Incident Investigation : An Advance Approach By: Shakir Imran Fauji Fertilizer Company Limited Fauji Fertilizer Company Limited Mirpur Mathelo

Incident Investigation : An Advance Approach

By:Shakir Imran

Fauji Fertilizer Company Limited Mirpur Mathelo

Fauji Fertilizer Company Limited – Mirpur Mathelo

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


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.


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)


Incident Causation Model

Safeguard 01Safeguard 02

Safeguard 03Safeguard 04


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


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)


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)


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.


Human Failures: Human Contribution to Loss

1. Errors

2. Violations


Errors and Violations

• Errors1. Action Errors Slips and Lapses (Skill Based Errors)2. Thinking Errors Poor Analysis/ Problem Solving (Rule

based Errors) Incomplete Information (Knowledge

based Errors)




Cognitive Deficiencies

• Perception

• Memory• Decision• Action


• Violations

1. Routine: A rule exists but no one follows it2. Situational: In effect the specific nature of the

situation induces the violation3. 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.



Correction and Corrective Actions

• Active and Latent Failures

• Single and Double loop learning


Active and Latent Failures

• Active FailuresOccurs in the close proximity of the incidents

• Latent FailuresHidden and mostly available within the deficiencies of management systems


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 ?


Investigator Biases

• Satisficing

• Heuristics:

• Confirmatory evidence

• Mental models

• Groupthink

• Hindsight


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)


Incident Statistics (2003 to June 2011)


June , 03

Dec, 03 June, 04

Dec,04 June, 05

Dec, 05 June, 06

Dec , 06

June , 07

Dec , 07

June, 08

Dec , 08

Dec, 09 Dec, 10 June, 11

0

2000000

4000000

6000000

8000000

10000000

12000000

93679668012

1265718

1930936

638623

1472016

2236828

2974131

3681274

4434034

5163279

5962293

7447968

9156691

10081432

1 MillionHours

,Apr 142004

2 MillionHours

,18th Jan2005

LWI on Jan2005 ,28

1 MillionHours

,07th Sept2005

2 MillionHours

,16th May2006

3 MillionHours

,10th Jan2007

4 MillionHours

,20th Sept2007

5 MillionHours

,24th May2008

6 MillionHours

,12th Jan2009

7 MillionHours

,08th Sept2009

8 MillionHours

, 2nd May2010

9 MillionHours

,22th Nov2010

Safe Man-Hours Statistics (2003 to June 2011)


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

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