Incident

Investigation
Root
Cause Analysis
 Incident Causation Model
Incident /Accident (LOSS) .....-.....

Contact

Immediate Causes INDUSTRIAL RELATION CONFLICTS

Root Causes (System)THE POTENTIALLY HIGH RISK FACTOR :

LACK OF KNOWLEDGE

LEADERSHIP LOWGRADING

System Defects QHSE KEY MANAGEMENT STANDARD

INDONESIA

(Lack of Planning, Organizing, Implementing and Controlling)

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 Poor Investigations
1. Focus only on personnel :
2. Are directed away from systems
3. Create a lack of co-operation
4. Foster distortion of facts
5. Reinforce cover-up
6. Tend to make employees protect
themselves
7. Do not present all facts
8. Do not eliminate system causes

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Benefits from Incident
Investigation?

Identify system
failures to prevent
future incidents.
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Phases of an Investigation
PreparationPhase
Preparation Phase Pre-Planning
 Set objectives.
 Develop procedures.

Preparation
 Select & train investigators. Critique Process for
Team Selection
  Prepare investigator’s kit. Continuous Improvement

Incident

Receive Alert Notification Secure Evidence

Implementation Phase

 Implementation  Execute
 Preserve
notifications.
evidence at scene.
 Interview witnesses.
 Follow 4Ps technique.
 Initiate data mapping.
Activate Team

Develop Team Plan

Collect Evidence

 Research Research Phase

 Review documentation.
 Conduct tests or re-creations.
 Perform calculations.
Research Additional
Evidence

Analysis Phase Analyze and Interpret

 Complete critical factors chart.
 Identify immediate causes.
Identify Immediate &

Analysis
 Identify system causes.
System Cause(s)

 Develop Proposals
for Corrective Actions

Corrective Phase Incident

 Write report. Prepare Report
 Develop proposals for corrective
action.
Investigation

Correction Flow Chart

 Share information and learnings.

 Share Key Learnings

Implement Corrective
Amoco Corporation, 6/97 Actions & Follow-up

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Formal Investigation Team Activities
Initial:
– Preliminary data review
– Statements from “stationary”
witnesses
Ongoing:
– Detailed interviews
– Testing of parts or other evidence
– Elimination of data or evidence
– Statements regarding cause
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 Preserving Evidence
Collect evidence
– parts, tools, materials & paper
– photos & sketches
Create a record
Subject to change
Step-by-step walk-through
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Evidence Categories

People
Parts
Positions
Paper
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 People
Direct Witnesses
– Injured / Co-workers
– Others in area
Indirect Witnesses
– Contractors
– Maintenance
Personnel

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Data From Witnesses
Written statement
Verbal or visual actions during
interview
Other documentation
video and audio tapes
instrument charts
operating logs

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Interviewing
I wish he
How to? would stop
poking me!
How
not to?

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Interviewing Guidelines
Plan Interview
Establish Rapport
Uninterrupted Narrative
Interactive Dialogue
Conclusion
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Interview Errors
Error of omission
Error of commission
Sequence error
Timing error

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The “5 Whys”
The “5 Whys” technique for
identifying the root cause of an
incident is a technique questioning
“Why” the incident happened
and/or “Why” the unfavourable
conditions existed.
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 Using
Using the
the 55 Whys
Whys
Select an event associated
with the incident
Ask why this event occurred
Solicit as many subevents or
conditions as possible

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 Corrective Phase
We now enter the “Corrective
Phase” of the investigation. Here
we develop proposals for
corrective action, and assemble the
evidence, analysis, system causes
and proposals into a final report.
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 Attributes of
Corrective Actions
Addresses system causes
Addresses incident events
Fixes the system
Clearly states intended action(s)
Practical, feasible & achievable
Eliminates or decreases risk
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Final Team Actions
Propose corrective action for
each system cause failure
Prepare formal,
written report
Present to
Management
for approval
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Management Responsibility
Approves/modifies proposed
corrective action
Assigns dates for correction
Assigns personnel for correction
Obtains feedback on progress
Ensures follow-up process
Verifies final correction
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Summary Report Format
Main Body
Who
– Background volunteered
– Evidence me for this job?

– Analysis (System Causes)

– Corrective Actions
– Signature Page
Appendices
– Facts
– Supporting Data
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 People Parts

Solutions

Positions Paper

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