making business & safety even better: ‘learning from weak ... · and occupational safety....

Professional Incident Investigation

Making Business & Safety Even Better:

‘Learning from Weak Signals’

Brian McConnell, CEO / Finance Director

George Dyer-Wilson, Global Business Development Manager

Professional Incident Investigation

Kelvin TOP-SET Background

• Improving Incident Investigation Globally

• Investigations

• Training

• Business Improvement

Professional Incident Investigation

What to expect:

• What is a ‘Weak Signal?

• Developing ‘Structured Curiosity’

• Using TOP-SET Indicators to Identify Weak Signals

• The Concept of ‘Organisational Rust’

• Weak Signals during Investigations

• Communication & Sharing Lessons Learned

• Business Improvement

Professional Incident Investigation

What are Weak Signals?

• Indicators of larger problems

• Something out of the ordinary

• Intuition

• What’s Changed?

Professional Incident Investigation

Weak signals example

Professional Incident Investigation

Weak Signals and Indicators

Professional Incident Investigation

Explosives Industry

With explosives, weak

signals can quickly turn to

disaster.

Professional Incident Investigation

Reliance on Procedures

What did the weak signals show us during this investigation?

Someone was killed, but picking up on the ‘weak signals’ could have prevented this.

False belief that

that paper based

rules were

followed…

Not the case.

Professional Incident Investigation

The importance of first impressions

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Looking at general conditions

Professional Incident Investigation

Looking at general conditions

Professional Incident Investigation

How many indicators?

Rule of

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Prediction through weak signals

Professional Incident Investigation

Professional Incident Investigation

Thinking in Investigations

15

First – Open Thinking

PLANNING &

INVESTIGATION

Then – Focused Thinking

ANALYSIS

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Structured Curiosity

• Tripod / TOP-SET Iterative Approach

• Testing Observation / Theories

• Looking outside comfort zones

Professional Incident Investigation

Using TOP-SET Indicators

Professional Incident Investigation

Professional Incident Investigation

Organisational Rust

Professional Incident Investigation

Organisational Rust ©

Operating as designed with all controls in place

DANGER ZONE

Even slight changes can lead to incidents.

Drifting from safe standards

Professional Incident Investigation

Top Eight Examples of Causes 1. Failure of management and or supervisors to walk about and

effectively engage and intervene

2. Going beyond the authority of the permits

3. Working to perceived time pressures

4. Failure to take responsibility

5. Communication failures

6. Errors and violations

7. Not stopping the job

8. Shortcuts.

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Communication and Sharing Lessons Learned

Professional Incident Investigation

Business Improvement

• Weak Signals are everywhere

• Everyone’s job to look out for them

• Take action

• Share / Communicate

• Evolve processes

Professional Incident Investigation

‘What Can You Do?’

Never forget that a safe workplace requires that

everyone in the facility pay attention to BOTH process

and occupational safety.

Recognize that safety culture and attitude, operating

discipline, safe working practices, and other elements

of a good safety programme are essential to success in

both process and occupational safety...

Professional Incident Investigation

Understand your plant’s process safety AND occupational

safety programmes and your role in making them

successful.

Actively participate in all of your plant’s safety activities

and encourage your co-workers to participate as well.

AIChE March 2014

Professional Incident Investigation

Questions?