687/ Incident Reporting, Investigation and Management / 992
I
nc
i
den
t
Rep
orti
ng,
I
nves
ti
ga
tio
n
and Managemen
t
BOS-PRD-0302.900801
The experience levels of assigned investigator(s)
shall
be related to the depth or seriousness of the incident
investigation requirements.
Personnel involved in the incident investigation
shall
be aware of their individual responsibilities, including
legal responsibilities.
4
.
9
.
2
I
nves
ti
ga
tio
n P
ro
cess
Ki
ck
-o
ff mee
ti
ng
Within 48 h after event, a kick-off meeting
shall
be carried out with the following participants prior to start any
investigation :
x
Operation
M
anager;
x
QHSE Coordinator;
x
Technical Superintendent (if technical issues or engine staff involved);
x
Head of Operations (upon severity/potentiality of the case);
x
QHSE
M
anager (upon severity/potentiality of the case);
x
Technical
M
anager (upon severity/potentiality of the case);
x
Crewing
M
anager or deputy (upon severity/potentiality of the case).
The meeting
shall
:
x
Clarify the case;
x
Determine the composition of the investigation team;
x
Determine the list of evidences to collect and dispatch the roles within the team;
x
Schedule a date for final investigation review.
In case of a Lost Time Injury (LTI) occurring, The kick-off meeting
shall
include following participants:
x
HSE Director;
x
Ship
M
anagement Organization
M
anaging Director;
x
Contracting Organization
M
anaging Director;
x
V
ice President Fleet
M
anagement;
x
V
ice President Operational Safety
M
anagement (OS
M
).
R
oot
cause
ana
l
ys
i
s
An HSE event is composed of three key factors that
shall
be clearly identified:
x
The direct cause(s): Has immediately generated the event. For example, an oil leak on deck is the
direct cause of the fall of the injured person;
x
The contributing factor(s): One or several factors that has contributed to the event. Following the
previous example, the leaking pipe which has generated the leak is the contributing cause;
x
The root cause(s): Origin of the event, the failure(s) in the system. From the previous example, it
could be an issue linked to the maintenance system that does not take into account the regular
piping verification.
The preferred root cause analysis tool for incident investigation is TapRooT
®
. TapRooT
®
software
should
be
used for all high potential impact incidents. The
5
Whys methodology
should
be used in addition to
TapRooT
®
in the following cases:
x
Real severity greater or equal to 2;
x
Potential severity greater or equal to 4.
V
ersion 06. Original date: 0
5
/06/2012.
V
ersion date: 31/12/201
5
.
V
alid version only on Q
M
S site.Uncontrolled document when printed.
Procedure prepared by: BOS QHSE
M
anager. Approved by: BOS QHSE
M
anager.
V
alidated by: BOS Quality Representative.
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