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5 items to gather before Investigating things that go wrong?
16 August 2020
Follow  up to assist new member, who may want to raise a post to wells problems that may arise or has been experienced. Please consider the 5 items to gather and the example attached prior to raising your post. Appreciated. 

Further though comments, learning to share, all further comments welcomed. 

Want to know how to then start gathering the events evidence without assigning blame? We can follow up in a further post if interest is shown. 

Gather the five (5) items.

The standard starting point to commence working towards both active and latent cause analysis failings within an investigation Is to first and foremost gather the following 5 items, i.e. before posting on this forum.

 

1.    Simple Statement.

2.    Simple (hand drawn) Schematic.

3.    (hand drawn) Relationships

4.    Short Summary sequence of events and

5.    Oddities (these always exist)


(Please refer to accident case study example file as attached)

 

5 items guideline notes.

1.      Accident / Incident near miss Statement

Construct one or two paragraphs. Intent is to be brief, to the point. Should be written by one person to summarize ESSENTIALS so that evidence freezing can begin immediately.

 

Hint: The accident / incident descript statement should read like a paragraph in the initial event statement developed.

1.    Who (did this happen tool)?

2.    What (was the actual / potential consequence)?

3.    Where (did this happen)?

4.    When (did this happen)?


2.      Schematic

Make a hand drawn schematic of the system(s)s, equipment, or components involved. – Not an engineering drawing pulled from the files. ‘HAND DRAWN’ showing the sequence of the state of things at the time of the accidents, incident event.   

o   What is known?

o   What is unknown?

o   Know what is unknown?

 

Hint: Take time to understand the schematic before moving on to begin any evidence gathering process, that later follows. Insert labels such that a reader can understand the reminder of the 5 item’s document. Make sure all items referred to in the other portions of the document are included. KEEP IT SIMPLE!

3.      Relationships

Make another HAND-DRAWN schematic, this time showing the relationships of the system, equipment or component parts involved in the accident / incidence event to the rest of the facilities.


4.      Summary Sequence

Make a summary of the sequence of event leading up to the accident / incident event. Written by ONE person (with approximately 5 bullet items).

Hint; Not intended to be a detailed sequence, i.e. only 5-8 bullet points


5.      List of oddities.

 

List what was odd about this event.

 


 

Documents uploaded by user:
5 ITEMS CASE STUDY.pdf
2 answer(s)
Companyrep
Drilling Specialist/Well Engineer/Training Consultant
Kingdom Drilling
Total Posts: 491
Join Date: 10/01/05
Shamram,

This method has work in other industries for 30years, no matter how complex the problem.

Human factors are also central to all aspects of the LCA investigation (including the initial gathering) where of note the People part evidence has to be captured quickly as it evaporates the fastest. So how can you mitigate this risk needs to be immediately addressed?

When investigation starts the five items gathered are invaluable for the (physical (parts) people and paperwork) evidence trails that investigators are assigned. Keeping these trails separate is important to avoid bias setting in.

The LCA method once all evidence is then gathered is resolved not by some expert, by through having a stakeholder meeting where the evidence gather by the investigators is presented to everyone to decide. There is only one rule. You cannot blame anyone but yourself. The stakeholders also must come up with the solutions and actions required. Introspection, where people must experience the pain of their failures if real change is too result. 

The final part of the LCA is then always to try and identify the latencies (i.e. human factors involved) as to why did people act as the evidence suggests. We try and put ourselves in others positions to try and understand why the 'people things' resulted as they did. 

Learning is much simpler through taking this evidence based approach.

The hardest part then by far is how to translate and assure sustained learning.

Where if we were as an industry really good at learning, we would not be having the same evident and recurring failures.

regards,

Peter. 
 
Shahram
Managing Director
SPREAD Associates
Total Posts: 3
Join Date: 19/05/17
Dear Peter ,

Back to your HAND-DRAWN schematic in relationship section, seems human issue has been ignored in your system loop 

Someone designed that part of engine or someone should have inspected or maintained that part, and why things goes wrong would give you better picture of incident

However i agree with your initial thought , "keep it simple" , but  literature review indicates that not single method suitable for all incidents ((even in oil fields where you have mixture of every things)) , due to complexity of some issues. even though most incident investigation techniques based on using cause and effect theory .




Posted by

Peter Aird

Drilling Specialist/Well Engineer/Training Consultant

Kingdom Drilling

Total Posts: 491
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