Investigations – what does Havtil do and what do the regulations require?

Investigations of accidents and undesireable incidents form a key part of the work to prevent further incidents in the petroleum industry. Investigations provide insight into what has happened, what the underlying causes are and how we can learn and improve. The objective is to prevent similar incidents from recurring.

Havtil’s investigations also have a clear purpose in terms of ensuring compliance with HSE regulations.

Requirement to investigate

When an accident or undesireable incident has, or could have, resulted in injury or pollution, the responsible party has a duty to review and, if appropriate, investigate the incident. This ensues from the Management Regulations, section 20 concerning the registration, review and investigation of hazard and accident situations. Companies are free to develop their own methods for such investigations, but they must ensure that the investigations provide a basis for learning and future prevention.

Havtil’s investigations are in addition to, and independent of, the companies’ own investigations.

Havtil’s investigations

Havtil investigates serious incidents and incidents with a potential for learning across the industry. Our investigations cover the course of events and causal connections, and we assess whether the companies have complied with the requirements of the regulations. Among other things, we look at whether established barriers and routines for risk management have worked as intended.

In the event of findings showing inadequate compliance with the regulations, Havtil can use sanctions, such as orders, suspensions, coercive fines and reporting to another authority.

The objective of our investigations is to ascertain proximate and underlying causes, actual and potential consequences and regulatory breaches. The intention is to contribute to learning and transfer of experience – and thereby to help prevent further incidents.

For Havtil, investigations are a means of bringing petroleum activities into compliance with applicable HSE regulations, and investigation reports are published to promote increased learning across the sector.

Special commission of inquiry

In addition to the companies’ and Havtil’s investigations, the Ministry may, pursuant to section 10-10 of the Petroleum Act, appoint a special commission of inquiry in the event of accidents or incidents that have resulted in serious danger to life, major damage to property or pollution of the marine environment. The Commission shall have legal, nautical and technical expertise. In 2010, the Ministry entered into an agreement with the Norwegian Safety Investigation Authority for practical assistance in setting up an ad-hoc independent commission of inquiry.

Different purposes

The different arrangements have different purposes. The companies’ investigations are aimed at internal improvements and learning in the workplace and within the company. Havtil’s investigations are intended to bring the business into compliance with applicable HSE regulations, and to promote learning and improvement across the sector. The ad-hoc independent commission of inquiry scheme is intended to contribute to improvement and learning at societal level, and means that the inquiry also comprises the role of the authorities.

Severity and learning potential

Havtil normally conducts between five and ten investigations annually. Severity is the most important criterion for the decision to investigate, but the potential for learning also weighs heavily.

In 2020, there was an increase in the number of serious incidents, and Havtil undertook 13 investigations – the highest number ever.

Strengthened follow-up of serious incidents

We work holistically and with many different projects and perspectives to strengthen the follow-up of serious incidents. As part of this, in recent years we have carried out a broad-ranging project to enhance our investigation processes and make data available for learning in the industry.

The project comprises the mapping of methods, pilots and development of frameworks, as well as improvements in work processes and knowledge sharing.

Havtil has chosen to use elements from the established HTO (Human, Technology and Organisation), CAST (Causal Analysis based on System Theory) and STEP (Sequentially Timed Events Plotting) investigation methods, as well as interview questions and performance-influencing factors from the HF (Human Factors) guidelines.

Seminar on investigations established

At the same time as we have worked to enhance our follow-up, we have given emphasis to the sharing of information with the industry and its stakeholders.

In extension of this, Havtil has now taken the initiative to establish an arena for sharing knowledge about investigations.

This work is in progress, and we will return with a time and framework for the seminar on investigations as soon as this is ready.