Accident/incident investigations process

In the example discussed in Section 4.2, the company found that by integrating its accident/incident investigations across its process safety and occupational safety activities, it has saved one year of duplicate time to date by avoiding conflicting models and coordinating training efforts. This represents a 50 percent reduction in effort. 

The word accident should not be used during the incident investigation process because the word implies surprise and lack of controllability. There is nothing anyone can do about accidents. The whole point of an incident investigation and analysis program is that all aspects of an operation are under control of management. Only unpredictable external events such as an airplane crash alluded to above are true accidents. 

The relevance of anticipations processes is also pondered by Kallus who recommends that the anticipation of and coping with critical flight situations must be considered in training and opportunities for the development of these skills. The author goes even further and believes that the consequences of anticipation processes need to be taken into consideration in accident-incident investigations and can also be explored in selection processes. 

Why is it important to conduct thorough accident/incident investigations You can learn from accidents and incidents. Injuries are lagging indicators, in that they already happened. However, if we consider them in terms of the probability of similar future incidents and use what we learn from them to change our processes, then we are treating them as leading indicators. ... 

The employer investigates incidents that result in, or could result in, a catastrophic release of highly hazardous chemicals. An incident investigation is initiated as soon as possible, but before 48 hours following the incident. An incident investigation team is established to consist of one or more experts in the process involved, and accident investigation. The report prepared at the conclusion of the investigation includes at a minimum ... 

However, MORT does not aid in the representation of the accident sequence which must first be determined before the method can be effectively used. Although MORT provides a comprehensive set of factors which may be considered when investigating an incident, it can easily turn an investigation into a safety program review as no guidance is provided on the initial investigative process. 

Three major themes have been emphasized in this chapter. The first is that an effective data collection system is one of the most powerful tools available to minimize human error. Second, data collection systems must adequately address underlying causes. Merely tabulating accidents in terms of their surface similarities, or using inadequate causal descriptions such as "process worker failed to follow procedures" is not sufficient to develop effective remedial strategies. Finally, a successful data collection and incident investigation system requires an enlightened, systems oriented view of human error to be held by management, and participation and commitment from the workforce. 

Like the previous edition, the book remains focused primarily on investigating process-related incidents that present realized or potential catastrophic consequences (that is, accidents as well as near misses). However, readers will find that the methodologies, tools, and techniques described in the following chapters may also be applied when investigating other types of occurrences such as reliability, quality, and occupational health and safety incidents. 

Trend analysis can be confused or invalidated by a sample that is too small. If the charting or analysis is limited only to major incidents, there will often be too few within a period to arrive at meaningful conclusions. For example, a facility with one thousand employees may experience only one or two serious incidents per year, and several years worth of data would be needed to make any meaningful statistical analysis. Minor incidents and near misses can be as useful in trend analysis and preventive prediction as major incidents. All process incidents should be reported, classified, and investigated as appropriate. The severity of an incident is frequently more a function of chance than actual fundamental system differences among accidents and near misses. 

As a result of the AIC s efforts, we now have a process for investigating accidents in which we construct an event tree for each incident. The tree is quite similar to a fault tree from the quantitative risk analysis discipline, except that in the investigations we often sacrifice some structural rigor to get the most results in a reasonable time. Basically, the process uses a team to reconstruct the chronology of the incident and to construct the event tree. We try to include those who are most familiar with what actually happened, including the injured person(s) if any. We use the same basic method to investigate process failures, spills, injuries, or any other system failures. Emphasizing the system aspects of the failure removes much of... 

Rohm and Haas is committed to using Event Trees for each incident. A technical paper, More Bang for the Buck Getting the Most from Accident Investigations, provides a thumbnail sketch of their investigating process. [10]... 

Thorough and effective analyses of workplace incidents are critical components of a comprehensive safety management system. Yet, many incident analysis processes (i.e., accident investigations) fall short. They frequently fail to identify and resolve the real root causes of injuries, process incidents and near misses. Because the true root causes of incidents are within the system, the system must change to prevent the incident from happening again. 

Here, although understanding has been positioned as the ultimate output of the accident investigation process, it is the worker who is effectively blamed for the incident, his action becoming the focus of the investigation process. There is a segregation of responsibility for this incident the worker s violation is separated and made distinct from the shared ownership of the accident as a whole. 

However, a thorough incident investigation into such an apparently simple accident could lead to the discovery of significant and subtle deficiencies in the overall management program that could, in turn, lead to ways of improving process safety. 

After one of my presentations, an attendee spoke to me about the poor quality of incident investigation reports that reached her desk. I had spoken of the need to emphasize systems causal factors and to get away from the excessive concentration shown in some of their investigation reports on what the worker had done in the accident process. She said that almost all of the investigation reports that came to her desk suggested a corrective action that would improve worker behavior, and stopped there. 

There is nothing earthshakingly new in the accident/incident prevention arena. Basic accident/incident prevention techniqnes espoused in this book have been used and modified over decades. Eew, if any, dramatically new approaches have been devised using more modem techniques. Thus, accident investigation has always been accident investigation, no matter the words nsed. However, the tools and processes utilized for accident prevention have experienced modification and evolution as accident prevention has become an integral part of the loss control initiatives of companies. 

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