Tripod-Beta Accident Investigation Technique

Tripod-BE Tri pod-BETA TA Incide Inci den nt Inv Invest estig igat atiion and Analys alysiis

Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Inciden Incide nts ar ar e an an in ind dic icato ator r to im imp pr ove our our pe perf rf orm rma anc nce e

Unde der r stan standing what happen happe ned and why enables us to imp im pr ove our our busin bus iness ess Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Str uctur tur e

of of the HSE Man Management

System ystem

Leader eader shi ship an and Commi Committment

Polic Policy y an and Str ategic ategic Objec Objectives ives

Tri ripod pod Beta

Orga rganisat nisatiion, Respon Responsibilities Resourc Resources es,, Stan tandar dar ds ds & Doc Doc. Hazar Hazar d an and Eff Eff ects Man Management Planning Planning & Pr Pr ocedur edur es es

Imple Implem mentati tation

Audi udit

Man Management Revi Review ew Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Corr Corr ective ive Act Action

Moni Monito toring ring

Corr Corr ective ive Act Action & Imp Impr ovement Corr Corr ective ive Act Action & Imp Impr ovement

What

is Tri Tripod-BE pod-BETA TA ?

ethodolog den analys alysiis during during A methodolo gy f or r inci incide nt an an inv invest estig igat atiion ... combining conc ncepts epts of of haza hazar r d management and ... the Tri Tripod pod theor theor y of of a acci ccide den nt causat ausatiion.


How does Tri Tripod-BE pod-BETA TA wo work rk ?

The inci incide den nt f acts ar ar e bui built in into to a tr tr ee ee diagr am show showing ing ... - What happen happened ... - What hazar hazar d management elem elements f ailed and - Why eac each elem element f ailed.


What

does the sof sof twar twar e do ?

sof twar twar e: e: The sof 

tor r es es Sto

invest inv estig igat atiion f acts



Pr ovi vides des tr tr ee-bui ee-build lding ing gr aphic aphics s



Check Che cks s the im impl plici icitt tr tr ee ee logic logic



Atta ttac ches data to tr t r ee ee elem elements



Asse ssem mbles attac attached data in into to a dr dr af t r epor epor t. t.


How does the tr tr ee ee work work ?

Let¶s walk walk th thr r oug ough a sim simple ple inci incide den nt inttr oducing in oducing the termin terminolo olog gy and logic logic that un unde der r pin ins s Tri Tripod-BE pod-BETA TA


The Inci Incide den nt 

Locat atiion: an off shor shor e platf platf orm



Inciden Incide nt: an ope oper r ativ ative e coming off sh shif if t sliips an sl and f alls alls in the shower shower r r oom oom



Conseque Con sequenc nce: e: he hur hur ts ts hi his back back and is off ff wo work rk



In the past thr thr ee ee months ther ther e hav have been bee n two simi simila lar r inci incide den nts


Inittial Fin Ini Find ding ings s



The inci incide den nt occ occu urr ed ed at 1820 hour hou r s



The oper oper ativ ative e sli slipped on on the wet f loor loor



Cleaning sta Cleaning staff ff a ar e supposed to keep the shower shower r r oom oom f loor loor d dr y


tar r ting Sta We

a Tri Tripod pod Tr ee ee

star t by ide star den ntif ying ing::



An EVEN EVENT T - wher e a hazar hazar d an and a targ ta rget et get tog togethe ether r



A TA TARGE RGET T - a per son son or r a an obje objec ct that was harm harmed ed



A HAZA AZARD RD - the thing that di did the harm harm


The Hazar Hazar d, Event, Targ rget et Tri Trio o They ar ar e shown show n in a Tri Tripod pod tr tr ee ee lik like e thi this:

Hazar Hazar d

Event

Targ rget et Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Hazar Haza r d, Event & Targ rget et

In th thiis inci incide den nt: The HAZA ZARD RD is : Wet f loor loor (sl (sliipp pping ing haza hazar r d) d) The EVEN EVENT T is r oom oom

: Oper ativ ative e f alls alls in showe shower r

The TA TARGE RGET T is : Oper ativ ative e


HET HE T Diagr am The Haza Hazar r d,

Wet

loor f loor (sli (slipping pping hazar hazar d) d)

Event

Target rget


HET HE T Diagr am The Hazar Hazar d, acting on the Targ rget et,,

Wet

loor f loor (sli (slipping pping hazar hazar d) d)

Event

Oper Oper ativ ative e


HET HE T Diagr am The Hazar Hazar d, acting on the Targ rget et,, r esulted esulted in the Event

Wet

loor f loor (sli (slipping pping hazar hazar d) d) Oper Oper ativ ative e f alls alls in shower shower r r oom oom



Is the inv invest estig igat atiion complete ? 

Does thi this show f ull ull un unde der r stan standing ? Fin ind ding ing:: The man must hav have been been car eless eless Recomm Rec mme endat datiion: He should tak ta ke mor e car e on on a wet f loor loor



Or r iis ther ther e som someth ething ing mor e ?


Was

the inci incide den nt pr pr eventable ?



We

know that a hazar know haza r d management measu easur r e was in pla plac ce



Cleaning sta Cleaning staff ff we wer r e assign assigned ed to keep the f loor loor d dr y



µbarrie er ¶ to the inci den That µbarri incide nt f ailed


Faiiled Barri Fa Barrie er The ba barri rrie er r should should hav have contr olled olled the hazar haza r d

Hazar Hazar d

Fai Failed Barri Barrie er

Target rget


Event

Incide Inci den nt Mec Mecha hani nis sm The inci incide den nt mecha hani nis sm loo look ks lik like e thi this:

Wet

loor f loor (sli (slipping pping hazar hazar d) d) Floor Floor dr ying



Oper Oper ativ ative e f alls alls in shower shower r r oom oom

Fur Fu r ther ther Inv Invest estig igat atiion

What

caused the barri barrie er r to to f ail ?



The clea lean ner could not keep the f loor loor dr y ...



because the shower bec shower r r oom oom was alway alw ays s cong ngested ested between between 1800 an and 1900 hr hr s


Acttiv Ac ive e Fai Failu lur r e An Activ ive e Fai Failu lur r e de def f eated eated the barri barrie er Act Active ive Fai Failur lur e Active Failure

Wet

loor f loor (sli (slipping pping hazar hazar d) d) Floor Floor d dr ying




Acttiv Ac ive e Fai Failu lur r e An Activ ive e Fai Failu lur r e de def f eated eated the barri barrie er Clean Cleaner u r unable to keep f loor loor dr y Act Active ive Fai Failur lur e

Wet





End of of Inv Invest estig igat atiion ? 

Is thi this the en end of of the the inv invest estig igat atiion ? Fin ind ding ing:: The clea lean ner was inc inco ompete peten nt Recomm Rec mme endat datiion: Clean Cleaner r should should be r eplac eplaced or or r r etr etr ain ined ed



Or r iis ther ther e sti still som someth ething ing mor e ?


Fur Fu r ther ther Inv Invest estig igat atiion



We

know that cong know ngest estiion was a f acto tor r that pr pr ompted the ac activ ive e f ailu lur r e



Telepho elephon nes ar ar e on only av available f or priv rivate ate calls up ti till 1900 hr hr s



The cong ngest estiion is caused by day shif sh if t cr ew ew hurr hurr ying to call hom home


The Full Pic Pictu tur r e

Now we hav have the f ull ull pic pictu tur r e: e: 

The cong ngest estiion is a µP µPr econdition¶ that inf luenc luenced ed the clea lean ner ¶s ¶s task task



Restricttion on telepho Restric telephon nes is a µL µLate aten nt Faiilu Fa lur r e¶ that cr eated eated the pr p r econdition


Pr econdition

Pr econdition Preconditio n

Clean Cleaner u r unable to keep f loor loor dr y Act Active ive Fai Failur lur e

Wet





Pr econdition

Cong Congest estiion 1800 1800 - 1900 1900 hr hr s Pr econdition


Wet





Late aten nt Fai Failu lur r e

Laten atent Fai Failur lur e Laten atent Fai Failur lur e

Cong Congest estiion 1800 1800 - 1900 1900 hr hr s Pr econditio n


Wet





Late aten nt Fai Failu lur r e

Restric Restricttion on private rivate phon phone calls Laten atent Fai Failur lur e

Cong Congest estiion 1800 1800 - 1900 1900 hr hr s Pr econditio n


Wet





Rec Re comm mme endat datiions Action ite tem ms should addr addr ess: ess: 

The f ailed barri barrie er r ... ... to r estor estor e saf saf e conditions on on a tem tempo por r ar y basiis bas (pr (p r ovi vide de extr extr a clea lean ner betwee between n 1800 an a nd 1900)



The late laten nt f ailu lur r e ... to r emove the un unde der r lying lying cause (exten (exte nd the av availab labiility of o f sho shor r e telephon telephone)


Com Co mplex Ev Events



That was a sim simple ple exam example



The Tri Tripod-BE pod-BETA TA methodolo ethodolog gy can also be appliied in complex ev appl events


Com Co mplex Ev Events Ide den ntif y the prim prime e Event,

Fir e


Com Co mplex Ev Events Ide den ntif y the prim prime e Ev Event, the Haza Hazar r d,

Ignit Ignition Fir e


Com Co mplex Ev Events Ide den ntif y the prim prime e Ev Event, the Hazar Hazar d, and Targ rget et.. Ignit Ignition Fir e

Flamm Flammable able Gas Cloud


Com Co mplex Ev Events If, say say,, the targ target et was cr eated eated by a pri p rio or event Ignit Ignition Fir e Flamm Flammable able Gas Cloud


Com Co mplex Ev Events Ide den ntif y the hazar hazar d ... Ignit Ignition Dr opped opped Objec Object

Fir e Flamm Flammable able Gas E vent Cloud & Target rget


Com Co mplex Ev Events and targ target et f or r that that ev event. Ignit Ignition Dr opped opped Objec Object

Fir e Flamm Flammable able Gas Cloud

Gas Line Line


Com Co mplex Ev Events imila lar r ly, ly, Simi

if a if a conseque sequen ntial ev event happen happens

... Ignit Ignition Dr opped opped Objec Object


Gas Line Line


Damage to Platform

Com Co mplex Ev Events bec be cause the prim prime e ev event cr eated eated a new hazar hazar d, Ignit Ignition Dr opped opped Objec Object


Gas Line Line


Damage to Platform

Com Co mplex Ev Events ide den ntif y the targ target et f or r the the new ev event. Ignit Ignition ource e Sourc Dr opped opped Objec Object


Damage to Platform

Gas Line Line Platf Platf orm


Com Co mplex Ev Events Ide den ntif y f ailed µba µbarri rrie er s¶, Ignit Ignition ource e Sourc Dr opped opped Objec Object


Fir e


Damage to Platform



Com Co mplex Ev Events and mi miss ssing ing ones ... Ignit Ignition ource e Sourc Dr opped opped Objec Object


Missing ssing Barri Barrie er

Fir e


Damage to Platform



Com Co mplex Ev Events includ inc luding ing mult ultiiple f ailu lur r es es ...

Ignit Ignition ource e Sourc Fai Failed Barri Barrie er

Dr opped opped Objec Object Missing ssing Barri Barrie er




Damage to Platform



Fir e

Com Co mplex Ev Events on ea eac ch r elev elevant µtr µtr ajec ajecto tor r y¶ y¶ ... Ignit Ignition ource e Sourc Dr opped opped Objec Object

Fai Failed Barri Barrie er Missing ssing Barri Barrie er


Gas Line Line





Platf Platf orm


Fir e Damage to Platform

Com Co mplex Ev Events until the Inci Incide den nt Mec Mecha hani nis sm is complete. Ignit Ignition ource e Sourc Dr opped opped Objec Object



Gas Line Line




Damage to Platform


Platf Platf orm


Fir e


Com Co mplex Ev Events Show

the Activ ive e Fai Failu lur r e f or r ea eac ch barri barrie er, ... Act Active ive Fai Failur lur e Active Failure

Ignit Ignition ource e Sourc Dr opped opped Objec Object



Gas Line Line




Damage to Platform


Platf Platf orm


Fir e


Com Co mplex Ev Events the Pr econdition(s) pr omot oting ing ea eac ch ac activ ive e f ailu lur r e, ... Act Active ive Fai Failur lur e

Pr econdition

Precondition

Active Failure

Hazar Hazar d Fai Failed Barri Barrie er

Hazar Hazar d Missing ssing Barri Barrie er



Event & Hazar Hazar d

Event

Event & Target rget

Target rget



Target rget



Com Co mplex Ev Events and the Late aten nt Fai Failu lur r e beh behin ind d eac each pr econdition. Laten atent Fai Failur lur e

Latent Failure

Act Active ive Fai Failur lur e

Pr econdition

Precondition

Active Failure






Event

Event & Target rget

Target rget



Target rget



Com Co mplex Ev Events 

Com Co mplete a µTri µTripod pod path¶ f or r ea eac ch barri barrie er . Laten atent Fai Failur lur e

Latent Failure

Laten atent Fai Failur lur e Latent Failure


Pr econdition Precondition


Active Failure

Act Active ive Fai Failur lur e Active Failure






Event

Event & Target rget

Target rget



Target rget



The completed Tri Tripod-BE pod-BETA TA tr ee ee Laten atent Fai Failur lur e Latent Failure





Laten atent Fai Failur lur e

Active Failure

Act Active ive Fai Failur lur e Active Failure

Hazar Hazar d

Latent Failure





Event Fai Failed Barri Barrie er


Latent Failure

Fai Failed Con Contr ol ol

Event & Target rget

Target rget

Laten atent Fai Failur lur e



Target rget

Active Failure







Str uctur tur e

of of the HSE Man Management

System ystem

Leader eader shi ship an and Commi Committment

Polic Policy y an and Str ategic ategic Objec Objectives ives

Tri ripod pod Beta

Orga rganisat nisatiion, Respon Responsibilities Resourc Resources es,, Stan tandar dar ds ds & Doc Doc. Hazar Hazar d an and Eff Eff ects Man Management Planning Planning & Pr Pr ocedur edur es es

Imple Implem mentati tation

Audi udit

Man Management Revi Review ew Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Corr Corr ective ive Act Action

Moni Monito toring ring

Corr Corr ective ive Act Action & Imp Impr ovement Corr Corr ective ive Act Action & Imp Impr ovement

Corr Co rr ectiv ive e Ac Acttions laten latent f ailur lur e

pr econdition

active ive f ailur lur e

laten latent f ailur lur e

pr econdition

Long te term rm action to r educ educe laten latent f ailu lur r es es Betashow.ppt 1999 Shell Shell International International Ex loration and Product Production ion B.V. B.V.

Replac Repla ce the f ailed barri barrie er

Corr Co rr ectiv ive e Ac Acttions 

If the barri If the barrie er s hav have not been been r eplac eplaced you should questi quest ion why oper oper ati ations hav ha ve r estar estar ted ted



Actions to r eplac eplace barri barrie er s ar ar e norm rmally ally on on site



Late aten nt Fai Failu lur r es es ar ar e deep seated do not expec expe ct to r emove them them to tom morr ow ow



Action to tack tackle le laten latent f ailu lur r es es ar ar e norm rmally ally at management lev level


Tripod-BE Tri pod-BETA TA 

Bring rings s a str str uctu tur r e to inv invest estig igat atiion



Helps di dist sting ingu uish r elev elevent f acts



Mak Ma kes causes an and eff eff ects explici explicitt



Enc ncou our r ages team team discuss ussiion



Reduc Redu ces the r epor epor t wri writting tas task k



Tripod-Beta Accident Investigation Technique

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