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Incident Investigation : An Advance Approach
By:Shakir Imran
Fauji Fertilizer Company Limited Mirpur Mathelo
Fauji Fertilizer Company Limited – Mirpur Mathelo
Synopsis
• Background• Incidents Definitions • Incident Causation Model• Incident Investigation : Traditional Model• Rational Vs Advance Model Comparison• Incident Investigation: The advance model• FFC Mirpur Mathelo Methodology• FFC Mirpur Mathelo Experience• FFC OH&SMS Performance
Fauji Fertilizer Company Limited – Mirpur Mathelo
Background
During a study on incident investigation methodology and record following were observation:
- In any year, 70~ 80% of accident were due to 20~ 30% of the root causes
- These root causes are repetitive in the all the years (from 2003 on ward)
- Actions were correction than the corrective actions.
Fauji Fertilizer Company Limited – Mirpur Mathelo
Incident
Work related event(s) in which an injury or ill health (regardless of severity) or fatality occurred, or could have occurred.
(OHSAS 18001:2007)
Fauji Fertilizer Company Limited – Mirpur Mathelo
Incident Causation Model
Safeguard 01Safeguard 02
Safeguard 03Safeguard 04
Fauji Fertilizer Company Limited – Mirpur Mathelo
The Alternative Arrangement
Traditional Approach: • Identification of critical events• Actions to prevent their recurrence
New Construction: • Interaction of critical events and human
behaviors. • How these work together forms a system
Fauji Fertilizer Company Limited – Mirpur Mathelo
Nature of Accident (Traditional Rational View)
• Time line and sequence of the events before
accident happening
• Identification of critical events during this
chain of events/ Failure of safeguards
• Dealing with these identified critical event(s)
(Active failures) to prevent reoccurrence
(single loop learning)
Fauji Fertilizer Company Limited – Mirpur Mathelo
Incident Investigation: The Advance Model
• Time line and sequence of the events before accident happening
• Identification of critical events during this chain of events/ failure of safeguards
• Human contribution to loss
• Identification of latent failures in root cause analysis (double loop learning)
Fauji Fertilizer Company Limited – Mirpur Mathelo
FFC Mirpur Mathelo Methodology
• Gap analysis between conventional and advance model methodology
• A training plan is developed for the implementation of the following critical areas:
Human behaviors/ factors Correction and Corrective Actions Investigators biases
• Risk assessment study is also revised and human factors/ behaviors were incorporated in the risk assessment study.
Fauji Fertilizer Company Limited – Mirpur Mathelo
Human Failures: Human Contribution to Loss
1. Errors
2. Violations
Fauji Fertilizer Company Limited – Mirpur Mathelo
Errors and Violations
• Errors1. Action Errors Slips and Lapses (Skill Based Errors)2. Thinking Errors Poor Analysis/ Problem Solving (Rule
based Errors) Incomplete Information (Knowledge
based Errors)
Human Failures: Human Contribution to Loss
Fauji Fertilizer Company Limited – Mirpur Mathelo
Human Failures: Human Contribution to Loss
Cognitive Deficiencies
• Perception
• Memory• Decision• Action
Fauji Fertilizer Company Limited – Mirpur Mathelo
• Violations
1. Routine: A rule exists but no one follows it2. Situational: In effect the specific nature of the
situation induces the violation3. Exceptional: these are rare and occur when
something has already gone wrong and people feel the need to improvise so as to correct the problem.
Human Failures: Human Contribution to Loss
Fauji Fertilizer Company Limited – Mirpur Mathelo
Correction and Corrective Actions
• Active and Latent Failures
• Single and Double loop learning
Fauji Fertilizer Company Limited – Mirpur Mathelo
Active and Latent Failures
• Active FailuresOccurs in the close proximity of the incidents
• Latent FailuresHidden and mostly available within the deficiencies of management systems
Fauji Fertilizer Company Limited – Mirpur Mathelo
Single and Double Loop Learning
Single Loop Learning• To change the behavior• e.g. Identification for retraining as a remedial
action
Double Loop Learning• To correct errors to change the identified
program• e.g. Why training is not effective in first place ?
Fauji Fertilizer Company Limited – Mirpur Mathelo
Investigator Biases
• Satisficing
• Heuristics:
• Confirmatory evidence
• Mental models
• Groupthink
• Hindsight
Fauji Fertilizer Company Limited – Mirpur Mathelo
FFC Mirpur Mathelo Experience
• We are in a process to implement this approach and certainly a new subject for us and in Pakistan. However positive impact on the statistics is already being observed. • Study has showed that this approach (originally developed
by BSI) has Improvement area were identified in:
Management Systems Training Plan Formulizations / Safety Trainings/
Orientation Structures Risk assessment study Job Safety Analysis Job suitability analysis (Induction phase)
Fauji Fertilizer Company Limited – Mirpur Mathelo
June , 03
Dec, 03 June, 04
Dec,04 June, 05
Dec, 05 June, 06
Dec , 06
June , 07
Dec , 07
June, 08
Dec , 08
Dec, 09 Dec, 10 June, 11
0
2000000
4000000
6000000
8000000
10000000
12000000
93679668012
1265718
1930936
638623
1472016
2236828
2974131
3681274
4434034
5163279
5962293
7447968
9156691
10081432
1 MillionHours
,Apr 142004
2 MillionHours
,18th Jan2005
LWI on Jan2005 ,28
1 MillionHours
,07th Sept2005
2 MillionHours
,16th May2006
3 MillionHours
,10th Jan2007
4 MillionHours
,20th Sept2007
5 MillionHours
,24th May2008
6 MillionHours
,12th Jan2009
7 MillionHours
,08th Sept2009
8 MillionHours
, 2nd May2010
9 MillionHours
,22th Nov2010
Safe Man-Hours Statistics (2003 to June 2011)
Fauji Fertilizer Company Limited – Mirpur Mathelo
Reference Documents
• Psychoalogica toolkit for advance incident investigation
• “The Fifth Discipline” by Peter Senge• “Root cause analysis (simplified tools and
techniques)” second edition by Bjorn Andersen and Tom Fagerhaug
• “Organizational Dysfunction” by Chris Argyris• “Human Errors and Their Classification” by
Rasmussen• “Normal Accident” Edition Two by Norman
Perrow