GMP01. S&EP Leaflet 12/2017 DE&S Requirements for the Management of Equipment Safety and Environmental Issues and Incidents (Replacing Leaflet 01/2010)

System Revision ID ASEMS Document Version Effective From State
3718 4.0 01/03/2017 - 00:00 Extant

1.1. Overview

1.1.0.1.

This document is S&EP Leaflet 12/2017

In DE&S, the efficient handling of equipment-related accident, incident and near miss reports requires the involvement of a number of stakeholders, with a wide range of tasks undertaken at Project Team (PT), Operating Centre (OC) and pan-DE&S level.  This ensures that underlying safety issues are identified, corrective action is implemented and lessons are learnt. This S&EP Leaflet describes how these requirements shall be implemented across DE&S, with particular emphasis placed on the role of the OC.

1.2. Procedure

1.2.1. Requirement

1.2.1.1.

The reporting of accidents, incidents and near misses by users utilises a number of domain-specific systems[1], each of which ensures that events involving equipment are brought to the attention of the DE&S PT sponsor. It is the responsibility of the sponsoring PT to assess these reports, identify whether equipment performance contributed to the event, and where applicable, initiate action to control resultant risks or prevent reoccurrence[2], liaising with Delivery Duty Holder(s) and other DLOD owners as necessary.

 

[1] ASIMS (SESORS), NLIMS, AINC, MID

[2] All incidents should prompt a Project Safety & Environmental Committee Hazard Log review

 

1.2.1.2.

Where the need for additional risk control measures is identified, the PT or other appropriate DLOD owner shall take action to introduce these within appropriate timescales, if necessary implementing interim controls while permanent solutions are developed[1]. The PT may also decide to recommend temporary restrictions on use or ultimately recommend withdrawing the system from service.

 

[1] Reference should be made to DE&S Safety and Environmental Protection Leaflet 02/2011 (ALARP in a Military Equipment Capability Context), Para 22

 

1.2.1.3.

OCs have a responsibility to maintain an overview of such activities, ensuring PTs discharge their responsibilities in an effective and proportionate manner, as well as identifying pan-Project, pan-Domain and pan-Defence issues that may have implications wider than the sponsoring PT.

1.2.2. Operating Centre Procedure

1.2.2.1.

This S&EP Leaflet requires OCs to develop and implement procedures which as a minimum shall ensure their PTs:

  • Employ robust processes for managing equipment-related incident reports, identifying, communicating and implementing corrective action in a timely manner.
  • Employ processes for identifying trends and common causes.
  • Consider whether reported issues may have wider implications for other platforms or systems beyond their own area of responsibility and report accordingly.
  • Have personnel, or access to personnel, who are suitably trained in reviewing accident, incident and near miss reports to establish root causes which is a key element of the review process.
  • Review hazard logs and safety cases to determine whether reported events impact on existing assessments, arguments or conclusions.
  • Be aware of requirements for reporting the most serious events through the management chain.

 

1.2.2.2.

At an OC level, the following activities shall also be implemented:

  • Reports which have implications for other systems or domains are to be identified and formally reported to relevant stakeholders.
  • Domain reporting databases shall be monitored to identify any incidents which involve equipment but have not been brought to the attention of the sponsor PT.
  • Incident reports which have been assigned to the incorrect owner shall be identified and re-directed, for instance equipment-related reports that have gone to Platform teams only.
  • Actions placed on PTs as a result of formal Service Inquiries shall be monitored to ensure they are fully implemented within stated timescales.

Mechanisms shall be employed to immediately inform senior management in their own Domain of significant equipment-related safety events, and the DE&S Safety Board of the most serious events.

 

1.2.3. Procedure Management

1.2.3.1.

To provide complete awareness of potentially significant issues, OCs and PTs shall also implement processes which aim to manage hazards/impacts resulting from:

  • Maintenance or repair activities (at all lines and depths of maintenance), where issues or faults may be identified which have the potential to result in a significant equipment-related accident, incident or near miss.
  • Advice from a Design Organisation, Original Equipment Manufacturer (OEM) or other external source that a potential issue with significant safety or environmental consequences may exist.
  • When any equipment-related accident, incident or near miss results in, or may require, a significant restriction or capability loss being imposed on the current platform or equipment use.

 

1.3. Required Outputs

1.3.1. Learning From Experience (LFE)

1.3.1.1.

OCs shall implement an effective system for conducting LfE. As part of this activity, they shall regularly review reported incidents to identify pan-project trends, common causes and control measures.

1.3.1.2.

When considering the implications and significance of a reported incident, PTs and OCs should utilise SME judgement to consider the potential safety or environmental implications of the incident for other Domain areas and / or equipments, i.e. where there may be a potential hazard with similar equipments or systems. In such cases, formal action shall be taken to communicate the potential issue to relevant stakeholders. 

1.3.1.3.

Where the issue is considered to be of appropriate significance, the DE&S QSEP team are to be provided with the necessary information to highlight the issue to the DE&S Safety Committee. A template to provide this information is provided at Enclosure 1.

1.3.1.4.

LFE shall be a standing agenda item at all Safety Committees.  The DE&S forums for such discussions are the DE&S Acquisition Safety Steering Group (ASSG) and the Acquisition Environmental Steering Group (AESG), both chaired by D S&EQT.

1.3.1.5.

Copies of equipment incident documentation and reporting should be managed and maintained by PTs and made available to Senior Management when requested.

1.4. Further Guidance

1.4.1. DE&S Safety Reporting Requirements

1.4.1.1.

Mechanisms shall be employed to immediately inform senior management in their own Domain of significant equipment-related safety events, and the DE&S Safety Board of the most serious events. 

1.4.1.2.

Where the issue is considered to be of appropriate significance, the DE&S QSEP team are to be provided with the necessary information to highlight the issue to the DE&S Safety Committee. A template to provide this information is provided at Enclosure 1.

1.4.2. Enclosure 1 - Reporting Template

1.5. Version Control

1.5.1. Version 2.3 to 3.0 uplift

1.5.1.1.

Major uplift from the Acquisition System Guidance (ASG) to online version.

1.5.2. Version 3.0 to 4.0 uplift

1.5.2.1.

S&EP Leaflet 01/2010 has been replaced by 12/2017 in a move towards a less prescriptive approach to the managment of equipment related accident, incident and near miss reports. This is a major update of GMP 01.

Header information updated. 

   

Subject to Policy Clauses

1.5

Data and Record Format

Data shall be maintained in a format which satisfies the reporting requirements of senior management within DE&S. Auditable records shall be made and kept under review in accordance with relevant legislation.

1.6

Significant Occurrences and Fault Reporting

All Project Teams shall record and report significant Product, System or Service faults, accidents, incidents and near misses to the DE&S Safety Committee through the Quality, Safety and Environmental Protection Team.

1.7

Learning From Experience

Operating Centres, Project Teams or equivalents shall ensure accidents and incidents are investigated to identify opportunities to reduce the likelihood and impact of reccurrence. Lessons learned shall be shared amongst all relevant stakeholders to maximise benefit.

3.1

Safety and Environmental Management System

Operating Centres, Project Teams or equivalents shall operate in compliance with established Safety and Environmental Management Systems.

3.2

Safety and Environmental Management Plan

Operating Centres or equivalent shall ensure that all Products, Systems or Services have a suitable and sufficient through life safety and environmental management plan.

3.5

Core Element Documentation

Operating Centres, Project Teams or equivalents shall establish, maintain and retain suitable and sufficient information that describes the core elements of the safety and environmental management system(s), their interaction and any related documentation.

3.7

Monitoring

Operating Centres, Project Teams or equivalents shall establish, implement and maintain a suitable and sufficient procedure to monitor and measure safety and environmental performance of their safety and environmental management system on a regular basis.

4.1

Safety Cases

Project Teams or equivalents shall establish and maintain through-life safety cases that provide a compelling, comprehensible and valid argument that a Product, System or Service is safe for a given application in a given operating environment.

4.2

Environmental Cases

Project Teams or equivalents shall establish and maintain through-life environmental cases that provide a compelling, comprehensible and valid argument that the environmental impact of a Product, System or Service is reduced or minimised as far as is reasonably practicable.

4.5

Environmental Impact Identification

Operating Centres, Project Teams or equivalent shall establish, implement and maintain a procedure for the on-going proactive identification of environmental impacts.

4.6

Safety Hazard Identification

Operating Centres, Project Teams or equivalent shall establish, implement and maintain a procedure for the on-going proactive identification of safety hazards.

4.8

Accident and Incident Records

Operating Centres, Project Teams or equivalent shall monitor and record incidents where the performance of their Product, Systems or Services either caused or had the potential to cause harm to individuals or damage to the environment and use this information to keep their risk assessments valid.

5.4

Consultation

Operating Centres, Project Teams or equivalent shall ensure that all stakeholders are identified and consulted so that their views and responsibilities are considered when managing safety and environmental risks.

Covered by Audit Question Sets

1.5

Audit Question Set Section 1.5 Data and Record Format

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 1.5.

1.6

Audit Question Set Section 1.6 Significant Occurrances and Fault Reporting

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 1.6.

1.7

Audit Question Set Section 1.7 Learning From Experience

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 1.7.

3.1

Audit Question Set Section 3.1 Safety and Environmental Management System

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 3.1.

3.2

Audit Question Set Section 3.2 Safety and Environmental Management Plan

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 3.2.

3.5

Audit Question Set Section 3.5 Core Element Documentation

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 3.5.

3.7

Audit Question Set Section 3.7 Monitoring

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 3.7.

4.1

Audit Question Set Section 4.1 Safety Cases

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 4.1.

4.2

Audit Question Set Section 4.2 Environmental Cases

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 4.2.

4.5

Audit Question Set Section 4.5 Environmental Impact Identification

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 4.5.

4.6

Audit Question Set Section 4.6 Safety Hazard Identification

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 4.6.

4.8

Audit Question Set Section 4.8 Accident and Incident Records

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 4.8.

5.4

Audit Question Set Section 5.4 Consultation

The Audit Question Set used as assurance in order to adhere to the policy described in policy clause 5.4.