HSE name

Main contractor Incident Investigation

– LTI# - Date ofguidance
incidentnotes

HSE Investigation template and guidance

Lost Time and HiPo Incident

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

Singular photograph of the incident: (MDIRC only)

6
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI
- Date of No), date of incident-
incident header on all
slides

Bulleted description key points from the incident (MDIRC only)

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

Incident details

PDO directorate/dept : (e.g. OSD /OSO/OSO4)

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)
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 : Short description of last (LTI/NAD) of the contractor, this applicable to all
contracts with PDO and not specified to a specific contract No.

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

Description of the incident:

9
 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident-
of incident header on all slides

Photographs, diagrams & sketches:

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

Critical Factors:

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

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

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:

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

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 #

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

Findings: Underlying causes (human and workplace):

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

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

Findings: Management system failures (MSF)

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

Description

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

Life Saving Rules Were life saving rule breaches related to the incident? - Yes / No? Delete which is not applicable

Who broke them? Which rule (s):

Names/Ref Inds: ………………………………….……..

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

Was it a violation or error? - Yes / No?

Why………………………………………
………………………………………………………………
HR Panel
………………………………………………………………. HOD/Project Lead, HSE & independent person from other directorate)

Is consequence management in PIM actions

Yes / No ?

If a contractor broke the rule has the Contract

Holder been informed of the action taken?

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

PDO Contract management

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 signed off 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
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

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

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

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

Remedial actions planned:

Remedial actions planned MSF Target Contractor PDO action Action party Status
Causation date action party party for PIM accepted Open /
number Yes / No Closed

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

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

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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:………………..

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 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 should be done right
and memorable )

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 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
• 2
• 3
• 4
• 5

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

Tripod Tree
(include copy of the Tripod tree flow diagram for all
4/5 incidents or High Potential)

Investigation reports requiring a Tripod must confirm that the findings and recommendations match the
Tripod findings

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 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

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

Sequence of events/timeline:

No. Date Time Description of event

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

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

2. Emergency response,
how effective was it, did it impact on the severity?
3. People,
training, age, experience, nationality, medical conditions, disciplinary record etc
4. Equipment,
type, serial number, maintenance, inspection, failings, appropriate for use etc
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 add into Kick off

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 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

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 Main Contractor
Main Name,
contractor Incident
name Type
– LTI# (eg. LTI),
- Date date of incident- header on all slides
of incident
Investigation timeline compliance

Item Action Deadline Achieved Variance Reasons for variance?

No (day)
1 Notified to Medical team
2 Medical team notified MSE3 1
3 MSE3 provided notification to 1
Director/MD
4 Notification email issued 1
5 Kick off meeting held 1
6 First draft produced 10
7 Final draft produced 21
8 MSE3 IRC held 23
9 Final report produced 25
10 IRC held 30
11 MDRIC held 42

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