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1. InvestigAction
A 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
• Reasons
• Objectives
• The approach
• The architecture
• The accident investigation protocol
• The AIP in the safety management processes
• The investigators
2

3. Reasons
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.
3

4. Reasons
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.
4

5. Reasons
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
5

6. Objectives
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).
6

7. The approach
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
7

8. The approach
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.
8

9. The approach
Three key guiding questions:
There were defences?
How and why did the defenses fail?
What can be done to prevent a recurrence?
9

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.
10

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.
11

12. The architecture
Main components Aim
Taxonomy 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
12

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.
13

14. The Accident Investigation Protocol
A tool: What to investigate
The fact (data /information /
documents to collect)
The context
The cognitive factors
The organizational conditions
THE METHODOLOGY:
“HOW” TO INVESTIGATE
14

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
15

16. The Accident Investigation Protocol
The protocol is structured as a sequence of activities.
For each activity, there is a form to fill out and a
guideline.
EVENT
MANAGEMENT
ACTIVITIES
EVENT
REPORTING
Deliverables
INVESTIGATION
TEAM ACTIVITIES
? Guideline/checklist
ANALYSIS
Attachments
INTERPRETATION
ACTIVITIES
DIAGNOSIS
16

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;
.
17

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.
18

19. The Protocol is a tool within the investigation phase
in the safety improvement process
Commitment
PREVENTION Safety plan
Safety culture
Safety improvement process
SECTION A
Investigation process
Event Reporting
INVESTIGATION SECTION B
Investigation Team LOW RISK EVENT
Analysis MEDIUM RISK EVENT
Interpretation
Diagnosis HIGH RISK EVENT
Communication of alerts
Approval of corrective actions
SAFETY Investigation debriefing
IMPROVEMENT Implementation of corrective actions
Sharing of conditions
Training
LEARNING AND Communication
COMMUNICATION Knowledge sharing
19

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
20

21. Thank you for the attention
21

22. Contacts
Fondazione Irso
The 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 BAGNARA
sebastiano.bagnara@gmail.com
Roberta MORICI
roberta.morici@irso.it
Fondazione Irso
Piazza Giovine Italia, 3
20123 Milano
Tel: +39 02 48016162
info@irso.it
www.irso.it

23. 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 SCOTTI
Davide.Scotti@saipem.com
Fondazione LHS
Via Martiri di Cefalonia 67
20097 San Donato Milanese (MI)
Tel. (+39) 02 520 54230
info@fondlhs.org
www.fondlhs.org