You are on page 1of 50

EXPERIENCE SHARING & LEARNING FROM

DUPONT TRAINING PROG. ON

ACCIDENT / INCIDENT INVESTIGATION


V.B.DOSHI

THE DUPONT APPROACH TO MANAGING PROCESS SAFETY & RISK


FOUR KEY STEPS ARE :

1) ESTABLISHING A SAFETY CULTURE 2) PROVIDING MANAGEMENT LEADERSHIP & COMMITMENT 3) IMPLEMENTING A COMPREHENSIVE PSRM (PROCESS SAFETY & RISK MANAGEMENT) PROGRAMME 4) ACHIEVING OPERATING EXCELLENCE THROUGH OPERATIONAL DISCIPLINE

MANAGEMENT LEADERSHIP & COMMITMENT

TECHNOLOGY

FACILITIES

PERSONNEL

1) PROCESS SAFETY INFORMATION

5) QUALITY ASSURANCE

9) TRAINING & PERFORMANCE

10) CONTRACTORS
2) PROCESS HAZARD ANALYSIS 6) PRE START-UP SAFETY REVIEWS 11) INCIDENT INVESTIGATION 7) MECHANICAL INTEGRITY 3) OPERATING PROCEDURES & SAFE PRACTICES

12) MANAGEMENT OF PERSONNEL CHANGE

4) MANAGEMENT OF TECHNOLOGY CHANGE

8) MANAGEMENT OF SUBTLE FACILITIES CHANGES

13) EMERGENCY PLANNING & RESPONSE

14) AUDITING

Auditing

Process Safety Information

Process Hazard Analysis

Operating Procedures & Safe Practices

Emergency Planning & Response

Technology

Management of Technology Change

Management of Personnel Change

Personnel

Management Leadership & Commitment

Quality Assurance

Incident Investigation

Facilities

Prestart-Up Safety Reviews

Contractors Management of Training & Performance Subtle Changes

Mechanical Integrity

INCIDENT INVESTIGATION

Why accidents must be investigated ?


1) To demonstrate commitment to safety 2) To increase employees confidence in workplace safety 3) To identify deficiencies in Safety Management & rectify them 4) To prevent recurrence 5) To share / communicate the lessons learned through accidents / incidents

Who should investigate ?

The LINE MANAGEMENT is responsible for investigating all accidents

INCIDENT INVESTIGATION PROCESS


It consists of 8 stages namely,

1) Make initial response and report


2) Form investigation team 3) Determine the facts 4) Determine the Key factors

5) Determining strengthened

.. Contd. systems to be

6) Recommend corrective & preventive actions 7) Document findings 8) Follow up & communicate the

: STEP 1 : INITIAL RESPONSE & REPORT

BRIEF
LIMITED TO KNOWN FACTS (DATE, TIME, PLACE, WHAT HAPPENED, IMMEDIATE ACTION TAKEN) IT HELPS THE MANAGEMENT TO IDENTIFY INCIDENTS THAT REQUIRE A COMPREHENSIVE INVESTIGATION

: STEP 2 : FORMING INVESTIGATION TEAM

SELECTING TEAM MEMBERS


MANAGERS / SUPERVISORS SAFETY / EMERGENCY OFFICERS TECHNICIANS ENGINEERS SPECIALISTS OPERATIONS / MAINTENANCE PERSONNEL OPERATORS

: STEP 3 : DETERMINING THE FACTS THROUGH INTERVIEWS & OBSERVATIONS

WHAT SHOULD WE LOOK AT ?


1) SAMPLE MATERIALS : Physical evidence Data Conditions that may have affected equipment 2) PRESERVE THE SCENE : Barricades Weather protection Sketches, Photographs, Videotapes

3) OBTAIN EYEWITNESS ACCOUNTS ON THE SPOT, IN ONE-IN-ONE PRIVATE INTERVIEWS Audio Tapes Video Tapes
4) EXAMINE KEY EQUIPMENT ( DISASSEMBLE IT, IF APPROPRIATE)

5) REVIEW ALL POTENTIAL INFORMATION SOURCES LIKE : Drawings Logs Charts Equipment manuals Oral instructions Training records Lab tests

6) SELECT ITEMS TO PRESERVE OR COLLECT As Found condition Repair records, if applicable 7)DEVELOP CHRONOLOGY OF EVENTS 8) LIST ALL KNOWN FACTS 9) IDENTIFY ALL DEVIATIONS NORMAL CONDITIONS CIRCUMSTANCES FROM OR

ASK QUESTIONS ABOUT...


1) PHYSICAL Weather Chemicals Tools Personal Protective Equipment Machinery 2) HUMAN Employees Supervision Company

3) OPERATING SYSTEMS Training Documentation Rules / Procedures Preventive maintenance Job Safety Analyses Tracking results Communication Culture

INTERVIEWING METHODS

TYPES OF QUESTIONS TO BE ASKED


GENERAL : allow the person to give information about any aspect of the subject SPECIFIC : narrow the subject to get more detail CLOSED : ask for confirmation, denial or a very short answer

EXAMPLES OF QUESTIONS
GENERAL QUESTIONS LIKE : WHAT HAPPENED ? DESCRIBE THE SITUATION.

SPECIFIC QUESTIONS LIKE : WHAT WERE THE READINGS OF TEMPERATURE & PRESSURE ? WHAT DAMAGE WAS DONE TO THE GLASS CONDENSER ?

CLOSED QUESTIONS LIKE :


(WHICH WILL GENERALLY LEAD TO AN ANSWER IN YES / NO ) * WAS THE FUSE REMOVED ? * DID THE LEVEL GO ABOVE THE LIMIT ? * DID THE ALARM WORK ? * WERE YOU TRAINED IN TAKING EMERGENCY SHUTDOWN ? IF THE ANSWER IS NOT CLEAR ASK FOR CONFIRMATION IN YES / NO

REFLECTING THE MEANING


THE RESTATING & SUMMARISING TECHNIQUE IS AN EFFECTIVE WAY TO KEEP AN INTERVIEW FOCUSED IT : DIRECTS YOUR ATTENTION ENSURES THAT YOU HEARD CORRECTLY BUILDS CONFIDENCE IN YOUR ABILITY TO UNDERSTAND

REFLECTING THE FEELINGS


TRY TO UNDERSTAND WHAT THE PERSON WAS FEELING WHEN HE / SHE IS DESCRIBING THE INCIDENT. RESPECT HIS / HER FEELINGS DEMONSTRATE THAT YOU HAVE UNDERSTOOD THEM BY EMPATHISING UNDERSTAND THEIR BODY LANGUAGE WHICH EXPRESS THEIR FEELINGS

EXAMPLES OF FEELINGS
ANXIOUS TENSE / WORRY PAIN / SORROW HELPLESS & LOOKING FOR HELP ANGER / RAGE FRIGHTENED

DOs OF INTERVIEWING
LISTEN EMPATHISE FIRST ASK GENERAL QUESTIONS & THEN SPECIFIC QUESTIONS BE POSITIVE ENCOURAGE ALLOW ENOUGH TIME MAKE THE PERSON FEEL COMFORTABLE

DONTs OF INTERVIEWING
PREJUDGE BLAME INTERROGATE START WITH SPECIFIC QUESTIONS INTERRUPT GET IMPATIENT

: STEP 4 : DETERMINE THE KEY FACTORS THAT CONTRIBUTED TO THE INCIDENT

CIRCUMSTANCES THAT CONTRIBUTED TO (OR MAY REASONABLY BELIEVED TO HAVE CONTRIBUTED TO) THE OCCURRENCE OF THE INCIDENT, EVEN THOUGH A CLEAR CONNECTION CANNOT BE ESTABLISHED
ESSENTIAL FOR DEVELOPING EFFECTIVE RECOMMENDATIONS

CATEGORIES TO EXPLORE : 1) PHYSICAL FACTORS 2) HUMAN FACTORS 3) OPERATING SYSTEMS FACTOR

INVESTIGATORS SHOULD NOTE THAT THERE ARE MANY KEY FACTORS WHICH ARE NOT EASILY VISIBLE

: STEP 5 : DETERMINE SYSTEMS THAT NEED TO BE STRENGTHENED

SOME MANAGEMENT SYSTEMS ARE LISTED BELOW


OPERATING PROCEDURES SAFE WORK PRACTICES MANAGEMENT OF CHANGE TRAINING / PERFORMANCE CONTRACTOR SAFETY / PERFORMANCE PROCESS TECHNOLOGY PROCESS HAZARD ANALYSIS

.. continued

INCIDENT INVESTIGATION / COMMUNICATION EMERGENCY PLANNING / RESPONSE QUALITY ASSURANCE MECHANICAL INTEGRITY AUDITS

: STEP 6 : RECOMMEND CORRECTIVE & PREVENTIVE ACTIONS

ELIMINATE HAZARDS

CONTROL HAZARDS

ADD RULES, PROCEDURES, & TRAINING TO PROTECT PEOPLE FROM HAZARDS

GOOD CORRECTIVE ACTIONS


CONSIDER THE EFFECTS OF HAZARDS : PROBABILITY

SEVERITY
COST IMPACT ON THE ORGANISATION

DEVELOP RECOMMENDATIONS
CORRECTIVE & PREVENTIVE ACTIONS SHOULD ADDRESS KEY FACTORS & INCLUDE FOLLOWING : DESCRIPTION OF ACTION

PERSON RESPONSIBLE FOR IMPLEMENTATION COMPLETION DATE

: STEP 7 :
DOCUMENT & COMMUNICATE THE FINDINGS

DOCUMENT ALL INCIDENTS


DIFFERENT FORMATS : SERIOUS INCIDENT REPORT FORM SERIOUS POTENTIAL INCIDENT SERIOUS POTENTIAL INCIDENT RECOMMENDATION STATUS

REVIEW INCIDENT REPORTS WITH ...


COMPANY EMPLOYEES CONTRACT EMPLOYEES WHO WERE INVOLVED IN THE INCIDENT OTHER SITES LEGAL DEPT. BEFORE SUBMITTING TO GOVT. AGENCIES

ELEMENTS OF COMMUNICATION WHAT


WHAT HAPPENED EFFECTS ON PEOPLE INVOLVED
CAUSES / LESSONS LEARNED

TO WHOM
AREA
PLANT COMPANY

HOW
BULLETIN BOARDS

ONE PAGE FLYERS


SAFETY MEETINGS NEWSLETTERS

CORPORA TION

E-MAILS

: STEP 8 :

FOLLOW UP

FOLLOW-UP SYSTEM
ENSURE THAT RECOMMENDATIONS RECEIVE PROMPT ATTENTION REQUIRE WRITTEN MANAGEMENT APPROVAL WHEN RECOMMENDATIONS WILL NOT BE FOLLOWED TRACK RECOMMENDATIONS PERIODICALLY BEYOND THE 1ST YEAR TO ENSURE :* Recommendations are carried out * Good habits are established

TRACKING PROCEDURES
IDENTIFY PROBLEMS WITHIN THE PROCESS DECIDE WHAT ACTION TO TAKE ENSURE THAT ACTIONS ARE FOLLOWED THROUGH.

NOW LETS SUMMARIZE THE ENTIRE PROCEDURE

STEPS FOR IMPLEMENTING INCIDENT INVESTIGATION


ESTABLISH PRELIMINARY REPORTING PROCEDURE

DEFINE THE INCIDENT REPORTING REQUIREMENTS


DEVELOP OPENNESS & CO-OPERATION ESTABLISH AN INVESTIGATIVE PROCEDURE

CHOOSE APPROPRIATE TEAM MEMBERS

STEPS FOR IMPLEMENTING INCIDENT INVESTIGATION


. Contd.

ENSURE COMPLETENESS OF REPORTS


AVOID USING EMPLOYEE NAMES IN

REPORTS
ESTABLISH A PROCEDURE FOR TRACKING RECOMMENDATIONS COMMUNICATE REPORTS ANALYSE PERFORMANCE TRENDS

THANK YOU