COMAH Remodelling - Investigation remodelling

1 Control of Major Accident Hazards COMAH Remodelling Investigation Procedure the Competent Authority Control of Major Accident Hazards 1. Operating Procedures for CA Investigation The purpose of this document is to guide the reader through the remodelled procedures for COMAH Investigation . 2. Investigation and the duty to investigate Investigation is the reactive work undertaken by the CA as a result of an incident or complaint at a COMAH establishment. This procedure covers the arrangements for COMAH and the functioning of the CA during investigations. Importantly, the CA will continue to ensure that for each COMAH relevant incident an Investigation Manager will be appointed who will ensure that the primary Investigation team are sufficiently briefed and possess the appropriate capabilities.

2 COMAH regulation 19(4) places a duty on the CA to investigate major accidents and take actions where necessary. COMAH regulation 21 places a duty on the CA to report specified major accidents to Europe. 3. Scope and Application of Investigation procedure This procedure provides a common framework for CA Investigation at COMAH establishments. It supplements existing arrangements for Investigation , as outlined in the separate policy and procedures of the Health and Safety Executive (HSE), Environment Agency (EA) and Scottish Environment Protection Agency (SEPA). Any person involved with an Investigation will retain their own powers as granted by their own warrants and will follow the procedures of their respective organisations, except where directed otherwise by this procedure.

3 It is recognised there are some differences between the way HSE, EA and SEPA investigate, but the CA has a proven track record in enforcement and prosecution, both independently and jointly. Investigation may be concerned with issues related to COMAH , or another legislative regime or many regimes (Health and Safety at Work Act or Environmental Permitting Regulations or Water Resources Act): a) where the facts of an incident are relevant to COMAH , this procedure applies (including investigations involving other non- COMAH legislation);. b) where the facts of an incident are not relevant to COMAH , this procedure does not apply. This procedure explains COMAH relevance in more detail (see Phase 1 Initial Alert).

4 Enforcement activities of the CA are not detailed in this procedure. Since enforcement considerations are fundamental to the way the CA approaches dutyholders following an incident or complaint, this procedure should be considered in combination with Competent Authority (CA). policy and guidance on enforcement. Investigation Procedure 1 of 24 pages Version 2/July 2010. Control of Major Accident Hazards 4. Purpose of Investigation Procedure This procedure aims to provide an efficient approach to joint working within investigations and to gather evidence to enable any necessary enforcement, other action or dissemination of causes, lessons and recommendations. The key aims are to strengthen and encourage teamworking and improve the way investigations are managed.

5 The procedure guides the working arrangements of the CA to achieve Investigation outcomes (see Investigation Outcomes section of this procedure). These outcomes are linked to the CA. Investigation Policy (see Appendix 1), actions for duty holders ( enforcement) and other CA. COMAH duties (Reg. 19 (4) & 21). The main purposes of Investigation are to collect and secure evidence, determine the factors leading up to the accident, its impact both on and off site, establish its causation including root causes, and to initiate in a timely manner any remedial or improvement actions. In addition, without prejudice to any potential enforcement action, the CA will seek to ensure early dissemination of causes and lessons from Investigation and will make recommendations on future preventive measures (including reporting to Europe as required).

6 A wider set of Investigation objectives can be found in Appendix 2. Investigation Procedure 2 of 24 pages Version 2/July 2010. Control of Major Accident Hazards 5. Introduction to revised procedures The Investigation process has been divided into four phases: 1) Initial Alert, 2) Initial Assessment, 3) Management Structure and Oversight, and 4) Dissemination of causes, lessons, recommendations and reporting to Europe. Each phase will be guided by the required outcomes, delivering action to achieve these outcomes. During first weeks Early release of information Within 5 days Incident at COMAH site &. Requires periodic (monthly) Without delay when periodic review immediate action required review Initial Alert Initial Assessment Management Structure and Dissemination of causes, Oversight lessons and CA Exchange information for Initial Impact Assessment recommendations and COMAH relevant incidents record.

7 Form primary Investigation Reporting to Europe without delay team. EC Reportable? Major Establish and implement Safety Alerts + bespoke Liaison between those who Accident? terms of reference, objectives, reports routinely inspect site Routine or Major incident and delivery plan. Investigation ? Annual summary report CA SMG oversight of EC analysing trends from routine reportable and Major investigations Incidents. Local management if routine Investigation data to inform future CA priorities Investigation outcomes Collect and secure evidence. A full analysis of the incident (including causation and root causes). Consider actions for duty holders (enforcement) and other actions as necessary 6.

8 Resource Planning Field teams should expect that they will undertake an ongoing level of routine Investigation and ensure resources are managed to achieve this without impact on delivery of other targets. Local knowledge is essential to predict this allocation, however, on average across the CA, routine Investigation requires an additional 10% of resource (all disciplines) above that required for delivery of inspection and assessment work. The CA Strategic Management Group (CASMG) acknowledges the resource implications of investigations and will review and revise CA resourcing levels as necessary. This will occur especially during major incident investigations. Investigation Procedure 3 of 24 pages Version 2/July 2010.

9 Control of Major Accident Hazards 7. Table of contents Page Investigation flow diagram 5. Investigation Outcomes 7. General Conduct of CA investigations 8. Investigation Phase 1: Initial Alert 9. Investigation Phase 2: Initial Assessment 10. Investigation Phase 3: Management Structure and Oversight 11. Investigation Phase 4: Dissemination of causes, lessons, 13. recommendations and reporting to Europe Glossary 15. Appendices 16. Investigation Procedure 4 of 24 pages Version 2/July 2010. Control of Major Accident Hazards 8. Investigation flow diagram Evidence gathering starts Initial alert (Refer to required outcomes - see reg 19(4). Info on incidents at & 21 plus Investigation and Without COMAH site received Enforcement Policies to delay by HSE, EA or SEPA.)

10 Guide required evidence). Information passed to team responsible for regulation of site Record decision No and investigate COMAH . outside of CA as relevant? appropriate Yes / Potentially Inform counterpart in CA. (inspector or team leader). Initial Team assessment - assessment Complete Initial Incident Impact Assessment form Within 5 days and periodic review Record decision No and investigate COMAH . outside of CA as relevant? appropriate Yes / Potentially Inform CA SMG via Yes Major . business support incident OR EC. group reportable Management Appoint Investigation structure & manager, Investigation Oversight team leader & team, legal support etc. Periodic review (at least monthly), Establish & implement including CA SMG oversight if Periodic Incident Investigation objectives, incident is EC terms of reference and Impact Reassessment reportable or Major delivery plan form Review local and national resourcing vs KPIs and overall service delivery Investigation Procedure 5 of 24 pages Version 2/July 2010.