Incident Investigation limitations

CSB CIRC Initial reports about chemical incidents around the world from official government sources, news media, and eyewitnesses 1998-Present Scope is beyond incidents reported to or investigated by regulatory agencies or first responders Includes domestic and international incidents Not comprehensive, only select incidents included Limited time span Frequent reliance on media accounts limits the depth of initial reports Not designed to be a lessons-learned database... 

Other examples of inductive tools that have limited application in incident investigation include failure mode and effects analysis (FMEA), hazard and operability study (HAZOP), and event tree analysis (ETA). These are detailed in the CCPS book, Guidelines for Hazard Evaluation Procedures... 

Other participants can be involved in a full time or in a limited consulting role depending on the nature of the incident, ft is important to include people who know what actually happens in the field—not just what is supposed to happen. The team selection should be able to withstand third party scrutiny such as that of employees, departments, union representatives, community groups, and legal. Some companies include trade union safety representatives in the incident investigation. Positions to consider include ... 

Another new challenge for incident investigators is capturing, preserving, and retrieving electronically stored data. As previously mentioned, electronic computer control systems have limited storage capacity for detailed process information. Capturing this detailed information is often an overlooked task. 

AAdienever an investigation reveals an employee action worthy of commendation, the incident investigation team should point this out in their comments. Cool rational actions in the middle of an emergency often limit the consequences of an incident. Those employees who demonstrate this type of response should he recognized and commended. 

For decades, most chemical manufacturers have employed a hierarchy of reviews, investigations, and reports for safety and environmental insults and incidents, ft is obvious that a Process Safety Incident Investigation is the highest level investigation that can incorporate other more limited investigations and reports. 

Where "NEVER EXCEED" limits are applicable, any deviation outside these limits will require a document incident investigation. ... 

As discussed above, incident investigators cannot possibly understand all the details and intricacies of the systems that they are investigating. This means that they must be very aware of their personal limitations, and be very willing to reach outside for expert help as soon as it is needed. 

General observations deriving from the study follow. They are just that— observations resulting from a subjective review of a limited number of reports, the 537 reports received. I do suggest that these observations deserve a broader consideration through a study that would meet the requirements of good science since the subject — incident investigation — is so important. 

Assume that the safety culture does not require effective incident investigation. Consider the following examples, limited to seven, of statements that could be made legitimately in investigation reports, but may be perceived as self-incriminating or accusatory of management levels above the first-line supervisor ... 

It is easy to write that if incident investigation is to be done well, effective training must be provided. Where training resources are limited, the program crafted should take into consideration that which... 

Limitations imposed on access to CORS data in the event of incident investigations. 

The incident investigation showed that the algorithm in the FPCP software had a serious limitation, which meant that in a very specific situation multiple spikes on the AOA signal from only one of the ADlRUs could generate a nose-down elevator command. A timeline for the event is shown in Fig. 5.3. 

Incidents are not investigated, or investigations limited to reports required for compliance purposes. 

Given the fact that incident investigation is a process at least as complex as auditing, and given the very limited reliability of auditing (see Chapter 7), we believe that extreme care is necessary in order to ensure a reliable investigation process, hi order to maximize reliability, it is necessary to have a very clearly defined process. This definition should include who should investigate and how. 

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