Tripod-Beta Accident Investigation Technique

August 2, 2018 | Author: Anand Padmanaban | Category: Business, Computing And Information Technology
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Tripod-BE Tri pod-BETA TA Incide Inci den nt Inv Invest estig igat atiion and Analys alysiis

Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Inciden Incide nts ar  ar e an an in ind dic icato ator  r  to im imp pr ove our  our pe perf  rf orm rma anc nce e

Unde der  r stan standing what happen happe ned and why enables us to imp im pr ove our  our  busin bus iness ess Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Str uctur  tur e

of  of  the HSE Man Management

System ystem

Leader  eader shi ship an and Commi Committment

Polic Policy y an and Str ategic ategic Objec Objectives ives

Tri ripod pod Beta

Orga rganisat nisatiion, Respon Responsibilities Resourc Resources es,, Stan tandar  dar ds ds & Doc Doc. Hazar  Hazar d an and Eff  Eff ects Man Management Planning Planning & Pr  Pr ocedur  edur es es

Imple Implem mentati tation

Audi udit

Man Management Revi Review ew Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Corr  Corr ective ive Act Action

Moni Monito toring ring

Corr  Corr ective ive Act Action & Imp Impr ovement Corr  Corr ective ive Act Action & Imp Impr ovement

What

is Tri Tripod-BE pod-BETA TA ?

ethodolog den analys alysiis during during A methodolo gy f or  r inci incide nt an an inv invest estig igat atiion ... combining conc ncepts epts of  of haza hazar  r d management and ... the Tri Tripod pod theor  theor y of  of a acci ccide den nt causat ausatiion.

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How does Tri Tripod-BE pod-BETA TA wo work rk ?

The inci incide den nt f acts ar  ar e bui built in into to a tr  tr ee ee diagr am show showing ing ... - What happen happened ... - What hazar  hazar d management elem elements f ailed and - Why eac each elem element f ailed.

Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

What

does the sof  sof twar  twar e do ?

sof twar  twar e: e: The sof  

tor  r es es Sto

invest inv estig igat atiion f acts



Pr ovi vides des tr  tr ee-bui ee-build lding ing gr aphic aphics s



Check Che cks s the im impl plici icitt tr  tr ee ee logic logic



Atta ttac ches data to tr  t r ee ee elem elements



Asse ssem mbles attac attached data in into to a dr  dr af t r epor  epor t. t.

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How does the tr  tr ee ee work work ?

Let¶s walk walk th thr  r oug ough a sim simple ple inci incide den nt inttr oducing in oducing the termin terminolo olog gy and logic logic that un unde der  r pin ins s Tri Tripod-BE pod-BETA TA

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The Inci Incide den nt 

Locat atiion: an off shor  shor e platf  platf orm



Inciden Incide nt: an ope oper  r ativ ative e coming off  sh shif  if t sliips an sl and f alls alls in the shower  shower r  r oom oom



Conseque Con sequenc nce: e: he hur  hur ts ts hi his back back and is off  ff wo work rk



In the past thr  thr ee ee months ther  ther e hav have been bee n two simi simila lar  r inci incide den nts

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Inittial Fin Ini Find ding ings s



The inci incide den nt occ occu urr ed ed at 1820 hour  hou r s



The oper  oper ativ ative e sli slipped on on the wet f loor  loor 



Cleaning sta Cleaning staff  ff a ar e supposed to keep the shower  shower r  r oom oom f loor  loor d dr y

Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

tar  r ting Sta We

a Tri Tripod pod Tr ee ee

star t by ide star  den ntif ying ing::



An EVEN EVENT T - wher e a hazar  hazar d an and a targ ta rget et get tog togethe ether  r 



A TA TARGE RGET T - a per son son or  r a an obje objec ct that was harm harmed ed



A HAZA AZARD RD - the thing that di did the harm harm

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The Hazar  Hazar d, Event, Targ rget et Tri Trio o They ar  ar e shown show n in a Tri Tripod pod tr  tr ee ee lik like e thi this:

Hazar  Hazar d

Event

Targ rget et Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Hazar  Haza r d, Event & Targ rget et

In th thiis inci incide den nt: The HAZA ZARD RD is : Wet f loor  loor (sl (sliipp pping ing haza hazar  r d) d) The EVEN EVENT T is r oom oom

: Oper ativ ative e f alls alls in showe shower  r 

The TA TARGE RGET T is : Oper ativ ative e

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HET HE T Diagr am The Haza Hazar  r d,

Wet

loor  f loor  (sli (slipping pping hazar  hazar d) d)

Event

Target rget

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HET HE T Diagr am The Hazar  Hazar d, acting on the Targ rget et,,

Wet

loor  f loor  (sli (slipping pping hazar  hazar d) d)

Event

Oper  Oper ativ ative e

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HET HE T Diagr am The Hazar  Hazar d, acting on the Targ rget et,, r esulted esulted in the Event

Wet

loor  f loor  (sli (slipping pping hazar  hazar d) d) Oper  Oper ativ ative e f alls alls in shower  shower r  r oom oom

Oper  Oper ativ ative e

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Is the inv invest estig igat atiion complete ? 

Does thi this show f ull ull un unde der  r stan standing ? Fin ind ding ing:: The man must hav have been been car eless eless Recomm Rec mme endat datiion: He should tak ta ke mor e car e on on a wet f loor  loor 



Or  r iis ther  ther e som someth ething ing mor e ?

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Was

the inci incide den nt pr  pr eventable ?



We

know that a hazar  know haza r d management measu easur  r e was in pla plac ce



Cleaning sta Cleaning staff  ff we wer  r e assign assigned ed to keep the f loor  loor d dr y



µbarrie er ¶ to the inci den That µbarri incide nt f ailed

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Faiiled Barri Fa Barrie er  The ba barri rrie er  r should should hav have contr olled olled the hazar  haza r d

Hazar  Hazar d

Fai Failed Barri Barrie er 

Target rget

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Event

Incide Inci den nt Mec Mecha hani nis sm The inci incide den nt mecha hani nis sm loo look ks lik like e thi this:

Wet

loor  f loor  (sli (slipping pping hazar  hazar d) d) Floor  Floor  dr ying

Oper  Oper ativ ative e

Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Oper  Oper ativ ative e f alls alls in shower  shower r  r oom oom

Fur  Fu r ther  ther Inv Invest estig igat atiion

What

caused the barri barrie er  r to to f ail ?



The clea lean ner  could not keep the f loor  loor  dr y ...



because the shower  bec shower r  r oom oom was alway alw ays s cong ngested ested between between 1800 an and 1900 hr  hr s

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Acttiv Ac ive e Fai Failu lur  r e An Activ ive e Fai Failu lur  r e de def  f eated eated the barri barrie er  Act Active ive Fai Failur  lur e  Active Failure

Wet

loor  f loor  (sli (slipping pping hazar  hazar d) d) Floor  Floor d dr ying

Oper  Oper ativ ative e

Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Oper  Oper ativ ative e f alls alls in shower  shower r  r oom oom

Acttiv Ac ive e Fai Failu lur  r e An Activ ive e Fai Failu lur  r e de def  f eated eated the barri barrie er  Clean Cleaner u r  unable to keep f loor  loor  dr y Act Active ive Fai Failur  lur e

Wet

loor  f loor  (sli (slipping pping hazar  hazar d) d) Floor  Floor d dr ying

Oper  Oper ativ ative e

Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Oper  Oper ativ ative e f alls alls in shower  shower r  r oom oom

End of  of Inv Invest estig igat atiion ? 

Is thi this the en end of  of the the inv invest estig igat atiion ? Fin ind ding ing:: The clea lean ner  was inc inco ompete peten nt Recomm Rec mme endat datiion: Clean Cleaner  r should should be r eplac eplaced or  or r  r etr  etr ain ined ed



Or  r iis ther  ther e sti still som someth ething ing mor e ?

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Fur  Fu r ther  ther Inv Invest estig igat atiion



We

know that cong know ngest estiion was a f acto tor  r  that pr  pr ompted the ac activ ive e f ailu lur  r e



Telepho elephon nes ar  ar e on only av available f or  priv rivate ate calls up ti till 1900 hr  hr s



The cong ngest estiion is caused by day shif  sh if t cr ew ew hurr  hurr ying to call hom home

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The Full Pic Pictu tur  r e

Now we hav have the f ull ull pic pictu tur  r e: e: 

The cong ngest estiion is a µP µPr econdition¶ that inf luenc luenced ed the clea lean ner ¶s ¶s task task



Restricttion on telepho Restric telephon nes is a µL µLate aten nt Faiilu Fa lur  r e¶ that cr eated eated the pr  p r econdition

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Pr econdition

Pr econdition Preconditio n

Clean Cleaner u r  unable to keep f loor  loor  dr y Act Active ive Fai Failur  lur e

Wet

loor  f loor  (sli (slipping pping hazar  hazar d) d) Floor  Floor d dr ying

Oper  Oper ativ ative e

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Oper  Oper ativ ative e f alls alls in shower  shower r  r oom oom

Pr econdition

Cong Congest estiion 1800 1800 - 1900 1900 hr  hr s Pr econdition

Clean Cleaner u r  unable to keep f loor  loor  dr y Act Active ive Fai Failur  lur e

Wet

loor  f loor  (sli (slipping pping hazar  hazar d) d) Floor  Floor d dr ying

Oper  Oper ativ ative e

Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Oper  Oper ativ ative e f alls alls in shower  shower r  r oom oom

Late aten nt Fai Failu lur  r e

Laten atent Fai Failur  lur e Laten atent Fai Failur  lur e

Cong Congest estiion 1800 1800 - 1900 1900 hr  hr s Pr econditio n

Clean Cleaner u r  unable to keep f loor  loor  dr y Act Active ive Fai Failur  lur e

Wet

loor  f loor  (sli (slipping pping hazar  hazar d) d) Floor  Floor d dr ying

Oper  Oper ativ ative e

Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Oper  Oper ativ ative e f alls alls in shower  shower r  r oom oom

Late aten nt Fai Failu lur  r e

Restric Restricttion on private rivate phon phone calls Laten atent Fai Failur  lur e

Cong Congest estiion 1800 1800 - 1900 1900 hr  hr s Pr econditio n

Clean Cleaner u r  unable to keep f loor  loor  dr y Act Active ive Fai Failur  lur e

Wet

loor  f loor  (sli (slipping pping hazar  hazar d) d) Floor  Floor d dr ying

Oper  Oper ativ ative e

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Oper  Oper ativ ative e f alls alls in shower  shower r  r oom oom

Rec Re comm mme endat datiions Action ite tem ms should addr  addr ess: ess: 

The f ailed barri barrie er  r ... ... to r estor  estor e saf  saf e conditions on on a tem tempo por  r ar y basiis bas (pr  (p r ovi vide de extr  extr a clea lean ner  betwee between n 1800 an a nd 1900)



The late laten nt f ailu lur  r e ... to r emove the un unde der  r lying lying cause (exten (exte nd the av availab labiility of  o f sho shor  r e telephon telephone)

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Com Co mplex Ev Events



That was a sim simple ple exam example



The Tri Tripod-BE pod-BETA TA methodolo ethodolog gy can also be appliied in complex ev appl events

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Com Co mplex Ev Events Ide den ntif y the prim prime e Event,

Fir e

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Com Co mplex Ev Events Ide den ntif y the prim prime e Ev Event, the Haza Hazar  r d,

Ignit Ignition Fir e

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Com Co mplex Ev Events Ide den ntif y the prim prime e Ev Event, the Hazar  Hazar d, and Targ rget et.. Ignit Ignition Fir e

Flamm Flammable able Gas Cloud

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Com Co mplex Ev Events If, say say,, the targ target et was cr eated eated by a pri p rio or  event Ignit Ignition Fir e Flamm Flammable able Gas Cloud

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Com Co mplex Ev Events Ide den ntif y the hazar  hazar d ... Ignit Ignition Dr opped opped Objec Object

Fir e Flamm Flammable able Gas E vent Cloud & Target rget

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Com Co mplex Ev Events and targ target et f or  r that that ev event. Ignit Ignition Dr opped opped Objec Object

Fir e Flamm Flammable able Gas Cloud

Gas Line Line

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Com Co mplex Ev Events imila lar  r ly, ly, Simi

if a if  a conseque sequen ntial ev event happen happens

... Ignit Ignition Dr opped opped Objec Object

Fir e Flamm Flammable able Gas Cloud

Gas Line Line

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Damage to Platform

Com Co mplex Ev Events bec be cause the prim prime e ev event cr eated eated a new hazar  hazar d, Ignit Ignition Dr opped opped Objec Object

Fir e Flamm Flammable able Gas Cloud

Gas Line Line

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Damage to Platform

Com Co mplex Ev Events ide den ntif y the targ target et f or  r the the new ev event. Ignit Ignition ource e Sourc Dr opped opped Objec Object

Fir e Flamm Flammable able Gas Cloud

Damage to Platform

Gas Line Line Platf  Platf orm

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Com Co mplex Ev Events Ide den ntif y f ailed µba µbarri rrie er s¶, Ignit Ignition ource e Sourc Dr opped opped Objec Object

Fai Failed Barri Barrie er 

Fir e

Flamm Flammable able Gas Cloud

Damage to Platform

Gas Line Line Platf  Platf orm

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Com Co mplex Ev Events and mi miss ssing ing ones ... Ignit Ignition ource e Sourc Dr opped opped Objec Object

Fai Failed Barri Barrie er 

Missing ssing Barri Barrie er 

Fir e

Flamm Flammable able Gas Cloud

Damage to Platform

Gas Line Line Platf  Platf orm

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Com Co mplex Ev Events includ inc luding ing mult ultiiple f ailu lur  r es es ...

Ignit Ignition ource e Sourc Fai Failed Barri Barrie er 

Dr opped opped Objec Object Missing ssing Barri Barrie er 

Fai Failed Barri Barrie er 

Fai Failed Barri Barrie er 

Flamm Flammable able Gas Cloud

Damage to Platform

Gas Line Line Platf  Platf orm

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Fir e

Com Co mplex Ev Events on ea eac ch r elev elevant µtr  µtr ajec ajecto tor  r y¶ y¶ ... Ignit Ignition ource e Sourc Dr opped opped Objec Object

Fai Failed Barri Barrie er  Missing ssing Barri Barrie er 

Flamm Flammable able Gas Cloud

Gas Line Line

Fai Failed Barri Barrie er 

Fai Failed Barri Barrie er 

Fai Failed Barri Barrie er 

Missing ssing Barri Barrie er 

Platf  Platf orm

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Fir e Damage to Platform

Com Co mplex Ev Events until the Inci Incide den nt Mec Mecha hani nis sm is complete. Ignit Ignition ource e Sourc Dr opped opped Objec Object

Fai Failed Barri Barrie er  Missing ssing Barri Barrie er 

Flamm Flammable able Gas Cloud

Gas Line Line

Fai Failed Barri Barrie er 

Fai Failed Barri Barrie er 

Fai Failed Barri Barrie er 

Damage to Platform

Missing ssing Barri Barrie er 

Platf  Platf orm

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Fir e

Missing ssing Barri Barrie er 

Com Co mplex Ev Events Show

the Activ ive e Fai Failu lur  r e f or  r ea eac ch barri barrie er, ... Act Active ive Fai Failur  lur e  Active Failure

Ignit Ignition ource e Sourc Dr opped opped Objec Object

Fai Failed Barri Barrie er  Missing ssing Barri Barrie er 

Flamm Flammable able Gas Cloud

Gas Line Line

Fai Failed Barri Barrie er 

Fai Failed Barri Barrie er 

Fai Failed Barri Barrie er 

Damage to Platform

Missing ssing Barri Barrie er 

Platf  Platf orm

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Fir e

Missing ssing Barri Barrie er 

Com Co mplex Ev Events the Pr econdition(s) pr omot oting ing ea eac ch ac activ ive e f ailu lur  r e, ... Act Active ive Fai Failur  lur e

Pr econdition

Precondition

 Active Failure

Hazar  Hazar d Fai Failed Barri Barrie er 

Hazar  Hazar d Missing ssing Barri Barrie er 

Fai Failed Barri Barrie er 

Fai Failed Barri Barrie er 

Event & Hazar  Hazar d

Event

Event & Target rget

Target rget

Fai Failed Barri Barrie er 

Missing ssing Barri Barrie er 

Target rget

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Missing ssing Barri Barrie er 

Com Co mplex Ev Events and the Late aten nt Fai Failu lur  r e beh behin ind d eac each pr econdition. Laten atent Fai Failur  lur e

Latent Failure

Act Active ive Fai Failur  lur e

Pr econdition

Precondition

 Active Failure

Hazar  Hazar d Fai Failed Barri Barrie er 

Hazar  Hazar d Missing ssing Barri Barrie er 

Fai Failed Barri Barrie er 

Fai Failed Barri Barrie er 

Event & Hazar  Hazar d

Event

Event & Target rget

Target rget

Fai Failed Barri Barrie er 

Missing ssing Barri Barrie er 

Target rget

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Missing ssing Barri Barrie er 

Com Co mplex Ev Events 

Com Co mplete a µTri µTripod pod path¶ f or  r ea eac ch barri barrie er . Laten atent Fai Failur  lur e

Latent Failure

Laten atent Fai Failur  lur e Latent Failure

Act Active ive Fai Failur  lur e

Pr econdition Precondition

Pr econdition Precondition

 Active Failure

Act Active ive Fai Failur  lur e  Active Failure

Hazar  Hazar d Fai Failed Barri Barrie er 

Hazar  Hazar d Missing ssing Barri Barrie er 

Fai Failed Barri Barrie er 

Fai Failed Barri Barrie er 

Event & Hazar  Hazar d

Event

Event & Target rget

Target rget

Fai Failed Barri Barrie er 

Missing ssing Barri Barrie er 

Target rget

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Missing ssing Barri Barrie er 

The completed Tri Tripod-BE pod-BETA TA tr ee ee Laten atent Fai Failur  lur e Latent Failure

Laten atent Fai Failur  lur e Latent Failure

Act Active ive Fai Failur  lur e

Pr econdition Precondition

Pr econdition Precondition

Laten atent Fai Failur  lur e

 Active Failure

Act Active ive Fai Failur  lur e  Active Failure

Hazar  Hazar d

Latent Failure

Fai Failed Barri Barrie er 

Hazar  Hazar d Missing ssing Barri Barrie er 

Laten atent Fai Failur  lur e Latent Failure

Event & Hazar  Hazar d

Event Fai Failed Barri Barrie er 

Act Active ive Fai Failur  lur e

Latent Failure

Fai Failed Con Contr ol ol

Event & Target rget

Target rget

Laten atent Fai Failur  lur e

Fai Failed Barri Barrie er 

Missing ssing Barri Barrie er 

Target rget

 Active Failure

Pr econdition Precondition

Pr econdition Precondition

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Laten atent Fai Failur  lur e Latent Failure

Laten atent Fai Failur  lur e Latent Failure

Missing ssing Barri Barrie er 

Str uctur  tur e

of  of  the HSE Man Management

System ystem

Leader  eader shi ship an and Commi Committment

Polic Policy y an and Str ategic ategic Objec Objectives ives

Tri ripod pod Beta

Orga rganisat nisatiion, Respon Responsibilities Resourc Resources es,, Stan tandar  dar ds ds & Doc Doc. Hazar  Hazar d an and Eff  Eff ects Man Management Planning Planning & Pr  Pr ocedur  edur es es

Imple Implem mentati tation

Audi udit

Man Management Revi Review ew Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Corr  Corr ective ive Act Action

Moni Monito toring ring

Corr  Corr ective ive Act Action & Imp Impr ovement Corr  Corr ective ive Act Action & Imp Impr ovement

Corr  Co rr ectiv ive e Ac Acttions laten latent f ailur  lur e

pr econdition

active ive f ailur  lur e

laten latent f ailur  lur e

pr econdition

Long te term rm action to r educ educe laten latent f ailu lur  r es es Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Replac Repla ce the f ailed barri barrie er 

Corr  Co rr ectiv ive e Ac Acttions 

If  the barri If the barrie er s hav have not been been r eplac eplaced you should questi quest ion why oper  oper ati ations hav ha ve r estar  estar ted ted



Actions to r eplac eplace barri barrie er s ar  ar e norm rmally ally on on site



Late aten nt Fai Failu lur  r es es ar  ar e deep seated do not expec expe ct to r emove them them to tom morr ow ow



Action to tack tackle le laten latent f ailu lur  r es es ar  ar e norm rmally ally at management lev level

Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Tripod-BE Tri pod-BETA TA 

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Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

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