Tripod-BETA

Incident Investigation and Analysis

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Incidents are an indicator to improve our performance

Understanding what happened and why enables us to improve our business

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Structure of the HSE Management System

Leadership and Commitment

Policy and Strategic Objectives Organisation, Responsibilities Resources, Standards & Doc. Hazard and Effects Management Planning & Procedures

Tripod Beta

Corrective Action

Implementation

Monitoring

Audit

Corrective Action & Improvement Corrective Action & Improvement

Management Review
Betashow.ppt

1999 Shell International Exploration and Production B.V.

What is Tripod-BETA ?

A methodology for incident analysis during an investigation ... combining concepts of hazard management and ... the Tripod theory of accident causation.

Betashow.ppt

1999 Shell International Exploration and Production B.V.

How does Tripod-BETA work ?

The incident facts are built into a tree diagram showing ...
- What happened ... - What hazard management elements failed and - Why each element failed.

Betashow.ppt

1999 Shell International Exploration and Production B.V.

What does the software do ?

The software:
 Stores

investigation facts tree-building graphics

 Provides  Checks

the implicit tree logic data to tree elements attached data into a draft report.

 Attaches

 Assembles

Betashow.ppt

1999 Shell International Exploration and Production B.V.

How does the tree work ?

Lets walk through a simple incident introducing the terminology and logic that underpins Tripod-BETA

Betashow.ppt

1999 Shell International Exploration and Production B.V.

The Incident
 Location:  Incident:

an offshore platform

an operative coming off shift slips and falls in the shower room he hurts his back and is

 Consequence:

off work
 In

the past three months there have been two similar incidents

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Initial Findings

 The  The

incident occurred at 1820 hours operative slipped on the wet floor

 Cleaning

staff are supposed to keep the shower room floor dry

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Starting a Tripod Tree

We start by identifying:
 An

EVENT - where a hazard and a target get together TARGET - a person or an object that was harmed HAZARD - the thing that did the harm

A

A

Betashow.ppt

1999 Shell International Exploration and Production B.V.

The Hazard, Event, Target Trio

They are shown in a Tripod tree like this:

Hazard

Event

Target
Betashow.ppt

1999 Shell International Exploration and Production B.V.

Hazard, Event & Target

In this incident: The HAZARD is : Wet floor (slipping hazard) The EVENT is room : Operative falls in shower

The TARGET is : Operative

Betashow.ppt

1999 Shell International Exploration and Production B.V.

HET Diagram
The Hazard,

Wet floor (slipping hazard)

Event

Target

Betashow.ppt

1999 Shell International Exploration and Production B.V.

HET Diagram
The Hazard, acting on the Target,

Wet floor (slipping hazard)

Event

Operative

Betashow.ppt

1999 Shell International Exploration and Production B.V.

HET Diagram
The Hazard, acting on the Target, resulted in the Event

Wet floor (slipping hazard) Operative falls in shower room

Operative

Betashow.ppt

1999 Shell International Exploration and Production B.V.

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 ?

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Was the incident preventable ?

 We

know that a hazard management measure was in place staff were assigned to keep the floor dry barrier to the incident failed

 Cleaning

 That

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Failed Barrier
The barrier should have controlled the hazard

Hazard

Failed Barrier

Event

Target

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Incident Mechanism
The incident mechanism looks like this:

Wet floor (slipping hazard) Floor drying Operative falls in shower room

Operative

Betashow.ppt

1999 Shell International Exploration and Production B.V.

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

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Active Failure
An Active Failure defeated the barrier
Active Failure
Active Failure

Wet floor (slipping hazard) Floor drying Operative falls in shower room

Operative

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Active Failure
An Active Failure defeated the barrier
Cleaner unable to keep floor dry
Active Failure

Wet floor (slipping hazard) Floor drying Operative falls in shower room

Operative

Betashow.ppt

1999 Shell International Exploration and Production B.V.

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 ?

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Further Investigation

 We

know that congestion was a factor that prompted the active failure are only available for private calls up till 1900 hrs congestion is caused by day shift crew hurrying to call home

 Telephones

 The

Betashow.ppt

1999 Shell International Exploration and Production B.V.

The Full Picture

Now we have the full picture:
 The

congestion is a Precondition that influenced the cleaners task on telephones is a Latent Failure that created the precondition

 Restriction

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Precondition

Precondition
Preconditio n

Cleaner unable to keep floor dry

Active Failure

Wet floor (slipping hazard) Floor drying Operative falls in shower room

Operative

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Precondition

Congestion 1800 - 1900 hrs

Precondition

Cleaner unable to keep floor dry

Active Failure

Wet floor (slipping hazard) Floor drying Operative falls in shower room

Operative

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Latent Failure

Latent Failure
Latent Failure

Congestion 1800 - 1900 hrs

Preconditio n

Cleaner unable to keep floor dry

Active Failure

Wet floor (slipping hazard) Floor drying Operative falls in shower room

Operative

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Latent Failure

Restriction on private phone calls

Latent Failure

Congestion 1800 - 1900 hrs

Preconditio n

Cleaner unable to keep floor dry

Active Failure

Wet floor (slipping hazard) Floor drying Operative falls in shower room

Operative

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Recommendations
Action items should address:
 The

failed barrier ... to restore safe conditions on a temporary basis (provide extra cleaner between 1800 and 1900) latent failure ... to remove the underlying cause (extend the availability of shore telephone)

 The

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events

 That  The

was a simple example

Tripod-BETA methodology can also be applied in complex events

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
Identify the prime Event,

Fire

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
Identify the prime Event, the Hazard,
Ignition Fire

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
Identify the prime Event, the Hazard, and Target.
Ignition Fire

Flammable Gas Cloud

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
If, say, the target was created by a prior event
Ignition Fire Flammable Gas Cloud

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
Identify the hazard ...
Ignition Dropped Object Flammable Gas Event Cloud
& Target

Fire

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
and target for that event.
Ignition Dropped Object Flammable Gas Cloud Gas Line

Fire

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
Similarly, if a consequential event happens ...
Ignition Dropped Object Flammable Gas Cloud Gas Line Fire

Damage to Platform

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
because the prime event created a new hazard,
Ignition Dropped Object Flammable Gas Cloud Gas Line

Fire

Damage to Platform

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
identify the target for the new event.
Ignition Source Dropped Object Flammable Gas Cloud Gas Line Platform

Fire Damage to Platform

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
Identify failed barriers,
Ignition Source Dropped Object Flammable Gas Cloud Gas Line Platform
Failed Barrier

Fire Damage to Platform

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
and missing ones ...
Ignition Source Dropped Object
Missing Barrier Failed Barrier

Fire Damage to Platform

Platform

Flammable Gas Cloud

Gas Line

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
including multiple failures ...
Ignition Source Dropped Object
Missing Barrier Failed Barrier Failed Barrier Failed Barrier

Fire Damage to Platform

Flammable Gas Cloud Gas Line Platform

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
on each relevant trajectory ...
Ignition Source Dropped Object
Missing Barrier Failed Barrier Failed Barrier Failed Barrier

Fire Damage to Platform

Flammable Gas Cloud

Gas Line

Failed Barrier

Missing Barrier

Platform

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
until the Incident Mechanism is complete.
Ignition Source Dropped Object
Missing Barrier Failed Barrier Failed Barrier Failed Barrier

Fire Damage to Platform

Flammable Gas Cloud

Gas Line

Failed Barrier

Missing Barrier

Platform

Missing Barrier

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
Show the Active Failure for each barrier, ...
Active Failure
Active Failure

Ignition Source Dropped Object

Missing Barrier Failed Barrier Failed Barrier Failed Barrier

Fire Damage to Platform

Flammable Gas Cloud

Gas Line

Failed Barrier

Missing Barrier

Platform

Missing Barrier

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
the Precondition(s) promoting each active failure, ...
Precondition Active Failure
Precondition Active Failure

Hazard
Failed Barrier Failed Barrier Failed Barrier

Hazard
Missing Barrier

Event & Hazard

Event & Target

Failed Barrier Missing Barrier

Event

Target

Target

Missing Barrier

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
and the Latent Failure behind each precondition.
Latent Failure Precondition Active Failure
Latent Failure Precondition Active Failure

Hazard
Failed Barrier Failed Barrier Failed Barrier

Hazard
Missing Barrier

Event & Hazard

Event & Target

Failed Barrier Missing Barrier

Event

Target

Target

Missing Barrier

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Complex Events
 Complete
Latent Failure
Latent Failure Precondition

a Tripod path for each barrier.

Active Failure
Active Failure

Precondition

Latent Failure
Latent Failure

Precondition
Precondition

Active Failure
Active Failure

Hazard
Failed Barrier Failed Barrier Failed Barrier

Hazard
Missing Barrier

Event & Hazard

Event & Target

Failed Barrier Missing Barrier

Event

Target

Target

Missing Barrier

Betashow.ppt

1999 Shell International Exploration and Production B.V.

The completed Tripod-BETA tree

Latent Failure
Latent Failure

Precondition
Precondition

Active Failure
Active Failure

Latent Failure
Latent Failure

Precondition
Precondition

Active Failure
Active Failure

Latent Failure
Latent Failure

Hazard
Failed Barrier Failed Barrier Failed Control

Hazard
Missing Barrier

Event & Hazard

Event & Target

Failed Barrier Active Failure Missing Barrier

Event

Target

Target

Latent Failure
Latent Failure

Active Failure

Missing Barrier

Precondition
Precondition

Latent Failure
Latent Failure

Latent Failure
Latent Failure

Latent Failure
Latent Failure

Precondition
Precondition

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Structure of the HSE Management System

Leadership and Commitment

Policy and Strategic Objectives Organisation, Responsibilities Resources, Standards & Doc. Hazard and Effects Management Planning & Procedures

Tripod Beta

Corrective Action

Implementation

Monitoring

Audit

Corrective Action & Improvement Corrective Action & Improvement

Management Review
Betashow.ppt

1999 Shell International Exploration and Production B.V.

Corrective Actions
latent failure precondition

active failure

latent failure

precondition

Long term action to reduce latent failures

Betashow.ppt

Replace the failed barrier

1999 Shell International Exploration and Production B.V.

Corrective Actions
 If

the barriers have not been replaced you should question why operations have restarted to replace barriers are normally on site Failures are deep seated do not expect to remove them tomorrow

 Actions  Latent

 Action
Betashow.ppt

to tackle latent failures are normally at management level

1999 Shell International Exploration and Production B.V.

Tripod-BETA
 Brings  Helps

a structure to investigation

distinguish relevent facts causes and effects explicit team discussion

 Makes

 Encourages  Reduces

the report writing task

Betashow.ppt

1999 Shell International Exploration and Production B.V.

Betashow.ppt

1999 Shell International Exploration and Production B.V.