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Incident Investigation and Analysis
Tripod-BETA Incident Investigation and Analysis
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Incidents are an indicator to improve our performance
Understanding what happened and why enables us to improve our business
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Structure of the HSE Management System
Leadership and Commitment Tripod Beta Policy and Strategic Objectives Organisation, Responsibilities Resources, Standards & Doc. Hazard and Effects Management Corrective Action Planning & Procedures Implementation Monitoring Audit Corrective Action & Improvement Corrective Action & Improvement Management Review
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What is Tripod-BETA ? A methodology for incident analysis during an investigation ... combining concepts of hazard management and ... the Tripod theory of accident causation.
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How does Tripod-BETA work ?
The incident facts are built into a tree diagram showing ... - What happened ... - What hazard management elements failed and - Why each element failed.
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What does the software do ?
Stores investigation facts Provides tree-building graphics Checks the implicit tree logic Attaches data to tree elements Assembles attached data into a draft report.
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How does the tree work ? Let’s walk through a simple incident
introducing the terminology and logic that underpins Tripod-BETA
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The Incident Location: an offshore platform
Incident: an operative coming off shift slips and falls in the shower room Consequence: he hurts his back and is off work In the past three months there have been two similar incidents 2
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Initial Findings The incident occurred at 1820 hours
The operative slipped on the wet floor Cleaning staff are supposed to keep the shower room floor dry 3
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Starting a Tripod Tree We start by identifying:
An EVENT - where a hazard and a target get together A TARGET - a person or an object that was harmed A HAZARD - the thing that did the harm 4
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The Hazard, Event, Target Trio
They are shown in a Tripod tree like this: Hazard Event Target
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Hazard, Event & Target In this incident:
The HAZARD is : Wet floor (slipping hazard) The EVENT is : Operative falls in shower room The TARGET is : Operative 5
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Wet floor (slipping hazard)
HET Diagram The Hazard, Wet floor (slipping hazard) Event Target
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Wet floor (slipping hazard)
HET Diagram The Hazard, acting on the Target, Wet floor (slipping hazard) Event Operative
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Wet floor (slipping hazard) Operative falls in shower room
HET Diagram The Hazard, acting on the Target, resulted in the Event Wet floor (slipping hazard) Operative falls in shower room Operative
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Is the investigation complete ?
Does this show full understanding ? Finding: The man must have been careless Recommendation: He should take more care on a wet floor Or is there something more ? 7
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Was the incident preventable ?
We know that a hazard management measure was in place Cleaning staff were assigned to keep the floor dry That ‘barrier’ to the incident failed
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Failed Barrier The barrier should have controlled the hazard Hazard
Event Target
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Wet floor (slipping hazard) Operative falls in shower room
Incident Mechanism The incident mechanism looks like this: Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative
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Further Investigation
What caused the barrier to fail ? The cleaner could not keep the floor dry ... because the shower room was always congested between 1800 and 1900 hrs
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Wet floor (slipping hazard) Operative falls in shower room
Active Failure An Active Failure defeated the barrier Active Failure Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative
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Active Failure An Active Failure defeated the barrier
Cleaner unable to keep floor dry Active Failure Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative
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End of Investigation ? Is this the end of the investigation ?
Finding: The cleaner was incompetent Recommendation: Cleaner should be replaced or retrained Or is there still something more ?
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Further Investigation
We know that congestion was a factor that prompted the active failure Telephones are only available for private calls up till 1900 hrs The congestion is caused by day shift crew hurrying to call home
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The Full Picture Now we have the full picture:
The congestion is a ‘Precondition’ that influenced the cleaner’s task Restriction on telephones is a ‘Latent Failure’ that created the precondition
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Precondition Cleaner unable to keep floor dry Precondition
Active Failure Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative
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Precondition Congestion 1800 - 1900 hrs
Cleaner unable to keep floor dry Active Failure Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative
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Latent Failure Congestion 1800 - 1900 hrs
Precondition Cleaner unable to keep floor dry Active Failure Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative
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Latent Failure Restriction on private phone calls
Congestion hrs Precondition Cleaner unable to keep floor dry Active Failure Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative
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Recommendations Action items should address: The failed barrier ...
to restore safe conditions on a temporary basis (provide extra cleaner between 1800 and 1900) The latent failure ... to remove the underlying cause (extend the availability of shore telephone)
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Complex Events That was a simple example
The Tripod-BETA methodology can also be applied in complex events
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Complex Events Identify the prime Event, Fire
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Complex Events Identify the prime Event, the Hazard, Ignition Fire
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Complex Events Identify the prime Event, the Hazard, and Target.
Ignition Fire Flammable Gas Cloud
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Complex Events If, say, the target was created by a prior event
Ignition Fire Flammable Gas Cloud
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Complex Events Identify the hazard ... Ignition Dropped Fire Object
Flammable Gas Cloud Event & Target
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Complex Events and target for that event. Ignition Dropped Fire Object
Flammable Gas Cloud Gas Line
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Complex Events Similarly, if a consequential event happens ...
Ignition Dropped Object Fire Damage to Platform Flammable Gas Cloud Gas Line
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Complex Events because the prime event created a new hazard,
Ignition Dropped Object Fire Damage to Platform Flammable Gas Cloud Gas Line
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Complex Events identify the target for the new event. Fire
Ignition Source Dropped Object Fire Flammable Gas Cloud Damage to Platform Gas Line Platform
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Complex Events Identify failed ‘barriers’, Fire Damage to Platform
Ignition Source Failed Barrier Dropped Object Fire Flammable Gas Cloud Damage to Platform Gas Line Platform
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Complex Events and missing ones ... Fire Damage to Platform Ignition
Failed Barrier Fire Ignition Source Gas Line Flammable Gas Cloud Dropped Object Platform Damage to Platform Missing Barrier
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Complex Events including multiple failures ... Fire Damage to Platform
Failed Barrier Fire Ignition Source Gas Line Flammable Gas Cloud Dropped Object Platform Damage to Platform Failed Barrier Failed Barrier Missing Barrier
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Complex Events on each relevant ‘trajectory’ ... Fire
Failed Barrier Fire Ignition Source Gas Line Flammable Gas Cloud Dropped Object Platform Damage to Platform Failed Barrier Failed Barrier Missing Barrier Failed Barrier Missing Barrier
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Complex Events until the Incident Mechanism is complete. Fire
Failed Barrier Fire Ignition Source Gas Line Flammable Gas Cloud Dropped Object Platform Damage to Platform Failed Barrier Failed Barrier Missing Barrier Failed Barrier Missing Barrier Missing Barrier
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Complex Events Show the Active Failure for each barrier, ... Fire
Failed Barrier Fire Ignition Source Gas Line Flammable Gas Cloud Dropped Object Platform Damage to Platform Failed Barrier Failed Barrier Missing Barrier Failed Barrier Missing Barrier Missing Barrier
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Complex Events the Precondition(s) promoting each active failure, ...
Hazard Failed Barrier Failed Barrier Failed Barrier Event & Hazard Hazard Missing Barrier Event Event & Target Failed Barrier Missing Barrier Target Missing Barrier Target
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Complex Events and the Latent Failure behind each precondition. Hazard
Active Failure Hazard Failed Barrier Failed Barrier Failed Barrier Event & Hazard Hazard Missing Barrier Event Event & Target Failed Barrier Missing Barrier Target Missing Barrier Target
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Complex Events Complete a ‘Tripod path’ for each barrier. Hazard
Latent Failure Precondition Active Failure Latent Failure Precondition Active Failure Hazard Failed Barrier Failed Barrier Failed Barrier Event & Hazard Hazard Missing Barrier Event Event & Target Failed Barrier Missing Barrier Target Missing Barrier Target
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The completed Tripod-BETA tree
Latent Failure Precondition Active Failure Latent Failure Precondition Active Failure Latent Failure Hazard Failed Barrier Failed Barrier Failed Control Event & Hazard Hazard Missing Barrier Event Event & Target Failed Barrier Missing Barrier Target Missing Barrier Active Failure Target Latent Failure Precondition Latent Failure Latent Failure Latent Failure Precondition
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Structure of the HSE Management System
Leadership and Commitment Tripod Beta Policy and Strategic Objectives Organisation, Responsibilities Resources, Standards & Doc. Hazard and Effects Management Corrective Action Planning & Procedures Implementation Monitoring Audit Corrective Action & Improvement Corrective Action & Improvement Management Review
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Corrective Actions latent failure precondition active failure
Long term action to reduce latent failures latent failure precondition active failure Replace the failed barrier latent failure precondition
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Corrective Actions If the barriers have not been replaced you should question why operations have restarted Actions to replace barriers are normally on site Latent Failures are deep seated do not expect to remove them tomorrow Action to tackle latent failures are normally at management level
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Tripod-BETA Brings a structure to investigation
Helps distinguish relevent facts Makes causes and effects explicit Encourages team discussion Reduces the report writing task
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