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Incident Investigation overview

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. [Pg.7]

Chapter 4— An Overview of Incident Investigation Tools and Methodologies... [Pg.7]

Personnel with proper training, skills, and experience are critical to the successful outcome of an incident investigation. This chapter describes team composition as a function of incident type, complexity, and severity as well as suggested training topics. It also provides team leaders with a high-level overview of the basic team activities typically required in the course of conducting an investigation. [Pg.7]

This optional attachment provides a visual way to view the flow of the major steps and decision-making points of an incident investigation. It can be a helpful overview for management. [Pg.33]

To be effective the investigation must apply an approach which is based on basic incident causation theories and use tested data analysis techniques. Investigating incidents to determine root causes and make recommendations can be as much an art as a science. Within the industry, best practices in incident investigation have evolved substantially in the last 20 years. This chapter provides a brief overview of some of the more relevant causation theories. [Pg.35]

An overview of the company incident investigation management system... [Pg.104]

An overview of the interviewing process is shown in Figure 8-7. The interviewing techniques discussed in the following section are generic to any interviewing activity, but have been modified to incorporate specific issues unique to incident investigation. [Pg.151]

Theoretical incident concepts and associated models have evolved from investigations into the how and why of case histories. Resulting insights have made it possible to better explain and understand incident causation. There are many other incident causation theories besides the ones presented in this chapter, such as the Process Theory. (See the additional references for this chapter.) Key theories on incident causation discussed in this overview are ... [Pg.38]

Failure of any of these three components may eventually result in a repeat incident. A system to follow-up and track each recommendation or resolution until completion must be in place. The investigation should produce a work product that facilitates prediction of the results of recommended changes that are observable and capable of being monitored because they are observable. Figure 13-1 presents an overview of the activities recommended in this chapter. [Pg.306]

The absolute values of the photoabsorption, photoionization, and photodissociation cross sections are key quantities in investigating not only the interaction of photons with molecules but also the interaction of any high-energy charged particle with matter. The methods to measure these, the real-photon and virtual-photon methods, are described and compared with each other. An overview is presented of photoabsorption cross sections and photoionization quantum yields for normal alkanes, C H2 + 2 n = 1 ), as a function of the incident photon energy in the vacuum ultraviolet range and of the number of carbon atoms in the alkane molecule. Some future problems are also given. [Pg.105]

Perhaps the best way to start a brief description is to quote an NFPA Journal article entitled Buildup to Disastef July/August 2007 [18]. Three investigators from the US CSB and Hazard Investigation Board concisely described an overview of the incident that wrecked the refinery as ... [Pg.100]

More than 80% of the cholesteryl esters (CE) found in human plasma derive from the reaction of lecithin cholesterol acyl transferase (LCAT). Since the content of CE in plasma high positively correlates with the incidence of atherosclerosis and myocardial infarction, there has been in the past and still is great interest in investigation of the enzymes involved in lipoprotein metabolism. This overview summarizes some general features, with particular emphasis on investigations carried out in our laboratory (a) the substrates of LCAT in plasma (b), the influence of LCAT on the Upoprotein spectrum (c) the distribution of formed CE after the action of LCAT (d) the impact of cholesteryl ester transfer/exchange protein (CETP) on Upoprotein metabolism. [Pg.49]

This section will provide an overview of an incident causation model that we believe will help you understand the investigation concepts for establishing the root cause of an incident. [Pg.231]

In 1990, the US Clean Air Act authorized the creation of an independent Chemical Safety and Hazard Investigation Board (CSB), but it did not become operational until 1998. Its role, as defined by 40 CFR Part 1600, is to solely investigate chemical incidents to determine the facts, conditions, and circumstances which led up to the event and to identify the cause, probable cause or causes so that similar chemical incidents might be prevented. Its mandate is significantly different than a regulatory enforcement body, as it does not limit the investigation to only determine if there was a violation of an enforceable requirement, but to determine the cause or the causes of an incident. An assumption stated in the overview for the CSB is that it estimated that annually there would be 330 catastrophic incidents and of these, between 10 and 15 would be major catastrophic incidents with life loss. This is an alarming prediction for the industry and clearly indicates some improvement is needed. [Pg.10]

Analyzing behavioral incidents is a difficult task. Too many safety investigations stop short with a simplistic analysis, such as failure to follow procedure or operator inattention, without doing a thorough analysis of the environmental factors that actually contributed to the behavior. The worksheet in Figure 21.8 provides an initial overview of factors that may have contributed to an unsafe act. These concepts will be developed more fully in the next chapter. [Pg.196]


See other pages where Incident Investigation overview is mentioned: [Pg.104]    [Pg.351]    [Pg.231]    [Pg.274]    [Pg.180]    [Pg.106]    [Pg.166]    [Pg.196]    [Pg.157]    [Pg.193]    [Pg.115]    [Pg.378]    [Pg.251]    [Pg.16]    [Pg.179]   
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