Incident Investigation : An Advance Approach

January 8, 2018 | Author: Anonymous | Category: Social Science, Psychology
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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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