Learning from incidents seminar 5: Linking research and practice in learning from incidents, 11 June 2015, London

April 30, 2015

‘Interdisciplinary Perspectives on Learning from Incidents’ (IP-LFI) ESRC Seminar Series

11 June 2015, 10am-5pm (registration from 9:30am)

British Safety Council, 70 Chancellors Road, London W6 9RS (Hammersmith)


You are invited to join an interdisciplinary group of researchers, practitioners and policy-makers from across Europe to explore how organisations can learn effectively from incidents across different sectors: energy, health, finance, construction and further afield.

So far this seminar series has explored key issues and gaps in the field of learning from incidents and has devised a set of preliminary research questions for an interdisciplinary R&D agenda (Seminar 1); examined various theoretical perspectives (Seminar 2) and methodological approaches (Seminar 3) to learning from incidents, from a range of disciplines across Engineering, Social and Life Sciences; and discussed examples and issues from policy and practice perspectives (Seminar 4).

In this fifth seminar we shall discuss how to strengthen the link between research and practice in learning from incidents (LFI). How could researchers, practitioners and policymakers collaborate to advance learning from incidents? What models and frameworks could effectively facilitate cooperation between these different stakeholders? What are the key priorities in learning from incidents and what could researchers do to help practitioners and policymakers improve LFI? How can LFI research be best communicated to practitioners and policymakers?

These questions will be addressed through the keynote talks and group discussions at this seminar. The keynote speakers are:

  • Dr Ritva Engeström, Senior Researcher, Centre for Activity Theory and Developmental Work Research, University of Helsinki, Finland: “Change Laboratory and Developmental Work Research”
  • Professor Eve Mitleton-Kelly, Director of the Complexity Research Group, London School of Economics and Political Science, UK: “Addressing complex problems through collaboration: A complexity theory approach”
  • Professor Lasse Gerrits, Chair in Governance of Complex and Innovative Technological Systems, Otto-Friedrich University, Bamberg, Germany: “Back to normal: Generating resilience in complex systems”

Participation is free. A buffet lunch will be provided.

Registration is required. To register for the seminar, please go to: https://eventbrite.co.uk/event/16547197112/

To join our LFI seminars community and to be kept up to date about the forthcoming events sign up at lfiseminars.ning.com http://lfiseminars.ning.com

Call for abstracts: Human factors application in major hazard industries, 6-7 October 2015

April 2, 2015

The deadline has been extended to submit an abstract for this biennial two-day conference, which returns in 2015 and will explore the practical application of human factors in the management of major accident hazards (MAH) in the energy and allied process industries. The event will focus on two key themes:

  • Assuring human factors performance: How can we ensure high performance through human and organisational factors?
  • Preventing incidents before they happen: How can we effectively investigate and analyse incidents and embed learning. How can we prevent incidents before they occur?

This conference, organised by the Energy Institute (EI)’s Human and Organisational Factors committee and the Stichting Tripod Foundation, will enable the learning and sharing of good practice between companies and industries, and offers excellent networking opportunities with delegates from around the world representing operating companies, suppliers, consultancies, and academia.

Call for abstracts

The deadline for submitting an abstract has been extended until 30 April 2015. Don’t miss this final opportunity to put forward your submission for an oral or poster presentation on the following key topics:

Assuring human factors performance:

  • Competence assurance
  • Non-technical skills and crew resource management (CRM)
  • Alarm handling
  • Risk analysis
  • Fatigue management
  • Other topics will be considered

Preventing incidents before they happen:

  • Safety culture
  • Human and organisational factors in Bow Tie diagrams
  • Embedding learning from incidents
  • Quality incident analysis
  • Other topics will be considered

To submit your contribution you will need to:

  • prepare an abstract of up to 500 words on the topic you intend to present in Microsoft Word format
  • indicate the presenter and co-authors with their affiliation and contact details
  • submit the abstract to Stuart King: e: sking@energyinst.org;

Submissions will be evaluated by the organising committee and successful entrants will be notified shortly after the submission deadline. Final deadline for abstract submission is Thursday 30 April 2015.


A range of sponsorship opportunities are available for this event. For details please contact Luigi Fontana: e: lfontana@energyinst.org;

Energy Institute seeks PhD proposals to raise energy industry safety performance

November 11, 2014

The Energy Institute (EI) seeks PhD proposals into new research to help the energy industry improve its safety performance.  Tuition and subsistence fees will be available for a three year full time study to commence mid-2015, using profits from the sale of the Hearts and Minds safety culture toolkit (www.energyinst.org/heartsandminds).


The Hearts and Minds toolkit was developed by Shell, based on research funded between 1980 and 2000 (key texts referenced below).  The Toolkit was published by the EI in 2004, and is used extensively in the energy industry and other industries to help improve safety culture, by engaging the workforce to help improve behaviour.  Within the broad remit of safety culture, the Toolkit focuses on issues such as supervision skills, managing rule breaking, and risk assessment.

The EI is a non-profit organisation, and will use some of the profits from the sale of the Hearts and Minds Toolkit to fund new research to energy industry improve its safety performance.  This new research may potentially turn into a new tool and form part of the Toolkit.

Topic area

The broad theme of the research should be on improving health, safety, and environment (HSE) performance through culture and behaviour. Within that, there are no restrictions on the topic of the research, and projects from all disciplines will be considered (psychology, sociology, anthropology, etc.).  Example topics could include teamwork, the effects of bias on human performance, and decision making, but other original ideas would be very welcome.

Topics that tackle energy industry needs, have a practical application (e.g. adaptable to a tool), and show promise for improving energy industry HSE performance are most likely to be considered highly.

Proposal format

Proposals should:

  • Be set out clearly and succinctly, and be no more than 10 pages A4 in total.
  • Identify the proposed university of study.
  • Include a full CV of programme supervisor.
  • Include a full CV of the PhD candidate (if available).
  • Identify the level of engagement with industry (e.g. requiring just an external supervisor or also case study sites).
  • Describe the topic of study, the problem it intends to address, the hypothesis, the method of research, the expected deliverables, and a bibliography of key texts the project will draw upon.
  • Provide project cost, including tuition fees, student bursary, and disbursements.
  • Provide start/completion dates.

Selection criteria

Proposals that garner the interest of the EI’s industry partners will be shortlisted, at which stage the selection may be narrowed further through interview.  Only one study can be funded, with an expected start date of mid 2015.

Submittal instructions

Please submit your proposal, via email (PDF or MS Word document) to Stuart King e: sking@energyinst.org tel: +44 (0)207 467 7163

Closing date for submission is 15th December 2014

Understanding the causes of accidents using Tripod Beta

October 30, 2014

This article first appeared in the October 2014 edition of Petroleum Review as ‘Who causes accidents?’.

With the publication of the new Tripod Beta user guide, the Stichting Tripod Foundation and Energy Institute look at how industry can get to the root causes of incidents. Stuart King, EI Technical Products Manager – Human Factors and Safety Management, explains…

Between 1980 and 2000, Shell funded world-class research into the behavioural aspects of risk management. During that period research tools like Tripod, Bow Tie, and Hearts and Minds were developed, which today are used by a large number of organisations worldwide.

The first task was to answer a seemingly impossible question: Can the causes of incidents and accidents be predicted before the incident occurs? Startlingly, the answer is, at a high level, ‘Yes’. The management of risk can best be thought of as the implementation of ‘barriers’ that block the potential negative consequences of a hazard. Incidents are caused by the failure of these barriers and are almost always due to ‘human error’.

This concept was popularised by James Reason’s Swiss cheese model of incident causation in 1991. Today, barrier-based risk management is the foundation on which our industry manages its operations.

However, people do not ‘err’ in a social vacuum. Their behaviour is heavily influenced by the situation and their state of mind. These situational and psychological preconditions are in turn created by, or have never been identified and managed out of the system, by the organisation. Organisational deficiencies are often the true underlying causes of incidents. If we can identify the organisational deficiencies, we can try to prevent incidents before they happen.

By 1996 this concept had been developed into the Tripod Delta survey tool, which is still being used successfully to help companies understand the underlying causes before incidents occur (contact the tripod@energyinst.org for more information).

Following Piper Alpha, it was realised that an investigation and analysis tool was required that would help the investigator uncover the underlying causes of incidents. Tripod Beta was born, alongside the Bow Tie methodology (in fact, both tools were developed by the same team) and with the advent of Microsoft Windows 3.1, incidents could be easily modelled graphically on a computer.

What is Tripod Beta?

Tripod Beta is a visual methodology for analysing incidents and accidents, helping the investigator to consider the human factors and directing them towards the underlying causes. Tripod Beta is now 20 years old, and since 1998 has been publicly available. Furthermore, following a partnership between the EI and the Stichting Tripod Foundation, Tripod Beta is more visible globally. The methodology is used in The Netherlands as the investigation technique of choice for the regulator, the Dutch Safety Board. Tripod is also used by major organisations in the Far East, Canada and other parts of the world, as well as by Shell globally. It is estimated that over a third of all incident and accident investigation methodologies in use today are Tripod Beta or Tripod derived.

Tripod Beta is one of the few incident analysis methodologies to be scientifically validated. Furthermore, the ‘Life-Saving Rules’, which were adopted and expanded by the International Association of Oil and Gas Producers (OGP) based on their annual occupational safety data, were originally based on Tripod Beta analysis of fatal incidents (http://www.ogp.org.uk/ publications/safety-committee/ life-saving-rules).

At the heart of Tripod Beta is the Swiss cheese model of incident causation. Incidents can be modelled as a series of events, each one leading to the next. Each event is the coming together of two things – a hazard/agent (eg a source of energy) acts on and changes an object (a person, fuel, equipment). This agent/object/ event combination is called a ‘trio’ and each trio leads to the next, creating a simple tree of what happened. Most incidents can be modelled in only two to five trios. However, organisations should have identified ‘barriers’(the layers of Swiss cheese in Reason’s model) to prevent each trio from having taken place. In a ‘typical’ incident modelled by three trios, there are at least three barriers to prevent the incident – each representing an opportunity to stop the incident in its tracks.

Tripod tree magazine illustration

Barriers are functions that, if enacted, would have prevented the next event from happening. They are not always human actions (eg, an automatic cut-off valve) but they often are.

For example, a high level alarm is not a barrier; but an operator reacting to a high level alarm and shutting off the flow into a tank is. Even if a barrier is purely mechanical, humans are responsible for designing, installing and maintaining them.

How an incident happened is ‘because the barrier failed’ and the barrier failed almost exclusively due to a ‘human failure’ – an error (such as a slip, lapse or mistake) or a violation of a rule or procedure.  Sometimes these human failures are made by designers or managers months before the incident. But usually errors are made at the front line, immediately before the incident.

Many incident investigation reports commonly cite ‘human error’ as the cause of incidents. However, Tripod Beta does not blame the person who caused the barrier to fail – their action was just the ‘active failure’ or the ‘immediate cause’, not the underlying cause. These people were set-up to fail at some point by the preconditions – the psychological or situational circumstances. These preconditions are often what we consider to be classic human factors issues, such as safety culture, competence, poor supervision, fatigue, workload, complicated tasks, the working environment, etc. Whilst we cannot say that these preconditions definitely caused the human failure, we can be reasonably sure that they increased the likelihood of it happening, and will increase the likelihood of it happening again to someone, somewhere else in the organisation.

Except for rare, unforeseeable natural disasters, preconditions are not random. In fact, they are precisely the human, environmental and operation factors that an organisation’s management system is meant to prevent or manage through the decisions that leaders make, by fostering a good working culture and having a robust process for managing risk. Therefore, the underlying or ‘root’ causes, ie why the incident happened, are actually the failures of the organisation to manage these preconditions.

Why is this important?

Interestingly, the actions taken to prevent an incident recurring should not focus on the individual(s) involved or even on the preconditions. In the short-term, they should focus on improving the barriers in place so that they cannot fail; but in the long-term, the underlying causes must be tackled. Barriers are many and are usually specific to an operation or incident. However, the underlying causes are few (they can be grouped into 11 categories) and are responsible for causing all incidents. If you can fix the underlying causes, you can potentially prevent many more incidents before they happen.

Resources available

Tripod Beta is a non-commercial methodology. It doesn’t require any special software, although commercial software is available. Tripod Beta is promoted by the Stichting Tripod Foundation, a group of volunteers who see barrier-based management of risk as being fundamental to safety performance.

Tripod Beta: Guidance on using Tripod Beta in the investigation and analysis of incidents, accidents and business losses, published by the EI, is available from www.tripodfoundation.com

The Foundation also lists accredited training courses on its website, and has an accreditation system to support and develop the competence of users of the Tripod Beta methodology.

e: tripod@energyinst.org

Learning from incidents seminar series

June 16, 2014

Effective learning from incidents (LFI) is critical for employees’ safety and environmental protection. Yet little is known about what constitutes ‘effective’ LFI and how to achieve it. Here, Glasgow Caledonian University’s Anoush Margaryan and Allison Littlejohn, and the Energy Institute’s Stuart King, explain.

Learning from incidents (LFI) is important across a range of industries and is relevant for professional and government bodies and third-sector organisations concerned about health and safety. Industrial incidents cause injury, loss of life and environmental degradation – of particular concern to major hazard industries like the energy industry. However, after incident investigation has taken place, LFI initiatives tend to focus too much on the dissemination of information, assuming that access to incident-related information will lead to organisational learning and behavioural change. Yet research into adult learning demonstrates that access to information does not necessarily lead to learning. To learn effectively, people and organisations must have opportunities for reflection and making sense of information by relating and integrating it within their everyday work context.

LFI initiatives in organisations seldom integrate reflection and sense-making opportunities. A key problem is that LFI has been limited to safety science and engineering. Theories and insights from adult learning and other relevant social sciences have seldom been applied to LFI. Also, integration of research and practice in LFI has been poor. To improve our understanding of LFI, an interdisciplinary, inter-sectoral approach bringing together scholars from relevant disciplines with stakeholders from the industry, professional bodies and the government is critical. To address these gaps, an international seminar series – ‘Inter-disciplinary perspectives on learning from incidents’ – is currently being organised. The first of its kind in the world, the series brings together practitioners and policymakers with scholars from a range of disciplines to provide new learning approaches and change methods that can be applied by organisations to improve health and safety across a range of industries. The seminar series is led by the Caledonian Academy, a research centre for Technology-enhanced Professional Learning at Glasgow Caledonian University (http://www.gcu.ac.uk/academy/), in collaboration with scholars from the universities of Aberdeen, Southampton, Edinburgh and Loughborough (UK), Trento (Italy), Helsinki (Finland), and Valencia (Spain), as well as stakeholders from the private and public sectors including senior representatives from the UK’s Energy Institute, the British Safety Council and the Health and Safety Executive. These people represent a range of disciplines spanning adult and organisational learning, sociology, industrial psychology and human factors engineering. Businesses represented within the seminars come from the energy, construction, transport, healthcare and finance sectors and include BP, ConocoPhillips, Costain Group, E.ON, Phillips66, Pinsent Masons and TC Global.

Seminar objectives

The aims of the seminar series are to:

  • Bring together scholars, practitioners and policymakers in order to advance the theory and methodology of LFI and to inject fresh conceptual ideas and innovative methods into the current approaches to LFI.
  • Facilitate a mutual learning process and the joint development of ideas across different disciplines, between researchers and key stakeholders from industry, professional bodies, the third sector and the government.
  • Strengthen the relationship between theory, practice and policy in LFI, ultimately in order to inform organisational strategies for better LFI.
  • Develop an inter-disciplinary research and development agenda in LFI, by providing the networking for industry-academia collaborations in this area, in order to bolster the UK performance in health and safety.
  • Disseminate awareness of research on LFI to a wide range of industries, organisations and policymakers and bring about the impact of research in LFI.

The seminar series will have an anticipated short- to medium-term impact through participants’ exposure to innovative, inter-disciplinary insights from a range of fields they do not yet engage in, triggering novel applications within their own context. Joint knowledge development by industry and policy executives with scholars means that the knowledge has a solid practical and theoretical basis, improving the likelihood of adoption and application of research in real-world settings. Anticipated longterm impacts include enhancement of the health and well-being of employees; improved economic performance, through enhanced individual, group and organisational LFI; and increased effectiveness of LFI policy, through better-quality conceptualisation and research-based evidence. The final outputs include a roadmap for future research and development in LFI, and an edited book with LFI case studies from the private and public sector alongside research-focused contributions.

Upcoming 2014–2015 Seminars

  • 15 October 2014, University of Southampton: LFI Methodologies
  • February 2015, Energy Institute, London: Practice and policy in LFI
  • June 2015, British Safety Council, London: Research-practice nexus in LFI
  • October 2015, Glasgow Caledonian University: LFI roadmap

Seminars are free to attend thanks to financial support from the UK Economic and Social Research Council. For further details and to register visit http://lfiseminars.ning.com/

Hearts and Minds training course: 4 – 6 March 2014

January 14, 2014

The EI is running a 3-day training course, ‘Delivering safety culture change using the Hearts and Minds toolkit’, in London, 4 – 6 March 2014.

This interactive training course and qualification has been developed to teach delegates the fundamentals of improving safety culture using the Hearts and Minds toolkit.

Facilitated by two of the original developers of the Hearts and Minds toolkit, Prof. Dianne Parker and Dr. Matthew Lawrie, the course will:

  • Teach the fundamentals of safety culture change – focusing on each stage of a culture change programme, from design to implementation and review.
  • Provide an overview of the Hearts and Minds toolkit – allowing delegates to get to grips with facilitating the Hearts and Minds tools.
  • Allow delegates to learn from some of the leading experts in safety culture change.

Illustrated with case studies and examples from the course facilitators’ own experiences, delegates will also have the opportunity to design a bespoke culture change plan for implementation in their own organisations.

Anyone with responsibility for leading or facilitating safety culture development and change will find this course of benefit. This may include health and safety managers, senior operational leaders, trainers, safety champions, specialist consultants, as well as those interested in learning more about designing a cultural change programme.

Cost (per delegate)

EI members: £1,350 (plus VAT)
Non EI member: £1,500 (plus VAT)

Book your place

For more information or to book your place visit the EI website or email Will Sadler (EI Training Manager) e: WSadler@energyinst.org

What is safety leadership?

November 4, 2013

In recent years, organisational leaders have been increasingly ‘in the spotlight’ when it comes to safety performance. The EI Process safety management framework and accompanying guidelines have been developed as a result of this increased attention, to ensure organisations are able to comprehensively manage all aspects of process safety.  The EI’s Human and Organisational Factors Committee (HOFCOM) is also currently producing guidance aimed at improving the safety decision making capability of senior executives through ensuring they are given the right information (safety KPIs, etc.) in the right format, and that all involved understand how their decisions will impact on safety.

Safety leadership is also gaining increased attention as a cornerstone to improving culture.  Proactive organisations want to know what it is that makes people good safety leaders, and more and more how they can develop key safety leadership qualities.  But what are these qualities?

The Hearts and Minds toolkit includes the established SAFE: Safety appraisals for everyone tool (formerly ‘Seeing yourself as others see you’), a 360 degree appraisal tool to allow safety leaders to understand their own leadership behaviour.  SAFE breaks down leadership qualities into 4 areas:

  • Walking the talk – leaders are credible – they do what they say they do and their behaviour sets an example to others.  Safety is a core a part of their business and will not be sacrificed for productivity or cost.
  • Informedness – leaders are aware of the safety conditions that affect their teams, and they check whether people are satisfied with their responses to unsafe conditions.
  • Trust – leaders hold their staff accountable for safety in a just and fair way.  They also hold themselves accountable and don’t blame others for their own mistakes.
  • Priorities – leaders promote their vision of safety.  They take into account safety when appraising other people’s performance, and they always make safety the top priority.

SAFE provides a way to measure safety leadership, and to focus on areas for improvement.

The EI Hearts and Minds development fund has also funded PhD research at the University of Aberdeen into the behaviours shown by the best safety leaders.  This research involved interviewing safety leaders, and examining the causes of major incidents, in order to distil leadership qualities down into a simple framework, which comprises 3 categories:

  • Leaders establish safety as a priority: they incorporate safety into decision-making; they act as a safety role-model.
  • Leaders set and manage safety standards: they communicate safety expectations; they reinforce behaviour with rewards and consequences.
  • Leaders maintain risk awareness: they promote continuous exchanges of safety information; they monitor the reality of operations.

Recently the International Association of Oil and Gas Producers (OGP) Safety Committee has produced a new report ‘Shaping safety culture through safety leadership’ (OGP report no. 452), available here.  This report provides an overview of the elements that make up good safety culture – staying informed, reporting, learning, flexibility, just culture – in order to give context to the areas that good safety leaders should nurture.  Safety leaders do this through a number of leadership qualities:

  • Credibility in what they say and do.
  • Action orientation – acting to address unsafe conditions.
  • Vision – their vision of safety excellence.
  • Accountability – they hold people accountable for safety-critical activities.
  • Communication – the way they communicate about safety.
  • Collaboration – encourage active employee participation in resolving safety issues.
  • Feedback and recognition that encourages safe behaviour.

The report provides some guidance on how leaders can demonstrate these qualities.

There seems to be parity among these three definitions, with the main differences being how safety leadership qualities are grouped and presented.  The cake can be cut in a number of different ways, and, thanks to the large amount of research that has taken place over the years, we now have a good sense of the ingedients – but who is hungry enough to have the first slice?