Incident Investigation initiating

Incident investigation, initially, should address the work system, applying a concept that... 

Adapted from health and safety executive report Buncefield major incident investigation initial report July 2006 Page 12. Contains public sector information hcensed under the Open Government Licence. Adapted by Manuel David. 

The initial incident report is very important. This document captures the initiator s firsthand knowledge of what occurred in the moments after the specific event. Example 5-2, Sample Toller Initial Incident Report, is an example of the data that should be documented as soon as possible. Note that it should be modified using the company s management system procedure and incident investigation procedure, which should describe the type of data needed, and level of detail desired. 

The employer investigates incidents that result in, or could result in, a catastrophic release of highly hazardous chemicals. An incident investigation is initiated as soon as possible, but before 48 hours following the incident. An incident investigation team is established to consist of one or more experts in the process involved, and accident investigation. The report prepared at the conclusion of the investigation includes at a minimum ... 

The regulation states An incident investigation shall be initiated as promptly as possible, but not later than 48 hours following the incident. In part, the reason for this quick response to an incident is to assure that all pertinent evidence and facts can be preserved to facilitate the investigation. 

The Chemical Incidents Report Center (CIRC) is an incident database initiated by the U.S. Chemical Safety and Hazard Investigation Board. An online search of this database (www.chemsafety.gov/circ), as well as a more general web search, may be a good starting point for a literature survey. 

A series of investigations initiated during this period led to the conclusion that DBS use by the mothers of these young women was the causative factor. Diethylstilbestrol is a developmental toxicant, because its effect was the result of exposures received in utero, but that effect - a rare form of vaginal cancer - was not fully expressed for about two decades following the exposure (the age at which the incidence of the disease peaked was later shown to be 19). The DES produced not only cancer but abnormalities of the sexual organs in both male and female offspring, most of which were not expressed until the children passed the age of puberty. 

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. 

Each incident investigation is unique and should be accompanied by a customized initial plan. The initial plan, specific to each incident, is continuously revised and updated as new priorities and concerns are identi-... 

The incident investigation team must look specifically for evidence that provides the point of initial failure, its progression path, and the preexisting conditions that led to the initiation. Having an understanding of a fundamental failure mode and the sequence of events, the investigator... 

The next item in the loop is a decision point for possibly introducing the use of inductive reasoning methods into the deliberations. If the deductive process continues to indicate progress, then additional facts are procured or the logic tree is restructured. For example, one witness stated a particular valve was open, yet the post-incident inspection found it to be closed. The team must be careful to ensure that the valve is closed because of the actions taken prior to the incident, and not as a result of post-event response activities. The position of this particular valve may be a critical item in determining which of two scenarios is the more probable case. The incident investigation team would then initiate a short-term action item to conduct a mini-investigation to resolve this question. 

In light of earlier evidence that genetic variations in prothrombin of human subjects are clearly associated with the risk of venous thrombosis, and before the results of HERS were known, investigators initiated a case-control study to assess whether prothrombotic mutations modify the association between HRT and the incidence of first MI. Cases were 232 postmenopausal women aged 50 to 79 years who had their first nonfatal MI between 1995 and 1998. 

An incident investigation shall be initiated as promptly as possible, but not later than 48 hours following the incident. 

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