Objectives

Participants are able to understand

•The need to conduct incident investigations

•The Investigation process

•How to use the Loss Causation Model to analyse

minor incidents

•The basics of Hazards & Effects Management

and how it is applied to analyse major or more
complex incidents using the TRIPOD-BETA
methodology

•Incident Reporting requirements

 Programme Outline

• Introduction
• Definitions of Accident, Incident, Near Miss
• Consequences, Costs of accidents / incidents
• Legal requirements
• Aim and results of investigations
• Investigation process – site visit, data gathering,
interviews
• Investigation Analysis
• Loss Causation Approach
• Tripod – Beta method including HSE Risk
management
• Reporting Requirements
 What is an

Accident or Incident ?
 Definitions
Incident
An unplanned event or chain of events, which has
or could have caused injury or illness to people
and/or damage (loss) to assets, the environment
Accident
An event which resulted injuries or illness to
people and/or damage (loss) to assets and the
environments
Near Miss
An event which did not result in injuries or illness
to people and/or damage (loss) to assets and the
environment
 What are the

Consequences of an

Accident or Incident ?
 THE CONSEQUENCES

Immediate Short Term Long Term

- Death - Medical - Suffering
Treatment
- Injury - Repairs - Disability
- Pain - Replacements - Lost Income
- Disease - Lost Production - Insurance
- Damage - Increased Cost - Compensation
- Loss - Discipline - Mistrust
- Fear - Low Morale - Profitability
- Pollution - Legal action - Deterioration of
environment
 Incident Costs
Insurance Costs
Medical Costs
Insured Costs Compensation

Uninsured Costs

Lost Time Loss of business

Legal costs Property damage
Fines Investigation costs
Extra wages Production delay
Accident / Incident Triangle

1 Fatality

30 Lost Time Injury

Minor Injuries / Property

300
damage

3,000 Near Misses

Unsafe acts/
30,000
conditions

At-risk
300,000
behaviour
 Aim of Accident Prevention

LTI

MTC
MTC
Near Miss
Near Miss

Unsafe Act Unsafe Act

At-risk Behaviour At-risk Behaviour

 Why Investigate an

Accident or Incident ?
Legal Requirements
In Malaysia the OSHA Act 514 of 1994 – Safety
& Health Regulations of 1996 Part III Section 13
states

(1) “A safety and health committee shall

inspect the place of work, as soon as it is safe
to do so, after any accident, near miss
accident, dangerous occurrence, occupational
poisoning or occupational disease has
occurred at the place of work”
 Legal Requirements (continued)

(2) “ Where a person is employed as a safety and

health officer, he shall furnish the chairman of the
committee with a report of his findings
subsequent to an investigation conducted by him
into any accident, near-miss accident, dangerous
occurrence, occupational poisoning or
occupational disease which has occurred at the
place of work; and the chairman shall, as soon as
it is practicable, convene a meeting of the
committee to discuss the report.”
 Legal Requirements (continued)

(3) “ Where no safety and health officer is

employed at the place of work, the employer or his
authorised manager shall forthwith inform the
chairman or the secretary of the committee of any
accident, near-miss accident, dangerous
occurrence, occupational poisoning or
occupational disease which has occurred at the
place of work, and the chairman or secretary shall,
as soon as it is practicable, after the committee
has inspected the place of work, convene a
meeting to investigate into such incident”
 Legal Requirements (continued)

(4) “ At the meeting of the committee convened

under subregulation (2) & (3), the committee shall
discuss the cause of the accident, near-miss
accident, dangerous occurrence occupational
poisoning or occupational disease and make
recommendations to the employer of the measures
to be taken to prevent the reoccurrence of such
incident.”
What is the Aim of an

Accident or Incident

Investigation?
 AIM of Investigation

 Comply with legal requirements

 Find the Root Cause

 Prevent the Occurrence of similar incidents

 Satisfy insurance claims

 Defend against liabilities

and NOT to apportion or assign the blame

What are the Results

of an Investigation?
 Investigation leads to

 Prevention of incidents recurring

 Identification of out-dated operation methods
 Improved work environment
 Increased productivity due to upgrading of
process system
 Raising of safety awareness and morale
 Lower medical costs due to fewer accidents
 Avoidance lawsuits or liabilities due to accidents
 Greater efficiency due to no work stoppages
The Investigation Process
 Investigation Process

Set up team Visit site

Draw up Terms of
Reference

Interview personnel
Finalise report
Present to
Management

Take photos

Consolidate facts
Analyse for root cause
Draw up recommendations Review documents
 Investigation Team

• Minor Incidents
• Relevant line supervisor should lead a team
of staff from line with HSE staff to facilitate
the process

• Major incidents
• Team to be lead by senior manager trained in
incident investigation and comprise of
experienced line and HSE staff

• Team to be mobilised to site as soon as possible

to ensure evidence of incident remains
undisturbed and to enable investigation to find
facts
 Site Visit

• Gather information on site affected by incident and

also the relevant procedures and HSE rules
• Isolate scene of incident and do not disturb
evidence
• Take photos, draw sketches, diagrams of the site
affected by the incident
• Interview relevant witnesses, affected or involved
parties and obtain facts not opinions or
assumptions
 Data Gathering (1)

1. Events leading to the Incidents

• System of work
• Work instruction
• Variations from safe practice/ Instructions
• Workplace conditions
• Environmental conditions
• Exact location of incident
• Materials/Equipment/ Tools used or
handled
 Data Gathering (2)

2. Facts of the Incident Itself

• State of work system

• Parties involved

• Materials/ equipment/ tools/ fixtures in direct

involvement

• List of Witnesses
 Data Gathering (3)

3. Relevant Facts of what happened immediately

after the incident

• Direct resultant injuries to people, damage to

assets or environment
• Events leading to consequential injuries or
asset/ environment damage
• Parties involved including emergency
response or recovery
• Effectiveness of emergency response or
recovery
 Interviews (1)

 Gather just the facts… make no judgments or

statements..no leading questions

 Conduct interviews one on one..give assurance

that no blame us to be apportioned to individuals

 Be friendly but professional..give appreciation

 Conduct interviews near the scene in private

 Interview all supervisors

 Interviews (2)

Ask All Witnesses

• Name, address, phone number

• What did you see?
• What did you hear?
• Where were you standing/sitting?
• What do you think caused the accident?
• Was there anything different today?
 Interviews (3)
Ask All Supervisors

• What is normal procedure for activities involved

in the accident?
• What type of training persons involved in
accident have had?
• What, if anything was different today?
• What they think caused the accident?
• What could have prevented the accident?
 Interviews (4)
Points to note during interviews

• who needs the information?

• does the person being interviewed want to be
involved?
• what is the work culture at the site – blame
culture?
• what language is to be used?
• do you need translators?
• where is the interview being held?
 Interview Questions

• OPEN - exploratory, seeking information/views,

through WHAT, WHY, WHEN, WHO,
WHERE & HOW type questions

• CLOSED - yes or no answers required to establish

facts

• LEADING - to set scene for discussion

• PROBING - seeking specific information, facts

• WHAT IF - seeking views and opinions

The Investigation Analysis
 Investigation Analysis Tools

There are many different approaches and tools

available to analyse investigation findings, the
main ones being:

1. The ILCI ( International Loss Control Institute)

Loss Causation Model

2. The TRIPOD – BETA Incident Investigation

Process
 The ILCI Loss Causation Model

Lack of Basic Immediate

INCIDENT LOSS
Control Causes Causes

People, Property,Process
Inadequate
Personal
Contact
Factors Substandard
with
Program Acts
Energy
and/or
or
Job Conditions
Substance
Factors
Standards

Compliance
 The ILCI Loss Causation Model
Definitions

Loss – harm to people, damage to property, process

interruption, reduced revenue

Incident – the event which results from contact with an

energy source that could or does cause harm or
damage

Immediate Causes – “unsafe acts” (behaviours that

could permit the occurrence of an
incident) and “unsafe conditions”
(circumstances that could permit
the occurrence of an incident)
 The ILCI Loss Causation Model
Definitions (continued)

Basic Causes – reasons why the substandard acts (unsafe

acts) occurred or why the substandard
conditions (unsafe conditions) existed
- sometimes referred to as root causes,
indirect causes, underlying causes

Lack of Control – refers to 3 areas

1. Too few proactive activities in the safety
programme
2. Standards set are not clear and not
specific
3. Non- compliance to set standards
 Incidents (as per ILCI)

• Striking against objects ( running or bumping into)

• Struck by objects ( hit by moving object)

• Falling to a lower level ( body falls or object falls)

• Fall on the same level ( slips, trips and falls)

•Overstress / overexertion / overload

 Incidents (as per ILCI)

• Caught in ( pinch and nip points)

• Caught on ( hung on to objects)

• Caught between ( crushed or amputated)

• Contact with ( electricity, heat, cold, radiation,

chemicals, noise etc.)

 Immediate Causes (as per ILCI)
Substandard Practice (Unsafe Act)

• Using defective equipment

• Using equipment improperly

• Improper lifting

• Not following procedures

• By-passing safety devices

• Not wearing correct PPE nor wearing PPE correctly

• Horseplay

• Operating without authority

 Immediate Causes (as per ILCI)

Substandard (Unsafe) Condition

• Inadequate guards or barriers

• Defective tools and equipment
• Congested areas
• Poor housekeeping
• Inadequate ventilation, illumination
• Exposures to noise, radiation, smoke, dust, chemicals
• Inadequate warning signs and systems
 Basic Causes (as per ILCI)
Personal Factors
• Lack of Knowledge
• Lack of Skill
• Inadequate motivation
• Physical/ psychological stress
• Inadequate mental/ physical capability

Job Factors
• Inadequate leadership and/or supervision
• Inadequate work standards
• Inadequate maintenance of tools and equipment
• Lack of proper tools and equipment
• Incorrect equipment and tools purchased,
 Lack of Control (as per ILCI)
Pre-contact
• Lack of risk prevention programme
• Lack of activities in safety programme
• Inadequate inspections/ audits and follow up on action items
• Lack of Training

Contact
• Not placing barricades to isolate scene of incident
• Not reducing the amount of energy released
• Not using less harmful substances
• Not modifying contact surfaces

Post-contact
• No proper emergency response plans
• Lack of resources and equipment to deal with emergencies
• Slow reaction to deal with emergencies and rectifying faults
 Example
An unprotected worker gets burnt when he
comes in hot pipes

Unsafe act

Worker does not

use gloves

Worker gets
burnt
Unsafe condition

Insulation is damaged
exposing hot pipes
 Example

Basic Cause – Job Factor

Gloves not
supplied

Worker does not

use gloves

Worker gets
burnt

Insulation is damaged
exposing hot pipes

Inspection
Not done

Basic Cause – Job Factor

 Example
Lack of Control
Insufficient stock Gloves not
In the store supplied

Worker does not

use gloves

Worker gets
burnt

Insulation is damaged
exposing hot pipes

Maintenance Inspection
schedule not Not done
coordinated

Lack of Control
TRIPOD –BETA Investigation

Methodology
 TRIPOD - BETA
•The TRIPOD - BETA methodology combines
concept of HSE Risk management and the accident
causation theory

•The incident facts are built into a tree diagram

showing:
• what happened
• what hazard was released causing the incident
• what or who was affected by the event
• which HSE risk management controls failed
• why each control failed – what was the latent
failure
Accident Causation Theory
 Tripod Accident Causation Chain

Latent Failures

Precondition

Active failures

Failed Barriers
or Defences
Understanding HSE Risk

Management
Activity or Condition which causes Recovery Measures
hazard release
Incident
Proactive
control

C
M O
P R
E
C
I N S
O
H T B T T
A H A
N
T I
S A O
Z R E
R TOP A G R
A R I Q
E EVENT A A
R I N U
A T
T
D
T
E M
E I
E E I
R N O
N
T O C N
N E R
S

Targets
 HAZARD

Anything which has the potential to cause harm,

including ill health and injury, damage to property,
products, the environment, production losses or
increased liabilities

Some examples

 Elevated Objects  Working at heights

 Hydrocarbons  Toxic substances
 Excessive Noise  Extreme temperatures
 Electrical energy  Radiation
 HAZARD

Toxic chemical

HC

under
pressure Transporting chemical

HAZARD

Treatment system
Pipeline
Effluent
 Top (First) Event

The first event that occurs on the release of a hazard

Some examples

 Loss of containment
 Exposure to toxic chemicals
 Contact with electrical energy
 Effluent discharge
 Falling objects from height
 Top (First) Event

Treatment system
Effluent

Discharge into
water, soil Toxic vapour
release

Toxic chemical
Air pollution

Transporting chemical
 Consequences

An event or a chain of events that results from the

release of a hazard

Some examples of Consequences

 Fatality  Hazardous Environment

 Injury  Burns
 Fire  Extreme Heat
 Explosion  Contamination of Environment
 Pollution  Loss of revenue
Consequences
 Threat
A possible cause that will release the hazard

 Thermal  Electrical
 High temperature  High voltage
 Chemical  Environmental condition
 corrosion  floods
 Biological  storms

 bacteria  Design
 marine growth  insufficient tolerances
 Kinetic  Human Factors
 fatigue  incompetence
 bad attitude
 Barriers

Protective measures that will prevent the threats

to cause the release of the hazard

 Procedures
 Guards or Shields
 Corrosion inhibitors
 High temperature cut-offs
 High pressure switches/ pressure relief valves
 Reduction in storage inventory
 Training
 Health surveillance
 Environmental monitoring
 Time delay switches
 Increasing space to reduce congestion
 Recovery Measures

All technical, organisational and operational

measures that limit the chain of consequences that
arises from the Top Event

 ESD, gas/smoke/fire alarms

 Emergency Response plans/procedures/drills
 Fire/blast walls
 Drain systems
 Clean- up, restoration
 First –aid, medical treatment
 Compensation
 Repairs
 Escalation Controls

Additional controls identified to takeover the

functions of barriers or recovery measures should
those initially identified be defeated or cannot
function as designed

 Procedures to adopt when equipment is being

maintained
 Additional shutdown equipment
 Oil spill booms
 Bundwalls
 Link with authorities for assistance in case
existing recovery facilities cannot cope
TRIPOD- BETA methodology
 Building a TRIPOD tree

Start by identifying:

 The EVENT ( or Incident) - where a hazard is

released and harm is done to people, property or
environment. The event that prompts an
investigation is usually the result of one or more
prior events

 The TARGET - people, property or environment that

was harmed

 The HAZARD - the thing that did the harm

The hazard or target may be the result of a

previous event
 Hazard – Event – Target (HET) Diagram

The HAZARD, EVENT and TARGET are built into the

HET diagram

Hazard

Event

Target

Note: For an event to occur there must be a hazard and a

target for the hazard to impact on
 Example

Hazard
Hot Pipes
Event
Worker gets
burnt

Worker

Target
 Example

Insulation – Barrier in place

Hot Pipes

No Event

Worker

PPE – Barrier in place

 Example

Insulation damaged –Failed barrier

Hot Pipes
Event
Worker gets
burnt

Worker

PPE not worn –Failed barrier

Investigation should be conducted

 What causes barriers to fail?

Active Failure – unsafe act or condition that caused the

barrier to be defeated

What causes Active Failures?

Precondition – personal factor or job factor that caused

the unsafe act or led to unsafe condition

What led to the Precondition?

Latent Failure – Root cause which is normally a

management or organisational failure
Latent Active
Precondition
Failure Failure

Insulation damaged

Hot Pipes
Event
Worker gets
burnt

Worker

PPE not worn

Latent Active
Precondition
Failure Failure
Maintenance Inspection Cladding
Schedule not done Worn out and
not coordinated not repaired
-reduced due to
cost cutting
Insulation damaged

Hot Pipes
Event
Worker gets
burnt

Worker

PPE not worn

Insufficient Gloves
Stock in Gloves not
supplied Not worn
store
 Complex Events

 The HET methodology can also be applied

in complex events
 Complex Events

Identify the prime Event, the Hazard, and Target.

Hazard

Event

Target
 Complex Events

If the target was created by a prior event …

Hazard

Event

Event
& Target
 Complex Events

Identify hazard and target for that event.

Hazard

Event
Hazard

Event
& Target
Target
 Complex Events

Similarly, if a consequential event happens ...

Hazard

Event
Hazard
Event
& Target
Target
Event
 Complex Events

because the prime event created a new hazard,

Hazard
Event &
Hazard hazard
Event
& Target
Target
Event
 Complex Events

identify the target for the new event.

Hazard
Event &
Hazard hazard
Event
& Target
Target
Event

Target
 Complex Events

Identify failed ‘barriers’,

Failed
barrier

Hazard
Event &
Hazard hazard
Event
& Target
Target
Event

Target
 Complex Events

and missing ones ...

Failed
barrier
Hazard
Event &
Hazard hazard
Missing Event
barrier & Target
Target
Event

Target
 Complex Events

including multiple failures ...

Failed Failed Failed

barrier barrier barrier
Hazard
Event &
Hazard hazard
Missing Event
barrier & Target
Target
Event

Target
 Complex Events

on each relevant ‘trajectory’ ...

Failed Failed Failed

barrier barrier barrier
Hazard
Event &
Failed hazard
Hazard
barrier
Missing Event
barrier & Target
Target Missing Event
barrier

Target
 Complex Events

until the Incident Mechanism is complete.

Failed Failed Failed

barrier barrier barrier
Hazard
Event &
Failed hazard
Hazard
barrier
Missing Event
barrier & Target
Target Missing Event
barrier

Target Missing
barrier
 Complex Events
Show the Active Failure, Precondition & Latent failure for
each failed / missing barrier

Latent Active
Precondition
failure failure

Failed Failed Failed

barrier barrier barrier
Hazard
Event &
Failed hazard
Hazard
barrier
Missing Event
barrier & Target
Target Missing Event
barrier

Target Missing
barrier
 The completed Investigation Tree

Latent Active
Precondition
Failure Failure

Latent Active
Precondition
Failure Failure

Latent
Failure Hazard
Failed Failed Failed Event
Barrier Barrier Barrier & Hazard
Hazard
Missing Event Event
Barrier & Target
Failed Missing
Target Barrier Barrier
Active
Failure Target Missing
Latent Barrier
Precondition
Failure
Latent Latent
Failure Failure
Latent
Precondition
Failure
 Latent Failures

Latent failures can be categorised into the

following General Failure Types (GFTs):

• Hardware (HW)
• Design Engineering (DE)
• Maintenance Mgmt. (MM)
• Procedures (PR)
• Error-enforcing conditions (EC)
• Housekeeping (HK)
• Incompatible Goals (IG)
• Communication (CO)
• Organisation (OR)
• Training (TR)
• Defences (DF)
 Latent Failures
1. Hardware (HW)
Failures due to poor quality of materials or
construction, ageing and non- availability of
hardware.
This GFT does not include
- error generated by poorly designed equipment
- hardware failures due to poor maintenance

2. Design (DE)
Deficiencies in layout or design of facilities,
plant, equipment and tools that lead to misuse
or unsafe acts
 Latent Failures

3. Maintenance Management (MM)

Failures in the systems to ensure technical
integrity of facilities, plant, equipment and tools.
Failures in the execution of maintenance are
included in other GFTs - Procedures, Hardware,
design, Communication etc.

4. Procedures (PR)
Unclear, unavailable, incorrect or unusable task
information that has been established to
achieve desired results
 Latent Failures
5. Error- enforcing conditions (EC)
Factors such as time pressures, changes in
work patterns, physical working conditions
(noisy, hot, cold) etc. acting on the individual or
in the workplace that lead to unsafe acts, errors
and violations

6. Housekeeping (HK)
Tolerance of deficiencies in conditions of
tidiness and cleanliness of facilities and
workspaces or in the provision of adequate
resources for cleaning and waste removal
 Latent Failures
7. Incompatible Goals (IG)
Failure to manage conflict; between
organisational goals, such as safety and
production; between formalised procedures and
informal work methods; between demands of
individual tasks and personal distractions and
pre-occupations

8. Communication (CO)
Failure in transmitting relevant information for
the safe and effective operation of the
organisation to appropriate parties in clear,
unambiguous and intelligble form
 Latent Failures
9. Organisation (OR)
Deficiencies in the structure of the company or
the way it conducts its business that allow
safety responsibilities to be ill-defined and the
overlooking of warning signs
10. Training (TR)
Deficiencies in the system for providing the
necessary awareness, knowledge or skill to the
relevant individuals in the organisation formally
and on-the-job
11. Defences (DF)
Failures in the systems, facilities and equipment
for control or containment of hazards or for the
mitigation of consequences resulting from
human or component failures
 The Tripod-Beta investigation benefits

 Brings a structure to investigation

 Helps distinguish relevant facts

 Makes causes and effects explicit

 Encourages team discussion

 Reduces the report writing task

 Reporting requirements

1. Incident Report form

2. Full investigation report

• Executive Summary
• Background to the incident
• Description of the incident
• Events leading to the incident
• Findings from site visits, interviews, document
reviews
• Investigation tree
• Immediate and root causes
• Recommendations