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1. SCOPE
This guideline provides the details for Incident Investigations as set out in Procedure xxx. It is meant to assist the investigator(s) with the sometimes difficult process of gathering and analyzing the data and to prepare comprehensive reports.
An in depth investigation that involves all aspects of the incident and that identifies immediate- and root causes that may be beyond the span of control of the project (HO / Design / Manufacturer / Legislation etc.) Normal investigation A detailed investigation that involves all directly related aspects of the incident and that identifies immediate- and root causes within the span of control of the project. Close-out A standard report that identifies the obvious immediate- and root causes. (statement of facts).
LEVEL DEGREE DESCRIPTION 1 Negligible People Slight injury or health effects Assets Slight damage Environment Slight effect Reputation Slight impact 2 Marginal People Minor injury or health effects Assets Minor damage Environment Minor effect Reputation Minor impact 3 Critical People Major injury or health effects Assets Local damage Environment Localized effect Reputation Considerable Impact 4 Severe People Single fatality or permanent total disability Assets Major damage Environment Major effect Reputation National impact 5 Catastrophic People Multiple fatalities or permanent total disabilities Assets Extensive damage Environment Massive effect Reputation International impact
(Potential) Consequences
LEVEL
DEGREE People Assets Environment Reputation People Assets Environment Reputation People Assets Environment Reputation People Assets Environment Reputation People Assets Environment Reputation
DESCRIPTION Slight injury or health effects Slight damage Slight effect Slight impact Minor injury or health effects Minor damage Minor effect Minor impact Major injury or health effects Local damage Localized effect Considerable Impact Single fatality or permanent total disability Major damage Major effect National impact Multiple fatalities or permanent total disabilities Extensive damage Massive effect International impact
Negligible
Marginal
Critical
Severe
Catastrophic
3. ASSIGNMENT
The assignment of Incident investigator or Incident Investigation team shall follow as soon as possible after the initial report of the incident has been assessed as per above criteria. The (HSE) Management shall inform the people in charge of- and/or involved in, the investigation. Most times this will be someone from the HSE department but it is possible that others will be in charge or involved. It is also possible that Client Representatives will participate in the Investigation. The (HSE) Manager shall, if possible, provide the Incident Investigator(s) with a scope or expected extend description. In any case he will indicate the type of requires investigation as per above criteria.
3.1. Qualifications
Although theoretical models and procedures etc. claim that adequate qualified staff with in-depth knowledge of the processes and years of experience within the field of Incident Investigations, are required, it is known that we do not always have that choice. HSE Staff on projects, with all respect, are not always marine or dredging specialists and/or have been involved in a limited number of investigations. Still the client and the management wants quick results with reports of a good quality and analysis of immediate- and root causes and the definitions of adequate recommendations. Also the complexity of the site logistics plays a part in the assignment of the incident Investigator(s). On xxx we might be limited by distances, weather, day/night shift, xxx, leave rotation schedules etc. where and when possible the following aspects shall be considered: Knowledge and experience of the process and subject (e.g. Marine) Experience with Incident Investigations Communication skills
4.3. Analysis
The investigator(s) shall in this next phase analyze the information that has been gathered. Usually that consists of two separate steps. 1) Is the step where a timeline is prepared and where the investigator(s) gain understanding of what happened? And, 2) Is the step where the events or triggers are linked in a logical way to show how they relate to each other. In this guideline the Bow-tie technique is explained. This technique can be replaced by other techniques if the investigators are more acquainted with such a technique. E.g. Fault tree analysis Event tree analysis Fish bone diagram The 5 why method Black-box analysis Etc. During the step where the investigator(s) create the timeline and gain understanding of what happened, it is possible that information need to be verified. This can e.g. include: Maintenance records
Instructions given Toolbox meetings held Training records Standards (Inter)national rules and regulations Handover documents Certificates Docking information Sub-contractor assessments Etc. The Investigator(s) shall seek adequate evidence of their assumptions and arguments in the final report. Note: It is important to know how people respond to investigation results that involve them; By nature people will feel attacked (even while this cannot be the purpose of the report) and will start to defend themselves. If there is one mistake or uncertainty in the report people tend to focus on that issue, leading the attention away from their worries. The report becomes doubtfully and with that also the recommendations in it. Therefore the Investigator(s) shall only incorporate facts that are or can be proven or clarify the status of his assumption clearly.
4.3.1. Bow-tie technique After that the Investigator(s) have completed the time line and understand what happened, they shall create the root cause analysis. Attached to this guideline is a example of the Bow-tie methodology. The Bow-tie technique has been developed by Shell and is used for both, Incident Investigations and Risk Assessments. Shell and its consultants have developed software for the detailed use for the technique (Thesis) which is nowadays used in oil-and gas, chemical, shipping and airline industries. (In our need we only use the top layer of what it does for these industries, but is suits our purpose well). The name of the bow-tie is only because of its usual shape, nothing else. On the left hand side the triggers are shown. The Top-event is in the middle and on the right hand side the (potential) consequences (further explained in attached template). Building the bow-tie (making the analysis) requires some exercise. Make it on paper first. Using pencil and eraser still works the best and you can concentrate on the process and events instead of the links in Word or any other software program. That comes later. Start with the unwanted event in the middle. Then put the triggers for the incident on the left hand side in a logical sequence top-down. Incorporate escalation factors if relevant. Keep on changing that until the process is logical and you think that others can follow the process as well. Then start to include the barriers. Think logical (and discuss) and incorporate the facts that you learned about in the timeline and initial investigation. In case of doubtleave it out. Than the consequence side and the recovery measures same process in reverse. For (potential) consequences it is important that we choose the correct wordings. It is easy and maybe interesting to exaggerate but it will not lead to correct understanding of the incident by report readers whom werent there. Avoid the use of strengthening words such as: A huge hole, An enormous fire, Major damage etc. It does not bring factual information and works distracting. A hole, A fire, damage will do. If you need to explain the severity or extend of a consequence, make sure you use the facts only. Be careful with potential worse case consequences (e.g. required in client report). You will rapidly
end up with Multiple Fatalities, Catastrophe, and Disaster etc. if you get carried away. Understandwhat they want to know; the potential worse case under the specific circumstances of that incident. Anyhow, real fixed guideline isnt possible here; use your common sense again. Often standard terminology can be used for Immediate and Root causes, followed by and explanation. The Standard terminology is needed for the database and statistical trend analysis, the explanation for the understanding by the readers of the report. E.g. Material not suitable. 2 mooring ropes are not sufficient for the mooring this barge. Inspections inadequate. The mooring ropes were in poor condition due to wear and tear. Equipment not available There was no equipment available to retrieve control over the barge. A tentative list with Immediate- and root causes is attached to this guideline
4.4. Reporting
Develop the draft report. The report could include: Scope and extend of the Investigation Summary of what happened General information with regard to the incident Equipment involved Timeline Consequences Immediate causes Root Causes (reference to Bow-tie) Post event actions (e.g. Emergency Response) Related aspects (e.g. finding that did not caused the incident) Responsibility (Functions, names & signatures of investigator(s) Recommendations Attachments
5. RECOMMENDATIONS
Based on the findings of the incident Investigations the investigator(s) shall now define recommendations for improvement. These action items are meant to reduce the change of reoccurrences of the incident and shall be SMART (Specific, Measurable, Attainable, Relevant and Time bound). Recommendations shall solve or reduce the root causes of the incident. There is no need for clichs such as: Good Communication at all times or Always focus on the tasks. In these cases it would be better to put: Standing orders shall be made by the PM that emphasis the importance of Pre-Start meetings, TBT and/or Take 5. Works managers to assign responsible persons for mooring inspections and to establish an procedure that includes criteria for inspection, frequencies and register.
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Time Weather conditions Sea state conditions (wave / swell / current) (force and direction) Illumination conditions Conditions that could have limited judgments Material People PPE Depth Draft List Height Size Numbers Quantities Diameter Surface Damage Failure Logbook Records Sea chart Update status (Sea charts / DGPS / Pilots / Certificates) Calibration status (measuring equipment / critical equipment) Voice Data Vessel tracking Forms (used) Position of switches / handles / buttons Position of safety devices Doors / hatches open / closed / locked Replacements / changes made after the event