Guidelines on the Culture of Incident Reporting

The Guidelines for Investigating Chemical Process Incidents [4] has a section on near misses. Included in that section is a discussion of the fragile balance between a manager s responsibility to promote and achieve near-miss reporting of incidents and the responsibility to discipline inappropriate behavior. It is a matter of trust and openness. A single occasion of necessary discipline (if viewed as somewhat unfair) can erode 

What is not reported cannot be investigated. What is not investigated cannot be changed. What is not changed cannot be improved. 

In his opening comment at the Mary Kay O Connor Process Safety Seminar, Michael Marshall, OSHA s Program Coordinator of Process Safety Services stated [5]  

After a process incident at a facility, the company involved has an opportunity to turn a negative event into a positive learning experience. By utilizing information obtained by the investigating team, the company can assess the effectiveness of its safety programs and determine if and to what extent changes are needed in their safety program. 

Marshall also suggests that world class organizations should not only address the probable cause(s) and root cause(s) of the incident, but also benefit from the knowledge of related potential scenarios. He suggests many organizations do not fully use newly plowed-up bonus information. He reported [5]  

---