GRK Vallend voorwerp; Scheidingsschot kabelbaan

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1 GRK Vallend voorwerp; Scheidingsschot kabelbaan
Wat is er gebeurd Op de UGS locatie Grijpskerk is in de compressor area een scheidingsschot uit een kabelbaan gevallen (vermoedelijk los gewaaid). Gewicht van het scheidingsschot is 1,3kg. De kabelbaan bevindt zich op een hoogte van 7 meter. De drops calculator geeft aan dat het voorwerp de potentie had om een major incident te veroorzaken(Oranje). Waarom is het gebeurd De scheidingschotten zitten op 2 punten vast. Het scheidingsschot is losgeraakt (vermoedelijk onder invloed van trilling door wind) De wind heeft het scheidingschot uit de kabelbaan geblazen. Genomen Acties Direct: - Area geïnspecteerd op overig loszittende scheidingsschotten - Nog twee losse scheidingschotten preventief verwijderd - Werkzaamheden op locatie zijn aangepast aan de weersomstandigheden. Leerpunten Door Extreme weersomstandigheden veranderen de condities in de plant. De gevolgen van de veranderingen zijn niet altijd direct zichtbaar.(wind, gladheid, onweer) Er zijn onderdelen in de plant die buiten een inspectie scope vallen. Vragen om op te reflecteren Bij welke weersomstandigheden overwegen we of het verstandig is de locatie te betreden? Hoe gebruik je de PTW in deze situaties? For any question please contact your LFI Coordinator – Lars van der Zande Locally shared LFI Alert preparation procedure Use this template to prepare a Onepager Send draft version to LFI Coordinator with approval of SME or TA for sign off content LFI Coordinator reviews draft versions and sends approval or comments to alert owner When final version is agreed on, the LFI coordinator will add the document to the incident in Fountain and on a Sharepoint site LFI Coordinator will communicate document link in Monthly LFI alert LFI Coordinator will share this on the WeCare App Guidance and Tips for writing an LFI Onepager For a good alert it is very important to know: What is the aim of this alert? What message do we want to communicate? Stick to the facts! Do not write down your assumptions. Write the onepager as a newspaper article. What happened should be a summary of the incident (like the first part of a newspaper article). Crisp and clear sentences help people understand your message. Using too much and complicated words will make it hard for people to understand what is going on. Try to minimize the onepager to 1 page. Make sure the alert flows in a natural way. Meaning…. Make a connection from Why it happened to lessons learned to discussion, which should resonate with your target audience. What should the target audience learn and do differently? Do not list too many lessons learned. Aim at maximum 3. No abbreviations. You might know the abbreviation, but others don’t. Do not state specific dates, names of people and locations (this is to anonymize the alert from a legal perspective). You can state things like offshore platform or production facility. Legal Guidance: When an incident is under investigation by an external authority we can’t publish it before the results and recommendations from this investigation are available. This to make sure we capture all learning and align with the outcome of the external authority investigation. In the first instance, Alerts are not intended for release to third parties (including to trade associations, other industry participants or employees of those participants) other than those third parties identified as part of the target audience above, namely Shell contractors and joint ventures in which Shell is a participant. Whether an Alert should be shared outside the initial target audience described above is a Business decision to be made after weighing the rewards of sharing with the risks (including legal and reputational risks). If publishing an Alert more broadly to an external audience, consideration must be given to compliance with the Shell Disclosure Standard and “anonymising” the Alert, where appropriate. Content Clearly state the facts and only the facts - assumptions or guesses about what happened or how it happened, or how someone felt, or what they thought, do not assist in the learning and may expose Shell to unintended consequences (legal and reputational). If you find yourself using words like “probably” or “maybe”, “she must have been X” or “the likely cause was” pause and consider whether or not you are recording a fact (e.g. “It was midnight when the driver hit the curb and his vehicle flipped over” vs. “It was midnight, the driver must have been tired and not attending to the road and so his vehicle flipped”) Don’t use words or phrases with legal meaning (e.g. actions are “negligent”, “reckless”, “not what a reasonable engineer would do”, or result in outcomes that are “reasonably foreseeable”, result in a “breach of duty of care” or “inherent”, “dangerous”, “good industry practice”). Don’t Use any written material or images produced by a third party without consent of the third party (copyright is the concern). Incident ID: Contact Persoon: Bart Schenk