INVESTIGATING MINE/UXO ACCIDENTS AND INCIDENTS

Transcription

1 INVESTIGATING MINE/UXO ACCIDENTS AND INCIDENTS 1. INTRODUCTION 1.1 The need to report and investigate mine/uxo accidents and incidents in a clear, comprehensive and timely manner is an essential part of mine action management. 1.2 The aims of any investigation are to establish the facts and to make deductions from them, to ascertain the cause of the accident or incident and finally to make recommendations that may be implemented to prevent any similar reoccurrence and to improve the safety and quality of the demining process. 1.3 The effective management and supervision of mine action programmes will reduce the likelihood of harm, but there will always be the potential for mine/uxo accidents and incidents to occur. There are legal and moral obligations on managers at all levels in mine action to ensure that the likelihood of harm is reduced to the lowest realistic levels. 1.4 Effective reporting and the thorough investigation of mine/uxo accidents and incidents can play an essential part in meeting this objective. Information collected and presented in a clear and accessible format will contribute to the lessons learned process and thereby assisting in any future emergency response, improving the quality of the demining process and reducing the likelihood of future demining accidents. 1.5 The aim of this NTSG is therefore to provide standards and guidelines on the minimum requirements for the reporting and investigation of mine/uxo accidents and incidents within the SudanMAP. 2. RESPONSIBILITIES 2.1 National Responsibilities: The UNMAO shall: a. Establish and maintain procedures for the reporting and investigation of mine/uxo accidents and incidents in accordance with this NTSG. b. Appoint personnel to investigate mine/uxo accidents and incidents in accordance with this NTSG. c. Disseminate the findings of all investigation reports to all mine action organisations operating in Sudan, and importantly to UNMAS, who can then extract information for other National Mine Action Authorities. d. Ensure that the results of any medical examination, post mortem or coroner s report are made available to the parent demining organisation. Page 1 of 6

2 2.2 Mine Action Organisation Responsibilities: Mine action organisations shall: a. Report all reportable mine/uxo accidents and incidents to the UNMAO in a timely manner. b. Take immediate photographs of the accident/incident site, and then preserve it until the site is inspected and released by the Board Of Inquiry (BOI) or investigating officer. c. Provide access and necessary administrative support to BOI personnel of whatever capacity. d. Make available for the investigation the original worksite records, SOPs, training records, radio log and any other pertinent documentation as requested. e. Assist UNMAO personnel that have been appointed to investigate mine/uxo accidents and incidents in any way requested in order for them to meet their aims and objectives. 2.3 Mine Action Organisation Employee Responsibilities: Mine action organisation employees shall: a. Apply appropriate standards and SOP s designed to prevent mine/uxo accidents and Incidents from occurring. b. Report perceived weaknesses in equipment training and procedures that may lead to a mine/uxo accident/incident. c. Report any reportable mine/uxo accidents and incidents; and assist in the investigation as required. 3. INVESTIGATION REQUIREMENTS 3.1 General requirements: Accidents and/or incidents shall be reported to the UNMAO in the following circumstances: a. When an event involving mine/uxo or explosives results in harm to a mine action organisation employee, a site visitor or a member of the local population at a demining workplace. b. When an event involving mine/uxo or explosives results in damage to equipment or property. c. At all times when a mine/uxo is located in an area previously cleared, recorded as cleared or marked as cleared. d. Where mine action organisation employees, site visitors or the local population are exposed to intolerable risk that results from the application of SOP or the failure of equipment issued to employees. e. When any unplanned detonation of a mine/uxo or explosives occurs irrespective of the cause or outcome. f. If a non-mine/uxo or non-explosive related accident occurs on a site that requires the urgent evacuation of a casualty to an advanced medical facility for treatment. Page 2 of 6

3 Page 3 of 6 Chapter 15 The UNMAO on receiving reports of mine/uxo accidents and/or incidents, that highlight inadequacies of equipment, standards or approved SOPs, or that indicate the presence of new types of hazard, shall disseminate a general warning to all mine action organisations applying the same equipment, standard or SOP, or likely to meet the same new hazards. 3.2 Investigations: The aim of any accident/incident investigation is to identify problems or opportunities to improve the safety and quality of the process. As such, all employees of mine action organisations should provide complete and accurate information about the circumstances surrounding the accident/incident and opinions on ways to improve procedures that may assist in preventing a reoccurrence. The UNMAO will have the final decision on whether an accident/incident warrants or requires an investigation however Annex A and the following provides details of occasions and/or circumstances which should result in an investigation: a. An accident resulting in injury or death. b. An incident resulting in damage to property. c. An incident causing damage that may result in a major claim for compensation from a member of the public. d. An incident involving a major event causing significant damage. e. An incident involving the discovery of a mine or UXO in an area previously cleared, recorded as cleared or marked as cleared. f. An incident where mine action organisation employees, site visitors or the local population are exposed to intolerable risk that result from the application of approved standards or procedures including the failure of equipment. g. An incident involving the unplanned detonation of a mine, UXO or explosives. h. An incident which could attract media attention or media report. i. When considered necessary by the UNMAO non mine, UXO or explosive related accident on a site that requires the urgent evacuation of a casualty to an advanced medical facility for treatment. 3.3 Investigation Types: The following applies: a. An accident/incident formal investigation may consist of one of three levels of investigation: (1) A BOI. (2) An independent investigation by an investigating officer from the UNRMAO. (3) An internal investigation by an investigating officer from the mine action organisation involved. b. The accident/incident type will decide what level of formal investigation is undertaken. Annex A provides a guide for selecting the appropriate level of formal investigation that will be undertaken however the UNMAO shall have the final decision on the level of formal investigation to be implemented.

4 Page 4 of 6 Chapter 15 c. Ideally any BOI should be comprised of a principal member from the UNMAO, a member from a third party mine action organisation and one member from the mine action organisation involved in the accident/incident but this shall not be any person directly involved in the accident/incident. d. Independent investigations shall be carried out by an appropriately qualified and experienced independent investigation officer appointed by the UNRMAO. e. Internal Investigations shall be carried out by an appropriately qualified and experienced member of the mine action organisation involved, but this shall not be any person directly involved in the accident/incident. 4. REPORTING OF ACCIDENTS / INCIDENTS 4.1 All mine/uxo accidents and/or incidents are to be reported initially to the UNRMAO and then to the UNMAO. Mine/UXO accidents and/or incident reports shall normally follow two formats, a. Initial Contact Report: Provides essential information about the accident/incident, which permits either the UNRMAO and/or UNMAO to assist with any emergency response and if necessary to provide a general warning to other mine action organisations. Submitted via appropriate in place communications system to the UNRMAO within 30 minutes of the mine/uxo accident/incident occurring. The minimum information required is: (1) WHEN Time of accident. (2) WHERE Location, province, district, Task No, lat / long coordinates. (3) WHO Organisation, C/S and/or name, nationality and blood group of injured. (4) WHAT Brief summary of available information (cause and injuries). (5) CASEVAC INTENTION What is intent at this time (6) ASSISTANCE Is immediate assistance required and if so what (7) CONFIRM - VHF/HF radio channel / telephone number for further contact. b. Follow up Report: Upon receipt of the initial contact report the UNRMAO will inform the UNMAO. Both will continue to monitor the situation and to provide support where required. As soon as the casualty is successfully transferred to a hospital and is in suitable medical care a more detailed verbal report is to be made by the mine action organisation to the UNMAO via the UNRMAO. This is generally to be made via telephone and is to include the following: (1) Confirmation that the casualty is in suitable medical care and that no further immediate assistance is required. (2) Confirm the details contained in the Initial Contact Report. (3) Confirmation that all other mine/uxo sites where the same organisation is operating are shut down and that the scene of the mine/uxo accident/incident is as secure as possible, pending the arrival of the Internal Investigating Officer.

5 c. Written Report: The mine action organisation is to complete an IMSMA Database Demining Report and attach as much relevant detail as possible and submit it to the UNRMAO within 48hrs of the incident. If this form is not relevant to the incident then an appropriate written report covering all details is to be drafted and submitted. 5. INVESTIGATION PROCEDURE 5.1 Once the initial information has been collated and assimilated by both the UNRMAO and UNMAO a decision will be made regarding what level of investigation will take place. 5.2 On the initiation of any formal investigation both the UNRMAO and the UNMAO shall ensure that: a. The investigation commences as soon as practicably possible. b. The personnel selected to conduct a formal investigation had no involvement with the accident/incident and have the qualifications, experience and skills needed to conduct a full and through investigation. c. The accident/incident site is preserved as far as possible, until released by the BOI or Investigating Officer, in order to prevent loss of valuable information. d. Photographs of the accident/incident site are taken immediately. e. Unless exceptional circumstances exist, the investigation report is submitted on time and that it is complete, clear, concise and accurate (including conclusions and recommendations for improvement). 5.3 The following reports are to be produced as applicable: a. Internal Investigations and the Detailed Investigation Report: The Detailed Investigation Report (see Annex B) is the result of an Internal Investigation carried out by the mine action organisation involved in the accident/incident. The report shall be completed by an Internal Investigation Officer, but this shall not be any person directly involved with the incident. This report shall be initiated by the mine action organisation involved. It shall be completed as soon as practically possible after the accident/incident and passed to the UNRMAO within 2 working days. Detailed Investigation Reports shall be automatically initiated by mine action organisations for all reportable accidents/incidents. A Detailed Investigation Report should precede a BOI and/or an independent investigation if required and should then form part of the formal BOI Report or Independent Investigation Report. b. BOI and Independent Investigations: BOI are nitiated by the UNMAO whilst independent investigations are initiated by the UNRMAO after consultation with the UNMAO. For both investigations a Convening Order and Terms of Reference (TOR) will be issued and personnel appointed to carry out an investigation. Annex C details a Convening Order and TOR for a BOI or Independent Investigation and Annex D details an example BOI or Independent Investigation Report. Page 5 of 6

6 c. BOI and Independent Investigation Report Findings: On completion of the BOI/Independent Investigation, the investigation report will be presented to the UNMAO/UNRMAO and the Chief of Operations and Programme Manager for their comments. Following this it will be signed, bound and produced as four copies for distribution as follows: (1) 1 x copy for the UNMAO QA cell. (2) I x copy for the UNRMAO QA cell. (3) 1 x copy for the mine action organisation in country senior appointment. (4) 1 x copy for the mine action organisation parent HQ. 5.4 Once the BOI report has been signed and prepared, the senior in-country appointment from the mine action organisation is to be given the opportunity to read and discuss its contents. This is to be conducted in a formal environment with the following personnel in attendance: a. National / Regional Programme Manager. b. National / Regional Chief of Operations. c. Investigating Officer. d. MDD / Medical specialists if applicable. e. Clearance Organisations Programme Manager. f. Any other personnel as identified by the Clearance Organisations Programme Manager. 5.5 Should the mine action organisation senior in-country appointment wish to have any additional comments included in the report he is to submit them in writing and they shall be inserted into the report prior to distribution. 5.6 The senior in-country appointment from the mine action organisation is to ensure that all recommendations are implemented without delay. The UNMAO is to ensure that a summary of lessons learnt are distributed to all mine action organisations as soon as possible. 6. REPORTING OF FATAL INCIDENTS TO LOCAL AUTHORITIES 6.1 Cultural and religious beliefs are to be considered when dealing with the repatriation of the deceased to their immediate family or in cases were non clearance staff have been injured/killed. Page 6 of 6