Element 9

Incident Reporting and

Analysis

.
Incidents shall be openly reported, investigated, . .

analyzed, and communicated to prevent recurrence

and improve performance. Corrective actions and
preventive measures shall be used to avoid or
r-luce future injuries and losses. Investigations
focus on both immediate and root causes.

Safety Management System

lncident reporting
Report all incidents and injuries on a timely basis using established processes.

lncident classification
Classify all injuries and near misses in terms of loss consequences to determine the level
of investigation necessary for analysis and educational purposes.

Investigations
Conduct thorough investigations of all incidents to prevent recurrence.

Corrective actions
Take corrective action promptly in response to incident investigation findings and
recommendations to prevent recurrence.

Communication
Share lessons learned from each incident with similar operations and implement the
appropriate corrective actions as applicable within each department.

Analysis
Use incident tracking systems to analyze performance tracking of equipment or groups
and to reduce losses.

Training
Provide appropriate incident investigation training to all supervisors and staff who may
be responsible for investigations.

Periodic reviews
Review incident reporting and analysis-related processes periodically to continually
improve loss prevention performance.
 Introduction
This element highlights the need to report and investigate all incidents, no matter how minor.
High-quality, timely, complete, and accurate incident reporting and investigation provide the
basis for responding to and learning from these incidents. Just as a maintenance supervisor needs
accurate information on equipment service life to make informed decisions to prevent equipment
failures in his area, other managers need timely and accurate loss prevention data to make decisions
to improve performance in their respective areas. Figure 9-1 summarizes the basics of incident
reporting and investigation.

Activate emergency responses

L
lnitiate medical response
Secure site
Respor Immediate notification Prevent secondary incidents
Interviewwitnesses
lncident response Preserve evidence

Additional notifications per

applicable general instructions

Initiate promptly
Fad-finding, not fault-finding
Focus on prevention
Interview witnesses
Examine tools and equipment
Check records
Analyze causes
Develop remedial actions
ive Action Report findings and recommendations

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1 Figure 9-1. lncident reporting and investigation flowchart
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 Incident Reporting and Analysis

Saudi Aramco requires reporting and investigation of all incidents classified as minor, moderate, or
major. Comprehensive incident reporting and investigation is crucial for addressing and preventing
all types of incidents, including those with the potential to result in
Injury or occupational illness to an employee
Injury or occupational illness to a contractor
Near miss
Leak or spill
Release of hazardous gases or liquids
Motor vehicle accident (MVA)
Fire/explosion
Damage to property or public impact
Damage to environment
Process upset or interruption
Incident reporting
Disruption or loss of production.
Definitions of loss incidents and detailed procedures can be found in General Instruction (GI)
6.001, Notijication Requirements for Incidents (Including Fire); GI 6.003, Guide for Committees
Investigating Major Incidents and Engineering Reviews of Other Incidents; GI 6.029, Reporting and
Recording Motor Vehicle Accidents; GI 7.026, Cranes and Heavy Equipment Accident Reporting
Procedures; and GI 1787.000,Report of Fire, Emergency or False Alarm. Reporting and analyzing
incidents of these types are addressed in this element. As outlined in Element 1, "Leadership and
Accountability," employees and contractors are responsible for immediately reporting incidents
and participating in investigations as necessary. Specific reporting requirements exist for incidents
classified as minor, moderate, or major.
lncident Reporting
To improve safety performance, it is necessary to learn from failures and prevent recurrence of
similar incidents. Some refer to this important concept as applying lessons learned.
To do this, all incidents-injuries, MVAs, fires, leaks, spills, and near misses-must be reported
immediately and investigated by supervisors/managers.
Managers must communicate requirements for incident reporting. For effective reporting, managers
must go even further by encouraging and supporting an environment for open reporting. In an open
reporting environment, an individual does not feel unduly pressured or otherwise influenced not to
report an incident out of fear of retribution, reprisal, or other negative consequences. Employees,
supervisors, and managers alike should not fear the repercussions of being involved in an injury or
incident (e.g., without assigning blame). Sincere concern for the employee should be evident. With
incidents involving unacceptable behaviors- generally handled as personnel matters- the employee
typically will learn from their improper or unacceptable behaviors and the manager can examine
failures within the context of the management system that led to the incident.
Prompt reporting is important for effective incident management and investigation and is also
required for timely government notification. Effective incident management may involve propel
injury treatment and/or efforts to mitigate an emergency. Delaying or failing to report or investigate
An insurance industry-sponsored study (Bird and Germain, 1990) profiling the collective loss
experience of participating companies indicated that a statistical relationship exists between various
types of injuries, incidents, and unsafe acts. Similar studies have also reported a statistical relationship
between various types of incidents. As Figure 9-2 illustrates, there are generally more unsafe acts,
near misses, and minor injury incidents for every reported incident involving serious or major injuries.
The same relationship or ratio exists for fires, MVAs, spills, and other types of loss incidents-an
operation should expect many more minor incidents for every major loss incident it experiences.

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b

Figure 9-2. Loss pyramid

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This basic relationship holds true for most industrial companies. For this reason, managers and
employees should view reporting of minor injuries and incidents as an opportunity to prevent further
losses. Examining the relationship of minor and major injuries also provides insights into the overall
health of the reporting process.
Incident Classification
Initial classification of the type and severity of injuries and incidents is important in applying the
proper resources and investigation techniques. Saudi Ararnco has defined classification details in GI
6.00 1.
Near Misses
In addition to incidents classified as minor, moderate, or major by GI 6.001, near misses also need
to be considered and addressed as well. Saudi Aramco defines a near miss as an incident or event
that had the potential for injury or loss. These incidents should be reported and investigated very
quickly to apply and share the lessons learned. Near misses should not be confused with unsafe
acts (as depicted in Figure 9-2), which are identified through the behavioral observation processes
outlined in Element 6, "Safe Operations." Near misses with apparent high potential for more serious
consequences or major losses should be formally investigated.

Investigations
As outlined in Element 1, "Leadership and Accountability", managers and supervisors are
responsible for investigating all incidents. Major incidents require an independent team approach.
Arrangements for team investigations for major incidents are discussed as follows. Incident
investigation techniques have benefited from significant advances during the past 20 years. Today
there should be increased

Recognition that incidents are usually the result of multiple causes

Identification and correction of asset integrity defects that have the potential to cause similar
incidents
Identification and correction of causal factors that lead to unsafe behaviors
Guidance toward the development and improvement of company policies, procedures, and
engineering standards
Assistance to help employees better understand what caused an incident and the preventive
actions taken to address their concerns.

Incident investigations are characterized by

Immediate notification
Timely investigation-Begin while the facts are fresh
Fact-finding, not fault-finding
Focus on prevention (what can we do to prevent recurrence?)
Interview of employees
Site visit-Review equipment, positions of workers, tools involved
Determination of immediate causes
Determination of causal factors and root causes
Two or more specific corrective actions to prevent recurrence based on root causes (telling
the employee to be more careful is an unacceptable corrective action).

Major lnciden t lnvestigations

Major loss events require a major incident investigation team approach, chartered by senior
management as outlined in GI 6.003. Teams will be ready to respond and trained in advanced
methods such as root cause analysis, causal factors, and forensic techniques. They will also be trained
in interviewing skills, technical report writing, and examination of systemic factors such as local
management processes. They should have institutional knowledge of operations and technical issues.
Adjunct members possessing special expertise (e.g., metallurgy, instrumentation) may be added to
the team. Prior to the arrival of the team, local management should

Safety M a n a g e m e n t System
 Secure the area. Do not disturb materials or evidence unless
necessary in initial operational recovery efforts.
Identify all potential witnesses. Have each witness independently
write a statement describing what he or she witnessed. Do not
allow them to compare notes.
Provide for accommodations, office space, and standard office
provisions (computers, supplies) for team members.
Upon arrival, the team will proceed with the investigation. At the
conclusion of the investigation, the team will produce a written report
to management that includes findings, analyses, conclusions, and
recommendations to prevent recurrence. Management will then develop
specific corrective actions and follow through to closure.

To reduce t h e Corrective Actions

probability o f a To reduce the probability of a repeat incident, corrective actions must
be implemented. Corrective actions are the specific outputs derived
repeat incident, from the investigation. Investigations should result in specific corrective
corrective actions rather than general recommendations. They should clearly state
who should do what by when. For example: Replace component A with
actions must be component B (maintenance supervisor by 11/30/03). Managers are
implemented. responsible for closure of corrective actions. Managers will implement
all applicable corrective actions to ensure similar conditions do not
exist within their areas of responsibility. The decision not to implement
a corrective action must be documented and approved by the appropriate
manager. Managers will report the status of all applicable corrective
actions until they are completely and effectively completed and closed.

Communication
One industry issue often identified in the investigation of incidents is
that lessons learned from past incidents are not properly communicated
and acted upon. Communication of lessons learned from incident
investigations is important for improvement both to the local
organization and to the company overall.
Locally, managers are responsible for communicating details of the
incidents and corrective actions (e.g., Safe Operations Committees
[SOCs]). Information on the incident causes and corrective actions will
be compiled for distribution to other parts of the company with similar
operations, activities, or equipment. Business lines and other supporting
organizations should apply lessons learned as appropriate.

Analysis
Incident tracking systems will be supported to allow for analysis,
performance tracking of equipment or groups, and overall loss reduction.
Analysis can be accomplished in several ways, including internal trend
analysis and external review.

Safety Management System

Incident reports will be analyzed for internal trends in incident occurrence, both locally and
companywide. Trends in the number of incidents will be examined periodically to identify areas
where further improvements in a management process, equipment, procedure, or other factor can
be made. For example, at the companywide level, deficiencies may be identified in a particular
management process (e.g., the ultrasonic thickness test process). Additionally, identifying the
performance trends by a particular group or department can provide useful management insight for
more successful approaches (see Element 1, "Leadership and Accountability").
Analysis of failure events or incidents industrywide should be performed to supplement internal
information.

Training
Training in basic incident reporting and further investigation is essential to analysis and
improvement. All employees will be trained in the basic reporting processes for injuries, spills,
fires, MVAs, near misses, property damage, and other incidents. Managers and supervisors will
receive training in investigation techniques and completion of reports, including corrective actions
to prevent recurrence. This training should be part of the uniform training curriculum, starting
with new employee orientation (see Element 4, "Competency and Training"). Staff and specialists
will receive training in advanced investigation methods and report writing to prepare them for
investigating the less frequent major and moderate incidents.
Contractors are also responsible for reporting all incidents. Contract requirements include
provisions that specify contractors must follow all company requirements, including incident
reporting. Contractors must be oriented in the incident reporting process for each company
workplace where they may be assigned.

Periodic Reviews
Department managers will perform an internal review annually of their operations to ensure that
All incidents are reported and an open reporting environment is encouraged
All employees are trained in the reporting process
All incidents are reported in a timely manner
All department supervisors and managers are trained in investigation techniques
Key employees are trained in advanced major investigation techniques
Investigation reports are thorough and completed promptly
Corrective actions have been properly implemented
Lessons learned are shared.
Periodic external management reviews will similarly focus on the adequacy of the departmental
incident reporting processes and the overall incident reporting and analysis program (see
Element 11, "Continuous Improvement").

Endnotes
Bird, F.E., and G.L. Germain. Practical Loss Control Leadership. Loganville, GA: Institute Publishing 1990.

Safety M a n a g e m e n t System