HSE name

Main contractor Incident Investigation

– LTI# - Date ofguidance
incidentnotes

HSE Investigation template and guidance

LTI, HiPo and HVL Incident

Lost Time Incident - High Potential – High Value Learning

Confidential - Not to be shared

outside of PDO/PDO contractors
 HSE name
Main contractor Incident Investigation
– LTI# - Date ofguidance
incidentnotes

Process flow for investigations

Notification Quality sign off IRC/MDIRC

Kick off MSE3 IRC Minutes

Investigation Reporting draft

PIM action
close out

Confidential - Not to be shared

outside of PDO/PDO contractors
 HSE name
Main contractor Incident Investigation
– LTI# - Date ofguidance
incidentnotes
Info to be established during Kick Off meeting
Incident Investigation Terms of Reference (ToR) Remember guidance notes on bottom of slides
Investigation protocols - Documents to be used to investigation PR 1418
Incident Owner - Name and reference indicator
PIM No - XXXXXX
Investigation Team Leader - Names, reference indicators, role in investigation
Special terms - Special conditions/requirements of the investigation (e.g. joint PDO/contractor)
Subject Matter Experts – as required to be discussed during Kick Off meeting
Investigation deliverable - The team is responsible for investigating the incident and completing the following: Investigation
report , MD/IRC presentation and learning pack.
Dates to be adhered to - Incident owner to book directorate IRC in line with time line
Previous LTI / NAD / Asset Integrity - Previous incident, similar incident, including PIM No from company
Immediate Cause – Bring to kick off meeting for agreement
Critical Factors –
1.
2.

Investigation Team Members- Names, reference indicators or job title, role in investigation
Note: Contractors should lead their own investigations, not PDO

1. Investigation Team lead Name Reference Ind, Role, attend the scene (yes / no), HII (ICAM) trained (yes / no)
2. Name Reference Ind, Role, attend the scene (yes / no), HII (ICAM) trained (yes / no)
3. Name Reference Ind, Role, attend the scene (yes / no), HII (ICAM) trained (yes / no)

If not HII (ICAM) trained the contractor is to provide Incident investigator, level of competency assurance from senior
management

Evidence repository must be provided electronically on data stick prior to MSE3 IRC

Confidential - Not to be shared

outside of PDO/PDO contractors
 HSE name
Main contractor Incident Investigation
– LTI# - Date ofguidance
incidentnotes

Timetable to be communicated during kick off meeting

•Incident classification, Critical factors, SME requirements, Timelines for reports

Rolling Days Action / Task

0 Notification received from MCOH
0-1 Initial Notification, and first Alert
1 Kickoff meeting
10* 1st Draft of report to MSE3 team - Review 1st draft return consolidated feedback
2nd Draft of report to MSE3 team - Review of 2nd draft return consolidated feedback
21 Final revision for MSE IRC
23* MSE3 IRC
Final report - MSE3 to complete QA/QC letter
30* Director IRC
42 MDIRC

* Escalation process milestones for not keeping to the timeline:

+3 days over due reminder 1 to Investigation Team Leader, HSE Team Leader and MSE 3
+5 days over due reminder 2 to Investigation team lead, HSE Team leader, MSE 3, MSEM and Director

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Singular photograph of the incident: (MDIRC only)

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI
- Date of No), date of incident- header on all
incident
slides

Bulleted description key points from the incident (MDIRC only)

• Insert key findings maximum 5 bullet points (high level)

Confidential - Not to be shared

outside of PDO/PDO contractors
Main Contractor Name, Incident
Main contractor name – Type
LTI# (eg. LTI of
- Date No), date of incident- header on all slides
incident
Incident details

PDO directorate/dept : (e.g. OSD /OSO)

Contractor name/number: (subcontractor-contractor-PDO)/CXXXXXX
Incident owner : Name / Ref Ind
Location : Area / unit - (road/yard/station/rig/hoist/plant etc)
Incident date & time : (d/m/yr) / (24 hour clock) – advise if estimated
Incident type : Fatal, LTI, high potential, significant incident etc
Actual severity rating : Number (1-5) / letter (P, E, A,R) – from RAM
Potential risk rating : Letter (A-E), Number (1-5)/letter (P, E, A,R) from RAM
Names of any IPs : Names of the injured people (for fatality add marital status with kids age
and sex)
Description of injury/damage: Worst injuries (fractures, head injury, amputation etc)/damage, body part
PIM ID : Number assigned in PIM
Immediate cause : Short description of what caused harm
Key mgmt system failure: Key Management system failure from conclusion slide including number
Previous LTI (PIM No.) : (LTI/HiPo) of the contractor, this applicable to all contracts with PDO and
not specified to a specific contract No.

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI#00),
- Date date of incident- header on all
of incident
slides

Description of the incident: (Read the guidance in foot notes of each slide)

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Photographs, diagrams & sketches:

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Sequence of events/timeline:
No. Date Time Description of event

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Critical Factors:

1. Critical Factor 1,
2. Critical Factor 2,
3. Critical Factor 3,

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Key Causational Factors:

1. Critical factor 1

Causational factor 1:
Causational factor 2:
Causational factor 3:

2. Critical factor 2

Causational factor 1:
Causational factor 2:
Causational factor 3:

3. Critical factor 3

Causational factor 1:
Causational factor 2:
Causational factor 3:

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Findings: Immediate causes:

Unsafe actions:
Immediate ICAM Causation description Justification for causation cited
Cause Ref No #

Unsafe conditions:
Immediate ICAM Causation description Justification for causation cited
Cause Ref No #

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Findings: Underlying causes (human and workplace):

IC Ref No# UC Ref No# ICAM Causation Justification for causation cited
Description

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Findings: management system failures (MSF)

UC Ref No # MSF Ref No # ICAM Management Failure Justification for management system failure cited

Description

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor name – LTI#
Incident Type (eg. LTI),
- Date date of incident- header on all slides
of incident
Life Saving Rules Were life saving rule breaches related to the incident? - Yes / No?

Who broke them? Which rule (s):

Names/Ref Inds: ………………………………….……..

Did the life saving rule breach, cause it? - Yes / No?
Why……………………………………… ..
………………………………………………………………

Delete which is not applicable

Is consequence management in PIM actions

Yes / No ?
PIM action number:

If a contractor broke the rule has the

Contract Holder been informed of the action
taken?

Yes / No ?
Confidential - Not to be shared
outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident

PDO Contract management to be completed and confirmed by the contract holder

Report on the state of the contract management and whether any omissions were causational
No Contract management process Evidenced Causational Comments
Y/N Y/N
1 HEMP signed off by Contract Holder

2 Annual HSE plan approved and tracked by Contract

Holder
3 Monthly HSE meetings held with Contract Holder and
actions recorded
4 Tracking register for close out of HSE actions in place

5 HSE audits, inspections , site visits conducted as per

plan
6 HSE competency assured in review of HSE training
matrix (Include % completed)
7 HSE VTCs implemented correctly

8 HSE procedural step-outs managed effectively

9 Evidence of MOC being effectively managed by Contract

Holder
10 Evidence of HSE defaults for non compliances

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Immediate actions taken:
Actions taken Date Action party Status
PDO /
contractor

1 Review HEMP for appropriateness in regards to the

incident, is it used, how is it translated into action, last
review date and what changes have been made.
2

*Immediate actions must be completed within 7 days of the incident

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Remedial actions planned:
Remedial actions planned MSF Target Contracto PDO Action party PIM action Status Post action
Causatio date r action action accepted No. Open / verifier
n number party party for Yes / No Closed for PIM
PIM

1 Mandatory action: If LSR is identified

it must be flagged in PIM as LSR

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Recommendations for MDIRC/IRC endorsement:
Recommendation No 01 Status Endorsed/Not endorsed

Causations No
Recommendation
.
Action party Reference Ind. Target date

Revised
recommendation
after IRC review

Recommendation No 02 Status Endorsed/Not endorsed

Causations No
Recommendation

Action party Reference Ind. Target date

Revised
recommendation
after IRC review

Confidential - Not to be shared

outside of PDO/PDO contractors
Main Contractor Name, Incident
Main contractor name –Type (eg.
LTI# LTI), date
- Date of incident- header on all slides
of incident

Incident Review Committee

Contractor Commitment Declaration
I, Mr. …………………………….…………………. CEO, and

I, Mr. ………………………………………………. Operations Manager

Of the Company: ………………………………….

We have signed below to demonstrate to PDO our commitment to personally conduct the
necessary follow up to ensure the effective implementation of the agreed actions contained in the
IRC endorsed investigation in all our units, and to demonstrate our personal leadership in
implementing the necessary consequence management in case of re-occurring of similar incident.

Moreover, we will disseminate the learning from this incident to all our workforce and our
subcontractors.

Mr. …………………… Signature:………………………… Date:………………..

Mr. …………………… Signature:………………………… Date:………………..

Confidential - Not to be shared

outside of PDO/PDO contractors
 PDO Second Alert
Main contractor name – LTI# - Date of incident

Date: Incident title

What happened?
Short description of what happened

Photo explaining what

was done wrong
Your learning from this incident..
(This must solely relate to the people at risk of harm or people at risk of
causing the harm)

• Learning points for them from the investigation

Photo explaining how it

Strap line – should be the key (keep short and
should be done right
memorable )

Confidential - Not to be shared

outside of PDO/PDO contractors
 Management self audit
Main contractor name – LTI# - Date of incident

Date: Incident title

As a learning from this incident and ensure continual improvement all contract
managers must review their HSE HEMP against the questions asked below

Confirm the following:

1. 1
2. 2
3. 3
4. 4
5. 5

* If the answer is NO to any of the above questions please ensure you take action to correct this finding.

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Directorate or MD IRC Minutes: Date held:

Directorate/dept:
Identity of minute taker: Name/Ref Ind:

Item No Action Action party Target date

1

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident

Supplementary investigation findings:

The findings are points to note but were not causational in the incident

1. Non causational findings to the incident but worth to address

Did you identify something important that is worthy of note
2. Emergency response,
how effective was it, did it impact on the severity?
3. People,
training, age, experience, nationality, medical conditions, disciplinary record etc should be in the form
of a table with dates completed
4. Equipment,
type, serial number, maintenance, inspection, failings, appropriate for use etc should be in the form of
a table with dates completed
5. Operational management ,
sub contractor management, supervision, TBTs, SJPs, SWPs, STOP, availability on site etc
6. Relevant environment,
workplace conditions, weather, lighting, floor surface, dust, cramped etc
7. Previous relevant incidents/ learning‘s
what, where, were they aware of it, were controls introduced

Confidential - Not to be shared

outside of PDO/PDO contractors
 Main contractor name – LTI# - Date of incident
Investigation Team Members- Names, reference indicators, role in investigation

Name Ref. Ind Role Attended HII* Date attended

the scene trained HII training
Yes / No Yes / No
1 Investigation Team Lead
2
3
4
5
6
7
8
9
10

*HII – HSE Incident Investigation

Confidential - Not to be shared

outside of PDO/PDO contractors