Incident Analysis and Root Cause Identification for Enhanced Safety Management

2. Goals Learning from incidents and near misses (near hits) Generate feasible recommendations Improve the Safety Management System Prevent similar and other incidents

3. Risk Management Plan Check / Monitor Do Implement & communicate the management system BSCAT | Tripod Beta | BFA | RCA

4. Timeline Always activated 3 notbarrier based incident models RCA TOPSET RCA (new!)

5. Non barrier incident models TimelineAnalyze the role of actors during an incident in a timely order RCA (Root Cause Analysis)Conduct an investigation by asking why until you find the root cause TOPSET RCAFind the root cause of the incident by summarizing the evens and failures

6. Tripod Beta 3 barrier based incident models BSCAT Barrier Failure Analysis

7. Barrier based incident models Tripod BetaInvestigate high risk, complex incidents in a detailed manner Barrier Failure AnalysisAsses and analyze the performance of your barriers during an incident. BSCATAsses and analyze the performance of your barriers during an incident

8. Barrier Failure Analyzis (BFA)Two ways of performing • “Free form”: 7 steps • Start with clean slate • Freely define events • Freely identify barriers • Link with BowTie after completion • BFA from BowTie: “Templated” • Reuse BowTie data • Select relevant BowTie arms • Identify barrier status • Automatic link with BowTie

9. BFA in 7 steps Fact finding: Timeline Event chaining Identifying barriers Assessing barrier state Causation analysis & categories Recommendations Reporting / link to bowtie diagram

10. BFA example

11. Different barrierstates The barrier functioned as planned and stopped the next event in the incident scenario. e.g. Seatbelt which prevented a fatality. The barrier stopped the next event in the incident sequence, but the organisation is uncertain if it will do so in the future. e.g. Seatbelt prevented a fatality, but the seatbelt is not always worn in the organization. The barrier functioned as intended by its design (envelope), but was unable to stop the sequence of events. e.g. Seatbelt was worn but it broke because it was not designed to withstand forces of impact which it encountered during the incident. The barrier was implemented, but did not function according to its intended design. e.g. Seatbelt did not prevent a fatality, because it was not worn. The barrier was described in the organization’s SMS or was considered an industry standard, but it was not successfully implemented. e.g. Seatbelt is described in policy and acquired, but was not yet placed in the vehicle.

12. Step 5: BFA analysis • Primary Cause • What exactly happened? • Secondary Cause • Why did it happen? • Tertiary Cause • How could the management prevent it?

13. Main Cause – Effect relationships Barriers: failed, missing, unreliable, inadequate, effective Causation path (incl. root causes)

14. BFA construction in BowtieXP

15. New features BowtieXPIncident grouping

17. Barrier-based audit Easy to spot weak spots Intuitive display Results focus on risks and barrier performance, not categories

18. Traditional audit Maintenance Training & Competency Work procedures Time scheduling Management system

19. Barrier audits Training & Competency Maintenance Work procedures Time scheduling Management system

20. Barrier components Maintenance Is the extinguisher in proper condition Training Do people know how to use it? Procedures Do people know where to find it? Barrier suitability Is this type of extinguisher suitable for the fire types that may be expected?

21. Scenario advantage Traditional Barrier-based Maintenance Compliance 95% Training Compliance 90%

22. Process of audit creation Define the scope Create the questions Link questions to barriers Create the survey Distribute and collect Interpret results

23. Survey to result