Croatia Wind Accident Investigation 2011

7/27/2019 Croatia Wind Accident Investigation 2011

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Investigation of complex accidents,analysing and learning from accidents

Workshop Croatian Institute for Health protection and safety at work 23-26th May

14-2-2012

Investigation and learning of accidents

1


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program

Accident causationComplex accidents

StakeholdersSystem levels involvedAccident investigation

MethodsProject

Getting impactAddresseeLearning cycle


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Complex accidents


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Accident: a moment..

When we understand that what we saw as

safe was w rong (Turner)

An oppo r tun i ty to learn!


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Complex?


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What you look for is what you get


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14-2-2012

Titel van de presentatie

8


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Example risk matrix used by oil companies


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Energy barrier

Hazard

Object

Acci

dent

Failed defence

Failed control


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Factors

TechnicalHuman

Socio technical (interaction withinorganizations)Inter organizational (dynamic and changingrelations)


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Accident causation

e.g:

Design

Hardware

Maintenance

Organization

Procedures

Training

Communication

Incompatible goals

Enforcing conditions

Housekeeping

Defences

Manage-ment

control

Underlyingfactors

Context Directcauses

Accident


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Direct (immediate) causes

What, when, how, where, who


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Context

Why, Why


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Underlying factors

Why, why, why,


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Bow tie
http://dreamlandapparel.com/wp-content/uploads/2010/09/bow-tie.jpg


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Fault tree


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Event tree


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Swiss cheese?


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Value of investigation

Acci

dent

Emergency

response

Evidence

gathering

Intermediate

investigation

Formal

investigation

Intermediate

reportFormal report

Unstructured

ideas


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What to look for?

Manage-

ment

control

Underlying

factorsContext

Direct

causesAccident

Effects/

escalationAccident

Operational

disturbance

(re) formulate

hypothesis


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Socio-technical system : who needs to learn?

Source: Rasmussen accimap

Borders/scope

of

investigation?


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Complex accidents: when to investigate

Risk:Potential for recurrence

Potential consequencesPopulation at riskSystem and stakeholders involved: interests,company policy, political pressureLegislation and other duties

Learning impactAgreement with authorities

If necessary commitment, budget, allows it


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What to investigate?

World view, safety culture companyAim: learn or blame, pay?

Methodology chosenTechnical, organizational perspectiveIntra or inter organizational (organizationalchains, networks)

Task or project (Instruction, procedures,contract)


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Methods (a priori knowledge, models)

STEP: sequential timed event plottingChange analysis: what is difference with accident freesituation

MORT: fault tree of technical organizational factorsTRIPOD BETA: energy barrier analysisSTAMP: dynamic system analysis

REF:

ESREDA

NTNU


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Project organization


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How to start (1)

Relevant?Assessment need, aim and value of results

Contracts, company procedure, legal obligationResearch questionsMethodology, world visionNo blame. Learning?Who needs to learn?

Agreement on independency and objectivityImmediate action:

Response team available to start investigation onplace incident immediately?


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How to start (2)

Intermediate actionDetermine scope, depth and time line investigation

Assess context accident: stakeholders involved,authorities active?Determine relation managementOrganize investigation team

Assignment investigation team

Project organizationWhat, how and when to deliver

Start and conduct accident investigation


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Investigation team

Project leaderResearch leaders (sub project leaders)SecretaryTeam members:

independent and objectiveexpertisediverse views

Back officesupportdata storage

ArchiveCatering


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Qualities team members

IntegrityObjectivePerseverance to trace symptomsCuriosityObserving detailsImaginationHumility

IntuitionTactRobustExpertise, skillsTeam player


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Terms of reference

Link to management, communication linesType of investigation

AimResearch questionsScope, object of investigation (systemborder)Project team (leader, memebers, authority)

To who to report: addresseeBudgetTime scaleDeliverables


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Plan

Assignment

Project

Monitor

implementation

Decision making

Discuss

preliminary results

Collect facts

Formulate

Hypotheses

Analyse data

Draw conclusions

Write report

Present findings

Draw up

recommendations

Direct response:

Safeguard

evidence


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Balance of efforts


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Cope with characteristics aftermath accident

Complexity, company starting up workCommunicationStakeholders

power and authority relationsStakeholders on playing field

criminal investigation teamauthorities

insuranceinvestigation board

Addressee(s) asking for preliminary resultsPressure for resultsCoping with external influences


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Conducting the investigation


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Key data to be covered: fact finding

The eventprocess, activityconsequencesplace, parts, positionsfunctions, roles, peopletimelineidentify witnesses

work documents

Needed:

Camera

PPE

Recording device

Measuring deviceSample containers

Identification tags

Torch

Catering

Etc.


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Aspects to be taken into account


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DOES and DONTs

Do not:Be subjectiveNot fact basedCommunicate outside project teamLooking for guilty person: whos to blameWork beyond scope without agreement ofcommissioner

Have open mind and be objective,professional, reliable, aimed at learning!


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How to report

Final aim: learning

Summary

Back ground and purposeFactual information

Analysis/methods followedResults

ConclusionsUrgent recommendationsSafety recommendations

If possible and wanted: site letter with expertopinion (other learning opportunities)

Dissemination and communication results


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Gaining impact


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OHS management: learning cycles

REF

OHSAS

Successful H&SM

Policy

Incident/accidentinvestigation

Organizing

Planning and

implementing

Measuring

perfomance

Reviewing

performance

Measuring

perfomance

Active monitoring

Reactivemonitoring


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Who needs to learn

Company

Contractor

Subcontractor

Industry/branche


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Learning barriers

3: Intervening

2: Planning of interventions

1: Incident Investigation and analysis

Incident

analysisFact finding

Determine

depth &

scoperesearch

Incident

registration

Incident

report

Communicate

action plan

Finding

resources &

performing

actions

Formulating

actionplan

Priority &

urgency of

actions

Formulate

recommen-

dations

4: Evaluating

Evaluate

implementation

& effectiveness

of actions


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Where do you think the main bottleneck islocated?

0

5

10

15

20

25

Incide

ntrep

ort

Incide

ntreg

istratio

n

Deter

minin

gscop

e

Factfin

ding

Analy

sis

Recom

mend

ations

Prioritize

Actio

nPlan

Comm

unica

tion

Interv

ention

Evalu

ation


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Getting impact

14-2-2012

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Accident electricity powerplant Amercentrale

plant shut for major overhaulboiler shut down for cleaning, repairing andinspection of boiler wallscollapsing scaffold5 persons killed


14-2-2012

Tit l d t ti

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trog

top

base

- 7 m- 9 m- 11 m- 13 m- 15 m- 17 m- 19 m- 21 m- 23 m- 25 m- 27 m- 29 m- 31 m- 33 m- 35 m- 37 m- 39 m- 41 m- 43 m- 45 m- 47 m- 49 m- 51 m- 53 m- 55 m- 57 m- 59 m- 61 m- 63 m


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Exercise 1: case 2 develop investigation plan30-45 minu tes

You are called by Amercentrale to do accident research.

Summarize accident (5 minutes)

What are direct causes?

What are indirect causes?

Exchange of results

What preventative measures you would advise on several

levels?

Who should implement?

Exchange of results


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Exercise 2: case 2 develop project plan30-45 minu tes

You are called by Amercentrale to doaccident research.

Define aim projectDesign first 10 steps to be done in theprojectWhat roles/functions need to be performed

Design investigation teamPropose research question

Jan and Johan provide information

14-2-2012


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Observations?What role would you prefer?Who would/need you to cooperate withWhat is next step of further developingservices institute

p


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Croatia Wind Accident Investigation 2011

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