HSE P1401 Incident Management and Investigation Procedure

Transcription

1 HSE P1401 Incident Management and 1 DOCUMENT CONTROL PURPOSE SCOPE DEFINITIONS ROLES AND RESPONSIBILITIES PROCESS DETAILS Incidents Immediate Post-Incident Actions (WHS and Operational) Immediate Post-Incident Actions (Environmental) Oil / Chemical Spill Discovery of an Aboriginal Heritage Artefact: Fauna (Fish) Kill Notifications... Error! Bookmark not defined. 6.5 Investigation Investigation Process 14 Level 1 Investigations Level 2 Investigations Level 3 Investigations Level 4 Investigations REFERENCE MATERIALS ATTACHMENTS Table of Figures Figure 1: Incident Management Process Flow Chart... 9 Table of Tables Table 1: Preferred Doctors List Table 2: Investigation Type Determined by the Assigned Risk Rating Page 1 of 18

2 1 DOCUMENT CONTROL Document Information Document ID Document Administrator Document Name Information HSEP1401 Issue Date April 2015 Document History WHS & HSE Systems Manager Incident Management and Rev No Date Description Approved by 1 22 / 10 / 13 Updates with regards to SAP 2 17 / 6 / / 4 / 15 Added requirement to record Incidents into SAP within 14 days Re-write of document to align with new company structures and HSE system requirements Manager Sustainability and Safety Systems and Quality Manager WHS & HSE Systems Manager Document Change Summary Date Section Change Description 1 / 4 / 15 All Document has been completely re-written and this version shall be considered as a new document Document Approvals Role Name Signature Date Manager Operations Paul Molnar 19/11/15 Page 2 of 18

3 Related Documents Document Name Author Page 3 of 18

4 2 PURPOSE The purpose of this document is to ensure that all Health, Safety and Environmental (HSE) and Operational Incidents are investigated in a consistent, timely and professional manner. This will ensure that root causes can be identified and appropriate Corrective Actions implemented to prevent recurrence of the same or similar circumstances, which will contribute to ensuring the safety of all Hydro Tasmania (HT) Workers and the environment. 3 SCOPE This procedure applies to HSE and Operational Incident Management and Investigation across all HT owned and operated Sites and activities. 4 DEFINITIONS Term or Acronym Action Owner Incident Incident Owner Investigation Lead Line Manager Operational Incident Operational Assets Reporting Worker Meaning See HSEREF Work Safe Roles and HSE Glossary The Worker who is responsible for completing or ensuring the completion of preventative and / or Corrective Actions An unplanned event or breach of procedure that has caused an accident, a loss or an unexpected gain The Worker who oversees the management of the Incident from start to finish. This defaults to the Line Manager of the Reporting Worker or the Asset Owner. The Incident Owner is also responsible for ensuring all Incident details are correct and recorded in sap EHS A Worker trained and competent in evidence gathering techniques, root cause analysis and report preparation. All Investigation Leads are trained in the Systematic Cause and Analysis Technique (SCAT) Investigation Methodology A Worker who holds authority in a vertical 'line' (chain of command) and to whom queries or approvals can be addressed. The immediate Manager of the Reporting Worker. Will be the Incident Owner where there is no Asset Owner or other nominated Incident Owner An Incident resulting from the operation or attempted operation of Operational Assets. This includes Incidents resulting from incorrect preparation and planning that may be detected before the actual physical operations commence Plant, equipment or other infrastructure associated with the generation of electricity from HT owned or operated assets The Worker who initially assesses the Incident and undertakes any immediate Emergency Response Corrective Actions. This Worker may also restrict immediate operations Page 4 of 18

5 sap EHS Supervisor TMR The Company enterprise system used to manage HSE Incidents and investigations The Worker in charge of the Workgroup Trunk Mobile Radio Page 5 of 18

6 5 ROLES AND RESPONSIBILITIES Work Requestor Incident Owner Work Planner Incident Owner Work Authoriser Incident Owner Work Supervisor Asset Owner Specialist Worker Roles Workers Advice / Support Investigation Lead Reporting HSE Team Worker Supervisor Workers Action Owner WHS & HSE Systems Manager HT Legal Counsel Reporting Worker initiate the initial response to the Incident, including any required Emergency Response or medical assistance; shall notify the immediate Supervisor and Line Manager ASAP, but always within 1 hour of the Incident occurring (see Section 6.4 Notifications); ensure that the Incident is reported to the Supervisor; assist with securing the Incident scene and preserving evidence; and ensure that the Incident is entered into sap EHS Incident Owner receive the Incident Notification from sap EHS; review the Incident information and Risk rating and either confirm the details or amend them as required; initiate the Incident Investigation in sap EHS as required by the Incident level; track the progress of the Investigation to ensure it occurs to schedule; in consultation with any nominated Investigation Lead, determine the required Corrective Actions and allocate the Corrective Action tasks to appropriate Action Owners in sap EHS; monitor the close out of Corrective Actions to schedule in sap EHS; and close the Incident once all Investigations and Corrective Actions are completed Page 6 of 18

7 Investigation Lead open the required Investigation process steps in sap EHS; establish an Investigation Team if required; complete the Investigation, including interviewing witnesses and gathering evidence; prepare a detailed written Investigation Report that is saved in sap EHS along with copies of all other documentary and photographic evidence; complete a root cause analysis and enter the immediate and underlying causes into sap EHS; and in consultation with the Incident Owner, determine the required Corrective Actions and ensure they are entered into sap EHS Line Manager take on the role of Incident Owner where there is no Asset Owner or other nominated Incident Owner; notify the following ASAP, but within 1 hour of becoming aware of the Incident occurring (see Section 6.4 Notifications): the WHS & HSE Systems Manager (for Health and Safety Incidents); the Operational Compliance & Capability Manager (for Operational Incidents); or the Sustainable Resources Manager (for Environmental) Incidents; assign resources required for Incident Investigation; review the progress of Incident Investigations within their Business Unit at least monthly and follow up on overdue Investigations or Corrective Actions; and assist the Incident Owner with completion of Investigations and close out of Corrective Actions where required. Supervisor assist with the initial management of the Incident scene if on Site, including the arrangement for attendance of any Emergency Services; ensure that the Reporting Worker enters the Incident details into sap EHS; accompany any injured Workers to hospital or other places for medical treatment; and consult with treating doctors after each injured Worker is treated to determine if alternative duties need to be arranged to allow the Worker to continue to work Action Owner complete the required Corrective Actions Page 7 of 18

8 Workers report all Incidents WHS & HSE Systems Manager in consultation with HT Legal Counsel determine whether or not the Incident is notifiable to the regulatory authorities; make all notifications to any regulatory authority; keep the Chief Operating Officer informed of any Incident that is notified to the regulatory authorities; and be the point of contact for the provision of any assistance related to Level 4 Investigations HT Legal Counsel in consultation with WHS & HSE Systems Manager determine whether or not the Incident is notifiable to the regulatory authorities HSE Team coordinate the HSE Risk Assessments; maintain and review HSE documentation; and communicate and provide training in the application of HSE processes Page 8 of 18

9 6 PROCESS DETAILS Figure 1: Incident Management Process Flow Chart Page 9 of 18

10 6.1 Incidents The primary concern after any health, safety, environmental or operational Incident is the safety of Workers, visitors and the general public and prevention of damage to plant and equipment or the environment. The following Corrective Actions shall take place immediately after any Incident. 6.2 Immediate Post-Incident Actions (WHS and Operational) Step 1: After making the scene safe for entry of assisting Workers, take all necessary steps to provide Emergency rescue and first aid for any injured Workers. Step 2: If any Worker has sustained injuries where urgent medical attention is required, call an ambulance on 000 from a landline or satellite phone, or 112 on a digital mobile phone. If there is no phone available but a HT vehicle is in the vicinity, the Emergency SOS facility or the Trunk Mobile Radio (TMR) may be used to raise the alarm. If phone contact is made with Emergency Services, stay on the line and provide clear and concise information to the operator on the exact location and details of the type and severity of any injury. Step 3: Secure the Incident scene, barricade off if possible and prevent any further entry prior to an Investigation being completed in order to preserve any evidence. Only re-enter the Site if required to prevent or minimise the Risk of further Incidents or injuries. Step 4: Notify the immediate Supervisor and Line Manager ASAP, but always within 1 hour of the Incident occurring. Initial notification should be via a phone call, followed up with an if possible. Step 5: Where a Worker is injured but the injury does not require an ambulance, and the Worker needs to attend a doctor or hospital for treatment (e.g. a cut requiring stitches), the Worker s immediate Supervisor shall accompany them to provide appropriate assistance. Where the Worker s immediate Supervisor is unavailable, another Supervisor or Manager shall be delegated. The treatment process to be followed is: attend the primary care facility (wherever possible select from Table 1: Preferred Doctors List); the Supervisor / Manager shall wait outside the consultation area until the initial treatment has been provided to the injured Worker; and once the injured Worker has been treated, the Supervisor / Manager shall meet with the treating doctor and the Worker and determine: the diagnosis; what treatment the Worker will now require; whether the Worker can return to normal duties; whether the Worker can perform meaningful restricted duties; and whether the Worker requires time away from work Page 10 of 18

11 Step 8: Where the Incident cannot be managed using only local Site based resources, or where evacuation of the Site is required, refer to the Emergency Response Plan for directions on managing the Incident. Step 9: Where an Operational Incident has occurred, the Workers directly involved in the operations that resulted in the Incident shall be stood down without prejudice, pending the outcomes of the Investigation. Preferred Doctors: Central Highlands General Practice, Ouse Hospital Lyell Highway, Ouse: Ph Davey St Medical Centre, 25 Davey Street, Hobart: Ph Flinders Island General Practice, 6 James Street, Whitemark: Ph (03) Hopkins St Clinic, 67 Hopkins Street, Moonah: Ph King Island General Practice, 5 Beach Road Currie: Ph (03) Lauderdale Doctors Surgery, 444 South Arm Road, Lauderdale: Ph Longford Medical Services, Cnr Smith & George Streets, Longford: Ph Newstead Medical Centre, 165 Elphin Road, Newstead: Ph Queenstown General Practice, 60 Orr Street, Queenstown: Ph Rosebery Medical Centre, Hospital Road, Rosebery Ph Scottsdale Doctors Surgery, 2 Fosters Road, Scottsdale Ph Sheffield Medical Practice, 48 High Street, Sheffield: Ph Preferred Medical Practice in Melbourne: EraHealth, 563 Bourke Street, Melbourne, Ph Table 1: Preferred Doctors List Page 11 of 18

12 6.3 Immediate Post-Incident Actions (Environmental) The following steps shall be undertaken to manage environmental Incidents immediately after the event: Oil / Chemical Spill (see HSEP Oil and Chemical Management Procedure): Prevent Spills from entering waterways; Protect yourself and the environment if a Spill occurs; Control the Spill, contain it when safe to do so, and arrange clean up; Warn others where necessary and call for help if needed. This may require calling Emergency Services if the situation gets out of control; Report the Incident to your Supervisor; and Clean-up wearing the correct PPE for the substance and the correct spill management products (pads, sausages, booms etc.); dispose of clean up pads and equipment in the appropriate waste bin (i.e. hydrocarbon bin); estimate the amount of the substance that has spilled and take photos; and notify the appropriate people using Section 6.4 Notifications Discovery of an Aboriginal Heritage Artefact: (see HSEP Cultural Heritage Management Procedure): Stop work and isolate Site; take photos and notes of the suspected artefact; and notify the appropriate people using Section 6.4 Notifications Fauna (Fish) Kill (see HSEP Animal Ethics Permit Procedure): Note exact location and any unusual conditions (smells, colour of water, recent works); and take photos and contact the Manager of the Aquatic Program ASAP. 6.4 Investigation When the Incident is recorded into the sap EHS system, a Risk rating will be assigned based on the potential impact (see Table 2: Investigation Type Determined by the Assigned Risk Rating). The Incident Owner shall review and confirm the risk rating and establish the investigation type based on the confirmed rating. Page 12 of 18

13 Risk Rating Investigation Type Investigation Owner Insignificant No further Investigation required N/A Minor Level 1 - Basic Investigation required. The root causes Incident Owner shall be noted in the investigation field within the sap EHS system and corrective / preventative actions assigned if required. The Investigation should consider a behavioural safety analysis using the SafeStart principles. Moderate Level 1 - Standard Investigation required. The Incident Owner Investigation will be undertaken by a nominated, trained Investigation Lead using the Systematic Cause and Analysis Technique (SCAT) Investigation Methodology, and corrective / preventative actions shall be assigned and tracked to close out. A detailed investigation report may be required by the Incident Owner. The Investigation shall include a behavioural safety analysis using the SafeStart principles. Major Level 2 Complex Investigation required. The Investigation will be undertaken by a nominated, trained Investigation Lead using the Systematic Cause and Analysis Technique (SCAT) Investigation Methodology. A full causal analysis will be completed and recorded using the sap EHS system function. A detailed Investigation Report shall be completed and all corrective / preventative actions assigned and tracked through the sap EHS system. The Investigation shall include a behavioural safety analysis using the SafeStart Incident Owner Extreme Catastrophic principles. Level 3 - Complex Investigation required. The Investigation will be undertaken by the WHS & HSE Manager or the Operational Compliance & Capability Manager (or their delegates) using the Systematic Cause and Analysis Technique (SCAT) Investigation Methodology. A full causal analysis will be completed using the sap EHS system function. A detailed Investigation Report shall be completed and all corrective / preventative actions assigned and tracked through the sap EHS system. The Investigation shall include a behavioural safety analysis using the SafeStart principles. Level 4 Investigation will be undertaken by regulatory and / or Emergency Services authorities with support from HT as required. Table 2: Investigation Type Determined by the Assigned Risk Rating WHS & HSE Manager or Operational Compliance & Capability Manager Chief Operating Officer Page 13 of 18

14 Investigation Process The Incident Investigation process will commence as soon as practicable after the initial management of the Incident scene is complete. The Incident Owner is responsible for ensuring that the Incident is investigated as required by the following sub-sections and that all sap EHS updates are completed through to close out. Note: If an Incident Owner does not believe that they are the owner of the Incident, they are responsible for consulting with, and then nominating an alternative Incident Owner and changing the Incident Owner details in sap EHS Page 14 of 18

15 Level 1 Investigations A Level 1 Investigation will generally only require a review of the information that has been submitted in the Incident Report. However, if the Incident Owner determines that a more complete Investigation is required, regardless of the Incident Level, they may instigate a full Investigation. The basic Level 1 Investigation requires the following steps to be completed by the Incident Owner: Step 1: Review the information contained within the Incident Report in sap EHS. Ensure that there is sufficient detail to understand the nature of the Incident and to clearly identify the root cause without further Investigation or analysis. Ensure that the Corrective Actions are sufficient to effectively close out the Incident without a full Investigation. Step 2: Ensure that the potential Impact Rating has been completed in the Impact Matrix. If the rating is incorrect it can be changed at this point. If the Impact Rating is changed to a higher level, then the Investigation process for that level shall be followed. Step 3: If no further Investigation is required make an entry in the incident management system with a comment detailing why no further Investigation is required is entered. Go to Step 6. Step 4: If the Incident Owner believes further Investigation is required to determine the root causes and implement appropriate Corrective Actions, the Incident Owner shall re-allocate the Incident to an Investigation Lead. Step 5: The Investigation Lead will complete the Investigation in the same manner as for a Level 2 Investigation. Step 6: Incident Owner closes the Incident. Page 15 of 18

16 Level 2 Investigations Level 2 Investigations are more complex in nature and require the skills of a trained Investigation Lead, and in many cases, the assistance of an Investigation Team made up of appropriate subject matter experts. The Level 2 Investigation process requires the following steps: Step 1: The Incident Owner reviews the information and Impact Rating contained within the Incident Report in sap EHS and confirms that the Incident meets the requirements for a Level 2 Investigation. Step 2: The Incident Owner, after consultation with the Investigation Lead, appoints a suitable Investigation Lead from the available list in sap EHS. Step 3: The Incident Owner commences the Investigation process within the incident management system. Step 4: The Investigation Lead undertakes a full Investigation of the Incident using the Systematic Cause and Analysis Technique (SCAT) Investigation Methodology. The Investigation Lead collects all relevant evidence, including statements, photographs, documents and physical evidence and prepares a full written Investigation Report. Step 5: The Investigation Lead loads the final Investigation Report and all other documentary evidence into sap EHS. Step 6: The Investigation Lead completes the immediate and underlying causal analysis steps in sap EHS and in consultation with the Incident Owner and identified Action Owners, allocates any required Corrective Actions tasks. Step 7: The Incident Owner monitors the close out of the Corrective Actions. When all Corrective Actions have been closed, the Incident Owner closes the Incident. Page 16 of 18

17 Level 3 Investigations Level 3 Investigations are undertaken in the same manner as a Level 2, however the role of Investigation Lead will be undertaken by: the WHS & HSE Systems Manager (or delegate) for all Health and Safety related Incidents; the Sustainable Resource Manager (or delegate) for Environmental Incidents; or the Operational Compliance & Capability Manager (or delegate) for Operational Incidents Level 4 Investigations Level 4 Investigations are those that are undertaken by an external authority, such as the police or WorkSafe Tasmania. In such cases, HT will provide assistance as requested. The WHS & HSE Systems Manager will be the point of contact for the provision of any such assistance, with the approval from the Chief Operating Officer. Page 17 of 18

18 7 REFERENCE MATERIALS The following manuals and references are used to provide a safe system of work. These requirements are a minimum standard and shall not be compromised under any circumstances. Work Health and Safety Legislation (as per State requirements) Environmental Management Legislation (as per State requirements) The following is a list of commonly referenced material used on HT Sites. HSEREF Work Safe Roles and HSE Glossary HSEF Incident Investigation Report Template HSEP Animal Ethics Permit Procedure HSEP0301 Hazard Identification and Operational Risk Management Procedure HSEP Cultural Heritage Management Procedure HSEP Oil and Chemical Management Procedure SAP Quick Reference Guides: Incident Management App Log a Safety Observation; Incident Management App Log an Incident, Hazard or Near Miss; Incident Management App Manage an Incident; Incident Management Flipchart Incident Reporting Instructions 8 ATTACHMENTS Page 18 of 18