- Site: Rosyth
- Inspection ID: 50897
- Date: August 2022
- LC numbers: N/A
Executive summary
Purpose of Intervention
The inspection will be led by ONR to examine the adequacy and application of RRDL arrangements for Licence Condition (LC) 7 (Incidents on the Site).The purpose of LC7 is to ensure that incidents on the site are notified, recorded, investigated, reported and learnt from by the licensee. An inspection scope was sent to the dutyholder in advance of the inspection.
This intervention forms part of the ONR Integrated Intervention Strategy for the Regulation of RRDL. The intervention will include the following themes:
- Adequacy of RRDL arrangements for the notification, recording, investigation, reporting of incidents and learning from incidents.
- Adequacy of the implementation of these arrangements across the licensee organisation.
Subject(s) of inspection
- LC7 - Incidents on the site - (Rating: Green)
Key findings
Interventions Carried out by ONR: The planned LC 7 compliance inspection was carried out on 2 August 2022 on the RRDL site. During the inspection, we gained evidence of how RRDL manage incidents on site in relation to notification, recording, investigation, reporting and learning.Specifically, we:
- Reviewed RRDL LC7 written arrangements
- Sampled how incidents are notified, recorded, investigated, reported and learnt from.
- Sampled how RRDL actions, trends, learns and disseminates learning from these incidents.
- Spoke to those who have responsibilities to report incidents.
The inspection was carried out in line with ONR’s Technical Inspection Guide NS-INSP-GD-007 Issue 6.1.
Key Findings, Inspector's Opinions and Reasons for Judgements Made
From our sample of the RRDL arrangements these were adequate and gave good coverage of notifying, reporting, recording and investigating. However, we did identify some minor shortfalls in how these were implemented on site from sampling RRDL's incident database.
In a number of areas we identified good practices, including: the utilisation of toolbox talks to disseminate learning from events; Governance and oversight of the events raised; Overdue events were well publicised on the incident database; discussions with persons on site regarding incidents showed a consistent approach to challenging peers with respect to safety.
There were areas for improvement identified from the inspection:
Trending and learning arrangements could be strengthened in the written arrangements.
- The incident database did not reflect the written arrangements fully.
- The incident database categorisation makes meaningful trending and analysis challenging.
- Consider proactive communications with staff regarding reporting events, as in our discussions with site personnel this was inconsistent.
Overall, we judged that relevant good practice was generally met with minor shortfalls being identified in relation to implementation of the compliance arrangements, which if addressed would improve the user interface with managing incidents database; learning and trending of the event data and provide clarity for staff on the expectations of reporting.
Judgements made
Overall, we judged that relevant good practice was generally met with minor shortfalls being identified in relation to implementation of the compliance arrangements, which if addressed would improve the user interface with managing incidents database; learning and trending of the event data to support management reviews and provide clarity for staff on the expectations of reporting.
Based on the evidence sampled we consider that an inspection rating of GREEN (no formal action) is appropriate for LC 7. A level 4 regulatory issue will be raised to capture areas for improvement identified during the inspection.