Incident Investigation facility management

Most facilities already have an established Incident Investigation Program as part of the Process Safety Management program. These existing Incident Investigation Programs should incorporate fire prevention requirements. 

Like all of the elements of process safety management, the incident investigation element continues to evolve. The AIChE Center for Chemical Process Safety assists this evolution hy providing interested parties with information to help them in safely operating process facilities. To this purpose, CCPS and the contributing authors offer this second edition of the Guidelines for Investigating Chemical Process Incidents. 

Making initial notification in a timely manner can present serious challenges immediately following an incident. The incident investigation management system should address how to handle these communications and how to coordinate with facility emergency response plans. A checklist with prearranged names, titles, and phone numbers should be developed and kept up to date for this use. 

The team leader s responsibilities need to be explicit. Normally a team leader chosen for more serious or more complex incident investigations will be independent from the operation or facility where the incident occurred. Actual team composition may vary significantly based on the nature of the process and the degree of technical sophistication. This flexibility of team composition is an important feature of a well-designed incident investigation management system. 

This optional attachment is used to promote continuous improvement of the entire safety management system. It is a checklist for anyone to use as a guide when auditing incident investigation activity. The facility from which this example was derived includes a similar checklist for each safe work practice at the site. 

Recommendations concerning restart of operations are often developed before the final report is published. This is a management decision, but may or may not be part of the incident investigation scope. Nevertheless, these recommendations should be clearly written, imderstood by all, and be approved and accepted by the management organization responsible for safe operation of the facility. Restart criteria deserve special attention and are addressed in further detail later in the chapter. 

The ultimate purpose of an incident investigation is to determine how the facility or company s management systems failed. Therefore, when conducting an investigation it is important to understand what level of management is being considered. The following four levels can be considered ... 

The incident owner usually reports to the facility manager (who may be referred to as the plant manager or as the offshore installation manager depending on the location of the event and the industry that is affected). He or she will ensure that the site is safe before the investigation team enters the property or facility. 

As with the incident owner, the facility manager should not be an active team member because the investigation may show that he or she has responsibility for some of the events covered. 

Audit findings can be incorporated into a facility s overall hazard management system. Items for the system can come from hazards analyses, incident investigations, and audits. The system will be designed such that managers can choose not to follow up on a finding. However, if they do so, they must clearly justify that decision. 

The second phase of the program will be more concerned with achieving quantified improvements in the facility s safety and environmental results. This phase is likely to emphasize elements such as Incident Investigation and Process Hazards Analysis in order to identify weak spots in the management systems. 

Case 4. An electronics manufacturer with almost 5,800 employees has established a joint committee consisting of seven management and eight hourly employees. They conduct monthly inspections of preselected areas of the facility, maintain records of these inspections, and follow up to make sure that identified hazards are properly abated. They investigate all incidents that occur in the facility. All committee members have been trained extensively in hazard recognition and incident investigation. 

To learn from incidents and help prevent similar incidents, your SEMS program must establish procedures for investigation of all incidents with serious safety or environmental consequences and require investigation of incidents that are determined by facility management or BSEE to have possessed the potential for serious safety or environmental consequences. 

A program similar to that shown in Table 7.3 should be developed for the SEMS program once implemented. Some of the on-going work can be estimated with some confidence. For example, management by the SEMS coordinator can probably determine how many hours will be spent on hazards analyses each year. Other elements are much more difficult to forecast, however. For example, the level of effort to be spent on the Investigation of Incidents will inevitably depend on the number and severity of those incidents. The facility s incident track record may give some guidance, but the reality is likely to be quite different. 

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