1. www.energyinst.org Energy Institute LFI work activities: overview 10 December 2013 Stuart King, Technical Products Manager sking@energyinst.org www.energyinst.org Learning from incidents

2. www.energyinst.org Highlight some of the issues that industry faces Outline EI learning from incidents activities Aims of this presentation

3. www.energyinst.org About the EI The Energy Institute (EI) is the professional membership body for individuals and organisations working in energy or a related field. We promote excellence by developing knowledge, skills and good practice for the benefit of the global energy sector, its people and society. By being part of the EI, our members ensure they stay informed, engaged and connected in a fast-changing industry. 16,000 individual members 250 company members Professional membership grades

4. www.energyinst.org EI Technical work programme Funded technical work programme 30+ Technical Partners BG Group BP Centrica Chevron ConocoPhillips DONG Energy EDF Energy ENI E.ON ExxonMobil International Power Kuwait Petroleum Maersk Oil Murco Nexen Phillips 66 Premier Oil RWE npower Saudi Aramco Scottish Power SGS Shell SSE Statkraft Statoil Talisman Total Tullow Valero Vattenfall World Fuel Services

5. www.energyinst.org Learning from incidents (LFI) involves: 1)understanding why incidents, near misses, business losses etc. happened, and 2)making the necessary corrections/improvements to ensure similar incidents do not happen. What is learning from incidents? How we learn, not about what needs to be learned

6. www.energyinst.org Some common issues Incident investigations often do not go far enough to investigate human and organisational factors issues (i.e. do not always go beyond the immediate causes) -Time & skill of the investigator -Resources linked to severity of incident, not learning potential -Politics, costs, ideology and culture -Avoiding blame of the individual or organisation -Are people responsible for their own actions? Hard to accept. How do we embed learning? -Creating good actions for learning -Taking time for reflection – contextualising, engaging workforce How do we know learning has taken place? - Effectiveness of follow-up actions measured for 6% of incidents

7. www.energyinst.org Work streams Human and organisational factors committee (HOFCOM) Process Safety Committee Technical work programme Tripod Beta methodology Stichting Tripod Foundation PhD research LFI toolkit (in development) Hearts and Minds

8. www.energyinst.org Work streams Human and organisational factors committee (HOFCOM) Process Safety Committee Technical work programme Tripod Beta methodology Stichting Tripod Foundation PhD research LFI toolkit (in development) Hearts and Minds

9. www.energyinst.org Guidance on investigating and analysing human and organisational factors aspects of incidents and accidents (2008) Why investigate HOF aspects of incidents? – An introduction Go beyond ‘human error’ being cited as underlying cause in investigations – it’s not an underlying cause! Introduction to human failure (error and violation) classifications. Uses the Tripod causation model of why incidents happen. Just culture – investigation is not about blame, it’s about learning. Performance influencing factors Brief description of 28 proprietary and public investigation and analysis methodologies. ‘a line in the sand’ Referenced on HSE website Still a well accessed publication. …. But due for an update

10. www.energyinst.org Guidance on meeting expectations of EI process safety management framework: Element 19: Incident reporting and investigation Provides a flow diagram of activities that should make up the accident reporting and investigation process. Performance measures for monitoring reporting and investigation process performance. High level, for informing the safety management system. Consistent process Expected Q2 2014

11. www.energyinst.org Work streams Human and organisational factors committee (HOFCOM) Process Safety Committee Technical work programme Tripod Beta methodology Stichting Tripod Foundation PhD research LFI toolkit (in development) Hearts and Minds

12. www.energyinst.org Tripod Beta Partnership with the Stichting Tripod Foundation Tripod is an established incident investigation and analysis methodology, used internationally and by a range of industries Governed by Tripod Board and Tripod Assessors Accreditation programme for practitioners and Training courses Tripod Beta: Guidance on using Tripod Beta in the investigation and analysis of incidents, accidents and business losses Expected Q1 2014

13. www.energyinst.org Work streams Human and organisational factors committee (HOFCOM) Process Safety Committee Technical work programme Tripod Beta methodology Stichting Tripod Foundation PhD research LFI toolkit (in development) Hearts and Minds

14. www.energyinst.org ReportingInvestigation Developing incident alerts DisseminationContextualising Implementing actions Business improvement Change in behaviour External incident Internal incident Hearts and Minds – Learning from incidents toolkit LFI process Many organisations stop here ‘The missing link’ Safety issue reported

15. www.energyinst.org Hearts and Minds – Learning from incidents toolkit PhD research, Glasgow Caledonian University (2009-2012) Exploring LFI from an adult learning perspective. Follow-up project to produce practical toolkit. Toolkit: Provide exercises to: A)help the organisation understand its LFI processes Includes LFI questionnaire B) engage staff with LFI to contextualise and embed learning 3 engagement exercises to help engage staff with incidents; apply learning to own work context. Next steps: development and testing

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17. Good practice guidance Investigation & analysis tools Learning & engagement tools Where are we going? The LFI landscape The focus

18. www.energyinst.org Reporting Initiate investigation Who; Remits; Team; legal; Etc. InvestigationAnalysisDeveloping action itemsLearning Future guidance

19. www.energyinst.org Thank you for your time Any questions?