Incident Investigation

0. Introduction

© DSMA Repsol YPF 2011

 Safety Moment

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 Course Contents
0. Introduction
1. Incident Investigation Procedure
2. Introduction to Root Cause Analysis Methodology
3.1. Incident Reality and Definition
3.2. Incident Definition within Repsol YPF
4. The Principle of Cause and Effect
5. Cause and Effect Analysis
6. Evidence
7. Effective Solutions
8. Conclusions
9. Committee of Inquiry Management
10. Interviews
11. Human Error
12. HGI
13. GAMA Investigation
14. Case Study
15. Conclusions

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 Unit Contents

0. Introduction
0.1. Welcome
0.2. Context of this Course
0.3. Course Approach
0.4. Expectations

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 0.1. Welcome

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 0.1. Welcome

Introduction of facilitators

• Marcos Gallego

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 0.1. Welcome
ERM is one of the world’s leading companies in
environmental consultancy services. It offers services
regarding:
• Environment
• Health and Safety
• Sustainability

• Over 35 years of experience in over 160 countries.

• 125 permanent offices in 41 countries and more than 3,500 professionals.
• We have worked with different leading national and international companies
designing and providing training courses, including several of Repsol’s
Business Units.
• We have developed and provided training programs on Change Management,
Health and Safety Leadership, and Corporate Health and Safety for other
companies in the sector, such as ENI, Anglo, Rio Tinto, Nalco, Henkel,
Novartis,…

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 0.1. Welcome

Course Rules

• Time management is everybody’s responsibility:

• Punctuality.
• Adjustment of group work to the given time.
• Confidentiality:
• Shared information during this course.
• After the course.
• Expectations of facilitators:
• Freely share own expectations.
• Ask all doubts!
• Contribute to group discussions.
• After the course, apply what has been learned.

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 0.1. Welcome

Introduction of participants

Tell us 3 key aspects to get to know the person next to you.

Name, Department,…

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© DSMA Repsol YPF 2011
 0.1. Welcome
• You come to the Group’s headquarters to the Incident Investigation Training
Course.
• You run into the company’s President, whom you had already met in a recent trip to
your Business.

• You have the following conversation:

• Mr Bufrau: “Hello, what brings you here today?”

• You: “I have come to a training course about
incident investigation”.
• Mr Bufrau looks at you and asks: “Interesting… and
for which three reasons do you think this course
is important?”
• All this takes place in 30 seconds, the time the lift takes to reach the 3rd floor.

In groups, describe the 3 reasons why you consider this course to be

important.

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© DSMA Repsol YPF 2011
 0.2. Context of this Course
Repsol Accident Rates
FI for Repsol YPF Number of Incidents in Repsol YPF
9,0
8,0
1000

Number of Incidents
7,0
800
6,0
600 579 No. of NLD incidents
5,0
FI

4,0 400 302 385 No. of WLD + F incidents

3,0 200 344 243 239
2,0
0
1,0
2008 2009 2010
0,0
2002 2003 2004 2005 2006 2007 2008 2009 2010 Year

Repsol YPF 2010 F: Incidents which cause death (fatalities).

Total Fatalities WLD NLD First Aid Remaining
Incidents Incidents
WLD: Incidents with associated lost days of work.
5,553 9 387 416 1,405 3,336 NLD: Incidents with no associated lost days of
work (medial treatment and/or work
restrictions).
FI: Integrated Frequency Index (F+WLD per
million hours worked).
TFI: Total Frequency Index (F+WLD+NLD per
million hours worked).
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 0.2. Context of this Course

Volume of investigations executed

Number of investigations
Year
carried out in Repsol YPF
2008 1,373

2009 1,227

2010 1,693

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© DSMA Repsol YPF 2011
 0.3. Course Approach
• The course is organised into two essential parts:
• Basic Incident Investigation Methodology Concepts and Root
Cause Analysis Techniques (ERM).
• Approach and management of elements associated to incident
investigation within Repsol (Repsol).
• Each unit is made up of theory sections supported with case studies.
• The selected case studies are mainly modified versions of real
incidents occurred in operations of the Group.
• The last day will be entirely dedicated to a case study, using all the
corporate tools available.

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 0.3. Course Approach

What are we going to see during the course?

• Investigation methodology (Root Cause Analysis; RCA).

• Contents of general procedure 411-PR032MG. Investigating Safety and
Environmental Incidents.
• What the corporate tools support the investigation.
• Human behaviour: Research Committee management, human error,
interviews,…
• Roles and responsibilities in Investigation.
• Case studies.

What are we not going to see during the course?

• How specific roles and responsibilities are defined within a Business.
• How Improvement Action Requests (IAR) are managed.
• GAMA (except modules related to the investigation).

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 0.4. Expectations

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 0. Introduction

Questions?
Doubts?

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