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HSES EXCELLENCE
Developed by J. Ray McDermott HSES
ACCIDENT/INCIDENT ACCIDENT/INCIDENT INVESTIGATIONINVESTIGATION
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Course ObjectiveCourse Objective• To gain the knowledge skill and ability
required to enable successful candidates to complete an Incident Investigation as per the requirements of JRM’s HSES Management System– JRM-1407-001
• HSES Guidelines Section 12.3– JRM-Global-HSES-002-7
• HSES Administration Manual Section 2.5
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Investigation DefinitionInvestigation Definition• To derive a level of understanding from a
systematic gathering and subsequent analysis of information (FACTS)
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
InvestigationInvestigation• Watch the film and prepare a brief summary
of what caused the incident.
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
InvestigationInvestigation
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Accident/IncidentAccident/Incident• Accident;
– Contact with an energy source beyond the threshold limit of the body or structure resulting in a downgrading of the business process (causes loss)
• Incident– Anything that could or does downgrade the
business process (causes loss)
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Why InvestigateWhy Investigate• To;
– Prevent a reoccurrence– Gather data and identify trends– Accountability
• Internal (discipline)• External (legal)
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Legislation and StandardsLegislation and Standards• Occupational Safety and Health Administration
OSHA;– 29 CFR Part 1904; 1904.1
• International Maritime Organization– International Safety Management Code (ISM); Section 9
• International Standards Organization (ISO)– Fault Failure Analysis
• Occupational Health and Safety Management Systems (OHSAS 18001); Section 4.5
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Why Investigate IncidentsWhy Investigate Incidents• Safety is like Health & Happiness, it’s not missed until it’s
gone. • We never measure our actions in terms of potential lives
saved yet we monitor Near Miss & High Potential Incidents.• Before starting a job, ask yourself “How will I answer the
investigators questions”?
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Hazard ControlHazard Control• All incidents are caused because a HAZARD was not
adequately controlled– HAZARD…A physical condition, act or omission with loss causing
potential
• All HAZARDS have associated RISK– RISK… Severity (how serious) X Probability (likelihood)
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Risk ManagementRisk Management• Every hazard has a degree of associated
risk• If Unacceptable levels of risk are accepted
then the incident rates are likely to be high
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
SafetySafety• Safety…A judgment as to the acceptability /
tolerability of risk– Facilities/individuals who tolerate risks above
what has been deemed acceptable (policy, procedure, codes, standards, etc.) are likely to have excessive incident rates.
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
ALARPALARP• Risks must be mitigated to As Low As
Reasonably Practicable– Returns justifies the Effort– Impact Versus Effort
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Incident Cost
Current Profit Margin
5% 10% 15% 20% 25%
500,000 10,000,000 5,000,000 3,333,000 2,500,000 2,000,000
1,000,000 20,000,000 10,000,000 6,666,000 5,000,000 4,000,000
5,000,000 100,000,000 50,000,000 33,333,000 25,000,000 20,000,000
10,000,000 200,000,000 100,000,000 66,666,000 50,000,000 40,000,000
15,000,000 300,000,000 150,000,000 100,000,000 75,000,000 60,000,000
20,000,000 400,000,000 200,000,000 133,333,000 100,000,000 80,000,000
30,000,000 600,000,000 300,000,000 200,000,000 150,000,000 120,000,000
50,000,000 1,000,000,000 500,000,000 333,333,000 250,000,000 200,000,000
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Uninsured CostsUninsured Costs• Uninsured costs can cover a wide range or aspects such as the
following;– Building damage– Damage to tools and equipment– Production delays– Damage to reputation– Product and Material damage– Wages paid to injured personnel for lost time– Wages paid other than compensation– Overtime – Extra Supervisors’ time– Decreased output– Cost of training new workers– Cost of training back-up workers– Clerical time– Travel expenses
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Safety Management SystemsSafety Management Systems• Incidents are indicative of system failure
– Systems must be constantly improved and upgraded– Incident Investigations point to areas requiring improvement
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Incident Ratio StudyIncident Ratio Study
1
1030
600
Fatality, Lost Time
Restricted Work,Medical Treatment, First Aid
Property Damage, Spill
Near Miss, UnSafeBBSM Observation
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Cause and Effect SequenceCause and Effect Sequence
1Management
System Failure
2Root Causes
3Immediate Causes
4Incident
5LOSS
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
The IncidentThe Incident
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Investigation TeamInvestigation Team• Will consist of the following personnel, as
required by company procedures;– HSE Representative/Manager– Division/Area/Regional Manager– Facility Personnel– Personnel Involved– Technical Resource Personnel
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Allocation of DutiesAllocation of Duties• Consider the following;
– Ability to Interrelate with People • Language, culture, jargon
– Technical Knowledge and Capability • Individual area of expertise
– Physical Condition • Physical size, medical restrictions, phobias
– Training • Members must be certified to conduct an investigation
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
PreparationPreparation• Investigate all Incidents
– Do not have pre-conceived opinions (You might be proven to be wrong. Recall initial exercise results)
– Inform relevant personnel– Assemble a competent team
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Investigation ToolsInvestigation Tools• Tools used in Incident Investigations
include, but are not limited to;– Camera: 35 mm; digital; video– Writing tools– Paper (waterproof is available)– Tape measures (25 and 150 foot/8 and 30 meter); and ruler– Audio Recorder– Flagging and barrier tape– PPE
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Barriers to InvestigationsBarriers to Investigations• Hostility towards team• Condemnation of management• Paranoid feelings of persecution• Lack of concern by team or facility personnel• Time constraints and regular duties• Competence of investigation team• Pre-conceived ideas• Cultural issues relating to required interaction with team• Legal intervention
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Physical EvidencePhysical Evidence• As with any formal investigations, physical
evidence provides key data in our ability to determine the following;– What– Why– When– Where– Who– How
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Scene PreservationScene Preservation• Have the scene isolated prior to the arrival of the
Investigator / Investigation Team• Preserve evidence• If it is not possible to isolate and preserve evidence prior to
the Team arrival, have the scene photographed, sketched and / or video taped in detail
• Normal working status at the scene cannot resume until a return to work form has been completed or the Area VP has provided written approval.
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Gathering EvidenceGathering Evidence• People• Positions• Parts• Paper
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
PeoplePeople• Have witnesses make a statement• Review statements• Identify who you will want to interview• Formulate a list of questions• Nominate a spokesperson with technical knowledge and
try not to use an interpreter
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Interview TechniqueInterview Technique• Conduct the interview as soon as possible• Show consideration for what people have been through• Ensure the interview is conducted in a relevant but safe
location• Assess timing of the interview• Interview separately
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Interview Technique Interview Technique (cont(cont’’d)d)
• Reassure the person being interviewed• Let the person tell their story starting well before the
incident and continuing after the event• Keep on track but don’t interrupt• Listen, hear and understand• Don’t take extensive notes first time around
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Interview Technique Interview Technique (cont(cont’’d)d)
• Tape if possible, ask permission• Target aspects of the cause and effect sequence• Relate the basis of the interview back to the witness to
ensure you understand the concept• Keep the line open for future discussion• Take a break and formulate new questions• End on a positive note
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
ReRe--enactmentenactment• Ensure that the incident is not repeated• Use only as a last resort if there is no other way to obtain
information
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Position/EnvironmentPosition/Environment• Drawings and Sketches• Helps visualize what happened• Document important information• Label clearly and use scale
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Position/Environment Position/Environment (cont(cont’’d)d)
• Photographs• Easier than drawing and more accurate• Excellent training aids• Photograph from all sides• Photo the general scene then use the long/medium/close-
up sequence• Use a known object (pencil, coin, bill, foot, etc.) to show
scale• Use a camera that you are familiar with
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Position/Environment Position/Environment (cont(cont’’d)d)
• Physical Conditions• Obscuring phenomena• Temperature• Wind• Vessel Movement
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
PartsParts• Tools
• Adequate, worn, ergonomic
• Equipment• Guarded, functional, fit for purpose
• Materials• Hazardous, heavy, sharp, defective
• Facilities• Housekeeping, industrial hygiene, crowding
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Parts Parts (cont(cont’’d)d)
• Proper items for task• Damage• Previous damage• Wear Safeguards• Labels, signs, markings• Manufacturer’s specification
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
PaperPaper• Policies and Procedures• Permits• Meeting Minutes• Certificates• Position Descriptions• Regulations• Training Records• Fitness for Work
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Paper Paper (cont(cont’’d)d)
• Eye Witness Reports• Maintenance Records• Manufacturer Supplied Information• Logs and Schedules
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Information AnalysisInformation Analysis• Information will be analyzed using the ‘Root Cause
Analysis’ system– The system goes beyond identification of Symptoms’ and identifies
Basic / Root Causes
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Casual AnalysisCasual Analysis• List Event Sequence (Reference TRA if applicable)
– Create a story board using stickies
• List Causal Factors for Each Step– Causal Factor…An inadequately controlled hazard (physical
condition, act or omission with loss causing potential), reference Hazard Control column on the TRA, if applicable
– Add to the story board using different color stickies
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Story BoardStory BoardEvent 1
Event 2
Causal Factor
Causal Factor
Causal Factor
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Cause SequenceCause Sequence• When a System failure occurs Root causes exist• When Root causes exist they allow for the existence of
Immediate causes• Immediate causes are symptomatic and lead directly to
Incidents
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Cause Sequence Cause Sequence (cont(cont’’d)d)
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
System Failure CategoriesSystem Failure CategoriesA1 Design/Engineering
ProblemA2 Equipment/Material
ProblemA3 Human Performance
Less Than Adequate
A4 Management Problem A5 Communications Less Than Adequate
A6 Training Deficiency A7 Other Problem
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Immediate CausesImmediate CausesA1.1 Design Input Less Than Adequate
A2.1 Calibration for Instruments Less Than Adequate
A3.1 Skill Based Error A4.1 Management Methods Less Than Adequate
A5.1 Written Communications Method of Presentation
A6.1 No Training Provided
A7.1 External Phenomena
A1.2 Design Output Less Than Adequate
A2.2 Periodic/Corrective Maintenance Less Than Adequate
A3.2 Rule Based Error A4.2 Resource Management Less Than Adequate
A5.2 Written Communication Content Less Than Adequate
A6.2 Training Methods Less Than Adequate
A7.2 Radiological/Hazardous Material Problem
A1.3 Design Documentation Less Than Adequate
A2.3 Inspection/Testing Less Than Adequate
A3.3 Knowledge Based error
A4.3 Work Organization and Planning Less Than Adequate
A5.3 Written Communication Not Used
A6.3 Training Material Less Than Adequate
A1.4 Design/Installation Verification Less Than Adequate
A2.4 Material Control Less Than Adequate
A3.4 Work Practices Less Than Adequate
A4.4 Supervisory Methods Less Than Adequate
A5.4 Verbal Communication Less Than Adequate
A1.5 Operability of Design/Environment Less Than Adequate
A2.5 Procurement Control Less Than Adequate
A4.5 Change Management Less Than Adequate
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Action PlanAction Plan• Once reports have been submitted, action
must be taken to;– Address identified problems
• Usually an element within the Safety Management System– Implement specific action steps required to eliminate the problem
• Must target Root Causes
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Root CausesRoot CausesA1 DESIGN / ENGINEERING PROBLEM
A2 EQUIPMENT / MATERIAL PROBLEM
A3 HUMAN PERFORMANCE LESS THAN ADEQUATE
A4 MANAGEMENT PROBLEM
A5 COMMUNICATIONS LESS THAN ADEQUATE
A6 TRAINING DEFICIENCY
A7 OTHER PROBLEM
A1.1 Design Input Less Than Adequate
A2.1 Calibration for Instruments Less Than Adequate
A3.1 Skill Based Error A4.1 Management Methods Less Than Adequate
A5.1 Written Communications Method of Presentation
A6.1 No Training Provided
A7.1 External Phenomena
A.1.1.1 - Design input cannot be met
A2.1.1 - Calibration LTA A3.1.1 - Check of work was LTA
A4.1.1 - Management policy guidance / expectations not well- defined, understood or enforced
A5.1.1 - Format deficiencies
A6.1.1 - Decision not to train
A7.1.1 - Weather or ambient conditions LTA
A1.1.2 - Design input obsolete
A2.1.2 - Equipment found outside acceptance criteria
A3.1.2 - Step was omitted due to distraction
A4.1.2 - Job performance standards not adequately defined
A5.1.2 - Improper referencing or branching
A6.1.2 - Training requirements not identified
A7.1.2 – Power failure or transient
A1.1.3 - Design input not correct
A2.2 Periodic/Corrective Maintenance Less Than Adequate
A3.1.3 - Incorrect performance due to mental lapse
A4.1.3 – Management direction created insufficient awareness of the impact of actions on safety / reliability
A5.1.3 - Checklist LTA A6.1.3 - Work incorrectly considered “skill-of-the- craft”
A7.1.3 – External fire or explosion
A1.1.4 - Necessary design input not available
A2.2.1 - Preventive maintenance for equipment LTA
A3.1.4 - Infrequently performed steps were performed incorrectly
A4.1.4 - Management follow-up or monitoring of activities did not identify problems
A5.1.4 - Deficiencies in user aids (charts, etc.)
A6.2 Training Methods Less Than Adequate
A7.1.4 – Other natural phenomena LTA
A1.2 Design Output Less Than Adequate
A2.2.2 - Predictive maintenance LTA
A3.1.5 – Delay in time caused LTA actions
A4.1.5 - Management assessment did not determine causes of previous event or known problem
A5.1.5 - Recent changes not made apparent to user
A6.2.1 - Practice or “hands-on” experience LTA
A7.2 Radiological/Hazardou s material Problem
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
ResponsibilityResponsibility• Who will be responsible for each step?
• Personnel must accept ‘responsibility’• Personnel must have ‘authority’• Personnel must be held ‘accountable’
• Realistic target dates must be set
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
ActionsActions• Corrective
– Target Immediate Causes– Immediate actions to prevent recurrence or escalation
• Barricades• Toolbox talk
• Preventive– Target Root Causes– Long term solutions to prevent recurrence
• Training• Management of change
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Follow UpFollow Up• This is the most important step in the
Investigation Sequence– Monitoring of actions determines the level of remedial actions
accuracy– Remedial actions that have been started can be modified if
necessary– It determines the accuracy of the Investigation
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Initial ReportInitial Report• The Investigator / Investigation Team will;
– Analyze the information gathered– Compile a preliminary report– Submit the report as per company/project/OU reporting procedures
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
Final ReportFinal Report• The Investigator / Investigation Team will;
– Analyze the information gathered– Compile a final report– Submit to OU Legal Department for clearance– Submit the report as per company/project/OU reporting procedures
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
SupervisorSupervisor’’s Responsibilitys Responsibility• Incidents should make Managers ask
themselves;– What is the real cause?– Did this person have the proper knowledge, skill and motivation?– Is there a physical or mental problem that was missed?– What could I have done to prevent this from happening?
HSES EXCELLENCE
Developed by J. Ray McDermott HSES
SummarySummary