Incident investigation immediate action

On resolution of this incident, the catalyst preparation area was secured against unauthorized entry, and plant management assembled for a meeting to discuss immediate actions. They decided to call in a corporate risk analyst to lead the team. With his help, by teleconference, management selected the following incident investigation team ... 

Recommended preventive actions should make it very difficult, if not impossible, for the incident to recur. The investigative report should list all the ways to foolproof the condition or activity. Considerations of cost or engineering should not enter in at this stage. The primary purpose of incident investigations is to prevent future occurrences. Beyond this immediate purpose, the information obtained through the investigation should be used to update and revise the inventory of hazards, and/or the program for hazard prevention and control. For example, the Job Safety Analysis should be revised and employees retrained to the extent that it fully refiects the recommendations made by an incident report. Implications from the root causes of the accident need to be analyzed for their impact on all other operations and procedures [6]. 

Inspections The quality of inspections made, as reflected by their thoroughness and the actions taken with respect to findings, is another immediate and outward evidence of an organization s safety culture. Hazards and risks may be overlooked when inspections are made because that is what is expected, and actions may not be taken on hazards identified in the inspection process. If that occurs, employees determine precisely that, no matter what management says or writes, management does not intend to have a safe operation. Those unidentified or unattended hazards appear regularly in incident investigation reports. 

Outline what is to be reported date and time the incident occurred location description of the incident identification data for employees injured (name, badge number, regular occupation, length of employment, length of time on the job involved) estimated potential injury, property damage, or environmental damage immediate actions taken further short-term actions to be taken reports made or to be made to OSHA, EPA, insurance carriers actions taken to assemble an investigation team. 

Safety significant events. Studies from a range of industries have shown that there is consistently a much greater number of less serious incidents than those which led to an injury (David, 2002). Often it was only a matter of chance that these near misses or non-injury accidents did not harm people. Incidents and accidents should be investigated immediately and any necessary corrective action taken. 

Near miss incidents are warnings that the management system is flawed. Not all near miss incidents, however, need immediate and in-depth actions as some near miss incidents have less potential than others do. Assessing the potential of a near miss incident gives a clear indication so that investigations can be prioritized. Using a simple risk matrix, each near miss incident s potential can be ranked and consequent investigations and follow-up actions prioritized. 

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