Incident Investigation evaluation

Another application area is the use of PIFs as part of the process of incident investigation. Any investigation which seeks to establish the imderlying causes of minor or major incidents will benefit from a systematic framework for evaluating the factors which can contribute to the human contribution to such incidents. This topic will also be discussed in Chapter 6. 

For a major incident investigation using a comprehensive root cause analysis system, teams will be formed to acquire information relevant to determine the structure and analyze the causes in depth. In addition to evaluations of the immediate causes, imderlying causes are likely to be evaluated by investigations in areas such as safety and quality management. Both paper- and computer-based systems will be used to acquire and record information for subsequent detailed analyses. 

With regard to evaluating these factors, it is recommended that structured checklists be used, such as those provided by the HFAM method described in Chapter 2. These checklists provide an explicit link between the direct causal factors and management policies. Figure 2.12 shows how these checklists could be used to investigate possible procedures deficiencies, and the policies that led to the deficiencies, as part of the incident investigation. Similar checklists can be used to investigate possible culture problems (e.g., inappropriate trade-offs between safety and production) that could have been implicated in an accident. 

Snee, T. J., "Incident Investigation and Hazard Evaluation Using Differential Scanning Calorimetry and Accelerating Rate Calorimetry," J. Occupational Accidents, 8 (1987). 

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. 

Other examples of inductive tools that have limited application in incident investigation include failure mode and effects analysis (FMEA), hazard and operability study (HAZOP), and event tree analysis (ETA). These are detailed in the CCPS book, Guidelines for Hazard Evaluation Procedures... 

The incident investigation team must evaluate potential effects of an incident on all the stakeholders interested in a facility s continued safe operation. Public perception and good will are very important. Stakeholders include ... 

Steinhubl SR, Tan WA, Foody JM, Topol EJ. Incidence and clinical course of thrombotic thrombocytopenic purpura due to ticlopidine following coronary stenting. EPISTENT Investigators. Evaluation of Platelet Ilb/IIIa Inhibitor for Stenting. JAMA 1999 281(9) 806-10. 

Probably the most important issue to evaluate is the closure of items on the risk register. These items can come from hazards analyses, incident investigations and audits. If an item is not closed then it represents a liability—after all the issue was known about but not responded to in a timely manner. But failure to close out findings and recommendations is symptomatic of a deeper problem—it shows that the overall PSM systems is not being operated properly. 

Based on their incident evaluation, management will put together the formal incident investigation team (which will usually have a similar composition to that of the Go Team) as illustrated in Figure 11.3. 

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. 

Structure and content variations in incident investigation forms were extensive, and precise and equivalent evaluations could not be made in report reviews. As an example, one of the simplest forms consisted in its entirety of these questions. What happened Why did it happen What should be done What have you done so far How will this improve operations ... 

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... 

While MORT is based on the fault tree method of system safety analysis, its logic diagram does not require statistical entries and computations for event probabilities. MORT is presented as an incident investigation methodology and as a basis for safety program evaluation. 

Three safety professionals are asked to evaluate their company s previous year s 129 incident investigation reports. Each separately makes a presentation to the vice president of safety, health and environment. The three presentations are made over the course of several days. 

Safety program System analysis Hazard report management Risk evaluation Incident investigation... 

An incident evaluation tool to investigate causes leading to incidents and as a framework for incident investigation. It models the flow of actions that lead to an incident or loss (Figure L.4). It was originally developed by Herbert W. Heinrich and later modified by Frank Bird. See also Domino Theory. 

The SSHA evaluates hazardous conditions, on the subsystem level, which may affect the safe operation of the entire system. In the performance of the SSHA, it is prudent to examine previous analyses that may have been performed such as the preliminary hazard analysis (PHA) and the failure mode and effect analysis (FMEA). Ideally, the SSHA is conducted during the design phase and/or the production phase, as shown in Chapter 3, Figure 3.4. However, as discussed in the example above, an SSHA can also be done during the operation phase, as required, to assist in the identification of hazardous conditions and the analysis of specific subsystems and/or components. In the event of an actual accident or incident investigation, the completed SSHA can be used to assist in the development of a fault tree analysis by providing data on possible contributing fault factors located at the subsystem or component level. 

Rebuild the investigation system Evaluating the incident investigation system is critical to make sure investigations are conducted in an effective manner. This should help get to the root cause of accidents and incidents. 

Deserves a much higher place within all the elements of a safety management system. Because—The quality of incident investigation emerges as one of the primary markers in evaluating an organization s safety culture. 

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