TripodBeta 01

Tripod-BETA
Incident Investigation and Analysis

WHAT IS TRIPOD BETA?
A methodology for incident analysis

during an investigation ...
combining concepts of hazard

management and ...
the Tripod theory of accident causation

HOW DOES TRIPOD-BETA WORK?
The incident facts are built into a tree diagram

showing ...
• What happened ...
• What hazard management barriers failed
and
• Why each barrier failed

HOW DOES THE TREE WORK?
Let’s walk through a simple incident
introducing the terminology
and logic that underpins Tripod-BETA

THE INCIDENT
 Location: an offshore platform
 Incident: an operative coming off shift slips

and falls in the shower room
 Consequence: he hurts his back and is off
work
 In the past three months there have been
two similar incidents
INITIAL FINDINGS
 The incident occurred at 1820 hours
 The operative slipped on the wet floor
 Cleaning staff are supposed to keep

the shower room floor dry
STARTING A TRIPOD-BETA TREE
We start by identifying:
 An EVENT - where a hazard and a target

get together
 A TARGET - a person or an object that

was harmed
 A HAZARD - the thing that did the harm

HAZARD / EVENT / TARGET TRIO
They are shown in a Tripod tree like this:

Hazard
Event
Target
HAZARD, EVENT AND TARGET
In this incident:
The HAZARD is: Wet floor (slipping

hazard)
The EVENT is: Operative falls in shower

room
The TARGET is: Operative

HAZARD, EVENT, THREAT DIAGRAM
The Hazard, acting on the Target,

resulted in the EVENT
Wet floor
(slipping hazard)
Operative falls in
shower room
Operative
IS THE INVESTIGATION COMPLETE?
Does this show full understanding?

 Finding: The man must have been
careless
 Recommendation: He should take more
care on a wet floor
Or is there something more?

WAS THE INCIDENT PREVENTABLE?
 We know that a hazard management

measure was in place
 Cleaning staff were assigned to keep

the floor dry
 That ‘barrier’ to the incident failed

FAILED BARRIER
The BARRIER should have controlled the

HAZARD:
Wet floor
(slipping hazard)
Failed
Barrier Operative falls in
shower room
Operative
INCIDENT MECHANISM
Wet floor
(slipping hazard)
Floor drying Non-slip

floor
Operative falls in
shower room
Operative
We could identify other barriers such as non-slip floor which were

not there; this would be depicted as a “missing barrier”. But, for
simplicity, let us concentrate on the “failed barrier”, i.e. floor drying
FURTHER INVESTIGATION
What caused the barrier to fail?
 The cleaner could not keep the floor

dry ...
 because the shower room was always
congested between 1800 and 1900 hrs
ACTIVE FAILURE
An Active Failure defeated the barrier:

Cleaner
Unable
Active to
Failure
keep
floor dry
Wet floor
(slipping hazard)
Floor
drying Operative falls in
shower room
Operative
END OF INVESTIGATION?
Is this the end of the investigation?
 Finding: The cleaner was incompetent
 Recommendation: Cleaner should be

replaced or retrained
Or is there still something more?

FURTHER INVESTIGATION
 We know that congestion was a factor

that prompted the active failure
 Telephones are only available for

private calls up till 1900 hrs
 The congestion is caused by day shift

crew hurrying to call home
THE FULL PICTURE
Now we have the full picture:
 The congestion is a ‘Precondition’

that influenced the cleaner’s task
 Restriction on telephones is a ‘Latent

Failure’ that created the precondition
PRE-CONDITION
Restriction on Cleaner
Congestion
Latent
private
Failure Pre-condition Unable to keep
1800-1900 hrs.
phone calls floor dry
Lat. Failure Pre-condition Active failure
Wet floor
(slipping hazard)
Floor
drying Operative falls in
shower room
Operative
TRIPOD THEORY OF ACCIDENT
MANAGEMENT
Fallible
Latent Active
Management Pre-condition
Failure Failure
Decision
Lat. Failure Pre-condition Active failure
Failed
Barrier
RECOMMENDATIONS
Action items should address:
 The Failed Barrier ...

to restore safe conditions on a temporary basis
(provide extra cleaner between 1800 and 1900)
 The Latent Failure ...

to remove the underlying cause
(extend the availability of shore telephone)
CORRECTIVE ACTIONS
 If the barriers have not been replaced you should

question why operations have restarted
 Actions to replace barriers are normally on site
 Latent Failures are deep seated; do not expect to

remove them tomorrow
 Action to tackle latent failures are normally at

management level
TRIPOD-BETA: BENEFITS
 Brings a structure to an investigation

 Helps distinguish relevant facts
 Makes causes and effects explicit
 Encourages team discussion
 Pictorial display assists analysis and communication
 Model backed by research into accident causation
 Simple data entry to speed analysis process
 Reduces the report writing task

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Tripod-BETA

Incident Investigation and Analysis

A methodology for incident analysis

combining concepts of hazard

the Tripod theory of accident causation

The incident facts are built into a tree diagram

• What hazard management barriers failed

• Why each barrier failed

Let’s walk through a simple incident

introducing the terminology

and logic that underpins Tripod-BETA

 Location: an offshore platform

 Incident: an operative coming off shift slips

 The incident occurred at 1820 hours

 The operative slipped on the wet floor

 Cleaning staff are supposed to keep

 An EVENT - where a hazard and a target

 A TARGET - a person or an object that

 A HAZARD - the thing that did the harm

They are shown in a Tripod tree like this:

The HAZARD is: Wet floor (slipping

The EVENT is: Operative falls in shower

The TARGET is: Operative

The Hazard, acting on the Target,

Does this show full understanding?

Or is there something more?

 We know that a hazard management

 Cleaning staff were assigned to keep

 That ‘barrier’ to the incident failed

The BARRIER should have controlled the

Floor drying Non-slip

We could identify other barriers such as non-slip floor which were

What caused the barrier to fail?

 The cleaner could not keep the floor

An Active Failure defeated the barrier:

Is this the end of the investigation?

 Finding: The cleaner was incompetent

 Recommendation: Cleaner should be

Or is there still something more?

 We know that congestion was a factor

 Telephones are only available for

 The congestion is caused by day shift

Now we have the full picture:

 The congestion is a ‘Precondition’

 Restriction on telephones is a ‘Latent

Action items should address:

 The Failed Barrier ...

 The Latent Failure ...

 If the barriers have not been replaced you should

 Actions to replace barriers are normally on site

 Latent Failures are deep seated; do not expect to

 Action to tackle latent failures are normally at

 Brings a structure to an investigation

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