Incident investigation management system implementation

This chapter provides an overview of a management system for investigating process safety incidents. It opens with a review of management responsibilities and presents the important features that a management system must address to be effective. It examines systematic approaches that help implement incident investigation teams, root cause determinations, recommendations, follow-up, and documentation. 

Analyze Weaknesses To learn from incidents, the final step is to recognize that the incident prediction and management systems are not perfect. Implementing practices to learn from mistakes and allowing continuous improvement to the systems to prevent incidents is essential. These practices are incident reporting and investigation processes. 

By gathering these data from each incident investigation, a database is established that will, over time, indicate the broad categories or management systems in which incident investigation findings tend to accumulate. The company can then devise and implement a more holistic approach to prevention than the one developed by addressing individual root causes. 

Center for Chemical Process Safety, Guidelines for Implementing Process Safety Management Systems, American Institute of Chemical Engineers, New York, 1994 Center for Chemical Process Safety, Guidelines for Investigating Chemical Process Incidents, Second Edition, American Institute of Chemical Engineers, New York, 2003... 

A systematic approach to incident investigation, a proper identification of causal factors, and a follow-through on the implementation of corrective actions is essential to a good safety management and engineering system. These incident investigation concepts and procedures are to... 

The requirements for incident investigation are concisely set forth in Section 6.2. They are contained in one paragraph, with no subsections. To fulfill the standard s requirements, organizations are to establish and implement processes to investigate and analyze hazardous incidents in a timely manner so as to identify occupational health and safety management issues (hazards, risks, management system deficiencies, and opportunities for improvement), and other possible incident causal factors. 

Monitoring should include the measurement of how well the policy is being implemented and whether hazards are being controlled properly. It covers inspections of the workplace and management systems the investigation of incidents and accidents to ascertain the underlying causes and effect a remedy. 

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