incident notification, reporting and follow-up procedure part 1

Petroleum Development Oman LLC Revision: 3.1Effective: Jan-14

Petroleum Development Oman L.L.C.

Document Title: Incident Notification and Investigation

Document ID PR-1418

Document Type Procedure

Security Un-Restricted

Discipline HSE

Owner MSE5

Issue Date 14 November 2013

Version 3.1

AUTHORISED

of 32 'PR1418 V.3.1' Procedure Printed 06/01/14

The controlled version of this CMF Document resides online in Livelink®. Printed copies are UNCONTROLLED.

Petroleum Development Oman LLC Revision:3.1Effective: Jan-14

This page was intentionally left blank

of 38 'PR1418 V.3.1' ProcedureThe controlled version of this CMF Document resides online in Livelink®. Printed copies are UNCONTROLLED.

Keywords: This document is the property of Petroleum Development Oman, LLC. Neither the whole nor any part of this document may be disclosed to others or reproduced, stored in a retrieval system, or transmitted in any form by any means (electronic, mechanical, reprographic recording or otherwise) without prior written consent of the owner.


i Document AuthorisationAuthorised For Issue

Document Authorisation

Document Authority

Head HSE Corporate Planning

Document Custodian

Lead Incident Investigoter

Document Controller

Lead Incident Investigoter

Younis Hinai

Ref. Ind::MSE5

Date: 06/01/2014

Talib Shaqsi

Ref. Ind::MSE54

Date: 06/01/2014

Talib Shaqsi

Ref. Ind: MSE54

Date: 06/01/2014



ii Revision HistoryThe following is a brief summary of the 4 most recent revisions to this document. Details of all revisions prior to these are held on file by the issuing department.

Version No. Date Author Scope / Remarks3.1 Jan

2014

Chris Evans MSE54 Various upgrades including investigation methodology, timings, AIPS advice, templates, PIM.

3.0 Nov

2012

Chris Evand MSE54 Total rewrite

2.2 Oct 2009

Nivedita Ram MSE5 Update in AI-PSM definitions

2.1 Sep 2008

Nivedita Ram MSE5 Updated in line with the Yellow Guide – issue Dec 31, 2007. Inclusion of the RAM, OSHA Guidelines

2.0 Dec 2003

Ohimai Aikhoje CSM4 Updated in line with new SIEP Standard for Health, Safety and Environmental Management Systems – Incident reporting and Follow up EP 2005-0100-29.

Follows new EP global procedure for Incident Reporting and Follow Up.

1.0 Jany-03 Andrew Ure MSE4X Update Procedure to bring it into line with PIM Incident Management tool, and with PDO re-organisation

iii Related Business Processes

Code Business Process (EPBM 4.0)SP1157 HSE Training SpecificationGU612 Incident Investigation, analysis and reporting guideline

iv Related Corporate Management Frame Work (CMF) Documents

The related CMF Documents can be retrieved from the Corporate Business Control Documentation Register CMF.


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TABLE OF CONTENTS

i Document Authorisation....................................................................................................3

ii Revision History................................................................................................................4

iii Related Business Processes.............................................................................................4

iv Related Corporate Management Frame Work (CMF) Documents.......................................4

1 Introduction....................................................................................................................... 7

1.1 Background................................................................................................................. 7

1.2 Purpose....................................................................................................................... 7

1.3 Scope.......................................................................................................................... 7

1.4 Objective..................................................................................................................... 7

1.5 Distribution/target audience..........................................................................................7

1.6 Deliverables................................................................................................................. 7

1.7 Performance monitoring...............................................................................................8

1.8 Quality assurance........................................................................................................8

1.9 Review and improvement.............................................................................................8

1.10 Step-out and approval.................................................................................9

2 Roles and Responsibilities...............................................................................................10

2.1 Overview:.................................................................................................................. 14

2.2 Immediate action to take following any incident (within 24 hours)................................14

2.2.1 Task 1: Initiate emergency response........................................................14

2.2.2 Task 2: Gathering information...................................................................15

2.2.3 Task 3: Organise remedial works, repairs or recovery...............................15

2.2.4 Task 4: Communication and escalation of the incident...............................16

2.2.5 Task 5: Preliminary assessment of incident severity & potential risk rating.17

2.2.6 Task 6: Identifying the directorate incident ownership...............................18

2.2.7 Task 7: Identifying the Incident Owner.......................................................19

2.2.8 Task 8: Determining work relatedness.......................................................19

2.2.9 Task 9: Create an initial learning from incident...........................................19

2.3 Conducting successful investigations.........................................................................20

2.3.1 Task 1: Incident investigation team set up................................................20

2.3.2 Task 2: Incident investigation terms of reference......................................21

2.3.3 Task 3: Conducting the investigation........................................................21

2.3.4 Task 4: Conducting the Tripod Beta (4/5 actual, High Potential or AI-PS)..21

2.3.5 Task 5: Statement of Fitness for Process Plant or Equipment...................22

2.3.6 Task 6: Local Quality Review, Incident Review (IRC), MD Incident Review (MDIRC), AI-PS Working Party and Serious Incident Review (SIR) process.....................22

2.3.7 Task 7: Report writing..............................................................................24

2.3.8 Task 8: Life Saving Rules.........................................................................26

2.3.9 Task 9: PDO Information Management (PIM)...........................................29



2.3.10 Task 10: Close out of remedial actions.....................................................31

2.3.11 Task 11: Learning from incidents..............................................................31

2.3.12 Task 12: Serious Incident Review Committee (SIR)..................................32

2.3.14 Task 14: Consequence management for poor quality investigations..........32

2.4 Follow up and record keeping.....................................................................................33

2.4.1 Task 1: Evaluate the adequacy of the incident follow-up process..............33

2.4.2 Task 2: MDC PIM review.........................................................................33

2.4.3 Task 3: Records from investigations.........................................................33

2.5 Training and competence...........................................................................................34

3 Appendices..................................................................................................................... 35

3.1 Appendix 1, Forms and Reports.................................................................................35

3.2 Appendix 2, Related Business Control Documents and References............................35

3.3 Appendix 3, Change Log............................................................................................36



1 Introduction

1.1 BackgroundLearning and applying lessons from incidents to avoid a repeat is essential for continual improvement of HSE performance. Investigations identify underlying causes and management shortfalls which PDO and contractor management can learn from.

1.2 PurposeTo ensure:

All incidents including near misses and hazardous situations are reported, investigated and analyzed to identify where management controls failed and recommendations to identify new or restore controls are implemented;

Early sharing of lessons to facilitate prompt corrective action where similar situations are found to prevent a recurrence both locally and at other locations.

1.3 ScopeThis procedure sets the minimum requirements in PDO operations for the notification, classification, investigation, report writing, remedial actions, incident analysis and dissemination of learning’s from incidents to bring about the continual improvement in the operations HSE performance.

1.4 ObjectiveTo provide management and contractors a simple process to follow linked to guidance in GU612 to enable them to take the appropriate action in dealing with any type of HSE incidents.

1.5 Distribution/target audienceThe target audience is HSE Teamleaders, HSE Managers/Advisers, Contract Holders, Contract Site Reps, Contract Managers, Contractor CEOs, operational management or indeed anyone who may be called upon to report or investigate an incident

1.6 DeliverablesThe following deliverables shall be achieved by adhering to this procedure:

1. Initial notification into PIM within 16 hours including initial RAM assessment and identification of the appropriate Incident Owner.

2. Director/MD notification for medium/high potential or a 4/5 actual incident shall be issued within 48 hours of confirmation.

3. The initial PIM notification shall be opened and accepted/rejected by the Incident Owner within 3 days of the incident.

4. Directorate IRC presentation to take place within 30 days if a medium potential or actual severity 3 incident.

5. Tripod Beta analysis conducted for all high potential or a fatal work related incidents.


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6. MDIRC to take place within 42 days (high potential or a fatal incident).

7. Appropriate and quality investigation reports uploaded into PIM within 50 days.

8. All relevant fields in PIM to be completed within 50 days.

9. Action items uploaded into PIM with action parties and deadlines agreed within 50 days.

10. Action items closed out by the deadlines in PIM with evidences uploaded by the deadlines.

1.7 Performance monitoringThe MSE5 team weekly monitor compliance with incident investigation protocol conducting a review of incident PIM entries and RAM ratings and correct errors.

The MSE5 team reports PIM non compliance levels to the MDC each month.

The MSE5 team conduct a quarterly review of the PIM incident data identifying trend analysis for learning and non compliances with PIM and PR1418 protocol.

Key performance indicators utilized:

Incident investigation timelimits achieved

Incident investigation quality check passed

Incident investigation details available in PIM

Action items closed out by the PIM deadlines with evidences uploaded

1.8 Quality assurance

1. A quality review of the PIM incidents is ongoing by the MSE5 team.

2. The MSE5 team review weekly the accuracy of PIM entries and RAM ratings.

3. A quarterly review of the PIM incidents by the MSE5 team analyses trends.

4. The PDO Lead Incident Investigator reviews MDIRC presentations before submission to the MDIRC secretary.

5. The lateral learning communication is reviewed, translated and distributed by the MSE5 team following all serious or medium potential incidents.

1.9 Review and improvementThis document shall be reviewed every 3 years and revised if necessary by the document custodian in line with GU612.



1.10 Step-out and approvalThe requirements of this document are mandatory. Non-compliance shall only be authorised by the Corporate HSE Manager through a STEP-OUT approval.



2 Roles and ResponsibilitiesThe following table formalizes the roles and responsibilities of different levels in the incident notification, investigation and reporting process.

R= Responsible: Responsible for the action being carried out

A= Accountable: Accountable to ensure the responsible person(s) carries out the action required

S= Support: Is called upon to provide support the responsible person to achieve the action required

C= Consult: Is consulted to ensure the correct action, timing or focus is being applied

I= Inform: Is informed to ensure that they are kept aware of progress on the actions.

STEP 1 NOTIFICATION

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I-PS

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1 Immediate emergency action R

2 Collect initial facts and eye-witness statements. R

3 Contact CCR 5555 R R I

4 Notify the Road Safety Standards Team if motor vehicle incident R I

5 Notify HSE Team Leader and Senior Operational Management R I I I I

6 Assess initial level of severity and potential classification from RAM R C S C C

7 Confirm the appropriate Incident Owner R A S I

8 Incident owner can re-assign incident owner in PIM one level lower if appropriate R A C C

9 Contact and inform the chosen incident owner R A

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STEP 2 INVESTIGATION

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10 Create an initial incident notification in PIM R A S

11 Create the Level 1 notification A R

12 Review Level 1 notification R R C C S A

14 Communicate Level 1 notification in/ outside of PDO. I S A R R

14 Create an appropriate core investigation team R I C C C A

15 Devise initial Terms of reference for the investigation A R S S I

16 Hold initial meeting of the investigation team A R S S I

17 Make initial assessment if work related and inform MSE5 A R S S S I C C C

18 Identify Tripodian and conduct tripod analysis A R S S

19 Design and issue initial incident learning A R S

20 Check website for relevant information on incident type A R C I

21 Complete initial short investigation report & upload in PIM A R S I I I I I

22 Review learning’s from previous incidents A R S S

23 Conclude investigation into the incident, including visits, interviews, inspection of equipment, review of records, HSE MS, safety cases, HEMP, procedures and specifications A R C I S

24 Analyze findings and identify underlying causes. A R S I S

25 Sign Statement of Fitness prior to restart of a process facility R C C C C C A

STEP 3 IRC PROCESS



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26 Create directorate Incident review (IRC) presentation A R C I S I I I

27 Reach agreement on work relatedness with MSE team A R C C C

28 Challenge to ensure the action items are SMART and appropriate A R C C

29 Arrange and hold Directorate IRC A C R C S

30 Identify high risk 'ESSENTIAL RECOMMENDATION' actions A R C C I

31 Update presentation and investigation report with points raised in Directorate IRC A R I I I

32 Upload agreed actions into PIM A R I I

33 Arrange MDIRC review slot via MSE54, informing all attendees A C R C

34 Confirm with MSE54 who will be secretary and take minutes A R I C

35 Review draft report and issue. A R C I I I I I

36 Attend MDIRC and present minutes to MSE54 A R C I C C

37 Create final report and presentation A R I C

38 Upload final report and presentation into PIM A R I

39 Upload additional agreed actions into PIM A C R I I

40 Issue final report including outcome of MDIRC A R I I I I I

41 Process and cascade final ‘learning from Incidents’ communication I I R I I A I



STEP 4 ACTION TRACKING

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42 Enter MDIRC minutes and report to PIM. A R I I

43 Develop Serious Incident Review material for MD. S S C S R A C C

44 Implement remedial actions successfully A R S I I

45 Update PIM to confirm action points are successfully closed A R S I I

46 Check status of action point close outs. A R S S I

47 Confirm the quality and accuracy of action points closed out R S S I I A

48 Challenge any failure to close out action point by deadline R S I I A

49 Conduct status reports and trend analysis S R A

50 Provide Directorates with monthly 'overdue PIM action item report' I R A I

51 Update overdue PIM items into the KPIs dashboard R A

52 Present dashboard in MDC R A

53 Process consequence management for sub-standard investigations R S I I



2.1 Overview:

2.2 Immediate action to take following any incident (within 24 hours)

2.2.1 Task 1: Initiate emergency response

Actions taken immediately following an incident can make a significant difference in reducing its consequences. It is important to act quickly. All staff should be trained in the following:

1. Ensure help has been requested and management informed. Call 24675555 or 24385555 if it looks like a serious incident. If in doubt…. call.

2. Make the area safe first before dealing with casualties. 3. If you suspect H2S could be a factor go down or across wind.4. Ensure all equipment is switched off and powered down.5. Ensure the immediate area is made secure to prevent spectators entering.6. Treat or arrange first aid treatment for casualties. 7. Liaise with the management and emergency services when they arrive.

Detailed emergency response information can be obtained from PR1065.

Reporting of spills and leaks

Where an oil leak/spill exceeds 10m3 the line management shall immediately report the incident to the MSE2 team who shall in turn inform MECA as legally required. Where spills exceed 50 tonnes, the shareholders will be informed by the Managing Director. of 32

'PR1418 V.3.1' Procedure Printed 06/01/14



2.2.2 Task 2: Gathering information

Continue to secure the scene to ensure evidence is not disturbed. Information from an incident scene is only of value if the scene is properly preserved. Once integrity has been lost then vital information is compromised.

All relevant staff shall be trained on what to do if they see an incident or attend an incident scene:

1. Identify who witnessed the incident and obtain their names and contact details2. Collect and make a note of the initial facts including;

a. What you saw when you arrived?b. What is the time?c. What is the weather?d. What is the lighting – where is the sun?e. What, if any non work related general clothes were people wearingf. Who was the person injured?g. What did the injured person say?h. What injuries were visible if any?i. What equipment was involved?j. What was the phase of operations, process condition, etc,k. Markings, scratches etc left by equipment involved,l. Where were relevant people and equipment

3. Ask witnesses what they saw, heard, smelt etc and make notes. Record who says what.

4. Ensure the road safety department is informed if it is a motor vehicle incident.5. Take measurements, heights, distances etc if applicable.6. Take photographs and/or video of the scene as quickly as possible if it is safe to do so.

Remember that taking too many photos is much better than not taking enough.7. Inform the PDO and contractor management as soon as possible.

2.2.3 Task 3: Organise remedial works, repairs or recovery

It is important for the area to be returned to its normal operation as soon as possible once the investigation team is confident that they have captured all of the necessary data from the incident scene and ensured there are no legal restrictions in doing so. The following actions should take place:

1. Confirm the area can be reopened and it is safe to do so.2. Confirm the hazards that led to the incident are no longer a threat.3. Confirm there are no other hazards resulting from the incident which must

be dealt with first.4. Confirm re-opening the plant or area will not result in further loss or

exposure.5. Confirm the necessary repairs are organized and planned.6. Confirm recovery equipment/spare parts etc have been ordered and

delivered.7. Confirm the immediate remedial actions have been organized and will take

place.8. If it is a process facility, see section GU612 (Page 67 & Page 181) on

statement of fitness to restart.


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2.2.4 Task 4: Communication and escalation of the incident

It is important to let the appropriate people know an incident has happened as soon as possible.

If the incident is an actual level 4 or 5 or early indications are it is a Lost Time Work Case then using the template in GU612, page (64) the incident needs escalating via email immediately to the list below within 16 hours.

Incident Owner, Director, HSE Teamleader, MSE5, MSE52 MSE54. MSE2 (Environmental only) MSE14 (Motor vehicle incident only) MSE4 (Process safety incident only for Tier 1,2 – see GUI612 page 16) MSE46 (Process safety incident only for Tier 1,2 – see GUI612 page 16)

The email should only include known facts so avoid any speculation. The MSE5 team will create a draft notification and after agreement with the operations/project supervisor the notification will be issued to the appropriate person for publishing as per the table below:

Type Issued by Published to Deadline

Actual 4/5 incident or High Potential

Managing Director

Ministry, Shareholders, Employees

48 hours

Non Accidental Death Director Employees, Shareholders

48 hours

Significant Environmental Incident

MSE2

Director

Ministry of Environment and Climate Affairs

Employees

24 hours

48 hours

Loss of primary containment over 50 tonne

Managing Director

Shareholders

Employees

24 hours

Lost workday case Director Employees 48 hours

Radiation exposure incident

Director Employees 24 hours

Electrical incident Director Employees 24 hours

All incidents, including near misses, (or unsafe acts and conditions with remedial action not closable within 24 hours and by local action only) which are or may be related to PDO's business and which have or could have caused injury or harm to people, assets, the environment or PDO's reputation, need entering in the PDO Incident Database (PIM) within 24 hours. See Task 9 – PDO Information Management if clarification is needed.




Before completing the PIM entry, ensure that you have determined the preliminary assessment of the actual incident severity and potential risk rating. (See 2.2.5). Guidance on inserting a notification in PIM is included in GU612 (page 120 & page 142)

On being notified of a serious incident (actual severity 3 or medium potential incidents or above ) an investigation team comprising a combination of local, coastal and contractor management as well as appropriate specialists relative to the incident shall be deployed to the incident scene to conduct the ‘on-scene’ investigation within 24 hours.

2.2.5 Task 5: Preliminary assessment of incident severity & potential risk rating

Utilise the PDO ‘Risk Assessment Matrix’ (RAM) in GU612 (page 9 & page 16) to make a preliminary assessment of actual severity and potential risk of the incident. This assessment can be changed later if circumstances change.

a. Actual severity rating

It is often difficult to calculate the actual severity of an incident straight away, particularly on asset damage, environment and reputation, however the best guess estimate should be made with the information available and using the guidance available in GU612.

For ‘people injuries’ a PDO doctor initially classifys any injury other than first aid treatment. This is done by either a face to face medical examination or where this is not possible, by the PDO doctor reviewing the case notes provided by an external medical establishment.

Whilst PDO or contractor management can provide information to the PDO doctor for him to make the classification, it is up to the PDO doctor to make the decision on whether it is a:

Permanent total disability Permanent partial disability Lost workday case Restricted workday case Medical treatment case First aid case Non accidental death

The classification shall be made within 48 hours of the incident.

It is important for the job description of the injured person to be fully understood and taken into account when the PDO doctor makes the decision whether the injured person reasonably requires time off work (and for how long), or is able to continue his normal work duties with restricted conditions or can work without any restrictions. The more manual or risky the work activity, the more likely an injury is to require time off work. A guide of work activities against injuries is included in GU612 page (19).

If there is a dispute regarding the classification, then a panel will meet to discuss and decide. (via meeting or conference call). This panel will include:

Head of Occupational Health Head Nurse who dealt with the injured person








HSE Team Leader for the relevant Directorate MSE54 Contractor HSE Manager (where applicable)

Where the Head of Occupational Health does not agree with the majority decision of the above panel then the final say on classification is to be taken by MSEM.

No person shall return to work until the PDO doctor has signed him back to work or normal duties if injured to a lost time injury or restricted work case.

b. Potential risk rating

For the assessment of potential risk, one shall review the details from the incident, consider the worst scenario that is reasonably probable from the incident and then consider how many times this has historically occurred within the industry, in PDO or more frequently at the same location. Utilise all available resources to determine the applicable history e.g.

1. PDO HSE web,

2. PDO PIM database search,

3. Previous local incident reports,

4. HSE Advisers and operations.

This will allow you to assign a potential severity and likelihood of such consequences using the definitions in the matrix.

Note: The initial classification of an incident made by the person entering the data into PIM shall be confirmed or otherwise by the Incident Owner and sanctioned by MSEM team.

An exception to this rule applies to Rig activities and ‘dropped objects’ where an alternative mechanism for assessing potential risk is applied by looking at the weight of the object and the distance the object fell. These alternative rules are embedded in SP-2097 – ‘Prevention of Dropped Objects’. A summary of the process is contained in GU612, section 2.2.4.2.

2.2.6 Task 6: Identifying the directorate incident ownership

It is important to establish single point responsibility for an incident to ensure the incident is investigated, reported and followed-up effectively. Ownership is first assigned to a PDO directorate and then delegated to the appropriate level within that directorate.

See GU612 page (21) for the rules determining line ownership. Where agreement between two assets or directors cannot be achieved, MSEM must be informed who will adjudicate.




2.2.7 Task 7: Identifying the Incident Owner

The PDO Incident Owner is the key person who will ensure a successful and efficient incident investigation. Once the directorate incident ownership is confirmed, the Incident Owner should be identified and agree to manage the investigation.

See GU612 page (22) for the rules regarding the appropriate level of person to be an incident owner for each severity of incident.

2.2.8 Task 8: Determining work relatedness

An incident can be classified in several ways:

PDO/PDO contractor work related reportable and recordable

PDO/PDO contractor work related reportable but non recordable

PDO/PDO contractor non work related

Third party incident work related reportable and recordable

Third party incident work related reportable but non recordable

Non accidental death, suicide Death by natural causes not related to work exposure

Non PDO incident

All incidents are considered as work related until proven otherwise. Where the investigation team believes an incident is not work related, it is the responsibility of the Incident Owner to provide the justification to MSEM who will make the final classification.

Guidance and examples for the classification for work relatedness are found in GU612 page (23)

2.2.9 Task 9: Create an initial learning from incident

It is essential that PDO capitalizes on learning from incidents and communicates lessons as soon as possible when the incident is still topical .

The HSE Team Leader shall ensure that within 7 days of an incident an initial incident learning is created by the investigation team for incidents of actual 4/5 or high potential and issued to MSE54 for review and distribution.

By sharing the lessons quickly from an incident it enables people to connect with the incident and also to dispel any false rumours.






2.3 Conducting successful investigations

First ensure all immediate actions have been conducted (section 2.2)

2.3.1 Task 1: Incident investigation team set up

Contractor or PDO?An investigation into an incident involving a PDO employee shall be led by the PDO line management.

An investigation into an incident involving a PDO contractor shall be led by the contractor management with close support from PDO. The PDO Incident Owner must ensure sufficient Company resource, including the Contract Holder is assigned to liaise with and support the contractors investigation team. The level of support and resource will be based on the severity of the incident and the contractor’s ability to conduct an in-house, unbiased, satisfactory incident investigation.

Investigation team membershipIf it is a PDO operational incident, the Incident Owner is himself responsible for setting up an appropriate investigation team within 24 hours. Guidance is in GU612 page (27)

This means identifying:

Resource (actual/potential)

1,2

/ Low

3 /

Med

ium

4,5

/ H

igh

/ H

igh

valu

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arni

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AI-P

SAn appropriate Investigation Team Leader with sufficient authority, time and focus to lead the team. X X X

Sufficient directorate investigation team members locally to the incident.X X X

Sufficient directorate investigation team members based at the coast. X X

Specialist support from other directorates. X X

The Directorate HSE Team-leader X X

A Tripodian X




2.3.2 Task 2: Incident investigation terms of reference

Incident investigations require a term of reference (ToR) to be formalized unless they are level 2 or below or minor potential. The ToR must be agreed as part of the first meeting of the investigation team. An example of a ToR is shown in GU612 page (29).

It is important to ensure that the membership of the investigation team, the frequency of meetings, the scope of the investigation, timetable of key milestones and roles and responsibilities are formalized at the start within the timeframes stipulated.

For level 2 or below or minor potential, investigations need to commence within 24 hours of the incident and conclude within 5 days.

2.3.3 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. (Guidance on conducting the investigation is contained in GU612, pages (34-46).

2.3.4 Task 4: Conducting the Tripod Beta (4/5 actual, High Potential or AI-PS)

All incidents of 4/5 actual, High Potential or high value learning AI-PS incidents require a Tripod Beta analysis to identify the underlying causes of the incident. Tripod analysis uses specific computer software and can only be conducted by a trained Tripodian. MSE4 will determine which AI-PS incidents provide high value learning and hence require tripod.

It is easy to apportion blame for an incident on the people primarily involved, however it is often managerial decisions (sometimes years before and often remote from the location) that can be linked via the causational pathway back to the immediate cause of an incident. The Tripod analyses and links the immediate causes of an incident to these underlying causes. By tackling and addressing these managerial issues a repeat of the incident is more likely to be avoided.

Each contractor and PDO Directorate HSE team shall employ or have access to a trained Tripodian with the Tripod software to enable a Tripod investigation to be conducted.

The Investigation Team Leader should identify an appropriate Tripodian to be a key member of the investigation team. A list of trained Tripodians is kept by MSE54.

To conduct a successful Tripod analysis, the Tripodian must have access to all information in the investigation and hence is a key member of the team from the very start of the investigation. Guidance on Tripod is contained in GU612 page (154)

TRIPOD IS NOT REQUIRED FOR INCIDENTS WHICH ARE NOT WORK RELATED






2.3.5 Task 5: Statement of Fitness for Process Plant or Equipment

Before restarting a process facility after a ‘significant incident’, uncontrolled shutdown, conditions outside the operational limits, or environmental conditions beyond the original design parameters the following criteria shall be confirmed as having been met:-

- The basic and immediate physical cause(s) of the incident are understood through incident investigation or Root Cause Analysis process.

- Corrective actions required for restart are completed and address the incident causes. This could include any or all of: repairs, alterations or modifications, required monitoring, temporary equipment, mitigations.

- 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 the incident.- Statements of Fitness requirements specified in SP-2062 have been met where

applicable.

See GU612 page (67) for template and GU 612 page (118) for guidance.

A STATEMENT OF FITNESS TO RESTART IS ONLY REQUIRED FOR INCIDENTS WHICH ARE 4/5, HIGH POTENTIAL OR HIGH VALUE LEARNING AI-PS

2.3.6 Task 6: Local Quality Review, Incident Review (IRC), MD Incident Review (MDIRC), AI-PS Working Party and Serious Incident Review (SIR) process

The IRC/MDIRC/SIR process applies as follows:

Loca

l qua

lity

revi

ew

Dire

ctor

ate

IRC

AI-P

S w

orki

ng

party

(If

Tie

r

M

DIR

C

SIR

High potential,level 4/5, High value learning AI-PS incidents (normally Tier 1)

x x x x x

Medium potential or level 3 x x

Unauthorised overdue medium potential or level 3 x x x

High value learning medium or level 3 incidents as determined by MSE team

x x x

Low potential or level 1/2 x

New technology or information to prevent a reoccurrence of a previous MDIRC incident

x x





Permit to Work violations x x x

For low potential or level 1/2 incidents where only a short and concise investigation is required it is the responsibility in the first instance of PDO site or field supervision, e.g. Contract Site Representative (CSR), Drilling Supervisor (DSV) to review and ensure the quality and accuracy of the investigation. The incidents owner (see GU-612, 2.2.7.7) is responsible to ensure that the investigation is taking place and is appropriate to the incident. The format of the investigation and incident report must follow the template provided in GU-612, 2.2.17.

Where the incident itself involves a PDO employee or asset, the incident owner in liaison with the Directorate HSE Team Leader. is responsible for the quality of the investigation and reporting in PDO.

It is not considered appropriate to expect contractors to create full IRC packs for minor incidents or conducting local IRCs as this discourages incident reporting; however where contractors are habitually providing poor quality investigations then this can be introduced on the authority of the middle and/or senior management.

For medium or high potential or level 3 and above actual, the IRC process must be followed

Middle management (Senior Well Engineers, Contract Holders, HSE Team Leads and Asset Team Leader) are responsible for arranging periodic quality reviews on the checks made by the local PDO management to ensure it is taking place and is appropriate. Directorate senior management teams can determine the set up of low potential investigation quality reviews most appropriate to their operation.

The media used for IRCs is PowerPoint. Guidance is found in GU612 page (49) and the template is in GU612 page (111). It shall be written in English and not deviate from the template without the permission of MSE54 and the Incident Owner.

The IRC process provides senior management opportunity to challenge the investigation scope, findings, actions taken and recommendations and assure the quality, integrity and area of focus of the investigation. It ensures the poignant learning’s have been extracted from the incident to prevent a reoccurrence as far as is reasonably practicable. In addition any Tier 1 AI-PS incidents must first be reviewed and confirmed as acceptable by the AI-PS Working Group before going to IRC and can be organised via MSE4.

The MDIRC presentation is the same as the IRC presentation with an additional slide highlighting the changes and discussions in the Directorate IRC. In addition the IRC presentation must be updated to reflect the amendments requested in the IRC.

The presentation shall have a maximum of 5 Essential recommendations highlighted. The actions are the 5 most important actions to prevent a reoccurrence of the incident.

The remaining actions and recommendations shall follow in a separate section.

The presentation shall conclude with the 2 page lateral learning slides which the MSE5 team shall then communicate to other contractors and PDO to spread learnings and help prevent a recurrence. The first page is for communication to employees, the second is the management failures that HSE Managers need to be aware of.





The Investigation Team Leader shall ensure the IRC presentation is created and agreed by the investigation team and quality reviewed by the local PDO management team before submission to the directorate IRC focal point.

Where the MDIRC/IRC endorses remedial actions and deadlines, the Investigation Teamleader shall ensure their upload into PIM within 5 days of the IRC taking place.

The deadlines for IRC and MDIRCs are as follows:

Directorate IRC – 30 days after the incident

MDIRC - Fatalities/NAD/HiPos/Permit to Work violations – 42 days after the incident

MDIRC – Tier 1 AI-PS – two months after the incident (even if not complete)

MDIRC slots are booked via MSE54 who shall be informed of the identity of the minute taker and provided with a copy of the MDIRC presentation and incident investigation report. Bookings shall be made no later than 6 days before the proposed MDIRC date. Tier 1 AI-PS incidents shall always be discussed on the last MDIRC of each calendar month.

During the MDIRC, minutes shall be taken by the minute taker and provided to MSE54 with a revised presentation and report within 4 days of the MDIRC.

The Investigation Team Leader shall upload any additional remedial actions requested from the MDIRC and the HSE Team Leader shall check this has been done. Support can be requested from MSE521 but is not guaranteed.

The timeframe of the incident investigation process is shown in GU612 page (155)

2.3.7 Task 7: Report writing

All reports shall be written in English and any statements or records attached in Arabic, shall be accompanied with an English translation.

For low potential or level 1 or 2 incidents the investigation report should be short, to the point and be no more than one page long where possible. Detailed analysis or long winded reports are not required for a low potential incident. The format for the report is contained in GU612 page (70). of 38 'PR1418 V.3.1'

ProcedureThe controlled version of this CMF Document resides online in Livelink®. Printed copies are UNCONTROLLED.





The report shall contain as a minimum:

- Place, time, date, and description of the incident;- Classification of incident (incident type)- Actual and Potential Consequences;- Critical factors- Key causational factors- Immediate causes- Underlying causes- Latent Management failings- Action items to prevent reoccurrence.

The report shall clearly highlight the key findings identified from the investigation.

For more serious incidents the Investigation Team Leader shall organise the investigation team to compile the more detailed Incident investigation Report. The format of this report is contained in GU612 page (88).

The report shall contain as a minimum:

- Place, time, date, and description of the incident;- Timeline of the incident- Photos and diagrams relevant to the incident- Classification of incident (incident type)- Actual and Potential Consequences;- Critical factors- Key causational factors- Immediate causes- Underlying causes- Latent Management failings- Action items to prevent reoccurrence.

The report shall be efficient and clearly highlight the key findings identified from the investigation and include an executive summary so a reader can identify the main output from the investigation without reading the entire report.

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 incident investigation report.




Action items identified from the investigation must be SMART, this means:

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?

Timed (T) When do you commit to achieve the set objectives?

Where the actions are long term they should be broken down into short and long term actions or instead the action should relate to obtaining the authorization, budget and timetable for the action to be closed.

e.g.

short term – obtain budget and sign off for replacement pipeline project.

Long term – pipeline replaced

The investigation team shall identify, liaise with and agree an appropriate action party for each action required. The wording of action points and reasonable deadlines shall be agreed with the action party before being formalized in the report. Any dispute shall be raised at IRC.

The investigation shall highlight the 5 Essential recommendations which have the greatest influence on preventing the incident happening again.

Note: Action items are often work in addition to a person’s normal role and so it is important to build in contingency when determining the deadline.

2.3.8 Task 8: Life Saving Rules

PDO’s 12 Life-Saving Rules are the next step in the Goal Zero Journey. These rules have been selected because they represent those activities where non-compliance has the highest likelihood to result in death or serious injury, the Life-Saving Rules apply to everyone and all operations under PDO’s operational control.

The Life-Saving Rules set out clear and simple “dos” and “don’ts” covering activities with the highest potential safety risk. Where violation of a Life-Saving rule is suspected, check



whether supervisors /managers have created pre-conditions which may have contributed to the violation.

Investigations into why a Life-Saving rule was not followed should include “the failed life saving rule”, “the human error/violation type” “the precondition” and “the underlying cause” and the corresponding weaknesses in the HSE-MS.

For all significant and high risk incidents and/or where it is established that a life saving rule has been violated, the following should at least be recorded by the incident owner in PIM under “add investigation"/“immediate causes”: accessible in the bottom part of incident report page by clicking on the "add investigation" icon. You will be able to view the tab "immediate cause"

Under the "immediate cause" the drop down menu, includes the Life Saving Rules.

1. Record if no life saving rule failed in the incident2. If concluded that a life saving rule failed o Select the relevant failed Life Saving rule(s)o Select the relevant human error/violation type : slip/lapse, mistake, unintentional

violation, situational violation, etc.

LSR Consequence Matrix

Warning Letter low potential impact Rule is broken for the

first time Final Warning Letter high potential impact

Final Warning

Letter Dismissal

Rule is broken for the second time or several rules are broken at the

same time

Final Warning Letter Dismissal

Rule is broken for the third time, or rule-

breaking caused injury or death, or was done recklessly or wilfully

Dismissal

Note on LSR Consequence Matrix:

• The Company reserves the right to take circumstances of the rule breaking into account to modify the disciplinary measures.

• The Breaking of a Life-Saving Rule is considered a Major Misconduct, and the HR disciplinary process as defined in the Employee Policy Manual will be used to administer this consequence matrix.

• ROP speed and alcohol thresholds will be used.

• Other existing rules and procedures remain valid.



Adding Life Saving Rule Violation incidents into PIM

All violations should be reported in PDO Incident Management (PIM) whether or not the violations lead to an incident. There is now a Life Saving Rules box to be completed by the incident owner, which provides the opportunity for tracking, this is located in the investigation part of the PIM report.

The process is:

1. Report incident/observation of a (suspected) life saving rule in PDO (as per normal procedure for actual or potential incident)

2. Investigate the suspected life saving rules violation, the human error type (why was the rule not followed e.g. to mistake, reckless violation etc), the precondition under which the rule was violated (e.g.: supervisor interaction) and underlying cause(s)

3. Conclude whether life saving rule was violated, in PIM go to "investigation" tab, click "add investigation", go to "Immediate Causes" tab, click "+", complete immediate causes from drop down menu indicating which Life Saving Rule was broken.

For consequence management reporting:

1. For contractor staff, the Life Saving Rules focal point is the Contract Holder, who will, update PIM with the record of the consequence applied.

2. For PDO employees, the incident owner will update the PIM records.

Please contact PDO Helpdesk at 75599 for any assistance.



2.3.9 Task 9: PDO Information Management (PIM)

PIM is PDOs Incident Investigation IT Tracking System used to track all incidents and actions and accessed through the HSE home webpage. A PDO employee’s MU number grants automatic access and contractor employees with an MUC number can request PIM access from their Contract Holder.

The PIM database should be used as per the following tables:

Entry into PIM Deadline for PIM upload

Level 3,4,5 or medium / high potential/Tier 1

Level 1,2 incidents or low potential

1 Initial incident report and photographs 24 hours 24 hours

2 Initial actual severity and potential risk

rating

24 hours 24 hours

3 Incident owner 24 hours 24 hours

4 Medical report when received when received

5 Initial investigation report/form 5 days

6 MDIRC presentation 36 days

7 Incident investigation report 36 days 7 days

8 Actions and action parties 36 days 10 days

9 Evidences of actions taken by action

deadline

by action

deadline

10 Close out of incidents with no actions 20 working

days

20 working days

11 Close out of actions by action

deadline

by action

deadline

The MSE52 team are the PIM focal point is available to answer queries about PIM.



When to use PIM or STOP for unsafe acts or conditionsIf the investigation team need to report an unsafe act or condition then this shall be recorded via the PIM system but only in cases where the unsafe act or condition requires either remedial action taking more than 24 hours or the involvement of other non-local parties (e.g. more senior management/other departments) or the procurement of equipment, goods, stock. The PIM system ensures an assurance process is in place for the closing out of the remedial actions. In such cases the Incident owner as formally assigned in the PIM system is responsible for ensuring the action is closed out.

If the unsafe act or condition can be resolved locally with actions closed out within 24 hours by local management then this shall be recorded via the use of a STOP card and recorded in the STOP system. The observer shall be responsible for the remedial action and he has to resolve it and/or report it to the local management for immediate rectification.

Example 1:An observer or a manager spots a manhole cover which has been taken off a manhole and laid to the side. He can coach the workers in the immediate area about leaving the manhole unprotected, investigate why it happened and replace it immediately. This unsafe condition shall be reported in STOP.

Example 2:An observer or a manager spots an exposed manhole but the manhole cover which has been removed cannot be located and the situation has not been reported or the manhole protected. After the manhole has been protected by a barrier, the situation must be reported in PIM due to the fact that the new manhole cover needs to be ordered and this action tracked until it is replaced. The investigation itself will still focus on why the manhole was not protected by the workers and reported in PIM.” If the manhole cover has been stolen then it also has to be reported using security incident report form available for download from the UIC homepage.

Change of PIM Action PartyWhen an action party changes position or leaves the company, the Incident owner should update the PIM action with the new action party in order to close out the action.

Change of PIM Incident OwnerWhen a person takes over a management role, he/she shall contact MSE52 to check if there are any incident/audit actions or Incident Owner responsibilities open for his/her new role. MSE52 will transfer the actions and incidents to the new person to avoid them being lost and having to be reassigned at a later date. The Line Manager of the person taking on the role should also ensure this process takes place.



2.3.10Task 10: Close out of remedial actions

The action party shall be aware of, agree and meet the action close out deadlines.

The action shall be formally closed out in PIM by the action party once the close out can be evidenced; otherwise PIM will report it as an overdue action. The Incident Owner must confirm acceptance of the action close out in PIM.

PIM will report the performance of action parties meeting or not meeting deadlines to the Incident Owner who shall manage instances of non compliance effectively.

On request of the MD, for certain incidents presented to MDIRC, the Incident Owner shall email an ‘essential recommendation’ close out report to the MSE54 team within 5 days of the last essential recommendation deadline providing evidence of their completion. If deadlines have not been met then the reasons why and contingency must be stated. The template is in GU612 page (110). The MSE54 team will inform the MD of the performance of essential recommendation close outs who may request the Incident Owner to present the success of these close outs to MDIRC.

When all actions have been successfully closed out from the investigation, the Incident Owner shall officially close out the incident in PIM.

2.3.11Task 11: Learning from incidents

It is essential that the lessons are learnt from incidents. By sharing the lessons from an incident other parties can learn lessons and identify if they are at risk of it happening to them and by implementing actions, prevent it happening in the future.

The MSE5 team will communicate a two page lateral learnings from all IRC/MDIRC incidents for all parties to learn lessons from, page 1 is a poster to educate the people at risk, page 2 is the management learning’s from the investigation to enable the management to review their procedures and HEMP to avoid it happening again. The template is found in GU612 page (104,105) and an example is in GU612 page (106).

The MSE5 team will periodically analyse the statistics from low potential and minor incidents in PIM and communicate these learnings for all parties to learn lessons from.







2.3.12Task 12: Serious Incident Review Committee (SIR)

The Managing Directors is required to present the learnings from the most serious incidents, including actual 4/5 or high potential to PDO shareholders on at least an annual basis. The MSE5 team are responsible for collating the information for the Managing Director presentation and will liaise with the Incident Owners to ensure all the required evidence for the incidents action close outs are available.

The SIR committee produce minutes from the SIR which will communicate any additional work which PDO has to conduct resulting from the incident. The MSE5 team will communicate any additional work requirements to the relevant action parties.

The template for the SIR presentation is found in GU612 page (109-110)

2.3.13Task 14: Consequence management for poor quality investigations

PDO contractors are required to employ sufficient and competent incident investigators who have passed the PDO incident investigation course and are able to conduct and deliver a good quality investigation.

Where an Incident Review Committee meeting has to be reconducted due to a poor quality investigation, presentation or report, the Contract Holder shall request the contractor to provide evidence of their competent investigation credentials via training records.

Where the contractor has not employed an incident investigator to support the investigation and this is contractually required, or the contractor provides poor quality investigations on more than one occasion then the Directorate HSE Team Leader shall ensure the contractor is penalized via the C9 HSE default section of the contract via the Contract Holder, the penalty to continue until they have employed a competent HSE incident investigator and improved the quality of the investigations provided.

Poor investigations are those that:

1. Have failed to follow the most up to date PDO IRC template.

2. Do not use the PR1418 v3.1 incident investigation methodology.

3. Do not include a lateral learning in the correct format.

4. Do not clearly identify the critical factors, immediate causes, underlying causes and latent management system failures.

5. Do not identify SMART actions and recommendations.

6. Do not contain the supplementary information for evidence.

7. Are not presented to IRC within 30 days without a valid justification.

If a IRC needs to be reconvened because of any of these, the consequence management can apply to both the contractor and PDO investigation team leader.




2.4 Follow up and record keeping

All documentation regarding incidents including investigations, statements, records, close out of actions shall be kept on file for a minimum of 10 years for future review or learning.

2.4.1 Task 1: Evaluate the adequacy of the incident follow-up process

The Incident Owner shall review the quality of the report, timeliness of investigation and agreed actions. Any outstanding actions which are overdue shall be challenged and rectified.

2.4.2 Task 2: MDC PIM review

The MSE5 data team shall provide a monthly report on over-due PIM actions to the MDC who are responsible for ensuring that the responsible action parties in their directorate are held to account for not meeting the deadline and for assuring the close out of the PIM actions at the earliest opportunity.

2.4.3 Task 3: Records from investigations

Each Directorate shall retain its incident reports after posting on PIM, connected learning, and notifications in line with local requirements and for at least 10 years.

Investigation notes and reports shall be posted on PIM and must contain.

- Notifications,

- Completed investigation report,

- Completed IRC/MDIRC presentation,

- Photographs,

- Lateral learning documents,

- Other relevant documents

Note: The medical examination records of workers exposed to hazards must be retained in the employee’s medical files and retained in a special file dedicated for the reason even after the end of the employee’s service. In the case of radiation examination reports, the records must be retained for a minimum of 30 years. Medical records shall be retained safely and securely and shall not be accessible except to authorized personnel.



2.5 Training and competence

Management need to ensure suitable and sufficient people are trained and competent in:

Course Who Medium Course Code

Incident Investigation Supervisors /

management / HSE

TLs / HSE Advisers /

Contract Holders /

CSRs / Contract

Managers

Classroom SP1157

IAI **

PIM training Supervisors /

management / HSE

TLs / HSE Advisers* /

Contract Holders /

CSRs / Contract

Managers*

Web Shell Open

University

HSSMGT000767

Tripod Beta HSE Advisers / HSE

TLs / persons

designated as

incident investigators

Classroom SP 1157

TPB

* Only contractor staff with MUC numbers and access rights to PIM are allowed.

** As of June 2014, PDO has introduced a new investigation course which is in line with the new concept of incident investigation in this procedure. It is highly recommended that people who have attend the previous course and who are involved in accident investigation attend the new course to become familiar with the new concept and to make it easier to be compliant.

Shell Open University accessed via http://sww.shell.com/hse/it/PIM/training/sou_access.html. Log on your account and enter “PIM’ in the search bar.

It is mandatory that a competent Incident Investigation Team member participate in the investigation unless it is a low potential or level 1 or 2 actual severity incident.


http://sww.shell.com/hse/it/fim/training/sou_access.html


3 Appendices

3.1 Appendix 1, Forms and Reports

All forms and reports are found in GU612

All definitions are found in GU612 pages (53-64)

Abbreviations (in alphabetical order)

AI-PS Asset Integrity, Process Safety

CH Contract Holder

EPM Exploration and Production, Middle East

IO Incident Owner

LFI Team Learning from Incident Team

MSEM Corporate S&E Manager

MSE5 Corporate Head of HSE Corporate Planning

MSE51 HSE Communication, & Business Support

MSE511 PIM and lateral learning focal point

MSE52 Corporate HSE Data Management Management

MSE54 Corporate Lead HSE Incident Investigator

3.2 Appendix 2, Related Business Control Documents and References

The following references provide useful information related to this procedure.

Process Safety Performance Indicators for the Refining and Petrochemical Industries (754), American Petroleum Institute, 2010

Recording and Reporting Occupational Injuries and Illness (1904.7), United States Department of Labour – click here, current


http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9638


http://sww3.pdo.shell.om/getdoc?dataid=8673736&action=fetch


3.3 Appendix 3, Change Log

The following is the change log for modifications to PR1418 between versions and can be used as a quick guide to determine the changes which have been made to the document without having to read the whole document again.

Sr. No

Date Section Topic Remarks and changes From To

1 09/05/14 All Changing the name of (Red line actions) to Essential Recommendation

Redline Action Essential recommendation

All redline action in PR1418 replaced with Essential recommendation

2 08/04/14 1.6 Time to enter incident into PIM

24 hours 16 hours

3 31/10/14 1.6 Time for IRC and MDRIC

IRC 20 daysMDRIC 28 days

IRC 30 daysMDIRC 42 days

4 31/10/14 2.0 Roles and responsibilities

Added consequence management in the RASCI chart

5 03/07/14 2.2.4 Reporting requirements

Added the requirement for LOPC over 50 tonnes to be reported to shareholders.

6 03/07/14 2.2.4 When to use PIM or STOP

Added a section to explain when STOP or PIM should be used to record an unsafe act or condition

7 03/07/14 2.2.4 Added requirement to inform MSE46 for AI-PS incidents

8 03/07/14 2.2.5 Included the DROPS calculator for well engineering in the determination of potential severity for dropped objects.

9 04/07/14 2.2.9 Expanded responsibility of HSE Teamleader to ensure initial incident learning is created and issued to MSE54 for review and distribution

10 04/07/14 2.3.4 Added that a list of



trained Tripodians is kept by MSE54

11 04/07/14 2.3.4 Corrected box indicating that Tripod is not required for non work related incidents.

12 03/07/14 2.3.4 Changed Tier 1 AI-PS incidents to High value learning AI-PS incidents for Tripod investigation

14 04/07/14 2.3.6 Revised process for Investigation Team Leader to upload MDIRC actions and HSE Team Leader to check.

14 03/07/14 2.3.6 Quality review of incidents

Provided guidance on quality reviews of minor incidents and the process to follow for checks

15 03/07/14 2.3.6 Adding quality check by local management for IRC presentations

The Investigation Team Leader shall ensure the IRC presentation is created and agreed by the investigation team and quality reviewed by the local PDO management team before submission to the directorate IRC focal point.

16 21/04/14 2.3.6 Task 6: Incident Review (IRC), MD Incident Review (MDIRC), AI-PS Working Party and Serious Incident Review (SIR) process

MSE54 MSE54Incident Owner shall inform MSE54 on progress on the close out of Essential Actions

17 31/10/14 2.3.6 Types of incidents elevated to MDIRC

Included the specific ability for a high value learning LTI to be raised for MDIRC review.



Included the ability to attend MDIRC to present additional technology/practices that could have prevented a previous fatal or HiPo

18 03/11/14 2.36 Added the two month requirement for MDIRC for AI-PS incidents

19 04/07/14 2.3.7 Changed the minimum requirements in an investigation report

20 043/11/14 2.3.10 Changed it so the close out of essential recommendations is on request of MD

21 03/07/14 2.3.14 Introduced the consequence management process for not employing competent investigation resource.

22 31/10/14 2.3.14 Added guidance as to what constitutes a poor investigation fo consequence management

23 31/10/14 2.3.14 Added guidance that consequence mgmt can apply to the PDO investigation team leader

24 17/12/14

Changed Fountain -FIM to PIM

PIM (PDO incident management

25 17/12/14 2.3.6Add Permit to Work violations to be subject to the IRC and MDIRC investigation process
