1.1 investigating accidents

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NEBOSH, International Certificate in Oil & Gas

Operational SafetyModule 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


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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


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VIDEO CASE STUDIES


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The process and purpose of

investigating occupational incidents


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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


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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 andDangerous Occurrences Regulations 1995 (RIDDOR) that require you to reportand 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


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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!


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Immediate cause cause for accidentsPremises - 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


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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

MonitoringAdequacy of pro-active and reactive

Reviewing Overall review and response to change


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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


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WitnessesInterviewing 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


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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


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Barriers for reporting accidents / incidents and near

misses

Blame culture

Human error

Perception

Attitude

Unmotivated


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The organisational requirements for recording

and reporting occupational incidents


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Why must accidents and ill health be reported?

As an employer, a person who is self-employed, or someone in control of workpremises, you have legal duties under Reporting of Injuries, Diseases andDangerous Occurrences Regulations 1995 (RIDDOR) that require you to reportand 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

1.1 investigating accidents

Documents