Main contractor name – LTI# - Date of incident Incident details PDO directorate/dept: (e.g. OSD _OSO_OSO4) Contractor name/number : (subcontractor-contractor-PDO)/CXXXXXX Incident owner: Name / Ref Ind Location : Area / unit - (road/yard/station/rig/hoist/plant etc) Incident date & time: (d/m/yr) / (24 hour clock) – advise if estimated Incident type: Fatal, LWC, high potential, significant incident etc Actual severity rating: Number (1-5) / letter (P, E, A,R) – from RAM Potential risk rating: Letter (A-E), Number (1-5)/letter (P, E, A,R) from RAM Names of any IPs :Names of the injured people (for fatality add marital statues with kids age) Description of injury/damage : Worst injuries (fractures, head injury, amputation etc)/damage FIM ID: Number assigned in FIM Immediate cause: Short description of what caused harm Key latent mgmt failure : Key latent Mgmt system failure from conclusion slide Previous LTI/NAD: Short description of last (LTI/ NAD) of the contractor, this applicable to all contracts with PDO and not specified to a specific contract No. 1 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides

Main contractor name – LTI# - Date of incident Description of the incident …………………. This should be free text writing and include the relevant facts explaining what happened to all the relevant parties: 1.Leading up to the incident, 2. Immediately before the incident, 3. During the incident, 4. Immediately after the incident, 5. In the emergency escalation of the incident. The description should be in sufficient detail to allow a person who does not know anything about the incident to imagine it. It should only be about what happened and not why it happened. Do not include investigation findings here, simply describe the incident as the investigation has shown it happened. Delete all Guidance Note text from your presentation – its there to help and once used it should not be included in your presentation. 2 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides Guidance Note

Main contractor name – LTI# - Date of incident Sequence of events/timeline You can use any format for a time line, or sequence of events, e.g. a list, a diagram or tables, which ever you believe best fits your investigation. Only include events which are key to explaining what happened. 3 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides Guidance Note

Main contractor name – LTI# - Date of incident Photographs, diagrams & sketches Only include photos or sketches if they add value explaining the incident or causes. Each photo/sketch must be labeled to explain what it is and why it has been shown. Ensure photos are labeled to explain context (e.g. road looking in direction of; historical photo of plant before fire etc). Ensure all photos are evidenced to the investigation. (have formed part of the investigation) Ensure all photos are of suitable clarity. Include a maximum of four photographs/sketches per page. Do not exceed three pages of photographs, diagrams and sketches 4 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides Guidance Note

Main contractor name – LTI# - Date of incident Critical Factors : 1.Critical Factor 1, 2.Critical Factor 2, 3.Critical Factor 3, A Critical factor is defined as: 1.Something which didn’t take place which should have done and if it had done it would have definitely prevented the incident. 2.Something which took place which shouldn’t have done and if it had not done the incident would definitely not have happened. 5 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides Guidance Note

Main contractor name – LTI# - Date of incident Key Causational Factors : 1.Critical factor 1 Causational factor 1: Causational factor 2: Causational factor 3: 2.Critical factor 2 Causational factor 1: Causational factor 2: Causational factor 3: 3.Critical factor 3 Causational factor 1: Causational factor 2: Causational factor 3: 6 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides Guidance Note The key causational factors are those aspects of the management system which failed and which were proven to be causational in allowing the critical factor to happen.

Main contractor name – LTI# - Date of incident Conclusion: Immediate causes: 7 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides Causation Ref N o # Causation descriptionJustification for causation cited Acts or conditions precipitating the incident. They usually involve the front-line staff, the consequences are immediate and can often be prevented by design, training or operating systems. See listing in GU612 for immediate causes and their Ref N o codes which must be used. Guidance Note Unsafe actions: Unsafe conditions: Causation Ref N o # Causation descriptionJustification for causation cited

Main contractor name – LTI# - Date of incident Conclusions: Underlying causes : 8 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides Underlying causes can be classified into two classes. Human factors &Workplace factors. They lead to the immediate causes i.e. they are the catalyst or pathway through which the immediate causes materialise. Guidance Note IC Ref N o #UC Ref N o #Causation DescriptionJustification for causation cited IC Ref N o #UC Ref N o #Causation DescriptionJustification for causation cited

Main contractor name – LTI# - Date of incident Conclusions: Latent management failures What changes to the management system are needed to prevent a reoccurrence in the future across all sites. They are identified by asking what led to the underlying causes being allowed to exist, 9 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides Guidance Note UC Ref N o #LMF Ref N o #Latent Failure DescriptionJustification for latent management failure cited

Main contractor name – LTI# - Date of incident Immediate actions taken: ….. 4.…… 10 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides

Main contractor name – LTI# - Date of incident Essential remedial actions : 11 Remedial action N o : 01Status Completed/Ongoing Causation N o Action taken Action party Reference Ind. Target date Remedial action N o : 02Status Completed/Ongoing Causation N o Action taken Action party Reference Ind. Target date Remedial action N o : 03Status Completed/Ongoing Causation N o Action taken Action party Reference Ind. Target date

Main contractor name – LTI# - Date of incident Recommendations for MDIRC/IRC endorsement:. 12 Recommendation N o 01Status Endorsed/Not endorsed Causations No Recommendation Action party Reference Ind. Target date Revised recommendation after IRC review Recommendation N o 02Status Endorsed/Not endorsed Causations No Recommendation Action party Reference Ind. Target date Revised recommendation after IRC review

Main contractor name – LTI# - Date of incident Directorate IRC Minutes:Date held : Feedback to Incident Owner: (Depth, accuracy, quality, robustness, feasibility and appropriateness of investigation findings and recommendations) 1.… 2.… Query raised: (raise questions which have not been adequately answered in the investigation or presentation) … Additional recommendations: (Including, revisiting the investigation to improve quality, adding any key recommendations that are requested by the directorate management but have been missed in the investigation, or removing inappropriate recommendations) 1.… 2.… 13 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides Item N o ActionAction partyTarget date Who: Directorate/dept/contractor Incident: Date/PIM/Location/Injury/Loss MDIRC/IRC Date: Identity of minute taker: Name/Ref Ind:

Main contractor name – LTI# - Date of incident Tripod Tree (include copy of the Tripod tree flow diagram for all 4/5 incidents or High Potential) Investigation reports requiring a Tripod must confirm that the findings and recommendations match the Tripod findings 14 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides

Main contractor name – LTI# - Date of incident Supplementary investigation findings : The findings are points to note but were not causational in the incident 1.People, training, age, experience, nationality, medical conditions, disciplinary record etc 2.Equipment, type, serial number, maintenance, inspection, failings, appropriate for use etc 3.Activities at the time of the incident, lifting, driving, commuting, drilling, POOH etc 4.Relevant environment, workplace conditions, weather, lighting, floor surface, dust, cramped etc 5.Operational management, supervision, TBTs, SJPs, SWPs, STOP, availability on site etc 6.Contractual management, audits, CH involvement, defaults, inspections, visits, issues, sub contractor management 7.HEMP, review, appropriateness to the incident, is it used, how is it translated into action 8.Previous relevant incidents/learnings, what, where, were they aware of it, were controls introduced 9.Emergency response, how effective was it, did it impact on the severity? 10.Non causational findings to the incident but worth to address 15 Main Contractor Name, Incident Type (eg. LTI), date of incident- header on all slides

Main contractor name – LTI# - Date of incident Date: Incident title What happened? Very short description of what happened Your learning from this incident.. (This must solely relate to the people at risk of harm or people at risk of causing the harm) Title (e.g. Drivers) Learning points for them from the investigation Strap line – (keep short and punchy) Photo explaining what was done wrong Photo explaining how it should be done right 16 PDO safety advice

Main contractor name – LTI# - Date of incident As a learning from this incident and ensure continual improvement all contract managers are to review their HSE HEMP against the questions asked below Confirm the following: Make a list of closed questions (only ‘yes’ or ‘no’ as an answer) to ask other contractors if they have the same issues based on the management or HSE-MS failings or shortfalls identified in the investigation. Pretend you have to audit other companies to see if they could have the same issues. Management actions 17