Incident Investigation : An Advance Approach
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Fauji Fertilizer Company Limited Mirpur Mathelo
Incident Investigation : An Advance Approach
By:
Shakir Imran
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
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
Human Failures: Human Contribution to Loss
Errors and Violations
• Errors 1. 2.
Action Errors Slips and Lapses (Skill Based Errors) Thinking Errors Poor Analysis/ Problem Solving (Rule based Errors) Incomplete Information (Knowledge based Errors) Fauji Fertilizer Company Limited – Mirpur Mathelo
Human Failures: Human Contribution to Loss
Cognitive Deficiencies • • • •
Perception Memory Decision Action
Fauji Fertilizer Company Limited – Mirpur Mathelo
Human Failures: Human Contribution to Loss • Violations 1. Routine: A rule exists but no one follows it 2. Situational: In effect the specific nature of the situation induces the violation 3. 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.
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 Failures Occurs in the close proximity of the incidents • Latent Failures Hidden 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
Incident Statistics (2003 to June 2011)
Fauji Fertilizer Company Limited – Mirpur Mathelo
Safe Man-Hours Statistics (2003 to June 2011) 12000000
9 Million Hours 22th Nov, 2010
10000000
8 Million Hours 2nd May , 2010
8000000
6000000
4000000
2000000
1 Million Hours Apr 14, 2004
10081432
9156691
7 Million Hours 7447968 08th Sept, 6 Million 2009 Hours 12th Jan, 5962293 5 Million 2009 Hours 5163279 4 Million 24th May, 2008 Hours 4434034 3 Million 20th Sept, 2007 Hours 3681274 10th Jan, 2 Million 2007 Hours 2974131 1 Million 2 Million 16th May, Hours Hours 2006 07th Sept, 18th Jan, 2236828 2005 1930936 2005
1265718
668012
LWI on Jan 28, 2005
1472016
638623
93679 0 June , Dec, 03 June, Dec,04 June, Dec, 05 June, Dec , 06 June , Dec , 07 June, Dec , 08 Dec, 09 Dec, 10 June, 03 04 05 06 07 08 11
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 Fauji Fertilizer Company Limited – Mirpur Mathelo
Change…......Before you have to (Jack Welch)
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