Tripos Beta new way of analysis Fire incident or Accident root causes and countermeasure.

1. MAP – HSE Workshop
Incidents Reporting & Investigation
Techniques
RCA - Tripod Beta Analysis

2. WHO AM I ?
Dr. Tahir Baig Barlas – HSE Consultant
• Global ITC ILO OSH Consultant & Master Trainer
• EX- Country HSSE Manager - Shell Companies in Pakistan
• Ex- OHS Advisor ICI Pakistan
• Visiting HSE Consultant - MAP, PSTD, EFP, Descon, ISL, Agriauto,
Dawlance Group of Companies, Engro, Dadex, CIC ----

3. Course Outline …
 The Business Case for Incident/Accident Investigations
 Accident Causation Mechanism
 Leading Causes of Accidents – The Human Factor
 Reporting & Investigation Techniques
 Root Cause Analysis – The Tripod Beta Methodology
 Incidents Case Studies - Syndicate Exercise
 Experience Sharing

4. Incident
Incidents are unplanned events or chains of events that have or
could have resulted in injury or illness or damage to asset, the
environment or company reputation
Accident
Accident is an incident which has resulted in actual harm and/or
damage to People, Assets, Environment or Reputation of the
Company
Harm / Damage Category
People / Assets / Environment / Reputation of the Company

5. Near Misses
Incidents that under slightly different circumstances could have
caused injury, illness, damage to asset, environment or company
reputation, but luckily did not…
Incident has occurred
Potential Incidents
Unsafe acts or hazardous situations/conditions that could result in an
incident…
Incident has not occurred

6. Don’t Accept the Unacceptable

7. Causes of Accidents
Causes to incluse stress & importance
of near miss reporting

8. Incident Classification
Incidents
Near Miss Accident
Injuries Non - Injuries Fire
Potential for :
• Injury / illness
• Damage to
• Asset
• Loss of property
• Damage to environment
• Fatalities
• LTC, RWC, MTC,
FAC
• PPD
• PTD (per. Tot. dis)
• Asset damage or loss
• Environment damage
• loss of reputation

9. Accident Mechanism
Safe Operation
No Price paid /
No Damage
C o n t r o l s /
B a r r i e r s
C o n t r o l s /
D e f e n c e s
H a z a r d
Potential to cause harm,
injuries, damage & loss
Potential to harm
T a r g e t
People, assets, reputation
environment paying the
price or damaged

10. Accident Mechanism
H a z a r d
Potential to cause harm,
injuries, damage & loss
T a r g e t
People, assets, reputation
environment paying the
price or damaged
B a r r i e r s
F a i l e d
D e f e n c e s
F a i l e d
I n c i d e n t /
E v e n t
Price paid or target
damaged
Hazard & Target get together
Potential to harm

11. Sources of Human Failure – Major Cause
of Accident
Human Failure
Intended Action Unintended Action
Violations Mistakes
Intentional
Routine
Situational
Optimising
Exceptional
Rules or
Knowledge
based
Lapses Slips
Memory
Failure
Attention
Failure

12. Sources of Human Failure – Major Cause
of Accident
Why do people bend / break the rules - violate
• Expectation
• Powerfulness
• Opportunity
• Inadequate work plans
- to get the work done
- feeling of ability
- to do it better
- doing in on the fly paradox of
“violation” Vs “initiatives”

13. Incident Reporting
&
Review Guidelines

14. Incident Reporting & Review Guidelines
 Incident / Accident notification within 24 hours
 Detailed report within 7 days
 Root Cause Analysis within 4 weeks
 Lost Time Injuries (TRIR Cases) to be discussed in
periodic HSE Leadership Meeting

15. Incident/Accident Investigation Process
The investigation should be carried out as soon as
possible after an incident. The quality of evidence will
deteriorate rapidly with time, therefore delayed
investigations are usually not as exclusive as those
performed promptly.

16. The investigation should include the following
activities:
• PROTECT THE SCENE, PEOPLE AND PROPERTY
• Conducting interviews
• Inspecting the location and gathering physical
evidences
• Collecting background information
• Fact finding
• Review records and procedures
• Conducting specialist studies
• Resolving conflicts in evidence

17. PROTECTING THE SCENE
•MAKE THE AREA & PEOPLE / PLANT
SAFE – ENSURE CASUALTIES ARE
PROFESSIONALLY DEALT WITH
•PROTECT THE SCENE AND ENSURE
THAT EVIDENCE IS NOT TAMPERED
WITH OR REMOVED / ALTERED
•RECORD IMPORTANT DETAILS: Time,
Weather Conditions, Positions of
Equipment, Vehicles, People - Look at
the bigger picture
• COMFORT PEOPLE
•NOTIFY THE RIGHT PEOPLE !
WHAT HAPPENED?

18. IDENTIFY THE KEY PARTS OF
INVESTIGATING AN ACCIDENT
THE SIX W’s :
• WHAT happened?
• WHEN did it happen?
• WHO was involved?
• WHERE did it occur?
• WHY did it happen?
•What can we learn to
prevent it from happening
again?
REMEMBER…THE DEVIL IS IN THE DETAILS!

19. INTERVIEWING WITNESSES IS
IMPORTANT…
• Interview SWIFTLY after accident
• Interview Professionally – Explain why
• Put people at ease / relax them
• May need individual Interview
• May need a group Interview
• Get them to repeat / confirm findings
• Preferably SIGN and date their
Statements

20. ESTABLISHING ROOT CAUSE
KNOW THE DIFFRERENCE BETWEEN IMMEDIATE CAUSE &
ROOT CAUSE and KNOW WHAT A CONTRIBUTING FACTOR IS
AN IMMEDIATE CAUSE IS WHAT IMMEDIATE CONTACT
ACTION CAUSED THE EVENT
Immediate Causes of this
accident could include
what?

21. There could be MANY CONTRIBUTING
FACTORS in an accident?
• MAN WAS RUSHING TO GET THE JOB
DONE
• SAW WAS INCORRECTLY GUARDED
• MAN SLIPPED WHILST USING THE SAW
• IT WAS DARK AND HE DIDN’T SEE THE
JOB CLEARLY
• MAN WAS A NEW WORKER & HAD
NEVER USED THIS MACHINE BEFORE
• MAN WAS BUMPED BY ANOTHER
WORKER
• MAN WAS UPSET EARLIER BY THE
NEWS OF THE DEATH OF HIS MOTHER &
WAS DISTRACTED

22. There is normally only one Immediate
& Direct Cause of an accident?
EXAMPLE ONE:
•MAN STEPPED IN FRONT OF AND
WAS STRUCK BY A VEHICLE
EXAMPLE TWO:
• WORKERS FINGERS CAME INTO
CONTACT WITH A PORTABLE
ELECTRIC SAW DURING WORK

23. TO SUMMARISE
• INVESTIGATE PROMPTLY & THOROUGHLY
• PROTECT THE SCENE, PEOPLE AND PROPERTY
• ENSURE YOU HAVE GOOD RESOURCES
• REMEMBER THE 6 W’s
• INTERVIEW WITNESSES / CASUALTY – RELAX THEM
• USE TRIPOD ANALYSIS BASICS TO GET TO A ROOT CAUSE
• DETERMINE REMEDIAL ACTIONS THAT WILL PREVENT
REOCCURENCE
• WRITE UP A GOOD REPORT
• COMMUNICATE TO OTHERS

24. Tripod Beta Incident Analysis

25. Investigation
path
Fallible
decisions
Latent
failures
dition
s
Pre-
con
e
Unsaf
acts
System
defences
by Top level decision makers
by Line management, designers, planners
by Line managers, supervisors
by Operators, maintenance crews
Accident
Tripod Causation Path
The Tripod causation path shows where to look.

26. Incidents are an indicator
to improve our performance
Understanding what
happened and why
enables us to
improve our
business operations

27. Past Approach to Safety Management
UNSAFE
ACTS
ACCIDENTS
Learn From
DEFENCES
Improve
Train & Motivate
Active Stages

28. Introduction to Tripod Beta

29. What is Tripod-BETA ?
A methodology for incident analysis
during an investigation ...
combining concepts of hazard
management
and ...
the Tripod theory of accident
causation.

30. How does Tripod-BETA work ?
The incident facts are built into a tree
diagram showing ...
- What happened ...
- What hazard management elements failed
and
- Why each element failed.

31. Tripod-BETA
 Brings a structure to investigation
 Helps distinguish relevent facts
 Makes causes and effects explicit
 Encourages team discussion
 Reduces the report writing task

32. What is Tripod Beta Analysis /
Technique ?
 Tripod aims to identify the deep-rooted causes of accident
 Tripod technique is mainly used as a means of exposing
weaknesses in management system / organization
structure when carrying out incident/accident investigation
and analysis

33. The incident facts are built into a tree diagram showing ...
- What happened ?
- What hazard management elements failed ? and
- Why each element failed ?
How does Tripod Work ?

34. Tripod Analysis
Preconditions
Accident
Chronological
sequence
Line Mgt
Latent
failures
Line Mgt
Latent Stages Active Stages
Management*
Fallible
decisions
“Sharp end”**
Unsafe
acts Defences
Safety Culture Causal
sequence
Accident Causation Sequence

35. Tripod Analysis
Accident Investigation Cycle
Accident
Investigation
Causes /
Recommendations
Corrective Action
(Implementation)
Operation
The vicious cycle

36. Tripod Tree – Breached Defences
Breached Defenses: what “last minute” measures failed or were missing?
Check question: Does the item describe the situation, system, conditions, equipment
or attribute which normally prevents, minimizes and recovers this
accident?
Breached Defenses
Barriers
(Controls for Threats)
Mitigation and Recovery Measures
(for Consequences)
. Awareness
. Detection
. Control
. Recovery
. Protection / Containment
. Escape and Rescue

37. Tripod Tree – Unsafe Act
UnsafeActs: which acts or omissions led directly to the accidents?
Check question: Does the item tell you about an error or violation of a standard or
procedure made in the presence of a hazard?
Unsafe Acts
Human errors
Intended action Unintended action
. Violation (1). Mistake (2) . Lapses (3) . Slips (4)

38. Tripod Tree – Preconditions
Preconditions
.
Preconditions: which states of mind or of the system allowed the unsafe acts?
Check question: Does this item describe something about the working situation, social
environment or a person’s thought process which influenced him to act in a certain way?
Preconditions can thus take both the form of a “state of mind” or “mental” precondition, or of a
“physical” precondition.
Examples : Unfamiliarity, Time shortage, Noisy signals, Poor system/human interface, Designer/user
mismatch, Irreversibility, Information overload, Technique unlearning, Knowledge transfer,
Misperception of risk, Poor feedback, Time of the day, Inexperience, Poor instructions or procedures,
Inadequate checking, Substance abuse, Educational mismatch, Macho culture, Physical capabilities
exceeded, Hostile environment, Low morale, Disturb sleep.

39. Tripod Tree – Latent Failures
Latent Failures – GFTs
.
Latent Failures: which underlying problems led to the preconditions?
Check question: Does this item identify a standard General Failure Type present before
the accident and which resulted in the Preconditions?
Examples
. Incompatible Goals
. Communication
. Training
. Maintenance
. Procedures
. Organization
. Error Enforcing Conditions
Management
•.Design
. Housekeeping
. Hardware
. Defenses

40. Tripod Analysis
General Failure Type (GFT)
• Hardware Defects
• Inadequate Housekeeping
• Inadequate Training
• Inadequate Procedure
• Communication Failure
• Incompatible Design
• Inadequate Defences
• Maintenance Management
• Organizational Failure
• Error Enforcement Condition
• Incompatible Goals
(HW)
(HK)
(TR)
(PR)
(CO)
(DE)
(DF)
(MM)
(OR)
(EEC)
(IG)

41. Tripod Tree – Fallible Decisions
Fallible Decisions
.
What decisions were made in the past - inside or outside the company
- which you can highlight as having been the underlying cause?
Fallible Decisions: Which decisions created latent failures?
Check question: Does this item explain a management decision process which
contributed to the General Failure Type?

42. Tripod Tree
.
Fallible
Decisions
General
Failure
Types
Preconditions
Unsafe
Acts
Breached
Defenses
Incident
Precondition
1
Unsafe Act
1
Breached
Defense 1
Latent
Failure 1
Unsafe Act
2
Breached
Defense 2
Fallible
Decision 1
Precondition
2
Accident
Latent
Failure 2
Precondition
3
Unsafe Act
3
Breached
Defense 3
Latent
Failure 3
Precondition
4
Unsafe Act
4
Unsafe Act
5
Breached
Defense 4

43. - Communicate findings to site
- Avoid disciplinary actions
- Peer review report
- Prepare presentation
- Communicate report internally
- Review report
- Brief external authorities etc.
- Review report
- Close – Out report
- Record report to file
- Publish ‘Lessons Learned’
- Implement recommendations
- Monitor implementation
Overview of Investigation & Analysis
Post – Analysis
FOLLOW-UP
Pre – Investigation
PREPARATION
- Ensure on-site safety
- Provide Emergency Response
- Notify relevant parties
- Collect initial data & evidence
- Generate Initial Incident Statement
- Classify incident
- Determine investigation level
- Form Investigation Team
INVESTIGATION
PLAN
1. Interpret Initial Incident Statement
2. Generate initial hypothesis
3. Develop investigation plan
INVESTIGATE
4. Conduct investigation
ANALYSE
5. Conduct analysis
6. Identify recommendations
7. Generate report
ANALYSIS

44. All Accidents are Preventable !
Thank you ! Any questions please ?