1. Learning from Events 12th June 2013 The Tata Steel Approach
Scott McKinnon
Hub Health & Safety Manager, Strip Products UK

2. Overview
Tata Steel have identified it as business critical to learn the lessons from events across all sites worldwide in order to avoid re-occurrence
How do we aim to achieve this:
High Level Ownership and Visibility:
Learning From Events (LFE) Procedure
Communication of Findings 2

3. Tata Health & Safety Management System 15 Principles3

4. Safety Management System – Principle 134

5. Safety Management System – Principle 135

6. Learning from Events (LFE)
POPMAR Approach 6

7. Policy – LFE
It is the policy of TSSP UK to create management system procedures and allocate appropriate ownership of such procedures that ensure the sustainability and continuous improvement of the learning from events system.
The Learning From Events system is used within TSSP UK for turning undesirable events into learning opportunities through the identification of root causes and fully implementing preventative actions. 7

8. Organisation –LFE Control
The Business Management Team (BMT) has overall accountability for the implementation of the management system.
Responsibility for the overall running & operating of the LFE system in TSSP UK is allocated to the health & safety department who provide assurance to the BMT on system performance via monthly updates at the governance meeting.
Co-operation
The creation of the document was undertaken jointly between the health & safety department, the Manager of Operational Support group (MOS) and the Joint Works Health & Safety Committee (JWHSAC). 8

9. Organisation –LFE Communication
Readily available procedures and work instruction documents are available via the intranet and triangle document library. The output of monitoring and trending activity will be communicated via the PDCA and site committee routes.
This document sets out the requirements for the reporting of events both within the business and group
Competence
Persons selected to participate in event investigation teams will be selected by appointed chair persons based on the discipline and the type of event.
It is expected that persons who are required to undertake key roles within the LFE system have attended the appropriate incident investigation modular training. 9

10. Planning & Implementation – LFE
It is essential that the right level of resource be allocated to the investigation process.
An event does not necessarily need to be an actual loss event. TSSP UK have near miss reporting systems at each works area. Near miss or “high potential” events should be assessed using the decision tool.
Following a decision being made to investigate an event, the person selected to chair the investigation process must ensure that the guide investigation timelines are adhered to. Total time spent during the investigation process will be captured along with any obvious financial loss incurred as a result of the event.
Where appropriate, members of contractor companies should always be involved in the investigation process. 10

11. Planning & Implementation – LFE11

12. Planning & Implementation – LFE12

13. Planning & Implementation – LFE13

14. Planning & Implementation – LFE14

15. Planning & Implementation – Investigation Methodology
HSG 245 proposes a 4 step approach which is adopted in the format of Tata investigations: 15

16. Planning & Implementation – Supervisor Investigation
The scene is contained and the event is reported upwards to the shift manager or equivalent. The scene is photographed and information is obtained from witnesses with the help of a safety representative.
Supervisor event report is completed and filed.
Investigation reviewed by line manager and Safety Dept and further action considered.
The line manager is responsible for ensuring that actions are implemented locally.
The Safety Dept is responsible for monitoring the appropriateness of actions and will ensure the line manager is updated.
The works manager for the area will undertake a feedback interview with the injured person. Comments will be noted prior to the event being closed out on SAP. 16

17. Planning & Implementation – LFE Management Investigation (over supervisor level investigation)
A departmental manager is given responsibility for establishing the root cause and acting as chairperson. This person will report to the senior manager accountable for the investigation.
The chairperson will ensure that persons with appropriate expertise are involved in the investigation. A minimum of 1 safety representative will take part in the investigation meeting.
The chairperson ensures that the investigation meeting takes place within 7 days of the event.
The findings of the investigation meeting will be captured and the final report available within 14 days.
The report will be authorised following review by the senior manager for the area who will sign the report along with the chair person and safety representative 17

18. Planning & Implementation –Panels of Enquiry
A panel of enquiry is convened ultimately to carry out a review a management investigation in order to ensure it has captured everything.
Departmental Panel: A senior manager is given responsibility for establishing the root cause and acting as chairperson. This person will usually report to the works manager for the area who is accountable for the investigation being undertaken.
Full Panel: A member of the BMT or an independent manager (other business) is given responsibility for establishing the root cause and acting as chairperson.
The report will be authorised following review by the Works manager for the area and the Health & Safety Manager who will sign the report along with the chair person and JWHSAC representative
The panel chairperson is responsible for undertaking a review of the implementation status of any recommendations at an appropriate time.
Very Serious incidents investigated using Kelvin Topset 18

19. Planning & Implementation – Kelvin Topset Methodology19

20. Planning & Implementation – Root Cause
Depending on the investigation, generally one of two methods is used to assist in identifying Root Cause:
Systemic Cause Analysis Technique or
Why Tree 20

21. Planning & Implementation – SCAT Type of Event21

22. Planning & Implementation – Immediate Cause22

23. Planning & Implementation – SCAT Type of Event23

24. Planning & Implementation – SCAT Reporting24

25. Planning & Implementation – SCAT Reporting25

26. Monitoring – LFE Monitoring
The health & safety department monitor the overall application of the LFE system and will review all events on a weekly basis providing an output that is subject to review.
On a monthly basis the health & safety department will monitor and trend the type of events that take place within TSSP UK. The output of this is communicated via the PDCA and site safety committee meetings.
Any event requiring an investigation management investigation level or above will have the status of the investigation formally monitored at the both site committee meetings (JWHSAC / LLSSC). These meetings contain the senior TU representatives along with members of senior management that represent TSSP UK. Any event that is not closed within a 3 month period is then subject to a detailed review by the respective Works Manager at the meeting allowing the committee to engage in discussions. 26

27. Audit & Review – LFE Audit
Audit of the application of these LFE management system procedures will be undertaken on an annual basis in order to drive continuous improvement. The audit will be undertaken by the health & safety department and inform the management review.
Review
All investigations at departmental panel of enquiry level and above will be subject to a formal review of the actions being built into the recommendations. It is the responsibility of the chairperson for the undertaking of this review.
The JWHSAC will undertake 24 area visits per year. A key part of the visit will be to undertake a review of events captured on the LFE matrix as being closed.
The health and safety department will undertake an annual review of the application of the LFE system procedures. 27

28. Audit & Review – LFE Review
Once the investigation is complete the Safety Manager will consider if it is appropriate to cascade any lessons business wide via the Red Stripe process. 28

29. Questions?…….. 29