incident management overview by shawn messier
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Please make yourself comfortable.
We will begin shortly.
Incident Management
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Objectives
“All Work Related Incidents Are Preventable”
Ø Understanding the Incident Management Process
Ø Provide an overview of the different causation models
Ø Understanding and distinguishing common and underlying causes and contributing factors, including organizational and corporate level causes
Ø Recognizing and removing bias and its influence in incident investigation outcomes
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Top 10 Most Expensive Accidents in History
“All Work Related Incidents Are Preventable”
10. Titanic $150 Million
9. Tanker Truck vs Bridge $358 Million
On April 15, 1912, the Titanic sank on its maiden voyage and
was considered to be the most luxurious ocean liner ever built.
Over 1,500 people lost their lives when the ship ran into an
iceberg and sunk in frigid waters. The ship cost $7 million to
build ($150 million in today's dollars).
On August 26, 2004, a car collided with a tanker truck containing
32,000 liters of fuel on the Wiehltal Bridge in Germany. The tanker
crashed through the guardrail and fell 90 feet off the A4 Autobahn
resulting in a huge explosion and fire which destroyed the load-
bearing ability of the bridge. Temporary repairs cost $40 million
and the cost to replace the bridge is estimated at $318 Million.
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Top 10 Most Expensive Accidents in History
“All Work Related Incidents Are Preventable”
8. MetroLink Crash $500 Million On September 12, 2008, in what was one of the worst train
crashes in California history, 25 people were killed when a
Metrolink commuter train crashed head-on into a Union Pacific
freight train in Los Angeles.
7. B-‐2 Bomber Crash $1.4 Billion
This B-2 stealth bomber crashed shortly after taking off from an
air base in Guam on February 23, 2008. This was 1 of only 21
ever built and was the most expensive aviation accident in
history. Both pilots were able to eject to safety.
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Top 10 Most Expensive Accidents in History
“All Work Related Incidents Are Preventable”
6. Exxon Valdez $2.5 Billion
On March 24, 1989, 10.8 million gallons of oil was spilled
when the ship's master, Joseph Hazelwood, left the controls
and the ship crashed into a Reef. The cleanup cost Exxon $2.5
billion.
5. Piper Alpha Oil Rig $3.4 Billion
The world's worst off-shore oil disaster. Spewing out
317,000 barrels of oil per day. Within 2 hours, the 300
foot platform was engulfed in flames. It eventually
collapsed, killing 167 workers and resulting in $3.4
Billion in damages.
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Top 10 Most Expensive Accidents in History
“All Work Related Incidents Are Preventable”
4. Challenger Explosion $5.5 Billion
The Space Shuttle Challenger was destroyed 73 seconds
after takeoff due on January 28, 1986. The cost of
replacing the Space Shuttle was $2 billion in 1986 ($4.5
billion in today's dollars). The cost of investigation,
problem correction, and replacement of lost equipment
cost $450 million from 1986-1987 ($1 Billion in today's
dollars).
3. PresOge Oil Spill $12 Billion On November 13, 2002, the Prestige oil tanker was
carrying 77,000 tons of heavy fuel oil when one of its
twelve tanks burst during a storm off Galicia. Total
cleanup cost $12 billion.
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Top 10 Most Expensive Accidents in History
“All Work Related Incidents Are Preventable”
2. Space ShuQle Columbia $13 Billion
The Space Shuttle Columbia was destroyed during re-
entry over Texas on February 1, 2003 after a hole was
punctured in one of the wings during launch 16 days
earlier. The original cost of the shuttle was $2 Billion in
1978. That comes out to $6.3 Billion in today's dollars.
$500 million was spent on the investigation, making it
the costliest aircraft accident investigation in history. The
search and recovery of debris cost $300 million.
In the end, the total cost of the accident (not including
replacement of the shuttle) came out to $13 Billion
according to the American Institute of Aeronautics and
Astronautics.
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Top 10 Most Expensive Accidents in History
“All Work Related Incidents Are Preventable”
1. Chernobyl $200 Billion
On April 26, 1986, the world witnessed the costliest accident in history. The Chernobyl disaster has been called the biggest socio-economic catastrophe in peacetime history. Ø 50% of the area of Ukraine is in some way contaminated. Ø Over 200,000 people had to be evacuated and resettled
while 1.7 million people were directly affected by the disaster.
Ø The death toll attributed to Chernobyl, including people
who died from cancer years later, is estimated at 125,000. Ø The total costs including cleanup, resettlement, and
compensation to victims has been estimated to be roughly $200 Billion.
Ø The cost of a new steel shelter for the Chernobyl nuclear
plant will cost $2 billion alone.
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What Do They Have In Common?
“All Work Related Incidents Are Preventable”
Ø The stage had already been set for the incident to occur by the presence of Latent
Failures - Technical or Human. Ø Deficiencies in the structure of responsibilities and accountabilities within the
organizations of the way it goes about its business which are not appropriate to current work.
Ø Fallible decisions which led to risk-inducing failures. Ø Chronic situations in which errors violations were made.
Ø Delayed , missed and poorly planned maintenance activities.
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What Do They Have In Common?
“All Work Related Incidents Are Preventable”
Ø The stage had already been set for the incident to occur by the presence of Latent Failures - Technical or Human.
Ø Delayed, missed and poorly planned maintenance activities. Ø Organizations and people trying to meet several goals at
once. Ø (Un)availability of accurate, understandable procedures. Ø Design faults were traced back to to a difference between
how the designer thinks the equipment will be used and the way operators actually use it.
Ø Communications – people tended to hear what they expect
to hear rather than what was actually sent. Ø Competency – inadequate training, for both routine work
and for dealing with emergencies
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Purpose - Incident Management
“All Work Related Incidents Are Preventable”
To ensure incident response, notification,
investigation, documentation, follow-up and
sharing of learning’s is completed in a uniform,
thorough and timely manner to prevent
recurrence of a similar incident
Blast at BP Texas refinery in '05
BP Gulf Oil Spill
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RESPONSE
NOTIFICATION
INVESTIGATION
DOCUMENTATION
FOLLOW-‐UP & SHARE LEARNINGS
WORKER
WORKER / LEADER
LEADERS(S) / INVESTIGATION TEAM
Incident Management Process (IMP)
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Incident Management Process (IMP)
Design
“All Work Related Incidents Are Preventable”
Ø To ensure workers are capable of recognizing and acknowledging when an incident has occurred.
Ø To encourage notification of all incidents, with the
understanding investigations are completed to identify facts not place blame.
Ø To ensure a thorough, consistent investigation of all incidents,
to identify root causes and Latent Failures which permit the development and implementation of appropriate corrective and preventive measures, eliminating potential for recurrence.
Ø To facilitate continual performance improvement, to share key
learning’s and prevent loss.
RESPONSE
NOTIFICATION
INVESTIGATION
DOCUMENTATION
FOLLOW-‐UP & SHARE LEARNINGS
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“All Work Related Incidents Are Preventable”
RESPONSE
NOTIFICATION
INVESTIGATION
DOCUMENTATION
FOLLOW-‐UP & SHARE LEARNINGS
Response
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Response
Emergency Management System
“All Work Related Incidents Are Preventable”
Safety
Isolate
Control
Notification
Ø Take Control – Ensure personal safety.
Ø Isolate & control the situation.
Ø Provide first aid and call emergency services.
Ø Control potential secondary accidents.
Ø Identify sources of evidence.
Ø Preserve evidence.
Ø Determine loss potential – risk assessment.
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“All Work Related Incidents Are Preventable”
RESPONSE
NOTIFICATION
INVESTIGATION
DOCUMENTATION
FOLLOW-‐UP & SHARE LEARNINGS
Notification
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Notification
“All Work Related Incidents Are Preventable”
Ø Verbal Notification – Internal Call Down System
Ø Incident Management Classification Guide
Ø External Agencies
Ø Crisis Communications - Media
Ø Written Incident Notification
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RESPONSE
NOTIFICATION
INVESTIGATION
DOCUMENTATION
FOLLOW-‐UP & SHARE LEARNINGS
Investigation
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What is an Investigation?
“All Work Related Incidents Are Preventable”
It is the analysis and account of an incident based on information gathered by a thorough examination of “ALL FACTORS” involved.
Purpose of Investigations is to determine:
Ø Underlying causes of incidents Ø To prevent recurrence
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Top 10 Investigation Mistakes
“All Work Related Incidents Are Preventable”
The natural tendency is to blame and incident on the careless, stupid or irresponsible acts of those people directly involved.
10. Uncooperative People or System 9. Conflicting Objectives 8. Surface Causes Only 7. Politics 6. Unskilled Investigators
5. Interview Biases / Untruthfulness 4. Untimely Investigation 3. Investigator Biases 2. Ineffective Corrective Action 1. Not Investigating Near Misses
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Ø We must investigate all accidents incidents to determine which has the potential for serious injury or major loss.
Ø We should give special attention to those with loss potential. (HIPO)
What Incidents should be Investigated?
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Who Should Do Accident Investigating?
Ideally, an investigation would be conducted by someone experienced in accident causation, experienced in investigative techniques, fully knowledgeable of the work processes, procedures, persons, and industrial relations environment of a particular situation.
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1) Initial Response - Emergency Response
2) Collect Evidence - What’s
3) Analysis on the Evidence - Why’s
4) Develop Recommendations
5) Prepare the Accident Report
6) Implement Corrective Actions
6) Evaluate the effectiveness of the corrective action
7) Make changes for continuous improvement
Investigation Process
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Ø Position Ø People Ø Parts Ø Paper
Collect Evidence – What’s
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Are the physical relationships of the people, equipment, materials and structures to each other.
Position Evidence
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Are those individuals who saw the accident or know something about the circumstance.
People Evidence
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Ø Interview separately
Ø Interview in an appropriate place
Ø Put the person at ease
Ø Get the individual’s version
Ø Ask necessary questions at the right time
Ø Provide feedback
Ø Record critical information quickly
Ø Use visual aids
Ø End on a positive note
Ø Keep the lines of communication open
Interview Process
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Are the equipment, tools, materials, signs, placards, labels, and other physical objects related to
the accident.
Parts Evidence
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Are the documents that relate to the accident. These can be Operating Procedures,
Hazard Assessments, Competency Assurance Records and numerous other documents
Paper Evidence
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Methods Employed to Look at Accident
Causation?
“All Work Related Incidents Are Preventable”
Ø Management Oversight and Risk Tree
Ø Logic Tree
Ø Tap Root
Ø 5 Why’s
Ø Fault Tree Analysis
Ø Cause & Effect
Ø DNV SCAT
Ø Fishbone Diagram
Ø Tripod
Many models of accident causation have been proposed, ranging from Heinrich's domino theory to the following sophisticated processes:
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Conventional View
Ø In the conventional view of how accidents happen, a number of unfortunate events come
together to form an accident.
Ø This view usually includes specific human component (unsafe acts) which, had not been
performed, would mean that the accident would not have happened.
Ø There has been and continues to be a widespread tendency in organizations to blame
accidents on the people who suffer them and to see unsafe acts as arising from the
stupidity, carelessness or recklessness of particular individuals
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Conventional View
Past techniques for improving safety performance tended to focus on the accidents
themselves, conducting detailed investigations and compiling accident statistics to identify the
reasons why accidents occurred.
Such techniques are essentially reactive.
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Active & Latent Failures
ACTIVE FAILURES
Are usually associated with the activities of the frontline operators. These are the people at
the human-system interface whose failures are capable of eliciting an immediate reaction.
LATENT FAILURES
Unsafe acts do not occur in isolation, but are influenced by external factors (the
preconditions) These factors themselves originate from failures elsewhere in the business
(latent failures)
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Ø Adverse consequences which lay dormant within the system for a long time, only becoming evident when they combine with other factors to break through the system’s defences
Ø These are committed by those far removed in time and space from the immediate area:
- designers, high-level decision makers, managers and maintenance personnel.
Ø Decisions are shaped by various factors: - economic, political, practical constraints.
Latent Failures
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Ø All physical failures are triggered by humans. But humans are negatively influenced by
latent forces.
Ø The goal is to identify and improve these latent forces
Latent Failures
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Latent Failures
“All Work Related Incidents Are Preventable”
Ø Hardware
Ø Design
Ø Maintenance Management
Ø Procedures
Ø Error-enforcing Conditions
Ø Housekeeping
Ø Incompatible Goals
Ø Communication
Ø Organization
Ø Training
Ø Defenses
Organizations with many latent failures are less able to survive occasional active failures, either technical or human
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The Hardware GFT is concerned with the quality, availability and position in the life-
cycle of tools and equipment and components. It does not include failures caused
by poorly designed items, or due to poor maintenance, but does include use of
incorrect or inappropriate materials or manufacturing.
Latent Failure - Hardware
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Design can become a GFT when it leads directly to the commission of avoidable
unsafe acts. Design faults can contribute to an accident by allowing unsafe acts to
take place, or even making unsafe acts necessary in order to make something
operate as intended. For example, a safety guard which can be held open with one
hand lets operators take risks.
Latent Failure - Design
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The GFT is concerned with the Management of Maintenance rather than the
practical execution of the tasks involved. Many maintenance problems arise out of
the conflict between cost and safety, whereas ideally the resources devoted should
be driven purely by the maintenance objectives.
Latent Failure – Maintenance
Management
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This GFT concerns the (un)availability of accurate, understandable procedures which
are actually known and used. Procedures are meant to ensure that staff carry out
tasks in a standard, safe way.
Latent Failure – Procedures
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This GFT refers to a chronic situation in which errors violations are made more
probable. It covers a broad range of conditions affecting the individual or the
workplace, which can lead to unsafe acts.
Latent Failure – Error Enforcing
Conditions
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Housekeeping constitutes a GFT where it has been neglected for a long time and
when various levels of management have been aware of it but have done nothing
about it. It refers to the tidiness and cleanliness of facilities, together with the
provision of adequate resources for cleaning and waste removal.
Latent Failure – Housekeeping
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This GFT recognizes that organizations and people are usually trying to meet several
goals at once and that this can lead to dangerous conflicts. Incompatible goals
become a problem when top management gives no guidance on priorities.
Latent Failure – Incompatible Goals
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This GFT covers failures to communicate when the target is known but the message
fails to get through or is late; this may be due to hardware problems or
misunderstanding between sender and recipient.
Latent Failure – Communications
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The organization GFT refers to deficiencies in the structure of responsibilities and
accountabilities within the company or the way it goes about its business which are
not appropriate to current work.
Latent Failure – Organization
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It is management’s responsibility to ensure that the right people get the right training. Problems can arise for many reasons, and usually not the fault of the
employees affected. Training requirements may not be properly understood, the training badly run, or not run at all.
Latent Failure – Training
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Problems in defenses take various forms:
Ø Detection and warning systems may give false alarms or fail to work;
Ø Control and interim recovery equipment may be missing, faulty or badly sited;
Ø Protection equipment or containment systems may have been deliberately
disabled or not even used, perhaps because they are awkward, cumbersome,
take too long to set up or are not understood by personnel;
Ø Escape and evacuation plans are rarely put to the test. Serious accidents can
take unexpected forms which planners may not have foreseen.
Latent Failure – Defenses
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Documentation
“All Work Related Incidents Are Preventable”
Ø Who, what, when, where and why
Ø Description of events
Ø Immediate and basic causes
Ø Contributing factors
Ø Remedial and permanent recommendations
Ø Action plan
Ø Attachments
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Follow-up & Shared Learning's
“All Work Related Incidents Are Preventable”
This is one of the most value added steps in incident management and must include
the following:
Ø Tracking of recommendations;
Ø Identify and notify individuals who are accountable for the implementation of
recommendations;
Ø Provide status on targeted completion dates; and
Ø Confirms the incident has been managed until all actions are completed.
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Follow-up & Shared Learning's
“All Work Related Incidents Are Preventable”
Implementation is successful if:
Ø The recommendations are implemented;
Ø The recommendations have corrected the root cause/latent failures and/or
prevented similar incident from occurring; and
Ø Follow-up with workers indicated the recommendations were successful in
eliminating the root causes / latent failures
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Summary
“All Work Related Incidents Are Preventable”
Ø Investigation is the analysis and account of an incident based on information gathered by
a thorough examination of “ALL FACTORS” involved;
Ø Organizations with many latent failures are less able to survive occasional active failures, either technical or human; Ø Incidents are an indicator to Improve our performance – “We Care”
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Questions?
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