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Integration of Quality Into Accident Investigation Processes. ASQ Columbia Basin Section 614 John Cornelison January 2008. Failure of weld on blow down system. Presentation Summary. Outline system processes for investigation, analysis and reporting Identify quality points.

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integration of quality into accident investigation processes

Integration of Quality Into Accident Investigation Processes

ASQ Columbia Basin Section 614

John Cornelison

January 2008

presentation summary
Presentation Summary
  • Outline system processes for investigation, analysis and reporting
  • Identify quality points
key elements of accident investigation
Key Elements of Accident Investigation
  • Reconstruct what happened
  • Collection of information
  • Analysis of facts
  • Determine why it happened
  • Develop findings
  • Decide on recommendations
  • Write report
performance logic
Performance Logic
  • The investigation and analysis processes should produce a finished report
  • Investigation and analysis information (facts) should be ready for the final report
  • Information is filtered through a group of causal factors
  • The investigator needs to place the information in the right report sections
quality considerations for ai processes
Quality Considerations For AI Processes
  • Written plan and procedures and personnel trained to them
  • Experienced investigators
  • Decisions based on facts and not hearsay
  • Information and evidence collected controlled
  • Findings and conclusions based on facts
  • Recommendations address both Systemic Management findings and Specific work findings
  • Use of AI Model to drive processes
advantages of system approach
Advantages of System Approach
  • Accidents are complex
  • Divides accident information into usable elements
  • Focuses on critical barriers and controls
  • AI Model ensures minimum processes
  • Structured process for traceability and reliability
  • Reduces bias
slide8

Accident Model

  • Management Policy drives which barrier and controls used
  • Barriers and controls must be maintained

Energies

3) Multiple barriers and controls must be used

Barriers

Controls

4) Management must maintain performance acceptable level

Targets

Sequence of Events

Accident

Task Performance

- Adequate

- Pre Accident

- LTA

- Accident

Causal Factors

Change

Status of Work Process

- Post Accident

- Prior

- Personnel

- Present

- Procedures

OR

6) Management must control changes

- Hardware

- Environment

5) Management must maintain work processes in an operational readiness state

ai model quality points
AI Model Quality Points
  • Are your current causal analysis and recommendations preventing similar accidents?
  • Causal factor selection may be LTA
  • Implementation of recommendations may be LTA
  • System for investigation and analysis may need to be changed
sequence of events
Sequence of Events
  • Accidents involve a sequence of events that set up LTA conditions – work planning
  • Investigation method – Event Charting
  • Recreates sequence of events, what happened
  • Systemic and specific conditions and causal factors
  • Is the system functioning as planned
quality points
Quality Points
  • Sequence of events in correct order based on time and date
  • Requires a complete investigation to ensure correct order
  • Looks at both systemic and specific events
  • Identifies missing sequences
  • Where did the Systemic and Specific failures occur; in work planning, in implementation or in control processes
barriers and controls
Barriers and Controls
  • All accidents involve failure of barriers and controls
  • Investigation Method – Barrier Analysis
  • Identifies energy sources, physical barriers, administrative controls and targets
  • Evaluates effectiveness of barriers and controls
  • Determines reliability of barriers & controls
quality points1
Quality Points
  • Identifies all the hazards
  • Separates physical barriers from administrative controls
  • Examines mode of failure
  • Identifies all potential targets of value
    • Personnel, Facilities, Processes, Environment
task performance
Task Performance
  • Accidents involve work performed which is adequate or LTA
  • Investigation Method – Task Analysis
  • Identifies basic tasks
  • Looks for task errors
  • Analyzes task errors for “Can Do” and “Motivational Behavioral Climate”
  • Questions methods to ensure performance
quality points2
Quality Points
  • Identifies tasks with potential for errors that can degrade system
  • Identifies task with errors
  • Looks at how the task errors occurred in the work processes
  • Quality monitoring to ensure critical systems are not affected by task errors
status of work processes
Status of Work Processes
  • Accidents involve many work processes
  • Each process may be in a different state of readiness
  • Investigation Method – Status of the Work Process Review
  • Looks closely at personnel, procedures, hardware and environment in OR mode
  • Time and interfaces
slide20

SYSTEMS APPROACH TO ACCIDENT INVESTIGATION

STATUS OF WORK PROCESSES ANALYSIS

quality points3
Quality Points
  • Investigates the OR status of key elements of the work process
    • Personnel
    • Procedures
    • Hardware
    • Environment
  • Determines when and how the elements lost their OR status
  • Set up monitoring points
change
Change
  • Most accidents involve some type of change in the work processes
  • Investigation Method – Change Analysis
  • Identifies present conditions and prior conditions
  • Looks for differences
  • Analyzes changes for affects on setting up LTA conditions
quality points4
Quality Points
  • Investigates how changes in the work processes were managed
  • Looks at planned and unplanned changes
  • Looks at the interface of the changes with the key elements of the work processes
  • Looks at how system performance was affected by the changes
causal factors
Causal Factors
  • Reasons or whys for an accident
  • Investigation Method – Root Cause Analysis
  • Identifies Systemic and Specific causes
  • Looks at chain of causes from management to work and back to management
  • Groups causes into 27 categories
slide26

Systemic Factors

  • Management
  • Policy
  • Policy Implementation
  • Risk Assessment
  • Technical Information
  • Hazard Analysis
  • Safety
  • Appraisals / Audits / Reviews
  • Change
  • Procedure
  • Codes / Standards / Regulations
  • Design
  • Human Factors
  • Quality Assurance / Quality Control
slide27

Specific Factors

  • Amelioration
  • Barriers & Controls
  • Operational Readiness
  • Maintenance
  • Inspection
  • Supervision
  • Task Performance
  • Personnel
  • Training
  • Environment
  • Equipment
  • Communications
  • Personnel Protective Equipment
slide28

Systems Approach to Accident Investigation

Causal Factor Analysis Selection Tree

quality points5
Quality Points
  • Looks at a complete system of causes
  • Systemic and Specific
  • Identifies the complete chain of causal factors
  • Fixes not just the primary accident causes but all the LTAs in the system
summary of the processes
Summary of The Processes
  • Use of the Systems Approach Accident Model to drive the investigation
  • Focuses on fixing all the LTAs in the system
  • Which prevents future accidents
  • Use of the systems analysis tools provides valid factual information to accident report
  • Maintains high level of performance
accident report
Accident Report
  • Title Page
  • Table of Contents
  • Executive Summary
  • Facts Section
  • Analysis Section
  • Finding Section
  • Recommendations
  • Signature
  • Appendix
slide34

Accident Model

  • Management Policy drives which barrier and controls used
  • Barriers and controls must be maintained

Energies

3) Multiple barriers and controls must be used

Barriers

Controls

4) Management must maintain performance acceptable level

Targets

Sequence of Events

Accident

Task Performance

- Adequate

- Pre Accident

- LTA

- Accident

Causal Factors

Change

Status of Work Process

- Post Accident

- Prior

- Personnel

- Present

- Procedures

OR

6) Management must control changes

- Hardware

- Environment

5) Management must maintain work processes in an operational readiness state