(Working Together for Safety) Recommendation 029 E Best Practice for Investigation and Inquiry into HSE Incidents TABLE OF CONTENTS 0. Introduction 1. Purpose 2. Definitions 3. Classification of incidents 4. Criteria for selecting level 5. Mandate 6. Process 7. Investigation / Inquiry Group 8. Roles and responsibilities 9. Quality assurance 10. Report 11. Follow-up 12. Communicate learning items Flow chart Example of table of contents for the report Page 1
0. INTRODUCTION In preparing this Best Practice, emphasis has been placed on ensuring that the processes surrounding investigation and inquiry can ascertain the facts of what occurred, and at the same time identify and recommend measures to prevent the incident from recurring. Furthermore, it is a prerequisite that the processes the companies currently employ to classify incidents and their potential or risk, can be retained. We have endeavoured to achieve a Best Practice that safeguards all parties in an incident in a correct and fair manner. The principal enterprise is responsible for ensuring that an investigation or inquiry is conducted. 1. PURPOSE The purpose of these guidelines is: To ensure a high-quality, thorough and objective investigation or inquiry into the incident To ensure follow-up of HSE incidents with a view towards learning and transfer of experience to prevent recurrence 2. DEFINITIONS Underlying causes Factors or acts that create situations or environments that enable the direct triggering cause of the incident. Barriers A function to prevent incidents from occurring by preventing the course of events, or reducing the extent of the consequences if an incident should nevertheless occur. Direct triggering cause A factor or an act that triggers the incident Page 2
Owner of the incident The owner of the incident is the head of the unit, department or activity where the incident occurred. Inquiry A formal process intended to clarify the course of events, causes and consequences, and identify effective, corrective and preventive measures. The inquiry will be conducted by an appointed, independent group on behalf of the company s management. Inquiry Leader The Inquiry Leader shall be impartial in relation to the incident. The Inquiry Leader shall be appointed by the Principal and shall lead the Inquiry Group. If the company has established its own independent unit to conduct inquiries, the Inquiry Leader shall be appointed by this unit. Impartiality No members of the Inquiry Group must be directly or indirectly involved in the incident or be disqualified in any other manner. Course of events A chain reaction of individual incidents that together constitute an incident. HF Human factors. This is defined as the factors that may influence people and their behaviour. (See www.hse.gov.uk/humanfactors/) HSE Incident (Incident) A hazard and/or accident situation that has occurred and may entail or has entailed injury/damage, pollution or loss of economic assets. Principal enterprise The party responsible for coordinating the safety and environmental work of the individual enterprises at the workplace http://www.ptil.no/regelverk/r2002/rammeforskriften_n.htm#_toc138663263 MTO Aspects concerning Man, Technology and Organisation HVO Senior Safety Delegate Page 3
Criticality Forum A forum consisting of HSE personnel, HVO and management Mandate A formal description from the Principal that describes the extent of the inquiry or investigations, and grants authorisation to conduct the inquiry or investigation. The mandate shall be agreed with the Inquiry Leader. Principal A superior owner of the incident and responsible for initiating an investigation or inquiry, and who is the recipient of the final report. The Principal shall ensure that measures are implemented. Investigation An investigation has the same purpose as an inquiry, but can conducted locally within the unit or department where the incident occurred. Investigation / Inquiry Group A group composed in such a manner that all relevant parties are represented and professional competence is safeguarded. Risk classification and the nature of the incident govern the group s composition. Investigation Leader The Investigation Leader should be impartial in relation to the incident. The Investigation Leader will be appointed by the Principal and shall lead the Investigation Group. VO Safety Delegate 3. CLASSIFICATION OF INCIDENTS In order to determine whether an incident shall be subject to an investigation or an inquiry, it must be classified. The classification specifies a minimum requirement. The classification is made as follows: the owner of the incident, the workplace managers and the Safety Delegate (VO) assess actual and potential consequences and the probability of recurrence and/or escalation to potential consequences. Quality assurance of this classification is subject to whether the incidents can be dealt with in a Criticality Forum or by qualified, independent personnel at a higher organisational level. Page 4
Incidents that comprise several types of consequences shall be classified in accordance with the consequence with the highest degree of severity. The result of the classification is given in the form of a colour code in accordance with a risk matrix. A good practice for identifying the Principal is: Highest potential/major accident (red); the Principal is the Managing Director or General Manager Next highest (red); the Principal can be the Onshore Field Manager, Production Director or similar Third highest / Medium (yellow); the Principal is the Offshore Installation Manager / Site Manager 4. CRITERIA FOR SELECTING LEVEL The level and the composition of the Inquiry or Investigation Group are determined in relation to the classification of the incident (see Chapter 3). Red / High classification of the incident Yellow / Medium classification of the incident Entails inquiry Entails investigating the matter For incidents and matters with a lower degree of severity (classified as Green / Blue / Low) and which are thus not automatically investigated individually, an assessment shall be made whether to conduct an overall investigation or inquiry to identify common features in the course of events and cause scenario. 5. MANDATE There is a distinction between an investigation and an inquiry. In both cases the Principal issues a mandate. Investigations can be conducted on the basis of the methodology for inquiries, but the same degree of detail is not expected in the report. The mandate for an inquiry shall as a minimum contain the following items to be clarified: Page 5
a) the actual course of events and consequences, b) other potential courses of events and consequences, c) any nonconformities in relation to requirements, processes and procedures, d) human, technical and organisational causes of the hazardous or accident situation, and in which processes and at which level such causes can be found, e) which barriers have failed, the causes of barrier failure and which barriers should have been established, f) which barriers functioned, i.e. which barriers contributed towards preventing a hazardous situation from developing into an incident, or which barriers reduced the consequences of an incident, g) Immediate compensating measures and measures that should be implemented to prevent similar hazardous and accident situations. The mandate should also contain the following items: h) Define the authorisations of the Inquiry / Investigation Leader in matters such as stopping work, cordoning off and releasing areas, etc. i) Define who is the owner of the incident and the group s contact person j) Members of the Investigation / Inquiry Group k) Principal l) Timeframe m) A brief description of the incident n) Assurance from the Principal that personnel who will be involved are secured through the Working Environment Act and rules and regulations 6. PROCESS The process is shown in the flow chart in Appendix 1, page 13 The actual investigation or inquiry shall be conducted by considering aspects of the incident concerning Man, Technology and Organisation (MTO). Page 6
If several companies are involved in the incident, only one group should be established. (Inquiry/investigation under the auspices of the authorities comes in addition). 7. INVESTIGATION / INQUIRY GROUP The group The group should cover the following functions/roles: Leader Method specialist Discipline specialists Safety Delegate Service appointed by the Senior Safety Delegate (HVO) in the principal enterprise and the HVO in the companies concerned Representatives from other companies when this is relevant One person can have several roles in the group. It is also a prerequisite that the group is composed in such a manner that its overall competence is fully adequate for the incident subject to investigation or inquiry. Investigation / Inquiry Leader The leader must have competence (a separate discipline plan must be prepared) and experience in incident inquiry. It is important that the leader can provide professional guidance to the rest of the group he/she shall lead. It is also important that the leader is familiar with the processes and organisational matters subject to investigation or inquiry. The leader must have integrity and instil confidence in the parties implicated. Method specialist This person shall be trained and have experience in incident inquiry, the tool to be used and knowledge of prevailing procedures for investigation and inquiry. Discipline specialist(s) The discipline specialist(s) shall be experts in the discipline field(s) comprised by the incident. General training in incident inquiry, so that the basic principles are familiar, is an advantage but not a requirement. For all investigations or inquiries it is recommended that discipline specialists in organisations and behaviour be included. Page 7
Safety Delegate Service The representative(s) shall contribute to safeguarding the employees interests in relation to the satisfactory implementation of the investigation or inquiry. The participant(s) from the Safety Delegate Service shall be trained in incident inquiry in accordance with the discipline plan. Suppliers / subcontractors It is a prerequisite that the representative has ample knowledge of matters concerning the suppliers/subcontractors involved in the incident. 8. ROLES AND RESPONSIBILITIES The Principal shall: Implement an investigation or inquiry on the basis of the incident s classification Prepare a mandate for the group that will be conducting the investigation or inquiry Put together and appoint a group to conduct the investigation or inquiry Ensure that impartiality is safeguarded Ensure that the investigation/inquiry is given priority Communicate with the Investigation / Inquiry Leader and be responsible for all internal and external information Sign for completion of task in accordance with the mandate and release the report for distribution Ensure that relevant learning items from the report are communicated in his/her own organisation and in the industry Ensure implementation of follow-up and recommended measures Follow up implementation of measures adopted The Investigation / Inquiry Leader shall: Put together and head the group on the basis of the mandate given by the Principal Ensure that disqualified members of the group are replaced if impartiality problems are identified underway Page 8
Gather facts through studies, inspections and interviews Release the incident area upon internal investigation or inquiry Seek to clarify the course of events Analyse materials and facts gathered Identify direct triggering causes and the underlying causes Continuously inform the Principal of any findings that require immediate measures Communicate with the Principal and units involved Propose measures Write and present a report Ensure that the report is quality-assured Obtain approval from the members of the group The owner of the incident shall: Secure the area and, if necessary, stop relevant work in the area where the incident occurred Assist the Investigation or Inquiry Group by facilitating the work, accommodations and other practical tasks Implement measures in his/her own unit The Method specialist shall: Be responsible for ensuring that the method tool supports the group s work Discipline specialists shall: Provide necessary support to the group through his/her professional competence. Typical discipline areas are: Electrical disciplines Process disciplines Mechanical disciplines HSE Human Factors (HF) Cranes & Lifting Drilling Maritime Page 9
etc. The Safety Delegate Service shall: Ensure that the employee s obligations and rights are safeguarded (ref. Working Environment Act - AML) Suppliers / subcontractors shall: Represent their companies in relation to the company where the incident occurred and shed light on the incident from the company s point of view. 9. QUALITY ASSURANCE The draft report shall be quality-assured and quality-controlled before completion. The Inquiry Leader can do this by presenting the report to a permanently appointed panel ( Review Panel ). In the event there is no permanently appointed review panel, the Principal and the Inquiry Leader shall consult and appoint persons to participate in the consultation (for example personnel in involved unit(s), legal staff, other internal units and any external companies, if relevant). The Inquiry Group Leader will conduct the consultation and receive comments from the parties comprised by the consultation. Following the consultation process, the comments received by the Inquiry Group will be reviewed. The Inquiry Group determines which comments to comply with before the final report is prepared and submitted to the Principal together with suitable presentation material. Any disagreement in the Inquiry Group concerning conclusions or proposals for measures shall be stated in the report. 10. REPORT The report shall as a minimum contain: A summary of the main points The group s members, mandate and signatures Page 10
Mandate reply Diagrams and/or models that explain the method and conclusions Other matters Other relevant material 11. FOLLOW-UP When the inquiry report has been approved by the Principal, all recommended measures shall be registered in the company s system for follow-up of undesired incidents. The Principal determines which of the recommended measures shall be implemented. If the Principal decides not to implement a recommended measure, this shall be substantiated and documented in the system for undesired incidents. The Principal shall also consider whether further measures shall be implemented than those recommended in the report and when and how the measures shall be implemented. The Principal shall also approve the parties responsible for measures. The inquiry report and list of adopted measures shall be presented in relevant Working Environment Committees (AMUs). Persons designated as responsible for measures must be informed in advance and prior to setting a deadline. This is to ensure that the persons responsible for measures have an adequate understanding of the measures, and that time and resources are set aside so that the measures are implemented in qualitative good manner. The measures are closed when the person responsible for the measures reports completion, and his/her supervisor has approved implementation. It is recommended that the companies regularly conduct internal audits to qualityassure the expediency of the measures. The report shall be entered into the company s system for follow-up of undesired incidents so that it can subsequently be consulted for clarification related to the measures. 12. COMMUNICATE LEARNING ITEMS When the investigation and inquiry reports have been approved the company shall have a system in place that ensures that learning factors from the incident can be shared both internally and externally. The method for communication of experience Page 11
must be adapted so that correct information is given to relevant personnel. The sensitivity of the information should be considered, particularly related to personal data and security incidents. The reports should be easily accessible internally in the company in a suitable software tool. It is recommended that a one-page bulletin ( Safety Alert ) be prepared, at least for red incidents, so that this information reaches all relevant personnel, thus helping to avoid recurrence of the incident. The companies must highlight the one-page bulletin internally and facilitate its use in a proactive manner so that learning from the incident is as optimal as possible. This may be achieved through review in relevant meetings. It is recommended that the one-page bulletin contain the following items: o Brief description of the work activity and the course of events that led to the incident o Description of what happened and the consequences o Relevant learning items o Explanatory illustrations o Reference or link to the complete inquiry report Externally, the one-page bulletin can be made available through a common website/portal with search functions for easy retrieval and systemisation. In relation to the assessed utility value, it may in some cases be expedient to present the incident in an interactive animation film. The companies should otherwise present relevant incidents in suitable forums. Page 12
Appendix 1: Investigation / inquiry process - distribution of work Principal: Order investigation /inquiry Prepare mandate Appoint investigation / inquiry group Propose candidates Adopt and follow up measures Inform Investigation / Inquiry Leader: Put the group Inspection and collection of evidence Reply to mandate tasks Prepare and present a preliminary report Initiate consultation round Prepare final report Owner of the incident: Stop the work Secure evidence Assist the group Implement measures Page 13