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Incident Reporting & Investigation for better emergency response & disaster management. A presentation By Rajnath Ram Joint Adviser (I), PNGRB. Contents. Definitions Incident type/ classifications Cause of incident/disasters Incident reporting Investigating incident - PowerPoint PPT Presentation
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Incident Reporting & Investigationfor better emergency response & disaster management
A presentation
By
Rajnath RamJoint Adviser (I), PNGRB
Contents DefinitionsIncident type/ classificationsCause of incident/disastersIncident reportingInvestigating incidentDeveloping action planCommunicating the incident
statisticsManaging documentation
DefinitionsFollow common definitions across your organization
(refer PNGRB(Codes of practices for Emergency Response and disaster Management Plan) Regulations, 2010 and any other applicable statutory documents)
Incident Emergency Risk analysis, risk assessment, risk management Degree of Emergency (L-I, L-II, L-III) Onsite emergency Offsite emergency Disaster management Plan (DMP)
Encourage to use common definitions across your organization and among your contractors/third party agency through the written procedures, review and updation on continuous basis
Incident Type/ ClassificationsAs per PNGRB regulations Level-I
◦which can be effectively and safely managed within the site by the available resources;
◦no impact outside the site, location or installation.
Incident Type/ ClassificationsLevel-II :Which cannot be effectively and
safely managed with available resources
additional support is alerted or required;
has the potential to effect beyond the site
May require mutual aid;
Incident Type/ ClassificationsLevel-III: an incident with off-site impact could be catastrophic and is likely to
affect the population, property and environment inside and outside the installation,
management and control is done by District Disaster Management Authority (DDMA)
Incident Type/ ClassificationsNote: Level-I & Level-2 :onsite
emergency Level-3: off-site emergency
For Level-III, till the District Authority step in, it should be the responsibility of the installations/units incharge to manage the emergency
Cause of incident/disasters
Man Made Natural Calamities Extraneous
Heavy Leakage
Fire Explosion Failure of
Critical Control system
Design deficiency
Unsafe acts In-adequate
maintenance
Flood Earth Quake Cyclone Outbreak of
Disease Excessive Rains Tsunami
Riots/Civil Disorder/ Mob Attack
Terrorism Sabotage Bomb Threat War / Hit by
missiles Abduction Food
Poisoning/ Water Poisoning
Sector –Wise fire incidents
50%
22%
15%13%
E&PRef & ProcessMarketingPipeline
Source: OISD
Causes of incidents
60%
6%
18%
16%
Human FactorElectricalEquip. failureothers
Source: OISD
Consequences of Incident The consequences of an Incident are fire
explosion, blast waves, fast spreading flames, BLEVE, UVCE resulting in direct effects like damage to buildings/property, burns, fatalities.
The consequences of an Incident may be confined within the premises or may spill off-site triggering cascading effects.
An Incident in the neighborhood may sometimes cascade into an on-site emergency. It should be prevented or managed to avoid major emergency.
Incident reporting As per PNGRB (Technical Standards and Specifications
Including Safety Standards for City or Local Natural Gas Distribution Networks), Regulations 2008:◦ Incident reporting as per Enclosure-I of SCHEDULE-IE. ◦ It must be read in conjunction with the PNGRB (Codes of
practices for ERDMP) Regulations, 2010.
As per PNGRB (Codes of practices for ERDMP)Regulations, 2010◦ Any incident of L-II and L-III shall be reported◦ Preliminary report as per Schedule VI must reach within 48
hours to PNGRB◦ Detailed investigation report within a month PNGRB can invoke penalty provision on Non-Compliance
Also report near miss incidents
Why Focus on Near Misses? Establish Causes
Provide learning to prevent recurrences before they become Serious
Establish corrective actions
Improve our companies safety culture
Statistical safety data base
Nothing is learned from unreported incidents and the causes are left uncorrected!
Why Minor Incidents Go Unreported Fear of:
◦ Supervisor/Manager Disapproval◦ Getting a Bad Reputation◦ Being terminated or disciplined
Not Wanting To:◦ Lose time from the job◦ Have a incident on their work record◦ Be the subject of or involved in an investigation
Not knowing why minor incidents should be reported or what near misses are.
Lack of Management follow-through in the past. Fear of having a poor or blemished safety record.
Encourage Reporting Incidents
Ensuring all employees are told to report near miss incidents also.
Positively reinforcing each other when reporting near miss incidents.◦ Put penalty provision for not reporting
Reminding ourselves of its importanceSharing successes—improve the work
environment across the entire company.Using the Emergency-O-Gram for
initiation of the investigation and reporting of document
Make the incident reporting format readily available to all the employees.
INCIDENT INVESTIGATIONS WHY?
* Prevent Reoccurrence * Valuable Asset to Management * Improve the Company's
performance and Profitability
?
16
??? ?
The ultimate purpose of investigations is to prevent future incidents.
Incident Investigation an example
17
As a rule of thumb, use the “5-W” principle! Simply ask “Why” five (5) times.
1. Why did you slip and Fall in the hall by the water cooler ? <answer> Because the floor was wet.
2. Why was the floor wet? <answer> Because there was water on it.3. Why was their water on the floor? <answer>I don’t know. It was coming out from underneath the water cooler.4. Why was water coming out from under the
water cooler? <answer> I don’t know. Let’s look. There is a hole in the drain pipe.
5. Why is there a hole in the drain pipe? <answer>It appears as if it rusted out.Was this an UNSAFE ACTIVITY or UNSAFE CONDITION?
Incident Investigation an example
18
It was an Unsafe Condition, caused by an Unsafe Activity.
The rusted pipe was caused by lack of preventative maintenance, which was an unsafe activity. If there is “blame” where does it lie? Was there a preventative maintenance program?, Who was in charge of it. Why was it not checked? Should this be subject to disciplinary actions?
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Steps to Incident Investigation
• Manage the Incident Site • Collect factual Information• Record witness statements• Analyze the Facts• Investigations must produce factual
information • Recommend Corrective Action • implement Corrective Action Follow-up
Investigating IncidentEssential Actions (planning) Prepare a written procedure for investigations (also refer
statutory requirements) Develop an investigation report form that guides
investigators Define the company’s responsibilities in assisting
investigations conducted by contractors on incident sites.
Make investigation procedures and forms available to employees and contractors.
Bring in external investigators to collect and verify data for incidents.
External investigators are third-party investigators/independent experts
Investigating IncidentEssential Actions (verifying data and
investigations) At the beginning of an investigation, hold a
meeting of all parties involved to:◦ review investigation goals and procedures◦ Fix specific roles and responsibilities of all
participants◦ describe the types of data to be collected and
how it will be verified and handled◦ Ensure all relevant documents available
including statutory documents◦ Review and verify data reported on
preliminary incident report ◦ physically inspect the incident site and take
photographs for inclusion in investigation report
◦ Review the circumstances that led up to the incident
Investigating IncidentEssential Actions (verifying data and
investigations) review operating conditions Review all documents prepared as a part of the incident report interview witnesses and other people who were involved in
the incident or preparation of incident reports compare new data to historical data to identify new problems
and trends Conduct root-cause analysis to further verify collected data
and determine why the incident occurred. Record all findings Collect, if possible, incident data documented by government
and insurance investigators for comparison purpose Treat incident data confidential.
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Employee responsibilitiesRESPONSIBILITY to comply with all policies and procedures
RESPONSIBILITY to report all unsafe acts and conditions
RESPONSIBILITY to be a team member - to assist others in compliance
RESPONSIBILITY to offer suggestions that may have a positive impact on safety
Steps to Develop Action Plan
(based on Recommendation by the third party
independent investigation) 1. Identify corrective actions
2. Assigning responsibility
3. Establish deadline for actions and follow-up
4. Obtain management approval
5. Communicate results
24
Communicating the incident statisticsTo the employees of the
organizations to the controlling authorities (full
report) ◦Organizational head◦Statutory organizations
Managing Documentation
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Conclusion Encourage incident
reporting Investigate accidents
immediately Provide the investigation
report within 48 hours of accident
Take leadership Provide safety training Conduct safety meeting Mock drills exercise Provide written rules Assess Personal Protective
Equipment
Follow technical, Safety & Health Regulations
Emergency Preparedness
Always go for Incident Investigations
Safety Consultations
Time based mitigation/action plan
Review & Revise Safety Program- Management of change
27
Thank You