1. Incident Investigation : An Advance Approach By: Shakir Imran Fauji Fertilizer Company Limited Fauji Fertilizer Company Limited Mirpur Mathelo

2. Fauji Fertilizer Company Limited – Mirpur Mathelo Synopsis Background Incidents Definitions Incident Causation Model Incident Investigation : Traditional Model Rational Vs Advance Model Comparison Incident Investigation: The advance model FFC Mirpur Mathelo Methodology FFC Mirpur Mathelo Experience FFC OH&SMS Performance

3. Fauji Fertilizer Company Limited – Mirpur Mathelo Background During a study on incident investigation methodology and record following were observation : - In any year, 70~ 80% of accident were due to 20~ 30% of the root causes - These root causes are repetitive in the all the years (from 2003 on ward) - Actions were correction than the corrective actions.

4. Fauji Fertilizer Company Limited – Mirpur Mathelo Incident Work related event(s) in which an injury or ill health (regardless of severity) or fatality occurred, or could have occurred. (OHSAS 18001:2007)

5. Fauji Fertilizer Company Limited – Mirpur Mathelo Incident Causation Model Safeguard 01 Safeguard 02 Safeguard 03 Safeguard 04

6. Fauji Fertilizer Company Limited – Mirpur Mathelo The Alternative Arrangement Traditional Approach: Identification of critical events Actions to prevent their recurrence New Construction: Interaction of critical events and human behaviors. How these work together forms a system

7. Fauji Fertilizer Company Limited – Mirpur Mathelo Nature of Accident (Traditional Rational View) Time line and sequence of the events before accident happening Identification of critical events during this chain of events/ Failure of safeguards Dealing with these identified critical event(s) (Active failures) to prevent reoccurrence (single loop learning)

8. Fauji Fertilizer Company Limited – Mirpur Mathelo Incident Investigation: The Advance Model Time line and sequence of the events before accident happening Identification of critical events during this chain of events/ failure of safeguards Human contribution to loss Identification of latent failures in root cause analysis (double loop learning)

9. Fauji Fertilizer Company Limited – Mirpur Mathelo FFC Mirpur Mathelo Methodology Gap analysis between conventional and advance model methodology A training plan is developed for the implementation of the following critical areas: Human behaviors/ factors Correction and Corrective Actions Investigators biases Risk assessment study is also revised and human factors/ behaviors were incorporated in the risk assessment study.

10. Fauji Fertilizer Company Limited – Mirpur Mathelo Human Failures: Human Contribution to Loss 1.Errors 2.Violations

11. Fauji Fertilizer Company Limited – Mirpur Mathelo Errors and Violations Errors 1.Action Errors  Slips and Lapses (Skill Based Errors) 2.Thinking Errors  Poor Analysis/ Problem Solving (Rule based Errors )  Incomplete Information (Knowledge based Errors) Human Failures: Human Contribution to Loss

12. Fauji Fertilizer Company Limited – Mirpur Mathelo Human Failures: Human Contribution to Loss Cognitive Deficiencies Perception Memory Decision Action

13. Fauji Fertilizer Company Limited – Mirpur Mathelo Violations 1. Routine: A rule exists but no one follows it 2. Situational: In effect the specific nature of the situation induces the violation 3. Exceptional: these are rare and occur when something has already gone wrong and people feel the need to improvise so as to correct the problem. Human Failures: Human Contribution to Loss

14. Fauji Fertilizer Company Limited – Mirpur Mathelo Correction and Corrective Actions Active and Latent Failures Single and Double loop learning

15. Fauji Fertilizer Company Limited – Mirpur Mathelo Active and Latent Failures Active Failures Occurs in the close proximity of the incidents Latent Failures Hidden and mostly available within the deficiencies of management systems

16. Fauji Fertilizer Company Limited – Mirpur Mathelo Single and Double Loop Learning Single Loop Learning To change the behavior e.g. Identification for retraining as a remedial action Double Loop Learning To correct errors to change the identified program e.g. Why training is not effective in first place ?

17. Fauji Fertilizer Company Limited – Mirpur Mathelo Investigator Biases Satisficing Heuristics: Confirmatory evidence Mental models Groupthink Hindsight

18. Fauji Fertilizer Company Limited – Mirpur Mathelo FFC Mirpur Mathelo Experience We are in a process to implement this approach and certainly a new subject for us and in Pakistan. However positive impact on the statistics is already being observed. Study has showed that this approach (originally developed by BSI) has Improvement area were identified in:  Management Systems  Training Plan Formulizations / Safety Trainings/ Orientation Structures  Risk assessment study  Job Safety Analysis  Job suitability analysis (Induction phase)

19. Fauji Fertilizer Company Limited – Mirpur Mathelo Incident Statistics (2003 to June 2011)

20. Fauji Fertilizer Company Limited – Mirpur Mathelo Safe Man-Hours Statistics (2003 to June 2011)

21. Fauji Fertilizer Company Limited – Mirpur Mathelo Reference Documents Psychoalogica toolkit for advance incident investigation “The Fifth Discipline” by Peter Senge “Root cause analysis (simplified tools and techniques)” second edition by Bjorn Andersen and Tom Fagerhaug “Organizational Dysfunction” by Chris Argyris “Human Errors and Their Classification” by Rasmussen “Normal Accident” Edition Two by Norman Perrow

22. Change…......Before you have to (Jack Welch )