Incident investigation Corrective action

The intent of the investigation should be to learn from the incident and help prevent similar incidents. A corrective action program should be established based on the findings of the investigation in order to analyze incidents (e.g., uncontrolled release or non-compliant pollution incident) for common root causes. The corrective action prc ram is a followup system to the incident analysis procedures. The investigation should be expedited and findings and recommendations resolved in a timely manner. 

Does the toller investigate serious incidents, injuries or illnesses and implement appropriate corrective actions If no, explain. 

There are at least a couple of conclusions we should draw from this example. If you are going to use safety alerts, even though your intentions are honorable, you may offend the injured party, the folks who took part in the investigation, and others. Be prepared for the fall-out. Also, keep in mind that you need to talk the talk and walk the walk. If an incident occurs and a corrective action is indicated, it behooves you to implement some level of corrective action. If you do not implement a sound corrective action, your company likely has an ineffective safety program to go along with a variety of outstanding lawsuits. 

An investigation is required if an incident involving serious safety or environmental consequences or the potential for these consequences occurs. The purpose of such investigation is to learn from mistakes made and provide corrective action. Investigations should be performed by knowledgeable personnel and should produce recormnendations for safer working conditions. 

OSHA 1910.119 does not mandate the specific type of investigation a plant must conduct when a reportable incident occurs. However, it provides stipulations that must be met for the following investigator qualifications, time requirements, report content, review process, and corrective actions. 

The manufacturer will then conduct a full investigation of the incident to determine the cause and the actions that must be taken in order to rectify the situation and/or prevent a reoccurrence. This may often result in a Field Safety Corrective Action (FSCA), whereby devices should be removed or modified in the field to avoid the risk of death or serious deterioration in the state of health associated... 

Line management participates in the investigation of all chemical reactivity incidents and near misses, and makes resources available to implement corrective actions. 

The tool helps the investigator to understand and focus on the failed harriers, which are normally identified as causal factors. These failed harriers may need to he strengthened, replaced, or supplemented, especially where weak administrative controls are highlighted. Even successful barriers that prevented more serious consequences may require reinforcement. Therefore, barrier analysis can give the investigator valuable insights into how the incident happened and some of the multiple causes that need corrective action to prevent recurrence. 

This investigation/systems analysis/fault tree analysis of this incident provided an excellent opportunity to demonstrate the power of the investigation method and the ease with which it may be adapted to a systems analysis for facilitating improvements and corrective actions. 

Every incident and potential incident involving reactive chemicals will be investigated and reported, including causes and corrective actions. 

Rohm and Haas uses Multiple-Cause, Systems-Oriented Incident Investigation techniques (MCSOII), or mac-soy. It is a direct adaptation of the Fault Tree Analysis logic and the Deming Principles of Systems and Quality. [10] The method was developed to improve the overall quality of investigations, to increase the uniformity of investigation made by various teams, and improve the usefulness of the proposed corrective actions. The quality of the mac-soy or MCSOII investigation is improved because the method [10]... 

Process and equipment integrity Process risk management Management of change Incident investigation Audits and corrective actions Continuous improvement Accountability at all levels... 

When safety or security incidents have occurred, does the carrier investigate and take corrective action ... 

The OOS guidance document indicates that laboratory or analyst errors should be relatively rare, and frequent occurrence can be an indication of inadequate training of analysts, poorly calibrated/maintained equipment, or careless work. It should not be assumed that the failing result is attributable to analytical error without performing and documenting an investigation. When a laboratory error is confirmed, the company must determine the source of error, take appropriate corrective actions, and prevent reoccurrence of the incident. 

Finally, Section 4.7 consolidates post-incident requirements, including decontamination and cleanup notifications final reports investigations of root cause(s) and corrective actions and rapid response to external evaluation and assessment findings. 

Incident and accident investigation reports and corrective actions taken... 

Methods, systems, and procedures for ensuring the occupational health of employees Emergency response including controls, personnel evacuation, escape, and rescue Incident investigation and reporting, corrective and follow-up action The method of performance review and audit including review in the light of external... 

Some incidents are outside the control of local management, and so require attention at a higher level. For example, most large corporations have a procurement policy that is used throughout the whole company. If an incident investigation at one site shows that problems with procurement were a contributing factor then the corrective action will probably have to be addressed at the corporate level. 

Effective incident investigation, reporting, and follow-up are necessary to achieve improvement in health, safety, and environmental performance. They provide the opportunity to learn from reported incidents and to use the information to take corrective action and prevent recurrence. 

Most importantly, results of investigations and the actions to be taken concerning causal factors are publicized. Quality of incident reporting and investigation required or tolerated is a principal measure of the accountability system, and of the culture of which the accountability system is a part. It s very difficult to achieve effectiveness in other aspects of hazards management if corrective action is not taken concerning the causal factors for the incidents that do occur. 

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. 

In some entities, it is required that an incident investigation team be selected and gathered if the results of the incident were serious or could have been serious under other circumstances. Reports prepared by investigation teams (12 of them were received) were a pleasure to read. Every one reflected an understanding of multiple causation and pursued several routes in causal factors determination and in selecting corrective actions. 

After one of my presentations, an attendee spoke to me about the poor quality of incident investigation reports that reached her desk. I had spoken of the need to emphasize systems causal factors and to get away from the excessive concentration shown in some of their investigation reports on what the worker had done in the accident process. She said that almost all of the investigation reports that came to her desk suggested a corrective action that would improve worker behavior, and stopped there. 

This 51-page publication is highly recommended as a reference for those who would evaluate and improve their incident investigation systems. A Guide for Identifying Causal Eactors and Corrective Actions is its centerpiece. Use of the Guide requires a systematic... 

In a form appropriate to the organization in which a safety professional provides counsel, a system of the sort outhned in this National Safety Council pubhcation should result in focusing on actual causal factors and on the development of effective corrective actions. For those who make incident investigations infrequently, a modification of the Guide for Identifying Causal Factors and Corrective Actions would serve as a valuable memory jogger. Such a Guide is included in this chapter. 

---