Tripod Beta – The forgotten next step

1. Tripod Beta – The forgotten next step Improving consistency of TRIPOD analysis and usage for managing HSE Daan Dankaart, Senior Safety Adviser Shell Nederland Chemie BV

2. Tripod Beta – The forgotten next step Improving consistency of TRIPOD analysis and usage for managing HSE Shell Nederland Chemie BV Norbert van Duuren, Safety Adviser

3. Latent Failures Hazards and Unsafe Acts Accidents Historic perspective We came from: “Blaming the poor guy who handled erroneously” • and we went to • understanding the relations • between: • Fallible decisions • Latent Failures • Preconditions • Active Failures • Incidents

4. TRIPOD philosophy

5. Current TRIPOD Beta diagram (simplified)

6. Where we were in 1996 • Making benefit of the TRIPOD philosophy: • Answering the “why” questions at the root of the erroneous handling of the individual(identifying the systemic causes of incidents) • Improving the quality of the “fact finding” as a spin off of the depth of the TRIPOD investigation but recognising • That a TRIPOD BRF-profile did not provide sufficient granularity on what’ caused incidents to happen: • The eleven Basic Risk Factors were too generic to point in a transparent and consistent way towards how the management controls would have to be corrected or improved

7. Improvement in 1996

8. Achieved in 1996 • Increased quality of HSE-management: • In the improvement of the management system and management controls, the ACT-phase of the Deming Cycle is linked to the CHECK-phase • The “PLAN – DO – CHECK – ACT – PLAN” is closed • Systemic Failures lead to corrective actions at managerial level Deming Cycle

9. Where we were in 2005 • Making benefit of the TRIPOD philosophy: • Answering the “why” questions at the root of the erroneous handling of the individual(identifying the systemic causes of incidents) • Improving the quality of the “fact finding” as a spin off of the depth of the TRIPOD investigation • Defining generic improvements to management controls, but this was done in a rather awkward way but recognising • Inefficiencies in the TRIPOD process until then: • Inconsistencies in classifying systemic causes into their Basic Risk Factors • Inefficiency in subdividing the Basic Risk Factors into manageable topics

10. What we changed in 2005 • Usage of CausedBy/LeadsTo checklists to increase consistency of selection • From 48 ad hoc defined categories to 144 CausedBy-categories • See next slide for an example • Recording the CausedBy-classification in the Tripod analysis in the current Incident registration system (SCIPR) • See next slide for an example

11. Example of CausedBy/LeadsTo checklist

12. What we changed in 2005 • Usage of CausedBy/LeadsTo checklists to increase consistency of selection • From 48 ad hoc defined categories to 144 CausedBy-categories • See next slide for an example • Recording the CausedBy-classification in the Tripod analysis and in the current Incident registration system (SCIPR) • See next slide for an example

13. What we changed in 2005

14. What we achieved 2005: understanding what failed and what to do (Detailed diagnosis and defined treatment) 1990: man at blame 2006 onwards: improving our HSE-MS 1996: understanding Systemic Failures (Diagnosis)

15. Prospect • Although the first multi-incident Tripod analysis is scheduled for early 2007 (derived from the 2006 single-incident TRIPOD analyses), trials have already demonstrated that the last changes can be considered to be substantial improvement: • Consistency will increase substantially due to the checks enabled by the CausedBy-sentences • Efficiency will increase because of the easy reporting of Tripod Basic Risk Factors and their CausedBy-categories • Increased buy-in for modifications or corrections of HSE-management system and management controls