Betashow.ppt 1999 Shell International Exploration and Production B.V.
Tripod-BETATripod-BETA
Incident Investigation and Analysis
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Incidents are an indicator to improve our performance
Understanding Understanding whatwhat happened and happened and whywhy
enables us to enables us to improve our improve our
businessbusiness
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Structure of the HSE Management System
Leadership and Commitment
Policy and Strategic Objectives
Management Review
Corrective Action & Improvement
Audit
Organisation, ResponsibilitiesResources, Standards & Doc.
Corrective Action & Improvement
Tripod Beta
Monitoring
Planning & Procedures
Hazard and Effects Management
Implementation
Corrective Action
Betashow.ppt 1999 Shell International Exploration and Production B.V.
What is Tripod-BETA ?What is Tripod-BETA ?
A methodology for incident analysis during an investigation ...
combining concepts of hazard managementand ...
the Tripod theory of accident causation.
Betashow.ppt 1999 Shell International Exploration and Production B.V.
How does Tripod-BETA work ?How does Tripod-BETA work ?
The incident facts are built into a tree diagram showing ...
- What happened ...
- What hazard management elements failed and
- Why each element failed.
Betashow.ppt 1999 Shell International Exploration and Production B.V.
What does the software do ?What does the software do ?
The software:
Stores investigation facts
Provides tree-building graphics
Checks the implicit tree logic
Attaches data to tree elements
Assembles attached data into a draft report.
Betashow.ppt 1999 Shell International Exploration and Production B.V.
How does the tree work ?How does the tree work ?
Let’s walk through a simple incident
introducing the terminology
and logic
that underpins Tripod-BETA
Betashow.ppt 1999 Shell International Exploration and Production B.V.
The IncidentThe Incident
Location: an offshore platform
Incident: an operative coming off shift slips and falls in the shower room
Consequence: he hurts his back and is off work
In the past three months there have been two similar incidents
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Initial FindingsInitial Findings
The incident occurred at 1820 hours
The operative slipped on the wet floor
Cleaning staff are supposed to keep the shower room floor dry
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Starting a Tripod TreeStarting a Tripod Tree
We start by identifying:
An EVENT - where a hazard and a target get together
A TARGET - a person or an object that was harmed
A HAZARD - the thing that did the harm
Betashow.ppt 1999 Shell International Exploration and Production B.V.
The Hazard, Event, Target TrioThe Hazard, Event, Target Trio
They are shown in a Tripod tree like this:
Hazard
Event
Target
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Hazard, Event & TargetHazard, Event & Target
In this incident:
The HAZARD is : Wet floor (slipping hazard)
The EVENT is : Operative falls in shower room
The TARGET is : Operative
Betashow.ppt 1999 Shell International Exploration and Production B.V.
HET DiagramHET Diagram
The Hazard,
Wet floor (slipping hazard)
Event
Target
Betashow.ppt 1999 Shell International Exploration and Production B.V.
HET DiagramHET Diagram
The Hazard, acting on the Target,
Wet floor (slipping hazard)
Event
Operative
Betashow.ppt 1999 Shell International Exploration and Production B.V.
HET DiagramHET Diagram
The Hazard, acting on the Target, resulted in the Event
Wet floor (slipping hazard)
Operative falls in shower room
Operative
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Is the investigation complete ?Is the investigation complete ?
Does this show full understanding ?
Finding: The man must have been careless
Recommendation: He should take more care on a wet floor
Or is there something more ?
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Was the incident preventable ?Was the incident preventable ?
We know that a hazard management measure was in place
Cleaning staff were assigned to keep the floor dry
That ‘barrier’ to the incident failed
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Failed BarrierFailed Barrier
The barrier should have controlled the hazard
Hazard
Event
Target
FailedBarrier
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Incident MechanismIncident Mechanism
The incident mechanism looks like this:
Wet floor (slipping hazard)
Operative falls in shower room
Operative
Floordrying
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Further InvestigationFurther Investigation
What caused the barrier to fail ?
The cleaner could not keep the floor dry ...
because the shower room was always congested between 1800 and 1900 hrs
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Active FailureActive Failure
An Active Failure defeated the barrier
Wet floor (slipping hazard)
Operative falls in shower room
Operative
Floor drying
ActiveFailure
Active Failure
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Active FailureActive Failure
An Active Failure defeated the barrier
Wet floor (slipping hazard)
Operative falls in shower room
Operative
Floor drying
Cleaner unable to keep floor dry
Active Failure
Betashow.ppt 1999 Shell International Exploration and Production B.V.
End of Investigation ?End of Investigation ?
Is this the end of the investigation ?
Finding: The cleaner was incompetent
Recommendation: Cleaner should be replaced or retrained
Or is there still something more ?
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Further InvestigationFurther Investigation
We know that congestion was a factor that prompted the active failure
Telephones are only available for private calls up till 1900 hrs
The congestion is caused by day shift crew hurrying to call home
Betashow.ppt 1999 Shell International Exploration and Production B.V.
The Full PictureThe Full Picture
Now we have the full picture:
The congestion is a ‘Precondition’ that influenced the cleaner’s task
Restriction on telephones is a ‘Latent Failure’ that created the precondition
Betashow.ppt 1999 Shell International Exploration and Production B.V.
PreconditionPrecondition
Wet floor (slipping hazard)
Operative falls in shower room
Operative
Floor drying
Precondition
Precondition
Cleaner unable to keep floor dry
Active Failure
Betashow.ppt 1999 Shell International Exploration and Production B.V.
PreconditionPrecondition
Wet floor (slipping hazard)
Operative falls in shower room
Operative
Floor drying
Congestion1800 - 1900 hrs
Precondition
Cleaner unable to keep floor dry
Active Failure
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Latent FailureLatent Failure
Wet floor (slipping hazard)
Operative falls in shower room
Operative
Floor drying
Latent Failure
Latent FailureCongestion
1800 - 1900 hrs
Precondition
Cleaner unable to keep floor dry
Active Failure
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Latent FailureLatent Failure
Wet floor (slipping hazard)
Operative falls in shower room
Operative
Floor drying
Latent Failure
Restriction onprivate phone calls
Congestion1800 - 1900 hrs
Precondition
Cleaner unable to keep floor dry
Active Failure
Betashow.ppt 1999 Shell International Exploration and Production B.V.
RecommendationsRecommendations
Action items should address:
The failed barrier ...to restore safe conditions on a temporary basis(provide extra cleaner between 1800 and 1900)
The latent failure ... to remove the underlying cause(extend the availability of shore telephone)
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
That was a simple example
The Tripod-BETA methodology can also be applied in complex events
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
Identify the prime Event,
Fire
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
Identify the prime Event, the Hazard,
Ignition
Fire
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
Identify the prime Event, the Hazard, and Target.
Flammable Gas Cloud
Ignition
Fire
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
If, say, the target was created by a prior event
Flammable GasCloud
Ignition
Fire
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
Identify the hazard ...
Event & Target
DroppedObject
Flammable GasCloud
Ignition
Fire
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
and target for that event.
Gas Line
DroppedObject
Flammable GasCloud
Ignition
Fire
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
Similarly, if a consequential event happens ...
Gas Line
DroppedObject
Flammable GasCloud
Ignition
Damage to Platform
Fire
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
because the prime event created a new hazard,
Gas Line
DroppedObject
Flammable GasCloud
Ignition
Damage to Platform
Fire
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
identify the target for the new event.
Fire
IgnitionSource
Gas Line
Flammable Gas Cloud
Dropped Object
Platform
Damage to Platform
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
Identify failed ‘barriers’,
FailedBarrier Fire
IgnitionSource
Gas Line
Flammable Gas Cloud
Dropped Object
Platform
Damage to Platform
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
and missing ones ...
MissingBarrier
FailedBarrier Fire
IgnitionSource
Gas Line
Flammable Gas Cloud
Dropped Object
Platform
Damage to Platform
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
including multiple failures ...
FailedBarrier
FailedBarrier
MissingBarrier
FailedBarrier Fire
IgnitionSource
Gas Line
Flammable Gas Cloud
Dropped Object
Platform
Damage to Platform
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
on each relevant ‘trajectory’ ...
MissingBarrier
FailedBarrier
FailedBarrier
FailedBarrier
MissingBarrier
FailedBarrier Fire
IgnitionSource
Gas Line
Flammable Gas Cloud
Dropped Object
Platform
Damage to Platform
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Events
until the Incident Mechanism is complete.
MissingBarrier
MissingBarrier
FailedBarrier
FailedBarrier
FailedBarrier
MissingBarrier
FailedBarrier Fire
IgnitionSource
Gas Line
Flammable Gas Cloud
Dropped Object
Platform
Damage to Platform
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex EventsShow the Active Failure for each barrier, ...
ActiveFailure
Active Failure
MissingBarrier
MissingBarrier
FailedBarrier
FailedBarrier
FailedBarrier
MissingBarrier
FailedBarrier Fire
IgnitionSource
Gas Line
Flammable Gas Cloud
Dropped Object
Platform
Damage to Platform
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Eventsthe Precondition(s) promoting each active
failure, ...
FailedBarrier
FailedBarrier
MissingBarrier
MissingBarrier
FailedBarrier
FailedBarrier
Event
Event & Hazard
Hazard
Target
Target
ActiveFailure
Active Failure
Precondition
Precondition
Event & Target
Hazard
MissingBarrier
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex Eventsand the Latent Failure behind each
precondition.
FailedBarrier
Failed Barrier
MissingBarrier
MissingBarrier
FailedBarrier
FailedBarrier
Event
Event & Hazard
Hazard
Target
Target
Latent Failure
LatentFailure
ActiveFailure
Active Failure
Precondition
Precondition
Event & Target
Hazard
MissingBarrier
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Complex EventsComplex EventsComplete a ‘Tripod path’ for each barrier.
FailedBarrier
FailedBarrier
MissingBarrier
MissingBarrier
FailedBarrier
FailedBarrier
Event
Event & Hazard
Hazard
Target
Target
Latent Failure
LatentFailure
ActiveFailure
Active Failure
Precondition
Precondition
Latent Failure
LatentFailure
ActiveFailure
Active Failure
Precondition
Precondition
Event & Target
Hazard
MissingBarrier
Betashow.ppt 1999 Shell International Exploration and Production B.V.
The completed Tripod-BETA treeThe completed Tripod-BETA tree
FailedControl
FailedBarrier
MissingBarrier
MissingBarrier
FailedBarrier
FailedBarrier
Event
Event & Hazard
Hazard
Target
Target
Latent Failure
LatentFailure
Latent Failure
LatentFailure
Latent Failure
LatentFailure
ActiveFailure
Active Failure
Precondition
Precondition
Latent Failure
LatentFailure
ActiveFailure
Active Failure
Precondition
Precondition
Latent Failure
LatentFailure
ActiveFailure
Active Failure
Precondition
Precondition
Latent Failure
LatentFailure
Precondition
Precondition
Event & Target
Hazard
Latent Failure
LatentFailure
MissingBarrier
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Structure of the HSE Management System
Leadership and Commitment
Policy and Strategic Objectives
Management Review
Corrective Action & Improvement
Audit
Organisation, ResponsibilitiesResources, Standards & Doc.
Corrective Action & Improvement
Tripod Beta
Monitoring
Planning & Procedures
Hazard and Effects Management
Implementation
Corrective Action
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Long term action to reduce latent failuresLong term action to reduce latent failures
latent failure
latent failure
precondition
precondition
active failure
Replace the failed barrierReplace the failed barrier
Corrective Actions
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Corrective Actions
If the barriers have not been replaced you should question why operations have restarted
Actions to replace barriers are normally on site
Latent Failures are deep seated do not expect to remove them tomorrow
Action to tackle latent failures are normally at management level
Betashow.ppt 1999 Shell International Exploration and Production B.V.
Tripod-BETATripod-BETA
Brings a structure to investigation
Helps distinguish relevent facts
Makes causes and effects explicit
Encourages team discussion
Reduces the report writing task
Betashow.ppt 1999 Shell International Exploration and Production B.V.
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