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PSM 11 - Incident Investigation (Level 1 Document)

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42 views5 pages

PSM 11 - Incident Investigation (Level 1 Document)

Uploaded by

m.amirch143
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Document No.

: CHDOC-
EEL-HSE/PSM/SP-11-01
Revision No. : Oct 2019
Process Safety Management Standard Incident Investigation Issue No. : 01
Level-1 Procedures Revision due : Nov 2022
Page No. : 1- 5
CHDOC Thar Power Project Orig. Prepared by: HNM
Department: HSE Unit / Section: Safety Area : All
Document No.: CHDOC-
EEL-HSE/PSM/SP-11-01
Revision No. : Oct 2019
Process Safety Management Standard Incident Investigation Issue No. : 01
Level-1 Procedures Revision due : Nov 2022
Page No. : 2- 5
CHDOC Thar Power Project Orig. Prepared by: HNM
Department: HSE Unit / Section: Safety Area : All

SECTION-1 TABLE OF CONTENTS


Section Description Page No.

SECTION-1 TABLE OF CONTENTS ................................................................................................................ 2

SECTION-2 PRINCIPLE ........................................................................................................................................ 3

SECTION-3 ESSENTIAL FEATURES ................................................................................................................ 3


3.1 CLASSIFICATION OF INJURIES AND INCIDENTS ........................................................ 3
3.2 INCIDENT REPORTING AND INVESTIGATION ............................................................ 3
3.3 OFF-THE-JOB ........................................................................................................................ 4
3.4 INCIDENT REPORT AND RECOMMENDATIONS .......................................................... 4
3.5 COMMUNICATION ............................................................................................................. 4
3.6 INCIDENT ANALYSIS ......................................................................................................... 4
3.7 TRAINING ............................................................................................................................. 4
Document No.: CHDOC-
EEL-HSE/PSM/SP-11-01
Revision No. : Oct 2019
Process Safety Management Standard Incident Investigation Issue No. : 01
Level-1 Procedures Revision due : Nov 2022
Page No. : 3- 5
CHDOC Thar Power Project Orig. Prepared by: HNM
Department: HSE Unit / Section: Safety Area : All

SECTION-2 PRINCIPLE
CHDOC to Thar power Project believes that reporting and analysis of incidents provides
valuable opportunity to learn about break down or deficiencies in our safety management
system. An incident can be major such as unable to work injury, a reportable loss (fire/explosion
etc.) or a condition or action that could have resulted in personal injury or damage to the plant /
environment (near miss).
Serious incidents and near misses recur unless key factors are identified and corrected.
Thorough and persistent investigation of all such incidents, coupled with actions directed at
prevention of recurrence, continually improve safety.

SECTION-3 ESSENTIAL FEATURES


A system should be in place to encourage employees to report all incidents openly, having actual
or potential safety / environmental consequences.

3.1 Classification of Injuries and Incidents


Site shall develop and maintain a system to classify types of injuries and incidents.

3.2 Incident Reporting and Investigation


1. Incident investigations shall be initiated as promptly as possible as but not later than
48 hours following the incident.
2. Organizational responsibility should be clearly assigned for filing incident reports
within the organization and with governmental agencies.
3. Incident investigation team membership shall also include contract employee(s) if the
incident involved work of the contractor.
4. Investigations should seek to determine the root cause in the management system as
well as the immediate cause. Corrective action must address both of the areas.
Attention should be paid to identify relevant PSM procedures or elements that were
not correctly followed and action taken to eliminate similar incidents in future.
5. A detailed incident investigation report shall be prepared for all the incidents /
incident selected for comprehensive investigations. The report shall include as a
minimum:
 Date and time of incident
 Date and time investigation began
 Description of the incident
 Details/ learning’s - Factual information arising from the investigation, including
chronology as appropriate and pertinent facts
 Key factors
Document No.: CHDOC-
EEL-HSE/PSM/SP-11-01
Revision No. : Oct 2019
Process Safety Management Standard Incident Investigation Issue No. : 01
Level-1 Procedures Revision due : Nov 2022
Page No. : 4- 5
CHDOC Thar Power Project Orig. Prepared by: HNM
Department: HSE Unit / Section: Safety Area : All

 System elements that need to be strengthened (PSM system elements)


 Recommendations - Recommendations must include responsibility for follow-up and
timing
 Investigation team membership
 Approvals
6. Significant learnings from process-related incidents must be added to the process
technology package.

3.3 Off the Job


Site shall also report, investigate and publish Off-the-Job incidents as appropriate.

3.4 Incident Report and Recommendations


1. A follow-up system shall be established to ensure prompt follow-up and resolution of
all incident investigation report recommendations.
2. Resolution and corrective actions shall be documented and maintained along with the
incident report files.
3. The incident reporting system should provide for closure and stewardship of follow-
up actions.
4. Incident reports shall be retained for five years.
Periodic reports listing open recommendations must be published at least quarterly and
distributed to the relevant interfaces i.e. all persons assigned to follow-up a recommendation
and the supervisors of persons assigned the recommendation’s follow-up. The report should
highlight recommendations that have passed the due date.

3.5 Communication
Incident reports shall be shared with appropriate personnel, including:
 Employees and contractors from the affected area
 Other individuals whose tasks are related to the incident findings
 All CHDOC operating sites that could benefit from the knowledge gained.

3.6 Incident Analysis


1. Incident performance shall be analyzed for trends on an ongoing basis. The focus shall
be on:
 Prompt detection of significant changes and
 Prevention of recurring incidents.
2. All incidents should be analyzed on yearly basis and analyses of results and concerns
must be brought to the attention of HSE Committee members and shared with
employees.
Document No.: CHDOC-
EEL-HSE/PSM/SP-11-01
Revision No. : Oct 2019
Process Safety Management Standard Incident Investigation Issue No. : 01
Level-1 Procedures Revision due : Nov 2022
Page No. : 5- 5
CHDOC Thar Power Project Orig. Prepared by: HNM
Department: HSE Unit / Section: Safety Area : All

3.7 Training
1. Personnel who will conduct incident investigations and analyses must be given
training in techniques of investigation with emphasis on determining root causes in
relation to safety management systems.
2. An incident report review sub-committee to deal with the process of incident
investigations should be in place.

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