INVESTIGATION CATALYST
Hazard Analysis Tutorial

2004 by Starline Software Ltd.

ANALYZING HAZARDS

To make chicken soup, you must have a chicken. To do a hazard analysis of a system operation (process) you need to start with a process description you can analyze.

IF YOU CAN'T FLOW CHART A PROCESS,
YOU DON'T UNDERSTAND IT!

The INVESTIGATION CATALYST hazard analysis process differs from conventional processes. It provides a display of dynamic system actions and interactions on a time/actor Matrix. That format permits examination of each individual act by each element of the system for potential unintended, unexpected or unwanted behaviors and their effects on subsequent actions. The Matrix display then helps analysts develop changes that would improve future operations.

Introduction:
The Basics

Investigators start by producing flow charts of the system operations in an actor/action matrix format. The matrix building blocks are prepared from designer or engineering or procedures inputs, or in test, startup or existing operations, by observing and documenting the actions driving the process.

This format describes what each element of the system does during the operation, relative to actions by all the other elements. That facilitates the identification of dynamic risk raisers or hazards during the process, by making process interactions, available for examination, one at a time, to discover potential unwanted behaviors by people, objects or energies. After analyzing the gravity of those behaviors, users can develop and evaluate changes that would improve future performance.

Such changes can be analyzed for new or residual hazards during design stages, during current operations, when changes are being contemplated to an existing operation or after a mishap.

Using the Matrix

INVESTIGATION CATALYST time/actor Matrix structures provide for the display of expected system behaviors and interactions during planned system operations. The Matrix displays can help designers and analysts work together to clarify intended operations as they evolve during the design process.

Once created, they become living documents, for long term use. For example they can be used during the investigation of new, changed, unexpected or undesired behaviors. They can be used to train or retrain process operators in the expected operation, or used to simulate possible misbehaviors to prepare operators for "surprises" they might encounter during emergency response planning. They can be used to compare planned with actual observed behaviors during system operations. They can be used to evaluate and manage changes to existing operations, and track their effects. They can be used during emergencies to guide decisions. They can be adapted to similar operations that incorporate similar interactions. In effect they offer a practical "corporate memory."


The Hazard Analysis Process

With INVESTIGATION CATALYST, hazard analysis process is to

  1. document intended system interactions,
  2. examine each interaction to find potential risk raisers or hazards,
  3. evaluate the significance of each risk raiser or hazard,
  4. develop and evaluate options to control or eliminate each hazard,
  5. determine the relative performance improvement offered by each option,
  6. analyze trade-offs to rank the options for decision making,
  7. use the analyses to set up a follow-on monitoring plan, and
  8. update the process description with monitoring or incident investigation outputs

Hazard Analysis Tutorials
  1. Documenting System operation
  2. Finding hazards
  3. Evaluating hazards
  4. Developing options
  5. Updating analyses
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