Tripod-BETA

1. Tripod-BETA Incident Investigation and Analysis

2. Incidents are an indicator to improve our performance Understanding what happened and why enables us to improve our business

3. Structure of the HSE Management System Tripod Beta Leadership and Commitment Policy and Strategic Objectives Organisation, Responsibilities Resources, Standards & Doc. Hazard and Effects Management Corrective Action Planning & Procedures Monitoring Implementation Corrective Action & Improvement Audit Corrective Action & Improvement Management Review

4. What is Tripod-BETA ? A methodology for incident analysis during an investigation ... combining concepts of hazard managementand ... the Tripod theory of accident causation.

5. How does Tripod-BETA work ? The incident facts are built into a tree diagram showing ... - What happened ... - What hazard management elements failed and - Why each element failed.

6. What does the software do ? The software: • Stores investigation facts • Provides tree-building graphics • Checks the implicit tree logic • Attaches data to tree elements • Assembles attached data into a draft report.

7. How does the tree work ? Let’s walk through a simple incident introducing the terminology and logic that underpins Tripod-BETA

8. The Incident • Location: an offshore platform • Incident: an operative coming off shift slips and falls in the shower room • Consequence: he hurts his back and is off work • In the past three months there have been two similar incidents

9. Initial Findings • The incident occurred at 1820 hours • The operative slipped on the wet floor • Cleaning staff are supposed to keep the shower room floor dry

10. Starting a Tripod Tree We start by identifying: • An EVENT - where a hazard and a target get together • A TARGET - a person or an object that was harmed • A HAZARD - the thing that did the harm

11. The Hazard, Event, Target Trio Hazard Event Target They are shown in a Tripod tree like this:

12. Hazard, Event & Target In this incident: The HAZARD is : Wet floor (slipping hazard) The EVENT is : Operative falls in shower room The TARGET is : Operative

13. HET Diagram Wet floor (slipping hazard) Event Target The Hazard,

14. HET Diagram Wet floor (slipping hazard) Event Operative The Hazard, acting on the Target,

15. HET Diagram Wet floor (slipping hazard) Operative falls in shower room Operative The Hazard, acting on the Target, resulted in the Event

16. Is the investigation complete ? • Does this show full understanding ? Finding: The man must have been careless Recommendation: He should take more care on a wet floor • Or is there something more ?

17. Was the incident preventable ? • We know that a hazard management measure was in place • Cleaning staff were assigned to keep the floor dry • That ‘barrier’ to the incident failed

18. Failed Barrier Hazard FailedBarrier Event Target The barrier should have controlled the hazard

19. Incident Mechanism Wet floor (slipping hazard) Floordrying Operative falls in shower room Operative The incident mechanism looks like this:

20. Further Investigation What caused the barrier to fail ? • The cleaner could not keep the floor dry ... • because the shower room was always congested between 1800 and 1900 hrs

21. Active Failure ActiveFailure Active Failure Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative An Active Failure defeated the barrier

22. Active Failure Cleaner unable to keep floor dry Active Failure Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative An Active Failure defeated the barrier

23. End of Investigation ? • Is this the end of the investigation ? Finding: The cleaner was incompetent Recommendation: Cleaner should be replaced or retrained • Or is there still something more ?

24. Further Investigation • We know that congestion was a factor that prompted the active failure • Telephones are only available for private calls up till 1900 hrs • The congestion is caused by day shift crew hurrying to call home

25. The Full Picture Now we have the full picture: • The congestion is a ‘Precondition’ that influenced the cleaner’s task • Restriction on telephones is a ‘Latent Failure’ that created the precondition

26. Precondition Precondition Cleaner unable to keep floor dry Precondition Active Failure Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative

27. Precondition Congestion1800 - 1900 hrs Cleaner unable to keep floor dry Precondition Active Failure Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative

28. Latent Failure Latent Failure Congestion1800 - 1900 hrs Cleaner unable to keep floor dry Latent Failure Precondition Active Failure Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative

29. Latent Failure Restriction onprivate phone calls Congestion1800 - 1900 hrs Cleaner unable to keep floor dry Latent Failure Precondition Active Failure Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative

30. Recommendations Action items should address: • The failed barrier ... to restore safe conditions on a temporary basis (provide extra cleaner between 1800 and 1900) • The latent failure ... to remove the underlying cause (extend the availability of shore telephone)

31. Complex Events • That was a simple example • The Tripod-BETA methodology can also be applied in complex events

32. Complex Events Fire Identify the prime Event,

33. Complex Events Ignition Fire Identify the prime Event, the Hazard,

34. Complex Events Ignition Fire Flammable Gas Cloud Identify the prime Event, the Hazard, and Target.

35. Complex Events Ignition Fire Flammable Gas Cloud If, say, the target was created by a prior event

36. Complex Events Ignition Fire Dropped Object Event & Target Flammable Gas Cloud Identify the hazard ...

37. Complex Events Ignition Fire Dropped Object Flammable Gas Cloud Gas Line and target for that event.

38. Complex Events Ignition Fire Dropped Object Flammable Gas Cloud Damage to Platform Gas Line Similarly, if a consequential event happens ...

39. Complex Events Ignition Fire Dropped Object Flammable Gas Cloud Damage to Platform Gas Line because the prime event created a new hazard,

40. Complex Events Ignition Source Fire Dropped Object Flammable Gas Cloud Damage to Platform Gas Line Platform identify the target for the new event.

41. Complex Events Ignition Source FailedBarrier Fire Dropped Object Flammable Gas Cloud Damage to Platform Gas Line Platform Identify failed ‘barriers’,

42. Complex Events Ignition Source FailedBarrier Fire Dropped Object MissingBarrier Flammable Gas Cloud Damage to Platform Gas Line Platform and missing ones ...

43. Complex Events Ignition Source FailedBarrier FailedBarrier FailedBarrier Fire Dropped Object MissingBarrier Flammable Gas Cloud Damage to Platform Gas Line Platform including multiple failures ...

44. Complex Events Ignition Source FailedBarrier FailedBarrier FailedBarrier Fire Dropped Object MissingBarrier Flammable Gas Cloud Damage to Platform FailedBarrier MissingBarrier Gas Line Platform on each relevant ‘trajectory’ ...

45. Complex Events Ignition Source FailedBarrier FailedBarrier FailedBarrier Fire Dropped Object MissingBarrier Flammable Gas Cloud Damage to Platform FailedBarrier MissingBarrier Gas Line Platform MissingBarrier until the Incident Mechanism is complete.

46. Complex Events ActiveFailure Active Failure Ignition Source FailedBarrier FailedBarrier FailedBarrier Fire Dropped Object MissingBarrier Flammable Gas Cloud Damage to Platform FailedBarrier MissingBarrier Gas Line Platform MissingBarrier Show the Active Failure for each barrier, ...

47. Complex Events Precondition ActiveFailure Precondition Active Failure Hazard FailedBarrier FailedBarrier FailedBarrier Event & Hazard Hazard Event MissingBarrier Event & Target FailedBarrier MissingBarrier Target Target MissingBarrier the Precondition(s) promoting each active failure, ...

48. Complex Events LatentFailure Precondition ActiveFailure Latent Failure Precondition Active Failure Hazard FailedBarrier FailedBarrier FailedBarrier Event & Hazard Hazard Event MissingBarrier Event & Target FailedBarrier MissingBarrier Target Target MissingBarrier and the Latent Failure behind each precondition.

49. Complex Events LatentFailure Precondition ActiveFailure Latent Failure Precondition Active Failure LatentFailure Precondition ActiveFailure Latent Failure Precondition Active Failure Hazard FailedBarrier FailedBarrier FailedBarrier Event & Hazard Hazard Event MissingBarrier Event & Target FailedBarrier MissingBarrier Target Target MissingBarrier • Complete a ‘Tripod path’ for each barrier.

50. The completed Tripod-BETA tree LatentFailure Precondition ActiveFailure Latent Failure Precondition Active Failure LatentFailure Precondition ActiveFailure Latent Failure Precondition Active Failure LatentFailure Hazard Latent Failure FailedBarrier FailedBarrier FailedControl Event & Hazard Hazard Event MissingBarrier Event & Target FailedBarrier MissingBarrier Target ActiveFailure Target MissingBarrier Active Failure LatentFailure Precondition LatentFailure LatentFailure Latent Failure Precondition LatentFailure Precondition Latent Failure Latent Failure Latent Failure Precondition