incident investigation basics - internodejames.redgrove/apcswg/syd2014... · this 2 hour workshop...
TRANSCRIPT
Incident Investigation Basics
UNSW, Kensington 27th November 2014
Who we are
Safety Wise Solutions is a dynamic company based in Melbourne, Australia that provides Workplace Health & Safety consulting and training services.
We work with organisations to develop and implement effective and sustainable improvements in Workplace Health and Safety performance and risk management.
We have 14 consultants based around Australia and one based in Toronto, Canada
Our Services
1. Training
Incident Investigation and Human Factors
2. Consulting
Independent investigation and quality review services
Human factors
HSE system development
Executive coaching 3. Aviation Risk Management Specialist aviation risk management advisory services
What we do
Safety Wise Solutions uses four principles to achieve WHS performance improvement: 1. Proactive analysis through risk assessment and system audits 2. Reactive analysis through effective incident investigation using Incident Cause Analysis Method 3. WHS performance monitoring to improve performance by measuring the right things in real time 4. Training to provide organisations with the skills to manage risk and investigate incidents
Introduction
Purpose
This 2 hour workshop provides an overview of the basics of incident investigation techniques that can be used by those who are required to
look into minor incident that occur in everyday operations
Outline
Module 1 – Overview Incident Investigation Basics Module 2 – A sample case study Module 3 – Facilitated group exercise
Outcome
At the end of the workshop you will have an appreciation of basic incident investigation. You will not be qualified to appear on “CSI Asia Pacific”
A Few Questions?
• What worries you?
• Where will your next incident happen?
• What type of incidents occupy most of your time?
• Had any new incidents lately?
• What’s wrong with what we have been doing for years?
• Are things improving?
Are things improving?
Today’s Operating Environment
Stakeholder &
society demands
Zero H
arm ethical organisation
Management
strategies & decisions
Maxim
um return to shareholder
Keep operating licence
Accident
Incident
Near miss
Flight delay
Poor service
How safe is safe enough?
What price safety?
Prove due diligence
Public expects & demands zero
risk
Repeat incidents are a symptom of poor investigations
and management of corrective actions
Good corporate citizen
Keep Regulator happy
What is Needed:
• A risk-based foundation for management systems
• More sophisticated risk and incident management processes
• Integration of risk management process into the company’s decision making processes
• Using every incident as an opportunity to reduce risk in our business processes and prevent repeat events
Tools for a safe system
Management support understanding & commitment
Safe System Design
Safe conditions
& equipment
Safe operating
procedures
Safe behaviours
Risk
management Compliance
Incident
Investigation
Data Management
Risk based investigation
Likelihood
Consequence
Insignificant Minor Moderate Major Extreme
Almost Certain Significant High High High
Likely
Significant
Moderate Significant Significant High High
Moderate Low Moderate Significant High High
Unlikely Low Low Moderate Significant High
Rare Low Low Moderate Significant Significant
What events should we investigate?
All adverse events should be reported – agreed?
Should all adverse events be investigated?
What determines what should or shouldn’t be investigated?
Changing smoke alarm battery example
What should we change?
Did somebody screw up ?
The role of the
investigator is to
find out why?
The role of
management is to
resource the
investigation and
support the
findings
Shared Responsibility
The Workforce
• Participate in the events
• Bend & break the rules of the events
• Try to complete the events
The Organisation
• Prepares the venue
• Sponsors the participants
• Sets the rules of the events
• Manages the events
• Adjudicates the events
• Sets the goals of the events
ICAM and risk management
Incident Investigation Process
What is the process?
Determine what happened
Collect information to
find out what happened, when did it happen and where
and who was involved.
Interviews
Document review
Examine & test
Environmental data
Organisational issues
Look for facts - PEEPO
People
• Interviews of those involved and witnesses to the event
• Personnel records (work history, training, medical etc)
• 72 hour profiles of those involved (FFW issues)
Environment
• Physical environment at the time of the incident i.e. weather, ambient light, noise, air quality, vibration levels etc
• Position of equipment and personnel
• Housekeeping
Data sources
Equipment
• Physical examination and testing
• Review of equipment records
• Review of operating manuals
• Comparison with new or similar type
Procedures
• Review of applicable procedures, CASR’s, bulletins etc
• The adequacy and utilisation of procedures
• Availability of prescribed tools and safety equipment
Data sources
Organisation
• Roles and responsibilities
• Supervision and manning levels
• Performance targets
• Audit, inspection and incident reports and records Additional data sources
• Applicable regulations, standards and codes of practice
• Site maps, sketches or pre-incident photographs
• Safety data sheets
• Event reconstruction
Data sources
Why did it happen - Analyse findings using ICAM
Workplace Incident
Workforce vs organisational contribution
A Structured Framework
Like sorting the deck into suits
ABSENT OR
FAILED
DEFENCES INDIVIDUAL /
TEAM
ACTIONS TASK /
ENVIRONMENTAL
CONDITIONS ORGANISATIONAL
FACTORS
On 1st July 2012 a welder is injured when the vehicle he was working on fell on him resulting in significant injuries
Absent or Failed Defences
Individual/ Team Actions
Outcomes Task/ Environment Conditions
Organisational Factors
Absent No hydraulic
hoist available
Failed Prop dislodged
Absent No wheel ramps
available
Welder worked under a poorly
supported vehicle
Supervisor directed the
welder to do the work The vehicle had
broken down in service was need
urgently
Ground beneath vehicle was
unsealed with a high clay content
The ground was wet from a recent
rain event resulting in a low friction surface.
There was no spare vehicle
available
MM LV’s were over running their PM schedule
MC Operational workload had increased and there was a shortage of LV’s to meet the demand
MC there was no 3rd party maintenance contract in place for PM over run or peak periods
MM the workshop was fully booked out with HV maintenance
Failed JSA did not identify the
potential for the vehicle to fall
The workshop was full
On 1st July 2012 a welder is injured when the vehicle he was working on fell on him resulting in significant injuries
Absent or Failed Defences
Individual/ Team Actions
Outcomes Task/ Environment Conditions
Organisational Factors
Absent No hydraulic
hoist available
Failed Prop dislodged
Absent No wheel ramps
available
Welder worked under a poorly
supported vehicle
Supervisor directed the
welder to do the work The vehicle had
broken down in service was need
urgently
Ground beneath vehicle was
unsealed with a high clay content
The ground was wet from a recent
rain event resulting in a low friction surface.
There was no spare vehicle
available
MM LV’s were over running their PM schedule
MC Operational workload had increased and there was a shortage of LV’s to meet the demand
MC there was no 3rd party maintenance contract in place for PM over run or peak periods
MM the workshop was fully booked out with HV maintenance
Failed JSA did not identify the
potential for the vehicle to fall
The workshop was full
Must be addressed with a recommendation
Recommendations for corrective action Must have a direct link back to the incident and must target :
• Prevention of recurrence
• Reduction of risk Must address each :
• Absent or failed defences - risk controls
• Organisational Factor - prevention strategies and risk reduction Not all contributing factors can be completely eliminated, and some may be eliminated only at a prohibitive cost. The investigation team should work with line management in the development of corrective actions.
What are we going to do about it?
Recommendations
1. Conduct strategic review of LV fleet to ensure adequate capacity to meet operational requirements and to ensure spare capacity to maintain PM schedule.
2. Audit LV PM program and develop maintenance plan to cover PM overruns
3. Tender contract for 3rd party LV maintenance to increase capability and workshop availability
4. Source wheel ramps for in field maintenance
Poor application of hierarchy of control
What did we learn that we can share?
Incident reports
Team briefings
Safety alerts
Investigator in full flight