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HSE PROCEDURE Doc. No. NUS-HSE-IIP/02

Rev 02
INCIDENT INVISTIGATION PROCEDURE Date 26/07/2016
SystematicCause AnalysisTechnique
SystematicCause AnalysisTechnique
LOSSCategoryorPotentialLossCategory
Health Safety Environment Quality
NonproductiveTime Client
Schlumberger
rd
3 Party
UseHSESCATforHEALTH-SAFETY-ENVIRONMENTCauseAnalysis Other Reputation
Fine/Penalties
Process
Revenue

INCIDENTorPotentialIncident
Tools/ Equipment/ Product/ Failure/Malfunction(FailDownhole) Chemicals/ Fluids/ Slurry notperformor placedasper design. Off depthor improper spaceout Mediaexposure
Not meetingexpectation(Wellproduction, Client, Others):
Tools/ Equipment/ Product/ Failure/Malfunction(Failonsurface) Unplanned/Undesiredenergy release Regulatory/Contract/ Licenseviolation
Tools/ Equipment/ Product not at fault.
Data/ Informationquality/ Integritydelivery failure Unable toreachdesireddepth Loss of well control Locationlogistics/ Procurement/ Customs incident

Late/No/ Substandarddelivery ofProduct/ Service/ Data Lost/Droppedinhole(Tool, Equipment, Others) Invoicefailure Globallogistics/ Procurement/ Customsincident

Failtodeliver (Customer/ Supplierinterdependency) Stuck inhole(Tool, Cable, Pipe,Others)

IMMEDIATECAUSE

SubstandardActs SubstandardConditions
Using unauthorized equipment InadequateGuards or Barriers
Operating Equipment without authority InadequateWarningSystem
Operating at improper speed Inadequateor Improper equipment
Operateequipment outof specification Inadequate3rdparty (non-SLBmanaged) equipment
Knowingly using defective equipment Inadequatedocumentedinstructions
Using equipment improperly Inadequate Information/Data
Making safety devices inoperative Inadequate Job/Workpreparation/Planning
Improper jobplanning Inadequate support/ Assistance
Improper Loading/ Lifting/ Handling/Placement/ Position for task Inadequate communication infrastructure/ Process
Improper chemicalmixing/Blending DefectiveTools, Equipment, MaterialsorSoftware
Improper equipment/ Product selection/ Jobdesign Inappropriateworksitecondition(Noise,Radiation, Mud, Snow,Ventilation, Illumination, Harmfulmaterial,Others)
Improper/ Inadequatemaintenance Fire&ExplosionHazard
Improper behavior/Foolingaround Poor Housekeeping/Disorder
Impropermake-up/ Assembly Congestionor Restricted Action
Improper Filing/ Archiving/Record keeping External conditions(Sea,Weather,Roadetc.)
Improper storage Downhole conditions(Temperature,Pressure)
FailingtousePPEproperly Downhole conditions(Obstruction, Restriction,Debris)
Failure towarn/Intervene Downhole conditions(Sand, Scale)
Failure tosecure/ Protect Downhole conditions(Reservoir, Flowrate)
Failure tofollowdocumentedinstructions Downhole conditions(Chemistry, Corrosion)
Failure toidentify Hazard/Risk Downhole conditions(Others)
Failure tocheck/Monitor/Observe
Failure toReact/Correct
Failure tocommunicate/Coordinate
Under influenceofalcohol andorOther drugs
 SystematicCause AnalysisTechnique
ROOTCAUSES
PersonalFactors JobFactors
Inadequate Inappropriate height, weight, size, strength, reach, etc Inadequate Unclearor conflictingreportingrelationships Inadequate Inadequatereparative Communicationofneeds

Physical/Physiologi Restrictedrange ofbodymovement Leadership and/or Unclearor conflictingassignmentofresponsibility Maintenance/Repair Schedulingofwork

calCapability Limitedabilitytosustainbodypositions Supervision Improperorinsufficientdelegation Unauthorizedmodificationimplemented
Substancesensitivitiesor allergies Givinginadequatepolicy,procedure,practicesor guidelines Examinationofunits
Sensitivitiestosensoryextremes(temperature,sound,etc) Givingobjectives,goals,orstandardsthatconflict Repairquality
Visiondeficiency Inadequatework/jobplanningorprogramming Testing
Hearingdeficiency InadequateTeamBuilding Partsubstitution
Othersensorydeficiency(touch,taste,smell,balance) InadequateLongTermPlanning Inadequatepreventative Assessmentofneeds
Respiratoryincapacity Inadequateinstructions,orientation,and/or training Lubricationandservicing
Otherpermanentphysicalcapabilities Providinginadequatereferencedocuments,directives,andguidancepublications Authorizedmodificationnotimplemented
Temporarydisabilities Inadequateidentificationandevaluationoflossexposures SchedulingofWork
InadequateMental / Fearsandphobias Lackofsupervisory/managementjobknowledge PartsReplacement
Psychological Emotionaldisturbance Inadequatecommunication/implementationoflessonslearned Adjustment/assembly
Mentalillness Inadequatematchingofindividualqualificationsandjob/taskrequirements Cleaningorresurfacing
Capability
Intelligencelevel Inadequateperformancemeasurementandevaluation Inadequate Inadequateassessmentofjobneedsandrisks
Inabilityto comprehend Inadequateorincorrectperformancefeedback Inadequate human factors/ergonomicsconsiderations
Tools/Equipment/Sy
Poorcoordination Inadequate Engineering Inadequatedesign,standards,procedures,guidelines Inadequate standards or specifications
stems
Slowreactiontime Inadequatedesigncriteria/specifications Inadequate salvage and reclamation
Engineering/Manu
Lowmechanicalaptitude Inadequatedesigndevelopment Inade quate removal and replacement of unsuitable items
Lowlearningaptitude
facturing Inadequatedesignacceptancecriteria Inadequatedesignreview Inadequateretirement/removal/replacement ofunsuitable/deteriorateditems
Memoryfailure Inadequatedesignqualificationtesting Inadequate Inadequatedevelopmentofstandards/procedures/work Inventoryandevaluationofexposuresandneeds
Physicalor Injuryor illness Inadequatedesigncommercialization/launch instructions Coordinationwithprocessdesign
Standards/Procedure
Physiological Fatigueduetotaskloador duration Manufacturing Inadequatecustomerorderinformationor processing Employeeinvolvement
s/WorkInstructions
Fatigueduetolackofrest Inadequateproductionplanning/flow Procedures/practices/rules
Stress Fatiguedueto sensoryoverload Inadequateproductionlinetools/equipment/systems Inadequatecommunicationof Distribution
Exposureto health hazards Inadequatereceivinginspectionandacceptance standards/procedures/workinstructionsPublication Translationofappropriatelanguages
Exposureto temperatureextremes Inadequateraw materials Training
Oxygendeficiency Inadequatecomponentpartsfabrication/machining Reinforcingwithsigns,colorcodesandjobaids
Atmosphericpressurevariation Inadequateinventory/stockcontrol Inadequatemaintenanceofstandards/procedures/work Trackingofworkflow
Constrainedmovement Inadequatecontrolofwaste instructions Updating
BloodSugarinsufficiency Inadequatemanufacturingdocumentation(partslists/assembly Monitoringuseofprocedures/practices/rules
instructions/drawings)
Drugs Inadequateassembly Inadequatemonitoringofcompliancewithstandards/procedures/workinstructions
Mental or Emotionaloverload Inadequatetesting ExcessiveWearand Inadequateplanningofuse
Psychological Fatiguedueto mentaltaskloador speed Inadequateuserinstructions/manuals Improperextensionofservicelife
Tear
Extremejudgment/ decisiondemands Inadequate Inadequateresearchon materials/equipment Inadequateinspectionand/ormonitoring
Stress
Routine, monotony,demandfor uneventfulvigilance Procurement/Purc Inadequatespecificationsonrequisitionorders Improperloadingofrateofuse
Extremeconcentration/ perceptiondemands Inadequaterequisition/orderingsystems Inadequatemaintenance
Meaninglessor degradingactivities
hasing Inadequatespecificationsto vendors Usebyunqualifiedoruntrainedpeople
Confusingdirections/ demands Inadequatecommunicationofsafetyandhealthdata Inadequate Inadequatecommunicationbetweenorganizations
Conflictingdemands/ directions Inadequateidentificationofhazardousmaterials Inadequatecommunicationbetweenworkgroups
Communications
Preoccupationwithproblems Inadequate Client InadequateIdentificationofneeds Inadequatecommunicationbetweenshifts
Frustration Inadequatetenderingprocess Inadequatehorizontalcommunicationbetweenpeers
Contracting
Mentalillness Inadequatebid Inadequateverticalcommunicationbetweensupervisorandperson
Lackof Knowledge Lackofexperience Inadequ atecontractwithclient Inadequ atecommunicationmethods
Inadequateorientation Inadequ atepre-contractmeetings Noco mmunicationmethodavailable
Inadequateinitialtraining Inadequ atemobilization Inco rrectinstructions
Inadequateupdatetraining Inadequateexecution/compliancewithcontract Inadequatecommunicationdueto jobturnover
Misunderstooddirections Inadequateperformancemonitoring Inadequatecommunicationofsafetyandhealthdata,regulationsorguidelines
Lackofsituationalawareness Inadequateroutinestatusmeetings Standardterminologynotused
LackofSkill Inadequateinitialinstruction Inadequatedemobilization Verification/repeatfeedbacktechniquesnot used
Inadequatepractice Inadequatepost-contractmeeting Inadequatemessagelength Messagestoolong
Infrequentperformance Contractors/Suppliers InadequateIdentificationofneeds Messagestooshort
Lackofcoaching Inadequatepre-qualification Speechinterference
Inadequatereviewinstruction Inadequatetenderingprocess Inadequate Inadequatepackage/container
Improper Improperperformanceisrewarded(tolerated) Inadequatecontractorselection Logistics/Delivery Inadequatepapers/documentation
Motivation Properperformanceispunished Inadequatecontractwithcontractor/supplier Inadequatecustomsclearance
Lackofincentives Inadequatepre-contractmeetings Inadequatetransportation(modeoftransport,availability,vehiclestandards/specifications
Excessivefrustration Inadequatemobilization Inadequatestorage/warehousing
Inappropriateaggression Inadequateexecution/compliancewithcontract Inadequatehandling/manipulation
Improperattemptto savetimeor effort Inadequateperformancemonitoring Insufficient/inadequateshipment/goods/loaddelivered
Improperattemptto avoiddiscomfort Inadequateroutinestatusmeetings
Improperattemptto gainattention Inadequatedemobilization Inadequate Inadequateunderstandingofmarketneeds
Inadequatediscipline Inadequatepost-contractmeeting Inadequatedevelopmentofclientrelationships
Marketing andSales
Inappropriatepeerpressure Inadequatecustomersatisfactionmonitoring
Impropersupervisoryexample Inadequateknowledgeofcompetitors
Inadequateperformancefeedback Inadequatecommunicationofcapabilities/technologies
Inadequatereinforcementofproper behavior Inadequateresponseto servicedeliveryfailures/complaints

AbuseorMisuse Improperconductthatis
condoned
Intentional Inadequateunderstanding/appreciationofoperationalcapabilities
Unintentional Overselling/overpromising
Improperconductthatisnot Intentional
condoned
Unintentional
Sc
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 LACKOFMANAGEMENTSYSTEMCONTROL
Commitment,Leadership PoliciesandObjectives Organizationsand ContractorandSupplier RiskManagement BusinessProcesses PerformanceMonitoring AuditsandReviews
andAccountability Resources Management andImprovement
C&SEvaluation,Qualificationand Assets, ProductsandSystems
Commitment andLeadership Policies OrganizationalResponsibilities Risk Management Process PerformanceReview Audits
Selection Integrity
Accountability Objectives OrganizationalStructure C&SManagement Risk Control Processes EventReportingand Management Reviews
TrainingandCompetence C&SPerformance ManagementofChange Business Continuity ComplianceMonitoring
CorrectiveActions andContinuous
InformationManagement
Improvement
Standards andGuidelines RecognitionPrograms
Records