Incident investigation process focus

Employees in the process area where the incident occurred should be consulted, interviewed, or made members of the team. Their knowledge of the events represents a significant set of facts about the incident that occurred. The report, its findings, and recommendations should be shared with those who can benefit from the information. The cooperation of employees is essential to an effective incident investigation. The focus of the investigation should be to obtain facts, and not to place blame. The team and the investigative process should clearly deal with all involved individuals in a fair, open, and consistent manner. 

Nurturing a blame-free, open culture within an organization is essential for the success of the incident investigation process. The investigation must focus on understanding ... 

Like the previous edition, the book remains focused primarily on investigating process-related incidents that present realized or potential catastrophic consequences (that is, accidents as well as near misses). However, readers will find that the methodologies, tools, and techniques described in the following chapters may also be applied when investigating other types of occurrences such as reliability, quality, and occupational health and safety incidents. 

Regardless of the method of investigation used for any incident, there are some mandatory OSHA requirements. The OSHA Process Safety Management (PSM) standard focuses on incidents that could reasonably have resulted or actually had resulted in a catastrophic release of highly hazardous chemicals. A major requirement is having a procedure that the employer can quickly implement. Here are a few considerations for an incident investigation procedure that addresses the major points of the PSM standard. 

Here, although understanding has been positioned as the ultimate output of the accident investigation process, it is the worker who is effectively blamed for the incident, his action becoming the focus of the investigation process. There is a segregation of responsibility for this incident the worker s violation is separated and made distinct from the shared ownership of the accident as a whole. 

This is intended to focus you on the process rather than individual tasks. It is common to have a tendency to focus on the accomplishment of tasks—for example, to train everyone on a particular topic or implement a new procedure for incident investigations [7]. 

A successful incident investigation not only determines what happened, but also finds how and why the incident occurred. Incident investigation is another tool for identifying hazards that were missed earlier or that slipped by the planned controls. However, it s only useful when the process is positive and focuses on finding the root cause, not someone to blame ... 

A better approach is to re-focus the investigation process by asking the question who could have done what to avoid, help to avoid, or mitigate the incident Normally there are three controlling minds to a workplace incident ... 

Incident investigations are used to identify and uncover the underlying causes of hazards that were missed or created when a process or operation has slipped out of control. The focus of an incident investigation is to determine the combination of factors that came together at a point in time to create the event. It attempts to determine what actually triggered the event. 

At the base of the why tree where fundamental management systems are implicated, the process ceases. The investigation team should then focus its efforts on the rigor and quality of the management systems that could have prevented the incident. Recommendations are developed to address system deficiencies and these are tested against the why tree. An example is included on the accompanying CD ROM. 

While thin sections are often easier to prepare on IR-reflective substrates, the use of IR-reflective substrates does come at a cost to the IR data collection process, and even spectral quality. As noted above, the incident flux in reflection mode is reduced by almost 50% compared to transmission mode, as only half of the focusing objective is used to direct the beam onto the sample, while the second half is used for collecting the reflected beam. In addition, any inhomogeneities in the thin section can cause interference effects (e.g., oscillations) in the background of the IR spectra. These artifacts can alter peak shapes, intensities and frequencies. Thus, care must be taken with sample preparation, and only certain (generally homogeneous) samples can be investigated well in this mode. 

When the compound absorbing radiation is transformed, the process is referred to as direct photolysis. Many studies in this area focus on the development of an understanding of the fundamentals of the process defining energies of the excited states and reaction pathways. Such studies would be carried out under conditions where the incident radiation and reaction environment is carefully controlled. By contrast, investigations under environmental conditions must account for the fact that solar... 

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