NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

Explain the purpose of and procedures for investigating incidents and how the lessons learnt can be used to improve health and safety in the oil and gas industries

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

FLIXBOROUGH PIPER ALPHA LONGFORD, AUS HUMBER REFINERY TEXAS CITY BUNCEFIELD ROUGH 47/3-B

1 JUNE 1974 6 JULY 1988 25 SEPT 1998 16 APRIL 2001 23 MARCH 2005 11 DECEMBER 2005 16 FEBRUARY 2006

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

VIDEO CASE STUDIES

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

The process and purpose of investigating occupational incidents

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

Reasons for investigation of accident / incident / near miss

To identify immediate and root causes To identify corrective action To record the facts of the incident For legal reasons For claims management For staff morale For disciplinary purposes For data gathering purposes

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

Why must accidents and ill health be reported?

As an employer, a person who is self-employed, or someone in control of work premises, you have legal duties under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) that require you to report and record some work-related accidents by the quickest means possible The following must be reported:

Deaths Major injuries Over three-day injuries Reportable diseases Reportable dangerous occurrences (near misses) Reportable gas incidents

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

Why should we carry out accident investigations?

Identify patterns of occurrence of accidents and incidents - types of machines, activity, part of the body injured Identify trends - increasing or decreasing numbers of occurrence Identify high risk activities that require further control Obtain information for civil claims Identify the immediate and underling cause of the accident!

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

Immediate cause cause for accidents

Premises - Physical layout, condition of building, environment (weather), tripping & slipping hazards Plant and Substances - Machinery guarding, substance in use - toxic, harmful, mobile plant, condition of work equipment - hand tools, chairs Procedures - Written system of work or operating procedure to be followed, safety policy, work instruction, quality standard, custom and practice People - Human factors, state of health and fitness for work, abilities, fatigue, errors knowledge based. skill based (slip or lapse), rule based, violations, behaviour pressures, culture

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

Underlying (root) cause for accidents

Planning Ineffective planning of tasks, ineffective planned maintenance Risk assessment absent or not suitable and sufficient Control - Poor supervision, unclear roles and responsibilities Co-operation - Between staff and management or contractors Communication - Verbal, written, information, posters Competence - Instruction, training, experience Monitoring Adequacy of pro-active and reactive Reviewing Overall review and response to change

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

Basic Accident Investigation Procedures

Decide on a team, include safety representatives, managers, specialists Attending the Scene: Ensure area is safe and try not to tamper with information / evidence Take photographs / video Measurements and sketches: record vital information View and collect relevant documents

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

Witnesses
Interviewing Witnesses: I kept six honest serving men, They taught me all I knew, Their names are What and Why and When And How and Where and Who? Rudyard Kipling Primary those involved Secondary eye witnesses Tertiary those that did not witness the event but can provide information on methods work and management arrangements

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

Interviewing Witnesses
Should invite a safety representative to be present Be neutral not a counselling session or an interrogation Ask open questions about the incident Record a summary / statement for each person interviewed and seek agreement

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

Barriers for reporting accidents / incidents and near misses

Blame culture Human error Perception Attitude Unmotivated

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

The organisational requirements for recording and reporting occupational incidents

NEBOSH, International Certificate in Oil & Gas Operational Safety

Module 1.1 Investigating Accidents

Why must accidents and ill health be reported?

As an employer, a person who is self-employed, or someone in control of work premises, you have legal duties under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) that require you to report and record some work-related accidents by the quickest means possible The following must be reported:

Deaths Major injuries Over three-day injuries Reportable diseases Reportable dangerous occurrences (near misses) Reportable gas incidents