Incident Investigation and Analysis
Presented By: Naman Shah
Pakistan Refinery Limited
HSE Management System - TRIPOD
Tripod
Incident Investigation and Analysis
HSE Management System - TRIPOD
Structure of the HSE Management System
Leadership and Commitment
Policy and Strategic Objectives
Tripod
Organisation, Responsibilities
Resources, Standards & Doc.
Hazard and Effects
Management
Planning & Procedures
Implementation
Audit
Management Review
HSE Management System - TRIPOD
Corrective
Action
Monitoring
Corrective Action &
Improvement
Corrective Action &
Improvement
Tripod framework
Remove
GENERAL
FAILURE
TYPES
Active Stages
Minimise
HAZARDS
DEFENCES
UNSAFE
ACTS
INCIDENTS
Improve
Train & Motivate
HSE Management System - TRIPOD
Learn From
Incident causation sequence
Latent Stages
Management *
Fallible
decisions
Active Stages
Line Mgt
Latent
failures
Line Mgt
Preconditions
“Sharp end”**
Unsafe
acts
Incident
Chronological
sequence
Safety Culture
HSE Management System - TRIPOD
Causal
sequence
Tripod - Breached Defences
Breached Defences
Breached Defences: what “last minute” measures failed or
were missing?
Barriers
(Controls for Threats)
. Awareness
. Detection
. Control
HSE Management System - TRIPOD
Mitigation and Recovery Measures
(for Consequences)
. Protection
/ Containment
. Escape and Rescue
Tripod - Unsafe Acts
Unsafe Acts
Unsafe Acts: which acts or omissions led directly to the accidents?
Human errors
Intended action
. Violation (1)
HSE Management System - TRIPOD
. Mistake (2)
Unintended action
. Lapses (3)
. Slips (4)
Tripod - Preconditions
which states of mind or of the system allowed the unsafe acts?
Preconditions can thus take both the form of a “state of mind” or “mental”
precondition, or of a “physical” precondition.
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Unfamiliarity,
Time shortage,
Poor system/human interface,
Technique unlearning,
Misperception of risk,
Time of the day,
Inexperience,
Poor instructions or procedures,
Inadequate checking,
Substance abuse,
Macho culture,
Physical capabilities exceeded,
Hostile environment,
Low morale,
Disturb sleep.
HSE Management System - TRIPOD
Tripod - Latent Failures
which underlying problems led to the preconditions?
. Organisation
. Incompatible Goals
. Training
. Error Enforcing Conditions
. Communication
. Maintenance Management
. Design
. Hardware
.
. Procedures
. Housekeeping
. Defences
HSE Management System - TRIPOD
Tripod Tree
.
HSE Management System - TRIPOD
OVERVIEW of Investigation & Analysis
Pre – Investigation
INVESTIGATION
PREPARATION
- Ensure on-site safety
- Provide Emergency Response
Post – Analysis
FOLLOW-UP
PLAN
1.
Interpret Initial Incident Statement
2.
Generate initial hypothesis
3.
Develop investigation plan
- Communicate findings to site
- Avoid disciplinary actions
- Peer review report
INVESTIGATE
- Notify relevant parties
- Collect initial data & evidence
4.
- Prepare presentation
Conduct investigation
- Communicate report internal
- Review report
- Generate Initial Incident Statement
- Brief external authorities etc.
- Classify incident
- Review report
- Determine investigation level
- Form Investigation Team
ANALYSE
5.
Conduct analysis
6.
Identify recommendations
7.
Generate report
- Close – Out report
- Record report to file
- Publish ‘Lessons Learned’
- Implement recommendations
- Monitor implementation
ANALYSIS
HSE Management System - TRIPOD