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  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    ACCIDENT/INCIDENT ACCIDENT/INCIDENT INVESTIGATIONINVESTIGATION

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Course ObjectiveCourse Objective To gain the knowledge skill and ability

    required to enable successful candidates to complete an Incident Investigation as per the requirements of JRMs HSES Management System JRM-1407-001

    HSES Guidelines Section 12.3 JRM-Global-HSES-002-7

    HSES Administration Manual Section 2.5

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Investigation DefinitionInvestigation Definition To derive a level of understanding from a

    systematic gathering and subsequent analysis of information (FACTS)

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    InvestigationInvestigation Watch the film and prepare a brief summary

    of what caused the incident.

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    InvestigationInvestigation

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Accident/IncidentAccident/Incident Accident;

    Contact with an energy source beyond the threshold limit of the body or structure resulting in a downgrading of the business process (causes loss)

    Incident Anything that could or does downgrade the

    business process (causes loss)

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Why InvestigateWhy Investigate To;

    Prevent a reoccurrence Gather data and identify trends Accountability

    Internal (discipline) External (legal)

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Legislation and StandardsLegislation and Standards Occupational Safety and Health Administration

    OSHA; 29 CFR Part 1904; 1904.1

    International Maritime Organization International Safety Management Code (ISM); Section 9

    International Standards Organization (ISO) Fault Failure Analysis

    Occupational Health and Safety Management Systems (OHSAS 18001); Section 4.5

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Why Investigate IncidentsWhy Investigate Incidents Safety is like Health & Happiness, its not missed until its

    gone. We never measure our actions in terms of potential lives

    saved yet we monitor Near Miss & High Potential Incidents. Before starting a job, ask yourself How will I answer the

    investigators questions?

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Hazard ControlHazard Control All incidents are caused because a HAZARD was not

    adequately controlled HAZARDA physical condition, act or omission with loss causing

    potential

    All HAZARDS have associated RISK RISK Severity (how serious) X Probability (likelihood)

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Risk ManagementRisk Management Every hazard has a degree of associated

    risk If Unacceptable levels of risk are accepted

    then the incident rates are likely to be high

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    SafetySafety SafetyA judgment as to the acceptability /

    tolerability of risk Facilities/individuals who tolerate risks above

    what has been deemed acceptable (policy, procedure, codes, standards, etc.) are likely to have excessive incident rates.

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    ALARPALARP Risks must be mitigated to As Low As

    Reasonably Practicable Returns justifies the Effort Impact Versus Effort

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Incident Cost

    Current Profit Margin

    5% 10% 15% 20% 25%

    500,000 10,000,000 5,000,000 3,333,000 2,500,000 2,000,000

    1,000,000 20,000,000 10,000,000 6,666,000 5,000,000 4,000,000

    5,000,000 100,000,000 50,000,000 33,333,000 25,000,000 20,000,000

    10,000,000 200,000,000 100,000,000 66,666,000 50,000,000 40,000,000

    15,000,000 300,000,000 150,000,000 100,000,000 75,000,000 60,000,000

    20,000,000 400,000,000 200,000,000 133,333,000 100,000,000 80,000,000

    30,000,000 600,000,000 300,000,000 200,000,000 150,000,000 120,000,000

    50,000,000 1,000,000,000 500,000,000 333,333,000 250,000,000 200,000,000

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Uninsured CostsUninsured Costs Uninsured costs can cover a wide range or aspects such as the

    following; Building damage Damage to tools and equipment Production delays Damage to reputation Product and Material damage Wages paid to injured personnel for lost time Wages paid other than compensation Overtime Extra Supervisors time Decreased output Cost of training new workers Cost of training back-up workers Clerical time Travel expenses

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Safety Management SystemsSafety Management Systems Incidents are indicative of system failure

    Systems must be constantly improved and upgraded Incident Investigations point to areas requiring improvement

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Incident Ratio StudyIncident Ratio Study

    1

    1030

    600

    Fatality, Lost Time

    Restricted Work,Medical Treatment, First Aid

    Property Damage, Spill

    Near Miss, UnSafeBBSM Observation

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Cause and Effect SequenceCause and Effect Sequence

    1Management

    System Failure

    2Root Causes

    3Immediate Causes

    4Incident

    5LOSS

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    The IncidentThe Incident

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Investigation TeamInvestigation Team Will consist of the following personnel, as

    required by company procedures; HSE Representative/Manager Division/Area/Regional Manager Facility Personnel Personnel Involved Technical Resource Personnel

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Allocation of DutiesAllocation of Duties Consider the following;

    Ability to Interrelate with People Language, culture, jargon

    Technical Knowledge and Capability Individual area of expertise

    Physical Condition Physical size, medical restrictions, phobias

    Training Members must be certified to conduct an investigation

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    PreparationPreparation Investigate all Incidents

    Do not have pre-conceived opinions (You might be proven to be wrong. Recall initial exercise results)

    Inform relevant personnel Assemble a competent team

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Investigation ToolsInvestigation Tools Tools used in Incident Investigations

    include, but are not limited to; Camera: 35 mm; digital; video Writing tools Paper (waterproof is available) Tape measures (25 and 150 foot/8 and 30 meter); and ruler Audio Recorder Flagging and barrier tape PPE

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Barriers to InvestigationsBarriers to Investigations Hostility towards team Condemnation of management Paranoid feelings of persecution Lack of concern by team or facility personnel Time constraints and regular duties Competence of investigation team Pre-conceived ideas Cultural issues relating to required interaction with team Legal intervention

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Physical EvidencePhysical Evidence As with any formal investigations, physical

    evidence provides key data in our ability to determine the following; What Why When Where Who How

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Scene PreservationScene Preservation Have the scene isolated prior to the arrival of the

    Investigator / Investigation Team Preserve evidence If it is not possible to isolate and preserve evidence prior to

    the Team arrival, have the scene photographed, sketched and / or video taped in detail

    Normal working status at the scene cannot resume until a return to work form has been completed or the Area VP has provided written approval.

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Gathering EvidenceGathering Evidence People Positions Parts Paper

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    PeoplePeople Have witnesses make a statement Review statements Identify who you will want to interview Formulate a list of questions Nominate a spokesperson with technical knowledge and

    try not to use an interpreter

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Interview TechniqueInterview Technique Conduct the interview as soon as possible Show consideration for what people have been through Ensure the interview is conducted in a relevant but safe

    location Assess timing of the interview Interview separately

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Interview Technique Interview Technique (cont(contd)d) Reassure the person being interviewed Let the person tell their story starting well before the

    incident and continuing after the event Keep on track but dont interrupt Listen, hear and understand Dont take extensive notes first time around

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Interview Technique Interview Technique (cont(contd)d) Tape if possible, ask permission Target aspects of the cause and effect sequence Relate the basis of the interview back to the witness to

    ensure you understand the concept Keep the line open for future discussion Take a break and formulate new questions End on a positive note

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    ReRe--enactmentenactment Ensure that the incident is not repeated Use only as a last resort if there is no other way to obtain

    information

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Position/EnvironmentPosition/Environment Drawings and Sketches Helps visualize what happened Document important information Label clearly and use scale

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Position/Environment Position/Environment (cont(contd)d) Photographs Easier than drawing and more accurate Excellent training aids Photograph from all sides Photo the general scene then use the long/medium/close-

    up sequence Use a known object (pencil, coin, bill, foot, etc.) to show

    scale Use a camera that you are familiar with

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Position/Environment Position/Environment (cont(contd)d) Physical Conditions Obscuring phenomena Temperature Wind Vessel Movement

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    PartsParts Tools

    Adequate, worn, ergonomic

    Equipment Guarded, functional, fit for purpose

    Materials Hazardous, heavy, sharp, defective

    Facilities Housekeeping, industrial hygiene, crowding

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Parts Parts (cont(contd)d) Proper items for task Damage Previous damage Wear Safeguards Labels, signs, markings Manufacturers specification

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    PaperPaper Policies and Procedures Permits Meeting Minutes Certificates Position Descriptions Regulations Training Records Fitness for Work

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Paper Paper (cont(contd)d) Eye Witness Reports Maintenance Records Manufacturer Supplied Information Logs and Schedules

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Information AnalysisInformation Analysis Information will be analyzed using the Root Cause

    Analysis system The system goes beyond identification of Symptoms and identifies

    Basic / Root Causes

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Casual AnalysisCasual Analysis List Event Sequence (Reference TRA if applicable)

    Create a story board using stickies

    List Causal Factors for Each Step Causal FactorAn inadequately controlled hazard (physical

    condition, act or omission with loss causing potential), reference Hazard Control column on the TRA, if applicable

    Add to the story board using different color stickies

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Story BoardStory BoardEvent 1

    Event 2

    Causal Factor

    Causal Factor

    Causal Factor

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Cause SequenceCause Sequence When a System failure occurs Root causes exist When Root causes exist they allow for the existence of

    Immediate causes Immediate causes are symptomatic and lead directly to

    Incidents

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Cause Sequence Cause Sequence (cont(contd)d)

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    System Failure CategoriesSystem Failure CategoriesA1 Design/Engineering

    ProblemA2 Equipment/Material

    ProblemA3 Human Performance

    Less Than Adequate

    A4 Management Problem A5 Communications Less Than Adequate

    A6 Training Deficiency A7 Other Problem

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Immediate CausesImmediate CausesA1.1 Design Input Less Than Adequate

    A2.1 Calibration for Instruments Less Than Adequate

    A3.1 Skill Based Error A4.1 Management Methods Less Than Adequate

    A5.1 Written Communications Method of Presentation

    A6.1 No Training Provided

    A7.1 External Phenomena

    A1.2 Design Output Less Than Adequate

    A2.2 Periodic/Corrective Maintenance Less Than Adequate

    A3.2 Rule Based Error A4.2 Resource Management Less Than Adequate

    A5.2 Written Communication Content Less Than Adequate

    A6.2 Training Methods Less Than Adequate

    A7.2 Radiological/Hazardous Material Problem

    A1.3 Design Documentation Less Than Adequate

    A2.3 Inspection/Testing Less Than Adequate

    A3.3 Knowledge Based error

    A4.3 Work Organization and Planning Less Than Adequate

    A5.3 Written Communication Not Used

    A6.3 Training Material Less Than Adequate

    A1.4 Design/Installation Verification Less Than Adequate

    A2.4 Material Control Less Than Adequate

    A3.4 Work Practices Less Than Adequate

    A4.4 Supervisory Methods Less Than Adequate

    A5.4 Verbal Communication Less Than Adequate

    A1.5 Operability of Design/Environment Less Than Adequate

    A2.5 Procurement Control Less Than Adequate

    A4.5 Change Management Less Than Adequate

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Action PlanAction Plan Once reports have been submitted, action

    must be taken to; Address identified problems

    Usually an element within the Safety Management System Implement specific action steps required to eliminate the problem

    Must target Root Causes

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Root CausesRoot CausesA1 DESIGN / ENGINEERING PROBLEM

    A2 EQUIPMENT / MATERIAL PROBLEM

    A3 HUMAN PERFORMANCE LESS THAN ADEQUATE

    A4 MANAGEMENT PROBLEM

    A5 COMMUNICATIONS LESS THAN ADEQUATE

    A6 TRAINING DEFICIENCY

    A7 OTHER PROBLEM

    A1.1 Design Input Less Than Adequate

    A2.1 Calibration for Instruments Less Than Adequate

    A3.1 Skill Based Error A4.1 Management Methods Less Than Adequate

    A5.1 Written Communications Method of Presentation

    A6.1 No Training Provided

    A7.1 External Phenomena

    A.1.1.1 - Design input cannot be met

    A2.1.1 - Calibration LTA A3.1.1 - Check of work was LTA

    A4.1.1 - Management policy guidance / expectations not well- defined, understood or enforced

    A5.1.1 - Format deficiencies

    A6.1.1 - Decision not to train

    A7.1.1 - Weather or ambient conditions LTA

    A1.1.2 - Design input obsolete

    A2.1.2 - Equipment found outside acceptance criteria

    A3.1.2 - Step was omitted due to distraction

    A4.1.2 - Job performance standards not adequately defined

    A5.1.2 - Improper referencing or branching

    A6.1.2 - Training requirements not identified

    A7.1.2 Power failure or transient

    A1.1.3 - Design input not correct

    A2.2 Periodic/Corrective Maintenance Less Than Adequate

    A3.1.3 - Incorrect performance due to mental lapse

    A4.1.3 Management direction created insufficient awareness of the impact of actions on safety / reliability

    A5.1.3 - Checklist LTA A6.1.3 - Work incorrectly considered skill-of-the- craft

    A7.1.3 External fire or explosion

    A1.1.4 - Necessary design input not available

    A2.2.1 - Preventive maintenance for equipment LTA

    A3.1.4 - Infrequently performed steps were performed incorrectly

    A4.1.4 - Management follow-up or monitoring of activities did not identify problems

    A5.1.4 - Deficiencies in user aids (charts, etc.)

    A6.2 Training Methods Less Than Adequate

    A7.1.4 Other natural phenomena LTA

    A1.2 Design Output Less Than Adequate

    A2.2.2 - Predictive maintenance LTA

    A3.1.5 Delay in time caused LTA actions

    A4.1.5 - Management assessment did not determine causes of previous event or known problem

    A5.1.5 - Recent changes not made apparent to user

    A6.2.1 - Practice or hands-on experience LTA

    A7.2 Radiological/Hazardou s material Problem

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    ResponsibilityResponsibility Who will be responsible for each step?

    Personnel must accept responsibility Personnel must have authority Personnel must be held accountable

    Realistic target dates must be set

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    ActionsActions Corrective

    Target Immediate Causes Immediate actions to prevent recurrence or escalation

    Barricades Toolbox talk

    Preventive Target Root Causes Long term solutions to prevent recurrence

    Training Management of change

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Follow UpFollow Up This is the most important step in the

    Investigation Sequence Monitoring of actions determines the level of remedial actions

    accuracy Remedial actions that have been started can be modified if

    necessary It determines the accuracy of the Investigation

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Initial ReportInitial Report The Investigator / Investigation Team will;

    Analyze the information gathered Compile a preliminary report Submit the report as per company/project/OU reporting procedures

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    Final ReportFinal Report The Investigator / Investigation Team will;

    Analyze the information gathered Compile a final report Submit to OU Legal Department for clearance Submit the report as per company/project/OU reporting procedures

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    SupervisorSupervisors Responsibilitys Responsibility Incidents should make Managers ask

    themselves; What is the real cause? Did this person have the proper knowledge, skill and motivation? Is there a physical or mental problem that was missed? What could I have done to prevent this from happening?

  • HSES EXCELLENCE

    Developed by J. Ray McDermott HSES

    SummarySummary

    ACCIDENT/INCIDENT INVESTIGATIONCourse ObjectiveInvestigation DefinitionInvestigationInvestigationAccident/IncidentWhy InvestigateLegislation and StandardsWhy Investigate IncidentsHazard ControlRisk ManagementSafetyALARPSlide Number 14Slide Number 15Uninsured CostsSafety Management SystemsIncident Ratio StudyCause and Effect SequenceThe IncidentInvestigation TeamAllocation of DutiesPreparationInvestigation ToolsBarriers to InvestigationsPhysical EvidenceScene PreservationGathering EvidencePeopleInterview TechniqueInterview Technique (contd)Interview Technique (contd)Re-enactmentPosition/EnvironmentPosition/Environment (contd)Position/Environment (contd)PartsParts (contd)PaperPaper (contd)Information AnalysisCasual AnalysisStory BoardCause SequenceCause Sequence (contd)System Failure CategoriesImmediate CausesAction PlanRoot CausesResponsibilityActionsFollow UpInitial ReportFinal ReportSupervisors ResponsibilitySummary