InvestigAction    A cognitive and organizational tool forlearning from accidents and improving safety            in oil an...
Outline•   Reasons•   Objectives•   The approach•   The architecture•   The accident investigation protocol•   The AIP in ...
ReasonsSaipem has already adopted in proactive safety policies, including a successful training program “Leadership in Hea...
ReasonsThe current investigations are not satisfactory because conducted through heterogeneous processes and methods that ...
ReasonsConsequently, there is a general difficulty in generating remedial actions that can impact on both organizational a...
ObjectivesDevelop a tool and a methodology of analysis /diagnosis of adverse events aimed at improving ofsafety.Promote a ...
The approachEvolution of the concept safety in organizations:From preventing undesirable states to the ability of thesyste...
The approach  Two key principles:Shift the focus of investigation from the search for guiltyperson(s) to make it a learnin...
The approachThree key guiding questions:There were defences?How and why did the defenses fail?What can be done to prevent ...
The approach  A combination of two views:a) Organizational view:      Errors and violations are not only human errors,    ...
The approachb) Cognitive view:      People are fallible, but able to correct errors,      to capture weak signals and to h...
The architectureMain components          AimTaxonomy of human error To understand the cognitive                        fac...
The Accident Investigation Protocol      The investigation protocol is a tool and      a methodology of analysis / diagnos...
The Accident Investigation Protocol       A tool: What to investigate                     The fact (data /information /   ...
The Accident Investigation ProtocolA methodology: How to investigate      How to conduct the inspections      How to condu...
The Accident Investigation ProtocolThe protocol is structured as a sequence of activities.For each activity, there is a fo...
The Accident Investigation Protocolanalyzes all events, be they accidents or near misses, as a  source and learning opport...
The Accident Investigation Protocolpromotes the collaboration of all actors involved, especially  witnesses and workers on...
The Protocol is a tool within the investigation phasein the safety improvement process                                    ...
A further step:The investigatorsThe protocol implies the design of the role of the investigator and its training and of it...
Thank you for the attention                              21
ContactsFondazione IrsoThe IRSO Foundation - Research Institute of Organizational Systems - founded byFederico Butera in 1...
ContactsFondazione LHSThe LHS Foundation is a non-profit organization aiming to change the approach to healthand safety by...
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InvestigAction: a cognitive and organisational tool for learning from accidents and improving safety in oil and gas industry by S. Bagnara

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InvestigAction: a cognitive and organisational tool for learning from accidents and improving safety in oil and gas industry by S. Bagnara

  1. 1. InvestigAction A cognitive and organizational tool forlearning from accidents and improving safety in oil and gas industrySebastiano BAGNARA and Roberta MORICI (Fondazione Irso) Davide SCOTTI (Fondazione LHS) Alias Conference Florence, 14-15 June 2012
  2. 2. Outline• Reasons• Objectives• The approach• The architecture• The accident investigation protocol• The AIP in the safety management processes• The investigators 2
  3. 3. ReasonsSaipem has already adopted in proactive safety policies, including a successful training program “Leadership in Health & Safety” (LiHS).The success of the program has encouraged the organization to engage even more with the development of safety culture and new tools and methods of safety management. 3
  4. 4. ReasonsThe current investigations are not satisfactory because conducted through heterogeneous processes and methods that produce non consistent and comparable outputs.Moreover, spontaneous reports of erroneous actions, near miss or unsafe behaviors are very rare. 4
  5. 5. ReasonsConsequently, there is a general difficulty in generating remedial actions that can impact on both organizational and behavioral conditionsTo overcome these shortcomings, it was decided to develop an investigation protocol customized for Saipem 5
  6. 6. ObjectivesDevelop a tool and a methodology of analysis /diagnosis of adverse events aimed at improving ofsafety.Promote a culture of "active safety" to counteradverse events, coherent with the already initiatedtraining program LiHS (Leadership in Health &Safety). 6
  7. 7. The approachEvolution of the concept safety in organizations:From preventing undesirable states to the ability of thesystem to address undesirable casesFrom pretending to reach zero risk, that is to preventany uncertainty, accidents, breakdowns to the ability toensure effective performance with results close to zeroaccidents, although operating in unpredictableenvironments and in inherently risky organizations 7
  8. 8. The approach Two key principles:Shift the focus of investigation from the search for guiltyperson(s) to make it a learning opportunity for thesystemUnderstand the conditions of adverse events, i.e. thefactors that can create the conditions for an accident ornear miss. 8
  9. 9. The approachThree key guiding questions:There were defences?How and why did the defenses fail?What can be done to prevent a recurrence? 9
  10. 10. The approach A combination of two views:a) Organizational view: Errors and violations are not only human errors, but they are socially organized, produced and reproduced by social structures within organizations and between organizations. Human nature is fallible, but we can change the conditions within which people work. 10
  11. 11. The approachb) Cognitive view: People are fallible, but able to correct errors, to capture weak signals and to handle unexpected. Understanding the cognitive factors that lead people to make errors allowsto distinguish the different types of errors and to identify the preventive and corrective measures most appropriate to the type of error, increasing the system reliability. 11
  12. 12. The architectureMain components AimTaxonomy of human error To understand the cognitive factors that lead people into error and codify the type of error Scope Error detection and correctionOrganizational latent Identifying the latent factorsconditions (defenses, barriers, controls, etc..) that make the scenario accident prone Scope Organizational resilience 12
  13. 13. The Accident Investigation Protocol The investigation protocol is a tool and a methodology of analysis / diagnosis / interpretation of adverse events oriented to the improvement of safety conditions. 13
  14. 14. The Accident Investigation Protocol A tool: What to investigate The fact (data /information / documents to collect) The context The cognitive factors The organizational conditionsTHE METHODOLOGY:“HOW” TO INVESTIGATE 14
  15. 15. The Accident Investigation ProtocolA methodology: How to investigate How to conduct the inspections How to conduct the interviews How to interpret and represent data collected How to diagnose How to identify key learning lessons for the system 15
  16. 16. The Accident Investigation ProtocolThe protocol is structured as a sequence of activities.For each activity, there is a form to fill out and aguideline. EVENT MANAGEMENT ACTIVITIES EVENT REPORTING DeliverablesINVESTIGATION TEAM ACTIVITIES ? Guideline/checklist ANALYSIS AttachmentsINTERPRETATION ACTIVITIES DIAGNOSIS 16
  17. 17. The Accident Investigation Protocolanalyzes all events, be they accidents or near misses, as a source and learning opportunity for the improvement of safety in the organization;emphasizes a systemic and organizational view of adverse events, moving away from a blame culture;defines investigation roles, responsibilities and activities in a clear, transparent and uniform way;. 17
  18. 18. The Accident Investigation Protocolpromotes the collaboration of all actors involved, especially witnesses and workers on site (often frightened and fearful) with the aim of understanding the actual mechanisms that can lead to adverse events;focuses attention on the effective implementation of improvement actions;is consistent with the strategies adopted and investments ​ made for the safety improvement;is a tool for communication and training on safety culture. 18
  19. 19. The Protocol is a tool within the investigation phasein the safety improvement process Commitment PREVENTION Safety plan Safety culture Safety improvement process SECTION A Investigation process Event Reporting INVESTIGATION SECTION B Investigation Team LOW RISK EVENT Analysis MEDIUM RISK EVENT Interpretation Diagnosis HIGH RISK EVENT Communication of alerts Approval of corrective actions SAFETY Investigation debriefing IMPROVEMENT Implementation of corrective actions Sharing of conditions Training LEARNING AND Communication COMMUNICATION Knowledge sharing 19
  20. 20. A further step:The investigatorsThe protocol implies the design of the role of the investigator and its training and of its credibility towards all players in the system through the clear definition of objectives, activities and expected outputs.The role of investigators together with its ad hoc trainingwill be designed next 20
  21. 21. Thank you for the attention 21
  22. 22. ContactsFondazione IrsoThe IRSO Foundation - Research Institute of Organizational Systems - founded byFederico Butera in 1974 - has been for over thirty-five years one of the leading centers ofItalian organizational culture. It conducts research, organizational consultancy andspecialized training programs in private organizations and public administrations.Its social purpose is to generate and disseminate new forms of organization culture andwork to promote competitiveness and economic prosperity, environmental and socialsustainability, quality of working life.Sebastiano BAGNARAsebastiano.bagnara@gmail.comRoberta MORICIroberta.morici@irso.itFondazione IrsoPiazza Giovine Italia, 320123 MilanoTel: +39 02 48016162info@irso.itwww.irso.it
  23. 23. ContactsFondazione LHSThe LHS Foundation is a non-profit organization aiming to change the approach to healthand safety by introducing an innovative method which is capable of influencing people’sbehavior on a long term basis.The LHS Foundation offers a team of professionals, specialists in a range of disciplines(Psychologists, Trainers, Coaches, Communication Experts), each of whom workscontinuously to identify a model of integrated consultancy that can communicate andpromote a culture of prevention in an effective and engaging way, both at home and atwork, from top management to on-site workers, from primary school teachers to youngstudents.Davide SCOTTIDavide.Scotti@saipem.comFondazione LHSVia Martiri di Cefalonia 6720097 San Donato Milanese (MI)Tel. (+39) 02 520 54230info@fondlhs.orgwww.fondlhs.org

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