1 UNPLANNED EVENT: LOPC ( LOSS OF PRIMARY CONTAINMENT)

The following scenario details a multi-dimensional safety incident resulting from an LOPC
with a subsequent investigation process.

At 9:37am on Tuesday, 3/7/12 the gauge on a diesel storage tank failed, resulting in a tank
overflow and spill of diesel to the module floor. In the process of securing the area for clean-
up, the Operator Peter Bolt, inadvertently slips on the diesel and falls, resulting in a fractured
ankle. Peter’s shift supervisor (Don) calls for medical assistance. Don records the loss of
primary containment (Event 829).

Don later amends Event 829 to add the material release and injury types to the event report.
While amending the event he identifies John Craw to lead the investigation. John receives
confirmation through an automated notification from the system. John completes the
investigation and adds an action to Event 829 for Dan Fuller, the plant engineer to perform a
root cause failure analysis on the tank gauge. Dan receives notification from the system,
performs the root cause analysis and raises a work order to replace the tank gauge. Upon
completion, the work order for the gauge replacement is linked to Event 829 to enable a
complete record of the event and corrective actions.

The investigation shows that the gauge that failed was considered obsolete by the vendor and
should have been replaced 6 months previous. John recommends a Lessons Learned be
issued to remind sites of the need to replace the gauge. John closes the event after the actions
are signed off and the Lessons Learned has been issued. The event is approved by Michelle
Jones (site manager).

Later that month Peter's injury worsens and he has a day off work. Don reopens Event 829
and upgrades the injury classification to a Day Away from Work Case injury. The changes to
the event are automatically sent to Michelle.

Helen generates an end of month report listing events by type, by location, by Division, the
location Day Away from Work Case Injury Frequency Rate, the Recordable Injury
Frequency Rate, Outstanding Investigations and Overdue Actions.

Actor Role
Peter Bolt Operator
Don Shift Supervisor
John Craw Investigation Lead
Dan Fuller Plant Engineer
Michelle Jones Site Manager
Helen Site Health and Safety Manager