Event Reporting and Investigation: at The Completion of This Module, You Will Be Able To

Event Reporting and Investigation
At the completion of this module, you will be

able to:
– Understand the application of QHSE Standard 2 in the
Schlumberger
Schlumberger Private
workplace
– Understand what, how, when and why to report SQ &
Private
HSE events
– Understand the loss causation model basic concepts
Owner: MEA / David Allison & Mark

Revalidated on: 3 August 2004: QHSE1-Reporting & Investigation
Cooper
Event Reporting and Investigation
“All serious accidents and potentially serious incidents shall
be investigated and analyzed.
Commitment, Leadership and Accountability
Lessons learned shall be communicated and corrective
actionsPolicies
implemented.
and Objectives “ Improvement
Schlumberger
Organization and Resources
Private
Contractor and Supplier Management
Corrections
Risk Management
Business Processes
 Performance Monitoring and Improvement Control
Audits and Reviews

Cooper
HSE Management System Objectives
Implementation and Monitoring
• Encourage reporting and recording of all incidents.
Schlumberger
• All serious and potentially serious occurrences shall be
investigated
Private
• Investigation teams shall include line management, the local
QHSE organization and appropriate internal or external
resources.
• Investigations shall be conducted according to the
Schlumberger accident investigation model.
• Line management shall prioritize the remedial actions

Cooper
QHSE Reporting Standard
• In order to ensure compliance with the HSE
Management System objectives two QHSE
Standards have been developed that outline the key
requirements in regards to SQ and HSE Reporting
Schlumberger
• The standards focus on the proactive identification
Private
and reporting of all risks, and the thorough
reporting and investigation of all SQ & HSE events.
• Refer to the SQ and HSE Reporting Standards for

more detailed information

Cooper
What is a Reportable QHSE event?
HSE Event (accident)
An undesired event which results in:
– Harm to people (fatality, occupational injury/illness)
– Damage to vehicles, assets, facilities
Schlumberger
– Damage to the environment
SQ Non-conformance
Private
An undesired event which results in:
– Non productive time (NPT)
– Loss of revenue
– Failure in process delivery
– Failure of product
– Damage to reputation and potential loss of future work

Cooper
What is a reportable QHSE event?
Near miss
• An undesired event, which under slightly different
circumstances had the potential to cause a HSE
Schlumberger
event or SQ non-conformance
Private
Hazardous situation
• Any situation where a substandard SQ or HSE
condition is present and/or a substandard act can
occur, or has occurred.

Cooper
How to report QHSE Events
QUEST
– The QEST system is the standard Schlumberger data capture system for
reporting all QHSE events
QHSE Improvement Kit
Schlumberger
– Improvement kits are the standard “quick and easy” paper system for
reporting QHSE events
Private
• Other systems exist within segments and locations for reporting
QHSE events. Ask your supervisor for more information.
• Examples of other reporting tools include:
– Using a STOP Card
– Verbally to your colleagues
– Verbally to the LPT Team
– Verbally to your Supervisor

Cooper
Who Needs to Report QHSE Events?
• All personnel are responsible for actively

participating in the reporting of SQ & HSE
events
Schlumberger
Private
Cooper
Notification and Reporting of QHSE Events
Catastrophic Events
• All catastrophic events must be captured in English in QUEST
within 24 hours. In addition, a HOTLINE message may be required
– ask for assistance from your supervisor if you are not sure.
Schlumberger
Major and Serious Events
• All major and serious events must be captured in English in QUEST
within 48 hours.
Private
Light Events, Near Misses and Hazardous Situations
• Light, near misses and hazardous situations must be captured in
QUEST and although reporting in English is strongly encouraged,
the official language of the country where the event occurred can be
used.
• Clarification on the CMSL classifications can be obtained from the QHSE

Reporting Standard
Cooper
Event Investigation and Closure Process
• After notification and reporting, all Schlumberger

Involved CMS HSE events shall be investigated and
preliminary action plans developed and documented in
QUEST within 15 days.
Schlumberger
• All Schlumberger Involved Light and Serious HSE events,
for which the potential risk level is between -12 and -25
Private
(as defined in the HARC standard), shall be treated as a
major accident, and consequently shall be investigated
with the same dedication.
• All QHSE events and associated RWPs must be reviewed
before closure by the appropriate line management as set
in the following responsibility matrices.

Cooper
HSE Investigation Responsibility Matrix
Schlumberger
Private
Cooper
SQ Investigation Responsibility Matrix
Schlumberger
Private
Cooper
Loss Causation Model
• The Loss Causation Model (LCM) is:
– A methodology to help analyze and understand why
incidents occur
Schlumberger
– Systematic analysis tool to identify the QHSE
management system failures which allow incidents or
Private
near incidents to occur

Cooper
Loss Causation Model (LCM) Principles
• Accidents don’t just happen.

• Multiple causes usually contribute.
• Fixing immediate causes is not prevention, and
Schlumberger
root (system) causes must be identified.
• Root (system) causes are created by a lack of
Private
management system control.
• Plans of action must correct the root causes and
lack of controls.

Cooper
The Loss Causation Model
• The Loss Causation Model, shows how a lack of control can
lead to a sequence of events that eventually leads to a loss.
• When applying the loss causation model for incident
investigation purposes it is important to start at the Loss and
Schlumberger
work backwards through the model.
• Generic categories exist in QUEST to assist in classifying
information for each step of the model (shown in yellow in next
Private
slides)
Immediate Causes
Lack of Control
Root Causes
Incident
Loss
Cooper
Loss
All Incidents result in a Loss. The loss can be categorised as either:
• people (injury, death)
• property (equipment damage, lost tools)
• process (non productive time, re-work, revenue)
Schlumberger
• reputation (lost work)
Example Loss: Broken leg, time off work, vehicle damage
Private
Immediate Causes
Loss of Control
Incident
Root Causes
Loss
•People
•Property
•Process
•Reputation
Cooper
Define the Incident / Accident
An incident/accident is defined as an undesired event which results
in:
• harm to people (fatality, injury, illness)
• damage to vehicles, assets, facilities
• damage to the environment
Schlumberger
• losses to assets, information under Schlumberger control
Example Incident: Vehicle accident (rollover)
Private
Im m ed ia te C au ses
L o ss o f C on tro l
R o o t C a use s
L o ss
In c id e n t
•Struck against
•Struck by
•Fall to lower level
•Fall on same level
•Caught between / in / on
•Contact with
•Overextension
Cooper
Immediate Cause
The immediate cause is a substandard act or condition that
was the direct cause of the incident occurring. The most
common mistake in incident investigations is stopping at the
immediate cause, this is mainly because at the time of the
Schlumberger
incident it appears the most obvious cause, or “worst case” is
Example Immediate Causes
used to allocate blame.
Immediate causes
Loss of Control
Private
•Driver fell asleep
Incident
Root Causes
Loss
substandard condition
(tiredness/lack of sleep)
Substandard Acts Substandard Conditions
•Driver speeding •Poor control of contractor
•Improper Loading
•Inadequate guards / barriers
•Defective tools/equip/materials
•Failure to use PPE •Inadequate warning system
substandard act •Lack of sleep •Poor housekeeping
•Using defective equipment •Pressure exposure
(using equipment improperly) •Using equipment improperly •Hazardous environmental conditions
•Improper lifting •Congestion / restricted action
•Improper position for task •Inadequate / improper PPE
•Failure to secure or warn •Fire & explosion hazards
•Safety devices inoperable •Slippery surfaces
•Removing safety devices •Noise exposure

Cooper
Root Cause Analysis
The root cause is the basic system failure that if fixed will
prevent re-occurrence of the same sequence of events.
A rule of thumb to determining the root cause is to ask
Schlumberger
“WHY” 5 times.
Example Root Cause
Private
Im m ed ia te Cau ses
L oss o f Con tro l
• No Journey
In cid en t
Root Causes
L oss
Management Policy
in place
Job Factors
•Inadequate
Personal Factors
• Driver had not •Inadequate capability
•Lack of knowledge
• Supervision
• Leadership
• Engineering
received training in •Lack of skill

•Stress
• Tools/Equip/Materials
• Work standards
• Purchasing
•Improper motivation
that type of vehicle •Substance Abuse
•Fatigue
•Abuse & misuse
•Organisational rules
•Conflicting goals/objectives

Cooper
Loss of Control
After the root cause/s have been identified it is necessary to
identify the element of the management system from which
the failure occurred.
This allows solutions to be implemented and ensures the
Schlumberger
continuous improvement cycle of the management system.
Management System Element
Causes
ImmediateCauses
Causes
Private
Root Causes
Incident
Incident
Loss
Loss
Control
Immediate
No Journey Management
Loss of Control
Root
Policy in place
“Policies and Objectives”
Lossof
Key QHSE MS Elements

• Commitment Leadership &
Accountability
Driver had not received • Organisation & Resources
• Policies & Objectives
training in that type of vehicle • Organisation & Resources
“Organisation and • Contractor & Supplier Management
• Risk Management
Resources” • Business Processes
• Performance Monitoring &
Improvement
• Audits
Owner: MEA / David Allison and reviews
& Mark
Cooper

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Event Reporting and Investigation

At the completion of this module, you will be

Owner: MEA / David Allison & Mark

 Performance Monitoring and Improvement Control

Audits and Reviews

• Encourage reporting and recording of all incidents.

Owner: MEA / David Allison & Mark

• Refer to the SQ and HSE Reporting Standards for

Owner: MEA / David Allison & Mark

Owner: MEA / David Allison & Mark

Owner: MEA / David Allison & Mark

QHSE Improvement Kit

Owner: MEA / David Allison & Mark

• All personnel are responsible for actively

• Clarification on the CMSL classifications can be obtained from the QHSE

• After notification and reporting, all Schlumberger

Owner: MEA / David Allison & Mark

Owner: MEA / David Allison & Mark

• Accidents don’t just happen.

Owner: MEA / David Allison & Mark

Example Loss: Broken leg, time off work, vehicle damage

Owner: MEA / David Allison & Mark

A rule of thumb to determining the root cause is to ask

received training in •Lack of skill

Owner: MEA / David Allison & Mark

Key QHSE MS Elements

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