Incident Investigation management levels

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 personnel responsible for the collection and analysis of incident data vary in different organizations. One common practice is to assign the responsibility to an investigation team which includes the first line supervisor, a safety specialist and a plant worker or staff representative. Depending on the severity of an incident, other management or corporate level investigation teams may become involved. 

Management s continuing endorsement and approval for the program is essential. It is beneficial to reaffirm that management understands the concepts of incident investigation on a periodic basis since changes in company leadership may affect the level of awareness and emphasis on incident investigation. 

This group must be familiar with the concepts, policies, extent of commitment from upper-level management, and specific assignments of responsibility associated with process safety incident investigation. 

Senior management can and must, play a crucial role in this process. It is senior management that establishes expectation levels and fosters a climate of trust and confidence. It is also senior management that bears the responsibility for establishing a clearly defined process for incident investigations. 

An incident investigation shall be initiated as promptly as possible, but no later than 48 hours following a catastrophic release of highly-hazardous chemicals or one which could reasonably have resulted in a catastrophic release. Upon the recommendation of the shift superintendent or a second-level supervisor, the incident investigation will be initiated by the affected plant manager or one of his superintendents. 

Process and equipment integrity Process risk management Management of change Incident investigation Audits and corrective actions Continuous improvement Accountability at all levels... 

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 ... 

Some incidents are outside the control of local management, and so require attention at a higher level. For example, most large corporations have a procurement policy that is used throughout the whole company. If an incident investigation at one site shows that problems with procurement were a contributing factor then the corrective action will probably have to be addressed at the corporate level. 

As an incident investigation proceeds, the teams will be required to brief management as to its findings on a regular basis. The frequency and level of detail of the briefings will naturally depend on the severity of the event. Figure 11.3 outlines a representative reporting procedure. The Go... 

If incident investigation is important to the boss, if it is a part of the accountability system, it will be well done. Where that is the case, safety professionals will receive requests for help from all levels of management. 

Setting the above knowledge and proposals together leads to integrated incident investigation procedure which is stUl based on the timeline development, causal factor identification and causal factor chart development, but which allows the determination of different Incident Cause Level for each of multiple causes. If the Incident Cause Level of specific cause is outside the internal safety management, the apph-cation of non-hnear analysis method is recommended. 

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 ... 

What interpretation can be given to the foregoing For this important aspect of safety management—incident investigation—a champion at the senior executive level is needed to drive improvement. In every company with which I am familiar that has achieved stellar safety results, incident experience is regularly reviewed at... 

When system changes are considered, their potential consequences must be evaluated in terms of risk acceptance. Here again, the appropriate management level must determine what is considered acceptable risk. Good business management will identify the need for proper control methods such as barriers to reduce levels of risk. MORT, then, is designed to investigate accidents and incidents and to evaluate safety... 

It is suggested that internal evaluations be made of the quality of incident investigations to determine what improvements are necessary. Such evaluations often indicate the existence of culture problems demonstrated by the accepted practice for supervisors, management personnel above the supervisor level, and safety professionals to sign-off on shallow investigation reports. 

It is evident and convincing that several observers recognize the impact that management decisions have on what become causal factors for hazards-related incidents in the sociotechnical work environment— in the system in which work is done. Similarly, this author s review of over 1700 incident investigation reports results in the conclusion that decisions made at a board of directors and at senior management level must be given prominence in a causation model. Figure 13.1 depicts such a causation model. Comments in support of the model follow. 

Acceptable risk levels cannot be maintained if systems are not adequately maintained. As this chapter was being written, incident investigation reports received by this author indicate that, because of severe expense reductions, maintenance has deteriorated—the result being serious injuries and fatalities. In the excerpt from Managing the Risks of Organizational Accidents (Reason, 1997) previously quoted, reference is made to maintenance failures as contributors to the... 

Fatality reports, only, were received from the federal government entity. Their thoroughness was commendable. Seldom do comments in incident investigation reports relate to the inadequacy of policies set at an upper management level, or of the appropriateness of standards and procedures, or decisions made affecting the design of the workplace and work methods. These reports did so.Tliey prove that it can be done. 

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