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:;

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:;

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 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 ( 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

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.


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

Event: Human factors application in major hazard industries: 26-27 November 2013

August 19, 2013

This biennial 2-day conference, organised by the Energy Institute Human and Organisational Factors Committee and the Stichting Tripod Foundation, explores the practical application of human factors in the management of major accident hazards (MAH) in the energy and allied process industries.

The event will include sessions on:

  • Competence, with a keynote presentation from Ian Travers, Head of Chemical Industries Strategy Unit, Health and Safety Executive, on regulatory developments to help support competence management systems at COMAH sites.
  • Learning from incidents, supported by the Stichting Tripod Foundation, providing delegates with the opportunity to explore the use and development of Tripod and related methods for understanding and learning from incidents.
  • Human factors risk management techniques.
  • Human factors integration, including contractor management.

Who should attend?

This conference will be of interest to anyone managing health, safety and the environment, including process safety and occupational safety, as well as those with a specialist interest in human factors and ergonomics. This will include those with responsibilities for managing competence and training and risk assessment. The event will also be of keen interest to those involved in incident investigation, analysis and learning from incidents processes – including users of Tripod Beta and related methodologies.

The conference will enable the learning and sharing of good practice between companies and industries, and offer excellent networking opportunities with delegates from around the world representing operating companies, suppliers, consultancies, and academia.

Book your place now

Click here for more information or to book your place at this event.

Obituary: Gerard van der Graaf (1947-2012)

November 6, 2012

It is with great sadness to announce that Gerard van der Graaf – the ‘grandfather’ of the renowned Hearts and Minds safety culture programme and founding member of the Tripod Foundation – passed away in September.

In his early days in Norway, Gerard worked on simple Quantitative Risk Analysis (QRA) studies where he developed a strong belief that the sensible use of QRA could be used to understand risk in order to help manage the key factors in safety critical tasks. This was not for the sake of setting ‘tolerability criteria’; rather, when used comparatively, Gerard saw that QRA could be a great help in analysis and decision making. Throughout his life, Gerard maintained a firm stand that QRA should be for this purpose and not used to justify poor operating or engineering practice.

Gerard led QRA in Shell from the mid-1980s to early 1990s and wrote the Shell Group’s standard, the ‘de facto’ approach in industry. The sensible use of emerging consequence modelling was core to his heart and he worked with others to make that available to engineering in the field. He spent a short spell as head of Health, Safety and Environment (HSE) for NAM before returning to a global HSE role at Shell International Exploration and Production.

In the post Piper Alpha days, HSE management systems were in place but, from experience of audits and incidents, Gerard became more convinced that they were not being effectively used. Turning his attention to the growing area of safety culture, Gerard steered Shell’s Hearts and Minds programme from initial conception to the current toolkit offered by the EI, and he was the Chair of the Tripod Foundation for a number of years, until ill health forced him to retire.

Gerard was a thought leader with a great vision of how to drive performance improvement, based on the premise that no one should ever be hurt at work. He was a source of inspiration and wise council and will be sorely missed.

EI partners with Tripod Foundation to further develop risk management tools

October 22, 2012

The Energy Institute (EI) has signed a partnership agreement with the Stichting Tripod Foundation to help develop deep learning from incidents using Tripod based tools. The agreement aims to build on the EI’s current risk management programme and strengthen the range of Tripod methodology tools and activities.

Identifying the root causes of incidents is fundamental in helping to stop their recurrence. Tripod BETA is internationally recognised as a robust incident analysis tool and Tripod DELTA enables organisations to proactively identify weaknesses in management systems, before incidents may happen. At its core, the Tripod methodology’s approach is aimed at identifying underlying organisational weaknesses and promoting understanding and better management of these issues to prevent future incidents.

As part of this partnership arrangement, the EI will be working to support and extend the Tripod community of users, including independent accreditation of its practitioners and trainers.

Martin Maeso CEnv MEI, Knowledge Director, Energy Institute, says, ‘The EI delivers good practice guidance to the global energy sector on behavioural and process safety, environment, health, distribution, measurement and testing methodology. By working in partnership with the Tripod Foundation the EI has an excellent opportunity to enhance and build its risk management activities. Furthermore, as a Royal Charter institute, the EI has extensive experience in managing a range of accreditation processes and so is well placed to support the further development of the Tripod network. This partnership strengthens the EI’s commitment to safety whilst providing vital support and potential for growth in the valuable work undertaken by the Tripod Foundation.’

Tony Gower-Jones, Secretary, Stichting Tripod Foundation Board, says, ‘Tripod was developed over 20 years ago, alongside the bow-tie model and in direct response to the Piper Alpha disaster. It is now used by a wide range of industries that extend well beyond the energy sector. Working with the EI, the Foundation now aims to develop the suite of Tripod tools and activities and we would like to encourage the current user community to participate in this development programme with us.’

To find out how you can engage with this work, please email