Incident Investigation executive management

The DuPont Company has faith in a process called the Analysis of Key Factors for incident investigation. In early 1998, in a small article entitled Getting to the Root of the Problem—The Importance of Incident Investigation appeared in DuPont s Executive Safety News. This article stresses the role of senior management in incident investigation. 

In a major company with exceptionally good OSHA recordable and lost workday case rates, the chief executive officer declared that results were still not acceptable and that significant reductions in injuries and illnesses were to be made. The extensive and well-qualified staff of safety professionals convinced management to use incident investigation as one means of reinforcing its intent to achieve better results. 

What interpretation can be given to the foregoing For this important aspect of safety management—incident investigation—a champion at the senior executive level is needed to drive improvement. In every company with which I am familiar that has achieved stellar safety results, incident experience is regularly reviewed at... 

Appendices contain case histories of chemical reactivity incidents, a sample inherently safer process checklist, and the Executive Summary of the CSB hazard investigation report on "Improving Reactive Hazard Management (CSB 2002b). 

Not all incidents are reported as with disease, prevention is better than cure, but it is obvious that the vital information needed to allow early diagnosis is not at present reaching those ultimately responsible for safety. Top management does already realize this paradox. One senior executive recently commented that, when a fatality occurs, we investigate the hell out of it. If the same incident, fortuitously, does not result in any injury it is ignored or a lip-service investigation takes place. ... 

Should a Health and Safety Executive (HSE) investigation be required after an incident, the HSE inspectors will take into account the principles as defined in Section 2 of this paper when judging the adequacy of a duty holder s arrangements for competence management. This will also take into accormt additional legislation and regulatory practice where applicable. 

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