Enhancing post-incident reviews through Incident Review Board (IRB) process
Authors: Leong Weng Fei 
Published: May 2016

Abstract
Many organizations in the oil and gas industry today commit extensive resources to the prevention of accidents in the workplace. Whilst accidents do happen from time to time despite the best efforts, even more resources is devoted into the post-incident processes which include response, reporting, investigation and reviewing processes. A review of incidents in the industry reveals that lessons learnt from past accidents were never effectively applied and very often, investigation of incidents were poorly done. This paper examines the common issues in post-incident processes that contribute to incident recurrence in the industry. The use of After Action Reviews (AAR) or Incident Review processes are tools that can be used to help ensure that root causes are identified and understood as well as ensuring that effective corrective actions are applied. The implementation of a structured Incident Review Board (IRB) process Baker Hughes globally has helped to improve post-incident learning and improve effectiveness of implementing remedial measures. The IRB process will be explained in detail and some insights into actual IRB's will be shared. A critical evaluation on the benefits and challenges posed by this process is undertaken.

Introduction
The tragedy on the Deepwater Horizon in April 2010 has certainly changed the way safety is managed in the oil and gas industry and its aftereffects will continue to reverberate in the years to come. One issue that emerged from the tragedy is the failure in learning and applying lessons learnt effectively from past incidents. Failures tend to be repeated over time which indicates the lack of sustainability of learning from past incidents and events. Also mentioned were deficiencies in incident investigation processes which often times failed to identify root causes and systemic causal factors. While the official report focused on one particular disaster, review of other incidents in the offshore oil and gas industry will reveal a consistent pattern of chronic deficiencies in the industry. The challenge to the industry from this is largely the question of ensuring that players in the industry:• Maintain a sense of vulnerability on the real and ever present risks in the industry• Identify root causes and systemic causal factors in incidents• Communicate and apply effectively lessons learnt from incidents in a sustainable manner• Address defiencies effectively at the right level of the organization
Many tools have been introduced to enhance incident management process in the industry ranging from various root cause analysis (RCA) techniques some of which are proprietary like TapRoot and DNV's SCAT (Systematic Cause Analysis Technique) Analysis to after action reviews. Many IT solutions were also developed to automate the incident management process from incident reporting to close out of incidents.
The implementation of a structured Incident Review Board (IRB) process and After Action Review (AAR) in Baker Hughes since year 2009 have helped to address some of these challenges in addition to harmonizing the learning and post incident management processes in Baker Hughes.