Presentation Layout - Tripod-BETAPresentation Layout - Tripod-BETA

•Where it fits in the HSE MS structure.

•Accident mechanism using Bow-tie concept (What happened.)

•Tripod Causation Path (Why it happened.)

•Illustrations using Trees of recent incidents.

•Benefits of Tripod-BETA methodology.

•Next Steps for Managers.

•Tripod-BETA Project Schedule.

•List of Trained Persons.

Structure of the HSE Management System

Leadership and Commitment

Policy and Strategic Objectives

Management Review

Corrective Action & Improvement

Audit

Organisation, ResponsibilitiesResources, Standards & Doc.

Corrective Action & Improvement

Tripod Beta

Monitoring

Planning & Procedures

Hazard and Effects Management

Implementation

Corrective Action

An Accident through the Bow-tie Concept

CONSEQUENCES

BARRIERS

Undesirable event withpotential for harm or damage

HAZARD

Harm to people ,assets reputation or environment

Fault Tree Event Tree

Engineering activitiesMaintenance activitiesOperations activities

Investigation path

FallibledecisionsFallibledecisions

LatentfailuresLatentfailures

Pre-conditionsPre-conditions

Unsafe actsUnsafe acts

SystemdefencesSystemdefences

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.

Tripod-BETA tree

Targete.g. operator

Hazarde.g. hot pipework

Event(Operator gets burnt)

Active FailurePreconditionLatent Failure

Active FailurePreconditionLatent Failure

FailedDefence

FailedControl

Galfar Fatality from Loading Pipes at Marmul, Oman.Galfar Fatality from Loading Pipes at Marmul, Oman.

Link to: Galfar Fatalityfrom Loading Pipes at

Marmul, Oman -Cont'd.

Crew used the scheduledbut "inappropriate"

vehicle

STOP (UAA)

Crew's HSEAwareness

Wrong vehicle scheduledfor the job

Crew

Site Management/Supervision

Active Failure

Failed to recognisehazards of pipe handling

/transportation

Procedure for PipeHandling

/Transportation

Galfar Work Planner,unaware of the hazards.

Precondition

Inadequate competencein hazard awareness for

crew members

Contract HSE Plan(HEMP Analysis)

Active Failure

Highlighted hazard but feltnot empowered to stop

work

Active Failure

Failed to recognisehazards of pipe handling

/transportation

Active Failure

Hazards for pipetransportation not

identified

PR PR PRLat.Failure

No integrated procedurefor pipe handling &

transportation in GALFAR

TR TR TRLat.Failure

Ineffective HSEcompetence dev. system

for workforce

Pipe Handling andTransportation

Precondition

Functional Demarcation

Precondition

Perception of notempowered to stop the

work

Precondition

Inadequate competencein hazard awareness for

the supervisors

Precondition

Assumption that hazardwould be covered bymaterial handling and

material transport

CO CO COLat.Failure

Inadequatecommunication about

empowerment

OR TR TRLat.Failure

Inadequate HSEcompetence dev. system

for supervisors

OR CO COLat.Failure

Inadequatecommunication across

functions

OR OR ORLat.Failure

Failed to recogniseinterdependency between

hazards

Galfar Fatality from Loading Pipes at Marmul - Cont’d.Galfar Fatality from Loading Pipes at Marmul - Cont’d.

Victim hits head on floorand died

Hard Hat

Hard Floor

Rolling pipe hit andknocked victim off height

Pipe Stops

Victim on vehicle (atheight)

69 kg pipe being stackedstart rolling

Active Failure

Incorrect use of hard hat(not wearing the chin

strap)

Active Failure

Stacked pipes two rowswhere "unintended" stop

is shorter than dia. of pipe

Active Failure

No tool box talk wasconducted

Tool box talks

Pipes being stacked

Precondition

Lower perception of riskover time

Precondition

Vehicle not designed forcarrying such load

Precondition

Perception that risk wasinsignificant

Precondition

Requirements were notclearly defined

Link from: GalfarFatality from Loading

Pipes at Marmul,Oman.

DF DF DFLat.Failure

Hard hats not designedfor side impacts

OR OR TRLat.Failure

Inadequate vehicleselection

OR OR TRLat.Failure

Inadequate HSEcompetence dev. system.

PR PR PRLat.Failure

Inadequate HSEstandards/ documentation

on tool box talks

Food Poisoning Incident at TOCO Camp in Saih RawlFood Poisoning Incident at TOCO Camp in Saih Rawl

Potential MultipleFatalities from Diarrhoea

ER / Medevac

!

Emergency Situation

Site Nurse

75 workers affected bythe food poisoning

Audits/ Inspections

Workers on the TOCO flycamp

Supervision by theCamp Boss

Competence of theFood Handlers

Active Failure

Inadequate hygieneknowledge by Food

Handlers

Active Failure

Failed to recognise theinadequacies with

equipment and personnel

Active Failure

Inadequate inspectionstandards /checklist

Active Failure

Carried out as a merepaper exercise without

reference to spec.requirement

HSE StandardsManual on Catering

Precondition

Checklist offered too littlehelp in the completion of

the task

Precondition

Important information wasnot being requested by

the appropriate person(s)or department(s)

Precondition

There was no orinsufficient oversight or

'grip' on all activitieswithin the company

Precondition

Employees withinsufficient ability to carryout the task were involved

Catering Hazards (Food/Water Poisoning

Bacteria)

OR OR ORLat.Failure

Management prioritieswere wrongly assigned

OR OR ORLat.Failure

Guidelines on minimumtraining and experiencerequirements for Food

Handlers were

PR PR PRLat.Failure

Checklist formatspecifications were

inadequate

OR OR TRLat.Failure

Training for Public HealthInspector on IndustrialHygiene was ineffective

Food Poisoning Incident at TOCO Camp in Saih RawlFood Poisoning Incident at TOCO Camp in Saih Rawl

Potential MultipleFatalities from Diarrhoea

ER / Medevac

!

Emergency Situation

Site Nurse

75 workers affected bythe food poisoning

Audits/ Inspections

Workers on the TOCO flycamp

Supervision by theCamp Boss

Competence of theFood Handlers

Active Failure

Inadequate hygieneknowledge by Food

Handlers

Active Failure

Failed to recognise theinadequacies with

equipment and personnel

Active Failure

Inadequate inspectionstandards /checklist

Active Failure

Carried out as a merepaper exercise without

reference to spec.requirement

HSE StandardsManual on Catering

Precondition

Checklist offered too littlehelp in the completion of

the task

Precondition

Important information wasnot being requested by

the appropriate person(s)or department(s)

Precondition

There was no orinsufficient oversight or

'grip' on all activitieswithin the company

Precondition

Employees withinsufficient ability to carryout the task were involved

Catering Hazards (Food/Water Poisoning

Bacteria)

OR OR ORLat.Failure

Management prioritieswere wrongly assigned

OR OR ORLat.Failure

Guidelines on minimumtraining and experiencerequirements for Food

Handlers were

PR PR PRLat.Failure

Checklist formatspecifications were

inadequate

OR OR TRLat.Failure

Training for Public HealthInspector on IndustrialHygiene was ineffective

Tripod-BETATripod-BETA• Brings a structure to investigation• Helps distinguish relevent facts• Makes causes and effects explicit• Encourages team discussion• Reduces the report writing task• Helps Increase quality of corrective actions

Next Steps for Managers•Insist on Tripod for High Risk Incidents•Nominate key staff for the Sept. 15th

course

Line Personnel Trained on Tripod-BETALine Personnel Trained on Tripod-BETA

Peter Jongens OIE/2

Yaqoob Al-Kiyumi OQO/11

Khalid Al-Zeedi OQO/13

Hamoud Al-Habsi OQO/19

Mohsin Al-Amri OQO191

Mark Crowther OIT/5

Mohamed Al-Harthy XGP/15

Xavier Shelton Jeganathan OBE/1

Kamil Siad Al-Dhamri OBE/55

Sami R. Baqi Al-Lawati OBE/5

Fareed Ali Said Al-Hinai OYS

Shukry Al-Suleimany OYO/15

Said Hamed Al-Hinai OFO/1L

Abdullah Al-Khanjary OQO/14

Hanif Qadir OQO/141

Saleh Al-Hammad OBE/35B

Ali Al-Harrasi OYO/1

Saif Al-Sumry OIE/34

Gerard Flanagan GGO

Mahmood Al-Shaqsy HES6

Suleiman Al-Wardy OFS/1F

Alan Busby

Arjan Ros

Richard Kraak OIP/4