Incident investigation purpose

Each event, such as equipment failure, process deviation, control function, or administrative control, is considered in turn by asking a simple yes/no question. Each is then illustrated by a node where the tree branches into parallel paths. Each relevant event is addressed on each parallel path until all combinations are exhausted. This can result in a number of paths that lead to no adverse consequences and some that lead to the incident as the consequence. The investigator then needs to determine which path represents the actual scenario. Generally, a qualitative event tree is developed when used for incident investigation purposes. 

Like all of the elements of process safety management, the incident investigation element continues to evolve. The AIChE Center for Chemical Process Safety assists this evolution hy providing interested parties with information to help them in safely operating process facilities. To this purpose, CCPS and the contributing authors offer this second edition of the Guidelines for Investigating Chemical Process Incidents. 

AVhen developing an incident investigation management system, it is important to define common terms and classifications. Several incident categories can be used to develop a classification system. Classification has two main purposes ... 

A witness may have several motives for purposely modifying statements. Witnesses have information that the incident investigation team needs in order to imderstand the incident and determine the causes. They may choose not to tell the incident investigation team all of the relevant information they have. Sometimes witnesses will purposely modify their testimony or withhold information during interviews. AVhat are some of their motives for doing this Usually they are the same as those for not reporting near misses. The most significant of these influences is fear of punishment. 

The following case study describes the investigation work process for a hypothetical occurrence using a logic tree based multiple root-cause systems approach. An example incident investigation report follows the work process description. The example is intended for instructive purposes only descriptions of process equipment and conditions are not intended to reflect actual operating conditions. 

The ultimate purpose of an incident investigation is to determine how the facility or company s management systems failed. Therefore, when conducting an investigation it is important to understand what level of management is being considered. The following four levels can be considered ... 

In the guidelines to be published and in training programs to be conducted, the purposes and objectives of incident investigation should be established and communicated in a language understood in the organization, particularly in relation to its established safety policies and procedures. Some such statements of purpose, taken from issued publications, follow. Choose and adopt from those that are helpful ... 

If a Reference for Causal Factors and Corrective Actions as thorough as the following is to provided, it could be included as pages 3 and 4 of the Incident Investigation Report Form. (In readable print, it can easily be contained in two pages.) Or, it could be a stand-alone reference (peihaps encased in plastic for preservation purposes) to be maintained in a suitable file, or just included in the procedure manual containing the instractions on incident investigation. 

Furthermore, whatever the particular safety process — management involvement, safety in the design stages, employee training, hazards communication, incident investigation, use of personal protective equipment, behavior modification, and so on—its fundamental purpose is to avoid, eliminate, or control hazards. 

The second problem is description errors included in reports. Reasoning of the causes of incidents or proposal of preventive measures is the crucial part of incident reports. Since non-experts of incident investigation sometimes make incident reports, however, mistakes in analyzing incident causes can occur. Though incident analysis is a complicated task, precise and correct analysis is an essential prerequisite for achieving the purpose of incident reporting. 

Incidents include near misses and accidents. Accidents result in loss. Near misses result in no loss. The purpose of any incident investigation is to determine cause(s). As already mentioned, the circumstances differentiating a near miss from a loss-producing incident or accident may be merely a matter of chance therefore, all incidents can be considered candidates for investigation, since correcting the contributing circumstances may help prevent future incidents. 

Conversely, information, related to potential scenarios which an investigation addressed but later rejected because evidence could not support the scenario, is in almost all cases not captured, reported, or as a result, used as input data from the incident investigation for program assessment purposes. 

The purpose here is to assure that hazards, risks, and safety and health management deficiencies observed in the monitoring and measurement, audit, incident investigation, and corrective and preventive action activities are properly communicated and considered in the continual planning and management review processes. 

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. 

The primary purpose of the incident investigation is to prevent future occurrences. Therefore, the results of the investigation should be used to initiate corrective action. 

Recommended preventive actions should make it very difficult, if not impossible, for the incident to recur. The investigative report should list all the ways to foolproof the condition or activity. Considerations of cost or engineering should not enter in at this stage. The primary purpose of incident investigations is to prevent future occurrences. Beyond this immediate purpose, the information obtained through the investigation should be used to update and revise the inventory of hazards, and/or the program for hazard prevention and control. For example, the Job Safety Analysis should be revised and employees retrained to the extent that it fully refiects the recommendations made by an incident report. Implications from the root causes of the accident need to be analyzed for their impact on all other operations and procedures [6]. 

All incident investigation reports for a 3-year period should be collected for a sorting operation. The purpose is to select out those reports describing situations for which, under slightly different circumstances, the results could have been a more serious injury or fatality. That could lead to analyses of operations in which the incidents occurred and furthering the idea that serious injury potential needs special consideration. 

All of these checks should be made in the context of the information available to the assessors at the time of the risk assessment since the purpose of the checks is to identify weaknesses in the current procedures for risk assessment and risk control. Once this has been done, the relevant risk assessment(s) can be reviewed in the light of the new information arising from the accident or incident investigation and, if necessary, the risk assessment can be revised. However, it should always be remembered that the occurrence of an accident or incident is not, per se, a demonstration that the risk assessment was incorrect. 

The purpose of both accident and near miss incident investigation is to carry out an investigation into the undesired event, to determine what happened, and what can be done to prevent a similar event recurring. If positive preventative measures are not taken after an accident or near miss incident, the probability of recurrence is great. The investigation procedure would lead to the root causes of the event and help determine what steps should be taken to prevent a similar accident or near miss incident. 

One of the investigatory principles embodied in Annex 13 dictates that certain records shall not be made available for purposes other than accident or incident investigation. .. (ICAO, 1994). Similarly, reporting and investigating incidents and accidents in healthcare in the Province of Alberta are protected by provincial legislation in the form of Section 9 of the Alberta Evidence Act ... 

A comprehensive safety investigation not only looks at how an incident occurred, but also looks at why it occurred. Most importantly, the investigation recommends corrective actions that can be taken across the organization to prevent such incidents happening again. An incident investigation should be seen as a safety improvement process. It is not the purpose of ICAM to apportion blame or liability. 

The purpose of accident and incident investigation is therefore to trace the developments backwards from the observable outcome to the efficient cause. Similarly, risk assessment projects the developments forwards from the efficient cause to the possible outcomes (cf., Figures 4.1 and 4.2). 

A root cause analysis is not a search for the obvious but an in-depth look at the basic or underlying causes of occupational accidents or incidents. The purpose of investigating and reporting the causes of occurrences is to enable the identification of corrective actions adequate to prevent recurrence and thereby protect the health and safety of the public, the workers, and the environment. Every root cause investigation and reporting process should include five phases. While there may be some overlap between phases, every effort should be made to keep them separate and distinct. The phases of a root cause analysis are... 

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