Incident investigation management system root causes

The typical chemical processing incident investigation reveals mirltiple root causes. The details above lead us to observe weakness in the mechanical integrity program and the hot work permit systems. Now let s look at management of change. 

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. 

An exceptional investigation report willfully explain the technical elements and issues associated with the incident. It will describe the management systems that should have prevented the event, and will detail the system root causes associated with human errors and other deficiencies involved in the incident. 

Establish a safety management system to investigate each injury or illness, analyze the facts of the incident to determine the root cause, and apply that knowledge by taking actions and developing programs to prevent injuries and illnesses. Periodically review all of the incidents... 

For a major incident investigation using a comprehensive root cause analysis system, teams will be formed to acquire information relevant to determine the structure and analyze the causes in depth. In addition to evaluations of the immediate causes, imderlying causes are likely to be evaluated by investigations in areas such as safety and quality management. Both paper- and computer-based systems will be used to acquire and record information for subsequent detailed analyses. 

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. 

After the root causes have been identified from the predefined tree, a generic cause test should be applied. By considering the plant operating history, especially other incidents that may indicate repetitive failures, the investigator may identify other generic management system problems. 

Using structured approaches such as those presented in the preceding chapter, an investigation team identifies the multiple system-related incident causes. These approaches provide the mechanism for understanding the interaction and impact of management system deficiencies. When the investigators understand what happened, how it happened, and why it happened, they can develop recommendations to correct immediate, contributing, and root causes. 

The best way to avoid claims and litigation is to prevent an incident from occurring in the first place by having adequate systems and preventive measures in place. The goal of the incident investigation is to learn the root causes of an incident in order to improve management systems, and... 

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. 

The terms root cause or multiple root causes appear several times without a clear definition. When Jack Philley teaches the Investigating Process Safety Incidents course for the AIChE, he offers several clear definitions. He describes a root cause as a prime reason, underlying cause, and most often associated with breakdowns or flaws in the management systems. Furthermore, Philley s class notes point out definitions from the Department of Energy Guidelines in his handout, which states ... 

Thorough and effective analyses of workplace incidents are critical components of a comprehensive safety management system. Yet, many incident analysis processes (i.e., accident investigations) fall short. They frequently fail to identify and resolve the real root causes of injuries, process incidents and near misses. Because the true root causes of incidents are within the system, the system must change to prevent the incident from happening again. 

Management. When we investigate an incident, the purpose is to identify the root cause of the incident as it relates to as many of the key elements as possible. We are looking at the adequacy and effectiveness of the management system. 

This chapter provides a brief summary of the root cause analysis process and will help you understand and conduct successful incident investigations. Incident investigation is an important element in an effective safety management system. The basic reason for investigating and reporting the causes of occurrences is to identify action plans to prevent recurrence of incidents. 

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