8/4/2019 EPEX Poster Incident Investigation and Analysis Overview 110624

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The driving force

(failings in assuring positive worksite factors)

(preventing incidents)

(defeating barriers)

Intentional acts

Mistake (knowledge)(intentions believed to be correct)

Unintentional acts

Error (skill)(correct intention, failure in execution)

Plan

1

PR, OR

Identify

hazard

2

PR

Assess risk

3

PR, OR, DF

Plan job(including

emergency

response)

Do Check

9

OR

Confirm

intent iscorrect

10

OR

Confirm

intent isfollowed

11

DF

Respond to

an emergency

12

OR

Monitor &

reportperformance

Review

13

OR

Review

plan

Task executionPlans (software)

3.1

PR, DF

Guidance,

instructions,procedures

3.2

OR

Schedule

 job, timepressure

7.1

COCommunicating

 job intent

3.3

OR

Roles andresponsibilities

authorisation

Slip or lapse

Rule

based

mistake

Knowledge

based

mistake

Violation (attitude)(intentions known to be incorrect)

Routine

violation (by

majority)

Situational

violation

Optimising

for Company

violation

Optimising

for Self 

violation

Reckless

violation

Perceived view ofthe world

Form intentCommunicate

intentMonitor and supervise

MisperceptionOften leads to

knowledge based

mistakes

Normal operation 

Be aware; provide

understanding & awareness

 Advise and

Guide

Off normal operation 

Repel with alarms

and warning

Protective action 

Restorestop, fail safe,

self correctLimit release or exposure 

InterposeGuard protect

Eliminate

or contain

Deny access 

Rescue and

escape

Escalation of incident 

1.1 Visibility 1.2 Proactive in target setting 1.3 Informed involvement

Plan

2.1 Content

2.2 Dissemination2.3 Strategic objectives

3.1 Roles and responsibilities

3.2 HSE Advisors3.3 Resources

3.4 Competence3.5Contractors

3.6 Communications3.7 Documentation and control

4.1 Identification of hazardsand effects

4.2 Assessment4.3 Recording of hazards

and effects4.4 Performance criteria for 

maintaining controls4.5 Risk reduction measures

controls and ownership4.6 Risk reduction measures

- recovery

5.1 HSE plan

5.2Asset integrity5.3 Procedures and

work instructions5.4 Management of 

change5.5 Contingency and

emergency planning

Do

6.1 Performance

monitoring6.2 Records

6.3 Non compliance andcorrective action

6.4 Incident reportingand follow up

Check

7.1Audit plan

7.2Auditor competency

7.3Contractor audits

Review

8.1Review

EPEX - Tripod Beta Incident Investigation And Analysis

Compiled by: EPEX, Date: 25-Aug-08, date of revision: 24-Jun-11, www.i3pod.com

Barriers

Immediate cause

Preconditions

Underlying cause

(promoting unsafe acts)

ToolsParts (hardware)

4.1

HW MM

Tools, plant,

equipment &material

PeoplePeople (liveware)

5.1

EC

Physical

condition

5.2

EC

Psychological

condition

5.3

EC

Physical &

psychologicallimitations

5.4

TR

Skill and

knowledge

8.1

OR, IG

Social,

teamwork &,attitude

Worksite ConditionPlace (environment)

6.1

HK

House

keeping,orderliness

6.2

EC

Environment

weather 

4

DE, DF, HW,

MM

Assureresources

5

TR, EC, OR

Assure crew

skill andknowledge

6

HK, EC

Assure

worksiteconditions

7

CO

Communicate

 job intent

8

IG

Promote a

positiveattitude

2 Policy and

strategic objectives

3 Organisation,

responsibilities, resources,standards & documentation

1. Leadership and commitment

4. Hazard and effect

management

5. Planning and

procedures

6. Implementation

and monitoring

7. Audits 8. Management

review

4.2

DF

PPE

Remedial actions

DEDesign

HWHardware

PRProcedures

ECError Enforcing Conditions

HKHousekeeping

TR

TrainingIG

Incompatible Goals

COCommunication

OROrganisation

MMMaint. Management

DFDefences

Barrier Function Barrier System Safety Critical Activities Fault Tree Unsafe Act

1 Leadership & Commitment

3, 4, 5, Plan6

78

2 Policy & objectives

Underlying Cause

BRFs within phases of the business

processOrganization

Goals

ManagementDesignBuild

OperateMaintain TR, PR, MM

TR, PR, HKHW, DFDE, DF

CFORIG

EC

Point in business process at which improvements are required i.e. Plan-Do-Check-Review / HSE maturity

4.3

DE

Man/machine

interface,layout