Incident

Date: TBA
Time frame: 2 days workshop Investigation and
Location: TBA Management
Training Workshop
IMS-24-01

for TBA INCIDENT

MANAGEMENT
B. Pre-requisite of this course is to be familiar with IMS-24-01-GROUP
Version 2a, April 2015
Administrative Matters,
etc…

•Safety
•Introductions – Course Leader(s)
•Timescales
•Breaks / Refreshments / Lunch
•Introductions - Delegates
•Delegates` expectations of the course
•Meeting `Rules` (develop our own)

2
 Course Format
Day 1 (am)
60 mins
 Module 1 – Introduction – Why investigate incidents? Who is
responsible? 90 mins
 Module 2 – Theory – General Requirements
90 mins
 Module 3a - Theory – Process of Incident Investigation (part 1)

Day 1 (pm) 120 mins

 Module 3b - Theory – Process of Incident Investigation (part 2)
120 mins
 Module 4a – Causal Tree Analysis – Practical Examples

Day 2 (am)
 Module 4b – Causal Tree Analysis – Current Incidents 240 mins

Day 2 (pm)
60 mins
 Module 5 – Dealing with the Media
 Module 6 – Reporting, Actions and Closure 60 mins

 Module 7 – Post-workshop Follow-on Actions 30 mins

3
What is the Workshop`s
Purpose?

• Establish a more consistent approach to incident investigation

• Improve the quality of incident investigations

• And as a result:

— LEARN THE LESSONS FROM INCIDENTS

 AVOID RECURRING INCIDENTS!!!

— REDUCE RISK THROUGH THE BUSINESS

— ACHIEVE LINDE`S VISION OF NOT HARMING PEOPLE OR THE ENVIRONMENT

4
Teams for this week`s
workshop…

TEAM NAME = TBA TEAM NAME = TBA

•TBA •TBA

•TBA •TBA

•TBA •TBA

•TBA •TBA

5
 Module 1

Introduction
—Why investigate incidents?
—Who is responsible?

6
Fundamentals for this
training course

Q 1. Why do we need to
investigate incidents?

CAPTURE IDEAS
Q 2. Who is responsible for ON FLIP CHART

incident investigations?

7
 Why we need to
investigate
incidents…
AVOID:
HARMING PEOPLE / ENVIRONMENTIdentify corrective and preventative actions:
WASTING TIME
— Avoid same incident
BEING PROSECUTED
CUSTOMER SUPPLY FAILURES — Avoid similar incident
DAMAGED REPUTATION
COMPARE WITH FLIP CHAR
UNNECESSARY COSTS

Unique possibility to Identify poor

learn about failures processes

INCIDENT
Continuous Identify training
Improvement needs and topics

Understand Identify Meet legal

costs weaknesses and requirements
measures
8
S,M,L
SUMMARY:
Why we want to investigate
incidents
WE WANT TO KNOW WHAT HAPPENED AND THUS

DETERMINE THE:

— Root Causes

— Relevant Controls

— Necessary Corrective and Preventative Actions

to Prevent Recurrence / Eliminate Loss

INCIDENT INVESTIGATION IS ABOUT IDENTIFYING THE FACTS

— IT IS NOT ABOUT BLAMING PEOPLE!!!
— Appropriate Consequence Management is essential

9
 Who is responsible for
incident investigations?
— Line / Operational Manager

—INITIAL LEAD
—REPORTING
—SUPPORT OF INVESTIGATORS
—OWNERSHIP OF ACTIONS ARISIN
— Safety / SHEQ Manager — Contractor `s Management

—INFORMATION & COMMENTS —INFORMATION & COMMENTS

—ADVISE & SUPPORT —ADVISE & SUPPORT

— Trained Investigator
— Equipment Suppliers
—INFORMATION & COMMENTS —LEAD
—ADVISE & SUPPORT —REPORTING
—SUPPORT
Specialists and Technical `Experts`
— Other Relevant Employees
—INFORMATION & COMMENTS —INFORMATION & COMMENTS
—ADVISE & SUPPORT —ADVISE & SUPPORT
10
Incident Investigators Role

Incident Investigators have to manage /

coordinate the activities and contribution of all
others involved in the incident investigation.

11
 Current Performance

Current Performance:
The need to investigate incidents….

12
 Number of Avoidable MIRs
per month (Linde Group)

16 2012
2013 120
2012 YTD
2013 YTD
Avoidable MIRs per month

12 100

Avoidable MIRs YTD

80

8
60

M AT ON
I40
4 I NFO R
LAT E ST
LY – U SE 20
PL E ON
EXAM
0 0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Key messages:
—Currently having same number of MIRs as per previous year
—We`re not learning from incidents! 13
Total MIRs per RBU:
REE&ME Avoidable and
Unavoidable
End April 2013

10 M A T ION
T I NFO R
E LAT ES V IS I ON)
N LY – US IO N / DI
MPL EO T O REG
EXA E LE V AN T
5
MA KER
(

8 8 7 6 5 5 4 3 3 2
0
RSA RSE RCN REE RNA RSP Gist RAU LE LE/ RGC GHC GTO
RGC

14
 Avoidable MIRs for Q1 2013
compared to average per Qtr
since 2010

M A T ION
T I NFO R
6
E LAT ES V IS I ON)
N LY – US IO N / DI
MPL EO T O REG
EXA E LE V AN T
MA KER
(
REE&ME have on
4
average 4 avoidable
MIRs to investigate
per quarter

0
RCN RSE RSA REE RNA RSP RAU RGC
Ave Q for 2010 Ave Q for 2011 Ave Q for 2012 Q1 2013

15
 Recent (region / division) MIRs
2012 / 13
(1 of X)

MI RS S Y E AR
H O W S VIOU
S PR E
HICH
MIR-07-15
S W E R THE
APH ) OV
Seatbelt
T G R NT S
O F PH O I N C IDE
D A SET I FI CAN T
D SI G N
H E R
O R OT

R-07-155 MIR-07-148
ermit to Work/Confined Space Lifting operations

16
LTIR
Cases per million hours
3.0

2.6
Linde Group
2.0
2.1 2.0
1.9

139
1.4
1.3
1.0
M AT ION
I NFO R
LAT E ST
LY – U SE
PL E ON
EXAM
0.0
2007 2008 2009 2010 2011 2012

17
LTIR End 2012 vs 2011
Cases per million hours
Key messages:
—REE have made significant improvements in LTIR – very well done
3.0
R MA TION
—Need to keep this up and continue by learning from incident investigations!
F O
IN 2012 LTIRN)
A T E S T IO
S E L D IV IS
O N LY–U EG IO N/ 2011 LTIR
MP LE T O R Group Average
EX A A N T
E R E LEV
2.0
(MAK

1.3
RU
K
1.0

31 19 10 24 10 7 15 14 4 2
0.0
RAU RNA RSA RCN RGC RSP LE GIST REE RSE e LTIR

18
 Module 2

Theory – General Requirements

19
 Terminology

ident = an undesired event in which harm was incurred / suffered

nt = an event in which an accident (or other adverse outcome) happened or could have hap

IDENT = `ACCIDENTS` + `NEAR-MISSES`

ar-Miss = an unintended incident NOT leading to harm but

er different circumstances could have been an accident

Reference EIGA Doc 90/13 - “Incident / Accident Investigation and Analysis”

20
THEORY:
Heinrich Triangle / Bird
Triangle

Herbert William Heinrich (1931) Frank Bird (1969)

21
THEORY: Unsafe Acts &
Conditions Underpin
Incidents

(Incident)

22
 Linde`s Standard
Requirements

• INVESTIGATE ALL SHEQ INCIDENTS

GOLDEN RULE #1

— Including those with minor outcome

— Including work related health conditions

— Including near-misses

— `SYNERGI` is the Linde Group tool for incident

management

— “All incidents must be investigated to a level consistent

with the actual or potential consequences of the incident”

— SEE NEXT SLIDE

23
 OPTIONAL SLIDE
EIGA Guidelines on level of
investigation

© EIGA Doc 90 – Incident/Accident Investigation and Analysis – Table of Section 5.3

Reference EIGA Doc 90/13 - “Incident / Accident Investigation and Analysis”

24
 Synergi Risk Matrix:
Implications for Incident
Investigations in Linde
 
Most likely timeframe for recurrence of incident
Most likely Less than between 1 1 per 1 per week 0 - 1 per
once per - 10 years month - - week
Severity 10 years 1 per year 1 per
month

RAR UNLIKE POSSIBL LIKE CERTA

E LY E LY IN
LOW LEVEL LOW LEVEL LOW LEVEL
Low OF   OF   OF   MEDIUM
OF
  LEVEL MEDIUM  LEVEL
OF
INVESTIGATI INVESTIGATI INVESTIGATI
INVESTIGATION INVESTIGATION
ON
LOW LEVEL ON
LOW LEVEL ON
Minor OF   OF   MEDIUM LEVEL
OF
  MEDIUM LEVEL
OF
  MEDIUM LEVEL
OF
 
INVESTIGATI INVESTIGATI
INVESTIGATION INVESTIGATION INVESTIGATION
ON ON
MEDIUM LEVEL
LOW LEVEL
Moderate   OF HIGH LEVEL  OF NCIDENT INVESTIGATION
    REQUIRE
OF
INVESTIGATION
INVESTIGATI
ON
MEDIUM LEVEL
Serious OF   HIGH
INVESTIGATION
LEVEL  OF INCIDENT  INVESTIGATION
  REQUIRED  

Major
HIGH LEVEL OF
  INCIDENT INVESTIGATION
    REQUIRED    

25
Near-Misses

•Near-Miss = An opportunity to learn and take

preventative actions without any harm having
been suffered!!!
•Remember - “All incidents must be investigated to a level
consistent with the actual or potential consequences of the incident”

•Actively seek out near-misses!!!

— Undertake Safety Walks
— LeadSafe engagements
— Conduct Planned Workplace Inspections
— (ref. IMS-12-01-GROUP)
— Listen to what people tell you
— Tool-box talks
— Safety Meetings
26
 General Requirements:
Some key points from IMS-
24-01
Incident management involves the
following roles:
•Line Managers

•Incident Manager:
–The manager that is responsible for the work activity/operation in which the
incident occurred and therefore is the `owner` of the incident IMS-24-01
INCIDENT MANAGEMENT
•Incident Investigation Sponsor:
–This is typically the senior line manager responsible for the area/activity in
which the incident occurred

•Incident Investigator/Lead Investigator:

–Incident investigators are typically from operational roles. Lead
Investigators are responsible for leading the investigation and managing the
input from all relevant sources

•Experts/Technical Specialists:
27
 General Requirements:
Some key points from IMS-
24-01
Incident Investigation:

—Incidents must be investigated to a level that is

appropriate to their outcome, or potential outcome, to
determine their causes, identify appropriate corrective
actions and learning points for preventative actions
IMS-24-01
—Incident investigations must start as soon as INCIDENT MANAGEMENT
possible
after the incident occurs and proceed in a timely
manner which enables preventive actions to be put in
place as soon as possible and lessons to be shared
quickly

—Incident Managers must take responsibility for the

overall management of all aspects of an incident
investigation including the provision of ongoing support
(and resources) 28
 General Requirements:
Some key points from IMS-
24-01
Incident Investigation:

—If it is not practical for an investigation to be led by a

competent investigator, it must be led by an
appropriate manager who obtains advice from others
with relevant expertise
IMS-24-01
—Incident Investigation Sponsors must ensure that INCIDENT MANAGEMENT

Critical Incidents or "MIR" type Major Incidents are

provided with sufficient and adequate resources to
enable them to carry out the investigation accurately,
efficiently and in a timely manner

—Incident Investigators must ensure that specialist

investigation standards and tools are used (if
applicable) and that a systematic analytical method is
used to identify the causes of the incident 29
Incident Investigators

30
 Incident Investigators

• Incident investigators are responsible

for:
— The overall management of all aspects of an incident
investigation including the provision of ongoing support

— Identifying the causes, including failures by individuals or the IMS-24-01

INCIDENT MANAGEMENT
organisation and any weaknesses in company standards or
procedures

— Recommending suitable corrective and preventative actions

— Identifying (together with the relevant managers) who is to

complete actions and the timeframes

— Reporting progress to management

31
 Lead Investigators

Those acting as a Lead Investigator also

need to be able to:
•Properly plan, prepare for and facilitate the investigation
•Conduct interviews in a professional manner with varying
types of interviewee (e.g. hostile, talkative)
•Guide the team in the use of the "Causal Tree" approach to IMS-24-01
incident investigation and of any other relevant techniques
INCIDENT MANAGEMENT
•Sensitively integrate source information into the report
•Develop effective actions with the investigation team
•Interact with the relevant network of stakeholders in an
incident:
— business managers, operations managers, project
managers, contractor managers, client management,
technical authorities and members of "Teams of Experts"

32
 Incident Investigators

Q 1. What are the characteristics

of1 a good Incident Investigator?
Team

CAPTURE IDEAS
Q 2. What are the undesirable ON FLIP CHART

Team 2characteristics of an Incident

Investigator?

33
The Characteristics of a Good
Incident Investigator
Ethical Credible
Respectful –wear correct PPE
–comply with rules
Trustworthy –well prepared
Honest –well organised
Observant –decisive
–confident
Analytical –impartial / fair
Perceptive –consistent
–knowledgable
Versatile
Straightforward
Independent Clear
Self Motivated Curious
Persuasive Persistent
Unbiased Flexible
Balanced
Open Minded Challenging
Pragmatic Problem Solver
Good Influencer Positive Attitude
Good Communicator Tenacious
Probing
Good Listener
Calm
Sensitive Passionate (about
Logical investigation and avoiding
harm)
34
 Undesirable Characteristics
an Incident Investigator

Arrogant Inappropriately Emotional

Conceited Ignorant
Argumentative Negative
Prejudiced Ruthless
Blinkered
Ambiguous
Untrustworthy
Inconsistent
Biased
Disorganised
Unhelpful
Quick to Jump to Conclusions Weak (easily influenced)

Seek to Blame People Poor Visible Leadership

Not Listen Insensitive
35
Beware!!!
Poor Investigation
Practices
A poor incident investigator may be characterised by:
•Thinking that nothing can be learned from ‘commonplace’ incidents

•Stop asking questions after just a few facts have been found

•Thinking that an incident is fully understood at a very early stage

•Allowing too much interpretation (vague / unclear)

•Making too many assumptions

•Not investigating the incident immediately

•Only identifying immediate (basic) causes

•Blaming people, preventing a thorough investigation

36
 Module 3a

Theory – Process of Incident

Investigation.
Part 1:
—Immediate Actions
—Attend
—Quarantine & Establish Investigation Team
—Capture Evidence
—Gather Facts; Interview

37
 Immediate Actions
(Prepare)

Attend
(Stop? Risk Assess)
Quarantine & Establish
Investigation Team
Capture Evidence The Incident Investigation Process
(+ photos, sketches etc)

Gather Facts
(& history), Interview

Review Documents,
Reconstruct &
Finalise Facts

Identify Actions
to Resume Service

Analyse
(Root Causes)

Report /Actions
(Timings, Agreed)

Communicate & Follow-Up

38
 Immediate Actions
(Prepare)

Attend
(Stop? Risk Assess)
Quarantine & Establish
Investigation Team
Capture Evidence NEAR-MISSES
(+ photos, sketches etc)

Gather Facts
(& history), Interview

Review Documents,
Reconstruct &
Finalise Facts

Identify Actions
to Resume Service

Analyse
(Root Causes)
DISCUSS - WHAT WOULD YOU
Report /Actions TYPICALLY DO AT EACH STAGE?
(Timings, Agreed)

Communicate & Follow-Up

39
 Immediate Actions
(Prepare)

Attend
(Stop? Risk Assess)
Quarantine & Establish
Investigation Team
OCCUPATIONAL ILLNESS
Capture Evidence INCIDENTS
(+ photos, sketches etc)

Gather Facts
(& history), Interview NOTE:
EXPOSURE OFTEN OCCURS
Review Documents, OVER A PERIOD OF TIME
Reconstruct & (E.G. WEEKS TO YEARS)
Finalise Facts
AND SOMETIMES IT IS
NO LONGER PRESENT.
Identify Actions
to Resume Service

Analyse
(Root Causes)
DISCUSS - WHAT WOULD YOU
Report /Actions TYPICALLY DO AT EACH STAGE?
(Timings, Agreed)

Communicate & Follow-Up

40
 Immediate Actions
(Prepare)

Attend
(Stop? Risk Assess)
Quarantine & Establish
Investigation Team
Capture Evidence MINOR INCIDENTS
(+ photos, sketches etc)

Gather Facts
(& history), Interview

Review Documents,
Reconstruct &
Finalise Facts

Identify Actions
to Resume Service

Analyse
(Root Causes)
DISCUSS - WHAT WOULD YOU
Report /Actions TYPICALLY DO AT EACH STAGE?
(Timings, Agreed)

Communicate & Follow-Up

41
 Immediate Actions
(Prepare)

Attend
(Stop? Risk Assess)
Quarantine & Establish
Investigation Team
MAJOR INCIDENTS
Capture Evidence
(+ photos, sketches etc)

Gather Facts
(& history), Interview

Review Documents,
Reconstruct &
Finalise Facts

Identify Actions
to Resume Service

Analyse
(Root Causes)
DISCUSS - WHAT WOULD YOU
Report /Actions TYPICALLY DO AT EACH STAGE?
(Timings, Agreed)

Communicate & Follow-Up

42
 IMMEDIATE ACTIONS
(PREPARE)
(MAJOR INCIDENTS)
Immediate Actions
— Things to consider before attending:
— How can you get to the incident quickly, but safely? Attend
(Stop? Risk Assess)
— Take tools, equipment and PPE that you may require
Quarantine & Establish
— camera, notebook and pen Investigation Team
— tape measure, torch, voice recorder
Capture Evidence
— specialist equipment e.g. tyre depth gauge (+ photos, sketches etc)
— is it already prepared?
Gather Facts
— If off-site determine who else may be attending (& history), Interview
and if you need assistance
Review Documents,
— Inform others before going (especially for off-site incidents)
Reconstruct & Finalise Facts
— delegate routine work responsibilities
— advise home etc Identify Actions
to Resume Service
— inform Corporate Communications (MAJOR)
Analyse - Causal Tree
— Prepare yourself for personal trauma, especially if there
is a fatality involved or serious injury…………. Report /Actions
— if you know the deceased or injured should you attend?
Communicate & Follow-Up
43
 ATTEND
(MAJOR INCIDENTS)
Immediate Actions
— When arriving at the incident scene:
Attend
(Stop? Risk Assess)
— use appropriate PPE - maintain safety (and show authority?)
Quarantine & Establish
— Linde jacket (High-Vis), hard hat, boots, eye protection, gloves, etc Investigation Team

— establish who is in charge & seek others from Linde Capture Evidence
(+ photos, sketches etc)
— start liaison with any emergency services
Gather Facts
(& history), Interview
— check that the incident scene is safe & maintain your safety

— assess the risks Review Documents,

Reconstruct & Finalise Facts
— restrict access (is it a crime scene?)
Identify Actions
to Resume Service
— take photographs, talk to people, start collecting evidence….
Analyse - Causal Tree
— be prepared to meet different types of people!
— Media, hysterical bystanders / relatives / friends, Report /Actions
`Do-gooders` (people trying to help), interfering people etc
Communicate & Follow-Up
44
QUARANTINE & ESTABLISH
INVESTIGATION TEAM
(MAJOR INCIDENTS)
Immediate Actions
 Prevent unauthorised access
Attend
— Avoid loss, damage or tampering of evidence (Stop? Risk Assess)
— Maintain safety Quarantine & Establish
Investigation Team
— Consider if need to stop operations
Capture Evidence
(+ photos, sketches etc)

Gather Facts
(& history), Interview
 Ensure that the Lead Investigator role
is established and others involved have Review Documents,
Reconstruct & Finalise Facts
the right skills / experience /
Identify Actions
characteristics to Resume Service

• Operations, SHEQ, Technical, HR, Analyse - Causal Tree

Contractor Management, Other Specialists etc
Report /Actions

Communicate & Follow-Up

45
 CAPTURE EVIDENCE (1 of
2)
(MAJOR INCIDENTS) Immediate Actions
— The requirements for examining the scene and
Attend
capturing evidence depends on the nature (Stop? Risk Assess)
of the incident Quarantine & Establish
Investigation Team
— Vehicles – driving, Construction, Plant explosion / fire
Medical customers, Warehouse, Customer engineering, (+ Capture Evidence
etc
photos, sketches etc)

When Capturing Evidence DO Gather Facts

(& history), Interview
NOT:
— Make comments that are: Review Documents,
Reconstruct & Finalise Facts
— legally sensitive
— ambiguous / confusing Identify Actions
to Resume Service
— unqualified
— Apportion Blame Analyse - Causal Tree
— Pass judgement Report /Actions
— Try to Hide Matters
Communicate & Follow-Up
46
 CAPTURE EVIDENCE (2 of
2)
(MAJOR INCIDENTS) Immediate Actions
Basic recommendations:
— Establish the scope / boundaries Attend
(Stop? Risk Assess)
— Observe, Listen, Think
— Be prepared to challenge what you are told / discover Quarantine & Establish
Investigation Team
— Look at the incident from every perspective
— Establish events up to the incident Capture Evidence
(+ photos, sketches etc)
— Consider physical conditions
— weather, lighting levels, space, obstructions, ground state etc
Gather Facts
(& history), Interview
— Consider if external agencies may have further evidence
— Talk to witnesses
Review Documents,
— What did they see, hear or smell? Reconstruct & Finalise Facts
— Is anything odd or different?
— Look for recent change Identify Actions
—
to Resume Service
What were people doing prior to the incident? (consider `behaviours`)
— Record everything Analyse - Causal Tree
— Photos, video, sketches, statements (written – preferably recorded)
— Ask for expert help / opinion as necessary Report /Actions
— Investigators are not expected to know everything!!! (SEE NEXT SLIDE)
Communicate & Follow-Up
47
`DESK` TYPE
INVESTIGATION SUPPORT
`Desk support` is information / comments that
may be obtained from people not on the
investigation team, and that may enhance the
quality of the investigation.
The investigation team must:
 Actively seek and obtain it (as soon as possible)
 Send them copies of findings, photos and draft reports
 Take it into account!
 Use their input as `facts` in the Causal Tree Analysis

• WHO ARE THE `EXPERTS`?

— Anyone with relevant knowledge and experience
— It is not by job title!!!
— Include (as applicable) supervisors (or operators),
members of Teams of Experts, Legal Department,
contractors, suppliers, etc NOTE: BEWARE SENDING EQUIPMENT TO
48
MANUFACTURERS!
GATHER FACTS (& HISTORY);
INTERVIEW (MAJOR INCIDENTS) (1 of 2)
GATHERING FACTS (AND HISTORY) Immediate Actions
• Reports from Police & External Agencies Attend
• Medical Reports (AS APPLICABLE) (Stop? Risk Assess)
• Confirm certification and qualifications Quarantine & Establish
Investigation Team
• Consider machine records
• E.G. TACHOGRAPH IN A TRUCK Capture Evidence
• Examine external reports
(+ photos, sketches etc)
• E.G. INDEPENDENT INVESTIGATION ENGINEER Gather Facts
• Review mobile phone reports (FOR DRIVING) (& history), Interview
• Examine closed circuit security TV
Review Documents,
• AND SIMILAR E.G. ROAD CAMERAS Reconstruct & Finalise Facts

Identify Actions
to Resume Service

Analyse - Causal Tree

Report /Actions

Communicate & Follow-Up

49
GATHER FACTS (& HISTORY);
INTERVIEW
(MAJOR INCIDENTS) (2 of 2)
Immediate Actions
INTERVIEWING
Attend
• Record what is said (Stop? Risk Assess)
• IF WRITTEN CONSIDER HAVING AN Quarantine & Establish
Investigation Team
ASSISTANT / WITNESS
Capture Evidence
(+ photos, sketches etc)
• Include all who heard, saw, felt or smelt
Gather Facts
anything (& history), Interview
• CONSIDER MATTERS LONG IN ADVANCE Review Documents,
Reconstruct & Finalise Facts
IF THEY MAY HAVE CONTRIBUTED
Identify Actions
to Resume Service
• Follow up on any missing witness
Analyse - Causal Tree
statements
Report /Actions

• Compare statements for conformation or Communicate & Follow-Up

50
 INTERVIEWING:
Question Types (1 of 2)
Open Questions
— used to get the interviewee talking
— they provide a lot of information on which to build more specific questions
— they start with phrases such as
— ”Describe to me…”; “Show me…”; “What other factors might be relevant?”
Closed Questions
— used to direct the conversation and keep the interviewee on track.
— help clarity and check facts and generate short answers - yes or no

Probing Questions
— are used to uncover critical / core issues
— are useful for obtaining more detail
— can feel like an interrogation, so should be used in conjunction with other
open questions

51
 INTERVIEWING:
Question Types (2 of 2)
Challenging Questions
— used when the interviewee`s answers contradict previous statements
— useful if you feel that the interviewee is missing the point, generalising,
exaggerating or being dismissive

Reflecting Questions
— used to test your understanding of what the interviewee has said
— express you`ve been told in your own words to confirm correct
understanding

Summarising Questions
— used to concisely list or tie together the main points noted in the interview
— a powerful way to show you have made correct records

52
 Immediate Actions
(Prepare)

Attend
(Stop? Risk Assess)

Quarantine

Physical Evidence NOTE: when gathering facts and

(+ photos, sketches etc)
interviewing, be prepared to return
Gather Facts back to seek more physical evidence
(& history), Interview
or re-examine previous material

Review Documents,
Reconstruct
& Finalise Facts
Identify Actions
to Resume Service

Analyse
(Root Causes)

Report /Actions
(Timings, Agreed)

Communicate & Follow-Up

53
 Role Play
(1 OF 4)
PRACTICAL EXERCISE – CONDUCTING INCIDENT
INVESTIGATION INTERVIEWS
IMPORTANT!!!
•`Volunteers` identified for roles: —Be sensible
— Witness —Be fair
— Investigator

•Role plays – EXECUTE

— Observers if not involved – take notes

•Debrief
— Critique each other
— Comments from Trainers

54
Role Play - Scenarios
(2 of 4)

SCENARIO #1
Investigator knowledge:
—A contractor worker has fallen off a
scaffold
—They are seriously ill in hospital and
unable to answer questions
—They had been inducted at the site in
preparation for working on the
assembly of a steel frame for a building

55
Role Play - Scenarios
(3 of 4)
SCENARIO #1
Relevant background information :
—The injured person was not working
under a Permit to Work
—The scaffold was in the process of
being modified – it did not have full
side bars
—The distance fell was about 6 metres
—The injured person was helping the
scaffold team modify the scaffold
in order to complete their work quicker
—Safety fall arrest harnesses were not
in use
—The scaffold was slippery from ice
that had formed overnight
56
Role Play
(4 of 4)

REMEMBER
—Be sensible
—Be fair
—Observers take notes
—Be prepared for constructive critique

As time allows:
—Develop more scenarios
—Inject real life situations

57
Role Play – Scenario #2

SCENARIO #2: MIR 11-146

Investigator knowledge:
—A liquid oxygen tanker motor
repeatedly tripped while offloading at a
customer. The contractor driver
reported this to his manager.
—A Master Electrician was sent out to
remedy the problem.
—The electric pump caught fire whilst
the electrician was trying to restart the
pump after it had tripped.
—The fire destroyed the rear of the
tanker.

58
 Role Play – Scenario #2

SCENARIO #2: MIR 11-146

Witness knowledge (Engineering
Manager):
—Inadequate control of electrical supply
to the motor (internal parts had
deteriorated through wear and tear due
to repeated phase change).
—Inadequate preventative maintenance
programme on cryogenic pumps.
—Inadequate application of knowledge
and training by Manager around hazard
awareness and safe oxygen operations.
—Manager had a poor attitude towards
safety (complacent – 15 years in role –
priority is customer demand)
—Poor training and assessment led to
lack of hazard awareness. Source of mechanical failure and ignition
59
Role Play – Scenario #3

SCENARIO #3: MIR 10-21

Investigator knowledge:
—An ASU`s spare compressor weighing
86.5 tons was being lifted up to enable
it to be wrapped in foil to protect it from
corrosion.
— At a height of about 0.75 meters the
lifting spreader bar suddenly failed and
twisted, causing the compressor to turn
on its side.
—It hit the wooden support, damaging
several parts of the compressor.

60
 Role Play – Scenario #3

SCENARIO #3: MIR 10-21

Witness knowledge (Lifting
Supervisor):
—The design configuration of the
spreader bar was inadequate.
— High risk lifting method – lifted below
the centre of gravity.
— The operator did not react to the
excessive tilt of the load and recognize
the hazard because he had seen this
issue 2 years previously with a similar lift.
— No written lifting method from the
manufacturer of the compressor.
—No Permit to Work as the crane
operator considered the lift as part of his
job. 61
LUNCH (Day 1)

62
 Module 3b
Immediate Actions
(Prepare)

Theory – Process of Attend

(Stop? Risk Assess)
Quarantine & Establish
Incident Investigation Team
Capture Evidence
(+ photos, sketches etc)
Investigation. Gather Facts
(& history); Interview
Part 2: Review Documents,
Reconstruct &
—Review Documents; Reconstruct; Finalise Facts
Finalise Facts Identify Actions
to Resume Service
—Identify Actions to Resume Service
Analyse
—Analyse (Root Causes)
—Causal Tree Analysis Report /Actions
(Timings, Agreed)

Communicate & Follow-Up

63
REVIEW DOCUMENTS,
RECONSTRUCT
AND FINALISE FACTS
(MAJOR INCIDENTS)
Review Documents Immediate Actions
• RISK ASSESSMENTS / WORK PROCEDURES /
Attend
PERMITS TO WORK: (Stop? Risk Assess)
•were safety controls in place? Quarantine & Establish
• PEOPLE RECORDS E.G. SICKNESS, TRAINING, REST Investigation Team
PERIODS: Capture Evidence
•were they fit / authorised / qualified? (+ photos, sketches etc)
•REGULATIONS: Gather Facts
•were they complied with? (& history), Interview
•MAINTENANCE, PRE-USE, INSPECTION / TEST
Review Documents,
RECORDS: Reconstruct & Finalise Facts
•were they correct?
Identify Actions
to Resume Service
Reconstruct – simulate up to the incident
Analyse - Causal Tree
• test against standards, evidence, facts
• is there further evidence or information required? Report /Actions
•do any `facts` need to be reviewed?
Communicate & Follow-Up
64
 Immediate Actions
(Prepare)

Attend - Make Safe

(Stop? Risk Assess)

Quarantine

Physical Evidence
(+ photos, sketches etc)

Gather Facts
(& history), InterviewNOTE: when reviewing documents,
reconstructing events and finalising
Review Documents, facts be prepared to return back to
Reconstruct previous activities
& Finalise Facts
Identify Actions
to Resume Service

Analyse
(Root Causes)

Report /Actions
(Timings, Agreed)

Communicate & Follow-Up

65
 IDENTIFY ACTIONS TO
RESUME SERVICE
(MAJOR INCIDENTS)
 There will typically be a great deal of pressure Immediate Actions
to Attend
resume operations / customer supply quickly (Stop? Risk Assess)
Quarantine & Establish
Investigation Team
 Service may be resumed before the analysis is
completed and a report produced Capture Evidence
(+ photos, sketches etc)

 Service must not be resumed, however, until: Gather Facts

(& history), Interview
• External authorities and agencies agree
• The Lead Investigator is satisfied that all evidence has Review Documents,
Reconstruct & Finalise Facts
been
gathered that may be lost when operations / service Identify Actions
to Resume Service
resumes
• The Lead Investigator and Senior Management are Analyse - Causal Tree
satisfied
Report /Actions
that the risk of a similar incident is at an acceptable level
(with suitable risk mitigation measures in place as Communicate & Follow-Up
66
applicable)
 ANALYSE
(MAJOR INCIDENTS)
Immediate Actions
— Post incident - the investigation analysis
— QUESTION: There is LOTS of data, where do you start? Attend
(Stop? Risk Assess)
— ANSWER: Develop a `Causal Tree`
Quarantine & Establish
— Keep an open mind Investigation Team
— Involve `experts` not previously involved Capture Evidence
(ask their opinions, confirm theories, check that there is no (+ photos, sketches etc)
missing information)
— Team of Experts Gather Facts
— Business Heads / Managers
(& history), Interview
— SHEQ Review Documents,
— Engineers / Technical Specialists etc Reconstruct & Finalise Facts
— Supervisors (practical experience!) Identify Actions
— Review every possible cause before to Resume Service
concluding Analyse - Causal Tree
— Identify which systems / processes failed and
which behaviours were present to `enable` Report /Actions
the incident to occur
Communicate & Follow-Up
— Reference `Reason`s Swiss Cheese Model` 67
 ANALYSE:
Reason`s Swiss Cheese
Model
The `Swiss Cheese' model of accident causation likens human system
defences to a series of slices of randomly-holed Swiss Cheese.

It was originally proposed by James Reason who hypothesized that most

accidents can be
traced to one or more of four levels of failure:
•Organisational influences,
•Unsafe supervision,
•Preconditions for unsafe acts, and
•The unsafe acts themselves.

68
 ANALYSE:
Reason`s Swiss Cheese
Model
An organisation's defences against
incidents are modelled as a series of
barriers, represented as slices of the
cheese.

The holes in the cheese slices represent

individual weaknesses in individual
parts of the system, and are continually
varying in size and position in all slices.

The system as a whole produces failures

when holes in all of the slices
momentarily align, permitting "a
trajectory of accident opportunity", so
that a hazard passes through holes in
all of the defences, leading to an
incident.
69
ANALYSE:
Domino Causation Model

70
 Immediate Actions
(Prepare)

Attend
(Stop? Risk Assess)

Quarantine NOTE: when analysing, be

prepared to return back to
previous activities as shown
Physical Evidence — Revisit
(+ photos, sketches etc) — Re-examine
— Re-interview
Gather Facts
(& history), Interview
Review Documents,
Reconstruct
& Finalise Facts
Identify Actions
to Resume Service

Analyse
(Root Causes)

Report /Actions
(Timings, Agreed)

Communicate & Follow-Up

71
Causal Tree Analysis
(Process Overview)
1. Initiate the Investigation
PREPARATION
2. Gather Information

—CAUSAL TREE 3. Reconstruct the Incident

ANALYSIS MUST BE
USED FOR ALL MAJOR
4. Formulate the Facts DRAWING THE
INCIDENTS.
CAUSAL TREE

5. Construct Causal Tree

& Identify Underlying Causes

6. Propose Preventative
Measures (Controls)
DEVELOPING AND
7. Decide Appropriate IMPLEMENTING
Action SOLUTIONS
8. Follow Up

72
 Immediate Actions 1. Initiate the Investigation
(Prepare)

Attend
(Stop? Risk Assess)

Quarantine

Capture Evidence
(+ photos, sketches etc) 2. Gather Information —SEE HOW THE
CAUSAL TREE
Gather Facts
(& history), Interview 3. Reconstruct the Incident ANALYSIS PROCESS
COMPARES
Review Documents, WITH THE GENERIC
Reconstruct 4. Formulate the Facts INCIDENT
& Finalise Facts
INVESTIGATION
Identify Actions 5. Construct Causal Tree PROCESS
to Resume Service & Identify Underlying Causes

Analyse 6. Propose Preventative

(Root Causes) Measures (Controls)

Report /Actions 7. Decide Appropriate

(Timings, Agreed) Action

8. Follow Up
Communicate & Follow-Up
73
Schematic - Causal Tree
Analysis

• Identify all root causes • Find effective controls to

prevent repetition of accide
Causes
Controls

Incident
74
OVERVIEW:
Causal Tree Analysis -
ADVANTAGES

Why use the Causal Tree Method to investigate incidents?

 Systematic method

 All causes can be found

 Helps to identify effective controls

 Team is included in the investigation

 It can be used to investigate other events, e.g. customer

complaints

75
Causal Tree Analysis:
BASIC EXAMPLE

76
 EXAMPLE: Causal Tree Analysis
within the MIR Report
Template

NB: Behaviours which contributed to the loss/incident should be included in the causal tree

RELEVANT UNDERLYING
IMMEDIATE INCIDENT &
77 LOS
(BASIC/ROOT
Immediate Causes

Immediate Causes are substandard acts or

conditions that directly contribute to an incident
occurring.
— May also be called `Direct Causes`

INCIDENT

Examples of Immediate Causes:

—operating machinery without guards fitted (causing injury)
—using a broken ladder (causing injury)
—tipping oil into a stream (causing pollution)
—driving an unsafe vehicle (causing death).
78
 Root Causes

Root Causes are the job and personal factors from which
substandard acts and conditions originate.
— May also be called `Basic Causes`, `Underlying Causes`, `Real
Causes`

INCIDENT

Examples of Root Causes include:

—lack of training
—no engineering standards
—no procedural controls, etc.
79
 Relevant Controls

The `Relevant Controls` form the end of Causal Tree

Analysis.
Typically they relate to loss prevention management
systems; standards; compliance with standards.

NOTE: you know when a `Relevant Control`

has been reached as it clearly identifies INCIDENT
the necessary preventative actions

Examples of Relevant Controls include:

—Training needs schedules / program
—Implementation of engineering standards
—Audit program
80
HOW to perform Causal
Tree Analysis

81
Organising a Causal Tree
session

Material & Resources

— Sufficient room (for investigation team and wall space)

— Cards (or `Post-its`) for facts and identified measures

— Adhesive tape

— Marker pens

— A board

— Flip chart

82
 Causal Tree Analysis
Process - Detail

Causal Tree Analysis Process Requirements:

1. Review all information - identify contributing facts
2. Write all facts on cards (only one fact per card)
3. Clearly mark any uncertain `facts`
4. Start with the consequence of the incident. Post it on the wall (right
side)
5. Create the Causal Tree using the identified fact (cards). Add more
facts whenever you recognize that one is missing
6. Connect the facts with lines to show the sequence of events
7. Record questions / queries arising (issues requiring further
investigation)
8. Check the logic of the tree
9. Identify and mark root causes 83
Guidance # 1: Collect
Facts
FACTS ONLY

Facts must be: Facts must not be:

- Objective - Value Judgement
- Measurable “He was not well formed“

- Apparent - Interpretation
”He is inattentive“
- Agreed
- Reliable

84
Guidance #2: Construction
of the
Causal Tree
Rules:
Go backwards (right to left) from the
last fact
B A Incident

direction of procedure

• Continue looking at every fact

• Look at every single branch

85
Guidance #2: Construction
of the
Causal Tree
Possibilities of connecting the
facts [1]
CHAIN ONE FACT ( CAUSE ) sufficient
B A

„AND“ – Connection: SEVERAL FACTS

necessary
B
A
C 86
Guidance #2: Construction
of the
Causal Tree
Possibilities of connecting facts
[2]

A
One fact causing several others

C
B

87
 Confirming the logic /
relevant controls (1 of 2)

Incident

No Incident
REMEMBER THE `SWISS CHEESE` MO

Incident Prevention by means of

Controls
If only one cause in the chain (Causal Tree)
is eliminated, the incident cannot occur

NOTE: `5 whys?` iterative question asking technique to identify cause / effect relationships
88
 Confirming
Confirming the
the logic
logic //
relevant
relevant controls
controls (2 of 2)

NOTE: `5 whys?` iterative question asking technique to

identify cause / effect relationships

MPLE:
is the car engine not working? - The battery is dead. (first why)
– Because the alternator is not functioning. (second why)
– Because the alternator belt has broken. (third why)
– Because the alternator belt exceeded its useful service life and was not replaced. (fourth
- The vehicle was not maintained according to the service schedule. (fifth why, a root cau
89
 Identify Controls

Step 1 – Identify (Brainstorming)

IDENTIFY SAFE CONTROLS FOR EVERY `FACT`

(Immediate Causes and Underlying Causes) AND LIST THEM

Result:
LIST POSSIBLE CONTROLS

Step 2 – Select (Team Discussion)

SELECT RELEVANT CONTROLS er so ns!
a c t edp
lv e imp
Invo
90
Choice of Controls Criteria

Criteria for the right choice of

Controls
 Must not create a new risk of unacceptable level
(risk assessment)
 Must comply with standards & regulations
 Robust
 Generally applicable
 ‘Get Buy In’ of people affected by the control
 `Reasonable` costs / effort / timescales 91
`Behaviours` in Causal
Tree Analysis

When doing Causal Tree Analysis we must explore the

different types of
Behaviours that may have been a cause in the incident.
—by employees, contractors, managers, visitors and 92
 Key Definitions…

Human Error
Human error occurs when an action or decision leads to an
undesirable unintended outcome. E.g.
— Gone into a room, and forgotten why you went there
— Putting something back in the wrong place (e.g. putting milk into the cupboard rather
than the fridge)
— Tried to brake but hit the accelerator instead

Violation
When a deliberate and intentional action or decision is taken
which contravenes known operational rules, restrictions and/or
procedures. Alternatively, when a person`s behaviour deviates
from accepted and expected behaviours. E.g.
— Knowingly broken the speed limit
— Changing the drill bit without first turning off the power

93
Human Error types

Un-intentional behaviour, e.g. dialling the wrong phone

number from your mobile. Human error is a fact of life!

– Perception error
— E.g. misperceiving a reading on a computer display or a road sign
— E.g. mistaking a ‘3’ for an ‘8’ on the display screen
– Memory error
— E.g. forgetting to implement a step in a operating procedure
— E.g. recalling 0131 667 8059 as 0131 677 8059
– Decision error
— E.g. failure to integrate various pieces of data and information, thus
misdiagnosing a process problem
— E.g. dialling home from abroad, and getting connected to a local number
– Action error
— E.g. inadvertently operating the wrong valve
— E.g. mis-keying two adjacent numbers

94
 Human Error Analysis –
Influencing Factors
Influencing Examples
Factors
•Workload – rushing to •Inadequate resources for task
The task finish
•Poor planning of task •Inadequate supervision of task
•Constant disturbances &
Communicati •Poor handwriting interruptions
ons •One way non verbal •Language
Procedures
& •Ambiguous wording
documentati •Missing instructions
on
•High background noise •Poorly maintained equipment
Environment •
Poor working conditions
•New starter •Ineffective training
Training & •Lack of
Competence knowledge/competence
•Lack of understanding
Human- •Alarm flood • Poor ergonomics
Machine •Poor design of plant &
Interaction equipment
•Recent bereavement •Fatigued/tired
Personal •Medical condition 95
Human Error Controls
Control Hierarchy.
Eliminate potential for human error – absolutely!
Error-Proof • Microwave oven – if door open, can’t operate
• ATM – must remove card for money to dispense

Prevent error being made – provide Attention Activators prior

Error to required action
Prevention • Seatbelt indicator
• Road signs and lines
• Signals, symbols, alarms

Ability to “undo” error before harm, often via additional

Attention Activators
Resilience
• “Undo” buttons
• Spell-checkers
• Rumble strip on road

Duplication of effort or resource aiming to reduce error

Redundancy • Multiple checks by different people
• Multiple copies (dilution of responsibility)

96
 Types of Violation
— Unintentional
— no awareness/knowledge or different knowledge/understanding of a rule or procedure
— not really a violation at all but an error situation
— may result from poor supervision, instruction and training
— Situational
— no way to get the job done otherwise
— violation deemed necessary in order to achieve the desired result
— Organisational benefit
— violation committed with the intention of improving company performance or results
— Personal benefit
— violation committed for personal gain (time, less hassle, financial, reputation etc.)
— Reckless
— violation of known rule, policy or procedure without regard for the consequences
— Routine violations (raising questions about the role of
supervisors /managers)
— Did they know and condone the behaviour?
— Didn’t they know what was going on in their part of the organization?

97
Violations - Understanding
why people behave in
certain ways
– First step in changing behaviour is to understand why people are
currently behaving as they are
– ABC analysis helps you to understand behaviour from the other
person’s perspective
– Activators get us going, consequences keep us going

ACTIVATOR BEHAVIOUR CONSEQUENCE

(or ANTECEDENT)

Causal events,
Outcome of the
circumstances or
conditions (triggers) Observable act that behaviour for the
preceding the a person does or individual.
behaviour, and sets does not do. Influences the
the stage for the likelihood that the
behaviour to occur. behaviour will be
e.g. repeated in future.
– suitable tools & equipment
– information, signs e.g.
– skills and knowledge — save time
– training — receive recognition/praise
– other’s expectations — get injured
– rules — receive a reprimand 98
 Violation Controls

Teams – identify a range of controls which might be

applied for violations which lead to an incident.

Consider controls for the various types of violation:

—Unintentional
—Situational
—Organisational benefit
—Personal benefit
—Reckless
—Routine violations (raising questions about supervision / management)

NOTE – consider the local Consequence Management policies

99
 Behavioural Analysis
Summary
Perception Error Human Error
Analysis Tool
Human Memory Error Identify
error influencin
Decision Error g factors

Unintentional Action Error

Unintentional
Re-evaluate causal tree &
Behaviours as violation of a corrective actions to address
Incident contributory rule or procedure behaviours as appropriate.
investigation
causes
& Causal Tree Consider technical,
(immediate or Violation procedural, behavioural &
underlying) Situational leadership fixes.

Violation
Organisational Routine violation?
Intentional Benefit • Individual or team?
• Does this happen a lot?
Violation • Would other people
have
Personal Benefit done it this way?

Violation Violation
Reckless
ABC Analysis 100
 Local example of good
Causal Tree Analysis in AMPLE
CA L EX
REE&ME = MIR S E R T LO
13-16
IN
MIR 13-16
5th February at 09.00am at the Miskolc plant yard loading area a Linde employee cylinder
ator had just finished checking the load of palletised cylinders that had come in on a truck
 another site when he fell down a distance of about 1.3m.

uffered an open fracture of an elbow and fractures to the upper part of his right arm.
l recovery is expected in time.

al reports state that his shoe became stuck in a side channel and that this contributed to hi
g balance and falling. 

101
Initial findings from
Investigation of MIR 13-16
X AM PLE
CAL E T LO
IN S E R
1. There is no safe access to get onto the platform

2. Shoes – in perfect condition

3. Edge of the platform – necessary part of the

truck 2 1

4. Water conditions:

Dry surfaces (no rain or snow)

4
5. The place of accident:
3
Incoming trucks needs to park on the road

between cylinder storage and filling plant.

The site is overcrowded, there is no place for the

separation the incoming cylinders.

5
102
Causal Tree of MIR 13-16
X AM PLE
LO CAL E
T
INSER

103
 Conclusions – CAUSAL TREE
ANALYSIS
The Causal Tree Analysis Method
 is a powerful tool to investigate all type of incidents
 helps to understand incidents and to find all (root) causes
 ensures we identify CONTROLS necessary to prevent future
incidents

By doing that..
...we will improve the quality of our investigations and of the
established controls …
…consequently reduce the number of incidents…
and vitalize our SHEQ Policy to realize our vision of ZERO
HARM!
104
Module 4a

Causal Tree Analysis

PRACTICAL EXAMPLES

105
 TRAINING CASE STUDY:
OOTER SKIDS AT SPILT LOAD FROM FORK

106
 INITIAL HANDOUT

Setting the scene… TO TRAINEES

It is 2pm On a factory road, Mr Wilson is driving a forklift truck pulling a

and it has trailer heavily loaded with boxes containing used metal parts. The
just road slopes down towards the factory entrance, where the forklift
rained… must do a right angle turn to get to the storeroom to unload the
trailer.

107
 INITIAL HANDOUT
TO TRAINEES

Initial stage of incident

108
 INITIAL HANDOUT
TO TRAINEES

The incident develops…

109
 INITIAL HANDOUT
TO TRAINEES

The incident

110
 INITIAL HANDOUT
TO TRAINEES

Outcome of the
incident

111
Trainees Identify Facts

112
 HANDOUT AT A LATER STAGE

Full List of Facts

(from the story board)
•Forklift truck towing a load
•Heavy load
•Unsecured load
•Sloping road
•Forklift truck speed of 24km per hr (15 mph)
•Tight bend
•Worn out forklift brakes
•Load falling
•Boxes and metal parts on the ground
•John Davis coming to work
•John Davis entering the plant
•John Davis seeing the blocked road
•Braking hard
•Wet ground
•Scooter skidding
•John Davis falling to the ground
•Injury to John Davis

113
 ONLY HANDOUT AS ADDITIONAL INFORMATION IF THE
COMPEXITY OF THE CAUSAL TREE IS TO BE INCREASED
Example – other facts that could
be
introduced to increase the
complexity
Later in the investigation it was found that:

Scooter tyres were worn

Road surface was damaged on corner

Forklift was travelling on an unauthorised route (taking short

cut)

John Davis was a new employee

John Davis was late back from lunch break

The forklift truck training program did not cover use with
trailers

114
Start of Causal Tree

115
Continued Development of
Causal Tree

116
Further Development of
Causal Tree

Immediate Causes The Incident

117
 SIMPLIFIED VERSION

The Causal Tree for Forklift

Incident
No site traffic
??? Inappropriate use of
management
private vehicle on site
standards

Lack of forklift Lack of or poorly

maintenance applied maintenance
standards procedures

Inadequate risk Inappropriate route

assessment for loaded forklift

Inadequate risk Lack of or poorly

assessment and applied rules for
controls loading of trailer

Mr Davis`s driving
No driver safety behaviour did not
program allow for poor conditions
(drive slower)

RELEVANT UNDERLYING
IMMEDIATE INCIDENT
118
(BASIC/ROOT
END OF DAY 1

119
DAY 2

What did we learn yesterday????

120
 Module 4b

Causal Tree Analysis

PRACTICAL – Current Incidents

121
Local current examples

122
 Process

1. Individuals present local examples of incidents

 What happened – Facts (not conclusion)
 Each is noted on flip chart
2. Everyone votes on which two incidents to review
 one per team
3. Teams review facts and build a Causal Tree
 Ensure someone on team knows details so can provide facts
 Identify the need for further evidence to be found (if
applicable)
 Do not compare with any previously developed Causal Tree!
4. Present back to other team and discuss:
 Immediate causes
 Root causes
 Ideas for control measures
123
LUNCH (Day 2)

124
Module 5

Dealing with the Media

125
 Team brainstorm

What are the `rules` and `guidelines` for dealing with the me

126
 Dealing with the media:
Requirements (1 of 2)
RULE # 1: Unless trained in dealing with the media try to avoid doing
so!

If circumstances force interaction with the media:

• Only make clear, complete, factual and truthful statements.
• Do not underestimate the seriousness of the crisis.
• Do not overestimate your resources for mastering the situation.
• Ensure the setting does not show the situation to disadvantage if the
interview is to be filmed.
• Adopt a positive attitude towards journalists. Remember you are not on trial.
• Behave in a responsible, positive and caring way. Do not try to pass the buck
to public authorities or contractors, but take care not to imply legal
responsibility.
• Do not bluff. If you do not know, say "I do not know but I will find out".
127
 Dealing with the media:
Requirements (2 of 2)

• Do not be drawn by provocative questions. Go over the information calmly

and firmly.
• Have key facts that offer news on people, then the environment, property if
applicable, and finally the financial cost of the incident.
• Do not speculate about cause, consequences, delays and costs. An
acceptable reply would be "this point is being investigated".
• Do not forget the context. We do a potentially dangerous job sometimes
and in spite of all our efforts to prevent incidents, there are still risks.
• Only use diagrams and photographs which you have checked as clear and
applicable.
• Do not hold a press conference unless you have to. Restrict the numbers to
those with specific knowledge of different aspects of the incident, never fall
into the comfort trap.
•Consider if relevant to have members of the Emergency Services present to
offer a united front.
•Stop as soon as it is clear that all useful information has been given. 128
 Role Play
Dealing with the Media
PRACTICAL EXERCISE – CONDUCTING INCIDENT INVESTIGATION
INTERVIEWS

•`Volunteers` identified for roles:

— Jounalist
— Investigator

•Role plays – EXECUTE

— Trainers to describe the scenario…
— Trainees to conduct role play
— Observers if not involved – take notes IMPORTANT!!!
—Be sensible
•Debrief —Be fair
— Critique each other
— Comments from Trainers
129
 Module 6

Reporting, Actions and Closure

130
 INCIDENT MANAGEMENT
Immediate Actions
Incident Management involves:
Attend - Make Safe
(Stop? Risk Assess)
• Reporting (What? How? When? Where?
Quarantine & Establish
Who? Why?) Investigation Team
Capture Evidence
• Actions arising (+ photos, sketches etc)

 Corrective Gather Facts

(& history), Interview

 Preventative Review Documents,

Reconstruct & Finalise Facts
• Communication & Follow-Up Identify Actions
to Resume Service
 Learning from Incidents Analyse

 Avoiding a Recurrence Report /Actions

Communicate & Follow-Up

131
 Reporting - General

 REMEMBER!!!
— All Incidents are to be Reported
 GOOD PRACTICE (& LEGAL REQUIREMENT!)
 ENABLES OTHERS TO ADD COMMENTS
 ENABLES OTHERS TO LEARN THE LESSONS

— The Level of Reporting Needs to be Proportional to the

Risk:
 `MAJOR` = `MIRs` & IMS-24-12 APPLIES
 MEDICAL TREATMENT CASES, FIRST AID CASES AND NEAR-
MISSES ARE
SUBJECT TO LOCAL REPORTING
132
 Summary of reporting
details in IMS-24-01 (1 OF
4)
Incident Investigators and Incident Investigation Sponsors

must ensure that incident investigation reports are factual,

clear, concise and clearly address the key issues, including:

—What happened?

—Who was involved?

IMS-24-01
—Where and when did it happen? INCIDENT MANAGEMENT

—What facts were considered in the analysis?

—How did it happen?

—Why did it happen?

—What causes contributed to the incident?

—What will be done to avoid it from happening in the future?

—Who is responsible for implementing the recommendations?

133
 Summary of reporting
details in IMS-24-01 (2 OF
4)

The type of incident dictates the depth of report required.

However, the goals remain consistent, i.e. information is sought

to:

—Prevent recurrence by determining all contributing causes

—Determine if the incident was avoidable/unavoidable IMS-24-01

INCIDENT MANAGEMENT
—Prevent unwarranted/excessive financial liability

—Maximise recovery from third parties

—Minimise operational disruptions

—Provide adequate basis for consequence management e.g.

disciplinary actions and/or identify areas for remedial training

134
 Summary of reporting
details in IMS-24-01 (3 of
4)
Reporting – detailed requirements:

—The level of detail provided in investigation reports must be

appropriate to the severity of the incident and the quantity of
information gained during the investigation

—The Incident Investigation Report and any other associated

records (e.g. working documents and attachments such as IMS-24-01
photographs, written statements, plans and sketches) must beINCIDENT MANAGEMENT
attached to the Synergi® Incident Report (where Synergi® is
used)

—In addition to the entries made into Synergi®, the local (or
regional) management team must consider whether a written
report is required for certain incidents where specialist
requirements apply and/or where further rigour is appropriate

—Incident investigation reports must be factual, clear, concise

and clearly address the key issues 135
 Summary of reporting
details in IMS-24-01 (4 of
4)
Identifying Actions – detailed requirements:

—As part of the overall incident management the Incident

Manager and Incident Investigation Sponsor must ensure that
a suitable range of corrective and preventive actions are
identified within incident reports
IMS-24-01
INCIDENT MANAGEMENT
—Incident Investigation Sponsors and Incident Managers must
ensure that towards the end of incident investigations the
reports are satisfactory and acceptable for close-out (and also
that Synergi® is updated)

—Incident Investigation Sponsors and Incident Managers must

also ensure that actions are followed up until completion and
that any external communications/reports relating to the
incident report and investigation are acceptable prior to them
136
being circulated
Actions in an incident
report
ACTIONS MUST:
— Be based on findings in the report!
— Must address the root causes; avoid creating new hazard
— Reference the Control Measures on Causal Tree Analysis
— Comply with standards and regulations
— Have been adequately reviewed and approved
— For example `Incident Review Panel`; Incident Sponsor; ToE
— Identify two types of action:
— CORRECTIVE (making good)
— PREVENTATIVE (preventing a recurrence)
— Be specific and fully accountable
— NAMES
— TIMESCALES
— Be good `quality` (SEE NEXT SLIDE)

137
 Summary flow chart

Does it address root causes and avoid creating a new risk or

INCIDENT New / Revised transferring it elsewhere?
NO
INVESTIGATION Control Measures
defined and each YES
REPORT
PRODUCED one reviewed as Does it comply with standards (updated if necessary) and NO
follows... regulations?
YES
Has it been adequately reviewed and approved? (e.g. by MIR
Review Panel; Incident Sponsor; ToE) NO

NO
Is the control measure an
administrative type?
YES
NO
Can it be shown that there are no higher
levels of control measures that could be
applied?
Take action to adequately
communicate
NO
Has the control measure been
adequately communicated for
implementation?
(with others as applicable)
YES
Incident investigation report
control measures agreed
YES
NO
Does the control measure eliminate, reduce or isolate the
hazard? (confirm it is a sustaining control)
YES
YES
Does the control measure (with others as appropriate) reduce
NO
the risk of recurrence to an acceptable level? (Risk
Assessment review / update)
YES
YES
Does the control measure pass the final quality checks? NO
(SEE BELOW) FINAL QUALITY CHECKS
•Reasonable time to implement
•Avoid significant extra burden of work (energy / time)
•Reasonably cost-effective
•Understood & accepted by affected personnel
•Can be applied on a wider basis e.g. regional / divisional / global
•Provide a `permanent` and robust (reliable / durable) solution
Good quality control
measure actions
`Final Quality Checks` for Control Measure Actions

•Provide a `permanent` and robust (reliable / durable) solution

• As high up the hierarchy of risk control measures as possible (SEE NEXT SLIDE)

• `Eliminate the hazard` is preferred

•Can be applied on a wider basis e.g. regional / divisional / global

•Reasonable time to implement

•Avoid significant extra burden of work (energy / time)

•Understood & accepted by affected personnel

• Subject to training and communications

•Cost-effective (in cases of multiple suitable options)

139
 Hierarchy of Risk Control
Measures
 Risk mitigation control measures need to be applied to
modify the level of risk and in accordance with the
following hierarchy:
— Eliminate the hazard
— redesign and change the work system so the hazard is not present
— Substitute to reduce the hazard
— change the material or process and replace with a less hazardous one
— Implement engineering control measures
— equipment/process safeguards against hazards, including isolation of people or
property
— Implement administration control measures
— Work instructions / work procedures (subject to training and competence assessment)
— controlling exposure to hazards, e.g. restricting work time; work at selected time of day
— Manage behaviour (compliance)
— Supervision
— Behavioural safety program, including peer-to-peer observation, consequence
management, etc
— Communications

— Apply personal protective equipment

14/04/20 Fußzeile 140
 Preference for Risk Control
Measures – increased
effectiveness and sustainability

Hierarchy of Risk Control

Measures

PREFERABLE

14/04/20 Fußzeile 141

 Hierarchy of Risk Control
Measures (Actions): Pros and
Cons - DETAILS
RATING OF THE CLASSIFICATION OF CONTROL MEASURE
EASE OF DEPENDENCE ON SUPERVISION EFFECTIVENESS / LEVEL OF OVERALL
CLASSIFICATION EXAMPLE DESCRIPTION IMPLEMENTATION BEHAVIOURS REQUIRED SUSTAINAIBILITY PROTECTION PREFERENCE
Discontinue use of material.
Stop using process.
Elimination Lowest Lowest Lowest Highest Highest Highest
Stop the activity.
Manual activity automated.
Replace with similar but less
hazadous material.
Substitution
Continue activity but in a less
hazardous place.
Guarding / barriers.
Mechanical assistance.
Engineering
Tooling provided.
Improved ergonomics.
Reduced exposure time.
Work procedures and Training.
Administrative
Rules e.g. speed limits.
Permit to Work.
Supervision.
Peer to peer observation.
Behaviour
Incentive / disciplinary schemes.
Safety posters.
Provision of PPE.
Train in use of PPE.
PPE Highest Highest Highest Lowest Lowest Lowest
PPE signs.
PPE free-issued.

142
 Consequence Management

•The Incident Investigator is not responsible for Consequence

Management!
They simply need to focus on:
— Identifying `facts`
— Suitable analysis of the `facts`
— Ensure behavioural matters are included in the analysis
— What enabled the human errors to contribute to the incident?
— What were the violations and why did they occur?
— Presenting the facts and analysis in a suitable (agreed) report

•Consequence Management is the responsibility of:

— Line Managers (as applicable)
— Incident Managers
— Incident Investigation Sponsors

•Consequence Management must comply with local

agreements
— Reference Consistent Consequence Management (CCM) Guidelines
143
 Follow-up from an incident
investigation
Immediate Actions
Incident Investigation Sponsors and Incident Managers must
ensure that towards the end of incident investigations the Attend - Make Safe
reports are satisfactory and acceptable for close-out by: (Stop? Risk Assess)
•Reviewing the findings to confirm the investigation was properly
Quarantine & Establish
conducted Investigation Team
•Ensuring that an appropriate level and quality of information is
contained and that it complies with data protection and legal Capture Evidence
requirements (+ photos, sketches etc)
•Ensuring that a suitable range of corrective/preventative actions are
proposed in the incident investigation report
Gather Facts
(& history), Interview
•The actions arising from the investigation are assigned to the
correct personnel and are understood; have reasonable closure
Review Documents,
dates; are followed up until completion Reconstruct & Finalise Facts
•Confirming that risk assessments have been updated (as relevant)
•Confirming that any external communications/reports relating to the Identify Actions
to Resume Service
incident report and investigation are acceptable prior to circulation
•The lessons arising from the incident investigation are properly
Analyse
captured and shared (in conjunction with the relevant Team of
Experts)
Report /Actions
•Consequence management has been applied correctly (if applicable)

Communicate & Follow-Up

144
Communicating lessons
from an incident
investigation report
“When you lose, don`t lose the
lesson”
— Dali Lama `s #2 Instruction for Life

 A High Performing Organisation learns from it`s

mistakes and continuously improves
 There are many different ways to communicate the
lessons learnt from incident investigations:
 `LESSONS FROM INCIDENTS` (LFIs)
 REVISED STANDARDS (IN LiMSS VIA ToEs)
 DIRECTIVES
 ALERTS
 REVISED TRAINING MATERIALS
 STATISTICAL REPORTS (USING `SYNERGI`)

145
 Module 7

ollow On Actions…
—What delegates need to do after this worksho

146
 Follow-on actions

•Pair up with a `buddy` who will help review some

investigations
Mo
di f y
/ De
•Submit 3 incident investigation
vel
op reports for review
this
slid
(by Trainers) e to s
uit
lo cal
s itua
•Support and train others tion

— Especially conduct training on Causal Tree Analysis

•Gain certificate!!!

147
Expectations met???

Did the course meet your expectations?

•Reference flip charts from yesterday

Any further feedback to improve the course?????

148
FINISH

HAVE A SAFE (INCIDENT-FREE) JOURNEY HOME

149