Incident reporting

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Incident reporting Updated PR1418 procedure July
2009
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Background Why change

• Introduction of the Life-Saving rules per 1 July
  09 requires formalisation of reporting and
  investigation of suspected Life-Saving rules
  violations. Currently this is not embedded in the
  PR1418
• Objective of this communication
• Clarify details of the reporting and
  investigation process in case of suspected
  Life-Saving rules violations.

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The changes Updated Incident Reporting and Follow
up Procedure

• All suspected violations of the Life Saving rules
  whether or not an incident occurs shall be
  reported in Fountain.
• Investigation report where a Life-Saving rule
  violation was suspected, can be limited to the
  failed life saving rule, the human
  error/violation type the precondition and the
  underlying cause.
• If concluded that a Life Saving Rule was
  violated, the incident owner should record in FIM
  which Life Saving rule was violated.
• Changes have been approved by MSE and is aligned
  to changes in EP2005-170
• The focus is on prevention and not on dismissal
  of workers. The worst consequence is that someone
  is injured due to violations of our Life-Saving
  rules

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Additional information
A In the current EP standard (EP2005-170 ST) it
is not well defined how to report violations of
rules in cases there is no actual injury/damage.
Also the type of investigation and report for
these violation of rules is not explicit. To
arrive at a simple and consistent process across
EP, the procedure is updated, with focus to
Life-Saving Rules violations BTicking the box
in FIM that life saving rules was violated is
done by incident owner after the investigation
concludes that there was a violation. The
consequence management is done by HR, based on
the investigation report, local legislation and
other relevant information. C As part of the
investigation report, the preconditions under
which the suspected violation took place is
investigated. If supervisor created the
conditions, his role will be investigated as
well. D Identification of the violation type,
precondition and underlying cause of the
suspected violated rule are essential to provide
a picture under which the suspected violation
took place. It is in line with EPs incident
causation theory.
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New FIM input Updated Incident reporting and
follow up procedure In FIM incident management
Add Investigation/Immediate Cause/
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For any questions ask

• Willem Peuscher UI HSE
• or
• David Milne UI HSE