incident management overview by shawn messier

HSE Consul+ng Services

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Incident Management


Objectives

“All Work Related Incidents Are Preventable”

Ø  Understanding the Incident Management Process

Ø  Provide an overview of the different causation models

Ø  Understanding and distinguishing common and underlying causes and contributing factors, including organizational and corporate level causes

Ø  Recognizing and removing bias and its influence in incident investigation outcomes


Top 10 Most Expensive Accidents in History


10. Titanic $150 Million

9. Tanker Truck vs Bridge $358 Million

On April 15, 1912, the Titanic sank on its maiden voyage and

was considered to be the most luxurious ocean liner ever built.

Over 1,500 people lost their lives when the ship ran into an

iceberg and sunk in frigid waters. The ship cost $7 million to

build ($150 million in today's dollars).

On August 26, 2004, a car collided with a tanker truck containing

32,000 liters of fuel on the Wiehltal Bridge in Germany. The tanker

crashed through the guardrail and fell 90 feet off the A4 Autobahn

resulting in a huge explosion and fire which destroyed the load-

bearing ability of the bridge. Temporary repairs cost $40 million

and the cost to replace the bridge is estimated at $318 Million.




8. MetroLink Crash $500 Million On September 12, 2008, in what was one of the worst train

crashes in California history, 25 people were killed when a

Metrolink commuter train crashed head-on into a Union Pacific

freight train in Los Angeles.

7. B-‐2 Bomber Crash $1.4 Billion

This B-2 stealth bomber crashed shortly after taking off from an

air base in Guam on February 23, 2008. This was 1 of only 21

ever built and was the most expensive aviation accident in

history. Both pilots were able to eject to safety.




6. Exxon Valdez $2.5 Billion

On March 24, 1989, 10.8 million gallons of oil was spilled

when the ship's master, Joseph Hazelwood, left the controls

and the ship crashed into a Reef. The cleanup cost Exxon $2.5

billion.

5. Piper Alpha Oil Rig $3.4 Billion

The world's worst off-shore oil disaster. Spewing out

317,000 barrels of oil per day. Within 2 hours, the 300

foot platform was engulfed in flames. It eventually

collapsed, killing 167 workers and resulting in $3.4

Billion in damages.




4. Challenger Explosion $5.5 Billion

The Space Shuttle Challenger was destroyed 73 seconds

after takeoff due on January 28, 1986. The cost of

replacing the Space Shuttle was $2 billion in 1986 ($4.5

billion in today's dollars). The cost of investigation,

problem correction, and replacement of lost equipment

cost $450 million from 1986-1987 ($1 Billion in today's

dollars).

3. PresOge Oil Spill $12 Billion On November 13, 2002, the Prestige oil tanker was

carrying 77,000 tons of heavy fuel oil when one of its

twelve tanks burst during a storm off Galicia. Total

cleanup cost $12 billion.




2. Space ShuQle Columbia $13 Billion

The Space Shuttle Columbia was destroyed during re-

entry over Texas on February 1, 2003 after a hole was

punctured in one of the wings during launch 16 days

earlier. The original cost of the shuttle was $2 Billion in

1978. That comes out to $6.3 Billion in today's dollars.

$500 million was spent on the investigation, making it

the costliest aircraft accident investigation in history. The

search and recovery of debris cost $300 million.

In the end, the total cost of the accident (not including

replacement of the shuttle) came out to $13 Billion

according to the American Institute of Aeronautics and

Astronautics.




1. Chernobyl $200 Billion

On April 26, 1986, the world witnessed the costliest accident in history. The Chernobyl disaster has been called the biggest socio-economic catastrophe in peacetime history. Ø  50% of the area of Ukraine is in some way contaminated. Ø Over 200,000 people had to be evacuated and resettled

while 1.7 million people were directly affected by the disaster.

Ø  The death toll attributed to Chernobyl, including people

who died from cancer years later, is estimated at 125,000. Ø  The total costs including cleanup, resettlement, and

compensation to victims has been estimated to be roughly $200 Billion.

Ø  The cost of a new steel shelter for the Chernobyl nuclear

plant will cost $2 billion alone.


What Do They Have In Common?


Ø The stage had already been set for the incident to occur by the presence of Latent

Failures - Technical or Human. Ø Deficiencies in the structure of responsibilities and accountabilities within the

organizations of the way it goes about its business which are not appropriate to current work.

Ø Fallible decisions which led to risk-inducing failures. Ø Chronic situations in which errors violations were made.

Ø Delayed , missed and poorly planned maintenance activities.


What Do They Have In Common?


Ø The stage had already been set for the incident to occur by the presence of Latent Failures - Technical or Human.

Ø Delayed, missed and poorly planned maintenance activities. Ø Organizations and people trying to meet several goals at

once. Ø (Un)availability of accurate, understandable procedures. Ø Design faults were traced back to to a difference between

how the designer thinks the equipment will be used and the way operators actually use it.

Ø Communications – people tended to hear what they expect

to hear rather than what was actually sent. Ø Competency – inadequate training, for both routine work

and for dealing with emergencies


Purpose - Incident Management


To ensure incident response, notification,

investigation, documentation, follow-up and

sharing of learning’s is completed in a uniform,

thorough and timely manner to prevent

recurrence of a similar incident

Blast at BP Texas refinery in '05

BP Gulf Oil Spill


RESPONSE

NOTIFICATION

INVESTIGATION

DOCUMENTATION

FOLLOW-‐UP & SHARE LEARNINGS

WORKER

WORKER / LEADER

LEADERS(S) / INVESTIGATION TEAM

Incident Management Process (IMP)


Incident Management Process (IMP)

Design


Ø To ensure workers are capable of recognizing and acknowledging when an incident has occurred.

Ø To encourage notification of all incidents, with the

understanding investigations are completed to identify facts not place blame.

Ø To ensure a thorough, consistent investigation of all incidents,

to identify root causes and Latent Failures which permit the development and implementation of appropriate corrective and preventive measures, eliminating potential for recurrence.

Ø To facilitate continual performance improvement, to share key

learning’s and prevent loss.

RESPONSE

NOTIFICATION

INVESTIGATION

DOCUMENTATION




RESPONSE

NOTIFICATION

INVESTIGATION

DOCUMENTATION


Response


Response

Emergency Management System


Safety

Isolate

Control

Notification

Ø  Take Control – Ensure personal safety.

Ø  Isolate & control the situation.

Ø  Provide first aid and call emergency services.

Ø  Control potential secondary accidents.

Ø  Identify sources of evidence.

Ø  Preserve evidence.

Ø  Determine loss potential – risk assessment.



RESPONSE

NOTIFICATION

INVESTIGATION

DOCUMENTATION


Notification


Notification


Ø  Verbal Notification – Internal Call Down System

Ø  Incident Management Classification Guide

Ø  External Agencies

Ø  Crisis Communications - Media

Ø  Written Incident Notification


RESPONSE

NOTIFICATION

INVESTIGATION

DOCUMENTATION


Investigation


What is an Investigation?


It is the analysis and account of an incident based on information gathered by a thorough examination of “ALL FACTORS” involved.

Purpose of Investigations is to determine:

Ø Underlying causes of incidents Ø To prevent recurrence


Top 10 Investigation Mistakes


The natural tendency is to blame and incident on the careless, stupid or irresponsible acts of those people directly involved.

10. Uncooperative People or System 9. Conflicting Objectives 8. Surface Causes Only 7. Politics 6. Unskilled Investigators

5. Interview Biases / Untruthfulness 4. Untimely Investigation 3. Investigator Biases 2. Ineffective Corrective Action 1. Not Investigating Near Misses


Ø  We must investigate all accidents incidents to determine which has the potential for serious injury or major loss.

Ø  We should give special attention to those with loss potential. (HIPO)

What Incidents should be Investigated?


Who Should Do Accident Investigating?

Ideally, an investigation would be conducted by someone experienced in accident causation, experienced in investigative techniques, fully knowledgeable of the work processes, procedures, persons, and industrial relations environment of a particular situation.


1) Initial Response - Emergency Response

2) Collect Evidence - What’s

3) Analysis on the Evidence - Why’s

4) Develop Recommendations

5)  Prepare the Accident Report

6)  Implement Corrective Actions

6)  Evaluate the effectiveness of the corrective action

7)  Make changes for continuous improvement

Investigation Process


Ø  Position Ø  People Ø  Parts Ø  Paper

Collect Evidence – What’s


Are the physical relationships of the people, equipment, materials and structures to each other.

Position Evidence


Are those individuals who saw the accident or know something about the circumstance.

People Evidence


Ø  Interview separately

Ø  Interview in an appropriate place

Ø  Put the person at ease

Ø  Get the individual’s version

Ø  Ask necessary questions at the right time

Ø  Provide feedback

Ø  Record critical information quickly

Ø  Use visual aids

Ø  End on a positive note

Ø  Keep the lines of communication open

Interview Process


Are the equipment, tools, materials, signs, placards, labels, and other physical objects related to

the accident.

Parts Evidence


Are the documents that relate to the accident. These can be Operating Procedures,

Hazard Assessments, Competency Assurance Records and numerous other documents

Paper Evidence


Methods Employed to Look at Accident

Causation?


Ø Management Oversight and Risk Tree

Ø  Logic Tree

Ø  Tap Root

Ø  5 Why’s

Ø  Fault Tree Analysis

Ø Cause & Effect

Ø DNV SCAT

Ø  Fishbone Diagram

Ø  Tripod

Many models of accident causation have been proposed, ranging from Heinrich's domino theory to the following sophisticated processes:


Conventional View

Ø  In the conventional view of how accidents happen, a number of unfortunate events come

together to form an accident.

Ø  This view usually includes specific human component (unsafe acts) which, had not been

performed, would mean that the accident would not have happened.

Ø  There has been and continues to be a widespread tendency in organizations to blame

accidents on the people who suffer them and to see unsafe acts as arising from the

stupidity, carelessness or recklessness of particular individuals


Conventional View

Past techniques for improving safety performance tended to focus on the accidents

themselves, conducting detailed investigations and compiling accident statistics to identify the

reasons why accidents occurred.

Such techniques are essentially reactive.


Active & Latent Failures

ACTIVE FAILURES

Are usually associated with the activities of the frontline operators. These are the people at

the human-system interface whose failures are capable of eliciting an immediate reaction.

LATENT FAILURES

Unsafe acts do not occur in isolation, but are influenced by external factors (the

preconditions) These factors themselves originate from failures elsewhere in the business

(latent failures)


Ø  Adverse consequences which lay dormant within the system for a long time, only becoming evident when they combine with other factors to break through the system’s defences

Ø  These are committed by those far removed in time and space from the immediate area:

- designers, high-level decision makers, managers and maintenance personnel.

Ø  Decisions are shaped by various factors: - economic, political, practical constraints.

Latent Failures


Ø  All physical failures are triggered by humans. But humans are negatively influenced by

latent forces.

Ø  The goal is to identify and improve these latent forces

Latent Failures


Latent Failures


Ø  Hardware

Ø  Design

Ø  Maintenance Management

Ø  Procedures

Ø  Error-enforcing Conditions

Ø  Housekeeping

Ø  Incompatible Goals

Ø  Communication

Ø  Organization

Ø  Training

Ø  Defenses

Organizations with many latent failures are less able to survive occasional active failures, either technical or human


The Hardware GFT is concerned with the quality, availability and position in the life-

cycle of tools and equipment and components. It does not include failures caused

by poorly designed items, or due to poor maintenance, but does include use of

incorrect or inappropriate materials or manufacturing.

Latent Failure - Hardware


Design can become a GFT when it leads directly to the commission of avoidable

unsafe acts. Design faults can contribute to an accident by allowing unsafe acts to

take place, or even making unsafe acts necessary in order to make something

operate as intended. For example, a safety guard which can be held open with one

hand lets operators take risks.

Latent Failure - Design


The GFT is concerned with the Management of Maintenance rather than the

practical execution of the tasks involved. Many maintenance problems arise out of

the conflict between cost and safety, whereas ideally the resources devoted should

be driven purely by the maintenance objectives.

Latent Failure – Maintenance

Management


This GFT concerns the (un)availability of accurate, understandable procedures which

are actually known and used. Procedures are meant to ensure that staff carry out

tasks in a standard, safe way.

Latent Failure – Procedures


This GFT refers to a chronic situation in which errors violations are made more

probable. It covers a broad range of conditions affecting the individual or the

workplace, which can lead to unsafe acts.

Latent Failure – Error Enforcing

Conditions


Housekeeping constitutes a GFT where it has been neglected for a long time and

when various levels of management have been aware of it but have done nothing

about it. It refers to the tidiness and cleanliness of facilities, together with the

provision of adequate resources for cleaning and waste removal.

Latent Failure – Housekeeping


This GFT recognizes that organizations and people are usually trying to meet several

goals at once and that this can lead to dangerous conflicts. Incompatible goals

become a problem when top management gives no guidance on priorities.

Latent Failure – Incompatible Goals


This GFT covers failures to communicate when the target is known but the message

fails to get through or is late; this may be due to hardware problems or

misunderstanding between sender and recipient.

Latent Failure – Communications


The organization GFT refers to deficiencies in the structure of responsibilities and

accountabilities within the company or the way it goes about its business which are

not appropriate to current work.

Latent Failure – Organization


It is management’s responsibility to ensure that the right people get the right training. Problems can arise for many reasons, and usually not the fault of the

employees affected. Training requirements may not be properly understood, the training badly run, or not run at all.

Latent Failure – Training


Problems in defenses take various forms:

Ø  Detection and warning systems may give false alarms or fail to work;

Ø  Control and interim recovery equipment may be missing, faulty or badly sited;

Ø  Protection equipment or containment systems may have been deliberately

disabled or not even used, perhaps because they are awkward, cumbersome,

take too long to set up or are not understood by personnel;

Ø  Escape and evacuation plans are rarely put to the test. Serious accidents can

take unexpected forms which planners may not have foreseen.

Latent Failure – Defenses


Documentation


Ø  Who, what, when, where and why

Ø  Description of events

Ø  Immediate and basic causes

Ø  Contributing factors

Ø  Remedial and permanent recommendations

Ø  Action plan

Ø  Attachments


Follow-up & Shared Learning's


This is one of the most value added steps in incident management and must include

the following:

Ø  Tracking of recommendations;

Ø  Identify and notify individuals who are accountable for the implementation of

recommendations;

Ø  Provide status on targeted completion dates; and

Ø  Confirms the incident has been managed until all actions are completed.


Follow-up & Shared Learning's


Implementation is successful if:

Ø  The recommendations are implemented;

Ø  The recommendations have corrected the root cause/latent failures and/or

prevented similar incident from occurring; and

Ø  Follow-up with workers indicated the recommendations were successful in

eliminating the root causes / latent failures


Summary


Ø  Investigation is the analysis and account of an incident based on information gathered by

a thorough examination of “ALL FACTORS” involved;

Ø  Organizations with many latent failures are less able to survive occasional active failures, either technical or human; Ø  Incidents are an indicator to Improve our performance – “We Care”


Questions?

incident management overview by shawn messier

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