Incident analysis process

Thorough and effective analyses of workplace incidents are critical components of a comprehensive safety management system. Yet, many incident analysis processes (i.e., accident investigations) fall short. They frequently fail to identify and resolve the real root causes of injuries, process incidents and near misses. Because the true root causes of incidents are within the system, the system must change to prevent the incident from happening again. 

Most companies have an accident/incident analysis process that identifies the proximal failures that led to an incident, for example, a flawed design of the pressure relief valve in a tank. Typical follow-up would include replacement of that valve with an improved design. On top of fixing the immediate problem, companies should have procedures to evaluate and potentially replace all the uses of that pressure relief valve design in tanks throughout the plant or company. Even better would be to reevaluate pressure relief valve design for all uses in the plant, not just in tanks. 

When we fail to conduct an incident analysis properly, we place people and property at risk. Jobs, procedures, and work areas are only as safe or unsafe as we choose to make them. If we properly conduct incident analyses, we can, and wiU, eliminate chance and risk in the process. Figure 12.3 summarizes the incident analysis process. 

You will get broader interest and involvement in an incident analysis process if corrective action plans are applied to all relevant work areas. This promotes a systems perspective rather than the piecemeal "band-aid" approach common to so many work cultures. Look at the bigger picture. Use the results of an incident analysis to improve relevant environment behavior and person factors plantwide. This sends the kind of actively caring message that not only promotes participation but also makes that participation more constructive. 

Promote accountability. Both the quantity and quality of participation in an incident analysis process depend on the numbers you use to evaluate success or failure. The success of any safety effort is ultimately determined by the bottom line outcome—the total recordable injury rate (TRIR), but this index provides no instructive guidance nor motivation to continue a particular safety process. 

Van der Schaaf, T.W. 1996. PRISMA A Risk Management Tool Based on Incident Analysis, International Conference and Workshop on Process Safety Management and Inherently Safer Processes, Center for Chemical Process Safety of the American Institute of Chemical Engineers, New York. 

Another publication produced by the Center for Chemical Process Safety, Guidelines for Investigating Chemical Process Incidents (CCPS, 1992d), is directed at achieving similar objectives but from a differing perspective and with differing emphasis. Both sources of information can be used in a complementary manner to improve the quality of data collection and incident analysis in the CPI. 

This section provides an overall structure within which the different aspects of data collechon and incident analysis methods can be integrated. The importance of effective data collection systems as part of the continuous improvement process in Total Quality Management. 

The case study has documented the investigation and root cause analysis process applied to the hydrocarbon explosion that initiated the Piper Alpha incident. The case study serves to illustrate the use of the STEP technique, which provides a clear graphical representation of the agents and events involved in the incident process. The case study also demonstrates the identification of the critical events in the sequence which significantly influenced the outcome of the incident. Finally the root causes of these critical events were determined. This allows the analyst to evaluate why they occurred and indicated areas to be addressed in developing effechve error reduchon strategies. 

Where a specific incident leading to safety, quality or production problems has occurred, the plant management may wish to perform a very focused intervention. This will be directed at identifying the direct and underlying causes of the problem, and developing an appropriate remedial strategy. The process for performing an analysis of this type is described in the incident analysis section of Chapter 6. 

Pedersen, O. M. (1985). Human Risk Contributions in the Process Industry Guides for their Pre-Identificationx in Well-Structured Activities and for Post-Incident Analysis. Report No. RIS0-M-2513, Riso National Laboratories, Roskilde, Denmark. 

Trend analysis can be confused or invalidated by a sample that is too small. If the charting or analysis is limited only to major incidents, there will often be too few within a period to arrive at meaningful conclusions. For example, a facility with one thousand employees may experience only one or two serious incidents per year, and several years worth of data would be needed to make any meaningful statistical analysis. Minor incidents and near misses can be as useful in trend analysis and preventive prediction as major incidents. All process incidents should be reported, classified, and investigated as appropriate. The severity of an incident is frequently more a function of chance than actual fundamental system differences among accidents and near misses. 

Piping and Instrumentation Diagram Probability of Failure on Demand Process Hazard Analysis Pressure Indicator Protection Layer Preventive Maintenance Process Safety Incident Database Process Safety Management Pressure Safety Valve (Relief Valve)... 

A sample from a suspected nuclear incident is processed by gamma-ray spectral analysis. The sample does not contain any "Mo, or at least none is observed. Also, the sample contains large amounts of 60Co and 137Cs but no other radionuclides detectable by gamma-ray emission. What do you conclude ... 

Svenson, 0. (1991), The Accident Evolution and Barrier function (AEB) model applied to incident analysis in the processing industries. Risk Analysis, J/, 499-507. 

P ID PHA PSI PSIC PSISR PSM Piping and Instrumentation Diagram Process Hazard Analysis Process Safety Incident Process Safety Incidents Count Process Safety Incident Severity Rate Process Safety Management (U.S. OSHA Regulation)... 

While the accident report was more thorough than most, information that would have been helpful in understanding the entire accident process and generating more complete recommendations, was omitted. A STAMP-based accident analysis process provides assistance in determining what questions should be asked during the incident or accident investigation. 

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 word accident should not be used during the incident investigation process because the word implies surprise and lack of controllability. There is nothing anyone can do about accidents. The whole point of an incident investigation and analysis program is that all aspects of an operation are under control of management. Only unpredictable external events such as an airplane crash alluded to above are true accidents. 

Possibly the most important contribution that the incident owner can make to the investigation and analysis process is to create an atmosphere of seeking means of long-term improvement, rather than looking to blame someone or trying to find a quick fix. 

Oscar Wilde s comment A tmth ceases to be a truth as soon as two people perceive it was presented in Chapter 1. His comment very much applies to the process of investigating incidents. Facts are never truly objective each person has their own perception of what they perceive to be the same reality. For example, when asked what happened in the case of the example, one person may say The pump seal failed, another may state Hydrocarbon vapors were released to the atmosphere. Both persons are correct but their statements reflect their different views of reality. Therefore, it is very difficult to develop a truly general incident analysis whose conclusions are independent of the profiles of the persons conducting that analysis. 

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... 

When designing an incident investigation and analysis process, a determination must be made concerning the causation model on which the process is to be based. What the designer of the process believes are the facts about incident causation has to be established before an instmctional guide can be written or a training program developed. Consider these extremes. 

A clinical scenario can be examined from a number of different perspectives, each of which may illuminate facets of the case. Cases have, from time immemorial, been used to educate and reflect on the nature of disease. They can also be used to illustrate the process of clinical decision making, the weighing of treatment options and sometimes, particularly when errors are discussed, the personal impact of incidents and mishaps. Incident analysis, for the purposes of improving the safety of healthcare, may encompass all of these perspectives but critically also includes reflection on the broader healthcare system. 

Incident analysis is usually seen as retrospective, while techniques such as FMEA, which examine a process of care, are seen as prospective and, therefore. 

Safety Research Group translating evidence into practice model (Figure 19.1). Considerable attention is paid to established clear objectives and the associated measures, such as infection rates from central lines. The evidence and the objectives form the core, but it is also necessary to understand the reahties of the work process and its context, and the barriers to doing the j oh well. Some of this understanding comes from formal analytic methods, such as incident analysis, but much comes from simply watching and talking ... 

The energy flow and barrier analysis (ETBA) technique described in Chapter 13 evolved from this part of the MORT chart, and the mini-MORT chart was developed from this configuration. This version of the chart had a block (not shown) under the incident branch that indicated that in cases of multiple energy flows the analysis process should be repeated for each energy flow and barrier failure that led up to the accident (Fig. 18-9). 

The causes of the specific types of accidents/incidents that have occurred within your workplace must be assessed. The approach you wish to use in the assessment and analysis process depends greatly on your familiarity with and the types of occurrences that have transpired in your workplace. Analyses covered in this book are root cause, causal factor, change, and barrier analysis. 

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