2 Health, Safety, Security and Environment (HSSE) Management System Requirements And Incident Investigation Process
3 HSSE Management System Why have an HSSE Management System? To provide a systematic approach to HSSE management and serve as a foundation for continually improving HSSE performance. To set clear expectations for minimum HSSE requirements and provide a structure for identification and prioritization of HSSE risks.
4 The JIG HSSE Management System Guideline Elements 1. Leadership, involvement and responsibility 2. Risk assessment and control 3. Asset design and construction 4. Documentation and records 5. Personnel and training 6. Occupational health and hygiene 7. Operation and maintenance 8. Management of change 9. Contractors and suppliers 10. Incident investigation and analysis 11. Emergency preparedness 12. Community 13. Management system review and improvement
5 HSSEMS References JIG Bulletin No. 32 (March 2010) Launch of the JIG HSSE Management System JIG HSSEMS Guidelines Issue 1 (March 2010) Available in English, French and Spanish JIG HSSEMS Gap Analysis Tool (March 2010) Available in English and French JIG Learning from Incidents Toolbox Packs Currently 7 packs on the website
6 HSSE Guidelines Document
7 HSSE Root Cause Analysis & Investigation Process Objectives Clarify why incident investigations are needed To provide guidance and awareness on incident investigations to identify root causes Highlight the importance of learning from incidents Encourage you to review and enhance your existing procedures for incident investigation Drive improvement in JIG HSSE performance
8 What is the Key Reason For Conducting Incident Investigations? Protect people and our environment Manage losses Comply with regulatory requirements
9 But are we learning the lessons? Texas City refinery explosion (2005) Longford gas plant explosion (1998) Piper Alpha (1988) What s next? Aug 2012: Venezuela's Amuay refinery and what failures will have played a role?
10 JIG HSSE Data
11 JIG HSSE LTI vs Oil Majors
12 Incident Investigations An incident investigation is an after the fact reaction to an unfortunate event. By determining the Root Cause and contributing factors, steps can be implemented through use of policy, procedures, and training to avoid future occurrences. The goal of the investigation is prevention and learning, not to place blame!
13 Causation Remember these three basic facts: Incidents are caused. Incidents can be prevented if the causes are eliminated. Unless the causes are eliminated, the same incidents will happen again. Usually there are four or five root causes or factors that contribute to an incident. Often there are even more. Your task, if asked to investigate an incident, is to identify as many as possible.
14 JIG Standards and Incident Investigation Section Section Section Section 2.3 See also HSSE Management System Requirements - Section 10
15 What is an Incident Investigation? A defined process by which we: Perform a systematic examination Determine (find) the facts Identify the immediate, underlying causes (Root Causes) Develop proposals for corrective action Communicate & share learnings Ensure actions are closed out
16 Why find Underlying / Root Cause(s)? Symptom Approach Errors are often the result of carelessness. Root Cause Approach Errors are the result of defects in the system. People are only part of the process. We need to train and motivate workers to be more careful. We need to find out why this is happening and implement corrective actions so it won t happen again. We don t have the time or resources to really get to the bottom of this problem. This is critical. We need to fix it for good or it will come back and bite us.
17 Incident Investigation - Process Steps 1) Preparation Consider what might have gone wrong: Organisational issues People Technology Environment Establish an investigation team with appropriate skills and training 2) Investigation Activities Site Visit / Physical Inspection Interviews Document Research Re-enactments or Modeling 3) Analysis Determination of Causes Immediate Underlying Root 4) Reporting Assemble Report and/or Update Incident Record Develop Corrective Actions Develop & Communicate LFI
18 CASE STUDY 1 Particle entered Operators eye Operator gets dust in his eye Why? - not wearing safety glasses This is the immediate cause. Was he trained? Was the task risk assessed? Are they the right safety glasses for the job? How many others operators do the job this way? Has the task been observed by site walkaround /inspection? Why use a compressed air line to do this is there a safer way?
19 Processes to Support Incident Investigation Fishbone Diagram
20 The Reason Model and Incident Causal Chain Some holes due to active failures HAZARDS Some holes due to preconditions LOSSES Some holes due to latent conditions Successive layers of defences, barriers & safeguards
21 Simple Model
22 Investigation Traps Put your emotions aside! - Don t let your feelings interfere - stick to the facts! Do not pre-judge. - Find out the what really happened. - Do not let your beliefs cloud the facts. Never assume anything. Do not make any judgments.
23 CASE STUDY 1 Particle entered Operators eye What happened? He felt a particle in the corner of his eye He rubbed his eye, as he felt an irritation It was later noticed by his work colleague that his eye was blood-shot Injury scratch to the cornea The injured party was not wearing Safety Glasses He was not able to wash his eye as there were no wash bottles in workshop No Inspections or Safety Audit completed in this area Supervisor is remote from Site, following team /business changes When questioned, it was mentioned it was not the first time this type of incident had occurred in this location The JSA (Risk Assessment) identified dust as a hazard and the PPE that was prescribed was appropriate safety glasses / goggles when risk of foreign object able to enter eyes
24 CASE STUDY Particle in Operators Eye What are the Direct, Immediate and Root Causes? What went wrong? Direct Cause(s): Dust entered eye of operator from non standard use of compressed air, he rubbed the eye, he did not use an eye wash Immediate Cause(s): Operator not wearing PPE, lack of eye wash & awareness of First Aid. Operator did not follow procedures (or he did not know them) Root Cause(s): Failure to report or investigate other incidents, unclear JSA, failure to recognise hazards, no interventions, lack of supervision at site Why did this happen? Lack of Safety Management System Failure to recognise risks Inspection schedule inadequate Management restructure following divestment Barriers Affected Plant and Equipment Incorrect use of air line Inadequate eye wash stations Processes Inadequate JSA Reporting of incidents/nms First Aid response People Poor supervision Operator training, hazard awareness or concern for own safety
25 Group Exercise Let s look at Case 2 to 7 Description of exercise: In Groups, review the incidents and the data given. Discuss in your group, and fill out the incident cause table. Process: 1. Examine the incident given, use the data to identify the Direct Cause Immediate Cause Root Cause 2. Assigned the failed barriers 3. What can we learn from this incident? Be prepared to feedback (nominate a 1 person to feedback)
26 Group Exercise Let s look at Case 2 to 7 Group Case Study
27 Incident Investigation - Final Check Investigation Report Final Check Fact Are all relevant facts captured Causes Underlying causes established Corrective Action SMART Corrective Actions linked to causes Final Health Check Would the incident still happen if corrective actions are in place? Specific Is it clear what has to be done & by whom? Measurable Will we know when it has been done? Achievable Is it possible? Realistic Can we afford it? Timely Is there a completion deadline?
28 Learning From Incidents JIG LFIs
29 Learning From Incidents How? Need a way of sharing learning that drives behavioural change and sustained learning Need to provide people with the time and space to think about the causes of an incident and what they need to do prevent this happening at their workplace Research shows that sharing learning via small group, face-to-face discussions, with video footage of an incident, is more than 5 times effective than just reading an LFI Alert (see next slide)
30 Learning From Incidents Best method?
31 Questions Incidents / Investigations / LFI?
32 Back Up Slides
33 Case Studies for Exercises CASE STUDY 2 Contractor cut Wrong Pipe CASE STUDY 3 Hot Work Fatality CASE STUDY 4 Lost Workday case resulting from tripping over hose CASE STUDY 5 Lost Workday case resulting from pulling a hose CASE STUDY 6 MVI Catering truck collided with Fueller CASE STUDY 7 - Finger Injury whilst lifting Hydrant Pit cover
34 CASE STUDY 2 Contractor cut Wrong Pipe What happened? The work-team were using a high pressure water jet cutting system to cut redundant steelwork and pipe work. The job was additional work that had been added to the scope after the team had arrived at the Site. The work-permit made only a general reference to removing equipment in the area. The team were instructed to cut all material in the area and the toolbox talk did not indicate which items should be cut or left. Various pieces of steelwork and pipe were marked with red andwhite tape. The team began cutting steelwork and pipes. Shortly after cutting a pipe an oily smell was noticed and the team stopped work. The area Supervisor (Permit Issuer) confirmed that they had cut through a live drain line. In the absence of any other indication, the team had assumed that the red-and-white tape marked the lines and steel which needed to be cut. In fact it marked trip hazards on the worksite.
35 CASE STUDY 3 Hot Work Fatality What happened? A contractor (Company A) was asked to remove two petrol and one diesel Underground Storage Tanks (USTs), as part of a site closure project. The tanks were removed from the ground by the contractor and then they engaged a subcontractor (Company B) to cut the tanks up. This activity was carried out onsite, not far from where the tanks had been sited. No work permits were issued for this process. The Sub-contractors (Company B) were inducted (in site emergency procedures) but no toolbox talks given. Diesel truck exhaust was used to degas the tanks (unapproved degassing method) and no gas testing was conducted. Tank that exploded The first tank was successfully cut without incident; however, when the welder began cutting the second tank, an explosion occurred. This explosion resulted in one fatality when the top of the tank hit another worker (from Company C), working close to the team doing the welding. Two workers were hospitalized (5 days) with burns (from Company B). No site walkabouts or checks were made about how the work was progressing. Tank end that struck and killed subcontract worker
36 CASE STUDY 4 Lost Workday case resulting from tripping over hose What happened? An operator descended the ladder from the elevated platform and tripped on the inlet hose. With the fall he suffered grazes and an injury to both his knees and ankle. This resulted in 2 weeks absence from work. No inspections had been carried out in this area for 2 years. No Safety walks (walkabouts) were done by the Supervisor. No risk assessments for this area. Other Operators were seen walking over trip hazards
37 CASE STUDY 5 Lost Workday case resulting from pulling a hose What happened? On the first fuelling operation of the day, an Operator proceeded to pull the fuelling hose from the Hydrant servicer towards the aircraft. While pulling the hose he suddenly felt a slight pain in his back. However, he managed to fuel the aircraft as scheduled and also completed fuelling the next aircraft. After fuelling the second aircraft, he contacted the doctor and visited for a consultation. He was prescribed 8 days sick leave (that was later extended). The Operator has a history of back related issues and had taken more than 40 days sick leave during the year. The manual handling technique used by the Operator in this incident was not known. His last Manual Handling training had been 7 years ago. No faults were found with the equipment used.
38 CASE STUDY 6 MVI Catering truck collided with Fueller. What happened? A catering company truck collided with a Fueller while it was en route to the apron, resulting in damage to the trailer unit, and the pipe work connecting the filters to the meters, this resulted in a release of Jet A1 (20 litres). The incident occurred at the junction of the catering company parking area and the apron access road. The cost of repair to the Fueller was 38,900. There were no road markings or vertical STOP sign posts in place at the exit of the catering truck parking area. Visibility to the left side when exiting the catering parking area was poor. Other vehicles were parked on the Apron roadway left of the exit reducing the visibility, this caused the catering truck driver to concentrate on looking left when exiting, and also forced him into the roadway to see around the parked vehicles. The visibility to the right was found to be adequate, and not obstructed. This was the direction that the Fueller was travelling from, but the driver of the catering truck failed to see the Fueller. Incident Schematic Hose & Coupling Catering truck parking area Apron access road Caterin g truck
39 CASE STUDY 7 Finger Injury whilst lifting Hydrant Pit cover What happened? Early in the morning, a two-man team working for a JV aviation depot was undertaking a routine hydrant integrity check. After parking near the Hydrant Pit area, one operator began unloading the test equipments from the back of the service vehicle, while the other operator commenced the integrity check by opening Dabico hinged-type hydrant cover. The latter operator did this activity by inserting his left hand inside the grab hole of the 15 kg hydrant cover and lifting. When the cover was slightly up, the operator then supported the cover weight by placing his right hand underneath the cover. After the pit cover was fully opened, he then began connecting the test equipment and conducting the test procedure. On completion of the testing, the operator reversed the process by inserting his left hand inside grab hole of hydrant cover and, at same time, supported the cover by placing his right hand underneath it However, in this instance when the cover was almost closed, he released his left hand grip of the cover before he had fully removed his right hand. The cover struck his fingers pinching them between the cover and the hydrant pit frame. The injury to the operators fingers required medical treatment at the local hospital. This manner of handling the hydrant pit lids was the common method employed at the location. Failure to see the hazard with this activity due to the very routine nature of the task. Neither men had undertaken manual handling training. A similar incident had occurred at another location 6 months previous.
40 CASE STUDY # Incident What are the direct, immediate and underlying causes? What went wrong? Barriers (controls) affected Plant and Equipment Processes Why did this happen? People
41 CASE STUDY # Incident What can we learn from this incident?
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