Incident investigation management system

Chapter 2—Designing an Incident Investigation Management System... 

The incident investigation management system should be described in a written document that defines the roles, responsibilities, protocols, and specific activities to be carried out by personnel performing an incident investigation. 

Note that near misses (Chapter 5), human factors (Chapter 6), and legal issues (Chapter 12) are special considerations in both preplanning and deploying the incident investigation management system. 

Management demonstrates commitment by recognizing that periodic reviews and reevaluations of the incident investigation management system are necessary to ensure it continues to function as originally intended and achieves the desired results. Periodic reviews provide four obvious benefits. 

The format and timing of all external notifications should be identified and incorporated into the incident investigation management system before an incident. With this information readily at hand, the proper notifications may be made quickly and accurately when an incident occurs. 

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. 

The incident investigation management system should help managers ... 

AVhen developing an incident investigation management system, it is important to define common terms and classifications. Several incident categories can be used to develop a classification system. Classification has two main purposes ... 

The incident investigation management system may include a description of how a team is organized and how it functions. The team organization, composition, and functions must be structured to provide flexibility based on the particular incident and the management system should emphasize that fact. The system may describe an investigation team s basic objectives... 

The team leader s responsibilities need to be explicit. Normally a team leader chosen for more serious or more complex incident investigations will be independent from the operation or facility where the incident occurred. Actual team composition may vary significantly based on the nature of the process and the degree of technical sophistication. This flexibility of team composition is an important feature of a well-designed incident investigation management system. 

An example of a typical approach for writing an incident investigation management system is presented on pages 30-31. It addresses all of the items described previously. 

This section lists sources used to develop the incident investigation management system corporate guidance, regulatory requirements, and other reference materials such as this hook. 

Example incident investigation management system courtesy of AntiEntropics, Inc. 

Studies indicate that the vast majority of incidents involve human performance issues. Incident investigations should not simply identify human performance as a cause the management system failure that did not prevent or compensate for the potential human performance must he identified and corrected in order to prevent recurrence. An incident investigation management system should provide the tools to identify and address applicable human factors issues. It is important to recognize that human performance problems can occur in all management system areas—not simply to the human operator or maintenance worker closest to the scene. 

The organization s incident investigation management system should specify the team leader s responsibilities and authority. Upon selection of the team leader, the leader and senior management should review and agree on all assigned responsibilities. The agreed responsibilities should... 

An overview of the company incident investigation management system... 

An incident has just been reported. How is a team activated The team activation segment of a company s incident investigation management system should guide the user to assemble a team based upon the following two areas of concern ... 

The Concorde aircraft tragedy in July 1999 involved a fuel tank puncture caused by tire failure.During the investigation, it was disclosed that there had been at least five previous incidents of almost the same scenario. In one of the previous incidents, a tire failed and punctured the fuel tanks, yet there was no ignition. The incident investigation management systems used by the airlines failed to adequately follow-up and apply lessons learned from previous investigations. 

Reviewing the incident investigation management system for opportunities to improve the actual investigation procedures... 

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