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Presentation Layout - Tripod-BETA Where it fits in the HSE MS structure. Accident mechanism using Bow-tie concept (What happened.) Tripod Causation Path (Why it happened.) Illustrations using Trees of recent incidents. Benefits of Tripod-BETA methodology. Next Steps for Managers. Tripod-BETA Project Schedule.
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List of Trained Persons. Structure of the HSE Management System Leadership and Commitment Tripod Beta Policy and Strategic Objectives Organisation, Responsibilities Resources, Standards & Doc. Hazard and Effects Management Corrective Action Planning & Procedures Implementation Monitoring Audit Corrective Action & Improvement Corrective Action & Improvement Management Review An Accident through the Bow-tie Concept Event Tree Fault Tree Harm to people,assets reputation or environment BARRIERS HAZARD CONSEQUENCES The ‘bow tie’ is a pictorial representation of how a hazard can be hypothetically released and further developed into a number of consequences. The left hand side of the diagram is constructed from the fault tree (causal) analysis and involve those threats associated with the hazard and the barriers associated with each threat. The right hand side of the diagram is constructed from the hazard event tree (consequence) analysis and involves recovery preparedness measures. The centre of the bow tie is commonly referred to as the ‘top event’ (or first hazardous event). Definitions: hazard: the intrinsic property to cause harm or damage threat: a possible cause that will potentially releases a hazard barrier: a measure (hardware or software)put in place to prevent the release of a hazard top event: the release of a hazard.
The undesired event at the end of the fault tree and the beginning of the event tree. Recovery preparedness measure:measures that limit the chain of consequences from the first hazardous or top event. These can reduce the likelihood that the first hazardous event will further develop into consequences or provide life saving or environmental mitigation capabilities should the hazardous or top event develop further. The bow tie is just one method of analysing hazards - it is not a mandatory requirement to use this method, but many companies find it useful. When an incident occures it can be seen as a path through the bow tie with the barriers that have failed Undesirable event with potential for harm or damage Engineering activities Maintenance activities Operations activities Tripod Causation Path The Tripod causation path shows where to look.
By Top level decision makers by Line management, designers, planners by Line managers, supervisors by Operators, maintenance crews Fallible decisions Latent failures Pre- conditions Unsafe acts System defences Leiden research 1988 to date Based on study of Shell (EP) fatal accidents Incidents are multi-causal Decisions may be right at the time they are made, based on info available. Circumstances within or outside mgt control can invalidate decisions Change control often implicated Investigation path Accident Event (Operator gets burnt) Tripod-BETA tree Target e.g.
Operator Hazard e.g. Hot pipework Event (Operator gets burnt) Active Failure Precondition Latent Failure Failed Defence Failed Control Galfar Fatality from Loading Pipes at Marmul, Oman. Galfar Fatality from Loading Pipes at Marmul - Cont’d. Food Poisoning Incident at TOCO Camp in Saih Rawl Food Poisoning Incident at TOCO Camp in Saih Rawl Tripod-BETA Brings a structure to investigation Helps distinguish relevent facts Makes causes and effects explicit Encourages team discussion Reduces the report writing task Helps Increase quality of corrective actions Next Steps for Managers Insist on Tripod for High Risk Incidents Nominate key staff for the Sept. 15th course Line Personnel Trained on Tripod-BETA Peter Jongens OIE/2 Yaqoob Al-Kiyumi OQO/11 Khalid Al-Zeedi OQO/13 Hamoud Al-Habsi OQO/19 Mohsin Al-Amri OQO191 Mark Crowther OIT/5 Mohamed Al-Harthy XGP/15 Xavier Shelton Jeganathan OBE/1 Kamil Siad Al-Dhamri OBE/55 Sami R.
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