Incident Investigation conducting

At the locations where the quality of investigations was good, it was determined that safety professionals had made much of the subject in their giving counsel, and management insisted on the job being well done. Also, as was found in previous studies, incident investigations conducted by teams produced exemplary reviews of causal data, in depth. 

Leading incident investigations Interviewing witnesses to incidents Preserving evidence from incident investigations Conducting root cause analyses Evaluating the results of root cause analyses... 

Is incident investigation conducted for all injuries For near misses ... 

The final incident investigation report written by the assigned incident investigation team (which may include members from the client) can be written in a less structured way depending on the extent of the incident. A detailed discussion of how and why to conduct incident investigations can be found in the AIChE publication. Guidelines for Investigating Process Safety Incidents, Second Edition. 

General guidelines for conducting process incident investigations are given by CCPS (2003). Specific practices that relate to the nature of chemical reactivity hazards are discussed below. 

Personnel with proper training, skills, and experience are critical to the successful outcome of an incident investigation. This chapter describes team composition as a function of incident type, complexity, and severity as well as suggested training topics. It also provides team leaders with a high-level overview of the basic team activities typically required in the course of conducting an investigation. 

The Center for Chemical Process Safety (CCPS) conducted a survey of its membership and other processing companies in preparation for this revised edition. Based on the responses, some general observations can be made about incident investigations ... 

The next item in the loop is a decision point for possibly introducing the use of inductive reasoning methods into the deliberations. If the deductive process continues to indicate progress, then additional facts are procured or the logic tree is restructured. For example, one witness stated a particular valve was open, yet the post-incident inspection found it to be closed. The team must be careful to ensure that the valve is closed because of the actions taken prior to the incident, and not as a result of post-event response activities. The position of this particular valve may be a critical item in determining which of two scenarios is the more probable case. The incident investigation team would then initiate a short-term action item to conduct a mini-investigation to resolve this question. 

There are a number of quality assurance checks that should be considered when conducting an incident investigation using predefined trees. Most of these checks have already been discussed, but will now be summarized in relation to the corresponding phase of the investigation. 

This approach is not recommended for process safety incident investigation. If the team conducting the incident investigation has been chosen for their experience, technical knowledge, and skills, they are best placed to develop the recommendations to prevent a recurrence. 

Swedish investigators conducted a prospective, long-term study of personality traits in patients with intractable obsessional illness treated by capsulotomy. These authors found that the incidence of adverse personality changes after capsulotomy is low and does not increase with time ( 250). German investigators have reported... 

Industry associations, professional societies, academic institutions, and government agencies provide information on process safety incidents. Several groups sponsor conferences (both domestic and international) that include major sessions on process safety incidents. Documented proceedings from these conferences provide valuable information for selecting metrics based upon historical incidents. The U.S. Chemical Safety and Hazards Investigation Board (CSB) conducts incident investigations and hazards studies, and documents causal... 

Mortality data are frequently used in cohort studies as opposed to incidence data because of the relative ease of obtaining information on deaths. In particular, the advent of the National Death Index has made mortality data more readily available. While all states maintain registries of incident cancer cases, many of the registries are relatively new and data quality can vary from state to state. Investigators conducting follow-up studies are required to comply with each state s requirements for use of the data. For cancers such as pancreatic cancer where survival is poor, mortality data is an excellent surrogate for the risk of the disease. For other cancers where the survival is much better, such as testicular cancer, mortality is a poor estimator of incidence. Table 15.5 describes the 5-year survival for several selected cancer sites for the period 1996-2004. As evident from the table, there is a considerable difference in survival rates for cancer of different sites. The 5-year survival rate for pancreatic cancer was only 5.1% compared to a survival rate of 98.9% for prostate cancer (SEER 2008). 

The ultimate purpose of an incident investigation is to determine how the facility or company s management systems failed. Therefore, when conducting an investigation it is important to understand what level of management is being considered. The following four levels can be considered ... 

Once the emergency responders have completed their work, the incident investigation team can move in. As noted in the previous chapter, some facilities create what is called a Go Team to conduct these first investigations. This team is put together very quickly after the occurrence of the... 

Conduct safety and/or environmental audits or incident investigations ... 

A new procedure was put in place to have all OSHA recordable incidents, and those incidents that were judged to have severity potential but did not result in harm or damage, investigated by teams, the talent for which would be selected in relation to the specifics of the incident. For other incidents, the practice of having immediate supervisors make investigations was continued. Retraining sessions on incident investigation were conducted. 

---