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)

http://lfiseminars.ning.com/

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


EI appearing at Hazards 25 conference – 13-15 May 2015, Edinburgh

April 1, 2015

The EI will be speaking at the IChemE Hazards 25 conference in May.  Steve Sharwen (ABB, member EI Area Classification Working Group) will provide an overview of key changes in the 4th edition of EI’s hazardous area classification publication (‘EI 15’); whereas Dr Ed Smith (DNV-GL, author to EI Human and Organisational Factors Committee) will describe work to prepare comprehensive guidance on learning from incidents.

EI will also have an exhibition stand, so come over and find out more about the technical work we are doing.

For full details on the conference programme, and to book your delegate place, visit the main conference website:

http://www.icheme.org/hazards25


High Reliability Organisations conference, 20 January 2015, London

December 9, 2014

Incidents over recent years have highlighted the importance of an organisation being able to demonstrate a top level safety performance. This has led to increased interest by senior leaders in High Reliability Organisations (HROs), characterised as organisations which aim to maintain excellent performance over long periods of time.

This event, hosted by the IChemE Safety and Loss Prevention Special Interest Group, will bring together speakers from a number of different organisations to share experience in working towards becoming a HRO. It will be of particular interest to senior managers interested in improving their organisations approach to process safety.

Speakers include Judith Hackitt (Chair of the Health and Safety Executive) and Helen Rycraft (International Atomic Energy Agency, and EI Human and Organisational Factors Committee member).

You can book your place at the event webpage.

 


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


New clothing policy for those travelling offshore by helicopter in the UK, from October 1st 2014

September 15, 2014

The Step Change in Safety Passenger Size workgroup has created a standardised clothing policy which sets out guidance on what should be worn under a survival suit when travelling offshore in a helicopter.   The policy will be effective from Wednesday, 1st October 2014 and should be observed by all workers travelling to installations in UK waters.  Information will be available at UK heliports that support the oil and gas sector.  Step Change in Safety has provided a poster for download and distribution here outlining the clothing allowed to be worn.


Distractions at work lead to poor performance

August 8, 2014

A recent study by George Mason University (here) tested the effects of distractions on people producing written essays. Those who suffered distractions produced less words over the same period of time and their work was graded lower in quality. An interview with the researcher can be found here, who suggests we should actively try to minimise the opportunity for disruption to our work.

Whilst this may be unsurprising to many, do most organisations actively consider ways to minimise distractions to employees?

 


EI publishes ‘Guidance on crew resource management (CRM) and non-technical skills training programmes’

July 23, 2014

Human error remains a constant risk in all workplaces but can be particularly hazardous in industries working with major accident hazards (MAHs), such as the energy industry. The systematic analysis of major process incidents in the energy industry has repeatedly indicated the risks of human error and unsafe behaviours.

Some industries, most notably aviation, strive to minimise human error by the use of crew resource management (CRM), an approach which identifies and trains non-technical skills (e.g. decision making, teamwork and personal resource skills) to improve safety and efficiency. In response to recent offshore incidents, it has been suggested by regulators that the energy industry should adopt CRM training.

The EI Human and Organisational Factors Committee (HOFCOM) has developed ‘Guidance on crew resource management (CRM) and non-technical skills training programmes’ to introduce CRM to the energy sector. Authored by Prof. Rhona Flin and Jill Wilkinson of Aberdeen University, it introduces what CRM training covers, sets out the case why CRM training might be implemented, and provides a process to help an organisation develop and implement a CRM training programme. Examples of CRM courses are given, and sources of background information and further reading are provided.

This publication should be seen as part of a suite of resources being developed in conjunction with the International Association of Oil and Gas Producers (OGP), the first of which, Report 501, has already been published.

This publication will be of interest to HS&E managers, and those responsible for, and for ensuring the competence of, operational crews. Those who are already creating CRM training programmes should seek to align their efforts with the guidance in this document.

How to access this publication

Guidance on crew resource management (CRM) and non-technical skills training programmes (1st edition, 2014, available as a free download, or priced hard-copy publication. After following the link, sign in to the energypublishing.org website to download)