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Learning from Incidents
• Minor technical errors leading to major events
• The importance of gathering facts
• The investigation process using 5 Whys
• Analysis to an actionable plan
• Benefits of hindsight, does it lead to foresight
• The future challenges, “safety differently” is it
new or feasible?
Adverse event report and investigation
form
• Part 1 Overview: Brief details
• Part 2 Initial assessment (to be carried out by
the person responsible for health and safety)
• Part 3 Investigation information gathering
Analysis and further action
• Part 4 The risk control action plan
Accidents
Investigations
Proactive actions
Buncefield Explosion UK
oilterminal,storage and
transferfacilities
oilrefinery
Shetland
Stromness
Lerwick
Orkney
G
Grangemouth
Port
Clarence
I
Stanlow
Pembroke
Milford
Haven
Fawley
Coryton
Dimlington
Easington
Figure8UK oil refinery and
pipeline network
35
Buncefield
UK pipeline system 2005
Fuelspillsoverdeflectorplate ullageventilationhole
Fuelisdivertedtowardthe
tankwallbydeflectorplate
Droplet fragmentation
enhanced by
intersectionof liquid
andvapoursprays
Airloadedwithfuelvapourdriven
rapidlydownwardbyliquidspray
bundwall
Increasedsurface area
allows volatile fractionsto
evaporate andvapour
gathersinbund
Liquidfuel
gathersinbund
Figure2The pattern of
fuel dispersion (for
illustration only)
Nottoscale
Storage tank showing overfilling
High level switch
Sheeted scaffold collapse
Anchor & Eye Bolt
Mobile Crane Fatal
Irregular Shape Steel Platform
Webbing Sling
(not actual case study hook/sling)
Lifting Hook Safe
Lifting Hook
Unsafe
Hook with retaining clip
Appropriate lifting shackles
What were immediate and root causes
1. What happened, how and why
2. Immediate causes
• Fell from crane hook
• Unbalanced load
• Heavy load
• DP underneath, no tag line
• Wrong lifting tackle
• Etc, etc
Root, underlying causes
• No procedure
• No lifting points in design
• Poor crane hook maintenance
• Crane operator not trained
• DP not supervised
• DP not trained, no tag line
• No management commitment
What risk control measures needed
• Risk assessment
• Planned preventive maintenance
• Operator training
• Plan lift at design stage, provide lifting eyes
• Supervision
• Management accountability, visibility
Stack
Butt showing tree age
Visibility 1
Visibility 2
The Decision to Investigate
Likelihood of
recurrence
Potential worst consequence of adverse event
Minor Serious Major Fatal
Certain
Likely
Possible
Unlikely
Rare
(The definitions of ‘consequence’ and ‘likelihood’ are set out in the section on
‘Understanding the language of investigation’)
Risk Minimal Low Medium High
Investigation level Minimal
level
Low
level
Medium
level
High
level
Painter breaks his leg
Falling due to gravity Painter falls off
The ladder slips
The ladder is not tied
Painter is on ladder
Access to the roof
Analysis
Slip
Lapse
Violation
Rule-based
Knowledge-based
Skill-based
errors
Human
failings
Mistake
Human Failings
Safety Differently
• Growth of complexity
• New roles & responsibilities
• Conventional risk and human factors approach
falling behind
• Move from Bureaucratic accountability to
individual and ethical responsibility
• Move from fault finding to good practice
• Role of safety practitioner?
Further reading & references
• Investigating accidents: Health & Safety
Executive guide HSE 245
• Buncefield Fire Wiki
• Investigation technique US OSHA
• Investigation technique EU OSH
• Chris J Ward further OHSMS (ISO 45001)
information
31
ISO 45001 OHS
Training Courses
• ISO 45001 Introduction
1 Day Course
• ISO 45001 Foundation
2 Days Course
• ISO 45001 Lead Implementer
5 Days Course
• ISO 45001 Lead Auditor
5 Days Course
• ISO 45001 Transition
2Days Course
Exam and certification fees are included in the training price.
https://pecb.com/en/education-and-certification-for-individuals/iso-
45001
www.pecb.com/events
THANK YOU
?
safetyinspector@hotmail.co.uk
https://www.linkedin.com/groups/8319963
linkedin.com/in/chriswardiso45001assessment

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An Introduction to Accident Investigation: How small errors lead to tragic consequences

Editor's Notes

  1. Buncefield UK 2005. Biggest explosion in Europe since 1945. Numbers killed/injured = 0 Immediate causes: Overflow of petrol ignited, because a source of ignition (ever present), together with air and source of fuel. Over flow due to faulty switch. Underlying causes: Poor switch design, poor maintenance, poor staff training, pressures of work, installation/bund design
  2. Float switch configuration and test lever
  3. Sheeted scaffold collapse, following high winds. Building refurbishment, no floor partitions. Nos. killed injured = 0 Take down over 5 days, during busy city centre Christmas shopping period. Immediate causes: High wind, sheeted scaffold, too few anchor bolts, poorly fitted anchor bolts Underlying causes: Poor training, poor supervision
  4. Lorry mounted crane, load dropped. Nos killed = 1 Immediate causes: Banksman under load, crane hook no retaining link, crowded hook Underlying causes: Poor training, poor maintenance, inadequate suitable equipment, poor design of load
  5. Web sling with two hoops Crane with retaining link
  6. Hook with retaining link