A "HOT" approach to incident investigation - SAFETY4SEA

... DNV GL, describes how an efficient incident investigation can ... says Richard Brilliant: “DNV GL didn't just provide practical and ... SubscribetoourMailingLists(It'sfree!) Friday,September16,2022 HomeSafetyAllAccidentsAlertsLossPreventionMaritimeHealthRegulationSafetySeafarersSecurity BSEE:Needformoreawarenesswhenusingtemporaryequipment Lessonslearned:Cleaningproductsshouldnotbemixed Lessonslearned:Fallcausedseriouspersonalinjury Lessonslearned:Foottrappedunderramcylinder GreenAllArcticBallastEmissionsFuelsGreenShippingPollutionShipRecyclingTechnology UpdatedanalysisofMARPOLAnnexVI Provaris,TotalEnergiescooperateongreenhydrogenprojects Siemens,Shelltodeveloplow-carbon,highlyefficientenergysolutions NGOscriticizeEUforfailuretophaseoutbiofuels SmartAllConnectivityCyberSecurityE-navigationEnergyEfficiencyMaritimeSoftwareSmart IAPH,BIMCO,IMOlaunchsinglewindowcampaign GasLogLNGtodigitalizeitsentirefleet NewprojecttoaddressAIissuesinshipping IMOdiscussessafety,legalandfacilitationaspectsofautonomousshipping RiskAllCICDetentionsFinesPSCFocus HowtouseUSCG’sPortStateControlJobAid Jordandetainsshipstrayingnearcoralreef 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Hapag-Lloydacquires49%shareofSpinelliGroup Columns CareerPaths:StineMundal,DNV&WISTANorway CareerPaths:CoreyRanslem,DryadGlobal Ammonia:anemission-freefueltodecarbonizetheshippingindustry TrendingTagsCareerPathsIndustryVoicesMaripediaMaritimeHistoryResilienceSeafarersStoriesSeaSenseEventsPlus NoResult ViewAllResult A“HOT”approachtoincidentinvestigation by FennavandeMerwe March28,2019 in Accidents,Opinions FacebookTwitterEmailLinkedinFennavandeMerwe, PrincipalConsultant,DNVGL,describeshowanefficient incidentinvestigationcanprovidesignificantbenefits.Ms. vandeMerwenotesthatDNVGLhasused human,organizationalandtechnicaldimensionsinordertohelp Carnivalestablishaproper investigationprocess.Reapingthefullbenefitsofincidentinvestigationsisacomplexchallenge.DNVGLintegratedhuman,organizationalandtechnicaldimensions,alsoknownasits“HOT”approach,tohelpCarnivalCorporation&plcdevelopamoreefficientinvestigationprocesswithoutcomesthathavegreaterimpact.GETTHESAFETY4SEAINYOURINBOX!Name:DNVGL’sexperiencefromarangeofhazardousindustriessuggeststhatwhilemostcompaniesarerelativelyconfidentabouttheirincidentnotificationandlesson-sharingsystems,theyoftenstrugglewiththecriticalstepinbetween:theeffectivenessoftheirinvestigationprocess.Themaritimeindustrytakesapredominantlyreactiveapproachtohigh-frequencysafetyeventsandhumanerror–actionistypicallytakenafterthedamagehasoccurred,ratherthanproactively.Theindustryisstilllearningtounderstandthatreducingoccupationalaccidentshaslittleornoeffectonthenumberofmajoraccidentswithmorecomplexcausesandmoresevereconsequences.Limitingthefocusofattentiontothesymptomsofmalfunctioningsystems,orblamingsomeonewhomadeamistake,haslittleeffectonthemoreunderlyingcausesofanaccident.RelatedNews Lessonslearned:Cleaningproductsshouldnotbemixed Lessonslearned:Fallcausedseriouspersonalinjury IdentifyingrootcausesofincidentsWhatisneededisastandardized,systematicandtraceableinvestigationmethodologythatallowscompaniestoidentifytherootcausesofincidentsandderivethenecessaryculturalchanges.Theincidentinvestigationprocessshouldbeembeddedinasafetymanagementsystemthatunearthsunderlyingcauses,explainingbothhowandwhyprocessesinthesafetymanagementsystemsucceedorfail.Whenthisisclear,systemicmeasuresforimprovementcanbeidentified.Becauseofitssheersizeandglobalreach,CarnivalCorporation&plc(Carnival),theworld’slargestleisuretravelcompany,playsanimportantroleinsettingsafetystandardsfortheindustry.Thisincludeslearningfromnearmisses,incidentsandaccidentstopreventreoccurrence.Whenperformingincidentinvestigations,Carnivalwasfacingthesamechallengesmanyinthemaritimeindustrystrugglewith.RichardBrilliant,ChiefAuditOfficerheadingCarnival’sRiskAdvisory&AssuranceServices(RAAS),explains:“Weunderstoodthatinvestigationsareapowerfultoolforlearningandimproving.Takingacriticallookatourprocesses,werealizedtherewereopportunitiestoreducetheamountoftimeittooktoperforminvestigations,tomakesurethecontentandformatofreportswereappropriate,andthatwehadafive-starorganizationalandprocessmodelthatsupportedinvestigatorcompetencyandinvestigationquality.”HOTdimensionsofsafetymanagementInpursuingitscontinuousimprovementphilosophy,Carnivallaunchedaninitiativetoassesstheirincidentinvestigationprocessagainstbestpractice,withanemphasisonidentifyingtherootcausesofincidents.AskedtoassistCarnivalinthisprocess,DNVGLofferedits“HOT”approachthathighlightstheinterdependenciesbetweenthehuman(H),organizational(O)andtechnological(T)dimensionstooptimizemanagementperformanceandfosteramatureorganizationalculture.Answeringthreekeyquestionsrelatingtothehuman(H),organizational(O)andtechnological(T)dimensionshelpscompaniesoptimizetheirsafetymanagementperformanceandfosteramaturesafetyculture/Credit:DNVGLInthisscheme,themanagementsystemassessment(O)isbasedonDNVGL’sInternationalSustainabilityRatingSystem(ISRS),whichrepresentsbestpracticeinsafetyandsustainabilitymanagement.Itisdesignedtohelpcustomersunderstandhowtomanagecomplexandemergingrisksanddemonstratetotheirstakeholdersthattheirrisksareundercontrol.IncidentinvestigationisincludedintheISRS“LearningfromEvents”process.DNVGL’sapproachtosafetycultureassessment(H)includesatoolfordiggingintotheunderlyingcausesofidentifiedweaknessesinsafetyperformance.Itrevealsdiscrepanciesbetweentheintendedprocessesofasafetymanagementsystemandwhatactuallyhappensontheworkfloor.Thecombinationofthesetwoassessmentshelpsorganizationschartgapsbetweentheirgovernanceonrisk(riskmanagementintheory)andtheemployeeperceptionofrisk(riskmanagementinpractice).AssessingtheinvestigationprocessInFebruary2018,tworepresentativesfromDNVGLinterviewed29seniormanagersandotherkeystakeholdersattheCarnivalheadquartersinMiami.Theinterviewswerebasedonthepredefinedreferencestructureofarobustincidentinvestigationprocess.Thepurposeofaninvestigationshouldalwaysbetomaximizethelessonslearntfromunintendedeventsandtopreventreoccurrence.DNVGLthereforelookedforindicationsthatCarnivalisanorganizationexhibitingacontinuousimprovementmindsetaswellas:areportingculture–whatgetsreportedwhenpeoplemakeerrorsorexperiencenearmissesafairculture–howpeopleapportionblamewhensomethinggoeswrongalearningculture–howadequatelypeoplecanconvertthelessonslearntintonewassumptions,frameworksandactionaflexibleculture–howreadilypeoplecanadapttosuddenandradicalincreasesinpressure,pacingandintensityDNVGLconcludedfromtheinterviewsthatwhileCarnivalhastakenstepstoimprovetheirinvestigationprocess,certainchallengesremain.DNVGLusesapredefinedflowchartrepresentingarobustinvestigationprocesstoguidetheprocessassessmentandidentifyopportunitiesforimprovement/Credit:DNVGLEstablishingacultureoftrustDNVGL’srecommendationstoCarnivalapplytomanyothersintheindustry.Raisingthequalityofinvestigationsrequiresorganizationstoestablishaconsistentinvestigationprocessthatisdocumentedinthemanagementsystemandownedbyanindividualorgroupofindividuals.Whilemanyorganizationsinvesttimeandmoneyinperforminginvestigations,theyoftenlackafeedbackloopthathelpstheorganizationlearnfromtheoutcome.Establishingthisfeedbacklooprequiresmanagementcommitmentandalevelofriskawarenessthatacknowledgestheimportanceofincidentinvestigations.DNVGLhasfoundthatmanagementsystemsalsooftenlackaconnectionwithwhatactuallyhappensattheworkplace.ThecultureassessmenthighlightedthatCarnival’sincidentinvestigationprocessneededtoberooteddeeperintheorganization.Learningfrominvestigationsmustbeacollectivemindsetandrequiresthatpeoplecantrusteachother.Peersandmanagersmustsupportaculturewhichencourageseverybodytoreportnearmisses,incidentsandaccidents,toaccepttheoutcomesofinvestigations,andtoimplementsystemicimprovementmeasures.ImplementingaconsistentprocessFollowingtheassessment,DNVGLsupportedCarnivalinestablishingthenecessarygovernancedocumentationforensuringsuccessfulimplementationofarobustandstandardizedincidentinvestigationprocess.Theteamiscurrentlyassistingtheclientinestablishingcompetencyrequirementsandanaccreditationprocessforinvestigators.Thisanswerstheneedforenhancedcredibilityofinvestigatorssothattheirworkenjoystrustwithintheorganization.TheassessmenthelpedCarnivalrealizehowriskmanagement,incidentinvestigationandculturegohandinhand.DNVGL’srecommendationswerecomprehensiveandpractical,saysRichardBrilliant:“DNVGLdidn’tjustprovidepracticalandtechnicalexpertise.Theycared.TheyunderstoodthattheresultsoftheirpartnershipwithCarnivalwouldyieldsafetyimprovements.Inmyopinion,theapproachtheytookwascollaborative,sincereandflexible.DNVGLdidnottakea‘boilerplate’approach.Theyspenttimetounderstandourpeople,processesandsystemssothatthesolutionstheyhelpfacilitatearebothimpactfulandsustainable.”Actingontheserecommendations,Carnivalhasstartedtooptimizeitsincidentinvestigationprocess,creatingaprocessthatismoreefficientandeffectiveindrivingsafetyinthecompany. ByFennavandeMerwe, PrincipalConsultant,DNVGLTheviewspresentedhereaboveareonlythoseoftheauthorandnotnecessarilythoseof SAFETY4SEAandareforinformationsharinganddiscussion purposesonly.About FennavandeMerwe, PrincipalConsultant,DNVGLFenna vandeMerweholdsaPhDdegreewithincognitivepsychology.Shehasextensiveexperienceinthefieldofhumanfactors,applyingasystemic(man,technologyandorganization)approachtoriskmanagement.Ms.vandeMerweisfluentinDutch,English,andNorwegian,andhasabasiccommandofFrenchandSpanish.Tags:DNVincidentinvestigationInfographiclessonslearnedlosspreventionsafetyculturesafetymeasures 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