1. AIPS event name Date PIM #XXXXXXX (20XX Tier X #XX)
PHOTO OF FACILITY OR EVENT
Investigation Team A B C D E
Peer Review A

2. AIPS Event Summary PDO directorate/asset Directorate/Asset Event owner
Name director or other event (incident) owner
Location
Name location
Event date & time
Date, time
Event type
AIPS Tier 1/Tier 2/LOPC/HiPo/HVL
Actual risk rating
RAM (only for applicable categories and only consequence, not likelihood)
Potential risk rating
RAM (rating for ALL 4 PEAR categories)
Description of Event
One liner of the event
Injury/Damage/Loss
List injury type
List quantity of product lost
List all direct associated cost and damage (including clean-up cost)
List indirect cost (e.g. deferment)
PIM ID
XXXXXXX
Immediate cause
Description (to be taken from “Causation”sheet)
Key latent mgmt failures
List no more than 4 failures (to be taken from “Causation” sheet)

3. Description of the Event
Short to the point description of the event (incident)
Include picture if/where relevant
This should be free text writing and include the relevant facts explaining what happened to all the relevant parties in a short sharp factual paragraph that describes 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.
Overview photo/drawing of EVENT

4. Overview of Damage/Impact
ADD PHOTOS/DRAWINGS or FLOWCHARTS
(include any further photos in back-up)
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

5. Sequence of Events Date & Time Events
INCLUDE summary sequence of events
Detailed descriptions to be captured in BACK-UP

6. Loss of Barrier Assessment
Which control/recovery barriers failed or were missing?
Include barrier picture if/where relevant
Include a bowtie representation if relevant

7. Key Findings
ANY KEY findings relevant to the event (divide these over design/operational/technical, emergency response and supplemental findings)
Design Integrity
ANY finding
Technical Integrity
Operating integrity
Emergency response
Supplemental Findings (any finding that is not directly related to the event, but was encountered during the event)

8. Causation Immediate Cause Loss of containment .......
Underlying Causes
Max 4 to 5 underlying causes
Latent Management Failures
Max 4 to 5 Latent MGT failures

9. AIPS Pattern Check
(Populate below matrix with the key findings where applicable)
Pattern
DESIGN INTEGRITY
TECHNICAL INTEGRITY
OPERATIONAL INTEGRITY
#1 Drive for production
#2 Training and Development
#3 Learning from Incidents
#4 Creating Error conditions

10. Recommendations (Verify that:
Action Party
Target Date
Status 1 2 3
(Verify that:
- Recommendations address root causes and a clear action to do
- Recommendations are agreed by the action party as well as target date)

11. Recommendations (from MDIRC/IRC)
Action Party
Target Date
Status 1 2 3
(Verify that:
- Recommendations address root causes and a clear action to do
- Recommendations are agreed by the action party as well as target date)

12. Add relevant photos/drawings of EVENT
PDO-LFI AIPS-20XX0X
PROCESS SAFETY EVENT: Title of the event (Date of event)
KEY WORDS: Add relevant key words, e.g. Design Integrity, Tier 1, Materials Corrosion & Inspection, Pipelines
WHAT HAPPENED:
Description of the event
ACTUAL CONSEQUENCE(S):
Description of the actual consequence and RAM rating [A3]
POTENTIAL CONSEQUENCE(S):
Description of potential consequence and RAM rating for all categories if applicable [A3C, P4B]
KEY LEARNING(S):
List and number all individual learnings and add integrity category (e.g. [DI]) and ensure learnings are endorsed by appropriate CFDH, e.g.
1. Formation water with low resistivity (<100 ohm.cm) can conduct CP (stray) currents. If in any doubt about the potential for water production assume it will occur at some time in the operational life and design for it [DI]
2. Cross-bond of existing Isolation Joints can only be a temporary measure, and needs to be followed by replacement or installation of SSD for earthing [TI]
Add relevant photos/drawings of EVENT
KEY DISCIPLINES:
Add relevant key disciplines, e.g.
Process Engineering (UEP1P),
Material Corrosion & Inspection (UEC)
KEY STANDARDS:
Add relevant standards, e.g.
PR-1418 Incident Notification and Investigation
DEP Design of Pressure Relief, Flare and Vent
20XX-Tier X #XX, PIM XXXXXXX

13. Back Up

14. 20XX-Tier 1 #XX Process Safety Event MDIRC Initial Update
Status on DD MM YYYY
PROCESS SAFETY EVENT: Directorate – Title of event (DD MM YYYY)
WHAT HAPPENED:
Provide short description of the event
IMMEDIATE CAUSE: Description of immediate cause
PRELIMINARY UNDERLYING ROOT CAUSES:
List and describe potential underlying causes of the event, e.g.
Stopping the incoming feed by third party supplier happened too late
PRELIMINARY LATENT MANAGEMENT FAILURES:
List and describe potential management failures of the event, e.g.
Inappropriate quality control systems for maintenance and inspection
PRELIMINARY LEARNINGS (not CFDH approved yet):
List all immediate learnings (note that these learnings are not necessarily complete nor will be approved at this stage), and add integrity category (DI, OI, TI), e.g.
Enforce third party communication protocol in the event of an emergency [OI]
Monitor the flare KOD level at all times and treat the HH level trip/alarm with the highest priority, even if the unit or plant is down and closed in [OI]
INVESTIGATION TEAM:
List all investigation team members
NEXT MDIRC SCHEDULED UPDATE: DD MM YYYY (within 60 days date of event)
Add relevant photos/drawings of EVENT
(Provide a copy of the MDIRC Initial Update (Tier 1 only),
required within 10 days after notification)
20XX-Tier 1 #XX, PIM XXXXXXX

15. Recommendations – Asset specific
Action Party
Target Date
Status 1
Add any immediate and/or further asset specific actions 2 3

16. Overview of Damage (More pictures and description if applicable)
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

17. Witness Statements
(Refer to witness statements where applicable)

18. (Provide Tripod diagram if Tripod has been used in the investigation)
(If other method has been used, provide any representation that may come with it)

19. ICAM Causation description
Findings: Immediate Causes
Unsafe Actions
IC Ref #
ICAM Causation description
Justification
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 No codes which must be used.
No free text allowed under descriptions, to be taken from ICAM document
(Provide ICAM tables if ICAM has been used in the investigation)

20. ICAM Causation description
Findings: Immediate Causes
Unsafe Conditions
IC Ref #
ICAM Causation description
Justification
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 No codes which must be used.
No free text allowed under descriptions, to be taken from ICAM document
(Provide ICAM tables if ICAM has been used in the investigation)

21. ICAM Causation description
Findings: Underlying Causes (Human and Workplace)
IC Ref #
UC Ref #
ICAM Causation Description
Justification
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.
No free text allowed under descriptions, to be taken from ICAM document
(Provide ICAM tables if ICAM has been used in the investigation)

22. ICAM Causation description
Findings: Management System failures (MSF)
UC Ref #
MSF Ref #
ICAM MSF Description
Justification for management system failure cited
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.
No free text allowed under descriptions, to be taken from ICAM document
Life Saving Rules - Were LSR breached related to the event? Yes/No
(Provide: description which rule was breached,
did the breach caused the event,
was it a violation or negligent error)