Integration of Quality Into Accident Investigation Processes

ASQ Columbia Basin Section 614

John CornelisonJanuary 2008

Failure of weld on blow down system

Presentation Summary

• Outline system processes for investigation, analysis and reporting

• Identify quality points

Key Elements of Accident Investigation

• Reconstruct what happened

• Collection of information

• Analysis of facts

• Determine why it happened

• Develop findings

• Decide on recommendations

• Write report

Performance Logic

• The investigation and analysis processes should produce a finished report

• Investigation and analysis information (facts) should be ready for the final report

• Information is filtered through a group of causal factors

• The investigator needs to place the information in the right report sections

Quality Considerations For AI Processes

• Written plan and procedures and personnel trained to them

• Experienced investigators• Decisions based on facts and not hearsay• Information and evidence collected controlled• Findings and conclusions based on facts• Recommendations address both Systemic

Management findings and Specific work findings• Use of AI Model to drive processes

Advantages of System Approach

• Accidents are complex

• Divides accident information into usable elements

• Focuses on critical barriers and controls

• AI Model ensures minimum processes

• Structured process for traceability and reliability

• Reduces bias

Accident

Accident Model

Sequence of Events

EnergiesBarriers

Controls

Task Performance

Targets

Status of Work Process- Personnel

- Procedures

- Hardware- Environment

OR

Change

- Pre Accident

- Accident

- Post Accident- Prior

- Present

- Adequate- LTA

1) Management Policy drives which barrier and controls used

2) Barriers and controls must be maintained

3) Multiple barriers and controls must be used

5) Management must maintain work processes in an operational readiness state

6) Management must control changes

4) Management must maintain performance acceptable level

Causal Factors

AI Model Quality Points

• Are your current causal analysis and recommendations preventing similar accidents?

• Causal factor selection may be LTA

• Implementation of recommendations may be LTA

• System for investigation and analysis may need to be changed

Sequence of Events

• Accidents involve a sequence of events that set up LTA conditions – work planning

• Investigation method – Event Charting

• Recreates sequence of events, what happened

• Systemic and specific conditions and causal factors

• Is the system functioning as planned

Quality Points

• Sequence of events in correct order based on time and date

• Requires a complete investigation to ensure correct order

• Looks at both systemic and specific events• Identifies missing sequences• Where did the Systemic and Specific

failures occur; in work planning, in implementation or in control processes

Night shift Oper attended safety comm meeting

6/1/2007 1:30:05 AM Event 1

Safety comm mts once per month

Start at beginning night shift

Night shift complete shift at powerhouse

6/1/2007 6:00:00 AM Event 2

Full shift designed with 6 operators

Shift Boiler Oper, Incin Oper, Comp Oper

Shift Lead Oper, Control Rm Oper

Shift Super

Incinerator assumed resp for comp and incinerators

6/1/2007 6:05:00 AM Event 3

Shift designed to function missing 1

Compressor Oper not on site

Day shift short one Operator

Incin , Lead, Control, Boiler Operators exchanged info

6/1/2007 6:10:00 AM Event 4

Shift turnover protocol Oper to Oper

Turnover specific to their area of operation

Regen in chem injectin state

chem caustic soda

Regeneration Demineralization skid ongoing train 2

6/1/2007 6:15:00 AM Event 5

Regen designed for 2 wks or 200,000 gal

Completed during 12 hour shift

If carry over it is during rinse state

Shift Super exchanged turnover notes

6/1/2007 6:16:45 AM Event 6

Barriers and Controls

• All accidents involve failure of barriers and controls

• Investigation Method – Barrier Analysis• Identifies energy sources, physical

barriers, administrative controls and targets

• Evaluates effectiveness of barriers and controls

• Determines reliability of barriers & controls

SYSTEMS APPROACH TO ACCIDENT INVESTIGATIONBARRIER ANALYSIS

Energies/Hazard Physical Barriers Administrative Controls

Targets/Value Evaluate B&C

Quality Points

• Identifies all the hazards

• Separates physical barriers from administrative controls

• Examines mode of failure

• Identifies all potential targets of value– Personnel, Facilities, Processes, Environment

Task Performance

• Accidents involve work performed which is adequate or LTA

• Investigation Method – Task Analysis

• Identifies basic tasks

• Looks for task errors

• Analyzes task errors for “Can Do” and “Motivational Behavioral Climate”

• Questions methods to ensure performance

SYSTEMS APPROACH TO ACCIDENT INVESTIGATIONTASK PERFORMANCE ANALYSIS

EventNo.

Task Description Task Error Evaluate TaskError

RiskLevel

Quality Points

• Identifies tasks with potential for errors that can degrade system

• Identifies task with errors

• Looks at how the task errors occurred in the work processes

• Quality monitoring to ensure critical systems are not affected by task errors

Status of Work Processes

• Accidents involve many work processes

• Each process may be in a different state of readiness

• Investigation Method – Status of the Work Process Review

• Looks closely at personnel, procedures, hardware and environment in OR mode

• Time and interfaces

SYSTEMS APPROACH TO ACCIDENT INVESTIGATIONSTATUS OF WORK PROCESSES ANALYSIS

EventNo.

Personnel Procedures Hardware Environment OR Status RiskLevel

Quality Points

• Investigates the OR status of key elements of the work process– Personnel– Procedures– Hardware– Environment

• Determines when and how the elements lost their OR status

• Set up monitoring points

Change

• Most accidents involve some type of change in the work processes

• Investigation Method – Change Analysis

• Identifies present conditions and prior conditions

• Looks for differences

• Analyzes changes for affects on setting up LTA conditions

SYSTEMS APPROACH TO ACCIDENT INVESTIGATIONCHANGE ANALYSIS

Present Condition Prior Condition Change/Difference Evaluate Affects of Change

Quality Points

• Investigates how changes in the work processes were managed

• Looks at planned and unplanned changes

• Looks at the interface of the changes with the key elements of the work processes

• Looks at how system performance was affected by the changes

Causal Factors

• Reasons or whys for an accident

• Investigation Method – Root Cause Analysis

• Identifies Systemic and Specific causes

• Looks at chain of causes from management to work and back to management

• Groups causes into 27 categories

Systemic Factors

• Management• Policy• Policy Implementation• Risk Assessment• Technical Information• Hazard Analysis• Safety• Appraisals / Audits / Reviews• Change• Procedure• Codes / Standards / Regulations• Design• Human Factors• Quality Assurance / Quality Control

Specific Factors

• Amelioration• Barriers & Controls• Operational Readiness• Maintenance• Inspection• Supervision• Task Performance• Personnel• Training• Environment• Equipment• Communications• Personnel Protective Equipment

Systems Approach to Accident InvestigationCausal Factor Analysis Selection Tree

RC Number

Causal Factor Categories

Root Causes Select 1 or more from RC 1-3

RC 1 Oversight

RC 2 Omission

RC 3 Assumed Risk

Systemic Causal Factors

Select 1 or more from RC 1A-3A

RC 1A Policy

RC 2A Policy Implementation

RC 3A Risk Assessment

Specific Causal Factors

Select 1 or more from DC 1-3

DC 1 BarriersPhysical Equipment

Safety Systems

DC 2 Controls - AdministrativeInformation/CommunicationOperational ReadyMaintenanceInspectionSupervision

DC 3 Task PerformancePerform Task CorrectlyMade Task Error

Contributing Causal Factors

Select 1 or more from CC 1-5

CC 1 PersonnelCriteriaFit For DutyTrainingExperienceMotivated

CC 2 ProceduresWrittenCurrentFollowedMatch work process

CC 3 HardwareDesignHuman FactorsHazard AnalysisQA/QC

CC 4 EnvironmentHot/ColdVibrationNoiseSpaceStress

CC 5 ChangeSpecific Changes

CC 6 Programmatic Programs

Quality Points

• Looks at a complete system of causes

• Systemic and Specific

• Identifies the complete chain of causal factors

• Fixes not just the primary accident causes but all the LTAs in the system

Summary of The Processes

• Use of the Systems Approach Accident Model to drive the investigation

• Focuses on fixing all the LTAs in the system

• Which prevents future accidents

• Use of the systems analysis tools provides valid factual information to accident report

• Maintains high level of performance

Accident Report

• Title Page• Table of Contents• Executive Summary• Facts Section• Analysis Section• Finding Section• Recommendations• Signature• Appendix

Accident

Accident Model

Sequence of Events

EnergiesBarriers

Controls

Task Performance

Targets

Status of Work Process- Personnel

- Procedures

- Hardware- Environment

OR

Change

- Pre Accident

- Accident

- Post Accident- Prior

- Present

- Adequate- LTA

1) Management Policy drives which barrier and controls used

2) Barriers and controls must be maintained

3) Multiple barriers and controls must be used

5) Management must maintain work processes in an operational readiness state

6) Management must control changes

4) Management must maintain performance acceptable level

Causal Factors