Considering

the Human Factor

in

20th General Assembly and OSH National Convention

29-31 August 2018
Great Eastern Hotel, Quezon Ave.
Quezon City
Melvin P. Roque
Phoenix Petroleum Philippines, Inc.
INCIDENT
Incident Investigation

Is the scientific and academic

analysis of the facts that
occurred during an event.
Why we need to study incident?

“Every defect is a treasure,

if the company can uncover its cause
and work to prevent it across the
corporation.”

Kilchiro Toyoda,
Founder of Toyota
The Common Incident Investigation Tools
The 5 “WHY” Method The “Bow Tie” Method
Root Cause is the fundamental breakdown or failure of
a process which, when resolved, prevents a recurrence
of the problem.

For a particular incident, “Root Cause” is the factor

that, when you fix it, the same incident will not happen
again.
What was Wrong with Investigation?
Wrong Questions

Most investigation lead

aren't asking the right
questions.
Wrong Questions

1. Who did it?

2. What's the fix?

3. How fast can we get back

in operation?

Page 9
Going Beyond Incident Investigation

Profound Knowledge

If you do not know how

to ask the right questions,
you discover nothing.
The Traditional Investigation Focus
Hardware Issues

Material Failure Equipment Malfunction

Operator Error
Common Problem in Incident Investigation:

Individuals are usually targeted for:

1. Incompetence - Fallen asleep on duty

- Under the influence of

alcohol or drugs

- Violation SOP’s

- Inattentive
2. Criminal Negligence
- Inappropriate decision
The Traditional Action Plan????
Why do we need to study and carefully
analyze the incident?

“Every incident is an opportunity if we

find the right root cause and implement
the appropriate action throughout the
organization.”
 Common Types of Human Errors

1. Incorrect decisions

2. Improperly performed action

3. Lack of action (inaction)

 What we need to understand?

PEOPLE
(Human Error)

TECHNOLOGY ENVIRONMENT

MAY NOT CONSIDRED DURING THE INCIDENT INVESTIGATION

ORGANIZATION
PEOPLE
Abilities to Perform
Alertness
Understanding
Memory Capability
Motivation
Skill
 Technology & People

TECHNOLOGY PEOPLE

Equipment Design Perception and Comprehension

Anthropometry Quickness, Reach, Strength

Information Display Decision Making
Equipment Maintenance Performance and Safety
 Environment & People

ENVIRONMENT PEOPLE

Temperature Physical Performance

Noise Metal Performance

Regulations Fatigue
Economics Risk Taking
 Organization & People

ORGANIZATION PEOPLE

Manpower Complement Knowledge and Skill

Training Work Process

Work Schedule Fatigue
Culture Teamwork
Communication Risk Taking
Summary

Human Error is
just a symptoms

What we need to find is the

ROOT CAUSE
1. Pertains to systems and processes
2. Not pertaining to individuals
3. Management has control over it
After an incident investigation, the team
agreed to sanction the involved operator as
action plan to avoid recurrence.
Will this solve the problem?
 In investigation process
consider
HUMAN FACTORS
but don’t make it as a
ROOT CAUSE.
Analyze factors that affect
HUMAN PERFORMANCE
“Nothing is of greater importance
that the conservation of
human life.“

Former U.S. President Calvin Coolidge

THANK YOU
For Listening