Incident investigation hazard analysis

Process safety information Compliance audits Process hazard analysis Incident investigation Operating procedures Employee participation Training... 

Most incident investigations follow formal procedures. This chapter discussed two of the most common procedures change analysis and job hazard analysis. An investigation is not complete until a final report is issued. Responsible individuals can use the information and recommendations to prevent future incidents [6]. 

On the other hand, there are a number of elements of fire prevention that overlap with elements of other programs. For example. Incident Investigation, Management of Change (MOC), Process Safety Information (PSI), and Process Hazard Analysis (PHA) input required for fire prevention can be derived from these same elements of the Process Safety Management (PSM) program. 

Other examples of inductive tools that have limited application in incident investigation include failure mode and effects analysis (FMEA), hazard and operability study (HAZOP), and event tree analysis (ETA). These are detailed in the CCPS book, Guidelines for Hazard Evaluation Procedures... 

Reliance on outside expertise may be the most feasible option for some of these issues. The incident investigation team may act as facilitators and advisors in a similar mode to a PHA (process hazard analysis) study. The outside expert would supply the failure mode information on which possible failures are credible. 

Create a periodic audit system on the safety of operations and the state of the plant. Audit scope might be defined by such information as the hazard analysis, identified leading indicators of risk, and past incident/accident investigations. 

The operations expert is a very important team member. He will know the unit in great detail and will be able to explain how things really work around here. He will also have knowledge of past incidents, including those that were not necessarily serious enough to be reported within the Incident Investigation process, but which nevertheless can provide useful pointers to the hazards analysis team. 

The register should coutaiu iDformation as to how and where the hazard was identified. Typically this will be a hazards analysis, but the information may come from other sources such as incident investigations or employee observations. 

The bow tie technique is being used increasingly within the process industries not only to analyze risk but also to communicate hazard and risk findings to a broad audience. It can be used not only in hazards analysis but also in incident investigations. 

Noninitiated changes cannot be controlled with the MOC program because no one knows about them until after an event. Instead, changes of this type are controlled by other elements of the risk management program such as asset integrity, process hazards analysis (PHA), and incident investigation. 

The second phase of the program will be more concerned with achieving quantified improvements in the facility s safety and environmental results. This phase is likely to emphasize elements such as Incident Investigation and Process Hazards Analysis in order to identify weak spots in the management systems. 

Replacing a subject matter expert (SME)/core competency [e.g., relief sizing, risk assessment, mechanical integrity, incident investigation, process hazard analysis (PHA), or hazard identification... 

All activities required for process safety management, such as process hazard analysis, mechanical integrity, incident and near-miss investigations, and management of change... 

If hazard identification and analysis do not relate to actual causal factors, the resulting corrective actions proposed will be misdirected and ineffective. A superior quality of incident investigation is required to identify and evaluate actual causal factors so that appropriate corrective actions can be taken. 

Discussions of achievements with safety professionals whose oiganiza-tions had top scores did not produce any surprises. Incident investigation for hazard identification and analysis gets done best where the organization s culture includes accountability for superior performance. Here is an aggregate Mst of the conoments made in discussions with safety professionals in those entities with the best incident investigation systems ... 

Effective investigation and analysis of hazards-related incidents is an important element in a quest to achieve superior results in safety. A high quality of incident investigation and analysis not only results in risk reduction, but also serves as a positive reinforcement for the safety policies and practices that management has established. 

MORT Safety Assurance Systems by WilMam G. Johnson This text serves well both for incident causation model building and for incident investigation. The accident investigation chapter states that while accident investigation has always been a major element in safety, pre-accident hazard analysis is preferable (p. 347). 

Safety program System analysis Hazard report management Risk evaluation Incident investigation... 

---