incident investigation course - cbia - connecticut ... · incident investigation 1 3 incident...

Incident Investigation 1

Incident

Reporting/Investigation CBIA Conference

May 19, 2017

Christopher Mayne, Vice President

Randy M. Feranec Senior Safety Specialist


Have You Seen This in an Incident Report?

• Root Cause:

– The employee failed to follow established procedures.

• Follow-up Recommendation:

– Reviewed procedure with employee

– Disciplined employee

– Reviewed incident in monthly safety meetings


A Common Problem with Incident Investigations

1. Prematurely stopping the investigation at what the

team may call “human error.”

2. Often at “failure of employee to follow

procedures.”

3. Is that the real root cause? Not necessarily

– Were procedures out of date?

– Were they not understood?

– Was there inconsistent enforcement?

– Were there time pressures?

– Were they ambiguous (hard to understand)?

– Was it an accepted practice?

– Many others...


Three Mile Island Nuclear Power Plant 3/28/1979

Initial Root Cause: Control Room Operator Error

• Actual Cause after investigation: Contamination of instrument air several unit upsets/false alarms control room operators did not believe there instrumentation, leading to an assumption and accepted practice loss of reactor control unit shutdown never to restart.

• Did you know? – Virtually the same initiating event occurred a year earlier involving

contaminated instrument air.

– Incident investigation failed to identify the true root causes and implement remedies.


Incident Investigation

A methodology to aid in identifying the actual

root cause(s) of incidents.

A process which should aid in preventing

future incidents.


Process Steps

1 Introduction

2 Conduct Initial Response

- Incident Recognition & Reporting

- Determine the need for a secondary (Level 2) investigation

3 Form Investigation Team

4 Capture Data

5 Analyze Data

6 Develop Recommendations

7 Incident Report

8 Closing the Loop – Management of Change


Introduction

Why are we doing this ?


Objectives

• To Understand;

– What an incident is

– Why we need incident investigation

– What can happen if incident investigation led to wrong corrective

actions

– Why incidents happen...Incident Cause

– How to investigate an incident

– Why it’s important to get the correct information ASAP

– Why preserve the scene

– How to analyze for causes

– How to develop recommendations

– How to write the report

– Use a format that employees will actually use and makes sense for

your site.


Expected Outcomes

You will be able to:

• Conduct high quality Incident Investigations

• Use the Incident Investigation tools

• Identify Direct Causes and Root Causes of

Incidents

The ultimate outcome is fewer future incidents.


0

What is an Incident?

INCIDENT

ACCIDENT or NEAR MISS

ACCIDENT

An undesired event which

did result

in an unwanted impact on safety

or health of people, property

or the environment

NEAR MISS


could have resulted

under slightly different circumstances



or the environment


1

Scope of Incidents

• Involve safety, health or has an environmental impact

• Incidents include: – Injury/Illness (Lost time/Restricted Duty)

– Medical Treatment

– First Aid Cases

– Near misses

– Regulatory compliance violations

– Property Damage

– Security

– Fires

– Fatality

– Spills

– Permit Violations (HOT Work, Confined Space, Fire System Impairment, Energized Electrical Work)


2

Why do we need to do Incident Investigations ?

• To eliminate injuries, protect the environment, and reduce risk

• To reduce number and severity of incidents by

– conducting high quality incident investigations

– being proactive

– determining root causes

– better understanding and modifying the root cause behaviors that result in

incidents

– developing and implementing recommendations.

• To learn lessons from incidents and share across an ORGANIZATION

– HVLI (High Value Learning Incidents) - those with recognized important

lessons that other sites can benefit from.

• To influence local and company-wide improvement plans by

– analyzing “common causes” for multiple incidents


3

Incident Initial conclusion / action Result Actual issue

Equipment failure

Defective equipment /

replaced with same type

Failed again

Material incompatibility

What can happen if the incident investigation led to wrong corrective action?

Pump failed in initial start up

Defective seal / replaced

Repeated failures

Start up procedure: needed

to open discharge side first

Door being opened nearly

struck someone walking

outside

Painted sidewalk red in

area of door movement

as warning

Employee fell, slipped on

paint on humid day

Corrective action created

a new hazard

Leaking hydrogen valve

Cold weather caused

packing to leak / replaced

New valve began to leak

Valve not intended for

hydrogen service

Hand crushed in machine

pinch point while cleaning

Inadequate guarding,

alarms, and interlocks

Installed expensive and

elaborate protection system

Operating conditions were

incorrect and resulted in

unnecessary cleaning


4

Incident Investigation Process

• A specific order of activities is defined to ensure

quality and consistency.

• The major activities include:

– Conduct Initial Response

– Form Investigation Team (Medium & High Level)

– Capture Data (Who, What, Where, When, Why & How)

– Analyze Data

– Develop Recommendations

– Write the Report


5

Conduct Initial

Response


6

Conduct Initial Response

1. Recognizes & Reports the incident

2. Initiate emergency response, if applicable

3. Communicate to Supervisor

4. Secure area

5. Capture facts & data on Initial Incident

Report Form

6. Input incident into Database

7. Determine & Assign Action Items

8. Review with Supervisor & team

9. Review with Management

10. Characterize severity & risk potential

11. Notify others, if applicable

12. Decide level of investigation needed

Employee/

Third party

Immediate

Supervision EHS

Section Sub-Process Steps

Follow emergency response plan which

includes lists for notifications (Site EAP)

HVLI reports from other units

enter process at this step

Invest.

Team

Legal

LOW MEDIUM / HIGHER


7

Once Again…What is an Incident?

INCIDENT

ACCIDENT or NEAR MISS

ACCIDENT


did result



or the environment

NEAR MISS


could have resulted

under slightly different circumstances



or the environment


8

Why Incidents Happen (Incident Causes)

• Three things to consider for the incident process to start:

– Hazard(s) A source of danger with potential to do

harm, e.g. chemical, energy, unsafe

condition or act

– Vulnerable objects Things that can be harmed, e.g.

people, environment, equipment

– Barriers Things that protect vulnerable objects

from the hazards, e.g. well designed

equipment, equipment guards, PPE,

procedures, etc.


9

Determining Cause

HAZARD VULNERABLE

OBJECT

B

A

R

R

I

E

R

• PROCESS

• LOCATION

• MACHINES & TOOLS

• AGENTS

• PEOPLE - UNSAFE BEHAVIOR

ENERGY CONTROLS TO PROTECT

• MANAGEMENT SYSTEMS

• PRACTICES / PROCEDURES

• FACILITIES & TOOLS

• PEOPLE - SAFE BEHAVIOR

• PEOPLE

• PROPERTY

• ENVIRONMENT


0

When Do Incidents Happen?

Hazards + Barriers + Vulnerable Objects = Safe Condition

(Normal Operating Condition)

Hazards - Barriers - Vulnerable Objects = Near Miss

Hazards - Barriers + Vulnerable Objects = Accident

In other words:

– An accident occurs if hazards and vulnerable objects are present

and barriers are less than adequate (LTA).


1

Secure area

• Prevent additional injuries, illness, or incident

escalation

– Operations/work should not resume until it has been

determined to be safe to continue.

– An assessment needs to be carried out to determine if work

can continue or not. Use a simple tool like the TRA/JSA

checklist, TPA, or other local techniques,

• Preserve site/conditions for further investigation

– Barricade (if necessary)

– do not change/move anything unless key for safety reasons

– Take photos


2

Initial Incident Information

• Collect initial incident information

– Every facility should have a management system for Incident

Reporting, Analysis, and Follow-up.

– For all incidents, regardless of severity, the initial information

gathering is the same and is normally the primary responsibility of

First Line Supervision.

– The information generated through the first twelve steps of the

Incident Reporting and Investigation Process is needed regardless

of whether a full team investigation is conducted.


3

Gather / Preserve evidence (Collecting evidence ASAP increases reliability)

• Collect pertinent information.

– identification of actors (persons or equipment that were actively involved)

– record their condition

– identify witnesses

• Record anything unusual at incident scene.

– position, appearance of equipment & tools

– physical agents (e.g. by smelling, hearing sounds)

– situations caused by weather conditions or lighting

• Take photos / video of incident scene or make sketches.

• Secure relevant records :

– Computer data / TDC / alarm system print outs

– Logs (e.g... shift change, preventive maintenance files / records)

– Work permits

– Work plans


4

Make Initial Incident Report

• Remember that this report is the foundation for activities like – further investigation

– Generating / supporting recommended actions

– future common cause analysis

• Utilize the site-specific incident reporting protocol

_ Capture data on Initial Incident Report Form – Input into YOUR SYSTEM (INTELEX,etc.)

• Be as factual as possible

• Do not speculate or include opinions. Just State the Facts !!!!!!!!


5

Critical Information

1. Who

2. What

3. Where

4. When

5. Why

6. How

7. This information fills in the blanks and creates a

timeline of events


6

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A Typical Timeline


7

Characterize Severity & Risk Potential

• The level of severity of the actual or potential

consequence determines the level of investigation.

• Tools and guides to characterize risk potential:

– Incident Categorization Matrix

– Risk Matrix

– Process Safety Measurement System

– Site-specific guidelines


8

For Most Incidents

• Generate Initial Incident Report (G Drive, Safety INCIDENT REPORTING, Initial Incident Report)

• Complete Blood Borne Pathogen Checklist if necessary (G Drive, Safety INCIDENT REPORTING, Blood Borne Pathogen Checklist)

• Enter into your reporting system

• Assign Action Items

• Follow Up as necessary

• If necessary, Start Secondary Investigation Process based on the Severity/Risk Model


9

What was the Cause?

• Incident or Near Miss ?

• What’s next ?

• Write an incident report based on this incident.


0

INCIDENT PROCESS PLOT (Timeline of Events)

1. 23:00 H

2. PROCES CONTROL ROOM

3. C. CHECK

4. GIVES ORDER TO BLOCK THE STEAM COIL IN THE TANK-TK858

REMARKS: DECIDED THAT IT HAD TO BE SOMETHING ELSE. (NOT AN INSTRUMENT

FAILURE) AND TEMPERATURE INDICATOR SHOWED 90 0C IN THE BOTTOM OF TANK

7. C. CHECK

1. 23:15 h

2. TANKFARM

3. TK-858

4. STEAM AND VAPORS (UNDER HIGH

PRESSURE) ARE VENTING FROM

EXHAUST TANK VENT

5. OPERATOR LEAVES SCENE

BEFORE

BLOCKING CONTROL VALVE.

REMARKS

7. P. STORE (TANK FARM

OPERATOR)

1.23:05 h

2. TANKFARM

3. TCV

4. STEAM TEMPERATURE CONTROL

VALVE IN OPEN POSITION

REMARKS

7. P. STORE (TANK FARM OPERATOR)

1. 23:40 h

2. TANKFARM

3. TK-858

4. VENTING VAPOR AND STEAM - ROOF

FAILURE

6. 6 HOURS

REMARKS: NO INJURY DUE TO THE

FACT THAT THE TANK FARM OPERATOR

LEFT THE INCIDENT SCENE WHEN THE

VENTING STARTED. IMPACT ON

ENVIRONMENT NOT YET ESTABLISHED.


23:00 23:40

Process Shift

Supervisor (C.

Check)

Cat Cracker Feed

Storage Tank

(TK-858)

1. 22:00 H

2. PROCESS CONTROL ROOM

3. D. SCREEN

4. HIGH TEMPERATURE ALARM (400F) ACCEPTED

6. 1 HOUR

REMARKS: THOUGHT THAT IT WAS A MALFUNCTIONING

INSTRUMENT

7. C. CHECK

Panel

Operator

(D.Screen)

26 MAY 199122:00

ACTORS

LINE

TIME

LINE

Temperature

Control Valve

1.23:05 h

2. TANKFARM

3. P. STORE (OPERATOR)

4. RESPOND TO ORDER TO BLOCK STEAM

TO COIL IN TK-858

REMARKS


Tank Farm

Operator

(P. Stone)


1

Risk Analysis, Follow-up,

Understanding

Work Practices / People

Equipment / Tools

Procedures

Training

Guidance / Supervision / Monitoring

Management / Leadership

Human Factor Engineering

People / Personal Performance

Communication

Causal Factors Why Tree Getting to Root Cause


2

Causal Factor Why Tree Simplified

INPUT CFWT

CFWT

LEVEL 1

CFWT

LEVEL 3

CFWT

LEVEL 2

EQUIP

MENT /

TOOLS

HUM

AN F

ACTO

R

ENGIN

EERIN

G

WORK P

RACTIC

ES /

PEOPLE

PEOPLE

/PER

SONAL

PERFO

RM

ANCE

PROCEDURES

TRAIN

ING

GUID

ANCE /

SUPER

VIS

ION /

MONIT

ORIN

G

MANAGEM

ENT /

LEAD

ERSHIP

COM

MUNIC

ATIO

N

RIS

K A

NALY

SIS,

FOLL

OW

-UP &

UNDERSTA

NDIN

G

CAUSAL FACTORS

Start

Root Cause Analysis

To SEP

for

Behavior Based

Safety Analysis

Determine

OIMS which were

Less Than Adequate

for each

selected causal factor /

defined cluster

OIMS LTA

List of Direct Cause(s) from

Incident Process Plot:

DC 1. _______________

DC 2. _______________

DC 3. _______________

OUTPUT

CFWT

Prioritized list of single

causal factors or clusters

for each Direct Cause :

1. __________________

__________________

2. __________________

__________________

3. __________________

__________________

Details

Key Behaviors for Analysis :

1. __________________

__________________

2. __________________

__________________


3

Determine Root Causes

• For each selected Causal Factor from the CFWT, do

a separate Root Cause Analysis, identifying the

most important components in your EHS

Management System which were LTA

– For those identified management systems, determine

whether local management system was

» LTA - management system issue

» not understood - execution of management system issue

» not followed - execution/people behavior issue


4

Why use the CFWT

• Forces a logical, deductive analysis with repeatable results.

• Demonstrates visually where information may be missing.

• Demonstrates to others the depth and sensitivity of the

analysis.

• It yields quality identification of Causal Factors and Root

Causes which can be used to develop improvement

recommendations.

– Specific recommendations which are part of the incident report.


Assigning Action Items

• What are we going to do about this ?

• Who’s responsible for doing this ?

• What is the timeframe for completion ?

• How are we going to communicate to others?

3

5


Closing the Loop

• Tracking the action items to completion

• Document your findings

• Communication of Findings

• Training ?

• Documentation Updates ?

• USE YOUR MANAGEMENT OF CHANGE PROCESS

TO ACCOMPLISH ALL OF THE ABOVE !!!

3

6


IN A NUTSHELL ……….

This is an Analytical Troubleshooting Process that

can be used for ANYTHING ………………… QUALITY,

PRODUCTIVITY and SAFETY !!!!!!!!

3

7

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