Military reference books and manuals (2009-2023, Volume 4)

AZSPU-HSSE-DOC-00054-2

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Incident Investigation and Reporting

REPORT DISTRIBUTION

DEVELOPMENT AND DISTRIBUTION OF LESSONS LEARNED

STORAGE OF RECORDS

10 HSSE & OPERATIONAL INCIDENT REPORTING BOUNDARIES

10.1

REPORTING AND RECORDING BOUNDARIES

10.2

“OPERATIONAL BOUNDARY”

10.3

“OPERATIONAL BOUNDARY” - SPECIAL CASES

10.4

“WORK- RELATED” BOUNDARY

10.5

ILLUSTRATIVE CASE

REFERENCES

APPENDIX A - MODEL TERMS OF REFERENCE TEMPLATE

APPENDIX B - DEFINITIONS

WORK-RELATED

BP WORK ENVIRONMENT

BUSINESS TRAVEL - BP EMPLOYEE

BUSINESS TRAVEL - BP CONTRACTOR

EMPLOYMENT STATUS

BP WORKFORCE

EMPLOYEE

CONTRACTOR

THIRD PARTY

INCIDENT

ACCIDENT

NEAR MISS

FIRST AID CASE

MEDICAL TREATMENT CASE

INJURY/ILLNESS

OCCUPATIONAL ILLNESS

OCCUPATIONAL INJURY

RECORDABLE OCCUPATIONAL ILLNESS AND INJURY

RESTRICTED WORK OR JOB TRANSFER (RW/JT)

DAYS AWAY FROM WORK CASE (DAFWC)

HIGH POTENTIAL (HIPO) INCIDENT

MAJOR INCIDENT (MIA)

RECORDABLE FATALITY

INCIDENT SEVERITY

VEHICLE ACCIDENT

SEVERE VEHICLE ACCIDENT

LOSS OF PRIMARY CONTAINMENT (LOPC)

UNCONTROLLED RELEASE/EVENT

PRIMARY CONTAINMENT

UNSAFE/UNHEALTHY CONDITION

INCIDENT INVESTIGATION

10.6

IM RELATED INCIDENT

PROCESS SAFETY

PROCESS SAFETY INCIDENT

EQUIPMENT /PROPERTY DAMAGE (INCIDENT DIRECT COST)

HOME AWAY FROM HOME

Control Tier:

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Incident Investigation and Reporting

EXPLOSION

FIRE

ACUTE RELEASE

FRAUD

SECURITY INCIDENT

MAJOR SECURITY INCIDENT

HIGH POTENTIAL SECURITY INCIDENT

MARINE RELATED INCIDENT

INCIDENT INVESTIGATION

BP‟S RCA INVESTIGATION

CRITICAL FACTOR

UNSAFE/UNHEALTHY CONDITION

“CONTRACT FOR AVIATION SERVICES”

“D2D SUPERVISED CONTRACTOR”

“DEDICATED TO BP‟S BUSINESS USE”

“E&P CONTRACTOR LED FACILITY DOING MATERIAL WORK FOR BP”

APPENDIX C - INJURY AND ILLNESS REPORTING DECISION TREE

APPENDIX D - SEVERITY MATRIX, HSE IMPACT LEVELS

APPENDIX E - SEVERITY MATRIX, BUSINESS IMPACT LEVELS

APPENDIX F - POTENTIAL SEVERITY CLASSIFICATION, LOPC OF FLAMMABLE

GASES, LIQUIDS AND OTHER HAZARDOUS CATEGORIES (ACUTE RELEASE)49

APPENDIX G - POTENTIAL SEVERITY CLASSIFICATION, LOPC OF TOXIC

SUBSTANCES (ACUTE RELEASE)

APPENDIX H - EXPORTS PU INTERNAL INCIDENT NOTIFICATION REQUIREMENTS

FOR ILLEGAL TAPS

APPENDIX I - ONSHORE OPERATIONS EXTERNAL NOTIFICATION REQUIREMENTS

................................................................................................................................ 52

APPENDIX J - INCIDENT CLASSIFICATION, RESOLUTION PROCEDURE

APPENDIX K - INITIAL INTERNAL INCIDENT NOTIFICATION FORM

APPENDIX L - GUIDANCE ON USE OF DROPS CALCULATOR AND DROPPED OBJECT

HIPO DETERMINATION

APPENDIX M - PROCESS SAFETY INCIDENT CLASSIFICATION GUIDANCE

REVISION/REVIEW LOG

Control Tier:

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Print Date: 1 February 2011

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Incident Investigation and Reporting

1 INTRODUCTION

1.1 PURPOSE

This document describes the procedures employed for reporting and investigating incidents

related to BP activities in the Azerbaijan Strategic Performance Unit (AzSPU) and in the

preparation of associated reports.

Note: The prime objectives of such an investigation are to establish the immediate and root

causes, analyze them, and make recommendations to prevent recurrence of a similar

incident. It is not to attribute blame.

1.2 SCOPE

This process shall be used for all types of incidents, including but not limited to:

 Fatalities

 Workplace injuries and illness

 Security breaches

 Spills and leaks

 Vehicle accidents

 Near misses

 All drilling and well operations safety and integrity management accidents,

incidents and significant near misses

 Process safety incidents e.g. overpressure of design plant, excursion from design

temperature, formation of hydrate plugs, misdirection of process fluids, ESD or

pressure safety valves lifting (whether to flare or vent)

 Plant/technical integrity incidents i.e. any incident where the root cause would be

addressed by the Group Defined Practice - Integrity Management (GDP 5.0-0001)

and there is actual or potential harm to people or the environment, including loss

of primary containment or failure of an engineered system

 Marine related incidents

 Aviation related incident

 Etc.

All types of incidents are to be reported immediately to the supervisor and / or the BP

representative.

1.3 CONTRACTOR INVESTIGATIONS

Contractor management may wish to conduct a separate internal incident investigation for

serious incidents involving contractor employees. BP policy is to respect the wishes of

contractors, and to encourage completion of a joint investigation in a cooperative manner

with representatives of both BP and affected contractors.

For incidents that occur at BP controlled sites or activities the investigation shall be led by a

BP representative.

Control Tier:

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Incident Investigation and Reporting

2 RESPONSIBILITIES

2.1 ALL PERSONNEL

Any person involved in or observing an accident or near miss must immediately report it to

his / her supervisor or BP Representative.

2.2 SPU LEADER (SPUL)

SPU Leader is responsible and accountable for ensuring that this procedure is implemented

in the AzSPU and for reporting major incidents and HiPos to the BP Group.

SPU Leader is responsible for

 Notification of Major Incidents and HiPos to the appropriate Group Vice President

through personal conversation within 8 hours

 Issue of MIA/HiPo notification to “G E&P Incident Notification” distribution list

 Being the “owner” of all major incidents in AzSPU (other than fatality incidents, which

require an externally led incident investigation team).

2.3 FUNCTIONAL VICE PRESIDENTS (VPS) OR DESIGNEE (OPERATIONS, MIDSTREAM,

D&C, HSE & ENGINEERING)

Vice President (VP) or designee is responsible and accountable for:

 Ensuring that this procedure is implemented in their area of responsibility

 Reporting MIA/HiPo/DAFWC incidents to SPU leader

 Being the owner of HiPo incidents in their respective Function.

2.4 AREA/WELL/LOGISTIC OPERATIONS MANAGER

Responsible for:

 Ensuring that this procedure is implemented in their specific area of responsibility

 Reporting level G (health & safety) and all F+ incidents to the relevant VP

 Being the owner of actual level F severity incidents in their respective area of

responsibility.

2.5 AZSPU ENTITY AVIATION AUTHORITY

AzSPU Entity Aviation Authority (EAA) is responsible and accountable for:

 Ensuring that this procedure is implemented for all aviation incidents

 Notifying Segment Aviation Authority and Group Head of Aviation about aviation

incidents and incidents that could require aviation as part of the incident response,

taking due consideration of the notification of the AzSPU Incident timing to ensure

that the notification does not precede the notification to the Functional VP and

Segment Management

 Providing the appropriate aviation expertise and resources to the investigation team

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Incident Investigation and Reporting

 Consulting with Segment Aviation Authority and Group Head of Aviation on level of

investigation and BP Aviation participation

 Acting as conduit to Segment and Group for promulgating lesson learned on aviation

incidents.

2.6 MARINE AUTHORITY

The SPU Marine Authority is responsible and accountable for:

 Ensuring that this procedure is implemented for all marine incidents

 Reporting MIA/HiPo/DAFWC marine incidents to Single Point Accountability -

Marine

 Ensuring SPA-Marine notifies BP Shipping of the incident, taking due

consideration of the notification of the AzSPU Incident timing to ensure that the

notification does not precede the notification to the Functional VP and Segment

Management

 Providing the appropriate marine resources to the investigation team

 Consulting with BP shipping on level of investigation and BP Shipping participation

 Acting as conduit to BP Shipping for promulgating lesson learned.

2.7 SITE MANAGER

Site Manager/OIM/Fleet Operations TL are responsible for estimating the worst probable

(not imaginable) outcome of a particular incident and making an initial assessment of the

severity of the incident and determining the level of management that should own the

investigation process.

(Refer to Section 2.8).

Site Managers are responsible for:

 Initial reporting of the incident

 Preservation of the incident scene (preservation of physical data and prevention of

destruction/alteration) and early collection of material evidence, taking

photographs etc

 Making an initial assessment of the severity of an incident

 Requesting drugs and alcohol testing whenever potential for substance abuse is

under question

 Obtaining initial witness statements (eyewitnesses) while incident details are still

fresh

 Instigating the appropriate investigation process

 Assuming ownership of minor incidents on his site

 Accepting the Incident Report and allocating the resulting actions

 Ensuring that all equipment is verified “fit for purpose” after a significant incident or

event, prior to return to service.

Control Tier:

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Print Date: 1 February 2011

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Incident Investigation and Reporting

Note: The incident scene shall be released for resumption of work only at the direction of the

incident investigation team. This shall be done (with advice from BP legal as needed) at the

direction of, or with the concurrence of, any involved regulatory or law enforcement bodies.

2.8 INCIDENT OWNER

The Owner is the individual who requested the Incident Investigation to be performed and

has the responsibility for the investigation through to closeout of the remedial actions. The

level of the Owner must be commensurate with the severity, or potential severity, of the

incident and should be:

 SPU Leader (SPUL) for major incidents in AzSPU (all actual level A-E incidents

other than fatality).

 Vice President (VP) for HiPos (potential severity A-E).

 Area/Well/Logistics Operations Manager for all actual level F severity incidents.

 Site Manager/OIM/Fleet Operations TL actual or potential incident severity Levels

G-H.

The Owner shall:

 Appoint the Investigation Team, other than for fatality incidents

 Draw up the terms of reference for the investigation

 Ensure that incident investigation team leads and members are given adequate

relief from their normal duties to complete the incident investigation

 Ensure investigation team is provided with all resources required for investigation

 Provide a business overview on actions prior to entry into the tracking system and

shall review each action item for confidentiality

 Review the selection of the Responsible Party for handling the action items

 Ensure that all new or reassigned action items are entered into the Accident and

Incident database (Traction) under the appropriate category

 Review progress reports to ensure that all outstanding action items are being

completed within specified deadlines

 Take appropriate action with the Responsible Party if action items are not being

completed within the required deadline

 The incident owner shall promptly advise BP Legal of any incidents classified as

“Major Incident”, and of any other incident where the possibility of regulatory action

or litigation exists.

2.9 INVESTIGATOR / INVESTIGATION TEAM

The Investigator/Investigation Team will be appointed by the Investigation Owner (Site

Management, Area/Well/Logistics Operations Manager, VP, SPUL) depending on severity of

incident, and specifics of the case, and is responsible for:

 Investigating the circumstances leading to the event

 Making recommendations to prevent recurrence

 Ensuring that the written report is completed

 Ensuring the MIA, HiPo and DAFWC report is handed over to the “owner”.

Control Tier:

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Incident Investigation and Reporting

The Investigation Team shall:

 Establish the situation before the incident

 Determine what happen during the incident

 Determine the critical factors

 Determine the immediate and system causes

 Determine actions to prevent recurrence of a similar incident

 Produce the incident report.

Note: Wherever the location of the incident, the investigation team shall not investigate in

circumstances where it may be unsafe to do so. It shall be the responsibility of the

investigation team leader (with help from the BP entity leader as requested) to ensure the

safety of the investigation team members during the investigation.

2.10 APPROVER

The Approver of the incident report will normally be the “Owner” of the incident and he/she is

responsible for agreeing actions with the Investigation Team. If the Owner is not satisfied

that the actions recommended fully address the immediate and system causes of the

incident, he should instruct the Investigation Team to seek further advice and formulate

further actions before he approves the incident report and actions in Traction.

The Approver is responsible for assuring the quality of the investigation report and the data

entered into the Accident and Incident Reporting database (Traction).

The Approver shall:

 Review the Incident Report to ensure an accurate document with proper root

cause analysis

 Ensure that:

o appropriate causes have been identified

o action items will effectively mitigate the hazards

o action items are clear and provide the Responsible Party with adequate

details to implement the action item

 Review the selection of the Responsible Party for handling the action item in order

to ensure that the action item has been assigned to an individual or job position

with sufficient authority and expertise to complete the action

 Approve the report in the Accident and Incident database (Traction).

2.11 INCIDENT REPORT ORIGINATOR

The Incident Report Originator is responsible for entering the Incident Report into the

Accident and Incident database (Traction).

Note: This will normally be a nominated Traction operator at the site of the incident.

Control Tier:

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Incident Investigation and Reporting

2.12 RESPONSIBLE PARTY

The Responsible Party is the individual who has been assigned an action item arising from

an Owner‟s Incident Investigation. The Responsible Party must have sufficient authority and

expertise to carry out the action.

The Responsible Party shall:

 Review validity of assignments of an action item with the Owner, if and when they

consider the assignment inappropriate

 Take accountability for ensuring that all of his/her action items are completed by

the target date

 Take appropriate action with the Owner if the action items are not being

completed within the desired deadline

 Ensure that all comments against their action items, updates of the status of their

action items and closure of their action items when completed are entered into the

Traction database

 Ensure actions are approved by the Owner and are closed in Traction.

2.13 HEALTH AND SAFETY MANAGERS (OFFSHORE, MIDSTREAM)

Responsible for:

 Providing support to Incident Owners in setting up the Investigation Team.

Control Tier:

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Incident Investigation and Reporting

3 RECORDING AND CLASSIFYING INCIDENTS

3.1 REPORTING OF INCIDENTS IN RECORDING SYSTEMS

BP Group has minimum timeframe requirements for incident reporting into appropriate

recording system. These requirements are summarized in Table 4.1 below.

Table 4.1. Requirements for entering incidents into Traction and MIA/HiPo database

Type of Incident

Recording Timescale

Recording System

Major Incidents (MIAs)

<24 hours

MIA/HiPo database

Levels A-E

<5 days

Traction

High Potential Incidents (HiPos)

<24 hours or on

MIA/HiPo database

identification

<5 days

Traction

Any BP Employee Fatality in the BP Work

<24 hours

MIA/HiPo database

Related Boundary

<5 days

Traction

Any BP Contractor Fatality in the BP Work

<24 hours

MIA/HiPo database

Related Boundary

<5 days

Traction

Any Third Party Fatality in the BP Operated

<24 hours

MIA/HiPo database

boundary

<5 days

Traction

Any non work-related Fatality in the BP

<24 hours

MIA/HiPo database

Operated boundary

<5 days

Traction

Loss of Primary Containment (LOPC)

<5 days

Traction

Security incidents

<5 days

Traction

Day Away from Work Case-Employee

<5 days

Traction

Day Away from Work Case-Contractor

<5 days

Traction

Restricted Work/Job Transfer-Employee

<5 days

Traction

Restricted Work/Job Transfer-Contractor

<5 days

Traction

Medical Treatment-Employee

<5 days

Traction

Medical Treatment-Contractor

<5 days

Traction

Loss of consciousness

<5 days

Traction

A significant injury or illness diagnosed by a

<5 days

Traction

physician or other licensed health

professional, such as cancer, chronic

irreversible disease, fractured or cracked

bone, or punctured eardrum

Needlestick and cuts from sharp objects that

<5 days

Traction

are contaminated with another person‟s blood

or other potentially infectious material

Medical removal under Government standards

<5 days

Traction

Occupational hearing loss (current hearing

<5 days

Traction

test must show 10dBA shift from current

baseline and total cumulative hearing loss

must be 25dBA or move above audiometric

zero).

Vehicle Accidents-Employee

<5 days

Traction

Vehicle Accidents-Contractor

<5 days

Traction

Spills >1 bbl

<5 days

Traction

Uncontrolled Releases/Events

<5 days

Traction

Fires

<5 days

Traction

Explosions

<5 days

Traction

MIA/HiPo database is located at: http://miahipo.bpweb.bp.com

Note: If there is any doubt as to whether an incident is within the reporting boundaries of this

procedure it shall be initially reported based on the assumption that it is.

Control Tier:

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Incident Investigation and Reporting

Note: The incident should not be recorded in the Traction system if information is classified

as „BP Confidential” of higher under the BP Global Information Handling Standard.

Note: Fraud incidents are not reported through Traction, but should be reported in line with

BP‟s Fraud Reporting Instruction and the local BP entity leader shall notify the local financial

controller or the relevant Segment / Function chief financial officer.

All other type of security incidents should be recorded in the Traction system.

3.2 CLASSIFICATION OF INCIDENT

The Incident Owner shall be accountable for the accuracy of the submitted data, including

classifications.

Incidents and unsafe/unhealthy conditions which are entered into Traction shall be:

 Classified for incident actual severity in accordance with Appendix D-E.

 Classified for incident potential severity in accordance with Appendix D-E, and

taking into account Figure 6.1.

 Loss of Primary Containment (LOPC) incidents that involve an acute release shall

be initially classified for potential severity in accordance with Appendix F-G, based

on the type of substance. This shall establish the minimum potential severity for

recording or notification purposes. Appendix D-E shall then be used to determine if

the potential severity classification should be higher based on the actual

circumstances of the incident.

 When the incident severity appears border-line between two levels, initially, the

more severe level shall be chosen. Where tools and calculations are used, the

information provided in conjunction with sound judgment and common sense shall

be used to support the decision.

When an initial recording of severity level is later revised due to additional or new

information, the Incident Owner shall review the new severity classification. Incident Owner

shall also ensure that the appropriate record within the designated HSSE information system

is updated, and applicable local or Group notification is made.

Appendix J shall apply to resolution of requests for clarification from BP group regarding the

recordability or classification of incidents or unsafe / unhealthy conditions.

Note: When entering MIA/HiPo and RI (recordable injury) incidents into Traction it is

mandatory to classify the incident as being related to either:

 Process Safety

 Integrity Management

 Security

 Control of Work

 Driving

 Marine.

Process Safety Incident Classification Guidance is provided in Appendix M.

For every incident the Safety Specialists/TA Team located in the Health and Safety

Organization Offshore (Safety Specialists/TA Team Leader or HSE Incident Investigation

Specialist) has to be informed and consulted to ensure that the selected category is correct.

Control Tier:

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Incident Investigation and Reporting

Additionally the LL One Pager report format

(AZSPU-HSSE-DOC-00054-A2) has been

updated to include mandatory indication of incident relatedness to the above categories.

4 TRAINING REQUIREMENTS AND COMPETENCE

4.1 INVESTIGATION TEAM LEADERS

Incident Investigation Team Leaders are considered

“trained” upon completion of a

standardized 12 hour “Basic RCA” training program that instils basic level competency for

Root Cause Analysis.

The training on its own doesn‟t prove competence, therefore the severity of the incident and

the person‟s previous experience in leading investigations shall be considered by the

Incident Owner before nominating the person to act as Investigation Team Leader. Incident

Investigation Team Leaders called on to investigate fatality incidents should receive ”Incident

Manager” training provided by Group Safety Advisor - incident investigation.

Untrained people should not lead RCA investigation.

4.2 ROOT CAUSE SPECIALISTS (RCS)

Root Cause Specialists are considered “trained” upon completion of a standardized 12 hour

“Basic RCA” training program that instils basic level competency for Root Cause Analysis.

The severity of the incident and person‟s previous experience should be considered by the

Incident Owner before the person is nominated to act as Root Cause Specialist.

4.3 MASTER ROOT CAUSE SPECIALIST (MRCS)

Major Incidents (level A-E) and HiPOs will require that at least one incident team member is

trained to Master Root Cause Specialist level. The person is considered “trained” upon

completion of a 3 day “Master RCA” training program. The master-level incident investigator

is the local centre of expertise that can train, coach, and mentor incident investigation team

leads trained at a lower competency level. There should be at least one person trained to

Master Root Cause Specialists level within AzSPU who shall be available to facilitate level A-

E severity incidents.

4.4 TEAM MEMBERS

Although there is no formal requirement for Investigation Team Members (other than Team

Leader and RCS) to attend above mentioned trainings, it is desirable for them to attend the

standard 12 hours “Basic RCA” training program.

Certain incidents will require Human Factors Analysis (HFA) to be performed. Only trained

people shall do this.

Note: A pool of trained RCS and MRCS are available in AzSPU. A rotational weekly

schedule has been developed with the intention that Incident Owner can select the required

MRCS or RCS dependent on the actual or potential severity of the incident. This rotational

schedule also ensures further development and application of RCA investigative techniques.

Control Tier:

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Incident Investigation and Reporting

5 CORPORATE NOTIFICATION REQUIREMENTS

The following paragraphs describe incident notification requirements.

5.1 SPECIFIC RESPONSIBILITIES

All incidents shall be reported immediately to the appropriate supervisor or line manager and

through the line management to the Site Manager/OIM/Fleet Operations TL. For level G

incidents (other than H&S) and all level H incidents this requirement is relaxed to 8 hours.

The Site Manager/OIM shall ensure that the scene of the incident is made safe and then

protected from disturbance.

5.1.1 Site Manager/OIM/Fleet Operations TL

Site Manager/OIM/Fleet Operations TL is responsible for notification of all incidents to

Area/Well/Logistics Operations Manager under following notification timetable:

 Any MIA, HiPo or DAFWC (Level F

- Health and Safety), immediate verbal

notification

 All Level F

(other than Level F

- H&S) and Level G incidents at the earliest

opportunity, but within 8 hours

 All Level H incidents at the earliest opportunity, but within 24 hours

For MIAs, HiPOs, injury/illness incidents, and production loss events Site Manager / OIM /

Fleet Operations TL must use the „Initial Internal Incident Notification Form‟ to assist with

verbal notification (see Appendix K)

For drilling related incidents the OIM shall notify the Well Operations Manager and make the

Area Operations Manager aware of the incident. The Well Operations Manager will

determine the level of investigation required.

In addition to their line notification responsibilities the Fleet Operations TL for Marine Related

Incidents shall notify the AzSPU Marine Authority taking due consideration of the notification

timetable.

5.1.2 Area/Well/Logistics Operations Manager/Marine Authority

Area/Well/Logistics Operations Manager is responsible for incident notification to relevant

VP under following notification timetable:

 Any MIA or HiPo incidents, immediate verbal notification.

 Level F - H&S incidents at the earliest opportunity, but within 8 hours.

 Any F (other than H&S) and Level G - H&S incidents at the earliest opportunity, but

within 24 hours.

The Area/Well/Logistics Operations Manager should exercise their best judgment whether

further notification is required for all other incidents.

For Marine Related Incidents the Marine Authority shall notify the AzSPU Single Point

Accountability -Marine.

Control Tier:

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Incident Investigation and Reporting

Logistics Manager in role as AzSPU EPRA (Entity Person Responsible for Aviation) shall

additionally to his line management notify AzSPU Entity Aviation Authority (EAA) of any

aviation incidents and incidents that could require aviation as part of the incident response.

5.1.3 Vice President (VP)

The VP is responsible for incident notification to Strategic Performance Unit Leader (SPUL)

under following notification timetable:

 Any MIA and HiPo incidents, immediate verbal notification

 All Level F - H&S incidents (including DAFWC) at the earliest opportunity, but within

24 hours.

The VP should exercise their best judgment whether further notification is required for all

other incidents.

The Single Point Accountability - Marine shall coordinate and effect the notifications of

Marine or Marine Related incidents to the Group Marine Authority and BP Shipping taking

due consideration of the AzSPU incident notification timing to ensure that the notification

does not precede the notification to the GVP and Segment Management.

Note: All Level A-E marine incident investigations shall be brought to the attention of BP

group marine authority.

5.1.4 Strategic Performance Unit Leader (SPUL)

The SPUL shall verbally notify the Group Vice President of MIA and HiPo incidents at the

earliest opportunity but within 8 hours.

The initial verbal MIA and HiPo notification shall be confirmed with global e-mail notification

within 24 hours using the Major Incident /HIPO announcement proformas (AZSPU-HSSE-

DOC-00054-A7). The SPUL should exercise their best judgment whether further notification

is required for Level F - H&S incidents.

Note: The SPUL shall verbally notify TVP Ops, HSE, Engineering of any BIL (BOTAS

International Limited) MIA/HiPo incidents at the earliest opportunity but within 8 hours.

The initial verbal notification shall be confirmed with email notification to “G E&P Non-Op

Incident Notification” within

24 hours by using the Major Incident /HIPO announcement

proformas (AZSPU-HSSE-DOC-00054-A7).

5.1.5 Incident Notification Details

The notifications should provide the following information:

 Type of occurrence (fire, explosion, injury, spill, etc)

 Site / location

 Date and time of incident

 Brief description of the event

 Actual severity (Level A-H)

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 Incident category, i.e. injury details, damage or oil / chemical spilled, whichever

relevant

 Immediate corrective action taken to prevent further loss

 Contact name (person supplying information) and telephone number.

5.2 Incident Notification Flowchart

Summarizing the above, Figure 5.1 describes the AzSPU incident notification flowchart.

Figure 5-1 Incident Notification Flowchart

TVP is a part of ”G E&P Incident Notification” distribution list.

Immediately

Within 8 hours

Within 24 hours

Note 1: Figure 5-1 specifies the minimum incident notification requirements which must be

followed at all times, however more stringent notification requirements may be exercised if

deemed necessary.

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Note 2: All Major incidents (A-E levels), HiPos and certain security sensitive incidents (e.g.

illegal taps) shall initially be sent to “G EUBAK MIA/HiPo Notification”, and shall not be

distributed any further without prior SPUL agreement. Distribution of MIA and HiPo LL One-

Pager Reports and HiPlus‟s outside AzSPU must be from SPUL office, not from individual

Operating Areas / Facilities.

Note 3: All F-H severity incidents (excluding HiPos and security sensitive incidents) should

be distributed accordingly to “G EUBAK AzSPU incidents_offshore” for offshore incidents

and to “G EUBAK AzSPU incidents_onshore” for onshore incidents.

Note 4: More details on Illegal Tap Incident Notification requirements for Exports PU are

described in Appendix H.

Note 5: Details on external notification requirements for Onshore Operations can be found in

Appendix I.

Note 6: For external notification of material release to the environment the AzSPU Internal &

External Material Release Reporting & Notification Procedure (AZSPU-HSSE-DOC-00075-2)

shall be followed.

Note 7: If for any reason any line position is unavailable (e.g. vacation, unreachable) their

delegate shall assume full responsibility to continue the line notification process.

Note 8: Notifications of Marine or Marine Related Incidents to E&P Segment Marine

Authority and BP Shipping will be coordinated and effected by the AzSPU Single Point

Accountability - Marine taking due consideration of the notification of the AzSPU Incident

timing to ensure that the notification does not precede the notification to the GVP and

Segment Management

Note 9: For a major security or HiPo security incident that may not be in the public domain,

the SPUL shall privately and securely if possible, communicate with the relevant segment or

function designated executive line management, regional security advisor and group head of

S&O. The regional security advisor shall inform additional senior leadership on a need-to-

know basis or based on who can advise or help. The notification chart in Figure 5.1 shall be

used.

Note 10: For drilling related incidents the OIM shall notify the Well Operations Manager and

make the Area Operations Manager aware of the incident. The Well Operations Manager will

determine the level of investigation required.

Note 11: SPUL, who has reason to believe that a fatality is either the result of natural causes

or is self-inflicted, shall consult with the BP regional health director for a preliminary cause

decision.

If the BP regional health director agrees that the fatality appears to be the result of a natural

cause or is self-inflicted, BP group notification shall not be required. If further investigation

provides new information that the fatality is not the result of natural causes or self-inflicted,

then the notification chart in Figure 5.1 shall be used.

If consultation with the BP regional health director is not possible, the BP leader shall comply

with the notification requirements in Figure 5.1.

If the fatality is classified as a natural cause or is self-inflicted, but circumstances associated

with the incident could have other potential consequences resulting in a potential severity

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level A-D or E classification (e.g., driver, crane operator, or another critical role), then

notification requirements in Figure 5.1 apply.

6 THE INVESTIGATION PROCESS

6.1 DETERMINING INCIDENT SEVERITY

The processes used to investigate an incident always follow the same principles. However,

the make up of the Investigation Team, and the investigation process followed, is determined

by the actual and potential severity of the incident and specifics of the case. For guidelines

on the level of investigation and investigation team make up AZSPU-HSSE-DOC-00054-A3

should be referred to.

If an incident has different types of HSSE and business impacts the most stringent

investigation requirements apply. For instance, an incident with classification level A for

environment and level H for health, safety and security is investigated using level A

requirements.

6.2 DEVIATION FROM INVESTIGATION PROCESS

The relevant VP accountable for the area of operation where the incident occurs shall

request the segment or group head of HSSE for approval of any exceptions from the

requirements of AZSPU-HSSE-DOC-00054-A3 . The relevant VP may request an exception

for an incident that appears to be a special case for the following reasons:

 The location of the incident.

 The nature of BP‟s relationship to the incident (e.g. the involvement of other parties).

 The nature of other investigations taking place, or the possibility of a joint

investigation with a governmental authority or other parties.

 The potential for litigation or regulatory action.

When an exception is requested, the relevant head of HSSE shall determine whether to

conduct an investigation, and if so, when and how to do so. If an exception is approved, the

decision of the segment or function head of HSSE as to whether, when and how to

investigate the incident shall replace the requirements of this practice for that specific

incident. The relevant head of HSSE shall inform the group safety adviser-incident

investigation of any exceptions for incidents at level A-E.

When relevant VP requests an exception for levels A-E, the segment head of HSSE (or

functional equivalent) should consult BP legal and

/ or other relevant functions

(e.g.,

security).

The first stage of the process is therefore to make an estimate of the most serious probable

outcome of the incident in order to determine the process to be followed. This will initially be

done by the Site/Wells Manager/OIM.

Note: Potential Incident severity is based upon the most serious probable outcome. For

example:

If a man cuts his finger with a knife, the most likely outcome of the incident is a cut

finger and the potential severity of the incident should be judged on that basis

but...

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If a man cuts his finger on a power saw, the most serious probable outcome could

easily have been an amputation and the potential severity of the incident is therefore

judged to be much greater.

Additionally the Figure 6.1 below can assist in assessment of the potential severity of

incident.

Figure 6.1 - Guidelines to Assess Potential Severity

Assessment of Potential Severity

Intent: To ensure that the potential severity classification of an incident or unsafe/unhealthy condition is based on the most

serious probable outcome.

Ask: Under different circumstances, could the consequence of the incident or unsafe/unhealthy condition have been more

serious for the:



Health, safety and security of people and the environment?



Equipment (e.g., damage)?



Privilege to operate?

Different circumstances include but are not limited to:



Time of day.



Weather (e.g., wind direction or strength).



Presence or absence of people going about their normal routine/business.



Exceptional intervention of people.



Similar activity with similar controls carried out by the same operation elsewhere.



A source of ignition could have been present, even if the likelihood is low.



If someone or equipment was struck with enough energy to injure an individual or damage/break the equipment, even if

the event was minor.

Consult the HSSE team for advice if the probable serious outcome / consequence seem extremely unlikely. For example, a

wasp sting can occasionally be fatal for someone allergic to wasp stings, but a first-aid case is a much more foreseeable

consequence.

6.2.1 Major Incident (Definition)

A major incident is an incident, including a security incident, involving any one of the

following:



1 or more fatalities associated with BP operations



10 or more injuries or health effects to BP workforce, either permanent or

requiring hospital treatment for more than 24 hours

 Significant adverse reaction from authorities, media, NGOs or the general public

 Costs from accidental equipment and property damage equal to or exceeding US

$ 1 Million

 Environmental Impact with A-E severity level.

6.2.2 High Potential Incident (HiPo) Determination

A High Potential Incident (HiPo) is an Incident or Unsafe/Unhealthy Condition or near miss,

including a security incident, where the most serious probable outcome is a Major Incident.

In addition, this includes any Loss of Primary Containment (LOPC) Incident where the

potential severity is classified at Level E or greater as defined in the Group-Defined Practice

„Reporting of HSSE and Operational Incidents‟ (GDP 4.4-0001).

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Figure 6-2 facilitates the process of decision making while determining the HiPo relevance

of the incident. A HiPo may not be identified as such at the time of the incident and it may

only be after the investigation that true the severity of the probable outcome becomes clear.

If, after investigation, an incident is found to fit these definitions, it should be reported as a

HiPo, even if it is outside the nominated reporting timeframe, or does not explicitly meet

these definitions. This requires a HiPo to be posted in the MIA/HiPo Database system and

the severity in the Traction Potential Risk Matrix to be increased to level A-E.

Figure 6-2 - HiPo Incident Determination Flowchart

See the guidance on

“use of DROPS Calculator” and on

“Dropped Object HiPo

determination” at Appendix L of this document.

6.3 TRACTION

Traction is a software tool designed to provide a single data entry system for all Health,

Safety, Environmental, Property Damage, Security, Reputation and Business

Interruption/Unit Outage incidents. Traction also offers an actual and potential severity matrix

that allows the user to assess the incident severity on a consistent basis.

6.4 ESTABLISH INVESTIGATION TEAM

The Investigation Team is appointed by the Investigation Owner.

The Owner initiates the RCA investigation by agreeing with and issuing

“Terms of

Reference” to the Investigation Team Leader.

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6.5 TERMS OF REFERENCE

Terms of Reference detail the requirements of the investigation and give official status to the

investigation. In particular they will:

 Identify references

 Define the scope of work

 List the team members

 Provide objectives/guidance

 Indicate any requirements for intermediate reporting.

Note: The investigation shall remain strictly within the Terms of Reference and deviate from

them only after discussion with the Owner. A model Terms of Reference template is

provided in Appendix A.

Copies of the Terms of Reference shall be provided to the Investigation Team and the Site

Manager.

The Team Leader of the Investigating Team shall discuss the Terms of Reference with the

Owner to ensure that he is fully briefed.

6.6 TEAM SELECTION

Incident investigation teams are determined according to the type of incident. Generally, the

team will consist of the following:

 A member designated as the Investigation Team Leader with seniority dependent

on severity of the incident

 At least one person knowledgeable in the process involved, e.g. operations or

technical engineer

 A contract employee, contractor management representative, and

/ or HSE

representative if the incident involved the work of a contractor

 A person knowledgeable in incident investigation techniques and system cause

analysis - Root Cause Specialist

 Other persons, as needed, with appropriate knowledge and experience to

thoroughly investigate and analyze the incident, i.e. may include persons from

other facilities or within the industry as a third party representative in major

investigations.

Note: People directly or indirectly involved in an incident A-E shall not be selected as

members of the incident investigation team.

Note: BP legal should be consulted on the arrangements for appointing any person from

outside BP (e.g., someone with a relevant area of expertise) to participate in the

investigation, whether as a team member or as a provider of expert opinion.

Note: Fatality incidents will require an externally led incident investigation team, with a

member of Group Leadership as a Team Leader trained as “Investigation Manager”

and a master level root cause specialist coming from outside AzSPU. BP‟s RCA

Investigation process shall be used.

All other non-fatality Major Incident (Level A-E) shall have a MRCS on the team.

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Safety related HiPo investigations shall be led by, or have a member of the team, that

has been trained as a MRCS or „basic‟ RCA, depending on the complexity of the

investigation. BP‟s RCA Investigation process shall be used. The investigation may

be internally led.

Level F (Health&Safety) incidents shall use BP‟s RCA Investigation process.

If a HiPo is not a safety related HiPo, then the actual severity will determine the

required level of investigation.

Only people trained in basic RCA or MRCS shall use Comprehensive List of Causes

(CLC) techniques in RCA investigations.

An incident investigation team assigned to investigate a level A-F security incident

shall include a security professional nominated or approved by the group head of

Security.

The further guidance on required level of investigation and investigation team make

up can be found at AZSPU-HSSE-DOC-00054-A3.

All team members shall be mobilized within 48 hours of the incident.

6.7 CONDUCTING THE INVESTIGATION

The Team Leader is responsible for managing the investigation.

6.7.1 Scope and Objectives

The investigation shall:

 Establish the facts surrounding the incident

 Review the application of management systems and management practices and

their impact

 Identify critical factors, immediate and system causes and make

recommendations to prevent recurrence.

6.8 FACT FINDING

Information on the incident can be obtained by collecting information from people, positions,

parts and papers - PPPP technique.

Interviews with witnesses shall be carried out as soon as possible after the incident; while

the incident is fresh in their minds and before too much discussion has taken place with their

colleagues.

Witnesses should be interviewed individually, so that they are not interrupted or questioned

by others involved. One member of the team should interview the witness and a second

record the interview. The interviewee must sign interview transcripts.

To ensure that all facts are uncovered, ask the broad “who, what, where, when, why and

how” open-ended questions.

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6.9 ESTABLISH THE SEQUENCE OF EVENTS

As the investigation progresses, the investigators should begin to identify the sequence of

events and concentrate efforts on increasing their knowledge in areas of uncertainty.

As the extent of physical factors involved in an incident becomes clear, the investigators

should shift the emphasis of their investigation and questioning to the system causes and

the reasons for people‟s actions.

Establish a chronology of events by date, time and place. The construction of a diagram

showing the connections between the various events and conditions leading up to the

incident, called Sequence of Events or timeline, is a useful technique in the investigation

process, especially for more complex incidents.

6.10 ESTABLISH AND ANALYZE FINDINGS

The findings of the investigation should establish the immediate and system causes of the

incident so that corrective measures can be taken to prevent future incidents.

6.10.1 Identify Critical Factors and Causes and Make Recommendations

The investigation process shall identify actions to prevent recurrence. This is achieved by

addressing the substandard acts and conditions and by identifying and correcting the latent

failures.

Not all causes can be completely eliminated and some may be eliminated only at prohibitive

cost. Some recommendations will, therefore, be focused on reducing the risk to a tolerable

level, while others will be focused on improving protective systems (the defenses) to limit the

consequences.

At least one recommendation should be made for each finding.

Actions shall be ranked for order or priority as follows.

1. Requires immediate action before activity at the site resumes.

2. Must be completed to an agreed plan.

3. Should be considered but not a priority.

6.10.2 System Cause Analysis

All incident findings should be reviewed to determine the critical factors, immediate causes

and system causes of the incident.

Before starting System Cause Analysis it is important to determine Critical Factors

surrounding the incident. Critical Factors are those actions or conditions that, if eliminated

would have either prevent the incident from happening or reduce its severity.

Identification of system causes of an incident may often reveal underlying management

system failures that resulted in the incident occurring.

System Cause Analysis is a process for analyzing incidents to:

 Provide consistent and repeatable results

 Provide objective and not punitive results

 Provide final results from which system causes can be identified.

 Identify actions which can be taken to correct the cause and prevent a similar

type of incident.

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After examining all the critical factors involved in an incident and arriving at the system

causes, a good check to use is to ask, “If these system causes were corrected, would this

prevent the incident from happening again?” If the answer is no, further evaluation is

needed.

6.10.3 System Cause Analysis - Example

It is very easy to mistake an immediate cause for a system cause of an incident. As stated

above, the system causes of an incident will often be a management system failure. The

following example illustrates this point:

A spill occurred when an employee overflowed a fuel truck while loading it at the bulk

fuel loading facility.

The initial investigation revealed that the operator of the truck overestimated the

amount of fuel required to fill the truck. By the time he realized he was running out of

tank capacity, he couldn’t reach the shutoff switch before the truck overflowed.

The initial finding was that the operator of the fuel truck was inattentive. However

further questioning of the driver and a survey of the scene revealed that the truck

was being loaded from the top and the emergency shutoff switch for top loading was

not functioning properly. This required the operator to climb down off of the truck and

to enter the pump room to shut off the flow of fuel. The malfunctioning switch had

been reported several weeks prior to the incident but had not yet been repaired.

Note: One system cause of the incident was subsequently found to be a management

system that allowed a critical component of an emergency shutdown system to remain

in service while not functioning properly.

After arriving at one of the most obvious causes of the incident, it is important to ask, “Why?”

In the case above, asking why the employee overflowed the tank resulted in the identification

of the malfunctioning switch, and the need for a system to prioritize work requests so critical

safety components are repaired as soon as possible.

The BP Comprehensive List of Causes Chart shall be used to determine system causes for

all incident investigations (AZSPU-HSSE-DOC-00054-A6). A CLC glossary is also available

(AZSPU-HSSE-DOC-00054-A5).

6.10.4 Human Factors Analysis (HFA)

HFA is performed to understand why people intentionally or unintentially behaved as they did

and to identify how to change this type of behaviour for another desired behaviour.

To perform HFA two techniques are used: Antecedent - Behaviour - Consequence analysis

(ABC Analysis) for intentional behaviour, and Human Error Analysis (HEA) for unintentional

behaviour.

It is not suggested that HFA is used in all investigations - rather it should be invoked as

required by investigation teams whenever they need a deeper understanding of intentional or

unintentional behavioural factors.

HFA should be performed once evidence gathering has been completed and critical factors

have been identified and written. It is performed at the beginning of the analysis phase of the

investigation and allows the investigator to reach a deeper understanding around why a

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person acted or behaved the way they did, so that the investigator is in the best possible

position to recommend appropriate corrective actions.

6.11 COMPILE REPORT

Note: All Incidents need to be reported through the Traction reporting system. For Major,

High Potential and Level F Incidents the RCA Incident Investigation Report must also

be completed. Reports must follow the layout described. Incident Investigation Report

should be completed within 30 days post HIPO/MIA. In cases when extraordinary

circumstances exist which would delay the report, e.g. legal review etc, then adjusted

completion target must be agreed with HSE & Engineering VP before 30 days

elapses who will communicate this to SPUL, as appropriate.

6.11.1 Report Outline

Investigation Team shall use investigation report format provided by BP for completing RCA

investigations.

A blank Investigation Report format with minimum required contents can be found at

AZSPU-HSSE-DOC-00054-A1.

A sample completed report of a fictional incident can be found at AZSPU-HSSE-DOC-

00054-A4.

Note: All formal RCA incident investigations must be marked "draft" or "final". Upon receipt

of comments and approval on draft formal RCA incident investigations, a “final” marked

report will be issued and “draft” versions will be destroyed. Only the corrective actions from

the “final” marked RCA incident investigation report shall be entered into Traction.

6.12 NON-CONTRIBUTORY FACTORS

The Team may find deficiencies when investigating an incident, which have no bearing on

the incident or outcome. If recorded these must be clearly stated as such in the report.

6.13 REVIEW WITH MANAGEMENT

6.13.1 BP Management

All Incident Investigation reports shall be reviewed with management including the incident

owner to confirm that the technical aspects are correct and the Terms of Reference have

been met.

6.13.2 Contractors

Investigations involving contractor owned / operated worksites or equipment, located on BP

operated areas, will be reviewed by BP and contractor management to obtain agreement on

the report.

However the essential element is that the report is agreed internally within BP and that

management accepts the findings. Preferably these findings will not contradict any

contractor investigation however if this does occur then the reasons for the discrepancy

should be investigated.

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6.13.3 Agree with Owner

The basic causes and actions of all Incident Reports must be agreed with the Owner before

the final „approved‟ or signed off report is produced. Each action in the recommendations

must be assigned to a person accountable for the action, a target date for completion and a

risk ranking (priority high/medium/low).

The Owner is responsible for making the actions, required completion date, and risk ranking,

known to the person accountable for the action and assuring timely completion.

Incident Owner shall determine which of the proposed corrective actions shall be accepted,

which shall be accepted with modification and which shall be rejected. Any changes to

proposed corrective actions shall be documented, along with the reasons for those changes,

and retained within the business. It is the responsibility of the Incident Owner to review any

proposed corrective actions having implications beyond their authority the incident owner

shall copy the report to the person(s) who would be able to accept or implement that action.

6.14 ACTIONS

Recommended actions must state explicitly what is to be done, when and by whom. Before

assigning actions the Responsible Party must be consulted to agree a reasonable timescale

for completion to avoid actions going unnecessarily overdue.

Traction contains three possible choice of priority when entering actions - these are listed

below with their criteria.

6.14.1 Prioritization

The investigation process shall identify actions to prevent recurrence.

At least one recommendation should be made for each finding. The Investigation Team must

consult whatever technical experts it feels may be necessary to determine possible actions.

Actions shall be ranked for order or priority as follows:

 High- Requires immediate action before activity at the site resumes

 Medium - Must be completed to an agreed plan

 Low - Should be considered by the Owner but is not a priority

Note: The decision about the establishment of the target dates for the completion of the

actions should be made and agreed by the Investigation Team and the Owner (e.g. VP,

Site/Installation Management) based on the levels of the priority prior to insertion into

Traction system.

6.14.2 Owner

The Owner (as per section 2.8) shall allocate actions to a Responsible Party. The Owner and

Responsible Party shall reach an understanding on the scope of the action and the timescale

by which it is to be completed.

6.14.3 Responsible Party

The Responsible Party shall ensure that the action is closed out in the Action and Incident

Data Base (Traction). An action will not be considered finalized until the database has been

updated.

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6.14.4 Close-Out of Actions and use of Traction system

Traction is the system BP uses globally to report all safety related incidents as well as Audits

and Other events. Traction is a web based tool that enables BP to fulfill their commitment to

openly report, investigate, analyze and document all health, safety, security and

environmental incidents. It is expected that all BP reportable incidents that occur during the

course of working activities will be entered into Traction.

Each Operating Area shall establish a process for tracking the close out of actions. The

Managers directly accountable to the VP shall do this on a monthly basis. The VP shall be

notified of the number of overdue actions each month. Actions resulting from Major

Incidents, High Potential Incidents, Day Away From Work Cases and significant audits will

be tracked to resolution at the SPU level in Traction.

All corrective actions from the final incident investigation report will be included into Traction

system for further follow-up and completion.

6.15 INCIDENT REPORT ORIGINATOR

Each Operating Area should appoint Incident Report Originators who will be responsible for

entering Incident Reports into the database and closing actions in the database when

advised to do so by Responsible Parties.

7 REPORT DISTRIBUTION

All RCA incident investigation reports shall as minimum be copied to:

 The Owner

 The Site Manager (if he is not the Owner)

 The Area H&S Team Leader

 Health and Safety Managers

(Offshore and Midstream)

(Major Incident and HiPo

Reports).

Note: The investigation team leader shall consult with the security professional team

member when determining the distribution list for any report of a security related incident.

8 DEVELOPMENT AND DISTRIBUTION OF LESSONS LEARNED

The main objective of carrying out an incident investigation is to identify the causes of

incidents and to prevent recurrence. In order to achieve the biggest benefit from the

investigation, the lessons learned need to be distributed to other sites where a similar

incident might occur.

Two types of documents currently utilised in AzSPU can be used for distributing of lessons

learned from accidents and incidents:

 AzSPU Lessons Learned (LL) One-Pager (AZSPU-HSSE-DOC-00054-A2).

 Safety Flash document.

There is a SPU specific protocol and process timeline established for development and

distribution of LL reports, which is as follows:

LL One-Pager must be issued for all work related MIA and HiPo incidents. Although not

specifically required, individual Sites may choose to issue LL One-Pager for lesser severity

incidents. In any case, LL One-Pager should be developed by the Incident Owner. It is the

responsibility of the Incident Owner (Area Ops Manager) to deliver the lessons learned to the

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HSE & Engineering VP, or his delegate, for review and agreement before submitting to

SPUL for distribution.

All MIA and HiPo LL One-Pagers must be submitted to SPUL office within 45 days from the

incident date. To ensure timely completion and submission of the MIA and HiPo LL One-

Pagers to the SPUL office, the Safety Specialists/TA Team located in the Health and Safety

Organization Offshore will enter a Traction Item on HSE & Engineering VP upon

classification of HIPO or MIA into Traction to expedite LL after 35 days.

Note: In case the MIA or HiPo LL One-Pager cannot be issued within this timeline, then

target date must be agreed with SPUL via HSE & Engineering VP.

Distribution of MIA and HiPo LL One-Pagers and HiPlus‟s outside AzSPU must be from

SPUL office, not from individual Operating Areas or Facilities. SPUL will circulate LL One-

Pagers to the applicable MIA and HiPo distribution list (G E&P Incident Notification).

Note: HSE & Engineering will also confirm with Segment HSE VP the HIPO/MIAs for which

LL will not be submitted (e.g. non work related fatality).

The SPU Marine Authority is accountable for ensuring marine Lessons learned are issued to

BP Shipping.

9 STORAGE OF RECORDS

The incident shall be entered into the Traction database.

When a site has access to Traction, the report in the database is sufficient record of the

incident.

When a site does not have access to Traction a copy of the report signed by the Originator

and Owner must be retained on the site.

Refer to AzSPU HSSE Record Control Procedure

(AzSPU-HSSE-DOC-00041-2) for

additional guidance.

Note: Incident investigation documents shall be managed in accordance with the applicable

requirements of the BP Global Information Handling Standard.

The incident investigation team shall maintain the confidentiality of the investigation

materials and information, control the flow of information regarding the incident investigation

and release the information only when they find it prudent or necessary to do so, or where

release is required by law.

Note: The incident investigation team should consult with the incident owner and the security

professional in the case of a security incident if there is any doubt as to the correct

classification of a document, under the BP Global Information Handling Standard.

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10 HSSE & OPERATIONAL INCIDENT REPORTING BOUNDARIES

10.1 REPORTING AND RECORDING BOUNDARIES

This section describes reporting and recording boundaries which are used to determine if the

incident is / is not BP reportable.

Table 10.1 below defines the applicable boundary for various types of incident. If an incident

is determined to be within a boundary described below, then the applicable reporting and

recording requirements apply, noting that an incident may fall into more than one of the

incident types.

Where the table states that the

“Work-related” boundary applies or the

“Operational

Boundary” applies, Figure

10.3 provides a flow-chart with supporting definitions and

guidance to use in determining whether the incident shall be reported.

Table 10.1 - Applicable boundary for each type of incident

Type of incident

Boundary

An incident involving an

“Work-related” Boundary*

injury/illness, fatality, or vehicle

accident to

- BP Employee or

- D2D Supervised Contractor

An incident involving an

“Work - related” due to an event or exposure occurring either

injury/illness, fatality to a BP

(i) at a facility or location that is within the “Operational

Contractor (excluding D2D

Boundary” or

Supervised Contractors)

(ii) during “Business Travel - BP Contractor “or

(iii) during a flight under a BP “Contract for Aviation Services

An incident to a BP contractor

“Work - related” and occurs either

(excluding D2D Supervised

(i) at a facility or location that is within the “Operational

Contractors)

Boundary” or

(ii) during “Business Travel - BP Contractor “or

Security incident

Affects the security of

(i) one or more members of BP‟s workforce (in their capacity

as such) or

(ii) BP premises /facilities or

(iii) BP operation or project.

Explosion

Flammable gas release

Fire

“Operational Boundary”

LOPC includes oil spills

Any other HSSE / Operational

Incident

10.2 “OPERATIONAL BOUNDARY”

An incident is within the “Operational Boundary” if:-

 It occurs at a BP-operated facility (which includes unmanned facilities such as wellheads

and pipelines where BP Workforce are not present on a day to day basis, where these

are operated by BP) or;

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 It occurs at a facility operated by a Joint Venture, in respect of which BP has the ability to

determine Board-level decisions.

 It occurs at an “E&P contractor-led site doing material work for BP” or;

 It is an operational incident that occurs at a BP operated site, irrespective of who is

operating the equipment or.

 It involves a facility that meets the relevant criteria in section 10.3 below.

Below shown are AzSPU sites that are deemed to be within and outside of BP Operational

Boundary.

Figure 10.2 - BP Operational Boundaries for AzSPU

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10.3 “OPERATIONAL BOUNDARY” - SPECIAL CASES

For HSSE and operational reporting purposes the following criteria apply:- “dedicated to BP‟s

business use”

 Vessels: BP holds the International Safety Management Code Document of Compliance

(DOC). For example, BP would not hold the DOC for time chartered vessels, spot

chartered vessels, or for vessels that are BP owned but not managed by BP.

 Vehicles/Aircraft/Rail transportation: The facility in question is

“dedicated to BP‟s

business use” (see definitions Appendix B).

 BP-maintained facilities: The incident involves a facility at a non-BP-operated location

(such as underground storage at a CoDo or DoDo retail site) and BP is responsible for

the maintenance and / or integrity of the facility.

 Service Level Agreements: The incident occurs at a non-BP operated location and

involves or is within the scope of a service provided by BP under a Service Level

Agreement or similar contractual arrangement.

10.4

“WORK- RELATED” BOUNDARY

A BP employee (or D2D supervised contractor) injury or illness is considered work-related

(for HSSE Reporting purposes) if an event or exposure in the work environment either

caused or contributed to the resulting condition or significantly aggravated a pre-existing

injury or illness. Work-relatedness is presumed for injuries and illnesses resulting from

events or exposures occurring in the work environment, unless exceptions specifically apply.

For a BP employee or D2D Supervised Contractor, the work environment is the

establishment and other locations where they are present as a condition of their

employment. The work environment includes not only physical locations, but also the

equipment or materials used by the employee or D2D supervised contractor during the

course of his or her work.

Any other BP contractor injury or illness is “work-related” (for HSSE reporting purposes) if an

event or exposure within the boundaries described in the previous table for Contractor

injury/illnesses either caused or contributed to the resulting condition or significantly

aggravated a pre-existing injury or illness. Work-relatedness is presumed for injuries and

illnesses resulting from events or exposures occurring within these boundaries, unless

exceptions specifically apply.

10.5 ILLUSTRATIVE CASE

For example an incident involving a loss of primary containment and an employee injury.

 If the incident occurs at a facility operated by BP and injures a BP employee, then it is

within the boundary for LOPC and BP employee injuries, and it is reportable as both an

LOPC and as an Employee injury.

 If the incident occurs at a customer‟s premises, which a BP employee is visiting as part

of their work for BP, then it is within the boundary for BP Employee injuries and is

reportable as such. However, it is outside the “Operational Boundary” for LOPC and any

LOPC would therefore not be reportable.

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Figure 10.3 - Flowchart helping to establish whether an incident is “BP-recordable”

incident for Group reporting purposes

Did it happen to a

BP employee

Yes

Did

it happen

to BP Contractor at

a) an asset/ location

Report as BP

Yes

within “Operational Boundary”

Yes

Was it work-related ?

Yes

workforce Injury/

b) during “Business Travel

(see section 4)

illness fatality or

- BP Contractor”

vehicle accident

c) during flight under BP

"Contract for Aviation

Services”

Did

Start

the incident

with the

involve an

Did incident

Yes

Did it happen to a

Go to

Injury/illness or fatality or

Yes

have other

Incident

“D2D Supervised Contractor”*

Box A

vehicle accident

outcome **

Do not need to

End

report as BP

workforce injury/

illness, fatality or

vehicle accident

BOX A

Did

Incident occur at

BP Operated asset

Yes

or one of the special cases

(see section 10.2 and 10.3)

Did

For injury and illness recordkeeping purposes;

incident occur at asset

operated by JV in which

Yes

Report the

* A D2D supervised contractor is a contractor

BP can determine

Incident

individual who is not on BP payroll but if BP

Board level decisions

supervises these employees on a day-to-day basis.

(Typically this would be a contractor who BP

supervises in the absence of their own supervisor).

Did

incident occur at

Yes

** An incident can have both a personal safety and an

E&P contractor - led

operational outcome e.g. a fire that injures someone

facility doing material work

for BP ? - see the

definition section

Do not report the

Incident

Key:

- Work related Boundary

- Operational Boundary

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REFERENCES

1. Group Defined Practice on Reporting HSSE and Operational Incidents (GDP 4.4-

0001)

2. Group Defined Practice on Incident Investigation (GDP 4.4-0002)

3. BP Group HSE Reporting Definitions

4. BP Group Recommended Practice for Marine Activity (GRP 5.6-0001)

5. Group Major Incident Reporting website

6. HSSE & Operational Data Reporting Requirements

7. Traction

8. Group OMS Glossary

9. Group OMS Library

10. BP Global Information Handling Standard

11. HSSE & Operational Incident Reporting Boundaries

12. Group Defined Practice on Aviation (GDP 3.7-0001)

13. Drilling and Well Operation Practice (GP 10-00)

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APPENDIX A - MODEL TERMS OF REFERENCE TEMPLATE

INCIDENT INVESTIGATION TEAM

The following Investigation Team members and leadership have been agreed by the

AzSPUL, Area / Wells Operations Manager, and Health and Safety Manager (Offshore,

Midstream).

Name

Position

6…etc

The Team Leader appointed by (Position

) is (Name

The Team Leader will:

 provide methodology guidance for the Investigation Team

 ensure compliance with the Terms of Reference

 ensure compliance with BP references for incident investigation

 ensure consensus among Team Members regarding report contents

 ensure persons accountable for actions agree with action(s) and date(s)

 report directly to (position), who is the Owner for this Investigation Team

 provide daily progress updates to the Owner for the duration of the investigation.

OBJECTIVES

1. Identify and review immediate causes of the incident.

2. Identify and analyze relative people, positions, parts and papers.

3. Identify and review system causes of the accident.

4. Map evidence; establish chronological list of events to identify critical factors.

5. Utilize “Comprehensive List of Causes; A Tool for System Cause Analysis” to analyze the

incident.

6. Develop recommendations, corrective actions and lessons learned for the Owner‟s review

and approval.

Focus is on prevention of recurrence of a like-in-kind incident and communications of

positive optics.

_______________________________(Owner)

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APPENDIX B - DEFINITIONS

Definitions in this procedure, where appropriate, are identical to BP Group HSE Reporting

Definitions.

Prompt reporting of incidents is essential. Before we can report we must be able to

accurately classify our incidents. The Injury and Illness Reporting Decision Tree in Appendix

F is an aid in this effort.

WORK-RELATED

An incident must be considered work-related if an event or exposure in the work environment

caused or contributed to that incident occurring. For injury or illness, an incident must be

considered work-related if the event or exposure caused or contributed to the resulting

condition or significantly aggravated a pre-existing injury or illness. Work-relatedness is

presumed for injuries and illnesses resulting from events or exposures occurring in the work

environment unless one of the following exceptions applies in its entirety:

 Occurs when the employee was present in the work environment as a member of the

general public

 Results solely from voluntary participation in a wellness program or in a medical, fitness,

or recreational activity

 Involves signs or symptoms that surface at work but result solely from a non-work related

event or exposure

 Is solely the result of an employee eating, drinking, or preparing food or drink for

personal consumption

 Is solely the result of an employee doing personal tasks at the establishment outside of

the employee‟s assigned working hours

 Is solely the result of personal grooming, self medication for a non-work-related

condition, or is intentionally self-inflicted

 Is caused by a vehicle accident and it occurs on a company owned parking lot or road

while the employee is commuting

 Is the common cold or flu; and/or

 Is a mental illness (unless it is post-traumatic stress syndrome where it can be tied to a

specific workplace incident, or are Incidents where the employee voluntarily provides an

opinion from a physician or other licensed health care professional stating the

employee‟s mental illness is work-related).

BP WORK ENVIRONMENT

The establishment and other locations (including marine vessels and vehicles) where one or

more BP Employees and or BP Contractors are working or are present as a condition of their

employment/contract. The work environment includes not only physical locations, but also

the equipment or materials used by the employee or contractor during the course of his or

her work.

BUSINESS TRAVEL - BP EMPLOYEE

Any travel undertaken for the purposes of work activities pursuant to the BP employee‟s

contract of employment with BP plc or one of its subsidiary companies, to the following

extent:

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 It includes the period from the time that person leaves their residence or their normal

place of work until they return or until the time they arrive at their destination and check

into temporary accommodation („home away from home‟)

 It includes, on the return trip, the period from when the person checks out of their

temporary accommodation until they arrive at their residence or their normal place of

work.

 It includes the whole spectrum of travel, from international travel through to simple acts

like crossing a public road on foot between two BP buildings.

 It excludes a person‟s normal commute to and from the office.

 It includes travel to the airport for a business trip from the time an employee leaves home

even if that travel follows the same route as their normal commute. If the employee

stops in the office first to work, then the period of the employee‟s business travel starts

from the office and not their home.

 It excludes that person‟s commute from their home away from home to their temporary

place of work or a significant detour made for personal reasons.

BUSINESS TRAVEL - BP CONTRACTOR

Any travel undertaken for the purposes of work activities in which the BP Contractor is

engaged in supplying BP plc or one of its subsidiary companies with goods and / or services,

to the following extent:

 It includes day to day travel undertaken by a BP Contractor in the course of carrying out

BP work-related activities.

 It excludes day to day travel undertaken by the BP Contractor when that person is not

engaged in BP work related activities (such as their normal commute, or any travel

undertaken in the interests of their own employer).

 It excludes Contractor mobilization and demobilization prior to work or on completion of

work for BP. If, however, BP directs a contractor to make a journey and specifies or

provides their means of travel (for example, specifies the airline to be taken, the route of

travel, or provides the use of a BP car and driver), such travel would normally be

included. In complex cases such as this guidance should be sought when reporting from

your local HSE manager/champion, or from Finance (HSE Sunbury).

EMPLOYMENT STATUS

We count both Company and Contractor incidents that are work related. Accounting for

Contractor incidents is a function of premises, as well as the nature of work and whether it is

at a 3rd Party fabrication site. A definition for Contractor follows in the next section.

BP WORKFORCE

The BP Workforce comprises all BP Employees, all BP Contractors and all BP Directors.

EMPLOYEE

An individual who has a current contract of employment with BP plc or one of its subsidiary

companies.

CONTRACTOR

An individual under a contractual relationship to supply BP plc or one of its subsidiary

companies with goods and/or services.

A contractual relationship covers:

 All individuals contracted directly or sub-contracted

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 All employees of companies contracted directly or sub-contracted

 All situations where a contract has not been raised but BP‟s procurement policy

would normally expect there to be a contract in place. This applies to all levels

including sub-contracted relationships.

Note: For the purposes of HSE reporting any sub-contractor is to be treated as if they held a

contract directly with BP plc or one of its subsidiary companies.

THIRD PARTY

Anyone who is not a BP Employee or a BP Contractor as previously defined in this

document.

Members of the BP Workforce may be classified as third parties under specific

circumstances. Three of the most common are:

 They are present in the BP Work Environment as a member of the general public (for

example, an office worker refueling their car at a BP Retail Station).

 They are present in the BP Work Environment but are still commuting to work under

OSHA definitions

 Those periods on a business trip when they are not deemed to be working under

OSHA definitions - for example, during their temporary commute or when residing at

their home away from home.

INCIDENT

An unplanned event or occurrence that affects or has the potential to affect the health or

safety, or security of:

 people, or

 assets, or

 the environment.

ACCIDENT

An unplanned event or occurrence that affects the health or safety, or security of:

 people, or

 assets, or

 the environment.

NEAR MISS

An undesired event that, under slightly different circumstances, could have resulted in harm

to people, damage to assets, environmental harm or unplanned operational shutdown. A

near miss is an incident involving the unintentional transfer of energy but has no negative

consequence.

FIRST AID CASE

An incident is classified as a First Aid if the treatment of the resultant injury or illness is

limited to one or more of the 14 specific treatments below.

These are:

1. Using a non-prescription medication at non-prescription strength

2. Administering tetanus immunizations

3. Cleaning, flushing or soaking wounds on the surface of the skin

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4. Using wound coverings such as bandages, gauze pads, etc; or using butterfly

bandages

5. Using hot or cold therapy

6. Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid

back belts, etc

7. Using temporary immobilization devices while transporting as accident victim

8. Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister

9. Using eye patches

10. Removing foreign bodies from the eye using only irrigation or a cotton swab

11. Removing splinters or foreign material from areas other than the eye by irrigation,

tweezers, cotton swabs or other simple means;

12. Using finger guards

13. Using massages, or

14. Drinking fluids for relief of heat stress.

If the treatment type isn‟t on the list then the case should be considered as medical

treatment and will be counted as a recordable injury or illness.

Note: When determining whether a prescription medicine was used the normal practise is to

apply the definitions used in the country where the incident occurred. However, when

making this classification it should be remembered that the intent is to distinguish those

more severe situations that require a medical practitioner to use strong antibiotics and

painkillers from those that only require simple first aid.

MEDICAL TREATMENT CASE

A case arising from an Incident, in which the management and care of the patient to address

the injury or illness is above and beyond First Aid. Medical Treatment does not include the

conduct of diagnostic procedures, such as x-rays and blood tests, including the

administration of prescription medications used solely for diagnostic purposes.

INJURY/ILLNESS

Injuries are a consequence of instantaneous events.

Instantaneous events are

characterised by a sudden and unexpected physical change which occurs over a short time

and which results in immediate harm to people. A short time may be described as the snap

of your finger or a single breath. Therefore, conditions such as sunburn, welders flash,

friction blisters, or repetitive motion induced conditions are illnesses.

OCCUPATIONAL ILLNESS

An occupational illness is any abnormal condition or disorder, other than one resulting from

an occupational injury, caused by exposure associated with the BP work environment. This

includes acute and chronic illnesses or diseases which may be caused by inhalation,

absorption, ingestion, or direct contact with physical, chemical, biological or psychological

hazards in or associated with the working environment.

Guidance: In the BP work environment, whether an adverse health effect is classified as an

occupational injury or occupational illness is determined by the nature of the original event or

exposure which caused the case. Illnesses are caused by anything other than identifiable

instantaneous events. e.g. if repeated or prolonged exposure is involved, the outcome is

considered to be an illness.

Where an injury or illness has multiple causations, if any of the causation is from a work

activity, it is sufficient to make the case work-related.

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Examples of occupational illnesses include: work-related upper limb disorders associated

with prolonged computer use; asbestosis due to exposure to asbestos; noise induced

hearing loss due to exposure to noise, gastro-intestinal illness due to food poisoning in the

work environment.

Back cases are always considered injuries, by OSHA definition.

OCCUPATIONAL INJURY

An occupational injury is any harm to an individual caused by an instantaneous event in the

work environment. Instantaneous events are characterised by a sudden and unexpected

physical change which occurs over a short time and which results in immediate harm to

people. A short time may be described as the snap of your finger or a single breath.

Guidance: In the BP work environment, whether an adverse health effect is classified as an

occupational injury or occupational illness is determined by the nature of the original event or

exposure which caused the case. Illnesses are caused by anything other than identifiable

instantaneous events. e.g. if repeated or prolonged exposure is involved, the outcome is

considered to be an illness.

Where an injury or illness has multiple causations, if any of the causation is from a work

activity, it is sufficient to make the case work-related.

"Back cases” should be treated like any other Health incident and dealt with on a case by case basis.

RECORDABLE OCCUPATIONAL ILLNESS AND INJURY

Guidance: There are two sets of criteria for determining recordability, based on OSHA. If a

case meets any of the listed criteria in either the general or specific, it must be considered

recordable.

General:

 Death

 Days away from work

 Restricted work or transfer to another job

 Medical treatment beyond first aid

 Loss of consciousness

 A significant injury or illness diagnosed by a physician or other licensed health

professional, such as:

o Cancer

o Chronic irreversible disease

o Fractured or cracked bone, or

o Punctured eardrum

Specific:

 Needlestick and cuts from sharp objects that are contaminated with another person‟s

blood or other potentially infectious material

 Medical removal under Government standards

 Occupational hearing loss (current hearing test must show 10dBA shift from current

baseline and total cumulative hearing loss must be 25dBA or move above audiometric

zero).

Control Tier:

Revision Date: 06 January, 2011

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Print Date: 1 February 2011

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RESTRICTED WORK OR JOB TRANSFER (RW/JT)

An incident is classified as a restricted work or job transfer case when:

 The member of the BP Workforce is kept from performing one or more of the routine

functions of his or her job, or from working the full workday that he or she would

otherwise have been scheduled to work or is transferred to a different job for all or

part of his/her period of recuperation.

 A physician or other licensed health care professional recommends that the member

of the BP Workforce not perform one or more of the routine functions of his or her

job, or not work the full workday that he or she would otherwise have been scheduled

to work or is transferred to a different job for all or part of his/her period of

recuperation.

Guidance: Routine functions are these work activities the member of the BP Workforce

regularly performs at least once a week.

DAYS AWAY FROM WORK CASE (DAFWC)

A work-related injury or illness that would prevent the injured person from working on the day

following that which the injury occurred, whether or not he or she is actually scheduled to

work the following shift. If the medical professional declares that the individual is not fit to

return to work on the day following the injury, then the case is classified as a DAFWC even if

the following day is not a scheduled workday. If a person subsequently must have corrective

surgery or otherwise miss work as a result of the work related injury, and does so during a

scheduled absence then the injury is still considered a DAFWC.

HIGH POTENTIAL (HIPO) INCIDENT

An Incident or Unsafe/Unhealthy Condition or near miss, including a security incident, where

the most serious probable outcome is a Major Incident. In addition, this includes any Loss of

Primary Containment (LOPC) Incident where the potential severity is classified at Level E or

greater as defined in the Group-defined Operating practice „Reporting HSSE and

Operational Incidents‟

Guidance on reporting HiPos: A HiPo may not be identified as such at the time of the

incident and it is only after investigation that true the severity of the probable outcome

becomes clear. If, after investigation, an Incident is found to fit these definitions, it should be

reported as a HiPo, even if it is outside the nominated reporting timeframe.

MAJOR INCIDENT (MIA)

An Incident, including a security incident, involving any one of the following:



1 or more fatalities associated with BP operations



10 or more injuries or health effects to BP workforce, either permanent or

requiring hospital treatment for more than 24 hours.

 Significant adverse reaction from authorities, media, NGOs or the general public

 Costs from accidental equipment and property damage equal to or exceeding US

$ 1 Million

 Environmental Impact with A-E severity level

RECORDABLE FATALITY

A fatality is deemed recordable unless the circumstances indicate that the event is not

relevant to the measurement of the health and safety performance of the Company.

Control Tier:

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Fatalities arising, for example, from suicide, inexplicable personal behaviour or natural

causes would normally be excluded.

INCIDENT SEVERITY

All incidents should be reported. Incident severity is determined per the Traction Severity

Matrix or Severity Matrices in Appendices D-E.

VEHICLE ACCIDENT

A work-related accident involving a motor vehicle that occurs on or off-road resulting in

injury, or loss/damage, or harm to the environment, whether this impacts BP and/or its

contractor directly, or impacts a third party This is irrespective of whether the accident was

preventable or non-preventable. It excludes all accidents where:

 The BP Workforce vehicle was legally parked

 The journey is to or from the driver‟s home and normal place of work

 Minor wear and tear is the case (e.g. stone damage to a windscreen, minor paintwork

damage)

 An Incident is the result of vandalism, or theft

 A company provided vehicle is being driven on non-work related activities (e.g.

private business, leisure).

SEVERE VEHICLE ACCIDENT

A Vehicle Accident that has been recorded in Traction with a severity level of A to G

inclusive. The very minor severity H incidents are excluded from this measure. If any one of

the following occurs the accident must have a severity level of at least G:

 Any incident involving a motor vehicle rollover, or incurring disabling damage requiring

any of the Motor Vehicle(s) involved (BP and/ or 3rd party) to be recovered from scene

with the following exceptions:

 Vehicle was operable, yet it was towed due to the driver not being physically fit to safely

operate their motor vehicle

 Damaged vehicle is repairable at the scene of the incident, yet it is determined that the

minor repairs, e.g., tire or lamp replacement, cannot be completed safely on the

roadside. Therefore, the motor vehicle is towed to a safe location to complete the minor

repairs.

 It is determined based on investigation and corroborating evidence that damages

sustained to a 3rd party motor vehicle rendering it inoperable occurred prior to contacting

the company unit.

 Recordable injury to any single person off site

 Any off-site spill greater than 1 barrel of product, while in transit, by a company motor

vehicle.

LOSS OF PRIMARY CONTAINMENT (LOPC)

An unplanned or uncontrolled release of material from Primary Containment.

Guidance: Unplanned or unintentional releases are to be reported as loss of primary

containment (LOPC) irrespective of the need for an immediate corrective action. However,

fugitive emissions or gases released to the atmosphere from properly designed and

operating safety devices

(such as a flare, scrubber or relief device designed per API

Standard 521 or an equivalent industry standard) are not considered as a loss of primary

Control Tier:

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containment and are excluded. Releases from safety devices which have not operated as

designed are to be reported as LOPC e.g. liquid releases from a gas flare system.

UNCONTROLLED RELEASE/EVENT

Any uncontrolled event where process fluids are released from primary containment and

which results in the need for immediate corrective action (e.g. shutdown, evacuation or

isolation) to mitigate the effects of loss of containment. Fugitive emissions and minor flange,

hose joint or seal liquid leaks which can be contained by capturing the fluid for safe disposal

should not be included.

Guidance: A „Hydrocarbon Spill Greater than or equal to 1 barrel‟ as defined above should

also be reported as an uncontrolled release, provided it meets the definition of an

uncontrolled release.

When reporting a material release in Traction the additional field “uncontrolled release”

should be checked if the release conforms to the above description.

Note: process fluids are defined as flammable, corrosive or toxic fluids; or inert gases that

could deplete oxygen levels; or otherwise inert fluids by nature of their temperature or

pressure are considered dangerous to people. For examples and further information Refer

Group IM Metrics and Reporting, http://integritymanagement.bpweb.bp.com/.

PRIMARY CONTAINMENT

A tank, vessel, pipe, rail car or equipment intended to serve as the primary container or used

for the transfer of the material. Primary containers may be designed with secondary

containment systems to contain and control the release. Secondary containment systems

include, but are not limited to, tank dykes, curbing around process equipment, drainage

collection systems into segregated oily drain systems, the outer wall of double walled tanks

etc.

UNSAFE/UNHEALTHY CONDITION

Any departure from the required or expected performance or condition of equipment (Plant),

procedures (Process), or People, which if not addressed could result in an Incident, or make

a consequence of an incident more severe. For example, thinning of pipes due to corrosion

or excessive work hours causing fatigue.

INCIDENT INVESTIGATION

The methodical examination of an incident; incident investigation activities are directed

toward identifying the facts and circumstances related to the event, determining the causes,

and developing remedial actions to control the risks.

10.6 IM RELATED INCIDENT

Any incident where the root cause would be addressed by the IM GDP and where there is

actual or potential harm to people or the environment. This includes:

 Loss or potential loss of primary containment

 The failure of an engineered system (including mechanical, electrical, structural, lifting,

process or process control, and protective systems).

Control Tier:

Revision Date: 06 January, 2011

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Print Date: 1 February 2011

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PROCESS SAFETY

A disciplined framework for managing the integrity of hazardous operating systems and

processes by applying good design principles, engineering and operating practices. It deals

with the prevention and control of incidents that have the potential to release hazardous

materials or energy. Such incidents can cause toxic effects, fire or explosion and could

ultimately result in serious injuries, property damage, lost production and environmental

impact.

PROCESS SAFETY INCIDENT

An unplanned event or occurrence which has, or could have, released hazardous materials

or energy.

Guidance: Examples of Process Safety Incidents include:

 Loss of Primary Containment (e.g. oil spills, gas releases) from process plant

 Fires or Explosions resulting from a flammable liquid or gas release

 Injuries or Fatalities resulting from a Fire or Explosion.

EQUIPMENT /PROPERTY DAMAGE (INCIDENT DIRECT COST)

Direct cost attributed to an Incident such as replacement value of equipment, cost of repairs,

immediate clean-up, and emergency response.

HOME AWAY FROM HOME

When an employee on travel status checks into a hotel, motel, or other temporary residence,

he or she is considered to have established a "home-away-from-home." In such cases, the

employee's activities must be evaluated in the same manner as an employee who leaves

work and is essentially "at home". If employee gets injured after "home-away-from-home"

has been established this will not be considered work related.

Injures and illnesses that occur to an employee while on travel status are work-related if at

the time of injure or illness the employee was engaged in work activities” in the interest of

BP”.

The normal exclusion for “Home Away From Home” is not applied to BP personnel and

contractors that are working and living in out remote sites

(offshore, onshore) as this

facilities owned, managed or controlled by BP. This means that BP-provided living

accommodations are considered a condition of employment where there is a BP policy or

contractual agreement that employee resides at BP owned, managed or controlled housing.

This will imply that any injury or illness experienced by the employee while at that housing

irrespective of whether injure/illness occurred in employee‟s working hours or off time will be

considered work related unless eliminated from reporting through the use of nine

exceptions to work relationship.

Reference: Clarification letter published by OSHA in 2007. This new exclusion for “Home

Away From Home” is applied in AzSPU from 1st January 2009.

However, if housing made available by BP is accepted by the employee voluntarily, for

example, on a normal landlord-tenant basis and in preference to other reasonably available

facilities, such housing would not constitute a condition of employment.

Control Tier:

Revision Date: 06 January, 2011

Document Number: AZSPU-HSSE-DOC-00054-2

Print Date: 1 February 2011

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EXPLOSION

An Incident involving the unintentional, rapid and destructive release of materials and / or

energy, including detonations, deflagrations and physical overpressures that result in

physical damage.

Guidance: Any explosion of any kind should be reported.

Explosions are typically related to Process-Safety Incidents. For example:

 A 'puff' during a furnace start-up that results in damage to the refractory or bends the

walls

 A failure of a pressure control system on a tank that results in an overpressure that

bulges a tank.

Explosions do not include:

 An overpressure that results in the activation of a relief valve

 An overpressure that results in the burst of a rupture disk

 A 'puff' during a furnace start-up that results in no damage to the furnace.

FIRE

An Incident involving either the unintentional ignition of material resulting in flame or smoke,

or an unintentional electrical arc.

Guidance: Any fire of any magnitude should be reported irrespective of whether it is

considered a Process Safety Incident or not.

Examples of fires that may be considered Process Safety Incidents include:

 A gas, oil or chemical release that results in a flame.

 A tangible indication of a fire in a plant handling hydrocarbons (e.g. soot on the inside

of a distillation tower) where no flame was actually seen.

 A fire, including an electrical arc, from a

120 or 220 volt shorted switch in an

operation handling hydrocarbons.

Examples of fires that are not normally considered Process Safety Incidents include:

 A paper or cardboard fire in a garbage / trash can in an office building.

 A fire during equipment repair in a maintenance shop.

 A solvent fire in a laboratory.

 Smouldering rags in a pump house (whether or not there is a flame).

 A fire in a vehicle in a parking lot.

ACUTE RELEASE

A sudden release of material that reaches or exceeds the LOPC reporting threshold in

approximately one (1) hour or less.

FRAUD

Intentional scheme to obtain money or property belonging to the company by means of false

pretence.

SECURITY INCIDENT

An incident within the scope of this practice that affects the security of BP‟s workforce,

premises or assets, or operation or project. Such an incident includes or may include any of

Control Tier:

Revision Date: 06 January, 2011

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Incident Investigation and Reporting

the following: assault / threat, burglary, civil unrest, criminal property damage, drug/alcohol

abuse / possession, robbery, security of information breach, and terrorist / guerrilla activity or

theft.

MAJOR SECURITY INCIDENT

An incident that involves:

 Kidnapping of company personnel or contractor‟s staff.

 Evacuation of personnel from an operative site.

 Security-related shutdowns of a well site, which might may result in present

production losses, thereby significantly affecting total daily production rates in excess

of 10,000 barrels per day (gross) or more.

 Civil disturbances in the country, which call for possible or actual evacuation of

personnel.

 Bombing, serious sabotage or serious crimes resulting in losses or damages.

 Hostage situation.

 Overt or explosive attacks against a location, vessel, aircraft, or company personnel

or assets, or explosive attacks.

 Significant extortion or blackmail.

HIGH POTENTIAL SECURITY INCIDENT

An incident that involves:

 Abductions or short-time (less than 12 hours) detention.

 Serious non-compliance with company directives to manage security information.

 Attacks against company or contractor personnel, locations or assets, or minor

explosive attacks.

MARINE RELATED INCIDENT

An unplanned event or occurrence that affects or has the potential to affect the health or

safety, or security of; people engaged in marine activity, or the marine systems or floating

structure of marine assets, the ship/shore interface of terminals or incidents involving

pollution of the marine environment.

INCIDENT INVESTIGATION

The methodical examination of an incident; incident investigation activities are directed toward

identifying the facts and circumstances related to the event, determining the causes, and developing

remedial actions to control the risks.

BP‟S RCA INVESTIGATION

An Incident Investigation undertaken by an incident investigation team using BP‟s RCA

process (CLC) for gathering evidence; undertaking interviews; utilising human factor tools;

determining root cause through identification of critical factors, possible immediate and

system causes and subsequent use of the 5-Why technique to identify underlying systemic

causes; developing proposed corrective actions; and submitting an incident investigation

report. Utilization of BP‟s RCA process requires basic root cause specialist or MRCS

training.

CRITICAL FACTOR

An event, action or condition contributing to the incident that, if eliminated would have either

prevent the incident from happening or reduce its severity.

Control Tier:

Revision Date: 06 January, 2011

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UNSAFE/UNHEALTHY CONDITION

Any departure from the required or expected performance or condition of equipment (Plant),

procedures (Process), or People, which if not addressed could result in an Incident, or make

a consequence of an incident more severe. For example, thinning of pipes due to corrosion

or excessive work hours causing fatigue.

“CONTRACT FOR AVIATION SERVICES”

A contract under which aviation services are provided to BP, which include or are expected

to include passenger travel in aircraft (excluding travel by personnel of the aviation supplier,

any aviation operator under the contract, or any personnel of their contractors or

subcontractors):

This definition includes shared services agreements and other such arrangements for the

carriage of passengers, under which BP‟s direct contract may be with another party (such as

another energy company) rather than directly with the aviation operator.

This definition includes BP contracts with an aviation supplier for the provision of emergency

response, where the aircraft are expected to carry passengers.

A turnkey contract involving aviation, including seismic, aeromagnetic or pipeline inspection

services, is not a contract for aviation services if the only personnel to be carried by aircraft

under those contracts are personnel involved in supplying the contracted service to BP.

However, if the contract also provides for the carriage of passengers, then those flights

which carry passengers is not a contract for aviation services shall be deemed

“D2D SUPERVISED CONTRACTOR”

For injury and illness recordkeeping purposes a day to day supervised contractor is a

contractor individual who is not on BP payroll but if BP supervises these employees on a

day-to-day basis.

“DEDICATED TO BP‟S BUSINESS USE”

A vehicle, aircraft or rail rolling stock is dedicated to BP‟s business use, for HSSE reporting

purposes, where it has been designated, normally under contractual terms, to be exclusively

available for the provision of goods and or services to BP during a period of time; the vehicle

is unavailable for business use by other parties. This excludes spot chartered vehicles,

aircraft or rolling stock because these are regularly available for business use by other

parties and as such are not dedicated to BP‟s business use.

“E&P CONTRACTOR LED FACILITY DOING MATERIAL WORK FOR BP”

The following list is intended to illustrate what is meant by the term “E&P contractor led

facility doing material work for BP”. The list is not exhaustive and members of E&P should

refer to the E&P Segment HSSE team if further guidance is needed:

An offshore construction vessel, once the vessel is in position and its activities

associated with the BP project have begun.

A drilling rig while the rig is secured in the location from which it will perform the well

work for BP (laid anchors for offshore).

Seismic activity once within the BP block from earliest of deployment streamers or

entering block.

Pipelay vessels while engaged in dedicated BP pipe laying activity.

Control Tier:

Revision Date: 06 January, 2011

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APPENDIX C - INJURY AND ILLNESS REPORTING DECISION TREE

If in the work environment,

assumed work-related unless:

Gather

•

Member of general public,

Information

•

Signs & symptoms surface at

work but result solely from non-

work-related event or exposure,

•

Voluntary participation,

•

Eating, drinking, preparing own

food,

•

Doing personal tasks outside

Did the employee

working hours,

•

Personal grooming, self-

experience an

medication, intentional self-

injury or illness?

inflicted injury,

•

Company parking lot while

commuting,

•

Common cold or flu, or

Yes

•

Mental illness.

Other work-related exceptions:

Is the injury or

•

Home away from home &

•

Personal detour while on

illness work-

company business.

related?

General Reporting Criteria:

• Death,

Yes

• Days away from work,

• Restricted work or transfer to

another job,

• Medical treatment beyond first

Is the injury or

aid,

illness a new

• Loss of consciousness, or

case?

• A significant injury or illness

diagnosed by a physician or other

licensed health professional:

• Cancer,

Update the

• Chronic irreversible disease,

previously

• Fractured or cracked bone, or

• Punctured eardrum.

reported injury

or illness entry if

Yes

necessary.

First aid treatments:

• Non-prescription medication in

non-prescription strength,

Does the injury or

• Tetanus immunizations,

• Cleaning, soaking, flushing wounds

illness meet the

on surface of skin,

general reporting

• Use of bandaids, Steri-Strips or

butterfly bandages,

criteria or the

• Hot or cold therapy,

application to the

• Non-rigid means of support,

• Temporary immobilization devices

specific cases?

while transporting an accident

victim,

• Drilling finger or toe nail,

• Eye patch,

• Removing foreign bodies from eye

using irrigation or cotton swab,

Do not

• Removing splinters or other

Report

foreign material from places other

report

the injury

than the eye by simple means,

the injury

• Using finger guards,

or illness.

• Using massages, or

or illness.

• Drinking fluids for relief of heat

stress.

Control Tier:

Revision Date: 06 January, 2011

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Print Date: 1 February 2011

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APPENDIX D - SEVERITY MATRIX, HSE IMPACT LEVELS

SEVERITY

HEALTH AND SAFETY

ENVIRONMENTAL

LEVEL

A-D



3 or more fatalities.



Event with widespread or extensive damage to any

environment, including sensitive and non-sensitive



Identified onset of life-threatening health

environments, and remains in "unsatisfactory" state

effects to 3 or more individuals.

for a period of > 5 years.



30 or more injuries or health effects, either



Event with widespread or extensive damage to a

permanent or requiring hospital treatment

for more than 24 hours.

non-sensitive environment and can be restored to an

equivalent capability in a period of around 1 year.



Event with localized, widespread or extensive

damage to a sensitive environment and can be

restored to an equivalent capability in a period of

around 1 year.



Event with widespread or extensive damage to a

non-sensitive environment and can only be restored

to a satisfactory / agreed state in a period of more

than 1 year and up to 5 years.



Event with widespread or extensive damage to a

sensitive environment and can only be restored to a

satisfactory / agreed state in a period of more than 1

year and up to 5 years.



Event with widespread damage to a sensitive or non-

sensitive environment and can be stored to an

equivalent capability in a period of months.



Event with extensive damage to a sensitive

environment and can be restored to an equivalent

capability in a period of months.



1 to 2 fatalities, acute or chronic, actual or



Event with localized damage to a non-sensitive

alleged.

environment and can be restored to an equivalent



10 or more injuries or health effects, either

capability in a period of 1 year.

permanent or requiring hospital treatment



Event with extensive damage to a non-sensitive

for more than 24 hours.

environment and can be restored to an equivalent

capability in a period of months.



Event with localized damage to a sensitive

environment and can be restored to an equivalent

capability in a period of months.



Event with extensive damage to a sensitive

environment and can be restored to an equivalent

capability in a period of days or weeks.



Permanent partial disabilities.



Event with localized damage to a non-sensitive

environment and can be restored to an equivalent



Several non-permanent injuries or health

capability in a period of months.

impacts.



Event with immediate area damage to a sensitive



Days Away From Work Case (DAFWC)

environment and can be restored to an equivalent

capability in a period of months.



Event with extensive damage to a non-sensitive

environment and can be restored to an equivalent

capability in a period of days or weeks.



Event with localized damage to a sensitive

environment and can be restored to an equivalent

capability in a period of days or weeks.



Single or multiple recordable injury or



Event with immediate area damage to a non-

health effects from a common source

sensitive environment and can be restored to an

event.

equivalent capability in a period of months.



Event with localized damage to a non-sensitive

environment and can be restored to an equivalent

capability in a period of days or weeks.



Event with immediate area damage to a sensitive

environment and can be restored to an equivalent

capability in a period of days or weeks.



First aid.



Event with immediate area damage to a non-

sensitive environment and can be restored to an



Single or multiple over-exposures causing

noticeable irritation but no actual health

equivalent capability in a period of days or weeks.

effects.

Control Tier:

Revision Date: 06 January, 2011

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Print Date: 1 February 2011

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Incident Investigation and Reporting

APPENDIX E - SEVERITY MATRIX, BUSINESS IMPACT LEVELS

When categorising business impact severity to meet the requirements of this practice, only equipment /

property damage (replacement cost) as a result of a HSSE incident or unsafe / unhealthy condition

shall be considered.

NON-FINANCIAL IMPACT

SEVERITY

EQUIPMENT/PROPERTY DAMAGE

LEVEL

PRIVILEGE TO OPERATE

>$10m Equipment/Property Damage



Public or investor outrage in markets

A-D

where we have presence or aspirations.



Prolonged adverse national or

international media attention.



Loss of license to operate an asset or

threat of global loss of license to operate.



Intervention from the government.



Severe enforcement action against a

material asset in a non-major market, or

against other assets in a major market.



Widespread adverse social impact.



Damage to relationships with key

stakeholders of benefit to the Segment or

BP group.



Localized or limited interest-group outrage

in a major market.

$1m - $10m Equipment/Property Damage



Other adverse enforcement action by

regulators.



Limited interest-group outrage in a non-

major market.



Short term adverse national or

international media coverage.



Damage to relationships with key

stakeholders of benefit to the Strategic

Performance Unit (SPU).

$100k - <$1m Equipment/Property Damage



Regulatory compliance issue which does

not lead to regulatory or other higher

severity level consequence.



Prolonged adverse local media coverage.



Local adverse social impact.



Damage to relationships with key

stakeholders of benefit to the Operating

Area.

$25k - <$100k Equipment/Property Damage



Short term adverse local media coverage.



Some disruption to local operations (e.g.,

loss of single-road access for less than 24

hours).

<$25k Equipment/Property Damage



Isolated and short term complaints from

neighbors (e.g., complaints about specific

noise episode).

Control Tier:

Revision Date: 06 January, 2011

Document Number: AZSPU-HSSE-DOC-00054-2

Print Date: 1 February 2011

PAPER COPIES ARE UNCONTROLLED. THIS COPY VALID ONLY AT THE TIME OF PRINTING. THE CONTROLLED

VERSION OF THIS DOCUMENT CAN BE FOUND AT http://docs.bpweb.bp.com/dkazspu/component/hssesms

AZSPU-HSSE-DOC-00054-2

Page 49 of 61

Incident Investigation and Reporting

APPENDIX F - POTENTIAL SEVERITY CLASSIFICATION, LOPC OF

FLAMMABLE GASES, LIQUIDS AND OTHER HAZARDOUS CATEGORIES

(ACUTE RELEASE)

Loss of Primary Containment - Potential Severity Classification

Type of

Flammable Gases and

Flammable Liquids ¹

Other Hazardous Categories

Substance

Vapours

including combustible or

corrosive gases/

fluids/vapours or solids

Onshore

Onshore,

Offshore -

Onshore -

Onshore/offshore - loss of

confined

unconfined

loss of

primary containment.

releases

primary

Oil spills related to marine

containment

Offshore

activity.

releases -

manned

unmanned

facilities

Level A-D

> 5000 kg

> 50000 kg

> 10000 kg

> 100,000 kg

>1000 bbl (fluids)

>200,000 kg

(gas/vapours/solids)

Level E

500 < 5000

5000 < 50000

1000 <

10000 <

100 <1000 bbl (fluids)

10000 kg

100,000 kg

20,000 <200,000 kg

(gas/vapours/solids)

Level F

50 < 500

500 < 5000

100<1000 kg

1000 < 10000

10 <100 bbl (fluids)

2000 <20,000 kg

(gas/vapours/solids)

Level G

5 < 50 kg

50 < 500 kg

10 < 100 kg

100 < 1000

1 < 10 bbl (fluids)

200 < 2000 kg

(gas/vapours/solids)

Level H

< 5 kg

< 50 kg

< 10 kg

< 100 kg

< 1 bbl (fluids)

< 200 kg (gas/vapours/solids)

Definitions

Definition of flammable gas:

Definition of flammable liquid:

A comprehensive list of substances is

available under the categorization of

Gaseous material, at ambient

Liquids having a flashpoint less than

Packing Group II or III materials as

temperature/pressure, that forms

or equal to 38 ˚C, or

defined by United Nations (UN)

a flammable mixture where the

Dangerous Goods definitions.

High-flash liquids (38 ˚C or higher)

Lower Flammable Limit is <13%,

stored or handled at temperatures

or the range between the Lower

(e.g., corrosives including acid or

above or within 8 ˚C of their closed

and Upper Flammability Limit is

base, organic peroxides, pyrophoric,

cup flashpoint.

>12%.

combustible liquid >38 ˚C flash point,

heating oils)

¹ Rule of Thumb: conversion factor is approximately 150 kg = 1 barrel.

Control Tier:

Revision Date: 06 January, 2011

Document Number: AZSPU-HSSE-DOC-00054-2

Print Date: 1 February 2011

PAPER COPIES ARE UNCONTROLLED. THIS COPY VALID ONLY AT THE TIME OF PRINTING. THE CONTROLLED

VERSION OF THIS DOCUMENT CAN BE FOUND AT http://docs.bpweb.bp.com/dkazspu/component/hssesms

AZSPU-HSSE-DOC-00054-2

Page 50 of 61

Incident Investigation and Reporting

APPENDIX G - POTENTIAL SEVERITY CLASSIFICATION, LOPC OF TOXIC

SUBSTANCES (ACUTE RELEASE)

Toxic Substances - Potential Severity Classification

(Potential Human Inhalation Hazard)

Substance

Lower Toxicity

Medium Toxicity

Higher Toxicity

Acutely Toxic

Class

Substance

(Class D)

(Class C)

(Class B)

(Class A)

All gas, vapour, mist or aerosol LOPC, regardless of location

Level A-D

> 4000 kg

> 2000 kg

> 1000 kg

> 50 kg

Level E

2000 < 4000 kg

1000 < 2000 kg

250 < 1000 kg

15 < 50 kg

Level F

200 < 2000 kg

100 < 1000 kg

25 < 250 kg

5.0 kg < 15 kg

Level G

50 < 200 kg

25 < 100 kg

5 < 25 kg

0.5 < 5.0 kg

Level H

< 50 kg

< 25 kg

< 5 kg

< 0.5 kg

From proposed CCPS and API guidelines based on UN Dangerous Goods definitions,

November 2007.

Control Tier:

Revision Date: 06 January, 2011

Document Number: AZSPU-HSSE-DOC-00054-2

Print Date: 1 February 2011

PAPER COPIES ARE UNCONTROLLED. THIS COPY VALID ONLY AT THE TIME OF PRINTING. THE CONTROLLED

VERSION OF THIS DOCUMENT CAN BE FOUND AT http://docs.bpweb.bp.com/dkazspu/component/hssesms

Military reference books and manuals (2009-2023, Volume 4) - page 29