Incident investigation comments

AAdienever an investigation reveals an employee action worthy of commendation, the incident investigation team should point this out in their comments. Cool rational actions in the middle of an emergency often limit the consequences of an incident. Those employees who demonstrate this type of response should he recognized and commended. 

Comments made about incident investigation in the previously mentioned August 2003 Report of the Columbia Accident Investigation Board are identical to the conclusions I drew as a result of that research. As the following excerpts from that report are read, I suggest that safety professionals think about how they relate to the quality of the incident investigation systems in the entities with which they are involved. 

In Chapter 3, Serious Injury Prevention, I commented on studies made of over 1200 incident investigation reports to assess the effectiveness of the incident investigation systems in place. I said that on a scale of 10, with 10 being best, some companies scored a 2, that causal factor determination was poor, and that opportunities to re-adjust the focus of preventive efforts to the benefit of workers and employers were lost. Observations were not made in that chapter on a rationale that may explain why incident investigations are often superficial. 

Comment on the cultural difficulties facing safety professionals who try to have incident investigations improved if an organization has condoned a low quality of incident investigation. 

Advisory comments on incident investigation are more extensive. They indicate that incidents should be viewed as possible symptoms of problems in the occupational health and safety management system the goal is to identify and correct hazards and system deficiencies before incidents occur experience shows that incident investigations should be commenced as soon as practical and lessons learned from investigations are to be fed back into the planning and corrective action processes. 

This is a relatively brief and inexpensive book that comments on the general incident investigation process, and on several investigation and analytical techniques, such as Events and Causal Factors Analysis Change Analysis Tree Analysis and Specialized Computerized Techniques. 

If a safety professional undertakes to improve the quality of incident investigation, I propose that the following comments about incident investigation as excerpted from the August 2003 Report of the Columbia Accident Investigation Board be kept in mind as a base for reflection throughout the endeavor. The Report pertains to the Columbia Space Shuttle disaster. It is accessed at http //caib.nasa. go v/news/press releases/pr031028.html) ... 

It is evident and convincing that several observers recognize the impact that management decisions have on what become causal factors for hazards-related incidents in the sociotechnical work environment— in the system in which work is done. Similarly, this author s review of over 1700 incident investigation reports results in the conclusion that decisions made at a board of directors and at senior management level must be given prominence in a causation model. Figure 13.1 depicts such a causation model. Comments in support of the model follow. 

Discussions of achievements with safety professionals whose organizations 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. An aggregate list follows of the comments made in discussions with safety professionals in those entities with the best incident investigation systems. 

In preparation for a presentation to be made at a gathering of safety professionals, this author asked the large company that engaged him to provide 40 randomly selected incident reports for review. A drive initiated by the board of directors was underway to improve incident experience. Since it was known by the safety staff that incident investigation was not well done, it was decided to obtain comments from an outsider on the subject. 

Fatality reports, only, were received from the federal government entity. Their thoroughness was commendable. Seldom do comments in incident investigation reports relate to the inadequacy of policies set at an upper management level, or of the appropriateness of standards and procedures, or decisions made affecting the design of the workplace and work methods. These reports did so.Tliey prove that it can be done. 

In the second major company, it was decided to maintain the status quo with respect to its guidelines on incident investigation and to ask management to provide additional staffing at headquarters for a review team that would receive reports on every OSHA-recordable incident and for incidents that could have resulted in serious injury but didn t. Reviewers would send their comments on report inadequacy to the originators of reports and require additional inquiry and report revision until the reviewer was satisfied. (Additional staffing had not been approved as of this writing.)... 

Very few safety texts comment on incident investigation in depth. For those who would study the subject, these references are recommended. 

The company employed some highly qualified staff with considerable expertise in the manufacture of organic nitro compounds. The HSE report describes some of the investigations of thermal stability, safety margins, etc., in which these staff were involved. It also comments in relation to the incident in question, "Regrettably this level of understanding was not reflected in the decision which was made on 21 September when it was decided that the 60 still base would be raked out."... 

The comments on reactions where exposure data suggests an apparent incidence between 1/1000 and 1/10,000, apply even more to new reactions found post-marketing with an incidence greater than 1 /lOOO. Rigorous, rapid investigation is essential. 

Otto von Bismarck once defined politics as being the art of the possible. His comment can be applied to virtually all human endeavors, including the follow-up to incidents on process facilities. Ideally, every incident would be investigated in depth, but the reality is that even the largest... 

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. 

Reference is made several times in this book to an organization s safety culture and how it impacts on the injury experience attained, favorable or unfavorable. Since causal factors for incidents resulting in serious injury are largely systemic and their accumulation is a reflection of the organization s safety culture, that subject must be explored. Comments made on organizational culture in the August 2003 Report of the Columbia Accident Investigation Board on the Columbia space ship disaster are pertinent here. They follow. 

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