1. Incident Investigation Analysis and Sharing

2. OVERVIEW OF INCIDENT MANAGEMENT PROCESS Reporting Incident/ Near Miss ImplementCorrectiveActions Share Learnings Notification - classify incident - communicate to management - notify regulatory/gov’t parties - manage incident Secure the Site INCIDENT MANAGEMENT CYCLE Investigation & Analysis Analyze trends PREVENTS

3. RATIONALE FOR PREVENTING INCIDENTS We want to prevent incidents from re-occurring for the following reasons:  To prevent unwanted and unintended impact on the safety or health of people, property, environment, or on legal and regulatory compliance  To maintain the “license” to operate  To improve safety, reliability and effectiveness of operations

4. LEARNING FROM THE INCIDENT  Uncover the causal factors (i.e. problems) associated with the incident that, if corrected, would have prevented the incident from occurring or significantly mitigated its consequences.  Ensure proper actions are taken to prevent re-occurrence at the site.  Ensure information is appropriately shared. Working Conditions poor fitting eye protection Human Behaviors not wearing eye protection Management Systems no safety training no written procedure Working with corrosive chemical

6. Leaf

7. Rope

8. Wall

9. Tree trunks

10. Spears

11. Snake

12. Basketball Pass video

13. From the beginning Do it now Get there safely Assess and take control Care for the injured Secure the site Keep everyone on site Keep everyone separated Document all controls that are modified to secure the site. This includes breaker panels, valves, etc. Preserve evidence, use chain of custody if appropriate Make a sketch of the scene Interview before looking at SOP’s, etc.

14. Interviews Interview individually List all facts, even those that seem unimportant Keep an open mind, don’t jump to conclusions Get written or recorded statements Go second by second Don't "lead" the person being questioned Ask every question - don't assume Sift down the facts to root cause (the puzzle will fit together if you get all the facts)

15. Building your chain of events and conditions  Find out what happened (Ask what happened next?)  Determine the sequence of events  Add conditions to the related events (These explain more info about the event such as how, what, where and why)

16. Look for questions in these areas Human engineering Policies/procedures Training Supervision

18. RCFA Process  Prepare an events, conditions and causes chart  Determine the root cause(s) of each finding  Recommend corrective actions to address each root cause  Develop investigation report

19. DEFINITIONS Findings –Any issue associated with the incident that, if corrected, would have prevented the incident from occurring, or would have significantly lessened its consequences. Note: These need to be analyzed further to get to the root causes. ROOT CAUSE –According to TapRoot ®, A root cause is the absence of best practices or the failure to apply knowledge that would have prevented the problem (or significantly reduce the likelihood or consequences of the problem). Note: Root causes are determined from further analysis of an incident’s findings and are things you can fix.

20. INCIDENT CAUSES - Example INCIDENT JD Paine is injured when grinding wheel explodes and he receives a cut on the nose. Findings Wrong wheel mounted on grinder Using Gasoline to clean motors Un-authorized employee using grinder General attitude of non-compliance

21. INCIDENT CAUSES - Example ROOT CAUSES Poor auditing system Note: Company required proper grinding wheel, but did not check work of supplier Standard not followed because it was ineffective Note: Company standards require using a detergent to clean motors, statements indicate it is ineffective and therefore not used.

22. MANAGEMENT’S ROLE  Ensure a system is in place to investigate incidents and to determine root causes.  Ensure learnings are communicated throughout the entire organization.  Ensure all safety alerts are properly communicated.  Ensure all actions items are completed in a timely manner.

23. IMPORTANCE OF SHARING INCIDENT LEARNINGS Sharing findings is critical so that every operation does not have to experience the same events. YOUR SITE NOCONSEQUENCES LESS SIGNIFICANT CONSEQUENCES MAJORCONSEQUENCES SEVERITY High Very Low F LTI MTI Property Damage First Aid and Minor Injuries Near Miss and Hazards UNSAFE BEHAVIORS 1 10 30 600

24. Questions

25. TRAITS OF A GOOD ROOT CAUSE ANALYSIS SYSTEM  Effective in consistently identifying root causes (repeatable)  Well documented  Accompanied by effective user training  Credible with the workforce (does not promote finger pointing and the search for someone to blame)  Helpful in presenting the results to management so that management understands what needs to be fixed  Designed to allow collection, comparison, and measurement of root cause trends

26. IDEAS FOR SHARING YOUR INCIDENTS  Ensure description of incident is clear  Include pictures if possible  Include possible causes Note: “The possible cause(s) of the incident include the following….”  Include recommended corrective actions Note: “We recommend that you consider the following course of action to help avoid similar future incidents….”

27. TAPE RECORDERS If you use a tape recorder Ask permission Your name His/her name Day - year - month Time

28. PHOTOGRAPHY Sketch the area first Take a lot of pictures Log the photos indicating their location on the sketch Take from several different angles Take pictures that may not appear to be relevant Date and sign the pictures when developed Use objects of known size (a ruler works well) to give perspective to the pictures

29. Accident investigation kit suggestions ◦ Camera with flash and film, 35 mm plus digital is ideal ◦ Writing materials including note paper, graph paper, pens and pencils ◦ Cassette recorder and cassettes ◦ Internal company report forms including chain of custody form ◦ Ruler and tape measures (16 foot and 100 foot) ◦ Identification tags and Zip lock style bags for evidence ◦ Barricade tape ◦ Gloves ◦ Adhesive tape ◦ Hand tools ◦ Flashlight ◦ Binoculars ◦ Spare batteries