Incident Investigation AEGIS Insurance Services, Inc. All rights reserved.

Transcription

1 Incident Investigation. 1

2 Discussion Items AEGIS Loss Control Loss Data Definition of an Incident Incident Investigation Is the Emergency Over? Lessons Learned Practice

3 AEGIS Background Information Utility Mutual Insurance Company (Member-owned) Formed in 1975 by 22 gas utilities Electric Utilities began joining in members 94% investor-owned utilities and related energy

4 AEGIS Loss Control Mission Statement To assist AEGIS member companies maintain effective and safe operating systems while reducing their overall long-term cost of risk, by developing and providing products, services and training programs specifically for this purpose.

5 Loss Control Division Products and Services Risk Assessments Self-Administered Risk Assessments Guides Review of Major Liability Losses Occupational Safety & Workers Compensation Program Assessment Lessons Learned Video Series Public Safety Awareness Program Electric How Safe Series Electric/Gas Hazard Awareness for Emergency Responders Consultation Gas Operator Training Program

6 6 Loss Control Division Loss Control Division Utility Risk Assessments, Services and Guides Natural Gas Risk Assessments Call Center Reviews Focused Services Webinars One hour technical sessions for Risk Managers, Safety, Claims, Engineering and Operating Personnel On-Site Training and Workshops (For Fee) Natural Gas Operator Training Natural Gas Incident Investigation Workshop Media Relations at Utility Incidents Scenes

7 7 Loss Control Division Publications and Guides Self-Administered Risk Assessments (SARA) Guide Natural Gas Emergency Response Tip Cards Review of Major Liability Losses What We Have Learned And What You Should Know Consulting and Presentations Technical Consultations Code changes & interpretations Company operating procedures & practices Utility design issues Independent review of operating documents & manuals Industry & Member meetings

8 8 Loss Control Division Additional Information on AEGIS Website For risk managers, operations, engineering, safety, legal & claims password protected. Go to Follow on-screen instructions

9 9 Natural Gas Reported Claims: All Systems/Third Party

10 10 Natural Gas Reported Claims: All System/Third Party/Fuel Piping

11 11 Natural Gas Reported Claims: All Systems/Third Party/Fuel Piping/Type of Loss

12 12 Natural Gas Reported Claims: All Systems/Third Party/Fuel Piping/Type of Loss/Contributing Factors

13 What Is An Incident? Title 49 CFR An unexpected release of gas from a pipeline or of liquefied natural gas, liquefied petroleum gas, refrigerant gas, or gas from an LNG facility, which results in one of more of the following consequences: A death, or personal injury necessitating inpatient hospitalization, or Estimated property damage of $50,000 or more, including loss to the operator and others, or both, but excluding cost of gas lost Unintentional estimated gas loss of three million cubic feet or more

14 What Is An Incident? An event that results in the emergency shutdown of an LNG facility Activation of an emergency shutdown system for reasons other than an actual emergency does not constitute an incident An event that is significant, in the judgment of the operator, even though it did not meet the criteria defined previously

15 Obvious

16 Not So Obvious

17 AEGIS Case Study RMLL Two people died from CO poisoning from a faulty furnace Examination of furnace revealed; rust, soot build up, furnace clogged & lack of combustion air vent to room only 25% of the required size Company visited the home on three separate occasions 1. After a flood --- company onsite; noted rust on unit no reference to vent size 2. Red tagged bad pilot safety.allowed furnace to remain in operation 3. Customer call of odd odor complaints of nausea service tech checks area with CGI does not check draft diverter with probe, as required by company procedures 4. Service tech gets permission to remove red tag for bad pilot safety. Allows furnace to remain in operation.incident occurs 8 months after last visit

18 AEGIS Case Study RMLL Lessons Learned Location of furnace and lack of combustion air Any red-tagged appliance must be repaired or replaced before it is put back into operation Ample opportunity to address the hazard Supervisors instructions to service tech to remove the red-tag Company SIR - $1,000,000 + AEGIS Loss $7,900,000 = $8,900,000

19 Is The Emergency Over?. 19

20 AEGIS Case Study - RMLL Is The Emergency Over? A gas leak was called into the gas company with the caller stating there is a strong odor of gas at the gas meter and its coming into my house. A gas company first responder was dispatched three minutes after the company received the leak report and was enroute to the scene when the home exploded, fatally injuring one and critically injuring another occupant. The first responder from the gas company arrived at the scene approximately 29 minutes following the explosion. Additional company personnel were dispatched to the incident scene and began searching for the source of the leaking gas.----find AND FIX SYNDROME About four hours after the initial explosion two other explosions in quick succession occurred, injuring two firefighters, a gas company employee and damaging several properties.

21 Initial Assessment of the Scene Is The Emergency Over? Scan the scene and immediate area Seek out the incident commander and the company s first responder Communication is Key Are you wearing the appropriate safety equipment? Inquire as to what has been done thus far? Do additional structures need to be checked or evacuated or has this already been done? Have available openings been checked (i.e. sewers)? Has bar testing been performed and documented? Job briefing ----Are you required to document a job briefing?

22 Initial Assessment of the Scene Emergency Over Investigation Team is Notified Job briefing all company personnel report in. Review responsibilities of each team member Initiate investigation procedures...don t get in a hurry! Determine if additional personnel is needed What equipment is needed. Use your checklist

23 Internal Control - Verbal Instructions to investigative personnel Job briefing Don t talk to strangers Don t talk unless necessary and only state the facts Don t speculate Be professional no wisecracks Stay calm - Keep your Head Expect to be on video and having your picture taken

24 Basic Equipment Needed Company policy/procedures Checklist Who is responsible Trained/Qualified personnel to use the equipment per manufacturers instructions Safety gear, ID card Combustible gas indicator Probe bar Surface sampling equipment Odorometer / odorant testing device Pressure testing equipment Photographic documentation Type to be determined in advance i.e., digital camera Calibration test kits Detailed investigative forms Rhino hit-kit Sign-in/Sign-out. Control of the Scene.especially the days following

25 Basic Equipment Needed Odorometers Manufactures instructions Threshold vs Olfactory Daily/monthly checks Calibration Company policies and procedures

26 Lesson Learned Odorization Equipment An explosion and fire destroyed a mobile home severely burning its occupants, a married couple. The cause of this incident was attributed to natural gas leaking from an open fuel line below the mobile home. The open fuel line was the work of the plumber the couple hired. Not being viable he was not a named defendant in the case. That left the gas company. Case centered around gas not odorized. Gas Company, having tested the gas system for odorant immediately after the incident felt confident During the trial the odor meter used was introduced as evidence. The tubing used was not that furnished from the manufacturer. Which would not have any odor. The tube was not from the manufacturer..it retain the mercaptan molecules it had an odor. The odor meter test was thrown out.

27 Lesson Learned Odorization Equipment Result Company SIR - $1,000,000 AEGIS incurred loss: $3,100,000

28 Photography Documentation & Testing

29 Photographic Documentation of the Incident Scene The pictures taken should tell a story Take a sufficient amount of pictures pertinent to the investigation or for possible future litigation, but take plenty of pictures A picture is worth a thousand words make sure that it is not a thousand words against you!

30 Photographic Documentation Be aware of images captured

31 Photographic Documentation Be aware of the people captured

32 Miracle on the Hudson I Knew I Could Do It For 42 years I ve been making small regular deposits in this bank of experience, education, and training. On January 15 the balance was sufficient so I could make a very large withdrawal.

33 Customer Public Awareness Damage Prevention Program New customer Information Instructions to customer Call Center Procedures Recorded lines Training OQ/QA 1 st Responder/Crew Response Info Procedures Training OQ/QA Gas Company Operations Contractor Company or 3 rd Party Public Awareness Damage Prevention Training,OQ/QA Dispatch Procedures Recorded lines Training OQ/QA Supervisor Response Info Procedures Training OQ/QA

34 Thank You! AEGIS Insurance Services, Inc.

35 AEGIS Contacts David G. Zak Senior Utility Consultant Aegis Insurance Services, Inc. 1 Meadowlands Plaza East Rutherford, NJ davidzak@aegislimited.com