1. Integration of Quality Into Accident Investigation Processes ASQ Columbia Basin Section 614 John Cornelison January 2008

2. Failure of weld on blow down system

3. Presentation Summary Outline system processes for investigation, analysis and reporting Identify quality points

4. Key Elements of Accident Investigation Reconstruct what happened Collection of information Analysis of facts Determine why it happened Develop findings Decide on recommendations Write report

5. Performance Logic The investigation and analysis processes should produce a finished report Investigation and analysis information (facts) should be ready for the final report Information is filtered through a group of causal factors The investigator needs to place the information in the right report sections

6. Quality Considerations For AI Processes Written plan and procedures and personnel trained to them Experienced investigators Decisions based on facts and not hearsay Information and evidence collected controlled Findings and conclusions based on facts Recommendations address both Systemic Management findings and Specific work findings Use of AI Model to drive processes

7. Advantages of System Approach Accidents are complex Divides accident information into usable elements Focuses on critical barriers and controls AI Model ensures minimum processes Structured process for traceability and reliability Reduces bias

8. Accident Accident Model Sequence of Events Energies Barriers Controls Task Performance Targets Status of Work Process - Personnel - Procedures - Hardware - Environment OR Change - Pre Accident - Accident - Post Accident - Prior - Present - Adequate - LTA 1)Management Policy drives which barrier and controls used 2)Barriers and controls must be maintained 3) Multiple barriers and controls must be used 5) Management must maintain work processes in an operational readiness state 6) Management must control changes 4) Management must maintain performance acceptable level Causal Factors

9. AI Model Quality Points Are your current causal analysis and recommendations preventing similar accidents? Causal factor selection may be LTA Implementation of recommendations may be LTA System for investigation and analysis may need to be changed

10. Sequence of Events Accidents involve a sequence of events that set up LTA conditions – work planning Investigation method – Event Charting Recreates sequence of events, what happened Systemic and specific conditions and causal factors Is the system functioning as planned

11. Quality Points Sequence of events in correct order based on time and date Requires a complete investigation to ensure correct order Looks at both systemic and specific events Identifies missing sequences Where did the Systemic and Specific failures occur; in work planning, in implementation or in control processes

13. Barriers and Controls All accidents involve failure of barriers and controls Investigation Method – Barrier Analysis Identifies energy sources, physical barriers, administrative controls and targets Evaluates effectiveness of barriers and controls Determines reliability of barriers & controls

14. SYSTEMS APPROACH TO ACCIDENT INVESTIGATION BARRIER ANALYSIS Energies/HazardPhysical BarriersAdministrative Controls Targets/ValueEvaluate B&C

15. Quality Points Identifies all the hazards Separates physical barriers from administrative controls Examines mode of failure Identifies all potential targets of value –Personnel, Facilities, Processes, Environment

16. Task Performance Accidents involve work performed which is adequate or LTA Investigation Method – Task Analysis Identifies basic tasks Looks for task errors Analyzes task errors for “Can Do” and “Motivational Behavioral Climate” Questions methods to ensure performance

17. SYSTEMS APPROACH TO ACCIDENT INVESTIGATION TASK PERFORMANCE ANALYSIS Event No. Task DescriptionTask ErrorEvaluate Task Error Risk Level

18. Quality Points Identifies tasks with potential for errors that can degrade system Identifies task with errors Looks at how the task errors occurred in the work processes Quality monitoring to ensure critical systems are not affected by task errors

19. Status of Work Processes Accidents involve many work processes Each process may be in a different state of readiness Investigation Method – Status of the Work Process Review Looks closely at personnel, procedures, hardware and environment in OR mode Time and interfaces

20. SYSTEMS APPROACH TO ACCIDENT INVESTIGATION STATUS OF WORK PROCESSES ANALYSIS Event No. PersonnelProceduresHardwareEnvironmentOR StatusRisk Level

21. Quality Points Investigates the OR status of key elements of the work process –Personnel –Procedures –Hardware –Environment Determines when and how the elements lost their OR status Set up monitoring points

22. Change Most accidents involve some type of change in the work processes Investigation Method – Change Analysis Identifies present conditions and prior conditions Looks for differences Analyzes changes for affects on setting up LTA conditions

23. SYSTEMS APPROACH TO ACCIDENT INVESTIGATION CHANGE ANALYSIS Present ConditionPrior ConditionChange/DifferenceEvaluate Affects of Change

24. Quality Points Investigates how changes in the work processes were managed Looks at planned and unplanned changes Looks at the interface of the changes with the key elements of the work processes Looks at how system performance was affected by the changes

25. Causal Factors Reasons or whys for an accident Investigation Method – Root Cause Analysis Identifies Systemic and Specific causes Looks at chain of causes from management to work and back to management Groups causes into 27 categories

26. Systemic Factors Management Policy Policy Implementation Risk Assessment Technical Information Hazard Analysis Safety Appraisals / Audits / Reviews Change Procedure Codes / Standards / Regulations Design Human Factors Quality Assurance / Quality Control

27. Specific Factors Amelioration Barriers & Controls Operational Readiness Maintenance Inspection Supervision Task Performance Personnel Training Environment Equipment Communications Personnel Protective Equipment

28. Systems Approach to Accident Investigation Causal Factor Analysis Selection Tree RC Number Causal Factor Categories Root CausesSelect 1 or more from RC 1-3 RC 1Oversight RC 2Omission RC 3Assumed Risk Systemic Causal Factors Select 1 or more from RC 1A-3A RC 1APolicy RC 2APolicy Implementation RC 3ARisk Assessment Specific Causal Factors Select 1 or more from DC 1-3 DC 1Barriers Physical Equipment Safety Systems

29. DC 2Controls - Administrative Information/Communication Operational Ready Maintenance Inspection Supervision DC 3Task Performance Perform Task Correctly Made Task Error Contributing Causal Factors Select 1 or more from CC 1-5 CC 1Personnel Criteria Fit For Duty Training Experience Motivated CC 2Procedures Written Current Followed Match work process CC 3Hardware Design Human Factors Hazard Analysis QA/QC CC 4Environment Hot/Cold Vibration Noise Space Stress

30. CC 5Change Specific Changes CC 6Programmatic Programs

31. Quality Points Looks at a complete system of causes Systemic and Specific Identifies the complete chain of causal factors Fixes not just the primary accident causes but all the LTAs in the system

32. Summary of The Processes Use of the Systems Approach Accident Model to drive the investigation Focuses on fixing all the LTAs in the system Which prevents future accidents Use of the systems analysis tools provides valid factual information to accident report Maintains high level of performance

33. Accident Report Title Page Table of Contents Executive Summary Facts Section Analysis Section Finding Section Recommendations Signature Appendix

34. Accident Accident Model Sequence of Events Energies Barriers Controls Task Performance Targets Status of Work Process - Personnel - Procedures - Hardware - Environment OR Change - Pre Accident - Accident - Post Accident - Prior - Present - Adequate - LTA 1)Management Policy drives which barrier and controls used 2)Barriers and controls must be maintained 3) Multiple barriers and controls must be used 5) Management must maintain work processes in an operational readiness state 6) Management must control changes 4) Management must maintain performance acceptable level Causal Factors