500-Incident Reporting, Investigation and Management / 748
Incident
R
e
p
ortin
g,
In
v
esti
g
ation
and Mana
g
e
m
ent
BOS-PRD-0302.900801
Version 04. Original date: 05/06/2012. Version date: 31/12/2014. Valid version only on QMS site.Uncontrolled document when printed.
Procedure prepared by: BOS QHSE Coordinators. Approved by: BOS QHSES Manager. Validated by: BOS Quality Representative
16 / 21
E
xp
ert
: External training programme enables:
x
Leading an investigation team during major incidents.
Le
v
el
C
o
mp
etence
1
Basic in house familiarization training
2
Advanced incident investigation training. Selected provider
–
Taproot user.
3
Expert incident investigation training. Selected provider
–
Taproot user.
4
.
5
.
3
C
ond
u
ctin
g
t
h
e In
v
esti
g
ation
All investigations:
x
Secure the site and evidence as applicable;
x
Gather information by interviewing witnesses, obtaining statements, taking photos, observing key
equipment;
x
Identify and assemble an investigation team as required by the assigned level of incident;
x
Identify the sequence of events leading up to and immediately following the incident; incident
description;
x
Identify the causal factors that contributed to the incident, for example the unsafe actions and
conditions that lead to the event;
x
Analyse causal factors for root/basic causes, for example continually break down the reasons for
unsafe acts and conditions until further resolution becomes unproductive;
x
Determine the root/basic cause(s) of each causal factor;
x
Recommend corrective actions to address each cause;
x
Corporate resources can be made available to help to obtain information and provide assistance in
responding to incidents, assisting with investigation, analysis and preventive action.
Incidents involving Contractors
shall
be reported and investigated as Company incidents. The Contractors
shall
be encouraged to be involved in the Company investigation.
Should
the Contractors wish to carry out
independent investigation, this
shall
be authorised by the
Mana
g
in
g
Director
.
Where possible, staff in charge of incident investigations have practical experience in this area, having
themselves already taken part or leaded investigations.
4
.
5
.
4
N
ear
-m
iss in
v
esti
g
ation
p
rocess
The Company investigates HIGH Near misses as appropriate as a regulatory requirement under the ISM
Code. It is good business and economic sense because it generally improves vessel and onshore
performance. Investigating near misses is an integral component of continuous improvement in safety
management systems.
When the Incident report form (Near Miss type of incident) is received, the vessel
O
ff
icers
shall
interview the
employee and as a minimum confirm the information and gather any additional information concerning:
x
Who and what was involved?
x
What happened, where, when, and in what sequence?
x
What were the potential losses and their potential severity?
x
What was the likelihood of a loss being realised?
x
What is the likelihood of a reoccurrence of the chain of events and/or conditions that led to the near-
miss?
Using the Incident Level Matrix the vessel
O
ff
icers
shall
assess the Near Miss potential
–
what level of
seriousness could have happened? This determines the level of investigation required. The significance of
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