FINDING HAZARDS

This tutorial assumes the user is familiar with the use of INVESTIGATION CATALYST Matrix displays and Diamond tools to identify problems, as described in the Recommendation Development Tutorial, so the procedures will not be repeated here.

The Hazard Analysts' second challenge is to discover the risk raisers or hazards in a system operation before they create problems or losses. The Matrixes describing the system operation in a flow chart facilitate the orderly examination of each interaction within which risk raisers or hazards may lurk, and their discovery and documentation.

During design stages, the Matrixes are usually incomplete, with roughly defined interactions. At this stage, the definition of concrete risk raisers or hazards is difficult, although typically, general principles can be applied. The main thrust of the effort during design should be to refine and complete the Matrix.

As sections of the Matrix are completed, the INVESTIGATION CATALYST Diamond process can be applied to those interactions and links to find and define hazards, and provide timely feedback to designers.

During construction and system start-ups, flow charts of any surprises can and should be examined for risk raisers or hazards or actions in a similar manner.

During ongoing operations, flow charts of potential changes can and should also be analyzed for risk raisers or hazards or actions in a similar manner.

During ongoing operations, the Matrixes produced by investigations of incidents should be analyzed for risk raisers and hazards as part of the investigation process, and for analyzing options to control or eliminate those hazards. The investigation matrix can also be merged with the matrix describing the current system operations, where the newly combined matrix can analyzed for risk raisers and hazards after changes are made. The edited merged file becomes the updated matrix.

Matrixes of the planned decommissioning process for a system should be similarly analyzed.