A presentation By Rajnath Ram Joint Adviser (I), PNGRB Incident Reporting & Investigation for better emergency response & disaster management A presentation By Rajnath Ram Joint Adviser (I), PNGRB

Contents Definitions Incident type/ classifications Cause of incident/disasters Incident reporting Investigating incident Developing action plan Communicating the incident statistics Managing documentation

Definitions Follow common definitions across your organization (refer PNGRB(Codes of practices for Emergency Response and disaster Management Plan) Regulations, 2010 and any other applicable statutory documents) Incident Emergency Risk analysis, risk assessment, risk management Degree of Emergency (L-I, L-II, L-III) Onsite emergency Offsite emergency Disaster management Plan (DMP) Encourage to use common definitions across your organization and among your contractors/third party agency through the written procedures, review and updation on continuous basis

Incident Type/ Classifications As per PNGRB regulations Level-I which can be effectively and safely managed within the site by the available resources; no impact outside the site, location or installation.

Incident Type/ Classifications Level-II : Which cannot be effectively and safely managed with available resources additional support is alerted or required; has the potential to effect beyond the site May require mutual aid;

Incident Type/ Classifications Level-III: an incident with off-site impact could be catastrophic and is likely to affect the population, property and environment inside and outside the installation, management and control is done by District Disaster Management Authority (DDMA)

Incident Type/ Classifications Note: Level-I & Level-2 :onsite emergency Level-3: off-site emergency For Level-III, till the District Authority step in, it should be the responsibility of the installations/units incharge to manage the emergency

Cause of incident/disasters Man Made Natural Calamities Extraneous Heavy Leakage Fire Explosion Failure of Critical Control system Design deficiency Unsafe acts In-adequate maintenance Flood Earth Quake Cyclone Outbreak of Disease Excessive Rains Tsunami Riots/Civil Disorder/ Mob Attack Terrorism Sabotage Bomb Threat War / Hit by missiles Abduction Food Poisoning/ Water Poisoning

Sector –Wise fire incidents

Causes of incidents Source: OISD

Consequences of Incident The consequences of an Incident are fire explosion, blast waves, fast spreading flames, BLEVE, UVCE resulting in direct effects like damage to buildings/property, burns, fatalities. The consequences of an Incident may be confined within the premises or may spill off-site triggering cascading effects. An Incident in the neighborhood may sometimes cascade into an on-site emergency. It should be prevented or managed to avoid major emergency.

Incident reporting Also report near miss incidents As per PNGRB (Technical Standards and Specifications Including Safety Standards for City or Local Natural Gas Distribution Networks), Regulations 2008: Incident reporting as per Enclosure-I of SCHEDULE-IE. It must be read in conjunction with the PNGRB (Codes of practices for ERDMP) Regulations, 2010. As per PNGRB (Codes of practices for ERDMP)Regulations, 2010 Any incident of L-II and L-III shall be reported Preliminary report as per Schedule VI must reach within 48 hours to PNGRB Detailed investigation report within a month PNGRB can invoke penalty provision on Non-Compliance Also report near miss incidents

Why Focus on Near Misses? Establish Causes Provide learning to prevent recurrences before they become Serious Establish corrective actions Improve our companies safety culture Statistical safety data base Nothing is learned from unreported incidents and the causes are left uncorrected!

Why Minor Incidents Go Unreported Fear of: Supervisor/Manager Disapproval Getting a Bad Reputation Being terminated or disciplined Not Wanting To: Lose time from the job Have a incident on their work record Be the subject of or involved in an investigation Not knowing why minor incidents should be reported or what near misses are. Lack of Management follow-through in the past. Fear of having a poor or blemished safety record.

Encourage Reporting Incidents Ensuring all employees are told to report near miss incidents also. Positively reinforcing each other when reporting near miss incidents. Put penalty provision for not reporting Reminding ourselves of its importance Sharing successes—improve the work environment across the entire company. Using the Emergency-O-Gram for initiation of the investigation and reporting of document Make the incident reporting format readily available to all the employees.

The ultimate purpose of investigations is to prevent future incidents. INCIDENT INVESTIGATIONS WHY? * Prevent Reoccurrence * Valuable Asset to Management * Improve the Company's performance and Profitability ? ? ? ? ? The ultimate purpose of investigations is to prevent future incidents.

Incident Investigation an example As a rule of thumb, use the “5-W” principle! Simply ask “Why” five (5) times. Why did you slip and Fall in the hall by the water cooler ? <answer> Because the floor was wet. Why was the floor wet? <answer> Because there was water on it. Why was their water on the floor? <answer>I don’t know. It was coming out from underneath the water cooler. Why was water coming out from under the water cooler? <answer> I don’t know. Let’s look. There is a hole in the drain pipe. Why is there a hole in the drain pipe? <answer>It appears as if it rusted out. Was this an UNSAFE ACTIVITY or UNSAFE CONDITION?

Incident Investigation an example It was an Unsafe Condition, caused by an Unsafe Activity. The rusted pipe was caused by lack of preventative maintenance, which was an unsafe activity. If there is “blame” where does it lie? Was there a preventative maintenance program?, Who was in charge of it. Why was it not checked? Should this be subject to disciplinary actions?

Steps to Incident Investigation Manage the Incident Site Collect factual Information Record witness statements Analyze the Facts Investigations must produce factual information Recommend Corrective Action implement Corrective Action Follow-up

Investigating Incident Essential Actions (planning) Prepare a written procedure for investigations (also refer statutory requirements) Develop an investigation report form that guides investigators Define the company’s responsibilities in assisting investigations conducted by contractors on incident sites. Make investigation procedures and forms available to employees and contractors. Bring in external investigators to collect and verify data for incidents. External investigators are third-party investigators/independent experts

Investigating Incident Essential Actions (verifying data and investigations) At the beginning of an investigation, hold a meeting of all parties involved to: review investigation goals and procedures Fix specific roles and responsibilities of all participants describe the types of data to be collected and how it will be verified and handled Ensure all relevant documents available including statutory documents Review and verify data reported on preliminary incident report physically inspect the incident site and take photographs for inclusion in investigation report Review the circumstances that led up to the incident

Investigating Incident Essential Actions (verifying data and investigations) review operating conditions Review all documents prepared as a part of the incident report interview witnesses and other people who were involved in the incident or preparation of incident reports compare new data to historical data to identify new problems and trends Conduct root-cause analysis to further verify collected data and determine why the incident occurred. Record all findings Collect, if possible, incident data documented by government and insurance investigators for comparison purpose Treat incident data confidential.

Employee responsibilities RESPONSIBILITY to comply with all policies and procedures RESPONSIBILITY to report all unsafe acts and conditions RESPONSIBILITY to be a team member - to assist others in compliance RESPONSIBILITY to offer suggestions that may have a positive impact on safety

Steps to Develop Action Plan (based on Recommendation by the third party independent investigation) 1. Identify corrective actions 2. Assigning responsibility 3. Establish deadline for actions and follow-up 4. Obtain management approval 5. Communicate results

Communicating the incident statistics To the employees of the organizations to the controlling authorities (full report) Organizational head Statutory organizations

Managing Documentation

Conclusion Follow technical, Safety & Health Regulations Emergency Preparedness Always go for Incident Investigations Safety Consultations Time based mitigation/action plan Review & Revise Safety Program- Management of change Encourage incident reporting Investigate accidents immediately Provide the investigation report within 48 hours of accident Take leadership Provide safety training Conduct safety meeting Mock drills exercise Provide written rules Assess Personal Protective Equipment

Thank You