Incident investigation performance

The assessment should also seek out systems for measuring performance. Remember that there is a need to measure both PSM and ESH performance, as well as the effectiveness of the processes in place. It is likely that at least some PSM and ESH performance measures will be in place, such as injury rates, number of incident investigations, regulatory infractions and insurance premiums. Your questions should probe for issues that managers track, but perhaps only informally, that could provide new measures of performance. 

Investigate Chemical Reactivity Incidents Incident Investigation Incident Investigation Monitoring Performance... 

These four steps will result in the greatest positive effect when they are performed in an atmosphere of openness and trust. Management must demonstrate by both word and deed that the primary objective is not to assign blame, but to understand what happened for the sake of preventing future incidents. This book helps organizations define and refine their incident investigation systems to achieve positive results effectively and efficiently. 

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. 

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. 

Human performance problems and resulting incidents Incorporating human factors into the incident investigation pro-... 

Conforming to certain expected conventions and meeting normal patterns of actions and habits can enhance human performance. The incident investigation team should be alert for built-in design deviations from normal conventions. These deviations are often an underlying cause for human error. 

There are several advantages to using a team approach when performing incident investigations. 

External resources may he needed if the incident investigation work exceeds site capahilities. These resources could include corporate personnel or experts from outside the company. (The team leader may also he external if the incident is major since the leader s independence sets the tone for the investigation.) Company business unit leaders should confer with the team leader to determine whether external assistance is recommended. Factors to consider include significant offsite consequences such as environmental impact or product quality concerns. A team of trained specialists should formally investigate any process incident that could significantly affect the business. At the lower end of the scale, if a near miss or minor incident occurs that has no potential for significant consequences, local supervision or front-line personnel normally may perform the investigation without outside assistance. 

After each incident investigation, the team should ask the following questions to review important aspects of their performance ... 

This chapter addresses typical data gathering needs of major investigations. A team may need to augment the activities in this chapter for the unique circumstances of the incident. Performing the activities oudined in this chapter plus special activities provides the incident investigation team with the data needed to complete the next step—systematic determination of the multiple root causes of the incident. However, data gathering and analysis typically involve much iteration as shown in Figure 8-1. 

Some items and components may require examination that is more detailed. Specific techniques for data analysis are beyond the scope of this guidebook. Entire volumes have been written on specific issues such as the fracture patterns of alloys and the corresponding clues for determining the actual cause and mechanism for the failure. Known specific materials and alloys perform and fail in consistent and predictable ways. This area of expertise is normally supplied to the incident investigation team via the use of specialists, from either within the parent organization or from outside experts or labs engaged specifically for the task. 

While preparing to present the recommendations to management, the incident investigation team should perform some analysis. Related recommendations may he grouped hy ... 

The incident investigation team should constantly perform some kind of self-examination to ensure objectivity and independence. Sometimes after being immersed in the details for a while, the team can lose its sense of perspective. 

Are the incident investigation follow-up expectations and requirements included in key performance indicators ... 

If incident case studies are periodically communicated to executives, they can help to reenforce the importance of doing things correctly. This typically translates into critical tasks that must he performed hy skilled workers and accoimtahility for those activities at an executive stewardship level. Such a commitment will carry over into incident investigation follow-up. 

Ad Hoc Investigation— An incident investigation fashioned from the immediately available information and concerns. Typically, the ad hoc investigation is performed whenever there are no prior investigation procedures. A synonym to ad hoc is unsystematic. 

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