Lessons-learned Add Title December January March February April Presenter / Date May This slide, which has images representing the themes is only for viewing – not for publication. June September August July

Lessons-learned Add Title Presenter / Date

Event Description Describe what happened Use images where this adds clarity

Event Significance For the activity that was underway when the Event occurred, evaluate the hazard exposure using the risk matrix: Estimate the Likelihood of the unplanned Event happening again, if no further action is taken Estimate the most likely Impact if the Event happens again (without additional safeguards applied) Plot the risk by dragging the black box onto the matrix: Is the risk ALARP? (yes / no) Is the risk acceptable? (yes / no)

Event Cause(s)

Event Prevention Indicate the control(s) that were / could be used to prevent the event recurring Use the Hierarchy of Controls (right) to indicate the type(s) of control Evaluate control effectiveness to indicate whether risk has been made acceptable Highlight any residual risks.

Event Significance For the activity that was underway when the Event occurred, evaluate the hazard exposure using the risk matrix: Estimate the Likelihood of the unplanned Event happening again, after the prevention measures have been applied Estimate the most likely Impact if the Event happens again (with additional safeguards applied) Plot the risk by dragging the black box onto the matrix: Now is the risk ALARP? (yes / no) Is the risk acceptable? (yes / no)

Summary Consider including: Description Significance Cause(s) Prevention What we have learned.

2016-17 Topics December 2016: Confined Space January 2017: Chemical Safety February: Working at Heights March: Dropped Objects April: Electrical Safety May: Energy Isolations June: Layers of protection (design) July: Loss of Containment August: Fire Safety September: Lifting Operations October: Permit-to-Work.