Incident Investigation : An Advance Approach

1. Fauji Fertilizer Company LimitedMirpur Mathelo Incident Investigation : An Advance Approach By: Shakir Imran

2. 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

3. 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.

4. 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)

5. Incident Causation Model Safeguard 03 Safeguard 01 Safeguard 04 Safeguard 02

6. 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

7. 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)

8. 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)

9. 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.

10. Human Failures: Human Contribution to Loss • Errors • Violations

11. Human Failures: Human Contribution to Loss Errors and Violations • Errors • Action Errors • Slips and Lapses (Skill Based Errors) • Thinking Errors • Poor Analysis/ Problem Solving (Rule based Errors) • Incomplete Information (Knowledge based Errors)

12. Human Failures: Human Contribution to Loss Cognitive Deficiencies • Perception • Memory • Decision • Action

13. Human Failures: Human Contribution to Loss • Violations • Routine: A rule exists but no one follows it • Situational: In effect the specific nature of the situation induces the violation • 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.

14. Correction and Corrective Actions • Active and Latent Failures • Single and Double loop learning

15. 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

16. 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 ?

17. Investigator Biases • Satisficing • Heuristics: • Confirmatory evidence • Mental models • Groupthink • Hindsight

18. 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)

19. Incident Statistics(2003 to June 2011)

20. Safe Man-Hours Statistics (2003 to June 2011)

21. 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

22. Change…......Before you have to(Jack Welch)