SEVEN DEADLY SINS OF INCIDENT INVESTIGATION Don Enslow BP Exploration (Alaska), Inc.
SEVEN DEADLY SINS OF INCIDENT INVESTIGATION • Are your company successes attributed to rolling the dice?
SEVEN DEADLY SINS OF INCIDENT INVESTIGATION Are you investigating all of your incidents?
SEVEN DEADLY SINS OF INCIDENT INVESTIGATION • Or is it just as easy to sweep it under the carpet?
SEVEN DEADLY SINS OF INCIDENT INVESTIGATION To sin may be human but poor root cause analysis can be fatal.
SEVEN DEADLY SINS OF INCIDENT INVESTIGATION If your investigations are not producing results someone may fall off of the truck.
SEVEN DEADLY SINS OF INCIDENT INVESTIGATION • What are the seven deadly sins of incident investigation?
SEVEN DEADLY SINS OF INCIDENT INVESTIGATION • Do you use a formal root cause analysis technique to eliminate the potential for poor incident investigations and recurrence of potentially serious incidents?
Panel of Experts From Wahoo, Nebraska! • Top Seven Sins of Incident Investigation
Sin Number Seven • Your investigation process for operational non-conformances, near misses and incidents is so poor you use the FBI assault on Waco, Texas as your benchmark for reaching corrective action. - Repeat Failures - Fault Finding - Corrective Action NI - Corrective Action Not Yet Implemented
Sin Number Six • Employee Behavior and Teamwork are so poor at your company the last 3 CEO’s were retired prison wardens. - Enforcement Needs Improvement - Accountability Needs Improvement - Crew Teamwork Needs Improvement - Team Selection Needs Improvement
Sin Number Five • Communication within your company is so bad you use the smoke shacks as the official distribution center for daily work activities and employee information (restrooms can be an alternate if you don’t smoke). - No Communication or Not Timely - Turnover Needs Improvement - Misunderstood Verbal Communication
Sin Number Four • Your engineering and design of new facilities, or, modifications to existing facilities is coordinated by the local tavern with specs and drawings neatly stored on napkins. - Specs Need Improvement - Design not to Specs - Problem not anticipated - Independent Review Needs Improvement - Human Engineering
Sin Number Three • Your company was founded by a cowboy. Adherence to Standards, Policies and Administrative Controls (SPAC) is window dressing. Short cuts and getting the job done are what counts. Three ring binders with policies were invented to keep auditors happy. - SPAC Need Improvement - SPAC Not Used - Infrequent Audits Evaluations
Sin Number Two • Orientation and training of employees to hazards in the workplace is accomplished by the Darwin Theory. Genetics is the key to reducing unsafe exposures. - Task Not Analyzed - Decided Not to Train - No Learning Objective - Continuing Training Needs Improvement
Sin Number One • Your retired prison warden/CEO has marketed your company motto for operational integrity as: “What you don’t know won’t hurt you.” - Management of Change (MOC) - Contractor adherence to SPAC - SPAC NI - SPAC Not Used - Procedures Not Used/Not Followed
Group Think Session –What Are the Safeguards You Have in Place to Reduce/Eliminate the Seven Deadly Sins