Incident investigation

1. Incident Investigation Procedure

© SEMD Repsol 2011

 General Index
0.Introduction
1. Incident Investigation Procedure.
2. Introduction to the Root Cause Analysis Methodology
3.1. Incident reality and definition
3.2. Incident definition in Repsol YPF
4. The Cause – Effect principle
5. Cause – Effect analysis
6. Evidence
7. Effective solutions
8. Conclusions
9. Managing the investigation committee
10. Interviews
11. Human error
12. HGI
13. GAMA investigation module
14. Practical example
15. Conclusions

2
© SEMD Repsol 2011
 Chapter index
1. Incident Investigation Procedure
1.0. Why?
1.1. What is an incident?
1.2. Investigation objective
1.3. Incident investigation process
1.4. Investigation steps
1.5. Final investigation report
1.6. Duties and responsibilities
1.7. Training and qualification
1.8. Summary

“It is of great importance for those who seek certainty in their research to know when to doubt in time.”
Aristotle

3
© SEMD Repsol 2011
 1.0. Why?
• SCOR N-04: Notification, investigation and recording of accidents and incidents.

2.3. Investigation of incidents

First of all the risk of all incidents should be assessed following the risk evaluation methodology described in
Appendix I: Safety and environmental risk assessment. Prioritisation of actions and an investigation should be
conducted on all high potential incidents and any incidents that have caused accidents. The incident investigation
shall be carried out according to the criteria established in the Investigating Safety and Environmental Incidents
Procedure (code 411-PR032MG).

• Inconsistent use of the current Incident Investigation Guide

• 2 different methodologies depending on the potential of the incident.
• Lack of IT support facilitating the investigation, their registration on GAMA and their
traceability.

Need to establish a single methodology for all Repsol YPF

PROCEDURE

4
© SEMD Repsol 2011
 1.0. Why?
Draft agreed to Process
Send
jointly with WG approved
1st draft regulation to
CMN

September 2009 December 2009 September 2010 29/11/2010

Investigation Evaluation with

BU Comments Latest comments
methodologies Working Group

Process Entry
approved into force
Fully in force

Skills acquisition Skills acquisition

• 5 corporate editions
• ?? business editions

29/11/2010 15/12/2010 15/12/2011

5
© SEMD Repsol 2011
 1.1. What is an incident?
Incident

An undesired isolated event, while conducting company-related work or activities, involving

people, assets, the environment or the image of the company, that results or may result in:
• Injuries to people or damage to their health
• Damage to company assets
• Damage to the environment
• Damage to the company's image
An incident may include any combination of accidents and near accidents

Accident
A combination of damage resulting from an incident that exceeds a minimum threshold and meets a
series of requirements.

Near accident
A combination of real or potential damage resulting from an incident that meets certain requirements
but does not exceed the thresholds to be considered an accident.

6
© SEMD Repsol 2011
 1.2. Investigation objective

Analyse the scenarios that led to the occurrence of the incident in order to:
• Identify the causes that contributed to it, and
• Act on the causes identified (or some of them) to prevent similar incidents from
occurring again

Identify the damage or consequences of

the incident and the key factors (human,
1. What happened?
material and environmental) involved in the
incident
Identify the root causes and explain how
2. Why did it happen? and under which circumstances they
occurred
Identify the solutions and improvement
3. What can be done to
action requests, and execute an
avoid it happening again?
implementation programme for the same

Basic questions for all investigations

7
© SEMD Repsol 2011
 1.3. Incident investigation process

8
© SEMD Repsol 2011
 1.4. Investigation steps
DEFINITION Incident defined
Incident
INCIDENT
What, when, where? Required resources
Importance, Risk

INCIDENT
Incident defined Network of causes
INVESTIGATION
Cause tree based on evidence

management
(cause-effect chart)

Incident
SOLUTION
Network of causes IAR
PROPOSAL

Brainstorming

ROOT CAUSE
IAR Root Causes
IDENTIFICATION

Association between IAR & Root Causes

Management
Company
SYSTEMATIC ERRORS
Root Causes SE error types
IDENTIFICATION

SE
Root causes group

9
© SEMD Repsol 2011
 1.4. Investigation steps
1.4.1. Definition of the incident. Which incidents need to be investigated?

• High-potential incidents
• Moderate, high, urgent or extreme risk

• Incidents that have caused accidents

• Incidents that have caused accidents but when their risk is evaluated, this is found to be
minor, will be investigated in accordance with the criteria laid down for a moderate level
investigation.

• Incidents that do not fulfil the requirements for being investigated

• The business unit can decide to investigate them

• The methodology described in the procedure is not required

10
© SEMD Repsol 2011
 1.4. Investigation steps
1.4.1. Definition of the incident. Risk and resource allocation
What, when, where, importance, risk
• Risk: CEL Methodology

• Resource allocation
Incident risk Minimum level of investigation
Minor risk Investigation at the discretion of the
Unit
Moderate risk Moderate level investigation
High risk
Urgent risk High level investigation
Extreme risk
11
© SEMD Repsol 2011
 1.4. Investigation steps
1.4.1. Definition of the incident. Summary

Investigation determined by BU
If no accidents were caused

Moderate level investigation

Does not require an investigation committee to be
formed

High level investigation

Requires an investigation committee to be formed
• 3 ≤ participants ≤ 5 (minimum possible)
• Contribute knowledge of the activity
• If urgent or extreme , expert personnel
from other units proposed by the
investigating unit and agreed on with the
source unit

12
© SEMD Repsol 2011
 1.4. Investigation steps
1.4.2. Incident investigation. Network of causes

Once the incident has been defined and the resources allocated, the next step is the
investigation proper.

• Establish the network of causes

• Establish the final consequence(s) to be investigated

• “Managed” brainstorming

• Cause-effect chart (HGI)

• All causes must be backed up with evidence
• Specific, objective facts before interpretations and value judgements

Brainstorming

13
© SEMD Repsol 2011
 1.4. Investigation steps
1.4.2. Incident investigation. Summary

Final consequence Brainstorming Network of causes

Cause-effect chart HGI

14
© SEMD Repsol 2011
 1.4. Investigation steps
1.4.3. Solution proposal

Once the network of causes has been defined, the next step is to propose actions that
prevent the incident or similar incidents from happening

• Look over the cause-effect chart from the ends of the branches to the damage
• “Managed” brainstorming
• Review, fine-tune and assess each of the solutions proposed
• Prevent the incident from being repeated
• Manageable directly by Repsol YPF
• Achieve the objectives and goals set
• The proposed solution does not cause or can cause other incidents
• The cost of the solution is proportional to its benefit

Brainstorming

15
© SEMD Repsol 2011
 1.4. Investigation steps
1.4.3. Solution proposal.Improvement Action Request (IAR)

Once the list of solutions has been assessed, the optimum set must be selected:

• From the viewpoint of technical, economic and legal viability

• From the viewpoint of implementation viability, analysing possible incompatibilities, among
them or with the equipment and facilities and the possible “new risks” added to the asset.
Of all the proposed solutions, only the IARs are proposed as effective actions to prevent
similar incidents from happening again
1. Causes 2.Solutions

Cause 3. Sol.
Cause
n IAR 1
1 1

Cause IAR 1 Sol.

2 2 2
Cause
3
IAR Sol.
Cause m
4 3

16
© SEMD Repsol 2011
 1.4. Investigation steps
1.4.4. Root cause identification

A root cause is the specific cause for which an improvement action request is defined, which
avoids the recurrence of incidents similar to that under investigation.

1. Causes 2.Solutions

Cause 3. Sol.
Cause
n IAR 1
4.
1 1

Root IAR 1 Sol.

1 2 2
Root
2
IAR Sol.
Root m
3 3

17
© SEMD Repsol 2011
 1.4. Investigation steps
1.4.5. Systematic error identification
The causes identified during the investigation have a systematic error type that occurs in the
company  root cause groups/types (RCG)

1. Causes 2.Solutions

Cause 3.
Cause n Sol.1
4. IAR 1
1
Incident Management

Root 1Sol.2
IAR 2
1
Root
2
Root IAR 3 Sol.m
3

6.

RCG 1 RCG 2 RCG 3 RCG 4 RCG 5 RCG 6 RCG 7 RCG 8 RCG 9 RCG 10 RCG 11

18
© SEMD Repsol 2011
 1.4. Investigation steps
1.4.5. Systematic error identification.RCG

19
© SEMD Repsol 2011
 1.4. Investigation steps
1.4.5. Systematic error identification.Company management
Incident Management
Management
Company

ΣRCG 1 ΣRCG 2 ΣRCG 3 ΣRCG 4 ΣRCG 5 ΣRCG 6 ΣRCG 7 ΣRCG 8 ΣRCG 9 ΣRCG 10ΣRCG 11

Act on systematic errors. HSE Management in the company

20
© SEMD Repsol 2011
 1.5. Final investigation report

1.5.1. Content
• Definition of the incident
• Risk assessment
• Root causes identified and root cause classification
• Improvement action requests
• Risk assessment criteria
• Reference levels

The improvement action requests are sent to the corrective

action manager or managers.

GAMA

21
© SEMD Repsol 2011
 1.5. Final investigation report
1.5.2. Dissemination
“Each unit will decide which people must receive incident
investigation reports in compliance with the requirements laid down
in regulation 343-NO032MG. Incident management”
2.3.3. Records
As a result of the investigation validation the Final Report of the investigation is obtained, which
will be distributed to the parties on the list defined in section 2.1.1.
The units shall define:

The group of people who must validate the information about the incidents

The group of people who should receive the notification of the incident, ensuring that the
information reaches at least:
- Manager of the Area
- Manager of the Work Centre
- Safety Coordinator of the Division, Unit and Work Centre Safety Coordinator,
where applicable.
- In the case of a contractor, the person responsible for the management of
the contract or, in their absence, the person responsible for the contractor's
supervision.
- In the case of serious incidents, the senior management of the unit, the
Insurance Division and the Safety and Environment Division. GAMA
The units shall also ensure that the external communication requirements,
established by the legislation applicable in each case, are met. 22
© SEMD Repsol 2011
 1.6. Duties and responsibilities

23
© SEMD Repsol 2011
 1.6. Duties and responsibilities

1.6.1. Communication validator

• Should the incident not comply with the requirements to be investigated,
request the corrective actions, in agreement with the areas involved and
the best information available.

Investigation determined by BU
If no accidents were caused

Moderate level investigation

Does not require an investigation committee to
be formed

High level investigation

Requires an investigation committee to be
formed
• 3 ≤ participants ≤ 5 (minimum
possible)
• Contribute knowledge of the activity
• If urgent or extreme , expert
personnel from other units proposed
by the investigating unit and agreed on
with the source unit

24
© SEMD Repsol 2011
 1.6. Duties and responsibilities

1.6.2. Unit/centre
• Indicate the investigation leaders
• Secure the resources
• Establish more restrictive criteria, if deemed appropriate
• Define the level of investigation dissemination
• Check qualification requirements
• Propose expert personnel and agree on their participation
with the unit in which they are working (urgent or extreme risk)
• Adapt duties and responsibilities to the structure and
resources

25
© SEMD Repsol 2011
 1.6. Duties and responsibilities

1.6.3. Investigation leader

• Carry out the incident assessment
• Assign the investigation level and define the necessary
resources
• Appoint the investigation co-ordinator
• Select the members of the investigation committee
• Report to the unit/centre
• Ensure that the investigation is carried out in accordance with
this procedure
• Review and validate the full investigation process
• Validate and ensure distribution of the investigation report
• Consult with Legal Services (investigation by Proper
Authority)

INVESTIGATION “MANAGER”

26
© SEMD Repsol 2011
 1.6. Duties and responsibilities

1.6.4. Investigation co-ordinator

• Understand the methodology
• Define the incident
• Give basic training to the participants in the investigation
committee
• Investigate
• Inform the leader of investigation progress
• Enter all information generated during the investigation in
GAMA
• Propose the IARs and draft the investigation report
• Present the results of the investigation to the parties involved

INVESTIGATION “EXECUTOR”

27
© SEMD Repsol 2011
 1.7. Training and qualification

TRAINING CATEGORIES REQUIREMENTS POWERS

Have attended official company training
Coordinate any type of investigation
on incident investigation
Participate in high level investigations
Have taken part in a specific incident
Advanced classified as being urgent or extreme risk
investigation workshop
in other units
Have broad experience in investigating
Deliver training basic
incidents in the company

Have received training by advanced staff

or
Basic Coordinate moderate level investigations
Have taken part in a significant number of
investigations in the company

Member of the incident Participate in the investigation for which

Be a company employee
investigation committee he has been selected by the investigation

28
© SEMD Repsol 2011
 1.8. Summary
DEFINITION Incident defined
Incident
INCIDENT
What, when, where? Required resources
Importance, Risk

INCIDENT
Incident defined Network of causes
INVESTIGATION
Cause tree based on evidence

management
(cause-effect chart)

Incident
SOLUTION
Network of causes IAR
PROPOSAL

Brainstorming

ROOT CAUSE
IAR Root Causes
IDENTIFICATION

Association between IAR & Root Causes

Management
Company
SYSTEMATIC ERROR
Root Causes SE error types
IDENTIFICATION

SE
Root causes group

29
© SEMD Repsol 2011
 30
© SEMD Repsol 2011