Presented By: Naman Shah Pakistan Refinery Limited

1. Presented By: Naman Shah Pakistan Refinery Limited Incident Investigation and Analysis

2. Incident Investigation and Analysis Tripod

3. Tripod Structure of the HSE Management System Leadership and Commitment Policy and Strategic Objectives Organisation, Responsibilities Resources, Standards & Doc. Hazard and Effects Management Corrective Action Planning & Procedures Monitoring Implementation Corrective Action & Improvement Audit Corrective Action & Improvement Management Review

4. Tripod framework Remove GENERAL FAILURE TYPES Active Stages Minimise Learn From HAZARDS DEFENCES UNSAFE ACTS INCIDENTS Improve Train & Motivate

5. Incident causation sequence Latent Stages Active Stages Management * Line Mgt Fallible decisions Line Mgt Latent failures “Sharp end” ** Preconditions Unsafe acts Incident Chronological sequence Causal sequence Safety Culture

6. Tripod - Breached Defences Breached Defences Breached Defences: what “last minute” measures failed or were missing? Barriers (Controls for Threats) Mitigation and Recovery Measures (for Consequences) . Awareness . Detection . Control . Protection / Containment . Escape and Rescue

7. Tripod - Unsafe Acts Unsafe Acts Unsafe Acts: which acts or omissions led directly to the accidents? Human errors Intended action Unintended action . Violation (1) . Mistake (2) . Lapses (3) . Slips (4)

8. Tripod - Preconditions which states of mind or of the system allowed the unsafe acts? • Preconditions can thus take both the form of a “state of mind” or “mental” precondition, or of a “physical” precondition. • Unfamiliarity, • Time shortage, • Poor system/human interface, • Technique unlearning, • Misperception of risk, • Time of the day, • Inexperience, • Poor instructions or procedures, • Inadequate checking, • Substance abuse, • Macho culture, • Physical capabilities exceeded, • Hostile environment, • Low morale, • Disturb sleep. .

9. Tripod - Latent Failures which underlying problems led to the preconditions? . Organisation . Incompatible Goals . Training . Error Enforcing Conditions . Communication . Maintenance Management . Design . Hardware . Procedures . Housekeeping . Defences .

10. Tripod Tree .

11. OVERVIEW of Investigation & Analysis INVESTIGATION Pre – Investigation PREPARATION Post – Analysis FOLLOW-UP • PLAN • Interpret Initial Incident Statement • Generate initial hypothesis • Develop investigation plan • - Ensure on-site safety • - Provide Emergency Response • - Notify relevant parties • - Collect initial data & evidence • - Generate Initial Incident Statement • - Classify incident • - Determine investigation level • - Form Investigation Team • Communicate findings to site • Avoid disciplinary actions • Peer review report • Prepare presentation • Communicate report internal • Review report • Brief external authorities etc. • Review report • Close – Out report • Record report to file • Publish ‘Lessons Learned’ • Implement recommendations • Monitor implementation • INVESTIGATE • Conduct investigation • ANALYSE • Conduct analysis • Identify recommendations • Generate report ANALYSIS