Immediate Causes

Acts/Practices: Definitions:

Act of Violence Any act of verbal or physical violence towards a person or group, or towards a piece of equipment. E.g. intentionally striking a colleague or piece of equipment.
Adjusted Equipment in Operation Adjusting an equipment which is working. For e.g. scaffolding tube touching a valve and changing its position
Equipment failure The working equipment has failed due to wear or tear, abnormal / transient operation condition etc.
Failure to Secure Failure to secure tools or equipment using the correct storage / lock down / lock out / lock off devices.
Failed to warn person(s) of the hazard: the person(s) failed to warn colleagues of a hazard or allowed an inappropriate action that subsequently resulted in the
Failure to Warn
incident. For example, failure to warn that the pipe contained nitrogen before allowing a person to enter a confined space.
Operation of plant or vehicle at an improper speed: once a known operating limit was exceeded, the person did not take the appropriate actions to correct the
Improper Operating Condition /Speed situation. (Note - as well as vehicle speed this can apply to any process plant operating limitation - temperature, flow, pressure etc.). This can also apply to the
speed at which a person is moving him/herself or moving manual equipment.
Inappropriate Behaviour Inappropriate workplace behaviour: the person(s) involved were engaged in inappropriate activities such as practical jokes, clowning around.
Disabled guards, safety devices or warning systems: the correct guards, warning systems or other devices were in place, but were disabled or overridden to
Made safety device inoperable
allow work to proceed without these protections. This includes deactivation or bypassing of interlocks or safety instrumented systems.
Operating without Authority The person failed to obtain the relevant permission to commence work or failed to follow the authorised procedure for carrying out the work.
Personal Protective Equipment (PPE) or methods not used. This could be because 1) the person performing the work did not recognise the situation required
Protective equipment (not used / incorrect use / not
PPE or methods or 2) the PPE or methods necessary in this situation were not used by the person doing the work or 3) the required PPE or methods were
available)
used, but not in the correct way.
Breach of Site, Personal or Information Security safeguards resulting in potential or actual loss or injury. For example, a break in and theft of equipment from a
Security breach
company premises or loss / theft of a lap top computer or hijack of a company vehicle etc.
Performing maintenance on equipment in operation. For instance taking a water sample from an engine driving a generator unit though a v belt drive and the IP
Serviced equipment in operation
placing their hand in the way of the belt drive resulting in an injury to IP's hand.
Damage to Plant / Equipment or vehicles as a direct result of the activities of third parties (i.e. neither company employees nor contractors/sub-contractors), for
Third Party Interference
example damage to a pipeline by a water company excavating in the same vicinity or an aircraft hitting a rig.
Impairment due to drug, alcohol or medication: at the time of the incident the person's performance was affected by drugs, alcohol or medication. This could
Under influence of drugs
also include failure to take prescribed medicines which resulted in impairment of performance.
Use of Tools, Plant, Equipment or Vehicle with a known defect: the person using the equipment has identified it as being defective, yet continued to use that
Used defective equipment equipment, for example, using a vehicle with inoperative lights or a ladder with a broken rung (does not include hidden defects - see defective equipment in
Substandard Conditions).
Tools, Plant, Equipment or Vehicle used in the wrong way: tool, equipment or vehicle was used for activities for which it was not designed or the equipment or
Used equipment improperly
vehicle was misused, for example using a forklift as a work platform, using a handrail as a ladder or using a wrench as a hammer.
Violation: Individual, supervisor or manager intentionally chooses to violate an established HSSE practice or Company standard not covered elsewhere under
Violation by Individual(s), Supervisor or Managers
immediate causes.
Wilful Damage Person deliberately carried out their job knowing that the outcome would result in damage to the asset, the environment and or injury to fellow personnel.
Substandard Conditions:
The layout of the workplace did not provide enough clearance from hazards, accessibility to equipment or tools was obstructed, or persons working could not
Congestion
achieve a correct posture.
The defective state of the Plant, Equipment, Tool or Vehicle was such that this was an immediate cause of the incident: the right equipment / tools were selected
Defective Equipment and used but had a hidden defect that lead to the incident. For instance, an electric tool had a short circuit and shocked the user or the jaws on the pipe lift
failed to secure resulting in the pipe falling to the deck.
Fire Hazard Fire: The person was involved in the immediate aftermath of a fire.
Hazardous Substances: The person was exposed to hazardous chemicals or materials in an amount or dose capable of causing an adverse health effect. For
Hazardous Substances
example, exposure to H2S or asbestos or a gamma radiation source.
Illness and Disease The person was exposed to a contagious disease or illness
Illumination The workplace illumination was so low or so bright, that it impacted the person's ability to see.
Inadequate guards or protective devices on Plant, Equipment or Vehicles: this could be because the design of the guard or protective device is inadequate or
Inadequate guards or protective devices because the guard or protective device failed when in operation or the guard or protective device has been removed at some prior time and not reinstalled or
reactivated.
Inadequate Personal Protective Equipment (PPE): The PPE used was not correct for the situation at the time of the incident or the wrong type of PPE was
Inadequate Personal Protective Equipment (PPE) specified or the PPE proved defective in operation. For instance, safety glasses were provided when safety goggles were required or cloth gloves were provided
when an impervious material glove was needed or the seam of a glove opened and allowed material to contact the hand.
Inadequate security arrangements in place to protect Plant / Equipment, Personnel or Company information: in the light of known threats inadequate security
Inadequate Security (Personal / Physical / IM)
resources have been deployed to deter a potential aggressor or inadequate training has been provided.
Warning systems defective or not effective: a warning system was present and working but failed to provide sufficient notice at the time of the incident. For
Inadequate Warning System example, an evacuation alarm that could not be heard in all locations. Or, a warning system was present but failed at the time of the incident. For example, a
tank high level alarm failed to activate.

Natural disaster Storms or acts of Nature: The person was exposed to the immediate effects of a storm, tornado, hurricane, ice storm, earthquake or other similar acts of nature.
Noise A person was exposed to a short term episode of unusually high noise levels, such as a blast or depressurisation event.
Poor Housekeeping Failure to maintain a tidy work place. For example, failure to keep the work place free of trip hazards or failure to properly dispose of waste products.
Radiation The person was exposed to radiation sources.
The person was involved in the immediate aftermath of a release of stored energy. This may be from exposure to reactive chemicals which when stored in
isolation do not pose a significant risk but which when brought together result in an explosive reaction. Or the person was exposed to sources of energy, such
Release of Stored Energy
as electrical, gravitational, pneumatic (including all compressed gasses), hydraulic, or chemical. For example this could include working on a pressurised
pipeline or working at height in an unprotected area.

There was insufficient fresh air movement, which led to increasing temperature or concentrations of chemicals or a decrease in oxygen levels. For example,
Ventilation
inadequate purging to air of a confined space prior to and during vessel entry or entering a pipe containing an inert gas used for purging or welding operations.
Personal Factors
Definitions:
Improper Behaviour
in an attempt to avoid physical discomfort the person exhibited incorrect behaviours. For example a person working in a confined space did not use the correct
Improper attempt to avoid discomfort
PPE because it made him hot.
Improper attempt to gain attention the person performing the task exhibited an incorrect behaviour in order to gain attention or recognition from supervisors or peers
Improper attempt to save time or effort the person performing the task exhibited an incorrect behaviour in order to save time or effort
The person performing the task had previously been rewarded in some way for performing the task in an unsafe manner and this had encouraged him to repeat
Improper performance rewarding
the infringement
Production incentives encouraged incorrect safety behaviours leading to the incident or near miss. For example weld perfection bonuses may have led a welder
Improper production incentives
to enter a pipe containing inert gas.
the leaders in an area did not demonstrate appropriate personal behaviours with respect to their role or respond appropriately when witnessing appropriate or
Improper supervisory example
inappropriate behaviour in their reports
Incorrect behaviours not confronted: a person's incorrect behaviours were not confronted or challenged by supervisor or peers, and therefore there was no
Inadequate intervention for incorrect behaviours
negative consequences to that behaviour.
Proper behaviour not rewarded: A person performing a correct behaviour did not receive any positive consequence for doing so therefore reducing the
Inadequate reinforcement of correct behaviour
motivation to continue to perform proper behaviours.
Inappropriate aggression A persons was involved in an unwarranted or inappropriate act of hostility/aggression.
Inappropriate peer pressure Peer pressure is generally an active factor in encouraging the wrong behaviours.
Lack of incentives Little or no motivation towards employees for displaying correct behaviours.

Lack of Knowledge / Skill / Competence

Inadequate Competence Assessment The knowledge and experience of the employee was not adequately assessed in determining his/her role and responsibilities on the job
Inadequate training given as an initial preparation upon taking up a post. The person was not provided with suitable induction training to make him/her aware of
Inadequate Induction training the risks that could be encountered in the workplace, what the workplace safety rules / standards are and what are the expected safety behaviours, as well as
the general layout of the facility.
Inadequate initial task specific training A person was not provided with suitable task specific training e.g confined space entry training or hot works training
Inadequate orientation The person was not suitably aware of the layout of the facility or fully aware of the risks on the facility
The person was not provided with adequate update training to ensure they were fully conversant with current techniques and procedures for carrying out the
Inadequate update training
tasks.
The training effort was successful in transferring the necessary knowledge, but the employee did not recall the material when needed. This could be the result of
Infrequent Performance / Practice
training not being reinforced on the job or an inadequate retraining frequency.
Coaching is a process that enables learning and development to occur and thus performance to improve. e.g The tool box talks did not provide sufficient
Lack of Coaching/Toolbox Talks
information to ensure all controls measures were highlighted to employees who had to do the job.
Lack of experience of the practical application of the training given. A well developed training effort was successful in transferring the basic knowledge, but the
Lack of experience
employee did not have the opportunity to practice its application and so could not apply the knowledge in the situation.
Misunderstood directions The person misunderstood the directions he was being given and this contributed to the incident. The directions were not clearly understood
Mental Incapacity
The person's job performance was impacted by his / her emotional status. This can include post traumatic stress situations or flashbacks. These will be longer
Emotional disturbance
term, generally single, emotional issues that may have existed for months or years
The person's job performance was affected by an existing fear or phobia, for example someone who is afraid of working at heights or climbing ladders or who is
Fears and phobias claustrophobic. A phobia is irrational, it is the fear of being in a situation or place, or around an object, where the person is afraid of becoming overwhelmed by
the fear, and how they will respond.
The person was unable to understand the instructions he was being given in order to do the job safely. This may be as result of a physical or mental impediment
Inability to comprehend
or may be as a result of a difference in languages between the communicator and the recipient.
The mental requirements of the task exceeded the intellectual capacity of the person. The requirements of the task exceeded the employee's capacity to
Intelligence level
understand and apply knowledge
Low learning aptitude The person's job performance was affected because they did not comprehend standard training materials which have been verified as adequate
Mechanical aptitude is usually thought of as an intrinsic mental ability that makes a person capable of understanding how things work. The person's job
Low mechanical aptitude
performance was affected because they did not understand the basic elements of how mechanical objects work.
Memory failure The person's job performance was affected by their inability to remember or recall information necessary to complete the work

At the time of the incident the person was suffering a medically recognised mental illness which affected either their ability to carry out the task safely or their
judgement. Mental disorder or mental illness are terms used to refer a psychological or physiological pattern that occurs in an individual and is usually
Mental illness associated with distress or disability that is not expected as part of normal development or culture. Serious mental illnesses include major depression,
schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD), and borderline personality disorder
e.g. at the time of the incident the person was suffering from major depression which affected his/her ability to carry out the task safely.

The persons hand - eye coordination, or hand - hand coordination or foot - hand coordination etc., was poor resulting in them being unable to perform the task
Poor co-ordination safely. Uncoordinated movement is an abnormality of muscle control or an inability to finely coordinate movements, resulting in a jerky, unsteady, to-and-fro
motion of the trunk or the limbs. The person's hand - eye coordination was poor resulting in him/her being unable to perform the task safely.

Poor judgement The person's job performance was affected by their inability to make an appropriate judgement when confronted by an ambiguous situation
Slow reaction time The person's job performance was affected by their inability to coordinate all the required actions or their reaction time was too long

Mental Stress
conflicting demands The person's performance was affected because two or more directions, instructions or demands were in conflict, making compliance impossible.
Confusing directions or demands: the person's performance was affected by inconsistent directions, instructions or demands. Examples would include
confusing directions procedures that do not match the existing equipment, generic Task Risk Assessments (TRA's), a lack of priority to assigned work or too many people giving
instructions.
The persons job performance was affected by high stress levels from either work or personal issues leading to inappropriate actions. These are generally
emotional overload
multiple shorter term emotional overload issues generally lasting no more than a few days or weeks
extreme concentration / perception demands Extreme concentration or perceptions demands: the work being done required great concentration and the person lost situational awareness
Extreme decision demands: the work being carried out required decision making under high stress, leading to an incorrect decision. Examples would include
extreme judgement / decision demands
time sensitive decisions, incomplete information on which to base decisions, or dangerous situations
fatigue due to mental task load or speed Tiredness resulting from mental overload of job which may lead to incorrect behaviours at the job site.
frustration The persons job performance was affected by high levels of frustration, which led to the person acting improperly
meaningless or "degrading" activities Performance was impaired through lack of concentration, frustration or anger as a result of being given meaningless or "degrading" work to perform
mental illness The persons job performance was affected because they were mentally unwell therefore affecting production.
preoccupation with problems The person's job performance was affected because they were preoccupied with problems and were not fully concentrating on the activities in progress
Routine or monotonous activity without thought: the person involved was performing a routine activity, such as walking up stairs, sitting down, stepping etc.,
routine, monotony, demand for uneventful vigilance
without conscious thought and was exposed to a hazard as a result
Physical Incapacity
Hearing deficiency: an existing hearing deficiency affected the person's ability to perform their job. This could include permanent hearing loss up to deafness or
Hearing deficiency
a temporary frequency threshold shift
Size or strength limitations: the person assigned to the work did not have required size or strength to complete the task safely, for example could not reach or
Inappropriate height, weight, size, strength, reach, etc
could not lift.
Limited ability to sustain body positions an existing condition or injury that affected the person's sustain body positions necessary to safely perform his / her job.
Other permanent physical disabilities all other permanent physical disabilities which affected a persons ability to perform their job. Example would include, lifting restrictions
Other sensory deficiency (touch, taste, smell, balance) Other sensory deficiency: An existing deficiency in taste, touch or smell affecting a person's ability to perform the job.
Respiratory incapacity Respiratory deficiency: an existing respiratory deficiency that affected the person's ability to perform the job.
Restricted range of body movement An existing condition or injury that affected the person's range of body movement necessary to safely perform the job.
Sensitivities to sensory extremes (temperature, sound etc) The person is sensitive to noise, temperature, smells etc. and this affected the way he/she performed his/her job
An existing sensitivity or allergy affecting a person's ability to do his/her job. This could include allergies to certain substances or a diagnosis of multiple chemical
Substance sensitivities or allergies
sensitivity.
Temporary disabilities Any of the above that is not necessarily permanent, but having a significant effect at the time of the incident
Vision Deficiency: an existing vision deficiency affected the person's ability to perform the job. This could include colour blindness or an uncorrected vision
Vision deficiency
problem such as cataracts, depth perception or long / short sightedness

Physical Stress
Physical or mental impairment of the person's performance due to high or low pressures, for example when diving or working at altitude pressure may affect the
Atmospheric pressure variation
persons ability to perform a task safely
Blood sugar insufficiency Due to illness or insufficient food intake
The persons range of movement was constrained by external factors such as congestion resulting in reduced physical ability. Extended travel in car, lorry or
Constrained movement airplane might create this type of constriction. Similarly working in a constrained space my induce cramps that could have affected the way the person
performed the task
Impairment due to drugs, alcohol or medication: at the time of the incident the persons performance was impaired due to drugs, alcohol or medications. In the
Drugs case of medication this may include failure to take medication prescribed to control / treat a known condition. Inappropriate behaviour on the job due to the use
of drugs, medicine or being intoxicated. Or in the case of prescribed drugs, failure to take them.
the person has been exposed to a toxic environment (H2S, chemical toxins etc.) or infectious diseases and this has affected his ability to carry out the work
Exposure to health hazards
safely
The persons ability to perform his job safely was affected by extremes of temperature. This will have resulted in recognised deterioration in the persons physical
Exposure to temperature extremes
or mental capacity.
Fatigue due to Circadian rhythm disturbance Fatigue was induced in the person as a result of jet lag or changing sleep patterns due to rotating shift work
The person involved in the incident was fatigued due to lack of rest, for example a driver who had performed a double shift immediately before the incident.
Fatigue due to lack of rest
Fatigue may also be present with normal work hours and a failure to rest adequately whilst off duty
Exhaustion due to the malfunction or breakdown of any of the five senses which causes a person to not be 100% fit to work. The person involved in the incident
Fatigue due to sensory overload
was fatigued due sensory overload, for example working in hot conditions with high light levels
Incident occurring due to the lengthy time duration of a specific task or job causing them to be physically and mentally fatigued. The person involved in the
Fatigue due to task load or duration incident was fatigued mentally or physically due to task load or duration, for example extended period involving heavy lifting without adequate recuperation
breaks
Pre-existing injury or illness: the person assigned to the work had a previous injury or illness that affected their ability to perform the job. This previous injury or
Injury or illness
illness can be either work related or not work related and the injury or illness may or may not have been reported to the Company
Oxygen deficiency The person was working in an oxygen deficient atmosphere and this affected their ability to do their job safely
Job/System Factors Definitions:
Abuse or Misuse
Abuse or misuse of plant, equipment, tools or people was condoned by a supervisor / manager and was not held to account. As a result he or she was more
Condoned by supervision
likely to repeat the action
- Intentional The supervisor or manager intentionally condoned abuse or misuse of plant, equipment, tools or people.
- Unintentional The supervisor or manager condoned an unsafe misuse or abuse of plant equipment, tool or people unintentionally or without knowing it.
An abuse of plant equipment, tools or people was not condoned by a supervisor in the past and, fearing being held to account the individual did not report the
Not condoned by supervision
incident or event

Contractor Selection and Oversight

A process of contractor oversight (management, QA supervision, Audit etc) was in place but was ineffective for whatever reason leading to an incident or
Contractor oversight not effective
noncompliance with Standard, procedure or contract occurred.
Although a prequalification process existed it was ineffective in identifying deficiencies in the contractor suitability, capabilities, competencies, approach to
Contractor Pre-qualification process not effective
managing HSSE and previous HSSE record. As a result a contractor who could be expected to perform badly is appointed.
A process of contractor oversight (management, QA supervision, Audit etc) was not put in place as a result an incident or non-compliance with Standard,
No contractor oversight process
procedure or contract occurred.
Contractors or subcontractors were selected without a prequalification process that that assessed their suitability, capabilities, competencies, approach to
No contractor pre-qualification
managing HSSE and Previous HSSE record.
An unapproved contractor or one who had previously been barred from the work was employed to carry out the work. For instance a contractor was used to
Use of non-approved contractor
carry out PE mains installation work but his permit had expired or been revoked

Inadequate Engineering / Design

Assessment of operational readiness not effective: the procedure for the hand over from construction to operation did not exist, was insufficient, was not correct
Inadequate assessment of operational readiness
or was not followed.
Incorrect ergonomic or human factor design: the facilities where the incident occurred were not designed in an ergonomically correct way. Examples of these
Inadequate consideration of human factors / ergonomics
would include work areas located too high or too low or valves out of normal reach, or poor allocation of functions between people and systems
Management of Change (MOC) processes inadequate or not applied effectively; This can apply to both physical changes to plant and networks and to
Inadequate evaluation of changes
organisational and procedural changes.
Technical analysis of Hazards and risks not effective: the design or engineering of a plant or equipment was not properly risk assessed, or the design or
Inadequate hazard and risk assessment engineering did not take into account and mitigate a high risk level. This would include a failure to perform appropriate (SIL, HAZOP, HAZID, QRA, LOPA or
Envid analysis).
Monitoring of construction was not effective: design specifications and criteria were proper but the facility was not constructed in accordance with the design or
Inadequate monitoring of construction
insufficient / ineffective QA was carried out as part of the construction process.
Monitoring of initial operation not effective: the procedures to monitor the start up of equipment to assure proper functioning did not exist, was not correct or was
Inadequate monitoring of initial operation
not followed

Design standards, specifications or criteria not correct: the information available to the designer was not suitable for use. Examples would include information
Inadequate standards, specification and / or design criteria
that was wrong, incomplete or not supported. For example, incomplete gas composition that was later found to contain contaminants, incorrect temperature etc.

Technical Design not correct: the design of the facilities involved in the incident was not suitable for the intended use (note this does not cover misuse or
facilities which have deteriorated over time). Examples would include inappropriate metallurgy for the intended service or incorrect support for the intended load.
Incorrect Technical Design
This would also include designs which were not risk assessed, where management of change was not followed, or where inherently safer design issues were
not considered.
Inadequate Maintenance
Inadequate preventative Inadequate preventative maintenance performed on Plant / Equipment / Tools or Vehicles leading to an incident
- Adjustment / assembly The quality of adjustment / assembly was poor leading to the Plant / Equipment/ Tools / Vehicle failing or being no longer fit for purpose.
- Assessment of needs Either the period between or the criteria on which preventative maintenance has been planned was inappropriate or inadequate, as a result the equipment failed.

Maintenance of the surface of the plant, equipment or vehicle was inadequate and this contributed to the incident. For example pipework was not properly
- Cleaning or resurfacing cleaned before painting and the proper adhesion between the paint and pipework was not achieved leading to early coating failure, as a result corrosion of the
pipe occurred.
Insufficient lubrication of plant, equipment or vehicles resulted in the equipment failing. For example regular checks were not carried out on engine oil levels as a
- Lubrication and servicing
result the engine seized during operation.
Inadequate reparative The quality of repairs made to Plant / Equipment / Tools / Vehicles was poor and this contributed to the incident
- Communication of needs The details of the defect or repair required were not adequately communicated to the maintenance personnel as a result an incomplete repair was made
Examination of the Plant / Equipment / Tools / Vehicles by the maintenance personnel did not identify all the defective conditions, as a result an incomplete
- Examination of units
repair was made
The maintenance was conducted using non standard or pre used parts which did not meet the service requirements. As a result the plant / equipment / tool or
- Part substitution
vehicle subsequently failed in service.
- Scheduling of work The scheduling of maintenance work was ineffective as a result necessary maintenance was not carried out within the prescribed service interval

Inadequate Management, Leadership and / or

Supervision
Consideration of HSSE in staffing not effective When selecting staff, HSSE behaviours or performance were not taken into account and someone with poor safety orientation was chosen.
The leaders in an area did not set the right direction or tone for HSSE or allowed roles and responsibilities for HSSE activities to be unclear or undefined. For
Giving inadequate policy, procedure, practices or guidelines
instance a manager failed to use the Enhancing Safe behaviours model to determine appropriate action when investigating a serious incident
Giving objectives, goals or standards that conflict The manager, leader or supervisor set conflicting objectives, standards or goals that contributed to the incident or near miss
The manger / leader or supervisor either 1) delegated responsibility to a person with insufficient knowledge or experience to carry out the task safely or 2) failed
Improper or insufficient delegation
to delegate sufficient responsibility to enable the task to be carried out safely
The leaders in an area did not fully understand the level of risk present or had a tolerance for an unacceptably high level of risk. The use of risk assessment
Inadequate Hazard and/or Risk Assessment
tools such as TRA's, JSA's or QRA's was at best patchy
Inadequate matching of individual qualifications and job/task
The worker was not competent to carry out the task he was assigned without supervision present
requirements
The manger or supervisor had not given clear feed back to the worker in the past when he had seen him exhibiting the wrong HSSE behaviours with respect to
Inadequate or incorrect performance feedback
the same or a similar task. As a result the worker (s) considered their actions acceptable
There was inadequate assessment / measurement of performance or inadequate evaluation of the measurements taken as a result trends were not spotted and
pre-emptive action was not taken to mitigate a risk or correct unsafe ways of working. For instance there was no inventory control on an oil tank so the
Inadequate performance measurement and evaluation
developing leak was not identified and rectified. Or, BBS observations were not analysed to identify a developing trend. As a result bad practice continued and
an incident resulted.
When a worker is seen to be exhibiting the right H,S,S or E behaviours they do not receive the appropriate positive reinforcement as a result they either become
Inadequate reinforcement of correct behaviours
disillusioned or fail to repeat these behaviours in other circumstances and this incident / near miss is the result.
Lack of supervisory / management job knowledge The supervisor or manager was not fully conversant with all the requirements of the job or the risks associated with it and how to mitigate them
Management has not put in place suitable monitoring and or auditing of the effective implementation of the HSSE Management System. As a result the asset is
Monitoring / auditing of HSSE processes not effective
not compliant with the system or is ineffective.
Participation in safety effort not effective The IP was not sufficiently involved with the safety improvement efforts going on in the company and as a result was not exhibiting the right safety behaviours

The documentation covering a process or activity were not adequate to explain how to carry out work safely or how to maintain plant and equipment safely. For
Providing inadequate reference documents, directives and guidance
instance the equipment manufacturers guidelines on maintenance frequency and calibration were not available. As a result the plant was not maintained when it
publications
should have been and failed in service.
When seeking to recruit safety professional or workers in safety critical positions the process did not identify anyone with the right credentials. As a result a less
Resourcing for HSSE not effective
than ideal candidate was selected and this may have contributed to the incident or near miss
Support of people not effective Parenting and support activities were ineffective in providing the worker with the right skills and competencies to carry out their role safely.
Management's assignment of responsibilities was unclear or conflicting. This could be linked to a situation where two workers both thought the other was
Unclear or conflicting assignment of responsibilities
responsible for a safety critical task. As a result neither performed the necessary operation and an incident or near miss resulted.
 Reporting relationships were not clear or conflicting as a result a worker did not know who they were reporting to or who they should be taking instructions from
Unclear or conflicting reporting relationships
as a result work that should have been completed was not or was not to the correct standard.

Inadequate Purchasing
Materials were mishandled as a result they were damaged and were not fit for purpose when used. For instance pipe being lifted with wire slings that damaged
Improper handing of materials
the anti-corrosion coating resulting in post installation corrosion / leak
Materials salvaged for later use were not properly certificated / or categorised as result they were used in a situation for which they were not suitable and
Improper salvage and/or waste disposal contributed to an incident. Or. Waste was not disposed of in a safe and environmentally friendly manner in accordance with company standards or local
regulation as a result an environmental incident did or could have occurred.
Material were improperly stored and damaged, as a result when withdrawn from the store they were not fit for purpose. For instance rubber diaphragms were
Improper storage of materials
stored in daylight as a result they deteriorated and failed in service.
Improper transporting of materials Materials were transported incorrectly as a result they were damaged and did not arrive in a fit for purpose state.
Materials or chemicals were issued for use without suitable safety or health data (MSDS, Material Safety Data Sheet) as a result an incident did or could have
Inadequate communication of safety and health data
occurred. For instance chemicals are issued without safety information and the IP selects the wrong PPE when handling the chemicals
Hazardous materials or tools are issued without suitable identification. For instance heavy objects are issued without suitable weight information and an
Inadequate identification of hazardous items
operative attempts to lift an item that is too heavy for him / her and as a result injures his/ her back.
Inadequate mode or route of shipment Materials are shipped un an unsuitable way either leading to loss or deterioration that later results in an incident
There was inadequate control over the receipt of good, including QA, as a result substandard items were taken into stock leading to either immediate loss or to
Inadequate receiving inspection and acceptance
an incident at a later date.

Inadequate research was done when specifying or ordering materials or equipment as a result the materials supplied or installed were not fit for purpose. For
Inadequate research on materials / equipment
instance at the design stage the gas / oil composition of the well was not fully defined as a result the materials ordered do not cater for all contaminants.

The specification provided to the procurement department did not fully specify the requirements of the material to be supplied as a result to wrong materials
Inadequate specification on requisitions
were ordered
The specification provided to the supplier did not fully specify the requirements of the material to be supplied. For instance although the correct details were
Inadequate specification to vendors
transferred from the designer to the procurement department these were not forwarded to the supplier.

Inadequate Security
There was inadequate control of access to sites, buildings or sensitive areas. As a result there was or could have been a loss or incident. This definition may
Inadequate access control
also apply to inadequate control of access to it or financial systems.
Inadequate security at the perimeter of a site resulted in unauthorised entry to a site. As a result there was a loss or potential loss to the company. For instance
Inadequate perimeter security
the perimeter fence was damaged and children were able to get onto the site.
The affected person exercised inadequate safety precautions and so experienced a loss or personal harm. For instance an employee leaves a lap top computer
Inadequate personal security
on the seat of their car and a thief breaks in and steals it or a person walks into an area known for assaults on pedestrians and is mugged.
Key areas such as control rooms, hydrocarbon marketing and trading areas, finance at quarter end, business strategy etc. had inadequate security protection
Inadequate protection of key areas allowing access by unauthorised persons. This definition could also apply to key areas of the IT system allowing hacking of company commercial or regulatory
sensitive information
There was inadequate awareness of the threat level currently posed and so suitable security measures were not put in place. For instance the terrorist threat
Inadequate security awareness
alert status is raised by government but no additional security precautions are considered
There are inadequate numbers of security guards or the quality of the security guards employed is not adequate. As a result they do not deter a threat to the
Inadequate security guards
company or its workers
Security procedures used do not cover all potential security risks or are not up to date. For example, an emergency plan does not have the an up to date phone
Inadequate security procedures
list as a result in a emergency or during an exercise the relevant managers or emergency services could not be contacted.
The surveillance systems or methods used do not cover the key risk areas of a site as a result a security breach dose or could have occurred. For instance
Inadequate site surveillance
there is no surveillance of car park areas as a result there is a break-in to a worker or visitors vehicle

The pre employment / job change vetting of (any) employees is inadequate so possible security risks in their past are not picked up. This could also include
Inadequate staff vetting
vetting of foreign nationals work permits to see if they have a right to work in a country. It could also include failure to spot potential conflicts of interest.
Inadequate Tools / Equipment / Materials
Inadequate preventative maintenance programme: the tools or equipment or vehicles involved in the incident were not covered by a preventative maintenance
Inadequate adjustment / repair / maintenance
and inspection programme and became unserviceable, or the tools, equipment or vehicles had not been correctly maintained or repaired when last serviced.

There had been inadequate assessment of the risks associated with using the tools, equipment or vehicle in the way intended. For example the selection of
Inadequate assessment of needs and risks
appropriate lifting equipment must consider not just the load to be lifted but also the rigging of the load and the extent of the lift out.

The correct tools or plant/ equipment or vehicle was not available: the necessary tools, equipment or vehicle were not available at the job site either because
Inadequate availability
they were never supplied or were inaccessible. In many cases this will be associated with the use of the wrong tool, equipment or vehicle for the job.

The tools, equipment or vehicle selected for the job did not take adequate account of human factors or ergonomics. For example the step down from a bulldozer
inadequate human factors/ ergonomics considerations
cab may be too high to allow safe dismounting in the field
Inadequate inspection of tools, equipment or vehicles prior to their use to identify any defects. This includes confirmation that all necessary certification is up to
Inadequate inspection of the tool, equipment or vehicle before use
date.
Removal or replacement of unserviceable items not effective: items that were no longer serviceable remained in use. For example lifting slings that had failed
Inadequate removal and replacement of unsuitable item
their inspection being used for subsequent lifts.
Inadequate salvage and reclamation Inadequate processes and procedures are in place to ensure that unserviceable equipment is removed and destroyed.
Wrong tools or plant and equipment provided: the tools, equipment or vehicles provided were thought to be right but proved to be inadequate for the job
Inadequate standards or specifications
because the risks associated with their use or the environment in which they were being used were incorrectly assessed

Inadequate Training / Knowledge Transfer

Training is provided by the company or Contractor but the process does not include a suitable competency assessment during /after the training. One or more of
the trainees has not fully understood the requirements of the training or how to put it into effect as a result when they go out to apply the knowledge they have
Competency not assessed
been given they make a mistake resulting an incident or near miss. For instance an employee is given working at height training but there is no assessment that
he knows how to put the harness on and tie off safely.

The IP or person causing the incident was not sufficiently trained, instructed or inducted as a result an incident or near miss occurred. For instance a new driver
Inadequate instructions, orientation and/or training
on a site is not properly made aware of a no reversing without a banks man policy and reverses into some workers walking past the back of the truck.

Although a Lessons Learnt process exists within the Company / Asset there is repeat or very similar incident either in the same assets or elsewhere in the
Lessons Learnt not applied company because the lessons identified in the first incident have not been applied. This may include failure to adequately communicate lessons to the workers
at risk as well as workers failing to absorb the lessons.
The training provided was not effective in preventing the incident. For instance a new driver on a site is properly made aware of a no reversing without a banks
Training not effective
man policy but chooses to reverse when the banks man is not present and in doing so hits some workers walking past the back of the truck
Inadequate Work Standards / Procedures
Communication of Standards or procedures not effective: Well crafted S&P's were in place but were not properly communicated, due to such factors as
Inadequate communication of standards / procedures
incomplete distribution, language difficulties, incomplete integration with training efforts or out of date S & P's being in place.
- distribution Distribution of standard or procedure incomplete: communication of the S or P has not reached those that it was intended for.
- publication Quality of publication poor making standard or procedure illegible or difficult to read
- reinforcing with signs, colour codes and job aids Standard or procedure not reinforced with suitable signage and job aids
- translation to appropriate languages Standard or procedure not translated into relevant local languages or poorly translated
The standards or procedures covering the task were inadequate or non-existent: there was no reliable Standard or Procedure available covering the work being
undertaken at the time of the incident, due to such factors as the failure to assign responsibility for the development of S&P's or the failure to recognise the need
Inadequate development of standards / procedures
for a standard instructions for this task or inadequate coordination with the design effort, having unknowledgeable people developing the S&P's, not identifying
the proper steps to be taken in problem situations or poor format that made the S or P difficult to use
- coordination with process design Poor coordination with the designer when drafting the Standard or Procedure
- employee involvement Lack of involvement of experienced operations employees in developing the S or P
The standards / procedures or rules are / were inconsistent in what they require. As a result an act or omission occurs that contributes to an incident. This may
- inconsistent standards / procedures / rules be that different standards are being applied in different parts of the business. So a worker who has worked in one Asset believes he is complying with company
practice without realising that a stricter standard applies in his new Asset.
The standards and procedures in used were not sufficiently broad to cover all exposure risks or storage and handling requirement of the products or materials
- inventory and evaluation of exposures and needs
being used.
Inadequate implementation of work standards / procedures Company standards / procedures were not consistently applied in the workplace.
Inadequate maintenance of standards Standards are not up to date with current best practice or site specific risks
There was no/inadequate monitoring of the applications of standards procedures and rules as a result they were not properly or fully applied leading to an
- monitoring use of standards/ procedures/ rules
incident.
- updating A standard has not been updated with a change that renders the old standard unsafe.
Management of change controls were not in place or were not being effectively applied as a result a modification took place that was unsafe or that rendered
Inadequate management of change controls in place
plant/ equipment or processes upstream or downstream unsafe. Modification can equally apply to people and procedures as it can to physical plant.

Wear and Tear

Plant and equipment was in use past the manufacturers / designers expected service life without proper service or revalidation. As a result it failed or resulted in
Improper extension of service life
action by an enforcement authority or regulator.
Equipment was over loaded or operated at a speed it was not designed to operate as a result excessive wear or failure of the equipment occurred. For instance
Improper loading or rate of use
overloading of a crane may result in the crane toppling over.
There was in adequate monitoring or inspection of plant or equipment as a result a defect or condition was not identified and remedial action was not taken in
Inadequate inspection and/ or monitoring time. For instance the oil in an engine was not checked on a regular basis and dropped below the required level or pressure leading to insufficient lubrication of
the bearings/ cylinders and resulting in seizure of the engine.
Plant or equipment was inadequately maintained and this resulted in a failure or near miss. For instance when maintaining a piece of equipment the fitter did not
Inadequate maintenance replace all the bolts as a result after re-entering service vibration loosened the remaining bolts and resulted in part of the equipment falling off. Or when
replacing a tyre the wheel was not balanced at the same time leading to premature wear or loss of control.
When selecting a piece of equipment for use insufficient planning was carried out to ensure that it was fit for the purpose intended or that it could be maintained
Inadequate planning of use
in service for the intended design life.
Use by unqualified or untrained people The equipment was used by unqualified or untrained people leading to miss use or abuse which resulted in premature wear and tear or failure
A piece of equipment was used for the wrong purpose leading to an incident. For instance a wrench/ spanner was used as a hammer damaging both the
Use for wrong purpose
wrench/ spanner and the object being struck.
Control Barrier Definitions:
Administrative Control Barriers
Alarms and annunciators Alarm systems visual (flashing lights etc) or audible (alarm bells etc.), or Public Address System announcements (abandon ship)
The certification process for trained engineers (to the specified level) was not effective because it failed to identify that the engineer did not have the relevant
Certification of engineers
competencies to carry out the work assigned unsupervised
The certification process for trained technicians or fitters (to the specified level) was not effective because it failed to identify that the technician/fitter did not have the
Certification of technicians and workers
relevant competencies to carry out the work assigned unsupervised
Engineering specifications The engineering specification relating to the work was not adequate to manage the risks or was not in place at all
Where workers are licensed or certificated to work on a company site there has been a breakdown in this process. This could include a failure in a safety passport
Licensing of workers
scheme where this is in use
Maintenance work should be controlled through the use of maintenance work orders or equivalent so that: clear instructions are given to the worker, risk are identified
Maintenance work requests and mitigated, materials and tools are available at the start of the job, control systems (i.e. PTW, tool box talks) are identified and adhered too, and so that there is a
record of the work having been carried out
Methods of communication The methods of communicating: BG safety expectations, instructions, standards, work requests, lessons learnt etc.

Operations and maintenance procedures are written to ensure the safe and efficient operation of plant and equipment. As such they will identify: the risks associated
Operations and maintenance procedures with the work, the controls to be put in place to mitigate the risks, the proper sequence of the work, the competencies required of those involved in the work, who is to
be informed before, during and after the work has been completed. and what to do in an emergency or if the procedure no longer matches the work to be carried out.

Policies and practices Policies and practices are a requirement in order to ensure safe working standard in the work environment.
Welders used on fabrication or maintenance activities must be qualified and currently certificated to carry out the type of welding being undertaken (i.e. full
Qualification of welders
penetration, hot work, special steels welding etc.)
Where national or international regulations are or should be in place, but their absence or lack of effectiveness have been contributory factors in the incident. For
Regulations
instance most industrialised nations have extensive HSE regulations but these may not be well established in developing countries.
Safety Rules Safety rules are basic safety requirements and would be expected to include BG Life Savers or JV equivalent
Where a task is deemed to require direct supervision, because of the need to; maintain quality, its complexity, the risks or the inexperience of the workers carrying out
Supervisory practices
the task, this should be in place. The supervisor should have all the necessary skills and experience to carry out the work in a safe manner
Training and Education To perform any role safely and effectively an element of training and education will be required. If this training is not provided or is not effective an incident may result.

Many activities require the work to be carried out under a Permit to Work (PTW) or Safe System of Work (SSOW) when assessed as having sufficient risk or where
Work Permits / SSOW the consequence of an error is high. Many plants require all work to be covered under a PTW or SSOW. However, the lack of a Permit to Work / a PTW system, or a
Safe System of Work permit /SSOW or the ineffectiveness of the system could be contributory factors in the incident

Physical Control Barriers

Where there is potential for contact with moving parts such as reciprocating or rotating equipment or energised electrical equipment, fixed guards should be provided.
Barriers/Guards
These include coupling guards on pump-motor set and screens/barriers to prevent access to energised electrical equipment.
Many designs include design allowances to cover material or manufacturing tolerances or to allow for deterioration during the service life. If these allowances have not
Conservative design allowance been made at all or are not sufficiently conservative there is a risk of failure during the working life of the plant / equipment. For instance, corrosion allowances when
calculating the thickness of line pipe or expected maintenance cycles for rotating equipment

Electrical Protection Devices This relates to the operation, or not, of electrical protection devices designed to interrupt the flow of electrical energy in the event of an fault ( e.g. short circuit to earth)

Engineering safety features such as pressure relief valves, bursting disks, air brakes, flare stacks, circuit breakers, slam shut valves etc. are all engineered safety
Engineered safety features features, as are protective devices built into a plant or pipeline to cut off flow in the event of a pipe rupture following excessive ground movement (i.e. earthquake or
landslide)
Many offshore platforms and high inventory storage sites require fire safety barriers (safety habitats etc.) or seals to protect workers from flame, heat or smoke in the
Fire barriers and seals
event of an ignited hydrocarbon release.
Locked doors, valves, breakers and controls A security / safety device such as a locked door or safety interlock etc. was not in place or was ineffective and as a result an incident or near miss occurred
Many high reliability installations/ systems include duplicate systems in the design to ensure continuity of operation / supply in the event that the working piece of
Redundant equipment equipment fails. For instance pressure reduction stations often include duplicate flow streams to ensure continuity of supply in the event of the loss of a whole stream
and monitor regulators to maintain flow in the event of the active regulator in a stream failing