Guideline for reporting prescribed incidents

Transcription

1 Guideline for reporting prescribed incidents Version 3 November 2015

2 This publication has been compiled by Department of Natural Resources and Mines. State of Queensland, 2015 The Queensland Government supports and encourages the dissemination and exchange of its information. The copyright in this publication is licensed under a Creative Commons Attribution 3.0 Australia (CC BY) licence. Under this licence you are free, without having to seek our permission, to use this publication in accordance with the licence terms. You must keep intact the copyright notice and attribute the State of Queensland as the source of the publication. Note: Some content in this publication may have different licence terms as indicated. For more information on this licence, visit The information contained herein is subject to change without notice. The Queensland Government shall not be liable for technical or other errors or omissions contained herein. The reader/user accepts all risks and responsibility for losses, damages, costs and other consequences resulting directly or indirectly from using this information.

3 Table of contents Purpose... 2 Legislative requirements... 2 Notification requirements... 2 How to notify the PGI... 4 Information to be provided immediately by telephone... 4 Information to be provided in writing... 5 Clarification of terms... 5 What is medical treatment?... 5 What is damage to property that increases the risk?... 5 What is a near miss?... 6 What is an unplanned fuel gas leak at operating plant?... 6 What is a fuel gas shortage?... 6 Incident investigation... 6 Do I have to restrict access?... 6 Do I have to conduct a safety investigation?... 7 What should be in a safety investigation report?... 7 References... 8 Other applicable legislation... 8 Related documents... 8

4 Purpose The Petroleum and Gas Inspectorate (PGI) is responsible for regulating and monitoring the safety and health performance of the petroleum and fuel gas industry in Queensland. The PGI plays a key role in helping industry (including operating plant) and the public to meet the requirements of the Petroleum and Gas (Production and Safety) Act 2004 ( the Act ). To help improve safety, the PGI monitors and investigates a range of prescribed incidents that are important to safety and health in the petroleum and fuel gas industry. The purpose of this guideline is to provide clarity and guidance to industry and the public about the requirements for reporting prescribed incidents under the Act to the Inspectorate. Legislative requirements Notifying the Inspectorate about prescribed incidents is a requirement under Section 706 of the Act. Section 11 and Schedule 2 of the Petroleum and Gas (Production and Safety) Regulation 2004 ( the Regulation ) specify the prescribed incidents and notification requirements that apply. For operating plant, the operator is responsible for notifying the Inspectorate about a prescribed incident. For prescribed incidents at a business other than an operating plant, the person carrying on a business is responsible for notifying the Inspectorate. Failure to notify the Inspectorate about a prescribed incident is an offence under sections 706(2) and 706(3) of the Act. You may be issued an on-the-spot fine or prosecuted for failing to notify. Notification requirements Section 705D of the Act also requires the operator of an operating plant, operating in the area of a coal or oil shale mining lease (other than a coal mining-csg operating plant), to notify the senior site executive of any significant incident. This includes death, admission to hospital, serious injury or endangering safety. The prescribed incidents and reporting requirements as prescribed in the Regulation are provided in Table 1 below. Table 1 Notification requirements for prescribed incidents Prescribed Incident (Regulation - Schedule 2) Notify the PGI by telephone Notify the PGI in writing An incident involving death of a person An incident involving injury to a person requiring medical treatment An emergency, including an emergency alarm activation other than as part of a routine test, at an operating plant that is a major hazard facility under the Work Health and Safety Regulation 2011 A fire at an operating plant An unplanned or uncontrolled release of petroleum, fuel gas or prescribed storage gas, attended by emergency services Guideline for reporting prescribed incidents, Department of Natural Resources and Mines,

5 An unplanned or uncontrolled release of a gas that is petroleum or prescribed storage gas or fuel gas from an operating plant, at a concentration of more than the lower flammable alarm level for the gas stated in the safety management plan for the plant, not attended by emergency services Not required An incident with the potential to cause a general shortage of fuel gas in Queensland or an area of Queensland An incident involving damage to property that substantially increases the risk of damage to plant or equipment or injury to persons An incident involving coal mining operations at an operating plant in the area of a coal or oil shale mining lease As required under the principal hazard management plan for the operating plant As required under the principal hazard management plan for the operating plant An incident at an operating plant to which the Work Health and Safety Act 2011 does not apply, if the incident is not otherwise mentioned in this schedule Not required but no later than 5 business days after the incident occurs An incident that had the potential to, but did not, cause the death of, or injury to, a person or damage to plant or equipment A work related illness of a person at an operating plant to which the Work Health and Safety Act 2011 does not apply Not required but no later than 5 business days after the incident occurs but no later than 5 business days after the operator of the operating plant becomes aware or, ought reasonably to have been aware, of the illness Note: For Coal Seam Gas (CSG) wellhead operations, all unplanned fuel gas leaks in relation to wellhead and associated equipment must be reported as to the requirements of the Code of Practice for CSG wellhead emissions detection and reporting as published on the Department s website. Guideline for reporting prescribed incidents, Department of Natural Resources and Mines,

6 How to notify the PGI The following contact information is provided for notifying the Inspectorate about a prescribed incident and an emergency or dangerous situation involving petroleum or fuel gas. Immediate notification by telephone: PGI Hotline Notification in writing: PGIHotline@dnrm.qld.gov.au For all other matters, visit or call 13 QGOV ( ) during business hours. Information to be provided immediately by telephone For prescribed incidents that must be immediately notified by telephone, the following information should be provided: 1. Notifier s details (full name, address, telephone number and address) 2. Type of operating plant or non-operating plant 3. Type of petroleum or fuel gas (LPG, Natural gas, Biogas, Synthetic Natural Gas, Hydrogen) 4. Prescribed incident details, including: a. date of prescribed incident b. time of prescribed incident c. location of incident (address, tenure number, and/or GPS coordinates (GDA94) d. on-site contact s details (full name, address, telephone number, and address) e. if emergency services were called f. if the scene was evacuated g. if access restricted to the scene h. activities being undertaken on-site i. summary of what happened j. prescribed incident type 5. Details of any injury or disease, including: a. injured person s details (full name, date of birth, and residential address). b. nature of injury or disease c. bodily location of injury or disease d. mechanism of injury or disease (if known) e. agency of injury or disease (if known). Guideline for reporting prescribed incidents, Department of Natural Resources and Mines,

7 Information to be provided in writing Notification in writing must be submitted as soon as practicable but no later than five business days after the prescribed incident. For prescribed incidents that must be notified in writing, the following information should be provided to the Inspectorate: 1. Notifier s details (full name, address, address and telephone number) 2. Type of operating plant or non-operating plant 3. Type of fuel gas (LPG, Natural gas, Biogas, Synthetic Natural Gas, Hydrogen) 4. Prescribed incident details, including: a. date of prescribed incident b. time of prescribed incident c. location of incident (address, tenure number, and/or GPS coordinates (GDA94) d. on-site contact s details (full name, address, telephone number, and address) e. if emergency services were called f. if the scene was evacuated g. if access restricted to the scene h. activities undertaken on-site at the time of the prescribed incident i. summary of what happened j. prescribed incident type. 5. Details of any injury or disease, including: a. injured person s details (full name, date of birth, and residential address) b. nature of injury or disease c. bodily location of injury or disease d. mechanism of injury or disease (if known) e. agency of injury or disease (if known) 6. Investigator s details (full name, address, address and telephone number) 7. Actions taken to date in relation to the prescribed incident. Clarification of terms What is medical treatment? Schedule 2 of the Regulation states a prescribed incident includes an incident involving injury to a person requiring medical treatment. The Inspectorate defines medical treatment as treatment by a doctor consistent with the Work Health and Safety Act This does not include first aid or treatment provided by any allied medical professions (e.g. paramedics, nurses, physiotherapists, dentists etc.). The Workplace Health and Safety Queensland First Aid in the Workplace Code of Practice 2014 defines first aid as the immediate treatment or care given to a person suffering from an injury or illness until more advanced care is provided or the person recovers. In relation to gathering and recording information about injuries, the Inspectorate conforms with Australian Standard AS Workplace injury and disease recording standard. What is damage to property that increases the risk? Schedule 2 of the Regulation states a prescribed incident includes an incident involving damage to property that substantially increases the risk of damage to plant or equipment or injury to persons. This means any primary event that has the potential to increase the risk of a secondary event. As the effect of a primary event may not be immediately apparent, it is important to undertake an effective investigation to ensure secondary risks are appropriately managed. Guideline for reporting prescribed incidents, Department of Natural Resources and Mines,

8 What is a near miss? Schedule 2 of the Regulation states a prescribed incident includes an incident that had the potential to, but did not, cause the death of, or injury to, a person or damage to plant or equipment. This is commonly referred to as a near miss. A near miss that had could have reasonably resulted in death or serious injury is referred to as a high potential incident ( HPI ). A near miss that could have reasonably resulted in injury (other than death or serious injury) or caused damage to plant is a low potential incident. The following factors should be considered when deciding potentiality: the exposure or proximity of people to the event the ability to predict or prevent the release of energy the amount of energy that was or could have been released during/by the event the risk of not taking action to reduce the risk or notifying others about the hazard. Contact the Inspectorate if there is any doubt about whether to notify about a near miss. What is an unplanned fuel gas leak at operating plant? Schedule 2 of the Regulation states a prescribed incident includes an unplanned or uncontrolled release of a gas that is petroleum or prescribed storage gas or fuel gas from an operating plant, at a concentration of more than the lower flammable alarm level for the gas stated in the safety management plan for the plant, not attended by emergency services. The lower flammability limit (LFL) alarm level, is the level at which a control system for an operating plant is activated in response to the concentration of released fuel gas in the air. The LFL alarm level relates to the unplanned or uncontrolled release of a fuel gas from an operating plant and is part of the plant s safety management system ensuring that unplanned or uncontrolled fuel gas leaks at operating plant are reported. Unplanned or uncontrolled leaks at or near the LFL should be considered as a high potential near miss and be reported to the Inspectorate as a prescribed incident. What is a fuel gas shortage? Schedule 2 of the Regulation states a prescribed incident includes an incident with the potential to cause a general shortage of fuel gas in Queensland or an area of Queensland. A fuel gas shortage is defined as a loss of supply to any high risk or major consumers (e.g. hospitals, nursing homes, utilities, critical infrastructure or major industry) and/or any loss of supply to more than six low risk consumers (e.g. businesses, homes etc.). Incident investigation Do I have to restrict access? Section 707 of the Act requires that the operator of operating plant, or a person carrying on a business other than at operating plant, restricts access to the scene of a prescribed incident until an inspector directs the person otherwise. Access must be restricted and actions taken to ensure the scene of a prescribed incident is not tampered with. It is an offence for someone to enter or remain at the site of a prescribed incident if action has been taken to restrict access to the site. This excludes actions to save lives or make safe if there is any entry for this purpose, a record of the entry and reason for entry should be made as soon as reasonably practicable. Under section 755 of the Act, inspectors may require reasonable help when carrying out their functions or exercising a power to determine compliance with the Act. Guideline for reporting prescribed incidents, Department of Natural Resources and Mines,

9 Do I have to conduct a safety investigation? While the Inspectorate encourages all notifiers to conduct safety investigations in relation to prescribed incidents, it is a requirement for operators of operating plant under section 675 and 701 of the Act. Safety investigations are essential to identifying the various contextual and systemic factors that contributed to an incident and to determine what can be done to reduce the risk of a recurrence. Effective safety investigations are focused on the incident, not the people involved. A good safety investigation is fair, prompt and undertaken by competent people it seeks various sources of facts and considers multiple perspectives of the circumstances about the incident. Safety investigations should consider local rationality and system complexity, and should not be influenced by hindsight bias or counterfactual reasoning. The investigation should seek to decide the causes of the incident (e.g. when, who, what, how and why the incident occurred) and make reasonable and practicable recommendations to ensure organisational learning and safety improvements. The outcome of a safety investigation should be communicated and followed-up to ensure organisational learning. This information should be recorded, listing dates and when actions were taken and successfully completed. This should refer back to any existing Safety Management Plan (SMP) where applicable for operating plant or where an SMP or equivalent exists to verify whether the people and organisation followed the procedures and processes in that plan. What should be in a safety investigation report? The Inspectorate may request a copy of the safety investigation report from the operator or person carrying on the business. The safety investigation report should include: 1. Summary of the report 2. Introduction about the prescribed incident that occurred 3. Methodology used to investigate the prescribed incident 4. Investigator s details (full name, address, address and telephone number) 5. Findings about how things usually work and what went wrong (contextual and systemic) 6. Discussion about the findings (theories about why things went wrong) 7. Conclusions (organisational learnings) 8. Recommendations (safety improvements) 9. References (sources of information relied upon in the report) 10. Appendices such as: a. a map of the prescribed incident scene (appropriately labelled) b. photographs of the scene and any injuries (appropriately labelled) c. any relevant documents (appropriately labelled). Guideline for reporting prescribed incidents, Department of Natural Resources and Mines,

10 The purpose of the PGI obtaining the safety investigation report is to review the contextual and systemic factors that may have contributed to the incident to support industry to improve safety. If not provided voluntarily, an inspector may exercise a power to require the production of documents. References Other applicable legislation Other safety legislation may apply at a site that may require additional reporting including: Coal Mining Safety and Health Act 1999 Mining and Quarrying Safety and Health Act 1999 Work Health and Safety Act Related documents Australian Standard AS Workplace injury and disease recording standard Coal Mining Safety and Health Act 1999 Mining and Quarrying Safety and Health Act 1999 Petroleum and Gas (Production and Safety) Act 2004 ( the Act ) Petroleum and Gas (Production and Safety) Regulation 2004 ( the Regulation ) Work Health and Safety Act 2011 Workplace Health and Safety Queensland First Aid in the Workplace Code of Practice 2014 For more information visit Guideline for reporting prescribed incidents, Department of Natural Resources and Mines,