1. HSE Management System - TRIPOD Presented By: Naman Shah Pakistan Refinery Limited Incident Investigation and Analysis

2. HSE Management System - TRIPOD Tripod Incident Investigation and Analysis

3. HSE Management System - TRIPOD Structure of the HSE Management System Leadership and Commitment Policy and Strategic Objectives Management Review Corrective Action & Improvement Audit Organisation, Responsibilities Resources, Standards & Doc. Corrective Action & Improvement Tripod Monitoring Planning & Procedures Hazard and Effects Management Implementation Corrective Action

4. HSE Management System - TRIPOD Tripod framework UNSAFE ACTS INCIDENTS Learn From Train & Motivate DEFENCES Improve GENERAL FAILURE TYPES HAZARDS Minimise Remove Active Stages

5. HSE Management System - TRIPOD Fallible decisions Latent failures Preconditions Unsafe acts Incident Chronological sequence Management Line Mgt “Sharp end” Incident causation sequence Latent Stages Active Stages * ** Safety Culture Causal sequence

6. HSE Management System - TRIPOD Breached Defences: what “last minute” measures failed or were missing? Breached Defences Barriers (Controls for Threats ) Mitigation and Recovery Measures (for Consequences). Protection / Containment. Escape and Rescue. Awareness. Detection. Control Tripod - Breached Defences

7. HSE Management System - TRIPOD Unsafe Acts: which acts or omissions led directly to the accidents? Unsafe Acts Human errors Intended actionUnintended action. Violation (1). Mistake (2). Lapses (3). Slips (4) Tripod - Unsafe Acts

8. HSE Management System - TRIPOD. 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. Tripod - Preconditions

9. HSE Management System - TRIPOD. which underlying problems led to the preconditions?. Organisation. Incompatible Goals. Training. Error Enforcing Conditions. Communication. Maintenance Management. Design. Hardware. Procedures. Housekeeping. Defences Tripod - Latent Failures

10. HSE Management System - TRIPOD. Tripod Tree

11. HSE Management System - TRIPOD PLAN 1.Interpret Initial Incident Statement 2.Generate initial hypothesis 3.Develop investigation plan - 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 - Record report to file - Publish ‘Lessons Learned’ - Implement recommendations - Monitor implementation OVERVIEW of Investigation & Analysis Post – Analysis FOLLOW-UP Pre – Investigation PREPARATION - Ensure on-site safety - Provide Emergency Response - Notify relevant parties - Collect initial data & evidence - Generate Initial Incident Statement - Classify incident - Determine investigation level - Form Investigation Team INVESTIGATION INVESTIGATE 4.Conduct investigation ANALYSE 5.Conduct analysis 6.Identify recommendations 7.Generate report ANALYSIS