Effective Process Safety Incident Investigation Approach Using the Comprehensive List of Cause (CLC)

All incidents that affect health, safety, security and environment must be investigated. The investigation should be conducted immediately after the incident occurs to identify root causes and lessons learnt so that the consequences of similar future incidents are minimized or eliminated. Incident investigations that focus on identifying and correcting root causes do not blame anyone; they are meant to improve workplace morale and increase productivity by demonstrating the leadership’s commitment to a safe and healthy workplace.

HSSE incident recorded in PHE ONWJ (Pertamina Hulu Energy – Offshore North West Java) cover all events, including both work-related and non-work related events. Work-related incidents are divided into process safety and occupational safety events. Process safety events deal with the possibility that hazardous materials and energy may be accidentally released and result in toxic exposures, fire or explosions.

Process safety incidents are broken down into five categories, i.e. LOPC or hydrocarbon leaks, fires, ship collisions, dropped objects and other events. Investigations of process safety incidents are conducted by using certain incident investigation tools such as The Five Whys, Fault Tree Analysis and the Comprehensive List of Causes (CLC). This paper explains the process safety incident investigation method using the CLC, which has proven to be very effective in determining root causes of the incident and developing truly effective corrective actions.

Incidents related to process safety that need to be reported and investigated include:

• Leaks of hazardous materials during operations or unanticipated releases during maintenance.

• Lifting of relief valves or operations of other over-pressured protection devices

• Failure of any protective device or system classified as Safety Critical Equipment (SCE).

• Detection of unanticipated forms or rates of equipment damage during planned inspections and maintenance.

The process safety incidents data comes from various sources, such as operations, facility integrity, engineering design, subsurface and drilling. The data is compiled using the CLC method to obtain the immediate and system causes of events. The CLC method used in the PHE ONWJ includes a list of causes that are related to process safety incidents. It also considers common scenarios and events in process safety as well as human errors and human behavior. Results from the investigations are analyzed to improve the process safety performance of the company.