Incident Investigation

8. Conclusions

© DSMA Repsol YPF 2011

 Course Contents
0. Introduction
1. Incident Investigation Procedure
2. Introduction to Root Cause Analysis Methodology
3.1. Incident Reality and Definition
3.2. Incident Definition within Repsol YPF
4. The Principle of Cause and Effect
5. Cause and Effect Analysis
6. Evidence
7. Effective Solutions
8. Conclusions
9. Committee of Inquiry Management
10. Interviews
11. Human Error
12. HGI
13. GAMA Investigation
14. Case Study
15. Conclusions

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 8. Conclusions

• RCA is an effective methodology for problem solving.

• Within Repsol, it is applied to incident investigation, to identify the

underlying causes and propose improvement actions.

• For incident investigation, a good initial agreed upon definition of

the incident works out to be crucial.

• Cause and effect are the same thing under a wide temporal
perspective.

• Any incident is the result of an infinite sequence of causes and

effects.

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 8. Conclusions

• Each cause / effect results from the combination of at least two

actions and conditions (at least one condition always).

• The Whys? technique allows us to progressively identify causes

starting from an event, until reaching its root causes.

• Root causes are those which, mitigated, help to avoid the incident’s
recurrence.

• Evidence is key in cause determination.

• For solutions to be effective, they have to be under our control

and be aligned with our business objectives.

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 8. Conclusions

• A chemical multinational with over 20 years of experience in RCA.

• Review of the causes leading to an increase in incidents:
• Inefficient corrective actions (they do not prevent recurrence).

• Distrust when tackling human behaviour issues.

• Inefficient facilitation of the investigating team.

• Poor incident validation (tick in the box).

• Feeling the roles of owner and facilitator are a burden.

• Lack of previous investigation and retention of evidence.

• Loss of capacity to see small changes or mistakes.

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 8. Conclusions
• Actions to change this situation:
• Change in the approach used for behavioural issues.
– What made the operator close the wrong valve?
• Separation of owner and facilitator roles.
• Investigation facilitator outside his/her area of expertise (allows for naïve questions).
• Good RCA training of the facilitator – timeframe.
• Review of criteria that condition a RCA (serious incident Vs minor incident).
• Previous investigation done in time.
• Choose key indicators for an effective RCA and control its observance (simple
software tools).
• The owner must ensure the RCA report is complete.
• Share experiences: before identifying solutions, check similar previous situations in
other businesses.
• Check “validations”: Has the solution really been implemented?

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 8. Conclusions

• Underlying causes of many incidents and near-misses:

• Management of Change processes
• Lack of supervision of activities subject to work permits
• Selection, management, and supervision of contractors
• Inadequate risk evaluations

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 8. Conclusions

• Underlying causes in ineffective incident investigations:

• Inadequate Problem Definition
• No establishment of relationships between causes and effects
• Culture of Blame
• Adoption of Preferred Solutions
• Lack of time, resources and commitments
• Unclear company objectives
• Poorly qualified team

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© DSMA Repsol YPF 2011
 8. Conclusions

• Underlying causes in successful incident investigations:

• Adequate Problem Definition
• Always establish the causal relationship between causes and effects
• Do not look for who’s to blame, look for areas of improvement
• Do not adopt Preferred Solutions, look for effective solutions
• Make sure there will be enough time and adequate resources
• Postulate solutions which are coherent with the company’s objectives
• Provide a qualified investigation team which has knowledge on the subject

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 8. Conclusions

• Strengths and weaknesses of incident investigation practices

within Repsol.

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 8. Conclusions

¿Questions?
¿Queries?

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