Incident Reporting & Investigation

Transcription

1 Incident Reporting & Investigation

2 Version Revision by Completion AL1 Date AL 2 Date AL 3 Date Rev12 aolfert Aug 2012 rrundell Aug 2012 NA Rev15 aolfert May 2015 rrundell NA 2

3 3 Table of Contents 1.0 Incident Investigation Policy Training Incident Reporting Incident Classification Notifications to Authorities & Regulators Conducting Investigations Onsite Activity Investigation Team Investigation Procedure Documentation Process Incident Follow up Regulatory, HS&E Policy Enforcement... 20

4 4 1.0 Incident Investigation Policy Chinook Drilling is committed to loss prevention. If, an incident accident or near miss occurs, to prevent recurrence an incident investigation program to identify causes and take action. A process of proper response to incidents and, examining causes to events will assist management and supervisors of proactive measures to control the potential for future occurrences. While most employees will only identify of obvious loss incident/accidents, investigations will include, but not limited to work refusals and harassment. The following section will outline duties and reporting procedures to manage a workplace incident. Management will support the entire process to ensure its effectiveness, along with Frontline Managers and Supervisors, required to implement control measures, ensuring controls are effective to protect workers. Workers will be required to comply with controls in place including but not limited to: new equipment training, procedure changes, policy changes or other control measures. Competent workers will be required to provide information on tasks performed to ensure investigations are thorough and controls are practical and ideal to prevent future occurrences. Prompt reporting of incidents will allow management & supervisors immediate response to incidents and gathering critical information. With prompt reporting and full disclosure of information to investigators, appropriate controls implemented protect all employees, property, and environment. Employees must protect evidence for investigators to ensure full examination of events. When dealing with serious incidents that involve critical equipment, serious injuries or fatalities, outside agencies are involved. Proper execution on all incident investigations will ensure proper and expedient investigations completion, no matter the level of impact. Ultimately, if we process each incident fully and consistently, it will continue demonstrate our commitment to health, safety, and environment and establish our due diligence. Definitions 1 : Incident is an event or set of circumstances that could, or does, result in an unintended harm or damage. It includes near miss, damage, chemical spills, and injury incidents. Accident is an unplanned event, or set of circumstances, which results in harm or damage. It includes ill health/injury; damage to property, plant, product or the environment; production losses; or increased liabilities. Near Miss is an incident that has the potential to cause damage or injury if the events were slightly different. 1 Occupational Health & Safety, Theory, Strategy & Industry Practice, Second Edition, Dianne E.G. Dyck

5 5 2.0 Training Office and Field Managers will train for incident investigation. External & internal courses or combination of both methods of delivery ensures proper information delivery and process. Applicable industry association courses will be used whenever possible, to allow for generic knowledge of investigation concepts and additional information to equip management and frontline supervision with skills necessary to assist with the process. Internal training courses provide knowledge of current company administration process and roles and responsibilities for frontline workers, supervisors, and managers. This will outline content included in this section and related process as they evolve. 3.0 Incident Reporting Reporting is the critical first step in the process of preventing recurrence and is the responsibility of all employees. Reporting occurs as soon as reasonably practicable, and all accidents and incidents to their immediate supervisor or manager. Chinook Drilling requires that all incidents reported accordingly: Crew Driller Rig Manager Field Superintendent / HSE Figure 1 - Minor Incident Notification (Field)

6 6 Crew Driller Rig Manager Operations Manager / Field Superintendent / HSE General Manager / Sales Manager Figure 2 Serious Incident Notification (Field) Employee Supervisor Manager & HSE Figure 3 All Incident Notifications (Office) In cases of serious incidents, notify all levels of management immediately and suspend operations. Operations remain suspended until company representatives, applicable authorities, and regulatory agencies complete investigation activities. Once investigation completed by all interested parties, work can continue. Upon notification, HSE Department will notify Senior Managers, and report serious incidents as required by law, to applicable regulatory bodies in specified provincial requirements upon direction from senior management. This includes but not limited to WCB for the province and Occupational Health & Safety Office as required. All levels of the organization will be accountable for ensuring that proper information disclosure to determine the severity, resources made available and proper personnel dispatched, and agencies notified. Notify your manager and HSE Department within twenty-four (24) hours for all incidents and serious near misses.

7 7 4.0 Incident Classification Incidents classified and investigated by management and supervision in adherence to policy. The following table outlines classification 2 of incidents on Chinook Drilling worksites: Incident Category Description Severity 3 Outside Report FT - Fatality Fatal injury, loss of human life Serious LTI - Lost Time Incident RWC - Restricted Work Case MA - Medical Aid Unable to work on any shift (1+day) Unable to continue regular work activities Treatment for injuries, not able to be attended by First Aider Serious Serious Serious RCMP, Local Authorities Hospitalized for 48hrs (AB) 24hrs(SK), (Immediate)BC Hospitalized for 48hrs (AB) 24hrs(SK), (Immediate)BC Hospitalized for 48hrs (AB) 24hrs(SK), (Immediate)BC FA - First Aid Minor injury attended by First Aider Minor NA NWR - Non Work Related ED - Equipment Damage EF - Equipment Failure MVA - Motor Vehicle Accident NM - Near Miss RNC - Regulator Non Compliance Inspection ENV - Environment Incident WC - Well Control Injury occurred on off-work hours/days off Minor NA Damage to equipment requiring repair or replacement Failure in proper function of critical equipment (i.e. Derrick, drawworks, pressure equipment, rotary equipment) Single or Multiple Vehicle Collision(MVC) An undesired event that could have resulted in personal harm, property damage, or loss $10,000+TBD 4 Serious Serious Over $2500 or MVC TBD As required by OHS (AB,SK,BC) As required by OHS (AB,SK,BC) RCMP, Local Authorities (as required) Compliance inspection deficiency TBD OHS, AER, Other Spill, Release of Gases, Other Poor Well Control Response, BOP equipment failure TBD Serious NA As required by Provincial Legislation AER (as required) WR - Work Refusal Refusal of Dangerous Work Serious OHS (if necessary) VH - Violence or Harassment Act of Violence to another worker, Act of Harassment to another worker Serious RCMP, Local Authorities (As necessary) Classification revisions completed when upon new industry standards, legislation, or company requirement. 2 Refer to current CAODC industry classification standards for additional details for fatality, lost time incident, restricted work case, medical aid and first aid 3 Severity determined by circumstances of events reported. In the above list, seriousness of accidents will increase or decrease depending on information submitted. 4 TBD (To Be Determined) classification will reference provincial legislation and events reported on depth of investigation.

8 8 5.0 Notifications to Authorities & Regulators Management and employees must refer to current and applicable legislation for operating province for notification of incident or accidents. Management will complete all notifications to provincial authorities and regulatory agencies as necessary. HSE department will advise and assist the notification process. 6.0 Conducting Investigations It is Chinook Drilling s Policy to investigate all incidents. The goal of investigations is to determine root causes 5, so that controls and actions taken can prevent recurrence. These controls could include changes to the work process, elimination, or substitution of tools, materials, or products. Engineering or administrative controls may also result from finding the root cause. Provincial legislation requires many types of incidents formally investigated and investigations retained and provided to the provincial regulator upon request. The product of all investigations should be helpful, constructive information to prevent a recurrence. The intent of the investigation is NOT to fix blame on anyone person. In the event of an incident defined in this manual, the operation will be suspended and damage, if present, assessed. Only after the Rig Manager or Management has given approval can operations be resumed; in the event of a serious injury, critical equipment damage, or death, operations are not to be resumed until approved by management or proper provincial authority. All incident investigation reporting documents, pictures and related information to be completed and submitted not more than 24 hours after an occurrence to reporting manager and HSE Department. Additional information and materials may be requested following initial reporting submission. The investigation team will complete a comprehensive evaluation of the individual incidents. The team will examine incidents on a case-by-case basis, but completing them will follow a consistent process. 6.1 Onsite Activity While all incident events are concerning, in order to provide guidance and determine priorities for management the following has been developed to guide decision making in whether onsite activities are necessary by levels of management. The guide does not restrict onsite visits, but only a general guide for required investigation team participation. See Figure 4 Onsite Activity Chart 5 Root cause is the absence of a best practice or failure to apply knowledge that would have prevented the problem or significantly reduce the likelihood of the problems reoccurrence.

9 9 Fatality Well Control Event causing serious injury and/or loss of equipment Harassment Fatality, LTI Reportable incident or Near Miss to regulatory agency Well Control Event causing serious injury and/or loss of equipment Harassment General Manager Operations Manager Sales Manager Field Superintendent HSE Manager & Coordinators Rig Manager Driller & Crews Administration All Recordable Injuries Reportable incident or near miss to regulatory agency Harassment Work Refusal Any incident or near miss that could have had a serious or negative impact All incidents reported to supervision that require active participation to determine root causes and corrective action Figure 4 Onsite Activity Chart

10 Investigation Team Position Employees Front Line Manager HSE Coordinator(s) Field Superintendent Operations Manager General Manager Vice President of Operations (TESI) Vice President & General Counsel (TESI) Responsibilities Complete witness statement forms & provide to reporting Manager, competent employees will assist in providing details on work activities as required. Gather witness statements, take pictures, and complete Injury paperwork, submit initial investigation report form. Submit to Direct Manager & HSE. Gather all information from frontline manager, ensure correctly completed. Follow up for additional information needed. Complete onsite investigation as necessary. Ensure all information from frontline manager submitted. Follow up for additional information needed. Complete onsite investigation as necessary. Review of incident investigations, and provide support and resources as necessary Review of incident investigations, and provide support and resources as necessary Review incidents quarterly, & comment on regulator submission. Review comment on authority and regulatory submissions. Provide guidance for management decisions. All investigation summary reports reviewed and approved by the following positions: - General Manager or Operations Manager - Field Superintendent - Rig Manager - HSE Coordinator In cases where the incidents are reportable to provincial authorities or regulatory agencies, additional review, and approvals will be required from the following positions: - Vice President Legal & General Counsel, Total Energy Services Inc - Vice President Operations, Total Energy Services Inc Serious incidents may require outside investigators in order to establish impartiality and due diligence. Decision to use outside resources is responsibility of Chinook Drilling & Total Energy Services Inc Senior Management.

11 Investigation Procedure 1 Report Incident Suspend operations; temporarily or permanently depending on severity Preserve incident scene until pictures can be taken, and authorization can be given to continue work by senior manager Complete and submit all documents, pictures and related information to line manager and HSE department 2 Manager & HSE assess incident information. HSE advise manager on HSE related compliance Manager provide decision on operations moving forward, depending on severity of incident Managers must not authorize continuance for servere incidents until authorized by senior management, authorities or regulatory agencies 3 Supervisor and Manager gather witness statements Employees must provide written witness statement Supervisor and Manager gather additional evidence; pictures, damaged equipment or materials, insurance documents, contractor statements, contractor training 4 Manager & HSE department will review all information gather and submitted HSE department will follow up on evidence submitted HSE department will submit WCB documentation, in all medically assessed injury cases 5 Incident summary will be written Causes will be determined Corrective actions will be assigned Management review of summary report and approvals 6 Corrective actions will be recorded and tracked for completion Assigned corrective actions implemented Management follow up and review of controls effectiveness Important Notes: Management will determine severity by detail of events from front line manager or supervisor. Details of events will allow reasonable decision on operations status, additional notification, and resources needed. (i.e. Rig shutdown due to fatality or medical aid to crew member requiring assessment to minor hand injury) Employees must provide witness statements or fulfill other requests before leaving office or field locations, and authorized by direct manager.

12 12 Take pictures of incident scene, injuries, equipment, and property and environment damage. See Figure 5, Figure 6, Figure 7, Figure 8, Figure 9 Use of digital camera is acceptable, ensure all images are forward to lead investigator for record keeping in the incident files Re-staging of incident required for examination or educational purposes of incident summary circulation Take measurements of anything required Diagram of scene and related information Operations management will conduct follow up interviews as necessary Do not alter incident scene in cases of serious events, unless necessary to protect employees, visitors, public, equipment and/or property from further harm. Record detailed notes on why scene was altered and submit to direct manager and HSE department. Management will notify authorities or regulatory agencies as necessary. All recordable injury incidents, severe damage, or failure of equipment, and significant property damage must reviewed by General Manager along with Operations Management. All assigned corrective actions tracked in database for closure. Contractors must provide statement and company contact details if involved

13 13 Use wide angle and alternate pictures of scene; Position of equipment and personnel. This allows investigation team to fully examine the scene and understand more aspects than written statements. Take additional angles as necessary to provide view points for additional visual descriptions for investigators, reviewers, etc Figure 5 Multiple Angle Pictures

14 14 Figure 7 Injury Pictures Figure 6 Close Up Pictures Top Left: Take close up pictures of equipment, property or environment, etc. for additional examination. This allows investigation team to fully examine the scene and understand more aspects than written statements. Above: Take pictures of injuries after they occur if possible, or following examination. This allows for additional reference later if injury management is required. Bottom Left: Take pictures of viewpoints when people are operating controls or other perspectives to add detail to incident file. Bottom Right: Take pictures of additional related environment conditions, such as where injured parties were following incidents. This may explain additional facts or trigger additional questions to be asked and influence actions taken Figure 8 Perspectives from Operator Controls or Equipment Figure 9 Positions of Injured Parties

15 15 Notify Supervision & Management Assess the incident Scene & Protect Worker, Equipment, Property & Public Gather witness statements & pictues of incident scene Submit all documents & pictures to Manager & HSE Management review of documentation & determine root cause Determine Controls, Implement & Follow up Figure 10 Incident Investigation Cycle

16 Documentation Process Proper documentation of all incidents events allows thorough evidence examination, demonstrates due diligence. Incident related forms list 6 : Witness Statement Initial Investigation Form Medical Release Form Acknowledgement of Modified Duties Form WCB Employer Form WCB Workers Form Return to Work Plan The following documentation required for incidents: Injuries, when worker goes for medical evaluation: 1 Medical Release Form Acknowledgement of Modified Duties WCB Employer & Workers Report Return to Work Plan 2 Witness Statement (all witnesses) Pictures of incident scene 3 Initial Investigation Form (Incident details & Manager Statement) Figure 11 Injury Documentation Process 6 Injury related forms will enclosed in 3 rd party service provider package for the province of operations. Company forms will also be included in the package.

17 17 All incidents, with exception of Medical Evaluation Injuries or Vehicle Collisions: 1 Witness Statement Form (All witnesses present) 2 3 Initial Investigation Form (Incident details & Manager Statement) Any cost related information, such as: equipment repair or replacement, hot shots, collision invoices Figure 12 All Incidents Other than Injury or Vehicle Collisions Vehicle Collision Incidents: 1 Witness Statement Form (All witnesses present) 2 Initial Investigation Form (Incident details & Manager Statement), Vehicle Incident Forms (As required by Rental Company) 3 Any cost related information, such as: vehicle repair or replacement, collision invoices, etc Figure 13 Vehicle Collisions (Single or Multi Vehicle)

18 Incident Follow up Management is responsible to follow-up all incident reports in an effort to prevent recurrence. Follow-up is necessary to confirm controls are effective to prevent a recurrence. Corrective actions tracked using a database to ensure stated actions implemented in a timely manner. Management follow-up will consist of: 1. Review of all incident reports and corrective actions. 2. Approve corrective action controls to be implemented 3. Track corrective actions approved to control future occurrences. 4. Follow up to ensure corrective actions taken, and controls appropriate and effective: Eliminated the hazard (equipment modification) Substitute the product for a less hazardous one. Develop or modify Management Systems (Safe Work Procedure, Control Plan, or Job Safety Analysis, Etc.) Isolated the hazards (i.e. guarding), or workers (i.e. signs, flags, barricades, etc.) control is effective Personal protective equipment Repair or replace faulty items Review Incident Summaries, root causes, and actions to be taken Make correction and follow up on details provided Review Incident Reports & Actions Approve Actions Comment, revise and approve corrective actions to be implemeneted Multiple level of management input to confirm final actions Enter corrective actions in tracking process, to ensure closure of actions Use current process Track Actions Follow Up Review actions taken to ensure controls are appropriate to avoid future occurences Modify controls as necessary Figure 14 Management Review & Follow up Process Complete will be submitted to management, and closed in the database. Management follow up needed to ensure proper controls are in place. See Figure 15 Example Investigation Actions Tracking Important Note: Selected Safety Alerts or Bulletins distributed to all locations for review. See Figure 16 Example Safety Bulletin

19 19 Assigned to HSE Activity Reference ID Corrective Action Assigned Date Total Items HSE - Mgmt Investigation R8 Investigation Q4.MA Apply grip tape/paint to engine skid on area between engine and fuel tan k wall were space is restricted for access and the open area between the fuel pump equipment and battery box 25-Nov-14 1 HSE - Mgmt Investigation Q4.FA Material as Part of orientation program for proper lifting or a supplemental training program 16-Jan-15 1 HSE - Mgmt Investigation Q3.ED SB# --> JSA s L-02 and M-09 on loader operations to be revised and redistributed to rigs for review and implementation. 1 DUE 13/10/13 26-Sep-13 HSE - Mgmt Investigation Q3.MA SB#: - WORKER PINCHES FINGER --> Review and revision of A Nov-13 1 Figure 15 Example Investigation Actions Tracking Figure 16 Example Safety Bulletin

20 Regulatory, HS&E Policy Enforcement In all cases, compliance with all governing agencies is priority and corrections made to ensure highest level of safety on all worksites be followed through. As such, Chinook Drilling will respond to any authorities or regulatory agency requirements as directed to ensure safety and compliance as needed following investigations where the involvement is necessary. Investigations are looking for cause, not to affix blame. If an employee disregards policy and legislation, company programs that protect employees, property, environment, and public from unnecessary harm, management will follow the disciplinary action policy.