Implementation, incident investigation

This chapter provides an overview of a management system for investigating process safety incidents. It opens with a review of management responsibilities and presents the important features that a management system must address to be effective. It examines systematic approaches that help implement incident investigation teams, root cause determinations, recommendations, follow-up, and documentation. 

Incident Investigation Previous incidents related to the chemicals or equipment involved in the new toll should be considered during the PHA and must be considered if subject to PSM/RMP compliance. In addition, procedures should be in place to describe how the client will be informed and involved in the investigation. It is veiy important to ensure that action plans addressing the root cause of past incidents were implemented. 

Amendments to the Clean Air Act require employer-employees consultation to develop and implement PSM program elements and hazard assessments. Section 304 requires employee training and education on the findings of PSM incident investigations. 

Check that all items from hazard analyses, incident investigations and other discovery processes have been properly implemented and documented. 

The recommendations generated from an incident investigation should be properly implemented in a timely fashion to decrease the probability of... 

The team can then recommend or implement improvements to the incident investigation work process. 

The incident investigation team is responsible for developing practical recommendations and submitting them to management. It is then the responsibility of management to approve, modify, reject, communicate, implement, and follow-up on the recommendations, including ... 

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. 

A large portion of these common events can be linked to less than adequate follow-up of recommendations from previous incident investigations. The earlier investigation teams may have properly identified underlying root causes, submitted suggested preventive actions, and attempted to share results yet the repeat occurrences continue due to incomplete implementation of recommendations or ineffective sharing of lessons learned between potentially affected parties. 

In summary, developing the recommendations is a responsibility of the incident investigation team. Implementing the recommendations is a management responsibility. The inclusion of the elements of the recommendation in daily work practice is the responsibility of each individual affected by the recommended action. 

Although not essential, it may be helpful to include a member of the original incident investigation team on the audit team to help assure that the final implemented actions address the original issues in an acceptable manner. 

By gathering these data from each incident investigation, a database is established that will, over time, indicate the broad categories or management systems in which incident investigation findings tend to accumulate. The company can then devise and implement a more holistic approach to prevention than the one developed by addressing individual root causes. 

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