Standard Number: 0060.25 Seattle City Light Superseding ... · 0060.25 New October 31, 2019 6 of 7 Step Description Timeframes / Milestones ... 21 Final report OK to publish. Directly

Seattle City Light

WORK PRACTICE

Standard Number:

Superseding: Effective Date:

Page:

0060.25 New October 31, 2019 1 of 7

Standards Coordinator Laura Vanderpool

Standards Supervisor John Shipek

Unit Director Andrew Strong

Incident Review

1. Scope

This document describes the Seattle City Light (SCL) process for reviewing Level 3 and

Level 4 incidents.

This process covers the steps from the point at which an incident review team is

appointed to the point at which a final report is published.

The review process for Level 1 and Level 2 incidents is outside the scope of this process.

The reporting process related to the Cority online platform utilized by the Safety, Health,

and Wellness division is also outside the scope of this process.

This process is designed as a best practice guideline. The incident review oversight

committee has final authority regarding the conduct and reporting of incident reviews.

Details of the report draft review and revision activities undertaken by the team are

outside the scope of this process.

2. Application

This standard is for SCL management as well as employees who have been tasked with

undertaking a Level 3 or Level 4 incident review, as well as for any SCL employees who

wish to have a greater understanding of the process. Further, this process also allows

individuals who find they will be involved in some aspect of a review to prepare in

advance for their subsequent roles and responsibilities.

Seattle City Light WORK PRACTICE Incident Review

Standard Number:


Page:

0060.25

New October 31, 2019 2 of 7

3. Definitions

Level 3 incident: An incident involving any electrical contact, exposure to arc flash, a

significant fall, serious motor vehicle collision, or emergency transport to a hospital of one

employee

Level 4 incident: An incident involving a fatality, probable fatality, or emergency

transport and admission to a hospital of one or more employees

IRO Committee: Incident Review Oversight Committee (“the IRO Committee”); consists

of three directors. See Table 5.

IR Team: Incident Review Team (“the IR Team”); consists of five or more individuals

selected by the IRO Committee. See Table 5.

4. Introduction

The goal of a quality incident review is to evaluate technical issues, safety protocols,

human performance, and environmental conditions, then identify a root cause and

recommend specific actions that promote critical and lasting improvements in worker

safety and help to ensure that whatever incident occurred will not be repeated.

Further, the goal of a formal process is to ensure timeliness, consistency, efficiency,

transparency, and accountability in all aspects of the review, from inception through to

completion of all recommended actions contained in the final report.

5. Process

This section presents a step-by-step description of the incident review process for Level 3

or Level 4 incidents.

Figure 5 shows an example of a process timeline. Actual timeframes will vary with each

incident review.

Table 5 describes each step in detail.


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Figure 5. Process Timeline Example


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Table 5. Process Steps

Step Description Timeframes / Milestones (See Figure 5)

1 The Incident Review Oversight Committee (“IRO Committee) is formed.

When a Level 3 or Level 4 incident occurs, a committee is formed to oversee the incident review process. This committee consists of:

▪ Director, Safety, Health, and Wellness

▪ Director, AMLP

▪ Operations Director of the crew involved in the incident

Within 1 business day of incident

2 The IRO Committee appoints an incident review team (IR Team) who conducts the review and produces a report. The team is composed of the following individuals:

▪ Safety, Health, and Wellness (SHaW) representative

▪ Field Operations managers as follows:

o If the incident is in the Looped Radial system: North Crew Field Operations Manager and South Crew Field Operations Manager

o If the incident is in the Network system: Network Crew Field Operations Manager and North OR South Field Operations Manager

o If the incident is in Generation: Generation Operations Manager and a Field Operations Manager of South, North, or Network

▪ Standards engineer (to be selected by Standards Supervisor)

▪ Technical writer (to be selected by Standards Supervisor

Within 3 business days of incident

3 The IRO Committee schedules and conducts an incident review briefing meeting to include at least one representative member of the IRO Committee and the full IR Team to discuss the incident and review the process and key expectations.

Within 1 week of incident

4 The IR Team schedules and conducts a kickoff meeting to identify the project scope, SMEs, and review components (interviews, material analysis, etc.). In that meeting, the team creates a timeline and milestones for the development and delivery of a report to the IRO Committee. In addition, working from a core set of interview questions, the team discusses any changes/additions that would be appropriate for the review at hand.

Within 1 week of incident

5 Field Operations Manager (part of the IR Team) representing the affected crew (NSC, SSC, or Network) contacts their Operations Director to request that they set up interviews with the affected crew, any other interviewees as determined by the IR Team, and any representatives that need to be present, such as union representatives/shop stewards. Field Operations Manager relays the following information:

▪ Names of IR Team members to include in the interview session Outlook invitation

▪ Expectations for when the interviews need to take place (ASAP)

▪ Interview protocols (one person at a time, at a single location during the course of a single day if possible, with a union representative present if requested, etc.)

Immediately following the kickoff meeting

6 The Operations Director of the crew involved in the incident schedules an interview block (ideally single location, same day) with the affected crew members and corresponding union representatives as appropriate, and IR Team interviewers. This is a closed-door, confidential meeting.

Within 1 business day following the briefing meeting described

in Step 3.

7 IR Team Technical Writer creates a final interview question set and distributes to IR Team interviewers in advance of the interview block. Questions are not shared with interviewees in advance of the meeting.

Within 1 business day following the briefing meeting described in Step 3


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8 Interviews take place. Ideally the team interviews one crew person at a time over the course of a single day, in a single location.

Within 1-2 weeks of date of incident

9 The IR Team meets to review interview notes to resolve discrepancies/ conflicting statements, identify any missing information, and discuss preliminary findings.

Ideally immediately following the interview block; no later than within 1 week of the interview

block

10 The IR Team conducts remainder of review activities including, but not limited to:

▪ Material and equipment analysis

▪ Review of relevant SCL processes, procedures, work practices, construction standards, etc.

▪ Presenting visual evidence (site photos, PPE, damaged equipment and tools, etc.)

▪ Consultation with SMEs

▪ Document gathering (work order, tailboard, SOC trouble log, manufacturer literature, etc.)

▪ Coordination with all parties declared as responsible for completion of recommended actions contained in the report to obtain review and approval of scope and timeline.

Variable depending on review components; target turnaround time for steps 10 and 11 combined is 6 weeks.

11 The IR Team assembles the report, sections of which may include, but not be limited to:

▪ Executive summary

▪ Incident summary

▪ Findings (facts from each review activity)

▪ Conclusions (declaration of root cause and secondary causes)

▪ Recommendations (corrective actions)

The report follows the Incident Review Report template. See Appendix.

Variable depending on review components; target turnaround time for steps 10 and 11

combined is 6 weeks.

12 The IR Team delivers a pdf of a final draft of the incident review report to the IRO Committee.

6 weeks from briefing meeting described in Step 3

TBD Labor Relations step to be determined.

13 The IRO Committee meets to review draft and come to consensus regarding any edits.

1 week from receipt of report final draft described in Step 11

14 The IRO Committee delivers a pdf draft with markups to the assigned Technical Writer to incorporate into the final report.

1 week from receipt of report final draft described in Step 11

15 The IR Team meets to review marked-up draft report, resolve any issues; Technical Writer incorporates edits as appropriate into the final report.

1 week from receipt of marked-up final draft from the IRO Committee

16 The IR Team delivers a pdf of final report to the IRO Committee. 1 week from receipt of marked-up final draft from the IRO Committee

17 The Director and/or Manager of the affected employees shares final report with affected employees prior to general distribution. This can either be done as a group or on an individual basis.

1 week from delivery of final report to the IRO Committee

18 The Director and/or Manager of the affected employees informs the IRO Committee that report has been shared with affected employees.

Immediately following conclusion of meeting with affected employees


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19 The SHaW Director distributes final report to the following individuals/entities:

▪ CEO/GM

▪ SCL Officers

▪ SCL Directors

▪ SCL Managers

▪ SHaW Division

▪ IRO Committee

▪ IR Team

Immediately following conclusion of meeting with affected employees

20 The SHaW Director distributes report company-wide via all-employee message.

1 business day after distribution of final report described in Step 18

21 Final report OK to publish. Directly following all-employee distribution of final report

6. Sources

DOE HANDBOOK, Accident and Operational Safety Analysis, DOE‐HDBK‐1208‐2012,

U.S. Department of Energy Washington, D.C. 20585, July 2012

Seattle City Light Policy DPP 500 P II-239 (canceled); “Incident Response,

Investigation, and Documentation”

Safety Standard SHW 09; “Safety Incident Response and Outcomes”

Shipek, John; Standards Supervisor and Co-Originator of 0060.25

([email protected])

Vanderpool, Laura; Standards Technical Writer and Co-Originator of 0060.25

([email protected])


Standard Number:


Page:

0060.25


Appendix. Incident Review Report Template

(see following pages)

CLR Report Title CLR Report Subtitle

Project Lead/By: Firstname Lastname

Prepared by: Firstname, Lastname, Organization

MM/DD/YYYY

DRAFT V.N.

Table of Contents CLR Front Section Title

1. CLR Heading First Level .............................................................................................................. 1 1.1. CLR Heading Second Level ............................................................................................. 1

1.1.1. CLR Heading Third Level .................................................................................... 1 1.2. CLR Heading Second Level ............................................................................................. 2 1.3. CLR Heading Second Level ............................................................................................. 2

2. CLR Heading Second Level ......................................................................................................... 3 2.1. CLR Heading Second Level ............................................................................................. 3

3. CLR Section Title ......................................................................................................................... 4 3.1. CLR Heading Second Level ............................................................................................. 4

3.1.1. CLR Heading Third Level .................................................................................... 4

INCIDENT REVIEW REPORT TITLE | DRAFT MM/DD/YYYY

INCIDENT REVIEW REPORT TITLE | PAGE 1

1. CLR Heading First Level

1.1. CLR Heading Second Level

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CLR Appendix Title

Documents

Standard Number: 0060.25 Seattle City Light Superseding ... · 0060.25 New October 31, 2019 6 of 7 Step Description Timeframes / Milestones ... 21 Final report OK to publish. Directly