Www.energyinst.org Energy Institute LFI work activities: overview 10 December 2013 Stuart King,...

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Energy Institute LFI work activities: overview10 December 2013

Stuart King, Technical Products [email protected]

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Learning from incidents

mailto:[email protected]

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• Highlight some of the issues that industry faces

• Outline EI learning from incidents activities

Aims of this presentation

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About the EI

The Energy Institute (EI) is the professional membership body for individuals and organisations working in energy or a related field.

We promote excellence by developing knowledge, skills and good practice for the benefit of the global energy sector, its people and society.

By being part of the EI, our members ensure they stay informed, engaged and connected in a fast-changing industry.

• 16,000 individual members

• 250 company members

• Professional membership grades

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EI Technical work programme

• Funded technical work programme

• 30+ Technical Partners

• BG Group• BP• Centrica• Chevron• ConocoPhillips• DONG Energy• EDF Energy• ENI• E.ON• ExxonMobil• International Power

• Kuwait Petroleum• Maersk Oil• Murco• Nexen• Phillips 66• Premier Oil• RWE npower• Saudi Aramco• Scottish Power• SGS• Shell

• SSE• Statkraft• Statoil• Talisman• Total• Tullow• Valero• Vattenfall• World Fuel Services

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Learning from incidents (LFI) involves:1) understanding why incidents, near misses, business losses etc.

happened, and 2) making the necessary corrections/improvements to ensure similar

incidents do not happen.

What is learning from incidents?

How we learn, not about what needs to be learned

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Some common issues

Incident investigations often do not go far enough to investigate human and organisational factors issues (i.e. do not always go beyond the immediate causes)- Time & skill of the investigator- Resources linked to severity of incident, not learning potential- Politics, costs, ideology and culture

- Avoiding blame of the individual or organisation- Are people responsible for their own actions? Hard to accept.

How do we embed learning?- Creating good actions for learning- Taking time for reflection – contextualising, engaging workforce

How do we know learning has taken place?- Effectiveness of follow-up actions measured for 6% of incidents


Work streams

• Human and organisational factors committee (HOFCOM)• Process Safety Committee

Technical work programme

• Tripod Beta methodology

Stichting Tripod Foundation

• PhD research• LFI toolkit (in development)

Hearts and Minds

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Guidance on investigating and analysing human and organisational factors aspects of incidents and accidents (2008)

• Why investigate HOF aspects of incidents? – An introduction• Go beyond ‘human error’ being cited as underlying cause in investigations –

it’s not an underlying cause!• Introduction to human failure (error and violation) classifications.• Uses the Tripod causation model of why incidents happen.• Just culture – investigation is not about blame, it’s about learning. • Performance influencing factors • Brief description of 28 proprietary and public investigation and analysis

methodologies.• ‘a line in the sand’

• Referenced on HSE website• Still a well accessed publication.• …. But due for an update

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Guidance on meeting expectations of EI process safety management framework: Element 19: Incident reporting and investigation

• Provides• a flow diagram of activities that

should make up the accident reporting and investigation process.

• Performance measures for monitoring reporting and investigation process performance.

• High level, for informing the safety management system.

• Consistent process

Expected Q2 2014


Work streams






Hearts and Minds


Tripod Beta

• Partnership with the Stichting Tripod Foundation

• Tripod is an established incident investigation and analysis methodology, used internationally and by a range of industries

• Governed by Tripod Board and Tripod Assessors

• Accreditation programme for practitioners and Training courses

Tripod Beta: Guidance on using Tripod Beta in the investigation and analysis of incidents, accidents and business lossesExpected Q1 2014


Work streams





Hearts and Minds


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Reporting

Investigation

Developing inci

dent alerts

Dissemination

Contextualising

Implementing

actions

Business improvement

Change in behaviour

External incident

Internal incident

Hearts and Minds – Learning from incidents toolkit

LFI processMany

organisations stop here

‘The missing link’

Safety issue reported

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Hearts and Minds – Learning from incidents toolkit

• PhD research, Glasgow Caledonian University (2009-2012)• Exploring LFI from an adult learning perspective.• Follow-up project to produce practical toolkit.

Toolkit:Provide exercises to:A) help the organisation understand its LFI processes

• Includes LFI questionnaire

B) engage staff with LFI to contextualise and embed learning• 3 engagement exercises to help engage staff with incidents; apply

learning to own work context.

Next steps: development and testing

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Good practice guidance

Investigation & analysis

tools

Learning & engagement

tools

Where are we going? The LFI landscape

The focus

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Reporting

Initiate investigationWho; Remits; Team; legal;

Etc.

Investigation

Analysis

Developing action items

Learning

Future guidance


Thank you for your time

Any questions?

Www.energyinst.org Energy Institute LFI work activities: overview 10 December 2013 Stuart King,...

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