Investigations, formal incident

Consideration of how formal data collection incident investigation methods are to be introduced into a plant in order to ensure acceptance and long-term support by the workforce... 

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. 

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. 

External resources may he needed if the incident investigation work exceeds site capahilities. These resources could include corporate personnel or experts from outside the company. (The team leader may also he external if the incident is major since the leader s independence sets the tone for the investigation.) Company business unit leaders should confer with the team leader to determine whether external assistance is recommended. Factors to consider include significant offsite consequences such as environmental impact or product quality concerns. A team of trained specialists should formally investigate any process incident that could significantly affect the business. At the lower end of the scale, if a near miss or minor incident occurs that has no potential for significant consequences, local supervision or front-line personnel normally may perform the investigation without outside assistance. 

Figure 7-1 offers a typical checklist to use during the planning stage of an investigation of a major complex incident. Low complexity incident investigations do not always call for a formal plan. Some simple investigations may require only 1 to 2 hours to complete. 

The incident investigation team should review the investigation and final draft of the formal written report to ensure the intended result was achieved. An example checklist is shown in Table 11-5. Reports should have technical review for clarity and accuracy, and where appropriate, legal review. 

For improved quality of formal written incident reports, the incident investigation team should follow these guidelines ... 

Words and phrases such as incident, accident, and near miss tend to be used quite loosely in general conversation. They also tend to have different connotations in English, American, and Canadian usage. However, in the context of formal incident investigation and analysis such words need to be tightly defined. The definitions used for these terms in this chapter are provided below. 

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. 

Team issues its first report which summarizes the major issues to do with the incident. The formal investigation team issues one or more interim reports as it progresses with its work. Lastly, the analysis team delivers the final report, containing both the root cause analysis, the findings, and suggested action items. 

Health and safety representatives who have received specific accident investigation training could be used to assist in accident and near-miss incident investigations. Since they will be conducting both formal and informal inspections, a training session in auditing techniques will help them to audit safety standards in their own areas. 

The Causal Factors Chart is a formal, and systematic, incident investigation and root cause analysis technique. The technique depicts the events and conditions leading up to an incident. It combines critical thinking, logical analysis, and graphic representations to analyze and depict an incident event scenario. It helps strncture the analysis and data gathering processes to ensure necessary and snfficient information is collected. The CFC also has been applied to Root Cause Analysis. The CFC is sometimes referred to as the Events and Causal Factors (ECF) chart. The ECF chart depicts the necessary and sufficient events and causal factors associated with a specific incident scenario. 

Unusual Incidents are Investigated by meoibers of Plant Operations organizations. Causes are determined and remedial action Is specified. Depending upon the seriousness of the Incident a formal report or reports may be made. 

Since this integrated approach is intended for use by incident investigators who may not have received any formal human factors training, it is useful to provide guidance on the generation of actions, or recommendations for action from the analysis. Such guidance might include ... 

Most incident investigations follow formal procedures. This chapter discussed two of the most common procedures change analysis and job hazard analysis. An investigation is not complete until a final report is issued. Responsible individuals can use the information and recommendations to prevent future incidents [6]. 

Lead formal incident investigations to identify root causes. Drive corrective action to prevent reoccurrence. 

The carcinogenic potential of bromomethane has not been formally investigated in epidemiological studies of occupationally-exposed workers. Wong et al. (1984) studied the incidence of cancer in a... 

As discussed, the major purpose of the investigation is prevention. The tone and choice of words used in the formal report should reflect the attitude of preventing a repeat of a similar incident rather than affixing the blame. 

In addition to the factual findings of the investigation, this incident helps to illustrate the importance of process safety information. AVhen unusual or unprecedented situations are encountered, every effort should be taken to understand the chemical properties and behavior of chemical substances before attempting their removal. The adhesive properties of the fly-ash/lime mixture were obviously affected by water and this led to a large release and structural failure. Had the development of formal procedures been attempted, the knowledge gap might have been identified and a dif-... 

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