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HSES EXCELLENCE

Developed by J. Ray McDermott HSES

ACCIDENT/INCIDENT ACCIDENT/INCIDENT INVESTIGATIONINVESTIGATION

HSES EXCELLENCE


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 JRM’s HSES Management System– JRM-1407-001

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

• HSES Administration Manual Section 2.5

HSES EXCELLENCE


Investigation DefinitionInvestigation Definition• To derive a level of understanding from a

systematic gathering and subsequent analysis of information (FACTS)

HSES EXCELLENCE


InvestigationInvestigation• Watch the film and prepare a brief summary

of what caused the incident.

HSES EXCELLENCE


InvestigationInvestigation

HSES EXCELLENCE


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


Why InvestigateWhy Investigate• To;

– Prevent a reoccurrence– Gather data and identify trends– Accountability

• Internal (discipline)• External (legal)

HSES EXCELLENCE


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


Why Investigate IncidentsWhy Investigate Incidents• Safety is like Health & Happiness, it’s not missed until it’s

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


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

adequately controlled– HAZARD…A physical condition, act or omission with loss causing

potential

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

HSES EXCELLENCE


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


SafetySafety• Safety…A 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


ALARPALARP• Risks must be mitigated to As Low As

Reasonably Practicable– Returns justifies the Effort– Impact Versus Effort

HSES EXCELLENCE


HSES EXCELLENCE


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


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


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


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


Cause and Effect SequenceCause and Effect Sequence

1Management

System Failure

2Root Causes

3Immediate Causes

4Incident

5LOSS

HSES EXCELLENCE


The IncidentThe Incident

HSES EXCELLENCE


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


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


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


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


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


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


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


Gathering EvidenceGathering Evidence• People• Positions• Parts• Paper

HSES EXCELLENCE


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


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


Interview Technique Interview Technique (cont(cont’’d)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 don’t interrupt• Listen, hear and understand• Don’t take extensive notes first time around

HSES EXCELLENCE


Interview Technique Interview Technique (cont(cont’’d)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


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


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

HSES EXCELLENCE


Position/Environment Position/Environment (cont(cont’’d)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


Position/Environment Position/Environment (cont(cont’’d)d)

• Physical Conditions• Obscuring phenomena• Temperature• Wind• Vessel Movement

HSES EXCELLENCE


PartsParts• Tools

• Adequate, worn, ergonomic

• Equipment• Guarded, functional, fit for purpose

• Materials• Hazardous, heavy, sharp, defective

• Facilities• Housekeeping, industrial hygiene, crowding

HSES EXCELLENCE


Parts Parts (cont(cont’’d)d)

• Proper items for task• Damage• Previous damage• Wear Safeguards• Labels, signs, markings• Manufacturer’s specification

HSES EXCELLENCE


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

HSES EXCELLENCE


Paper Paper (cont(cont’’d)d)

• Eye Witness Reports• Maintenance Records• Manufacturer Supplied Information• Logs and Schedules

HSES EXCELLENCE


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


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

– Create a story board using stickies

• List Causal Factors for Each Step– Causal Factor…An 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


Story BoardStory BoardEvent 1

Event 2

Causal Factor

Causal Factor

Causal Factor

HSES EXCELLENCE


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


Cause Sequence Cause Sequence (cont(cont’’d)d)

HSES EXCELLENCE


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


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


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


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


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


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


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


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


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


SupervisorSupervisor’’s 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


SummarySummary

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