE adviser on request only).
SBEP (HSE Dept)
(EP HSE adviser should remind company if
necessary)
Within one year of review
meeting
Review of follow up report
Confirm receipt and ask further questions as required.
EP HSE adviser Within two weeks of
receiving follow up report
This simple table shows the Timescale for Reporting to Group and
subsequent Actions after a SIGNIFICANT Incident. (RAM classification 4&5)
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Distribution of Lessons Learned
As the main objective of carrying out an investigation is to identify the causes
of incidents and to prevent recurrence, the biggest benefit from the
investigation is to distribute the lessons learned to other sites where a similar
incident might occur.
There are several ways of communicating lessons to others.
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Incident Database
The HSE Manager will transfer the initial incident findings and lessons
learned to target groups in the most appropriate means.
Safety Communications
One of the key roles of an Incident Review Panel is to identify significant
learning points arising from incidents and to disseminate them within the
Company.
If the IRP deem it important to share the incident information and lessons
with other parts of the organization or with the industry as a whole, then the
HSE Department will issue the most appropriate form of safety
communication/alert.
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Corrective Action Tracking
Approval of Corrective Actions
The Owner of the incident report is responsible for agreeing
corrective actions with the Investigation Team and for ensuring
they are entered into the HSE Database.
If the Owner is not satisfied that the actions recommended fully
address the active and latent failures of the incident, then the
Owner should instruct the Investigation Team to seek further
evidence and formulate further actions before the incident
report and actions are approved.
The Incident Owner must satisfy himself that the actions will actually make a
positive contribution to preventing this incident reoccurring.
If he is not happy in any way, then he is quite entitled to ask the
investigating team to reconsider their findings.
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Notification of Action Parties
Once the Owner approves the incident report and corrective
actions, actions will be emailed to the Action Parties by the HSE
Manager. Where this is not possible (e.g. due to the Action
Party not having email access), then the Owner shall ensure
that the Action Party is notified by sending them a paper copy of
the action item.
The Incident Owner must specify not just the action items to be addressed
but also a time table for completion.
The target timescale for close out of the actions must be realistic and
achievable, and where at all possible, measurable.
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Corrective Action Implementation and Closeout
The Action Party implements the action through to completion. The Action
Party may also be required to update the Owner of progress. On
completion, the Action Party will inform the HSE Manager so that the action
can be marked as complete in the action tracking system.
Closeout Monitoring
The Owner monitors the progress of actions against their incident reports
and ensures that corrective actions are completed. Each Department should
establish a process for the periodic review of action status.
It is helpful if the person monitoring the Action Tracking System issues
bulletins to all departments with outstanding action items to make them aware
and remind them of their deadlines.

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Page 1

As per SHELL Corporate Guidelines, the Investigation must be conducted

All reported incidents must be recorded in the Incident Reporting Database so

All incidents need to be Classified, to help us decide how and when to

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