AIPS event name

Date
PIM #XXXXXXX
(20XX Tier X #XX)

PHOTO OF FACILITY
OR EVENT

Investigation Team
A
B
C
D Peer Review
E A
 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
List injury type
Injury/Damage/Loss 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
Description (to be taken from “Causation”sheet)
Immediate cause
Key latent mgmt failures • List no more than 4 failures (to be taken from “Causation” sheet)

2
 Description of the Event
Short to the point description of the event (incident)

Include picture if/where relevant

Overview
photo/drawing of
EVENT
3
 Overview of Damage/Impact

ADD
PHOTOS/DRAWINGS or
FLOWCHARTS

(include any further photos in back-up)

4
 Sequence of Events
Date & Time Events
INCLUDE summary sequence of events
Detailed descriptions to be captured in BACK-UP

5
 Loss of Barrier Assessment
Which control/recovery barriers failed or were missing?

Include barrier picture if/where relevant

Include a bowtie representation if relevant

6
 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
• ANY finding

Operating integrity
• ANY finding

Emergency response
• ANY finding

Supplemental Findings (any finding that is not directly related to the event, but was encountered during the event)
• ANY finding

7
 Causation
Immediate Cause
• Loss of containment .......

Underlying Causes
• Max 4 to 5 underlying causes
Latent Management Failures
• Max 4 to 5 Latent MGT failures

8
 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

9
 Recommendations
Recommendation Action Target Status
Party Date
1

(Verify that:
- Recommendations address root causes and a clear action to do
- Recommendations are agreed by the action party as well as target date)

10
 Recommendations (from MDIRC/IRC)
Recommendation Action Target Status
Party Date
1

(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
 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]

KEY DISCIPLINES: KEY STANDARDS: Add relevant

Add relevant standards, e.g.
Add relevant key disciplines, e.g.
PR-1418 Incident Notification and Investigation
photos/drawings of
Process Engineering (UEP1P),
Material Corrosion & Inspection (UEC) DEP 80.45.10.10 Design of Pressure Relief, Flare and Vent EVENT

20XX-Tier X #XX, PIM XXXXXXX 12

Back Up

13
 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.
Add relevant
 Inappropriate quality control systems for maintenance and inspection photos/drawings
 of EVENT
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)

(Provide a copy of the MDIRC Initial Update (Tier 1 only),

required within 10 days after notification)
20XX-Tier 1 #XX, PIM XXXXXXX 14
 Recommendations – Asset specific
Recommendation Action Target Status
Party Date
1 Add any immediate and/or further asset specific actions

15
 Overview of Damage

(More pictures and description if applicable)

16
 Witness Statements

(Refer to witness statements where applicable)

17
 TRIPOD
Ianadequate process
implemenation for
working plant, S/D,
Inadequate S/U
Inappropriate quality Management of
control system Change
implementation

Inadequate Pre-start up check

Project initiated to
implemenation of list not available for
replace pumps
Standards Ops
Work instrcutons not
clearly
communicated ???

Design/ construction
flaw
Operations check
prior to pump start
not done
Not following
Preventive Modular skid design
communication
maintenance without draining
procedure by
discontinued in 2013 facility
Technician

Ignition by heat of
friction between
pump-house and
shaft
Piping stress action
on pump nozzle
Fire at the Hot Oil
pump B
Pump skid draining
facilities
Piping stress Loss of shaft center
elimination Pump bolts loosen Hot Oil LOPC from Both Hot Oil pump
Pump Vibration line damage the
and release damaged seal damaged due to fire
pump seal
Condition monitoring Maintenance Operations

Hot Oil pumps

Pump seal B

Pump nozzle

Pump bolts

Bearing pump B

(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)

18
 ICAM Causation description
Findings: Immediate Causes

Unsafe Actions
IC Ref # ICAM Causation description Justification

(Provide ICAM tables if ICAM has been used in the investigation)

19
 ICAM Causation description
Findings: Immediate Causes

Unsafe Conditions
IC Ref # ICAM Causation description Justification

(Provide ICAM tables if ICAM has been used in the investigation)

20
 ICAM Causation description
Findings: Underlying Causes (Human and Workplace)

IC Ref # UC Ref # ICAM Causation Description Justification

(Provide ICAM tables if ICAM has been used in the investigation)

21
 ICAM Causation description
Findings: Management System failures (MSF)

UC Ref # MSF Ref # ICAM MSF Description Justification for management system failure cited

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)
22