Incident investigation data management

The initial incident report is very important. This document captures the initiator s firsthand knowledge of what occurred in the moments after the specific event. Example 5-2, Sample Toller Initial Incident Report, is an example of the data that should be documented as soon as possible. Note that it should be modified using the company s management system procedure and incident investigation procedure, which should describe the type of data needed, and level of detail desired. 

Three major themes have been emphasized in this chapter. The first is that an effective data collection system is one of the most powerful tools available to minimize human error. Second, data collection systems must adequately address underlying causes. Merely tabulating accidents in terms of their surface similarities, or using inadequate causal descriptions such as "process worker failed to follow procedures" is not sufficient to develop effective remedial strategies. Finally, a successful data collection and incident investigation system requires an enlightened, systems oriented view of human error to be held by management, and participation and commitment from the workforce. 

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. 

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. 

Incident investigation reports may include valuable data on predictive indicators pertaining to serious injury and fatality potential. However, this author has found that the gap between issued procedures on incident investigation and what actually takes place can be huge. Even in the best safety management systems, the quality of incident investigation can be less than adequate. 

The personnel responsible for the collection and analysis of incident data vary in different organizations. One common practice is to assign the responsibility to an investigation team which includes the first line supervisor, a safety specialist and a plant worker or staff representative. Depending on the severity of an incident, other management or corporate level investigation teams may become involved. 

One approach is to mesh all investigation and root cause analysis activities under one management system for investigation. Such a system must address all four business drivers (1) process and personnel safety, (2) environmental responsibility, (3) quality, and (4) profitability. This approach works well since techniques used for data collection, causal factor analysis, and root cause analysis can be the same regardless of the type of incident. Many companies realize that root causes of a quality or reliability incident may become the root cause of a safety or process safety incident in the future and vice versa. 

Immediate outcome—the adverse state the system reached immediately after the active failure. Examples are release of agent, plant damage, or personal injury. Reporting and investigation flow charts supplied by the Army indicate that the severity of outcome often determines the incident s prominence for managers, the workforce, or the community, which in turn drives subsequent responses. Incidents with more salient outcomes naturally receive more scrutiny, which may bias the data set used for analysis. 

Monitor leading indicators using the Safety Scorecard Identify and report incidents, near misses, and unsafe conditions Track accident investigations and store causal factor data Assign and manage corrective actions / Collaborate with multiple departments for incident resolution Monitor the status of tasks and projects Manage OSHA-recordable and other injury records... 

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