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)


Helicopter safety reports published

July 17, 2014

The UK House of Commons Transport Committee has published its report into offshore helicopter safety available here.  The report acts as a companion to the technical report conducted by the Air Accident Investigation Branch (here), focusing on the May 2012 Aberdeen, and August 2013 Shetland Super Puma helicopter incidents, where both helicopters were ditched into the sea after coolant failures.

The Government report notes:

  • problems with the safety briefings provided to passengers, where the passengers chose not to use the emergency breathing system, based on what they were told during the pre-flight briefing, and
  • a ‘culture of bullying’, where staff concerns over the safety of the helicopters were ignored (although no evidence was found to suggest the Super Pumas are less safe than other helicopters).

The Government has asked for a further report from the Civil Aviation Authority as to why more helicopter incidents are reported in Norway than in the UK.  The Government also notes that the impact of commercial pressure on helicopter safety has not been looked at in enough detail, due to commercial sensitivities making it difficult to see the contractual obligations being placed on helicopter providers.


Barrier based risk management network event

June 20, 2014

CGE Risk Management’s biennial network event will focus on barrier-based risk management and incident investigation. The event will include a morning plenary session, featuring different speakers and perspectives on the latest developments and challenges in barrier based risk management.

CGE writes:

What is the role of risk management in your organization? Sometimes risk management is only seen as a necessity, or for compliance reasons. Few organisations use it as an integral part of their core business and the operational processes. And very rarely is it part of strategy planning. However, as risk and award mostly go hand in hand, really understanding what you are good at and knowing how to manage this enables your organisation to achieve operational excellence.

So why is risk management not seen as an instrument for strategy execution and achieving operational excellence? The current risk management frameworks do not tell the real story. There is a saying; “all models are false, but some are useful”. We believe certain risk management methods can be used in addition to existing control frameworks, such as the “BowTie”-method. This method is a visual and “barrier based” risk management method, and has been the standard in the Oil & Gas industry for more than 20 years. It shows a clear picture of what is really happening and what to focus on to be ‘in control’ and to achieve your objectives. Click here to read more.

Learn more from your peers

On 22 September 2014, engaging speakers (a.o. from Anglo American and E.On) share their stories and experience on achieving Operational Excellence by using risk management. The set-up of the programme is very interactive and in the afternoon you can participate in three sessions on related topics. These topics all deal with the challenge of the question of how to realize results and make a difference in large organisations.”

Afternoon break-out sessions will further address a number of in-depth topics:

  • Learning from Incidents
  • Cultural and Organisational Aspects
  • Bringing BowTies to the Enterprise with BowTieServer

The break-out sessions will be repeated, enabling you to choose which topics you would like to learn more about.

This event will be of interest to users of Tripod Beta, Bow Tie analysis, and those responsible for risk management and incident investigation.

The EI and the Stichting Tripod Foundation will be in attendance.

For more information, visit www.cgerisk.com/networkevent2014


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/