MANAGING
the
INCIDENT LIFE CYCLE
Presented at the 2010 TapRooT® Summit
Keith Recsky, P.Eng
Sr Integrity the INCIDENT
MANAGINGEngineer LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
Terasen Gas – A Fortis company
WELCOME
• Introduction
• Objective:
− How can my (your) organization improve
our management of the incident life
cycle?
• Share my thoughts and questions
• Solicit world class best practices
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
Play video clip
http://www.youtube.com/watch?v=xwSCHRQCIBY
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
TERASEN GAS INC
• Natural gas distribution utility
• British Columbia, Canada
• 970,000 customers
• 1600 employees
• TapRooT: 10 yrs
• 18 active, part time investigators
• Primarily used for OH&S incidents…but is changing
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
TRADITIONAL INCIDENT INVESTIGATION
Root
Corrective
Incident Cause Prevention
Action
Analysis
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
The INCIDENT LIFE CYCLE
Post
incident
review
Response
& Improve
Recovery
Incident Plan
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
The INCIDENT LIFE CYCLE
Post
incident
review
Response
& Improve
Recovery
Incident Plan
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
Post
incident
review
Response
& Improve
Recovery
• Leadership
• SPAC
Incident Plan • Education
• Competency development
• Simulation, tabletop, etc
• Budget, resourcing
• Responsibilities
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
PLAN: Leadership
• Corporate Champion(s)
− Vision and passion for corrective action
− Influences others to “get on the bus”
− Active involvement for sustainment
− Owner of the SPAC
• Mentors / Coaches
− Technical leadership
− Team leads
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
PLAN: SPAC
• Is there a common approach to different kinds of
incidents?
• When is a post incident review required?
• Are there different levels of post incident reviews?
• Who can request one?
• Who decides if it will be done?
• Are there special requirements for culpability
and/or liability?
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
PLAN: SPAC (cont’d)
• Who funds the post incident review?
• Are there any special accounting rules for post
incident reviews?
• Is there anything unique for post incident reviews
required by external agencies?
• Are there any special approvals required before
copies of post incident reviews are released to
outside agencies?
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
PLAN: Education
• Root cause analysts
• Corrective action developers
• Post incident review sponsors
• Leadership
• Managers & workleaders
• Employees
• Unions
• Post Incident Review 101
• Learning From Incidents 102
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
PLAN: Development
• Education
• Networking
• Best practicing
• Peer reviews
• Exercises
• How is development funded?
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
PLAN: Resourcing – immediate needs
• Centralized or de-centralized?
• Full time or part time?
• How are they selected?
• How are they rewarded / compensated if part time?
• Are they given adequate time to participate?
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
PLAN: Resourcing – sustainment
• Succession planning
• Mentors / coaches
• Ongoing or rotational involvement?
• Who is responsible for the sustainment model?
• How often is the sustainment model reviewed?
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
PLAN: Responsibilities
• Sponsors
• Managers / workleaders
• Employees
• Unions
• Post incident reviewers
• System Administrator
• Legal, Risk Management, Governance Dept’s
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
Post
incident
review
Response
& Improve
Recovery
Incident Plan
Oh oh!!!
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
INCIDENTS
• Traditional: environmental, health & safety
• Near misses
• Hypothetical
• Proactive
• Variations
− Audit non-conformances
− Customer complaints
− Business process breakdowns
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
Post
incident
review
Response
& Improve
Recovery
• Notifications
• Containment
Incident Plan
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
Post
incident
review
Response
& Improve
Recovery
• Notifications
• Containment
Incident Plan
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
What actually happened
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
What should have
happened per SPAC
What actually happened
What could have been
improved upon
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
• Sponsorship
Post • Root cause
incident • Corrective action development
review
Response
& Improve
Recovery
Incident Plan
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
POST INCIDENT REVIEW: Sponsorship
• Who is the post incident review being done for?
• What is the scope of the post incident review?
• Are there any real or perceived conflicts of
interest?
• Who has the influence and/or authority to affect
change arising from the post incident review?
• Who sets deadlines for the post incident review?
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
POST INCIDENT REVIEW: Sponsorship (cont’d)
• Who can commit and/or obtain the necessary
resources for the post incident review?
• Is there a need for shared sponsorship for complex
scenarios? Or for a “lead” sponsor?
• Is there a need for different sponsors for root cause
and corrective action phases?
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
POST INCIDENT REVIEW: Root Cause
• Should the root cause analysis be separated from
the corrective action phase or combined?
• Peer reviews
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
POST INCIDENT REVIEW: CA Development
• How are specific root causes selected for
corrective action?
• Is there a parking lot for corrective actions that are
not practical now but could have future use?
• How are personnel selected for correction action
teams?
• Do they have adequate resources for the task?
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
Post • Corrective Action implementation
incident • Corrective Action System
review • Using the information
Response
& Improve
Recovery
• Audits
• Suggestions / feedback
• Legislation / codes
• Best practicing
• Networking
Incident Plan
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
IMPROVE: Corrective Action Implementation
• How are corrective actions selected and approved
for implementation?
• Is a formal risk reduction considered in the decision
making?
• Are due dates monitored and managed?
• Is there effective validation and verification?
• How are they communicated to key stakeholders?
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
IMPROVE: Corrective Action System: IT
• IT solution: TapRooT or similar
• Is the information accessible by those who need it?
• Is the data secure?
• Can all relevant info be stored on it?
• Is terminology standardized?
• How is the system administrator selected?
• Is there a succession plan for the system
administrator?
• Is the software staying current?
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
IMPROVE: Using the information
• Are there good reporting and/or dashboarding
features?
• Who uses the reports or dashboards; who needs to
use them?
• Are they used for performance plans?
• Does anyone do any trending?
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
IMPROVE: Other Improvement Drivers
• Internal or external audits
• Legislation or code changes
• Soliciting suggestions and feedback
• Best practicing
• Networking
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
The INCIDENT LIFE CYCLE
Post
incident
review
Response
& Improve
Recovery
Incident Plan
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company
My contact info
• keith.recsky@terasengas.com
• (250) 868-4511
• Kelowna, British Columbia, Canada
MANAGING the INCIDENT LIFE CYCLE
TapRooT® Summit 2010
Terasen Gas – A Fortis company