Fauji Fertilizer Company Limited
Mirpur Mathelo
Incident Investigation
: An Advance Approach
By:
Shakir Imran
Synopsis
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Background
Incidents Definitions
Incident Causation Model
Incident Investigation : Traditional Model
Rational Vs Advance Model Comparison
Incident Investigation: The advance model
FFC Mirpur Mathelo Methodology
FFC Mirpur Mathelo Experience
FFC OH&SMS Performance
Fauji Fertilizer Company Limited – Mirpur Mathelo
Background
During a study on incident investigation
methodology and record following were
observation:
- In any year, 70~ 80% of accident were due to
20~ 30% of the root causes
- These root causes are repetitive in the all the
years (from 2003 on ward)
- Actions were correction than the corrective
actions.
Fauji Fertilizer Company Limited – Mirpur Mathelo
Incident
Work related event(s) in which an injury or ill
health (regardless of severity) or fatality
occurred, or could have occurred.
(OHSAS 18001:2007)
Fauji Fertilizer Company Limited – Mirpur Mathelo
Incident Causation Model
Fauji Fertilizer Company Limited – Mirpur Mathelo
The Alternative Arrangement
Traditional Approach:
• Identification of critical events
• Actions to prevent their recurrence
New Construction:
• Interaction of critical events and human
behaviors.
• How these work together forms a system
Fauji Fertilizer Company Limited – Mirpur Mathelo
Nature of Accident (Traditional Rational View)
• Time line and sequence of the events before
accident happening
• Identification of critical events during this
chain of events/ Failure of safeguards
• Dealing with these identified critical event(s)
(Active failures) to prevent reoccurrence
(single loop learning)
Fauji Fertilizer Company Limited – Mirpur Mathelo
Incident Investigation: The Advance Model
• Time line and sequence of the events before
accident happening
• Identification of critical events during this
chain of events/ failure of safeguards
• Human contribution to loss
• Identification of latent failures in root cause
analysis (double loop learning)
Fauji Fertilizer Company Limited – Mirpur Mathelo
FFC Mirpur Mathelo Methodology
• Gap analysis between conventional and
advance model methodology
• A training plan is developed for the
implementation of the following critical areas:
 Human behaviors/ factors
 Correction and Corrective Actions
 Investigators biases
• Risk assessment study is also revised and
human factors/ behaviors were incorporated
in the risk assessment study.
Fauji Fertilizer Company Limited – Mirpur Mathelo
Human Failures: Human Contribution to Loss
1. Errors
2. Violations
Fauji Fertilizer Company Limited – Mirpur Mathelo
Human Failures: Human Contribution to Loss
Errors and Violations
• Errors
1.

2.

Action Errors
Slips and Lapses (Skill Based Errors)
Thinking Errors
Poor Analysis/ Problem Solving (Rule
based Errors)
 Incomplete Information (Knowledge
based Errors)
Fauji Fertilizer Company Limited – Mirpur Mathelo
Human Failures: Human Contribution to Loss
Cognitive Deficiencies
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Perception
Memory
Decision
Action
Fauji Fertilizer Company Limited – Mirpur Mathelo
Human Failures: Human Contribution to Loss
• Violations
1. Routine: A rule exists but no one follows it
2. Situational: In effect the specific nature of the
situation induces the violation
3. Exceptional: these are rare and occur when
something has already gone wrong and people
feel the need to improvise so as to correct the
problem.
Fauji Fertilizer Company Limited – Mirpur Mathelo
Correction and Corrective Actions
• Active and Latent Failures
• Single and Double loop learning
Fauji Fertilizer Company Limited – Mirpur Mathelo
Active and Latent Failures
• Active Failures
Occurs in the close proximity of the
incidents
• Latent Failures
Hidden and mostly available within the
deficiencies of management systems
Fauji Fertilizer Company Limited – Mirpur Mathelo
Single and Double Loop Learning
Single Loop Learning
• To change the behavior
• e.g. Identification for retraining as a remedial
action
Double Loop Learning
• To correct errors to change the identified
program
• e.g. Why training is not effective in first place ?
Fauji Fertilizer Company Limited – Mirpur Mathelo
Investigator Biases
• Satisficing
• Heuristics:
• Confirmatory evidence
• Mental models
• Groupthink
• Hindsight
Fauji Fertilizer Company Limited – Mirpur Mathelo
FFC Mirpur Mathelo Experience
• We are in a process to implement this approach and
certainly a new subject for us and in Pakistan.
However positive impact on the statistics is already
being observed.
• Study has showed that this approach (originally
developed by BSI) has Improvement area were
identified in:
 Management Systems
 Training Plan Formulizations / Safety Trainings/
Orientation Structures
 Risk assessment study
 Job Safety Analysis
 Job suitability analysis (Induction phase)
Fauji Fertilizer Company Limited – Mirpur Mathelo
Incident Statistics (2003 to June 2011)
Fauji Fertilizer Company Limited – Mirpur Mathelo
Safe Man-Hours Statistics
(2003 to June 2011)
12000000
9 Million
Hours
22th Nov,
2010
10000000
8 Million
Hours
2nd May ,
2010
8000000
6000000
4000000
2000000
1 Million
Hours
Apr 14,
2004
10081432
9156691
7 Million
Hours 7447968
08th Sept,
6 Million
2009
Hours
12th Jan,
5962293
5 Million 2009
Hours
5163279
4 Million 24th May,
2008
Hours
4434034
3 Million 20th Sept,
2007
Hours
3681274
10th Jan,
2 Million 2007
Hours
2974131
1 Million
2 Million
16th May,
Hours
Hours
2006
07th Sept,
18th Jan,
2236828
2005 1930936 2005
1265718
668012
LWI on Jan
28, 2005
1472016
638623
93679
0
June , Dec, 03 June, Dec,04 June, Dec, 05 June, Dec , 06 June , Dec , 07 June, Dec , 08 Dec, 09 Dec, 10 June,
03
04
05
06
07
08
11
Fauji Fertilizer Company Limited – Mirpur Mathelo
Reference Documents
• Psychoalogica toolkit for advance incident
investigation
• “The Fifth Discipline” by Peter Senge
• “Root cause analysis (simplified tools and
techniques)” second edition by Bjorn Andersen
and Tom Fagerhaug
• “Organizational Dysfunction” by Chris Argyris
• “Human Errors and Their Classification” by
Rasmussen
• “Normal Accident” Edition Two by Norman
Perrow
Fauji Fertilizer Company Limited – Mirpur Mathelo
Change…......Before you have to
(Jack Welch)