Incident investigation

13. GAMA investigation module

© SEMD Repsol YPF 2011

 Table of contents
0.Introduction
1.Incident investigation procedure.
2. Introduction to the Root Cause Analysis Methodology
3.1. Reality and definition of an incident
3.2. Definition of an incident at Repsol YPF
4. The Cause – Effect principle
5. Cause – Effect analysis
6. Evidence
7. Effective solutions
8. Conclusions
9. Managing the investigating committee
10. Interviews
11. Human error
12. HGI
13. GAMA investigation module
14. Practical example
15. Conclusions

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© SEMD Repsol YPF 2011
 Chapter index

13. GAMA investigation module

13.1. New investigation module
13.2. Main changes

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© SEMD Repsol YPF 2011
 13.1. New investigation module

• This change has unified the "GAMA programming language":

 It unifies the screen design and makes browsing easier (e.g.: the browser menu is to
the left, as in the incident)
 It provides a single programming environment, making maintenance simpler
• Clients' comments and suggestions have been incorporated

• Development began in June 2009 and it was implemented on 12 May 2010

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© SEMD Repsol YPF 2011
 13.2. Main changes
The roles involved in Investigation are the same as in the earlier
version:
• Investigation validator  Investigation leader
• Investigation co-ordinator
• Investigation Committee
• Computability validator (in the case of accidents involving people)
Now the INVESTIGATION VALIDATOR is the
person in charge of assigning resources:
• Select the Investigating Committee
• Select the investigation co-ordinator from among the committee members

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© SEMD Repsol YPF 2011
 13.2. Main changes
• The RISK EVALUATION of the investigation can be different from the risk evaluation of the
incident, enabling a reduction in the risk as long as this is potential

• Calculation of the investigation route is based on the result obtained in the risk evaluation.
The options are:

• Lowest Risk - Do not investigate

• Moderate Risk - Low Risk
• High Risk - High Risk
• Urgent Risk - High Risk
• Extreme Risk - High Risk

• The co-ordinator can choose a higher level of investigation, but never a lower one than the
calculated level

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© SEMD Repsol YPF 2011
 13.2. Main changes
• The investigation screens are the same regardless of the type of investigation being carried
out (high or low risk)

• When adding a BASIC/ROOT CAUSE first we add the Request for Corrective Action and
this will then be categorised in the list of available basic causes

• A new role has been created for the distribution of the Final Report (Role 52). Thus, when
the investigation is validated, the Final Report will be sent to the people included in the
parameters

• The investigation co-ordinator can propose the computability of the accident victims, but
the Computability Validator has the final word

• In the case of accidents while travelling to and from work, the computability validator will
have to ratify the classification of Not Computable

• This new module is prepared for loading files from the HGI tool, importing the results (basic
causes, SAM, contribution etc.) but their use is not obligatory

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© SEMD Repsol YPF 2011
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© SEMD Repsol YPF 2011