Derivation, Application, and Evaluation of the KUBO-TEPA Matrix for Generating Corrective Actions

Abstract

ProposalRecently, it has become possible to realistically forecast future safety performance using a systematic classification of corrective actions given on accident reports. This new method redefines standards for "good" reports, but it also changes the root cause assessments. Fortunately, this is a good change, reducing accident causes from 227, on a commonly used list, to a mere four. It also greatly simplifies the analysis process, eliminates the need for investigations by specialists in routine cases, and produces more effective corrective actions in nearly all cases.The new analysis process begins with the assumptions that all accidents are a result of acts of people, and therefore are correctible by changing acts of people. Because an accident, by definition, is an event that nobody tries to make happen, it follows that all accidents occur because someone, somewhere, didn't Know, Understand, Believe, or Observe (KUBO). Correcting these four basic causes can always be reduced to some provision to Teach, Educate, Persuade, or Assign (TEPA). These theories are the origin of the KUBO-TEPA accident analysis guide that is rapidly gaining acceptance in the Gulf of Mexico petroleum industry.Combining this guide with the new standards for corrective actions produces a three by four matrix of clues to corrective actions that apply to all accidents. A brief training program has proved to be enough to teach frontline supervisors how to use this matrix to devise effective corrective actions with minimal outside assistance. The bottom line is greatly improved accident prevention initiated at the lowest operational levels and easily evaluated by upper management.