InvestigActionA cognitive and organizational tool for

learning from accidents and improving safety in oil and gas industry

Sebastiano BAGNARA and Roberta MORICI (Fondazione Irso) Davide SCOTTI (Fondazione LHS)

Alias Conference Florence, 14-15 June 2012

2

Outline

1.Reasons2.Objectives3.The approach4.The architecture5.The accident investigation protocol6.The AIP in the safety management processes7.The investigators

3

Saipem has already adopted in proactive safety policies, including a successful training program “Leadership in Health & Safety” (LiHS).

The success of the program has encouraged the organization to engage even more with the development of safety culture and new tools and methods of safety management.

Reasons

4

The current investigations are not satisfactory because conducted through heterogeneous processes and methods that produce non consistent and comparable outputs.

Moreover, spontaneous reports of erroneous actions, near miss or unsafe behaviors are very rare.

Reasons

5

Consequently, there is a general difficulty in generating remedial actions that can impact on both organizational and behavioral conditions

To overcome these shortcomings, it was decided to develop an investigation protocol customized for Saipem

Reasons

6

Develop a tool and a methodology of analysis / diagnosis of adverse events aimed at improving of safety.

Promote a culture of "active safety" to counter adverse events, coherent with the already initiated training program LiHS (Leadership in Health & Safety).

Objectives

7

Evolution of the concept safety in organizations:

From preventing undesirable states to the ability of the system to address undesirable cases

From pretending to reach zero risk, that is to prevent any uncertainty, accidents, breakdowns to the ability to ensure effective performance with results close to zero accidents, although operating in unpredictable environments and in inherently risky organizations

The approach

8

Two key principles:

Shift the focus of investigation from the search for guilty person(s) to make it a learning opportunity for the system

Understand the conditions of adverse events, i.e. the factors that can create the conditions for an accident or near miss.

The approach

9

Three key guiding questions:

There were defences?

How and why did the defenses fail?

What can be done to prevent a recurrence?

The approach

10

The approach

A combination of two views:

a) Organizational view:

Errors and violations are not only human errors, but they are socially organized, produced and reproduced by social structures within organizations and between organizations.

Human nature is fallible, but we can change the conditions within which people work.

11

The approach

b) Cognitive view:

People are fallible, but able to correct errors, to capture weak signals and to handle unexpected.

Understanding the cognitive factors that lead people to make errors allowsto distinguish the different types of errors and to identify the preventive and corrective measures most appropriate to the type of error,

increasing the system reliability.

12

The architectureMain components AimTaxonomy of human error To understand the cognitive

factors that lead people into error and codify the type of error

Scope Error detection and correction

Organizational latent Identifying the latent factors conditions (defenses, barriers, controls,

etc..) that make the scenario accident prone

Scope Organizational resilience

13

The Accident Investigation Protocol

The investigation protocol is a tool and

a methodology of analysis / diagnosis /

interpretation of adverse events oriented

to the improvement of safety conditions.

14

The Accident Investigation Protocol

A tool: What to investigate The fact (data /information /documents to collect)

The context

The cognitive factors

The organizational conditionsTHE METHODOLOGY:

“HOW” TO INVESTIGATE

15

The Accident Investigation Protocol

A methodology: How to investigate

How to conduct the inspections

How to conduct the interviews

How to interpret and represent data collected

How to diagnose

How to identify key learning lessons for the system

16

The Accident Investigation Protocol

EVENT REPORTING

INVESTIGATION TEAM ACTIVITIES

EVENT MANAGEMENT

Deliverables

Guideline/checklist?

Attachments

The protocol is structured as a sequence of activities. For each activity, there is a form to fill out and a guideline.

DIAGNOSIS

ANALYSIS

INTERPRETATION

ACTIVITIES

ACTIVITIES

17

The Accident Investigation Protocol

analyzes all events, be they accidents or near misses, as a source and learning opportunity for the improvement of safety in the organization;

emphasizes a systemic and organizational view of adverse events, moving away from a blame culture;

defines investigation roles, responsibilities and activities in a clear, transparent and uniform way;

.

18

The Accident Investigation Protocol

promotes the collaboration of all actors involved, especially witnesses and workers on site (often frightened and fearful) with the aim of understanding the actual mechanisms that can lead to adverse events;

focuses attention on the effective implementation of improvement actions;

is consistent with the strategies adopted and investments made for the safety improvement;

is a tool for communication and training on safety culture.

19

The Protocol is a tool within the investigation phase in the safety improvement process

PREVENTION

INVESTIGATION

SAFETY IMPROVEMENT

LEARNING AND COMMUNICATION

CommitmentSafety planSafety culture

SECTION AEvent Reporting

SECTION BInvestigation TeamAnalysisInterpretationDiagnosis

Communication of alerts Approval of corrective actionsInvestigation debriefingImplementation of corrective actionsSharing of conditions

TrainingCommunicationKnowledge sharing

LOW RISK EVENT

MEDIUM RISK EVENT

HIGH RISK EVENT

Saf

ety

im

pro

vem

ent

pro

ces

s

Inve

stig

atio

n p

roce

ss

20

A further step:The investigators

The protocol implies the design of the role of the investigator and its training and of its credibility towards all players in the system through the clear definition of objectives, activities and expected outputs.

The role of investigators together with its ad hoc training will be designed next

21

Thank you for the attention

Contacts

Fondazione IrsoThe IRSO Foundation - Research Institute of Organizational Systems - founded by Federico Butera in 1974 - has been for over thirty-five years one of the leading centers of Italian organizational culture. It conducts research, organizational consultancy and specialized training programs in private organizations and public administrations. Its social purpose is to generate and disseminate new forms of organization culture and work to promote competitiveness and economic prosperity, environmental and social sustainability, quality of working life.

Sebastiano BAGNARAsebastiano.bagnara@gmail.com Roberta MORICI roberta.morici@irso.itFondazione IrsoPiazza Giovine Italia, 320123 MilanoTel: +39 02 48016162info@irso.itwww.irso.it

Contacts

Fondazione LHS The LHS Foundation is a non-profit organization aiming to change the approach to health and safety by introducing an innovative method which is capable of influencing people’s behavior on a long term basis. The LHS Foundation offers a team of professionals, specialists in a range of disciplines (Psychologists, Trainers, Coaches, Communication Experts), each of whom works continuously to identify a model of integrated consultancy that can communicate and promote a culture of prevention in an effective and engaging way, both at home and at work, from top management to on-site workers, from primary school teachers to young students.

Davide SCOTTIDavide.Scotti@saipem.comFondazione LHSVia Martiri di Cefalonia 6720097 San Donato Milanese (MI)Tel. (+39) 02 520 54230info@fondlhs.orgwww.fondlhs.org