Incident Investigation documentation

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. 

Check that all items from hazard analyses, incident investigations and other discovery processes have been properly implemented and documented. 

This chapter provides an overview of a management system for investigating process safety incidents. It opens with a review of management responsibilities and presents the important features that a management system must address to be effective. It examines systematic approaches that help implement incident investigation teams, root cause determinations, recommendations, follow-up, and documentation. 

Once the likely causes of an incident have been identified, investigation teams evaluate what can be done to help prevent recurrence. The incident investigation recommendations are the product of this evaluation. This chapter addresses types of recommendations, some attributes of good recommendations, methods to document and present recommendations, and management s responsibilities. 

In the case of incident investigation, a major milestone is completed when the final incident investigation report is submitted. The incident report documents the investigation team s findings, conclusions, and recommendations. This chapter describes practical considerations for writing formal incident reports, a discussion of the attributes of quality reports, and the issue of commimicating the report findings to affected persons, both internally and externally. 

The incident investigation management system should be described in a written document that defines the roles, responsibilities, protocols, and specific activities to be carried out by personnel performing an incident investigation. 

They ensure documentation exists explaining why a recommendation was rejected or modified after its original approval in an incident investigation report. 

This section provides a summary description of what this management system document contains. Some organizations choose to place their incident investigation policy statement here. 

This section describes the formal approval and acceptance method for the report and where the final report and any supporting documentation will be maintained. It may state the company document retention policy for incident investigation or refer to another resource to determine how information must be kept. 

The team leader is responsible to plan and direct the team activities. The specific plan for the team should include a designated mechanism for documenting the team activities, deliberations, decisions, commimications, and a record of documents requested, received, or issued. The primary objectives of a process safety incident investigation plan are to ... 

Incident investigation involves varying levels of photographic expertise. For most minor incidents, the team or a company employee can adequately meet the photographic needs. Incidents that are more serious require an experienced individual, such as a forensic specialist, who systematically documents the scene, equipment involved, damage, evidence collection, and position data. For specialized photographic needs, the services of a professional commercial photographer or other specialists are necessary and are justified. Examples of such needs include ... 

The normal practice is to designate a single person on the incident investigation team to coordinate photography. This person works closely with the team member responsible for documentation and record keeping and coordinates with other groups outside the team. 

Eliminate other distractions from the room if possible. Do not allow the witness to see any documents, such as causal factor charts, fault trees, showing the incident investigation team analysis of the occurrence. This may he appropriate for later interviews when only specific information is needed or a specific time gap is being filled in. 

Events Causal Eactor Charting (E CE) (5) was adopted by the developers of MORT to identify and document the sequence of events leading to an incident. A number of proprietary process safety incident investigation methodologies, such as SOURCE ) and TapRooT C) include E CF as one of their building blocks. 

The first phase of process safety incident investigation involves gathering all the pertinent facts from the collected evidence, whether derived from interviews, site and equipment inspections, or document reviews. At this... 

In summary, the report is the vehicle for transmitting and documenting the investigation. It is a direct reflection of the quality and professionalism of the incident investigation team. The entire team should review the report before release. 

Some documents created by an incident investigation team may besulyect to disclosure to ... 

The incident investigation team should consult legal counsel to determine other activities that will assist in preparing for facility inspections or investigations and document preparation depending on the incident. 

Document lessons learned in the incident investigation management system. 

Were there any legal issues from this latest investigation that were related to incident investigation reports or documentation that need to be resolved before the next major incident investigation ... 

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