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Learning from incidents. www.energyinst.org. Energy Institute LFI work activities: overview 10 December 2013 Stuart King, Technical Products Manager [email protected]. Aims of this presentation. Highlight some of the issues that industry faces - PowerPoint PPT Presentation
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www.energyinst.org
Energy Institute LFI work activities: overview10 December 2013
Stuart King, Technical Products [email protected]
www.energyinst.org
Learning from incidents
www.energyinst.org
• Highlight some of the issues that industry faces
• Outline EI learning from incidents activities
Aims of this presentation
www.energyinst.org
About the EI
The Energy Institute (EI) is the professional membership body for individuals and organisations working in energy or a related field.
We promote excellence by developing knowledge, skills and good practice for the benefit of the global energy sector, its people and society.
By being part of the EI, our members ensure they stay informed, engaged and connected in a fast-changing industry.
• 16,000 individual members
• 250 company members
• Professional membership grades
www.energyinst.org
EI Technical work programme
• Funded technical work programme
• 30+ Technical Partners
• BG Group• BP• Centrica• Chevron• ConocoPhillips• DONG Energy• EDF Energy• ENI• E.ON• ExxonMobil• International Power
• Kuwait Petroleum• Maersk Oil• Murco• Nexen• Phillips 66• Premier Oil• RWE npower• Saudi Aramco• Scottish Power• SGS• Shell
• SSE• Statkraft• Statoil• Talisman• Total• Tullow• Valero• Vattenfall• World Fuel Services
www.energyinst.orgwww.energyinst.org
Learning from incidents (LFI) involves:1) understanding why incidents, near misses, business losses etc.
happened, and 2) making the necessary corrections/improvements to ensure similar
incidents do not happen.
What is learning from incidents?
How we learn, not about what needs to be learned
www.energyinst.org
Some common issues
Incident investigations often do not go far enough to investigate human and organisational factors issues (i.e. do not always go beyond the immediate causes)- Time & skill of the investigator- Resources linked to severity of incident, not learning potential- Politics, costs, ideology and culture
- Avoiding blame of the individual or organisation- Are people responsible for their own actions? Hard to accept.
How do we embed learning?- Creating good actions for learning- Taking time for reflection – contextualising, engaging workforce
How do we know learning has taken place?- Effectiveness of follow-up actions measured for 6% of incidents
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Work streams
• Human and organisational factors committee (HOFCOM)• Process Safety Committee
Technical work programme
• Tripod Beta methodology
Stichting Tripod Foundation
• PhD research• LFI toolkit (in development)
Hearts and Minds
www.energyinst.orgwww.energyinst.org
Work streams
• Human and organisational factors committee (HOFCOM)• Process Safety Committee
Technical work programme
• Tripod Beta methodology
Stichting Tripod Foundation
• PhD research• LFI toolkit (in development)
Hearts and Minds
www.energyinst.org
Guidance on investigating and analysing human and organisational factors aspects of incidents and accidents (2008)
• Why investigate HOF aspects of incidents? – An introduction• Go beyond ‘human error’ being cited as underlying cause in investigations –
it’s not an underlying cause!• Introduction to human failure (error and violation) classifications.• Uses the Tripod causation model of why incidents happen.• Just culture – investigation is not about blame, it’s about learning. • Performance influencing factors • Brief description of 28 proprietary and public investigation and analysis
methodologies.• ‘a line in the sand’
• Referenced on HSE website• Still a well accessed publication.• …. But due for an update
www.energyinst.org
Guidance on meeting expectations of EI process safety management framework: Element 19: Incident reporting and investigation
• Provides• a flow diagram of activities that
should make up the accident reporting and investigation process.
• Performance measures for monitoring reporting and investigation process performance.
• High level, for informing the safety management system.
• Consistent process
Expected Q2 2014
www.energyinst.orgwww.energyinst.org
Work streams
• Human and organisational factors committee (HOFCOM)• Process Safety Committee
Technical work programme
• Tripod Beta methodology
Stichting Tripod Foundation
• PhD research• LFI toolkit (in development)
Hearts and Minds
www.energyinst.orgwww.energyinst.org
Tripod Beta
• Partnership with the Stichting Tripod Foundation
• Tripod is an established incident investigation and analysis methodology, used internationally and by a range of industries
• Governed by Tripod Board and Tripod Assessors
• Accreditation programme for practitioners and Training courses
Tripod Beta: Guidance on using Tripod Beta in the investigation and analysis of incidents, accidents and business lossesExpected Q1 2014
www.energyinst.orgwww.energyinst.org
Work streams
Technical work programme
• Human and organisational factors committee (HOFCOM)• Process Safety Committee
Stichting Tripod Foundation
• Tripod Beta methodology
Hearts and Minds
• PhD research• LFI toolkit (in development)
www.energyinst.org
Reporting
Investigation
Developing inci
dent alerts
Disse
minatio
n
Contextualising
Implementing
actions
Business improvement
Change in behaviour
External incident
Internal incident
Hearts and Minds – Learning from incidents toolkit
LFI process Many organisations
stop here
‘The missing link’
Safety issue reported
www.energyinst.org
Hearts and Minds – Learning from incidents toolkit
• PhD research, Glasgow Caledonian University (2009-2012)• Exploring LFI from an adult learning perspective.• Follow-up project to produce practical toolkit.
Toolkit:Provide exercises to:A) help the organisation understand its LFI processes
• Includes LFI questionnaire
B) engage staff with LFI to contextualise and embed learning• 3 engagement exercises to help engage staff with incidents; apply
learning to own work context.
Next steps: development and testing
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www.energyinst.org
Good practice guidance
Investigation & analysis
tools
Learning & engagement
tools
Where are we going? The LFI landscape
The focus
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Reporting
Initiate investigationWho; Remits; Team; legal;
Etc.
Investigation
Analysis
Developing action items
Learning
Future guidance
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Thank you for your time
Any questions?