Major Incident

Sharing & Learning Standard

Elviera Putri
SSHE Advisor
ExxonMobil Cepu Limited

Sharing Session at Forum PAKKEM Migas

17th July 2020
Outline

• Investigation Process

• Purpose

• Scope

• Process and Expectation

• “Within 1 Day” – Communication Requirements
• “Within 3-5 Days” – Communication Requirements
• “Post Incident Investigation” – Communication Requirements

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Investigation Process

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Purpose
To ensure timely sharing and response to early learnings from actual higher
consequence (AHL4+ / IRAT 2000+) personal and process safety incidents in an
effort to eliminate high consequence events of similar causes.

Scope
The Standard fits within the incident management cycle. Good practices exist
for sharing incident information. This Standard enhances consistency, depth, and
feedback on the early learnings of actual higher consequence incidents, and
targets:

• Workforce Performing Like Work – For immediate awareness and longer term learning
• Leadership – For immediate awareness, reinforcement of standards /expectations, and
longer term improvement
• SSH&E / Engineering – For improvements to standards, systems, and/or processes

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Sharing & Learning Standard
This standard does not:
- Supersede a Business Line’s broader OIMS Element 9 Incident Management (IM).
- Supersede Business Line’s Higher Learning Value Incident (HLVI) processes
- Supersede the emergency response severity assessment notification per Business Line
OIMS Element 10 Emergency Response (ER) procedures, which are designed to
mobilize levels of response resources/activities

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Process and Expectations

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Major Incident – Sharing & Learning Standard Flowchart
(details)

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Example of Immediate Communication

Why?
Increase cross functional awareness and “heads up” that an early
communication is coming

Intent of format:
Just a few sentences to communicate known facts that can be
shared

Example:

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“3-5 Day” Field Incident Summary Template & Examples
Why? Increase awareness for front line workers doing similar tasks, an opportunity for
leadership to reinforce site standards, and a “heads up” to expect post investigation
learnings when available

Template: Less words / more photos; enough incident information to provide relevancy
to workers exposed to similar risks

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 Example 1: Illustrates use of verifying safeguards / procedural compliance

Other “procedural” discussion ideas:

• What protocol should be followed when the decision is made to deviate from a procedure?
• How can you ensure everyone understands why a procedure was written the way it was?
• What training opportunities between first line employees, leadership and engineer would be beneficial to
understanding all of the hazards behind a job?
• What is the level of risk tolerance in your group when it comes to potential profit and gain from action? (Are you10
willing to take more risk to save time and/money? Why?)
Example 2: Illustrates use of asking questions to localize issues

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Other “relevancy” questions to consider:
Is there any equipment, in your area, that is not working as designed?
• Do you engage others to help assess the problem?
• Do you find yourself saying, “That has never worked right?” How do
• you mitigate that?
• What procedural issues keep coming up on a regular basis that remain ignored over
time?

Are there any safeguards we bypass to speed up the completion of a task?

• Are you bypassing something that is crucial to operations?
• Are there scenarios that need additional safeguards to protect ourselves?
• Do you rely on automation as the only safeguard for tasks you are doing?
• When the safeguards are down, how do we avoid the situation of solely relying on a
person’s memory to keep us safe? (Daniel had a good alternate safeguard strategy in
place: manually close the three main fuel valves while he lights the pilot; however,
they forgot to close one.)

What is your risk tolerance when it comes performing critical procedures?

• Do you find yourself accepting more risk to save time?
• How can you make sure you do not miss a critical step for jobs you perform often?

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Example 3:

Illustrates how a BL can make

it relevant for their
organization by providing links
to their standards

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Final Incident Investigation Summary Template
Why? Facilitate local level consideration of lessons learned, standards and systems
adequacy/health, and leadership engagement opportunities

Template: A focus on the key findings about why the incident occurred, linked to the
health of key systematic prevention and mitigation safeguards at the time of the incident

Page 1:

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Page 2:

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Thank You

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Incident: <IMPACT #>
OIMS Tie: <entered>
HL: XX LSA: <entered>
What Happened?
Use this space to describe succinctly what happened. This space
will also be mapped to IMPACT executive summary for future
automation capability
How to Prevent
Future Events
This space used to reinforce
specific items to consider or
actions to take: Examples
• Stop Work Authority
• Pre-task planning is..
Specific
• Flagger must be
present…
Safety Alert: Title and Mo/Yr
Picture#1
Provide a description
Picture#2
Safeguards & Layers
of Protection
This space used to recognize
successful and failed
protections: Examples Provide an explanation
Examples:
X Work Planning -
description What Could Have Happened?
X Stop Work Authority -
description
✓ Hazard Recognition - Use this space to communicate the
description
potential finding.
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 CRAFT Engagement
Event Details – Classification LXX (with an explanation what each X means. Example: Actual 1, minor hurt with the
potential for a 4, fatality)

<Incident description> will be eventually mapped to IMPACT for automation

Discussion points for the “What Happened?”

Ask workers why they think this happened
Are you comfortable calling “time out” to revisit work plan when something changes?
Is your pre-task planning normally specific to the task?
Does everyone involved in the task understand the “line-of-fire” hazard(s)?
Should the workers have Stopped the Work? Would you have intervened?

Ask workers to identify how their potential hazards for the day can be prevented
When could a similar incident happen to them on their current job?
How do you help your co-workers see and get out of the “line-of-fire”?

Impact/Active Learning discussion ideas

Ask workers to get in groups of 2 or 3 to discuss:
How do you approach someone to intervene when they are a Supervisor or an Authority Figure?
What are ways to eliminate working under temporarily supported / fit up loads?
How would your family / loved ones be impacted if you were severely injured (paralyzed) or killed at work?

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