Complex Incidents

One of the primary tenets of ICS relates to recognizing the many different activities that must occur to successfully manage response to any event. These tasks can be grouped into categories that reflect functional similarities. For instance, all tasks that represent support of the organization s 

The conunand function provides overall direction of the response through the establishment of objectives for the organization to meet. Consider other important management issues  

Safety—Identify and assess hazards to the organization s personnel and develop measures to prevent injury or illness from the hazards. 

Liaison—Provide coordination and integration with agencies or organizations external to the response system in question. 

Public information—Develop and provide, subject to the incident commander s approval, incident information for both the public and response personnel. 

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The team leader s responsibilities need to be explicit. Normally a team leader chosen for more serious or more complex incident investigations will be independent from the operation or facility where the incident occurred. Actual team composition may vary significantly based on the nature of the process and the degree of technical sophistication. This flexibility of team composition is an important feature of a well-designed incident investigation management system. 

Complex Incidents Investigation Team Leader Training... 

These leaders will handle the most complex incidents (top 10% or less)... 

These leaders will handle low to moderate complexity incidents (90% or more or the incidents)... 

Causal factor identification tools are relatively easy to learn and easy to apply to simple incidents. For more complex incidents with complicated timelines, one or more causal factors can be overlooked, ultimately leading to missed root causes. Another disadvantage is that an inexperienced investigator could potentially assume that suppositions are causal factors, when in reality the supposed event or condition did not occur. 

It provides the ability to separate a complex incident into discrete smaller events (segments) and then to examine each piece individually. 

Causal Trees were developed in an effort to use the principles of deductive logic found in Fault Tree but make it more user-friendly. Originally, private companies developed the Causal Tree Method (CTM) for safety, process safety, and environmental incident investigations applications. Rhone-Poulenc, for example, was an early user.<20.21) Multiple-Cause Systems Oriented Incident Investigation (MCSOfl) is another name for the CTM. At this time, most companies use simplified versions of fault trees for complex incident investigations. 

Figure 7-1 offers a typical checklist to use during the planning stage of an investigation of a major complex incident. Low complexity incident investigations do not always call for a formal plan. Some simple investigations may require only 1 to 2 hours to complete. 

The following tools can assist with the identification of causal factors for complex incidents with complicated timelines. 

A more complex incident may require the use of harrier analysis or change analysis to assist in developing the causal factor chart. 

For complex incidents or causes, confirmation of all scenarios or causes may require a lengthy period—perhaps years. Rather than waiting for this, the team should write a complete report, indicating open research action points. As the open research items become resolved, this status should be documented. If new information indicates that conclusions on recommendations should be changed, the report document should be updated or annotated as necessary. 

Develop a list of potential scenarios and remain open minded. On complex incidents, it is sometimes helpful to develop a list of potential scenarios. Do not fall in the trap of only pursuing the initial obvious scenario. It is important to prove that the actual scenario did happen but it is also important to prove that other potential scenarios did not happen. 

Kletz was a gifted writer and could simplify a complex incident. His woik examined the causes and aftermaths of numerous incidents that provide learning opportunities for those involved with chemical plants and refineries. The book has 640 pages and currently sells for 76. 

Assistance may be provided in various ways. For some minor Incidents, only advice by telephone may be necessary. In some cases the Re onat Coordinating Office may arrange for assistance to be provided at the scene of the incident by knowledgeable persons who are located nearby. If the circumstances warrant, a radiological assistance team will be dispatched by the Regional Coordinating Office to the scene of the incident. For most incidents in which a team is dispatched, the response may be made by one or two individuals. However, for larger or more complex incidents the team may consist of several specialists. Teams may include Team Leader, Radiation Monitors, Medical Officer, Public Information Officer, and other specialists as required. 

Since the premise on which the 5 Why concept is based is uncomplicated, it can be adopted easily in the incident investigation process, as some safety professionals have discovered. For the occasionally encountered complex incident situation, starting the investigation with the 5 Why approach may lead to the eventual use of Event Trees, Fishbone Diagrams, or more sophisticated investigation systems. 

A large complex incident may require many employees and difficult, time-consuming efforts to control. In these situations, the individual in charge of the ICS will want to delegate different tasks to subordinates in order to maintain a span of control that will keep the number of subordinates, that are reporting, to a manageable level. 

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