Checklists incident investigation team

This chapter addresses methods and tools used successfully to identify multiple root causes. Process safety incidents are usually the result of more than one root cause. This chapter provides a structured approach for determining root causes. It details some powerful, widely used tools and techniques available to incident investigation teams including timelines, logic trees, predefined trees, checklists, and fact/hypothesis. Examples are included to demonstrate how they apply to the types of incidents readers are likely to encounter. 

The decision authority and responsibility for restart rests with site and corporate management. Depending upon the scope of the investigation, the incident investigation team may be requested to assist by identifying any recommendations that should be implemented before resumption of operations. If so, then the team should clearly specify the minimum acceptable criteria recommended for safe resumption of operations. This list should be in writing and may contain a special checklist of items to be verified and completed before attempted restart. If a specific authorization or waiver of constraint is needed, this fact should be clearly indicated and communicated. 

The incident investigation team should review the investigation and final draft of the formal written report to ensure the intended result was achieved. An example checklist is shown in Table 11-5. Reports should have technical review for clarity and accuracy, and where appropriate, legal review. 

This useful companion disk contains root cause analysis examples, predefined tree examples, practical checklists that can be customized, and incident evidence photograph examples. It includes a quick checklist for investigators traveling to an incident, examples of methodologies that may be usefiil in training the onsite team, and checklists and samples from the text that can be printed out at the incident site to help organize the team s work. 

Checklist analysis tools can be a user-friendly means to assist investigation teams as they conduct root cause analysis.h) Each causal factor is reviewed against the checklist to determine why that factor existed at the time of the incident. The Systematic Cause Analysis Technique (SCAT)(9> is an example of a proprietary checklist tool. 

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