Incident Incident

Investigation Investigation

Analysis and Analysis and

SharingSharing

OVERVIEW OF INCIDENT MANAGEMENT OVERVIEW OF INCIDENT MANAGEMENT PROCESSPROCESS

ReportingReporting

Incident/Incident/Near MissNear Miss

ImplementImplementCorrectiveCorrective

ActionsActions

Share LearningsShare Learnings

NotificationNotification- classify incident - communicate to management- notify regulatory/gov’t parties- manage incident

Secure Secure the Sitethe Site

INCIDENT MANAGEMENT INCIDENT MANAGEMENT CYCLECYCLE

Investigation Investigation & Analysis& Analysis

Analyze trendsAnalyze trends

PREVENTSPREVENTS

RATIONALE FOR PREVENTING INCIDENTSWe want to prevent incidents from re-occurring for the following reasons:

To prevent unwanted and unintended impact on the safety or health of people, property, environment, or on legal and regulatory compliance

To maintain the “license” to operate

To improve safety, reliability and effectiveness of operations

Human Behaviors• not wearing eye

protection

Working withCorrosiveChemicals

SAFETY FILTERS - INCIDENT EXAMPLESAFETY FILTERS - INCIDENT EXAMPLE

Management Systems• no safety training• no written procedure

Working Conditions• Poor fitting eye protection

EYEINJURY!

LEARNING FROM THE INCIDENT

Uncover the causal factors (i.e. problems) associated with the incident that, if corrected, would have prevented the incident from occurring or significantly mitigated its consequences.

Ensure proper actions are taken to prevent re-occurrence at the site. Ensure information is appropriately shared.

Working Conditions•poor fitting eye protection

Human Behaviors•not wearing eye protection

Management Systems•no safety training•no written procedure

Working with corrosive chemical

Leaf

Rope

Wall

Tree trunks

Spears

Snake

Basketball Pass videoBasketball Pass video

From the beginningFrom the beginning

Do it now Get there safelyAssess and take controlCare for the injuredSecure the site Keep everyone on site Keep everyone separatedDocument all controls that are modified to

secure the site. This includes breaker panels, valves, etc.

Preserve evidence, use chain of custody if appropriate

Make a sketch of the scene Interview before looking at SOP’s, etc.

InterviewsInterviews

Interview individually List all facts, even those that seem

unimportantKeep an open mind, don’t jump to

conclusionsGet written or recorded statements Go second by second Don't "lead" the person being questioned Ask every question - don't assume Sift down the facts to root cause (the puzzle

will fit together if you get all the facts)

Building your chain of events and Building your chain of events and conditionsconditions

Find out what happened (Ask what happened next?)

Determine the sequence of events

Add conditions to the related events (These explain more info about the event such as how, what, where and why)

Look for questions in these areasLook for questions in these areas

Human engineeringPolicies/proceduresTrainingSupervision

RCFA Process

Prepare an events, conditions and causes chart

Determine the root cause(s) of each finding Recommend corrective actions to address

each root cause Develop investigation report

DEFINITIONSDEFINITIONS

Findings– Any issue associated with the incident that, if corrected,

would have prevented the incident from occurring, or would have significantly lessened its consequences.Note: These need to be analyzed further to get to the root

causes.

ROOT CAUSE– According to TapRoot ®, A root cause is the absence of best

practices or the failure to apply knowledge that would have prevented the problem (or significantly reduce the likelihood or consequences of the problem). Note: Root causes are determined from further analysis of an incident’s findings and are things you can fix.

INCIDENT CAUSES - ExampleINCIDENT CAUSES - ExampleINCIDENT• JD Paine is injured when grinding wheel explodes and he receives a cut on the nose.

Findings• Wrong wheel mounted on grinder• Using Gasoline to clean motors• Un-authorized employee using grinder• General attitude of non-compliance

INCIDENT CAUSES - ExampleINCIDENT CAUSES - Example

ROOT CAUSES • Poor auditing systemNote: Company required proper grinding wheel, but did not check work of supplier

• Standard not followed because it was ineffective Note: Company standards require using a detergent to clean motors, statements indicate it is ineffective and therefore not used.

MANAGEMENT’S ROLEMANAGEMENT’S ROLE

Ensure a system is in place to investigate incidents and to determine root causes.

Ensure learnings are communicated throughout the entire organization.

Ensure all safety alerts are properly communicated.

Ensure all actions items are completed in a timely manner.

IMPORTANCE OF SHARING INCIDENT LEARNINGSIMPORTANCE OF SHARING INCIDENT LEARNINGS

Sharing findings is critical so that every operation does not have to experience the same events.

YOUR SITEYOUR SITE

NONOCONSEQUENCESCONSEQUENCES

LESS SIGNIFICANT LESS SIGNIFICANT CONSEQUENCESCONSEQUENCES

MAJORMAJORCONSEQUENCESCONSEQUENCES

SE

VE

RIT

YS

EV

ER

ITY

High

Very Low

F

LTI

MTI

Property Damage

First Aid and Minor Injuries

Near Miss and Hazards

UNSAFE BEHAVIORS

1

10

30

600

QuestionsQuestions

TRAITS OF A GOOD ROOT CAUSE TRAITS OF A GOOD ROOT CAUSE ANALYSIS SYSTEMANALYSIS SYSTEM

Effective in consistently identifying root causes (repeatable)

Well documented Accompanied by effective user training Credible with the workforce (does not promote

finger pointing and the search for someone to blame)

Helpful in presenting the results to management so that management understands what needs to be fixed

Designed to allow collection, comparison, and measurement of root cause trends

IDEAS FOR SHARING YOUR INCIDENTSIDEAS FOR SHARING YOUR INCIDENTS

Ensure description of incident is clear

Include pictures if possible

Include possible causes

Note: “The possible cause(s) of the incident include the following….”

Include recommended corrective actions

Note: “We recommend that you consider the following course of action to help avoid similar future incidents….”

TAPE RECORDERSTAPE RECORDERS

If you use a tape recorder Ask permission Your name His/her name Day - year - month Time

PHOTOGRAPHYPHOTOGRAPHY

Sketch the area firstTake a lot of pictures Log the photos indicating their

location on the sketchTake from several different angles Take pictures that may not appear to

be relevant Date and sign the pictures when

developed Use objects of known size (a ruler

works well) to give perspective to the pictures

Accident investigation kit suggestionsAccident investigation kit suggestions

◦ Camera with flash and film, 35 mm plus digital is ideal

◦ Writing materials including note paper, graph paper, pens and pencils

◦ Cassette recorder and cassettes ◦ Internal company report forms including chain of

custody form ◦ Ruler and tape measures (16 foot and 100 foot) ◦ Identification tags and Zip lock style bags for

evidence ◦ Barricade tape◦ Gloves ◦ Adhesive tape ◦ Hand tools ◦ Flashlight◦ Binoculars ◦ Spare batteries