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
Corrective
Planning & Procedures Action

Implementation Monitoring

Audit Corrective Action &

Improvement

Corrective Action &

Management Review
Improvement

HSE Management System - TRIPOD

 Tripod framework

Remove

GENERAL
FAILURE
TYPES

Active Stages
Minimise
Learn From
HAZARDS DEFENCES

UNSAFE INCIDENTS
ACTS

Improve
Train & Motivate

HSE Management System - TRIPOD

 Incident causation sequence

Latent Stages Active Stages

Management *
Line Mgt
Fallible
Line Mgt
decisions Latent
failures Sharp end**
Preconditions
Unsafe
acts

Incident

Chronological
sequence

Safety Culture Causal

sequence

HSE Management System - TRIPOD

 Tripod - Breached Defences

Breached Defences

Breached Defences: what last minute measures failed or

were missing?

Barriers Mitigation and Recovery Measures

(Controls for Threats) (for Consequences)

. Awareness
. Protection
/ Containment
. Detection
. Escape and Rescue
. Control

HSE Management System - TRIPOD

 Tripod - Unsafe Acts

Unsafe Acts

Unsafe Acts: which acts or omissions led directly to the accidents?

Human errors
Intended action Unintended action
. Violation (1) . Mistake (2) . Lapses (3) . Slips (4)

HSE Management System - TRIPOD

 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.

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
PLAN
1. Interpret Initial Incident Statement
- Ensure on-site safety
2. Generate initial hypothesis
- Provide Emergency Response 3. Develop investigation plan
- Notify relevant parties INVESTIGATE
4. Conduct investigation
- Collect initial data & evidence
- Generate Initial Incident Statement
- Classify incident
- Determine investigation level
- Form Investigation Team
5.
6.
7.
ANALYSIS
HSE Management System - TRIPOD
Post Analysis
FOLLOW-UP
- Communicate findings to site
- Avoid disciplinary actions
- Peer review report
- Prepare presentation
- Communicate report internal
- Review report
- Brief external authorities etc.
- Review report
- Close Out report
ANALYSE
- Record report to file
Conduct analysis
- Publish Lessons Learned
Identify recommendations
- Implement recommendations
Generate report
- Monitor implementation