#1BAKERRISK Identify | Evaluate | Solve Guidelines for Investigating Process Safety Incidents Third Edition, CCPS Hazards 29 - Incident Investigation Roger Stokes BSc CEng FIChemE MInstPet Thursday 23 May 2019 | 16:25 PM-16:50 PM CZW1 1#2About CCPS • Center for Chemical Process Safety • March 1985, in response to Bhopal, AIChE formed CCPS with seventeen charter member companies. An AIChE Technology Allione CPS Center for Chemical Process Safety www.aiche.org/ccps • A collaborative effort to eliminate catastrophic process incidents by advancing state of the art technology and management practices, serving as the premier resource for information on process safety, supporting process safety in engineering, and promoting process safety as a key industry value • Now over 100 member companies including most of the world's leading chemical, petroleum, pharmaceutical and related manufacturing companies. • Over 100 books and products BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 2#3BAKERRISK Guidelines for Investigating Chemical Process Incidents Second Edition 2003 CCP OVERW DENOLPROXIM WENT An AKCHE industry echnology Alano Evolution GUIDELINES FOR INVESTIGATING PROCESS SAFETY INCIDENTS 3 THINGS EDITION 2019 CPS WILEY Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 3#4Acknowledgements - CCPS & Subcommittee Jerry Forest Michael Broadribb • Dan Sliva CCPS Staff Liaison Celanese (Chair) - Muddassir Penkar Evonik Canada Inc. Morgan Reed BakerRisk Laurie Brown Eastman Meg Reese Exponent Occidental Chemical Corp. Chonai Cheung Contra Costa County Marc Rothschild DuPont Eddie Dalton BASF Joy Shah Reliance Industries Ltd Carolina Del Din PSRG Dan Sliva CCPS Staff Advisor Scott Guinn Christopher Headen Chevron Corporation Bob Stankovich Eli Lilly Cargill Lee Vanden Heuvel ABS Consulting Kathleen Kas Dow Chemical Company Terry Waldrop AIG Mark Paradies Nestor Paraliticci System Improvements Inc. Andeavor Scott Wallace Olin Della Wong BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 Canadian Natural Resources#5Acknowledgements - Peer Reviewers Amy Breathat Steven D. Emerson Patrick Fortune NOVA Chemicals Corporation Emerson Analysis Suncor Energy Walter L. Frank Frank Risk Solutions Barry Guillory Jerry L. Jones Gerald A. King Susan M. Lee William (Bill) D. Mosier Mike Munsil Pamela Nelson Katherine Pearson S. Gill Sigmon BAKERRISK Louisiana State University CFEISBC Global Armstrong Teasdale LLP Andeavor Syngenta Crop Protection, LLC PSRG Solvay Group BP Americas AdvanSix Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 LO 5#6BakerRisk Project Team Quentin Baker Michael Broadribb Cheryl Grounds Thomas Rodante Roger Stokes BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 6#7Major Process Safety Incidents since 2003 2003 Repsol Puertollano Refinery Explosion - • 2004 - Sonatrach Skikda, Algeria Explosion 2005 - BP Texas City Explosion 2005 HOSL Buncefield Explosion - 2008 Alon Refinery Explosion - 2009 - Caribbean Petroleum Explosion • 2010 - BP Macondo/ Deepwater Horizon 2011 - TEPCO Fukushima Daiichi BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 7#8Major Process Safety Incidents since 2003 2012 Chevron Richmond Refinery Fire - 2013 - Williams Olefins Explosion / West Fertilizer explosion 2014 - Shell Moerdijk Explosion • 2015 ExxonMobil Torrance Refinery Explosion - 2016 - BASF Ludwigshafen ethylene pipeline explosion • 2017 - Grenfell Tower Fire 2018 Bayernoil, Germany Explosion - BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 80#9Incident Investigation Developments 2003-2019 Methodologies used to investigate process incidents Attitudes about investigation focus and practices Technological developments Regulatory agency expectations Legal rulings regarding admissibility of evidence and expert opinions BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 9#10• . Focus of Third Edition Primarily process safety incidents, but concepts equally applicable to other potentially hazardous industries - Manufacturing/ mining o Construction Transportation Emphasis on investigating near-misses and minor incidents 。 Had the potential for significant damage/injury and should be considered for a higher level of investigation commensurate with the potential consequence. • Witness management, evidence analysis, the scientific method, and human factors • To be more global 。 Flexibility in the investigation approach for varying regulatory, industry, cultural, and situational considerations. BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 10 10#11Role of Third Edition Detailed reference on investigation of process safety incidents in processing facilities Guideline 。 Cultures 。 Corporate approaches ○ Experience level • Several suggested methodologies for activities including: ○ Timeline development o Causal Factor Determination o Root Cause Determination BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 11 11#12Target Audiences Company management 。 Chapters 1 - 4 (Introduction, Incident Causation, Overview of Investigation Methodologies, and Designing an Incident Investigation Management System) Novice investigator 。 Guide for learning the entire investigation process. • Experienced investigators o Reference when they require information on a specific subject or a refresher on a topic. BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 12#13• Terminology Incident An unusual, unplanned, or unexpected occurrence that either resulted in, or had the potential to result in harm to people, damage to the environment, or asset/business losses, or loss of public trust or stakeholder confidence in a company's reputation. BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 13 13#14Terminology Near-Miss (Near Hit) • Follows the lead of HSE Guide 245 and API RP 585 in treating a near-miss as an incident. • Significant philosophical shift as many companies have treated near-misses as events that did not have to be investigated like accidents. The book encourages investigating near-misses with the same rigor as accidents based on potential severity (damage/injury) of the near miss. o A Free Lesson BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 14#15• Terminology Causal Factor A major unplanned, unintended contributor to an incident (a negative event or undesirable condition), that if eliminated would have either prevented the occurrence of the incident, or reduced its severity or frequency. Root Cause A fundamental, underlying, system-related reason why an incident occurred that identifies a correctable failure(s) in management systems. There is typically more than one root cause for every process safety incident. BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 15#16• · ● Organisation of the Book Overview of Investigations ○ Introduction to Investigations o Incident Causation 。 Overview of Investigation methodologies Designing an Investigation Management System Responding to an Incident o Initial notification and classification of an incident ○ Building/ leading an investigation team 。 Witness Management / interviews o Evidence identification, collection, and management ○ Analysing data BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 16#17• Organisation of the Book Determining Causal Factors • Determining Root Causes • The Impact of Human Factors • • • Developing Recommendations Preparing a Report Implementing Recommendations Sharing and Institutionalising Lessons Learned • Improving the Investigation Program . ⚫ Checklists 。 Evidence preservation, the investigators toolkit, report writing, auditing BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 17#18Book / Incident Flowchart The Incident Investigation Management System Chapter 4 Determine Root Causes Chapters 10 & 11 Appropriate Team Members Trained on Causation Theory, Investigation Methodologies, and Management Systems Chapters 2, 3, & 4 Develop Recommendations Chapter 12 Incident Occurs and Notification Made Chapter 5 Activate Investigation Team and Develop Specific Action Plan Chapter 6 Gather, Document, Preserve Evidence Chapters 7 & 8 Analyze Evidence and Identify Causal Factors Chapter 9 BAKERRISK Develop Incident Report Chapter 13 Implement Recommendations and Ensure Follow up Chapter 14 Critique and Constantly Improve the Management System Chapter 15 Share Lessons Learned Chapter 16 Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50#19Notification and Classification Legal / agency/corporate / stakeholder requirements Classifying incidents and determining appropriate level of investigation. ○ A near-miss that potentially could have been a severe incident would be investigated in the same way as a major incident ○ Tiered approach (e.g., based on API RP 754 / CCPS metrics & severity categories) • Logic Tree o Risk Matrix BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 19#20Investigation Methodologies Informal, One- Brainstorming on-one Traditional, Informal Investigation usually performed by immediate supervision Judgment/ experience to find credible causes. Structured brain- storming may employ tools such as What-If and 5- Whys. Increasing Structure Process of Elimination Eliminates potential causes. and the cause(s) not eliminated are concluded to be the final cause(s). Timeline Sequence Diagram Chronological listing of events using a variety of formats from simple sequential list to diagrams showing events/ conditions along a straight axis. Graphical depiction of timeline that allows investigators to exhibit related events and conditions in parallel branches. BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50#21Scientific Method Test hypotheses based on Investigation data, to prove disprove them, and Iteratively resolve to the final hypothesis using scientific approaches. BAKERRISK Investigation Methodologies Causal Factor Identification Negative events, conditions, and actions that made major contributions to the incident. Tools such as Barrier Analysis and Change Analysis may be used. Increasing Structure Checklists Review of causal factors against Investigative checklists to determine why that factor existed. A combined what- if/checklist approach may be used. Pre-Defined Trees Logic Trees Ready-made tools. Investigators apply causal factors to each branch in turn, disregard those branches that are not relevant to the specific Incident. Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 Tools using a multiple cause, system-oriented approach to determine root causes integrated with a PSM program. E.g.: fault tree, event tree, causal tree, why tree.#22● Objectivity of Investigations Scientific method used to objectively, systematically, and scientifically determine the causal factors. Supports latest guidance in NFPA 921: Guide for Fire and Explosion Investigations, 2017 Helps to avoid bias o Pre-conceptions (confirmation bias) / hindsight bias BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 22 22#23BAKERRISK Scientific Method 1. Define the problem 2. Collect data 3. Analyze the data 4. Develop a hypothesis (inductive reasoning) 5. Test the hypotheses (deductive reasoning) 6. Select final hypothesis Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 23#24Scientific Method Example - Seal Leak Potential cause Poor installation by one fitter Poor installation by all fitters Overpressure Generic seal problem Component problem BAKERRISK Verification Review of maintenance history where similar work carried out Review of maintenance procedures with all fitters concerned Review of DCS data Background gas level measurements Review spares stock against manufacturer's specification · Finding Leaks have occurred where other fitters have installed seal Hypothesis FALSE No evidence that the work was being done differently to that in FALSE the manual No evidence of overpressure Slight rise in average toxic gas levels for past 18 months (not acted upon) Spares supplier changed 2 years previously. Same spec but slight difference in compressibility of O-ring seal Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 FALSE CONFIRMED CONFIRMED 24 24#25Identify: Witnesses Interviewers Plan Interview locations Determine: Order of interviews Witnesses and Interviews Open Ended Questions Long answers Interview schedule Core topics/questions Whether/how interviews will be recorded Documents that will be available during the interview Reference information that will be available during the interview Closed Ended Questions Short answers Wrap Up Summarize and review with witness to confirm Document observations Identify follow-up items Establish Rapport Introductions (if necessary) State the purpose BAKERRISK YES Second Follow up interview needed? Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 Provide Report NO 25 25#26Evidence Collection/ Analysis Witness-sensory information. Witness task knowledge What was seen, heard, smelled, felt What they were doing, what others were doing Witness personal electronic device Physical evidence Captured data, sound, video, timestamps, etc. Position, condition Materials analysis Paper records System electronic data Etc. (Chapter 8) Generating new information needs Evidence Analysis and Hypothesis Testing (Determining What Happened) BAKERRISK Analyzing Data for causal factors (Chapter 9) Determining Root Causes / Human Factors (Chapters 10-11) Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 26 26#27Investigation Team Activities LOSS REPORT INTERVIEWS VOICE RECORDINGS PHYSICAL MODELING EQUIPMENT RECORDS WHO - WHAT - WHEN WHERE-HOW - WHY INVESTIGATION TEAM COLLABORATION SEQUENCE OF EVENTS ROOT CAUSE ANALYSIS DISCUSS FINDINGS, CONCLUSIONS AND RECOMMENDATIONS REPORT RECOMMENDATIONS BAKERRISK PHOTOGRAPHS AND VIDEOS PHYSICAL MEASUREMENTS PROCESS DATA FORENSIC REPORTS Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 FOLLOW-UP#28• • Recommendations – clarification of roles Recommendations developed in collaboration with the management team. Implementation of the recommendations - management's role. • Decision whether to restart a process - management's role. • Decision on partial restart (major incident, lengthy investigations) - management's role but based on Interim reports / recommendations. BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 28#29Lessons Learned Expanded to include: • • • • Sharing at local level Sharing more broadly within the company Sharing with outside industry o Regulatory / litigation issues Receiving lessons from industry 。 Why we're here BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 29 29#30Summary of key developments - Edition 3 • Treat near-misses as incidents • Decision on the level of investigation based on the potential severity of the incident • Scientific method was added to the book to improve objectivity of investigations • Roles of the investigation team and management in implementing recommendations and deciding on restarting processes were clarified • Methods are suggested on sharing lessons learned both internally and externally as well as institutionalising them BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 30 30#31• Conclusions The new book is a comprehensive guide to investigating incidents - not just on chemical/ process plant It also guides the reader through the management systems and processes that are required to have an effective incident investigation system. If you are looking for a comprehensive reference for incident investigation you might find it a useful addition to your library and reading material Note: We are not on commission! BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 31#32Roger Stokes Contact Us Thornton Science Park, Ince, Chester CH2 4NU +44 (0) 1244 405960 [email protected] BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 32 32#33BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 33#34Chapters 1. Introduction 2. Overview of Causation 3. Overview of Methodologies 4. Design of Incident Investigation Management System 5. Initial Notification, Classification and Investigation of Process Safety Incidents 6. Building and Leading an Incident Investigation Team 7. Witness Management 8. Evidence Identification, Collection and Management 9. Evidence Analysis and Causal Factor Determination BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 34#35Chapters 10. Determining Root Causes-Structured Approaches 11. The Impact of Human Factors 12. Developing Effective Recommendations 13. Preparing the Final Report 14. Implementing Recommendations 15. Continuous Improvement for the Incident Investigation System 16. Lessons Learned - Institutional Knowledge • Numerous Checklists O 。 Evidence preservation, the investigators toolkit, evidence preservation, report writing, auditing, BAKERRISK Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50 35 55