Mandatory
Shell HSSE Control Framework
HSSE MANAGEMENT SYSTEM MANUAL
Restricted
Incident Investigation and Learning
Purpose
To log, investigate and learn from Incidents1.
Who is this for?
• Business Heads;
• Business Leaders;
• Managers; and
• LFI coordinators, personnel involved in, communicating or applying Learning from Incidents (LFI).
What situations are covered?
Incidents that are related to activities carried out, and Learning from Incidents.
Requirements
Managers are accountable for establishing and maintaining procedures that cover the requirements
1 to 8 below, including defining who is responsible for each requirement.
Misses, to the supervisor of the work activity.
1. Report all Incidents, including Near Misses,
1.1. All personnel must report any incident they become aware of, as soon as possible: and
no later than end of the same working day or shift.
1.2. Include in the initial report the following if known: incident location, what happened,
when it happened, the outcome and who was involved.
2. Make an initial classification of the incident. Use the Risk Assessment Matrix 2, to determine in
two
two steps how the incident must be notified and investigated (see Figure 1 – RAM ratings):
1
Underlined terms in this document are included in the HSSE Control Framework Glossary.
2
Italicized terms reference manuals and manual sections in the HSSE Control Framework.
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Step 1 – Use the actual consequences to determine the initial RAM Severity Rating: 0-5, for
People, Assets, Environment, or Reputation.
Step 2 – Use the combination of the potential consequences severity rating (0-5) and their
likelihood rating (A-E) to determine the initial RAM Risk Rating: Red, Yellow or Blue.
CONSEQUENCES INCREASING LIKELIHOOD RAM
RAM
risk
severity A B C D E
SEVERITY
Environment
rating
Reputation
rating Never Heard of in Has Has Has
People
heard of in the Industry happened in happened at happened
Assets the Industry the the Location more than
Organisation or more than once per
or more than once per year at the
once per year in the Location
year in the Organisation
Industry
No injury or No No effect No
0 health damage impact
effect HIGH
Slight injury Slight Slight Slight POTENTIAL
1 or health damage effect impact
SIGNIFICANT effect INCIDENT
INCIDENT 2
Minor injury
or health
Minor
damage
Minor
effect
Minor
impact
(= RAM risk
(= RAM severity effect rating RED)
Major injury Moderate Moderate Moderate
rating 4 or 5) 3 or health damage effect impact
effect
PTD or up Major Major Major
4 to 3 damage effect impact
fatalities
More than Massive Massive Massive
5 3 fatalities damage effect impact
Figure 1 – RAM ratings
2.1. Classify incidents with actual consequences 4 or 5 as Significant Incidents.
2.2. Classify incidents and near misses that have a red RAM risk rating as High Potential
Incidents.
3. Log the incident in Fountain Incident Management (FIM) or equivalent recording system.
3.1. Appoint an Incident Owner.
4. Notify the appropriate Line Manager as soon as practical.
practical.
4.1. The supervisor’s Line Manager must be notified of any incident, including any near miss.
4.2. The Manager must be notified of any incident with actual consequence RAM severity
rating 2 or higher and any incident with RAM risk rating Yellow or Red.
4.3. Treat all Non-Accidental Death cases including suicides and homicides, and Third Party
Fatalities from Work Related Activities, as Significant Incidents until determined otherwise.
5. Investigate the incident as soon as practical after it occurred.
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5.1. The notified line manager, or a nominated delegate from the line organisation where the
incident occurred, must take on the role of incident owner and must determine the level of
investigation.
5.2. The Incident Owner must approve the investigation report, recommendations and action
plan within 3 months of the incident, and follow up the action plan until implemented.
5.3. Obtain legal advice before beginning to write any investigation report that may need to
be shared with external parties and obtain a legal review before it is finally approved.
6. Notify, investigate, review and apply LFI to Significant Incidents and High Potential Incidents
with a RAM risk rating of C5, D5 or E5 as specified in the Table 1.
6.1. Send initial incident notification reports and final investigation reports to the Business or
Function LFI Coordinator.
6.2. The Incident Owner must appoint an Incident Investigation Team Leader of a seniority
appropriate to the incident’s actual severity and level of risk and establish an investigation
team that includes an Incident Investigation Facilitator who is competent in the
methodology used.
6.3. The investigation report must include an analysis of immediate and underlying causes and
weaknesses in the HSSE management system
7. Make a final classification of the incident based on the outcome
outcome of the incident investigation.
7.1. Review the initial classification of RAM severity rating of actual consequences and the
RAM risk rating and revise if necessary.
7.2. Apply the requirements specified in the HSSE Management System manual sub-section
Performance Monitoring and Reporting for all other aspects of classification.
8. Update the incident record in Fountain Incident Management, or equivalent recording system,
with the investigation report including final classification and action plan.
Business Leaders and LFI Coordinators are accountable for requirement 9 as specified.
9. Learn from Significant Incidents and High Potential Incidents through communication and
implementation of required actions.
9.1. Business Leaders are accountable for nominating LFI Coordinators in each business and
function.
9.2. LFI Coordinators must communicate learning and required actions within their business or
function and to all other LFI Coordinators using LFI Alerts.
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9.3. LFI Coordinators must review initial incident notification reports and, if immediate action is
required, communicate the known key facts about the incident and the required immediate
action in an LFI Alert.
9.4. LFI Coordinators must obtain Business line approval of actions proposed by LFI Alerts.
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Table 1 – Timelines for Notification, Investigation, and Review of Significant
Incidents and High Potential Incidents
Significant Incidents
Notification Notify Business Head or Function Head, senior Business Leader or Function Leader, Business or Function
HSSE VP and Group HSSE VP
Within 24 hours
Underlying causes TRIPOD, TRIPOD Beta, Causal Learning
analysis method
Investigation report To Business Head or Function Head, senior Business Leader or Function Leader, Business or Function HSSE
VP and Group HSSE VP
Within 1 month. Business or Function HSSE VP can agree an extension to the deadline
Significant Incident Review by Business or Function Head
Review (SIR) Meeting Within 3 months of incident. Business or Function HSSE VP can agree an extension to the deadline
Follow-up report within 12 months of SIR by Incident Owner
Learning From Apply process
Incidents
High Potential Incidents with a RAM risk rating of C5, D5 or E5
Notification Notify Regional or Class of Business Executive VP and Business or Function HSSE VP. Further mandatory
notification is discretion of Business / Function Leader
Within 24 hrs
Underlying causes Discretion of Business HSSE VP
analysis method
Investigation report To Business or Function HSSE VP. Further mandatory distribution of investigation report is discretion of
Business / Function Leader
Within 1 month. Business or Function HSSE VP can agree an extension to the deadline
Include in Significant Discretion of Business HSSE VP
Incident Review
Meeting
Learning From Apply process
Incidents
Version 3, March 2009
Manual section: Incident Investigation and Learning Page 5 of 5
