Latent Cause Analysis ‘LCA’ Plan How to respond to ‘everything that goes wrong’ in well operations

GOLDEN RULE for Well Operations: Have a plan for everything that goes wrong, so that:

When some-thing big or little goes wrong we know

• WHAT evidence are we going to gather and • HOW are we going to gather it

Also Remember! That LCA is an introspective, no-blame method that;.

• Always starts by looking at one’s-self and asking ‘How did I contribute to this event?’ • Addresses the same question within organisation(s) and other parties. • The purpose is to avoid finger pointing and blame assignation. • The objective is based on evidence to understand why big and little things go wrong.

Key concepts of LCA • LCA is evidence driven • The process of the three forms of LCA, i.e. the Maxi, Midi and Mini methods presented are

all very similar. o The main differences are the no of people and how they are involved.

• The bigger the problem ‘of things that go wrong’ the more a need for a non biased outsider and a more formal investigation structure to be imposed.

• Without evidence, LCA is impossible. • It is vital to gather evidence as soon as practicable. • It is important to let each form of evidence ‘speak for itself’ and lead us to the truth. • People evidence is most important of the 3 P’s, i.e. Physical, Paper, People evidence forms. • Make sure to look for the emerging, early and missed warning signs. • Keep the 3 P’s separate to counteract bias. • The most mundane things can contain a wealth of evidence. • It is critical to through the 3 P’s and the latent cause evidence prism. • 80% of the time is spent on an LCA for evidence gathering, evaluating and summarizing.

Gather the five (5) items i.e. The 5 standard LCA investigative starting point items are.

1. Make a Statement 1. Someone senior first writes down one or two paragraphs of the event, describing

what they think happened, including WHO, WHAT, WHERE and WHEN. 2. Intent is to be brief, to the point and written by ONE person simply to summarise

the essentials so that freezing the evidence can begin promptly.

Example Statement Who: An employee.

What: Experienced a fire in the works Van.

When; June 8th 2015, at approximately 12.25pm

Where: Approximately one block from out work depo in Glenrothes, Fife.

Our employee experienced a fire in our works van approximately one block from our main office in Glenrothes at about 12.25pm.

Why and how did the van catch fire?

2. Schematic 1. Must be hand drawn of well, schematic, system, equipment, process being

followed, or components involved in the accident/incident. 2. NOT AN ENGINEERING DRAWING but HAND DRAWN to show the essence of the

state of things at the time of the event. 3. Investigators assigned, must take time to study and understand the schematics

before ones start to gather the evidence. This is important.

3. Relationships 1. Another hand drawn schematic. 2. This time showing the RELATIONSHIPS of the system, equipment, or components

involved in the incident to the rest of the situations, conditions, circumstances.

4. Sequence of events 1. A brief summary of events. 2. Written by one person. 3. Approximately 5-10 bullet items.

Sequence of events example • Decided to run an errand • Got 1 block from works office in Glenrothes. • Smelled something burning, like plastic or rubber. • Got out of van to check. • Noted Van was smoking a lot from engine area. • Called fire brigade via my mobile phone. • Called to tow truck after brigade had finished.

5. List of oddities 1. Aside from the failed event in itself. 2. What was there odd about this accident/incident event, e.g. the latent or

surrounding circumstances to this?

List of oddities example • Lots of smoke but little or no fire • Resulted within 2 or 3 minutes of starting engine • All that smoke and there only appears to be one main area of damage i.e. the

burned hole in a plastic manifold, that we saw after fire brigade had made engine safe and we opened the hood.

Note: The order of fragility • The order of fragility defines the order in which evidence evaporates (or how fragile is each

form of evidence.) • People evidence normally evaporates the fastest, then the Physical evidence, and then the

Paper evidence. • The most important thing to remember is to try and gather the most fragile evidence first.

‘LCA’ Levels of Investigation

LCA Levels of Investigation, There are three LCA levels of investigation i.e. Maxi, Midi and Mini

Maxi Level 1 or Maxi Level 2 . • Maxi Level 1 or 2 threshold metrics are commonly stated in company policy or HSE

safety/risk matrix? o If not? We have to define and decide what the thresh hold levels are?.

• Assign a lead ‘Mother source’ investigator. o Better if they have ignorance of the event (this assures less bias) o Expertise in investigation. o Available with a passion for revealing the truth. o Has compassion for people.

• Lead investigator ‘Mother source’ then assigns 3 non-bias investigation gatherers, i.e. one each for.

o Gathering the Physical, Paper and People trails of evidence.

List the evidence to be gathered • Assisted with the help of the clients and 3rd parties involve people. One list for each of the

P’s. i.e. Physical, Paperwork and People evidence is beneficial in a Maxi event. • Simply ask the key people involved.

o What do we need to gather? What physical evidence will we gather What Paper evidence will we gather What People evidence will we gather Who will assist to gather the evidence.

• Gather evidence, doing one’s best to keep the 3 P’s separate.

Evidence review • When leader declares evidence gathering is finished in a MAXI event, ONLY THEN take the

separation walls down. • Review all evidence to define the Physical, Human and Latent causes for each form of

evidence gathered.

Midi investigation • No mother source or lead investigators needed. • Simply gather the 3P’s amongst the team involved. I.e. the drill crew, the deck crew, the

marine crew ask yourselves; o What physical evidence will we gather o What Paper evidence will we gather o What People evidence will we gather o Who else will assist to gather the evidence.

• Involve everyone in gathering the Physical, Paper, People, evidence.

Mini investigation • You yourself gather the 3 P’s i.e. Physical, Paper, People, evidence.

o What physical evidence will I gather o What Paper evidence will I gather o What People evidence will I gather

OTHER evidence gathering stuff MAXI EVENT: AVOID SHARING ANY OF EVIDENCE GATHERING WITH THE STAKEHOLDERS

This should not result until the stake holder(s) meeting is held. Ref. stakeholder meeting notes.

More about physical evidence gathering • A lead investigator or a company would develop a go-bag, e.g. this would typically contain.

o Hardware Flashlight Magnifying glass Magnet Tape measure Safety tape. Report, interview templates etc. Pens pencils. Marker pens. Index cards. Gloves, safety glasses. Zip lock, sample bags etc.

o Camera o Whatever else if found useful in an investigation.

• Go back several steps to the beginning of the sequence of events or event further back. • Start from the outside (with an exploratory open mind) and work in. • Then start working in smaller details until one starts to connect the dots.

o Note: It general takes time and effort to see what needs to be seen! • Divide the physical evidence into pieces or separate components. • Make a written list of oddities and/or each set of observations, initial conclusions about each

piece of physical evidence. • Attempt to explain each oddity observed or noted. • If applicable, characterise the ‘essence’ of what you have discovered with a further discovery

sketch (where appropriate.) • Note emerging symptom’s (the early warning signs) that you should always generally

discover. • What does the evidence suggest about the physical and latent causes?

More about Paper evidence gathering • Paper evidence history?

o Regulatory or company standards related. o Design related. o Construction related. o Operations related. o Maintenance, inspection, repair related. o Personnel-related history.

• Start from the outside (with an exploratory open mind) and work in. • Then start working in smaller details until one gets to the points where one starts to connect

the dots. o Note: It takes time to see what needs to be seen!

• Divide the paper evidence into pieces or separate components. • Make a written list of oddities and/or each set of observations, initial conclusions about each

piece of paper evidence. • Attempt to explain each oddity observed or noted. • If applicable characterise the ‘essence’ of what you have discovered with a discovery sketch

(where appropriate.) • Note emerging symptom’s (the early warning signs) that you discovered. • What does the evidence SUGGEST about the paper and latent causes?

More about People evidence gathering • PEOPLE generally will KNOW EVERYTHING if one asks the right questions, in the right way

and manner. • Focus initially on eye witnesses involved.

o Use standard interview questions. Introduce yourself and remind them of purpose of the interview. Understand who you are interviewing, their name, their position and normal

role. Try and understand their perspective. What is their role in the accident/incident being investigated.

o Have a standard way to interview participants. • Perform interviews ONE on ONE as SOON AS POSSIBLE after an event has resulted. • Interview people where they feel in a comfortable environment, if possible near their

location at the time of their involvement. • Resist all temptation to record an interview.

o Take them through their involvement step by step. What did you do first? What happened first? When they pause, ask ‘then what’?

o Listen closely for discrepancies. o Don’t be afraid to probe them.

Why do you think this incident occurred? Probe their responses, Be curious.

o You may also have to recall some people later. o Listen for and record Other people? to interview.

• Conclude interview with a non-leading set of questions. o E.g. Tell interviewee to forget about the incident and to think about their role, in

general (pause for about 30seconds – silence is often the best method of communicating).

o Say things like ‘what’s it like to be in your shoes here?’ (pause again) What are the general frustrations experienced in your role, can you share

these with me? Try to understand, AS-IS vs AS-Desired.

o Finally at the end, ask them once again to think about the incident and rate each frustration for its influence on the event. e.g. on a scale of 0 - 5 with 5 as high.

• When eye witness interviews are completed, interview the Other People. • When interviews are complete summarize findings.

o Who (functionally) did you speak to? o How do/did people respond to the phenomena of the event? o What did people see, hear, smell and feel, relating to the event phenomena. o Ask why do you think people THINK this phenomena occurred. o What miscellaneous issues were raised and discussed? o What frustration (problem) issues have people raised and discussed, and what was

their weightings to these? o What were the ‘key quotes’?

• What emerging symptoms and warning signs were emerging? What else did you discover? • What does the evidence SUGGEST about the human and latent causes?

Reviewing the evidence • After combining the 3 P’s of evidence. • Try and identify the Physical, Paper, Human and Latent causes with the evidence gatherers. • If you cannot define the causes? You simple do not have enough evidence,

o Remember People generally know everything as to why things go wrong. • Determine additional evidence requirements.

o Continue to gather until you are satisfied you have defined the causes as best as practically possible to do so.

• These are called PRELIMINARY causes o In a Maxi investigation: These are not to be Shared with the stakeholders until the

stakeholder meeting is held.

Key ‘LCA’ Evidence take away 1. The Evidence gathering process of the Maxi, Midi and Min LCA’s are very similar. 2. No software is used or needed. 3. The main evidence gathering difference is

1. The no of people involved. 2. How they are involved.

4. The BIGGER the things that go wrong the more is needed e.g. 1. An outsider to lead the Maxi LCA 2. The importance of structure to be imposed.

5. WITHOUT EVIDENCE; an LCA (Maxi, Midi and Mini) is impossible. 6. It is VITAL to gather evidence as soon as practically possible. 7. It is important for each form and trail of evidence to ‘speak for itself’. 8. People evidence is perhaps the most IMPORTANT of the 3 P’s. 9. Make sure to look for emerging and early warning signs (missed warning signs) of evidence.

1. Sometimes one has to go back further to find these. 10. Separate the 3 P’s to counter act bias. 11. The most mundane things often contain a wealth of evidence. 12. It is critical to look at the evidence through a prism i.e.

1. The Physical, Paper, Human and latent cause prism. 13. Let the evidence pull you to the truth. 14. Things don’t simple go wrong, they are caused. 15. Causes can be determined.

Stakeholder concept and meeting

Key Concepts 1. A stakeholder (in respect to LCA) is anyone whose behaviour has to change as a result of

things that went wrong. 2. Stakeholders are identified as and after evidence is gathered, and causes become apparent

to the evidence gatherers within events that resulted. 3. Stakeholders can be from any level within the organisation internally or sometimes

externally. Typically they include a cross section ranging from hands on all the way up to executive levels.

4. Stakeholders are members of the crew when investigating Midi-LCA. 5. A Stakeholder is someone who performs a mini LCA, on typically small problems of things

that are wrong, where and what they generally have ultimate personal responsibility for. 6. The process for all 3 forms of LCA all ought to involve the stakeholder. 7. No pain no gain concept is then applied. E.g.

a. “Your pain is the breaking of the shell that encloses your understanding” Khahil Gibran, the Prophet.

b. Going through the shock of self-discovery is far more effective that someone telling you the answer, finger pointing or assigning blame in your direction.

Organising the stakeholders

Maxi LCA Include all people inferred to in the human and latent cause e.g. People

• Whose behaviour must change? • Who will have recommended technical changes? • Who have written the instructions or operating standards etc? • Who has designed, constructed the equipment or systems that have failed? • Who has had the authority to authorise the expenditure of tools, equipment resources etc? • Who are either accusing someone or being accused themselves? • Who include ANYONE who will be the recipient of an action item?

Midi LCA • Whole team involved is considered the stake holders • Involve everyone throughout the process.

Mini LCA • Do the LCA on YOUR OWN problem. • Consider yourself as the stakeholder.

Key take away 1. The stakeholder concept is one of two main aspects that make LCA ultimately effective. 2. The 2nd and other is a requirement that everyone must first look at themselves if involved in

a problem or in things that go wrong. 3. All 3 forms of LCA need to involve the stakeholder(s). 4. Stakeholder’s need to be appalled at themselves or LCA is completely futile. 5. Stakeholders are defined from the preliminary evidence and causes as identified by the

evidence gatherers in a Maxi LCA. 6. Teams that experience the even are the responsible stakeholders in a Midi-LCA. 7. Individuals are the responsible stakeholder in a Mini-LCA.

Stakeholder meeting

Key concepts 1. Physical, Human and latent causes are identified at this phase of the LCA. 2. Action items are identified in Midi-LCA’s 3. The Maxi-LCA stakeholder meeting is generally a life changing event for all. 4. Always focus on the three most significant human and latent causes of the event. 5. Everyone must agree with everything written on Maxi meeting flip charts or on the Midi and

Mini LCA templates. 6. No one is allowed to write up a human cause about anyone else. Everyone must only write

about themselves. 7. Actions are to be taken immediately in Mini-LCA’s 8. Note: Remarkable potential for positive change is available when stakeholders come to their

own conclusions. 9. The WHY tree tool can be a valuable aid to help others understand what has been

concluded. (As people learn in different ways.)

The Stakeholder meeting After evidence is gathered stakeholders are identified notably in a Maxi investigation and asked to attend a meeting.

During this meeting Summarized Evidence is presented to the stakeholders for the first time.

Note: For a maxi event a stakeholder meeting will generally require about 8hrs.

It is also imperative to have an agenda for this meeting and then to rigidly stick to this. Note: All this is well documented and all is offered for free. So no reinvention is required. LCA is being applied in other industries over the last 20years!

It is important to break this meeting into three session segments over two days.

Generally after one night of contemplation to assure that the evident ‘pain of failure’ soaks in, the meeting continues so that the Stakeholders themselves can define and conclude what they see as the Physical, Human and Latent causes (as well as any action items needed.)

1st Stakeholder meeting 1. Review stakeholder preparation slides 2. Review the 5 items 3. Review all evidence one at a time. 4. After each form of evidence, ask stakeholders what have they learned? 5. Allow time for discussion. 6. Conduct this meeting on the afternoon after the 1st day.

Notes: The stake holder meeting is perhaps the most critical in the LCA process. This meeting is where significant personal ‘human factors’ behavioural change can occur.

Stakeholders will likely expect you to tell them the causes and recommendations. This is not the way LCA is intended to work. The meeting is the opportunity to dramatically change the way stakeholders see the truth, and therefore work to change the way they are.

i.e. If we allow them, to come to their own conclusions.

More importantly, it is an imperative that each stakeholder sees themselves as part of the problem (after having been presented and reviewed all the evidence) and what they then intend to change, starting with themselves.

A golden rule of an LCA is: We must try and understand to such an extent that we are convinced we would have done the same thing if we were that person. This is true for all levels of an organisation.

Typical Ground rules for meeting.

• A willingness to hold one’s self accountable instead of trying to hold someone else accountable.

• No stakeholder is allowed to blame anyone else or on any other thing. • Instead all stakeholders will be required to see themselves as part of the cause’s of

the event. • In return for open and honest reflection, the management of the organisation

promises that they will not punish or reprimand anyone as a result of this LCA.

2nd stakeholder meeting (morning of 2nd day) 1. Divide stakeholder’s into groups of 4 or 5. 2. Ask each group to define the physical, and human causes. 3. Assure everything is based n the evidence presented. 4. Agree on physical and human causes. 5. Agree on action items.

6. If appropriate start to develop a why tree.

a. Causes first. b. Why tree next.

Key Stakeholder meeting takeaway 1. The Maxi-LCA stakeholder meeting is generally life changing. 2. Have a plan (AGENDA) for stakeholder meeting. Rigidly stick to it. 3. Always focus on the 3 most significant Human and Latent causes. 4. Everyone has to agree with everything written on the flip charts etc or on the Midi, Mini LCA

templates provided. 5. If everyone cannot agree (referring to the above) use OR. 6. No one is allowed to write up Human causes about anyone else. Everyone can only write

about them self as appropriate based on evidence presented and group consensus conclusions made.

7. Actions are taken immediately in Mini-LCA’s 8. Tremendous opportunity for positive change exists in this method. i..e if you let the

stakeholders state the truth and their own conclusions. 9. The WHY Tree TM is a valuable tool to help others understand what has been concluded.

Latency

Key Latency concepts 1. We have to know ‘who did what wrong’ before we can understand ‘why they did it’.

Therefore the human cause is the doorway to latency. 2. Latent causes are hidden, concealed, and veiled. But Alive, Active, Potent and Mature. 3. What thoughts was going through the person mind?, Actual vs Desired? 4. What is about the way we are that contributed to these thoughts? 5. Always use a situation-filter-outcome model when defining latent causes. 6. Never tell people their latencies, instead ask them to tell you. 7. All LCA’s ask people to be introspective with themselves and their surroundings. 8. Human beings cause things to go wrong not systems, processes or technologies.

3rd stakeholder meeting 1. Focus on the three human causes as chosen by the stakeholders. 2. For each cause, use the situation filter outcome model to yield evidence about latent causes. 3. Stakeholder’s to agree on their latent causes. 4. Agree on SMART actions to be taken. Specific, measureable, achievable, realistic, time

based. 5. Allow about 1hr for each human cause.

Example: Foreman’s personal latent causes.

1. I scare some of my employees and I know this is not right. 2. I do not pay enough attention to new people coming into my team and work areas and I

know this is not right. 3. I generally do not ask people if they have any questions. I assume they will ask me if they

don’t know something and I know this is not right.

Key ‘Latency’ takeaway 1. We have to know ‘who did what wrong’ before we can understand ‘why they did it’.

Therefore the human cause is the doorway to latency. 2. Latent causes are hidden, concealed, and veiled. But Alive, Active, Potent and Mature. 3. The 1st of 3 key latenchy quesiotns is;

a. What thoughts went through the persons mind actual vs desired? 4. The 2nd of 3 key latency quesiotns is;

a. What is it about the way we are that contributed to these thoughts. 5. The 3rd of the 3 latency questions is;

a. What is it about the way I am that contributed to these thoughts? 6. Never tell people their latencies, Instead ask them to tell you. 7. All LCA’s ask people to be introspective with themselves and their surroundings. 8. Human beings cause things to go wrong not systems, processes or technologies.