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Incident reporting Updated PR1418 procedure July 2009

Incident reporting Updated PR1418 procedure July 2009. Background Why change. Introduction of the Life-Saving rules per 1 July 09 requires formalisation of reporting and investigation of suspected Life-Saving rules violations. Currently this is not embedded in the PR1418

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Incident reporting Updated PR1418 procedure July 2009

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  1. Incident reporting Updated PR1418 procedure July 2009

  2. Background Why change • Introduction of the Life-Saving rules per 1 July 09 requires formalisation of reporting and investigation of suspected Life-Saving rules violations. Currently this is not embedded in the PR1418 • Objective of this communication: • Clarify details of the reporting and investigation process in case of suspected Life-Saving rules violations.

  3. The changes Updated Incident Reporting and Follow up Procedure • All suspected violations of the Life Saving rules whether or not an incident occurs shall be reported in Fountain. • Investigation report where a Life-Saving rule violation was suspected, can be limited to “the failed life saving rule”, “the human error/violation type” “the precondition” and “the underlying cause”. • If concluded that a Life Saving Rule was violated, the incident owner should record in FIM which Life Saving rule was violated. • Changes have been approved by MSE and is aligned to changes in EP2005-170 • The focus is on prevention and not on dismissal of workers. The worst consequence is that someone is injured due to violations of our Life-Saving rules

  4. Additional information A: In the current EP standard (EP2005-170 ST) it is not well defined how to report violations of rules in cases there is no actual injury/damage. Also the type of investigation and report for these violation of rules is not explicit. To arrive at a simple and consistent process across EP, the procedure is updated, with focus to Life-Saving Rules violations B:“Ticking the box” in FIM that life saving rules was violated is done by incident owner after the investigation concludes that there was a violation. The consequence management is done by HR, based on the investigation report, local legislation and other relevant information. C: As part of the investigation report, the preconditions under which the suspected violation took place is investigated. If supervisor created the conditions, his role will be investigated as well. D: Identification of the “violation type”, “precondition” and “underlying cause” of the suspected violated rule are essential to provide a picture under which the suspected violation took place. It is in line with EP’s incident causation theory.

  5. New FIM input Updated Incident reporting and follow up procedure In FIM incident management – “Add Investigation”/”Immediate Cause”/

  6. For any questions ask Willem Peuscher UI HSE or David Milne UI HSE

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