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. The amount of effort and resources applied in an investigation should be in keeping with the potential severity of the incident AND the potential for learning. The incident “owner” should provide the investigation teams with clear terms of reference (TOR) from the start. Set up an incident investigation room that has plenty of clear wall space and office facilities e.g. Photocopier, projector, flip charts etc. Spend time planning what you are going to do and assign responsibilities to each team member.
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Sequence the order in which you want to collect information i.e. It is pointless speaking to senior managers without knowing what has happened. Give as much notice as possible when making appointments for interviews. Review the information already available e.g. First report of incident, similar past incidents.03 Compiling a time line.
EVENTs are unplanned, unwanted changes in the OBJECT. AGENTs have the potential to cause harm. OBJECTs have the potential to be harmed. Each trio should have: an EVENT, an AGENT and an OBJECT. The AGENT or the OBJECT can be shared with another trio. EVENTs must run in time sequence moving from left to right starting with the oldest and ending with the most recent.
Each trio must start with an AGENT and an OBJECT and end with an EVENT i.e. BARRIERs can be in one of four states: effective, failed, inadequate, missing. BARRIERs either control AGENTs or defend OBJECTs. Barrier descriptions should state what the barrier should do and how it does it. It should be clear from the BARRIER description that had had the barrier been effective the next event could not have happened. An effective BARRIER stops the next EVENT and all those occurring later. Interpose type BARRIERs e.g.
Blast wall, can go in either leg of a trio. The level of detail in defining requirements for BARRIERs within company documentation is usually related to the level of risk involved e.g. Low risk – reference to the hazard (generic rules and procedures), medium risk – reference to the specific task (PTW or JHA), high risk – reference to the actual barrier (safety case).
BARRIERs can be categorised by function e.g. A) provide awareness, b) guidance, c) warning, d) restore, e) interpose, f) contain, g) escape. BARRIERS can also be categorised by system e.g. A) behavioural (follow safe operating procedure), b) technical (pressure relief valve), c) combination of behaviour and technical (stop pump on hearing high level alarm).
BARRIERs can also be categorised by some characteristic of the barrier e.g. A) hard / soft, b) technical / behavioural / organisational, c) passive / active.07 Immediate cause. An IMMEDIATE CAUSE is always an unsafe act, never an unsafe condition. A BARRIER is defeated by a single IMMEDIATE CAUSE. However, a single IMMEDIATE CAUSE can defeat more than one BARRIER. It may appear as if the failure of a technical barrier is due entirely to some unsafe condition however, often humans are involved e.g. Pressure relief valve failed to operate due to maintenance technician resetting the opening pressure too high.
Failed technical barriers often turn out to be inadequate barriers e.g. Pressure relief valve failed to operate due to corrosion brought about by standard specifying wrong material. If a technical BARRIER is defeated by some form of energy then consider redrawing the diagram showing the BARRIER as an OBJECT and the force an AGENT e.g. Underlying causes are related to the systems and organisational arrangements that your company has in place to manage risk. They cause most PRECONDITIONS.
The PCs not caused by UCs are situations where the Company has no influence over what a person is thinking e.g. Someone is absent minded after hearing that they have won the lottery.
It is often a one to one relationship between UC and PC but any number of UCs are allowed. Failed barriers link back to HSE-MS elements that relate to the means by which barriers are implemented and maintained e.g.
1) document control, 2) roles and responsibilities, 3) provision of resources, 4) competence assurance, 5) communication, 6) leadership, 7) monitoring performance. Inadequate barriers link back to HSE-MS elements that relate to the specification of barrier requirements e.g. No plant operating procedures, incomplete PTW procedures. Missing barriers link back to HSE-MS elements that relate to risk identification. Missing barriers back track directly to the UC with no intermediary IC and PC (STF allow intermediary IC & PC in exceptional circumstances). The description of an UNDERLYING CAUSE should be in two parts. 1) identification of the system that is flawed, and 2) explanation of the way in which it is flawed e.g.
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The permit to work system fails to identify who is responsible for controlling jobs that have the potential to interact. The responsibility for identifying the barriers for high and medium risks lies with: system custodians, technical authorities, contract managers, HSE advisers. The responsibility for identifying the barriers for low risks lies with: line managers, supervisors, contract holders. The responsibility for establishing and maintaining all barriers lies with: line managers, supervisors, contract holders10 Managing errors. Recognise that errors are consequences rather than causes. Regard human errors as both universal and inevitable. Focus on trying to change the conditions in which humans work rather than changing the human condition.
Realise that the best people make the worst mistakes. Be aware thet people cannot easily avoid those actions they did not intend to commit. Be aware that errors can occur at all levels in the organisation. Aim for continuous reform rather than local fixes11 Violators beliefs. An introduction to health and safety What you should know about - where to get more informationHSE UKPublished38 pages372 Kb1) Managing health and safety, 2) slips trips and falls, 3) Asbestos, 4) Hazardous substances, 5) Falls from height, 6) Musculoskelatal disorders, 7) Display screen equipment, 8) Noise, 9) Vibration, 10) Electricity, 11) Work equipment and machinery, 12) Workplace transport, 13) Pressure systems, 14) Fire and explosion, 15) Radiation, 16) Stress, 17) First aid and accident reporting. Human Performance Improvement Handbook DOE Vol 1 Concepts and principlesPublished: June 2009175 pages1.1 Mb1) Human performance, 2) Anatomy of an event, 3) Strategic approach to human performance, 4) Principles of human performance, 5) Human fallibility, 6) Performance modes, 7) Error likely situations, 8) Error precursors, 9) Managing controls, 10) Performance model, 11) Finding latent organizational conditions, 12) Culture and leadership, 13) Human performance evolution, 14) Factors that impact organizations. Many leaders are deeply troubled by the persistence of serious injury and fatality (SIF) events - especially as they see the rate of less severe injuries continue to fall.
A 2011 study conducted by BST and Mercer ORC, along with seven global companies, helps us understand why safety systems frequently assume that reducing smaller injuries will also reduce SIF events. The findings of the study show that the causes and correlates of SIF events are distinctly different than those of less severe injuries. In addition, the data tell us that the potential for serious injury is actually low for the majority (about 80%) of non-SIF injuries. Put in practical terms, reductions in overall injuries may or may not result in reductions of SIF events.What do these findings imply for safety leadership? The encouraging news is that much of what we're learning about SIF events shows us that there are concrete steps that leaders can take to address serious injury events.
A guide to selecting apprpriate tools to improve HSE culture Oil and Gas Producers AssociationIOGP Report No. 435Published: March 201018 pages740 KbHSE tool guide, 1) Reporting and recording HSE information, 2) Incident investigation and anlaysis, 3) Auditing, 4) Human factors in design, 5) Work practices and procedures, 6) Risk management, 7) HSE management system, 8) HSE training and competence, 9) HSE appraisals, 10) Situation awareness, 11) Questionnairs and surveys, 12) Observation, and intervention, 13) Incentive schemes, 14) HSE communications, 15) Other HSE tools. Chemical Safety BoardThe CSB is an independent federal agency charged with investigating industrial chemical accidents to determine the conditions and circumstances which led up to the event and to identify the cause or causes so that similar events might be prevented.A large amount of excellent, free training material is available on their site including high quality videos; a 'must visit' for anyone involved in the chemical / oil and gas industries.CSB videos are also available on YouTube.