Level of investigation: 2

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Resources
INCIDENT REPORT - SITE SAFE INCIDENT #

Incident Date: Company: Short Incident Description:

Incident Title: Location: Type of facility: Type of Equipment:

Team Members:
Name Role Title Organization

Incident Costs: Direct: Indirect:

Summary of Incident:

Response to Incident:

Sequence of Events: Refer to the attached Events Chart

Data Analysis:

Root Causes:
Root Cause Category Cause Description

Tenets Broken:
Recommendations:
Recommendation Owner

Contacts:
5798 4541
Authorizations:

Attachments: Revision History:

WHY TREE
Protective Systems References:
Events Chart
quipment:

Organization
Date Due
 Document

Click on this to open the report form in word format

DATA COLLECTION
No Data
PTW
JSA
MEDICAL CHECKUP
Source PIC Status
LOKASI SUPERVISORptw tdk ada
HRD Bdu on progress
Remark
Check List for Required Data of Investigation
Data Group Type of Data
People Person data

Interview note
Position Equipment Conditions at the time of
incident
Job and process status at the time of
incident
Weather conditions
Road Conditions
Sea Conditions
Other environmental conditions
Paper Safe Operating Procedures
Maintenance/inspection Procedures
& records
Design/Modification Records
Risk Assessment
Communication Records
Training Records
Lab reports, metallurgical reports of
broken parts
Electronic records and data in
control systems,
Logs, charts, control data notes,
turnovers/handback logs, work
orders, permits,
Contractor HES Program
Audit/inspection records
Emergency Response records
Part Pictures, videos, sketches or
diagrams of the scene, equipment
involved or what was going on at
the time.
Data of Investigation
Remark
Education, Qualification, Work Experiances, Training
Records, Medical Condition

Pressure, temp,Speed, physical condition etc

normal operations, startup, shutdown, maintenance,

mobilization, demobilization, construction etc

Use or applicable to the situation when the incident

Related to Equipment/machines involved in the incident

Related to the jobs involved in the incident

Latters/e-mail related to the jobs
Related to person involved in the incidents
List of Interview
No Name Position Company Inverview Date
1
2
3
4
5
6
7
8
9
Interviewer Status
Sequence of Event - Time Line
Draft -
On the Day of Incident :

Date Time Critical Event

13/01/15 7.30 TGM W CREW
8.00 RISK ASSESSMEN
8.15 PERSIAPAN PEKERJAAN PJM

16.30 KEJEPIT
Before the Day of Incident

Date Time Critical Event

17 SEND TO HOSPITAL
17.50 MEDICAL TREATMENT BY PHYCISIAN
Verified by

Verified by
Review of Protective System
No Category Protective System Exists & Exists & Not Not Exist
Working Working would have
work
1 Hardware SEAT BELT X
2 Hardware SLING 3/4 X
3 Hardware

4 Hardware

5 Hardware

6 Software

7 Software

8 Software

9 Software

10 Software

11 Software

12 Software

Additional Issues that are Relevant, but would not have effected outcome of incident
1 Hardware

2 Software

Software
Remarks
Checklist for Protective System
No Category Example
1 Hardware Basic Surface Safety System
F&G Detection System
ESD System
Fire Figthing/suppression System
Life Saving Equipment
Machine/Equipment Guarding/Locking Devices
Overspeed and Breaking System
PPE
Fall Protection System
Hazard Warning/Sign

Software Procedure & Safe Work Practice

Risk Assessment
Pre-Startup Safety Reviews (PSSR)
Quality Control Program
Equipment Maintenance/Inspection Program
Design and MOC Program
Project Management
Incident and Near-Miss Investigation Program
Contractor HES Program
Communication Program
Audit/Metrics
Contractor Safety
Personel Selection/Qualification and Training Program
Emergency Response
Leadership Accountability
Supervision
Stop Work Auhority Program
Hazard Communication Program
Fitness for Duty Program
Motor Vehicle Safety Program
Hazardous Material Storage and Handling
Work Permit
Isolation and LOTO
Housekeeping
JSA
Motor Vehicle Safety
Confined Safe Program
 Remarks

ning Program
Verification: Verification:
Interview Interview

Verification:
Written data

Verification:
Interview
Verification:
Visual
Verification:
Interview

Verification:
Interview

PC
Verification: Verification: Verification:
Interview Verification: Interview Interview
Interview

Verification:
Interview

Verification: Verification:
Verification: Interview Interview
Interview

RC
 Fire

Oxygen Fuel Ignition Source

present present present

Injury to
person

Person in Area Hazard in Area Person comes

into contact
with Hazard

Error occurs
with
consequences

Error occurs Fail to detect Situation for

and/or correct consequences
(other failed
protections)
 Spill or
Release

Material in a Hole / gap in Force to get

container container material out of
container

Lost Profit
Opportunity

Shutdown or Not fixed in No other

Slowdown timely fashion way to
make-up
 Verifying Potential Causes
In systematically confirming or ruling out possible physical and human causes, verify y
Visual - eye witness observations (the operators saw the fire at the bleeder v
Testing/Lab Analysis, such as metallurgical tests on parts, lab tests on oil sa
Expert Theory educated opinions by subject matter experts based on their
Conventional wisdom conditions know to exist by experienced personnel
Written Data design documents, procedures, specifications, repair historie
Ignition Source
Interviews - Do not rule out possible human/behavior causes in the same wa
present

Person comes
into contact
with Hazard

Situation for
consequences
(other failed
protections)
Force to get
material out of
container

No other
way to
make-up
al and human causes, verify your assumptions as to whether a cause is real or not. Use the following methods to rul
rs saw the fire at the bleeder valve, inspection indicates the block valves are kept closed)
sts on parts, lab tests on oil samples, body fluids tests, etc.
matter experts based on their experience or calculation (with the suction pressure noted, the pump specialist felt tha
xist by experienced personnel (the head operators know that every time the injection system is started up, the system
, specifications, repair histories
ehavior causes in the same way you ruled out possible physical ones. It is easier to re-interview the person than spe
se the following methods to rule out causes:

ed, the pump specialist felt that cavitation would occur).

ystem is started up, the system pressure increases).

interview the person than speculate on human thought processes.

 Document

Click on the icon above to open the IF report in Word format

No RC Category
LACK OF SUPERVISION
1

4
 Root Causes

TIDAK ADA PENGAWASAN SAAT PEKERJAAN DILAKUKAN

CIEP List for Root Cause Category
No Root Cause Category Explanation
Audit Includes formal auditing procedures; analyzing
audit results; closing out audit action items.
Could audits or metrics have
indicated where insufficiencies of critical systems
1 may fail, preventing this incident?
Communications Includes communication between work crews;
operating shifts; shift turnover reports; work
direction from supervisors and leaders.
Have instructions
been conveyed clearly? Have
recommendations been passed on and confirmed?

Are turnover logs used as a

communication tool? What systems
2 ensure correct interpretation of communication?
Contract Employee Safety Includes CHESM related root causes; do not use
this root cause simply because a contract
employee was involved in the incident.
Is there
a process that ensures that all contract employees
3 hired, met the standards for company systems?
Design Design standards Chevron Engineering Standards (CES); industry
inadequate or not used standards such as API Recommended Practices;
codes such as NFPA and International Fire Codes;
ISGOTT not used (do not use this root cause if the
codes were not in effect at the time of
4.1 construction).
Design Did not anticipate Design met a standard but the standard that was
the conditions applied did not meet the conditions.
4.2
Design Did not consider Includes instances of the human-machine
human factors interface, such as difficult to ergonomically access
a valve handle; confusing instrumentation and
signage; excessive alarms; noisy and distracting
4.3 work locations.
Design Inadequate Review Includes all aspects of design reviews that
should have identified and corrected a faulty
condition; also includes when the right people
were not involved in the review process.
4.4
Design Inherent Safety Check when an inherently safer design option is
4.5 Design not Incorporated identified, but not adopted
Emergency Response The incident was caused by or the consequences
were made worse by a less than adequate
emergency response plan or effort.
Did emergency
response in any way contribute to the magnitude
of this incident?
Could better emergency response have
mitigated or terminated this incident sooner?
5
Human Factors Includes situations when human conditions
caused or contributed to the incident. Examples
include when a person is overly tired, stressed,
distracted or under the influence of drugs or
alcohol. Can also be used when a person is given
too many tasks to safely accomplish in the time
given. Should not be used just because a person
chose to not follow a procedure.
6
 Incident and Near-Miss Previous near misses or similar incidents were
Investigation not reported, investigated or acted upon and could
have prevented this incident.
Did a previous incident or
near-miss recommend action that would have
prevented this incident? Did
lack of investigating a previous incident contribute
to this incident?
7
Inspection/Quality Control Includes inspection of workmanship; quality of
parts and products including lubricating oils and
chemicals; verification of material; and the
processes that should have ensured those
inspections were properly conducted.

Were the appropriate inspections requested and
made?
Were the proper
8 materials used?
Leadership Accountability Were
they installed
Leadership correctly?
allowed a condition to exist for some
period of time; when clear Isexplicit
there an inspection
expectations
schedule and was it followed?
were not established; when there is an absence of
upper and lower limits of operation; when
insufficient resources or time exists. There should
be factual evidence leadership had opportunity to
correct the faults or should have taken the proper
steps to recognize and correct the faults.
Is this an issue of
enforcement?
Could clearer communications of managements
expectations have prevented this incident?
9
Management of Change Changes occurred that should have been
(MOC) evaluated and corrected via the MOC procedure;
includes organization changes.
Was there
an MOC system in place?
Did the MOC system fail?
10 Was it followed?
Natural Phenomenon Includes incidents resulting from earthquakes,
hurricanes, typhoons, tornados, wild land fires that
originate outside Company property. Evaluate
whether the design considered these natural
phenomena and if not, use one or more of the
design root causes.
Was the incident
caused by an act of God?
(This root cause is often used in conjunction with a
11 design flaw.)
Pre-Startup Safety Reviews A pre-startup safety review should have
(PSSR) identified and prevented the conditions that
resulted in the incident but did not.
Was
the PSSR procedure established and followed?
12 Was the
PSSR adequate?
Preventive Maintenance / Includes all aspects of the preventative
Repeat Failure maintenance processes; also includes when a
situation of repeated equipment failures is
occurring but not acted upon.

13 Was recommended maintenance carried out,

either scheduled or due to prior failure?
 Procedures and Safe Work It has been accepted to deviate from known
Practices Accepted to procedures; consider also leadership
Deviate or Work Routine Not accountability issues.
in Accordance with Accepted
Procedures
14.1
Procedures and Safe Work Includes when a Company representative fails to
Practices Lack of Job oversee a job site; a senior operator fails to
Oversight properly oversee a less experienced operator; a
person in charge fails to adequately oversee a job
site. There should be evidence that an
experienced, knowledgeable person overseeing
14.2 the job could have prevented the incident.
Procedures and Safe Work The people doing the task had all the skills and
Practices Mistake or Mental knowledge, had proper work direction and
Slip priorities, and did not intentionally choose not to
14.3 follow procedures.
Procedures and Safe Work No procedure exists for a task (could be a
Practices None Exists or procedure developed one time specifically for that
14.4 Available task, not just formal standing procedures).
Procedures and Safe Work There is a task procedure, but it is incomplete or
Practices Not Complete or inaccurate.
Accurate
14.5
Procedures and Safe Work All other factors have been eliminated and the
Practices Not Determined team cannot determine why the procedures and
safe work practices were not followed.
14.6
Procedures and Safe Work Closely tied with leadership accountability. The
Practices Not Enforced, expectation to follow procedures is not enforced,
Audited, Expected audited or expected; can also tie to CHESM
process if not included in contract language.
14.7
Procedures and Safe Work People performing the task were not properly
Practices Not Trained on trained on the procedures.
Procedure
14.8
Procedures and Safe Work Closely tied with leadership accountability. There
Practices Other Priorities are other directions or priorities that create conflict
Conflicted with following procedures (e.g., a direction that
demands a task be completed by a specified time
no matter what it takes).
14.9
Procedures and Safe Work Work direction and training programs fail to
Practices Risk of Not describe the consequences of not following a
Following Not Understood procedure or safe work practice; ties closely with
14.10 risk management
Procedures and Safe Work Only when all other procedural root causes have
Practices Willful Deviation been eliminated; the person was trained,
equipped, had clear and proper direction and still
chose to not follow the procedure.
14.11
Risk Management The work crew or job-specific risk management
Inadequate Job Hazard / tools fail to adequately identify the risk. Tools
Safety Analysis typically include the pre-job toolbox talks, JSA / JHA
15.1 processes and permit
Risk Management The higher level design type risk assessment
Inadequate Process Hazard failed to prevent the incident; ties closely with
Analysis Design review and inherently safer root causes.
15.2
Risk Management - A persons decisions put themselves or the
Individual Snap Decision equipment at risk.
Quick Decision That Was
Made Without Assessing the
15.3 Risk
 Supervision and Oversight Includes a supervisor instructing a newer worker;
an experienced operator watching over a newer
operator; a project engineer overseeing a
construction job; a company representative
overseeing a contract employee.

Was the amount of supervision appropriate to the
risk of the work?
Could improved
16 supervision have prevented this incident?
Training / Competency Includes orientation training programs; formal
Was
operator, anyone looking
maintenance at the bigtraining
and technical picture?
programs; and when the competency of the
people doing the work is not checked or verified.
Can tie to CHESM root causes when contract
employees are involved; can also tie to leadership
accountability when workers are asked to do a
task they are not competent to perform.
Did a
training deficiency in any way contribute to this
17 incident?
 Example Root Causes
Insufficient staff to carry out safety audits and management
was not committed

No end of shift written turnover required

Instructions not understood and no process to
confirm understanding

Contract employee safety records not audited by company

A walkway that meets SID but did not provide adequate space
for a maintenance task

No system to ensure local fire department trained in

hydrocarbon firefighting techniques

Person fatigued, bored, distracted or overwhelmed.

 Near-miss reporting and investigation not required

Wrong material installed no positive material identification

process

Procedure audit process not enforced

PSSR process not enforced
Expectations
regarding the use of procedures not adequately communicated

No accountability process for adhering to

procedures A faulty critical level control
system that has been reported for several years but whose
repair keeps getting deferred. Evidence of work direction than
conflicts with OE expectations
A faulty critical level control system that has
been reported for several years but whose repair keeps getting
deferred. Evidence of work direction than conflicts with OE
expectations
No MOC process
MOC not used commonly
viewed as not worthwhile

Lightning, hurricane, earthquake, flood, tornado, storm, etc.

No PSSR conducted prior to startup, not emphasized by

management

No preventive maintenance program

 Less than adequate supervision and/or oversight
Inadequate job planning
Inadequate
coordination of work activities

Chevron employee missed training session and no system

was in place to ensure all training was carried out.
Individual needs more
skill/knowledge to perform the job.
Review of Broken Tenets of Operation

No Tenets of Operation Team Analysis

1 Always Operate within design or
environmental limits.
Intent: Reduce the risk of injury,
environmental releases and equipment
failure & damage by staying within
specified mechanical and operating limits.

2 Always Operate in a safe and

controlled condition.
Intent: Each employee and contractor is
expected to work safely and must seek
out, identify, and correct unsafe and
uncontrolled conditions/actions
immediately.
3 Always Ensure safety devices are in
place and functioning
4 Always Follow safe work practices and
procedures.
Intent: Safe work practices are cast in
concrete so that employees do not have
to rethink why all the steps are necessary.

5 Always Meet or exceed customer's

requirements
6 Always Maintain integrity of
dedicated systems.
Intent: We will maintain the integrity of our
production systems and supporting utility
systems.

7 Always Comply with all applicable

rules and regulations.
Intent: We are expected to achieve 100%
compliance on reporting.
8 Always Address abnormal conditions.
Intent: Identify abnormal conditions,
evaluate the risk and begin resolution
9
immediately.
Always Follow written procedures for
high-risk or unusual situation
10 Always Involve the right people in
decisions that affect procedures and
equipment.
Intent: Decisions are made with
knowledgeable people and the most
current/accurate data and information.
Corrective Action

No. Root Cause Corrective Action RP Due Date

1
2
3
4
5
6
7
8
9

Additional Issues to be considered from this incident

No. Issue Corrective Action Owner Due Date

1
2
3