EPEX Poster Incident Investigation and Analysis Overview 110624

EPEX - Tripod Beta Incident Investigation And Analysis Remedial actions 1.1 Visibility

1. Leadership and commitment

The driving force

1.2 Proactive in target setting

Plan 2 Policy and strategic objectives

3 Organisation, responsibilities, resources, standards & documentation

2.1 Content 2.2 Dissemination 2.3 Strategic objectives

3.1 Roles and responsibilities 3.2 HSE Advisors 3.3 Resources 3.4 Competence 3.5 Contractors 3.6 Communications 3.7 Documentation and control

Underlying cause

BRFs within phases of the business processIG Goals Organization OR Management CF Design DE, DF Build HW, DF Operate TR, PR, HK Maintain TR, PR, MM EC

1.3 Informed involvement

Do

Check

Review

7. Audits

8. Management review

4. Hazard and effect management

5. Planning and procedures

6. Implementation and monitoring

4.1 Identification of hazards and effects 4.2 Assessment 4.3 Recording of hazards and effects 4.4 Performance criteria for maintaining controls 4.5 Risk reduction measures controls and ownership 4.6 Risk reduction measures - recovery

5.1 HSE plan 5.2 Asset integrity 5.3 Procedures and work instructions 5.4 Management of change 5.5 Contingency and emergency planning

6.1 Performance monitoring 6.2 Records 6.3 Non compliance and corrective action 6.4 Incident reporting and follow up

7.1 Audit plan 7.2 Auditor competency 7.3 Contractor audits

8.1 Review

1 Leadership & Commitment 2 Policy & objectives 3, 4, 5, Plan

6 7

Underlying Cause

8

Point in business process at which improvements are required i.e. Plan-Do-Check-Review / HSE maturity DE

HW

PR

EC

HK

Design

Hardware

Procedures

Error Enforcing Conditions

Housekeeping

TR Training

IG

CO

OR

MM

DF

Incompatible Goals

Communication

Organisation

Maint. Management

Defences

Preconditions

(failings in assuring positive worksite factors) Plan

Perceived view of the world 1 PR, OR Identify hazard

2 PR Assess risk

3 PR, OR, DF Plan job

4 DE, DF, HW, MM Assure resources

Check

Communicate intent

Form intent

(including emergency response)

3.1 PR, DF Guidance, instructions, procedures

Do

5 TR, EC, OR Assure crew skill and knowledge

6 HK, EC Assure worksite conditions

7 CO Communicate job intent

Review

Monitor and supervise

8 IG Promote a positive attitude

9 OR Confirm intent is correct

10 OR Confirm intent is followed

11 DF Respond to an emergency

12 OR Monitor & report performance

13 OR Review plan

Task execution

Tools

People

Worksite Condition

Plans (software)

Parts (hardware)

People (liveware)

Place (environment)

3.2 OR Schedule job, time pressure

3.3 OR Roles and

7.1 CO Communicating

job intent

responsibilities

authorisation

4.1 HW MM Tools, plant, equipment & material

4.2 DF PPE

4.3 DE Man/machine interface, layout

5.1 EC Physical condition

5.2 EC Psychological condition

5.3 EC Physical & psychological limitations

5.4 TR Skill and knowledge

8.1 OR, IG Social, teamwork &, attitude

6.1 HK House keeping, orderliness

6.2 EC Environment weather

(promoting unsafe acts) Immediate cause

(defeating barriers)

Intentional acts

Reckless violation

Unintentional acts

Violation (attitude)

Mistake (knowledge)

Error (skill)

(intentions known to be incorrect)

(intentions believed to be correct)

(correct intention, failure in execution)

Optimising for Self violation

Optimising for Company violation

Barrier Function

Situational violation

Barrier System

Routine violation (by majority)

Rule based mistake

Safety Critical Activities

Barriers

Misperception

Knowledge based mistake

Often leads to knowledge based mistakes

Fault Tree

(preventing incidents)

Slip or lapse

Unsafe Act

Escalation of incident

Be aware; provide

Advise and

Repel with alarms

Restore

Interpose

Eliminate

Rescue and

understanding & awareness

Guide

and warning

stop, fail safe, self correct

Guard protect

or contain

escape

Off normal operation

Protective action

Normal operation

Compiled by: EPEX, Date: 25-Aug-08, date of revision: 24-Jun-11, www.i3pod.com

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