Incident investigation management system responsibilities

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. 

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 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. 

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... 

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. 

One approach is to mesh all investigation and root cause analysis activities under one management system for investigation. Such a system must address all four business drivers (1) process and personnel safety, (2) environmental responsibility, (3) quality, and (4) profitability. This approach works well since techniques used for data collection, causal factor analysis, and root cause analysis can be the same regardless of the type of incident. Many companies realize that root causes of a quality or reliability incident may become the root cause of a safety or process safety incident in the future and vice versa. 

Immediate outcome—the adverse state the system reached immediately after the active failure. Examples are release of agent, plant damage, or personal injury. Reporting and investigation flow charts supplied by the Army indicate that the severity of outcome often determines the incident s prominence for managers, the workforce, or the community, which in turn drives subsequent responses. Incidents with more salient outcomes naturally receive more scrutiny, which may bias the data set used for analysis. 

Chief— The incident command system title for individuals responsible for management of functional sections operations, planning, logistics, finance/administration, and intelligence/investigations, if established as a separate section. 

The risks are that IT failures may cause harm or deafiis and subsequent investigations and litigation. Experience with incidents would indicate fliat this is a real possibility to be taken seriously. There is an ever increasing dependence on IT and its infrastructure. The more successful it is the more it will be trusted, and the more responsibility there is on us to perform effective safety management on our IT systems. 

Management now set standards of accountability by delegating authority to certain positions for ongoing safety work to be done. Coordination and management of the NEMIRR system needs to be allocated to certain departments and individuals and this standard dictates who must do what, and by when, to run the system. The preceding example of a standard clearly defines who is responsible for a number of aspects of the near miss incident reporting and investigation system. 

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