Incident reporting and investigation

Purpose

An essential aspect of HS&E and process safety performance improvement is learning from incidents and near misses and taking appropriate action to prevent their recurrence.

EI statement

"Management must ensure that incidents and near misses are consistently reported and investigated and that identified actions and learnings are implemented on a timely basis."

Integrated reading

No business documents needed to be placed here, but the element should still be read broadly. Any adverse event, whether an IT outage, a fraud or an upheld grievance, should feed the same reporting, investigation and learning loop. The IT major incident procedure sits in 14 for the response; what is learnt from it belongs here.

No documents placed here by the integrated reading.

Expectations (14)

19.1A system is in place for incident reporting, investigation, follow-up and capturing lessons learned from incidents and near misses including: injury to people; work causal ill health; environmental incidents; damage to assets; loss of process containment; energy release; demands on SCDs; and business interruption.
19.2The reporting of incidents and near misses by all personnel, including contractors and suppliers, is obligatory.
19.3Incidents and near misses are classified and investigated on the basis of actual and potential outcome.
19.4Incidents and near misses are investigated on a timely basis.
19.5Investigations identify root causes, including human and organisational factors, and recommendations to address them are identified.
19.6Effective arrangements are in place to ensure that incidents or near misses are appropriately investigated when they involve contractor or supplier personnel.
19.7There are processes in place to learn from relevant incidents and near misses, and good practices in other organisations and sectors.
19.8Adequate numbers of competent personnel are available to carry out the required investigation arrangements.
19.9Completed investigations are reviewed and approved by specific levels of management appropriate to the classification of the incident.
19.10Where appropriate, and recognising legal and security constraints, all stakeholders are kept informed about the findings and recommendations from investigations.
19.11Recommendations are tracked to completion.
19.12Senior management periodically reviews the effectiveness of corrective and preventative actions.
19.13Arrangements for incident reporting and investigation are understood and followed; understanding of arrangements, and compliance with them, are regularly tested.
19.14Compliance, HS&E and process safety incident statistics and performance trends are reviewed by specified levels of management.

By department

Engineering

3 documents: Continuous Improvement through Learning from Experience · Quality Incident Reporting, Investigation and Quality Alert · Quality Findings Reporting Guide

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Operations & Maintenance

2 documents: Loss of Primary Containment Notification · Hazardous Leak Reporting

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HSSE

3 documents: Statutory Reporting of Incidents and Regulatory Non-Compliances · Environmental Incident Regulatory Reporting · Event Investigation Report Template

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Subsurface

1 document: Subsurface Lessons Learned Process

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Wells

1 document: Offset Well Review Process

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