Incident Investigation recommendations

Once the likely causes of an incident have been identified, investigation teams evaluate what can be done to help prevent recurrence. The incident investigation recommendations are the product of this evaluation. This chapter addresses types of recommendations, some attributes of good recommendations, methods to document and present recommendations, and management s responsibilities. 

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. 

With regard to evaluating these factors, it is recommended that structured checklists be used, such as those provided by the HFAM method described in Chapter 2. These checklists provide an explicit link between the direct causal factors and management policies. Figure 2.12 shows how these checklists could be used to investigate possible procedures deficiencies, and the policies that led to the deficiencies, as part of the incident investigation. Similar checklists can be used to investigate possible culture problems (e.g., inappropriate trade-offs between safety and production) that could have been implicated in an accident. 

The third step in incident investigation is to generate a report detailing facts, findings, and recommendations. Typically, recommendations are written to reduce risk by ... 

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. 

In the case of incident investigation, a major milestone is completed when the final incident investigation report is submitted. The incident report documents the investigation team s findings, conclusions, and recommendations. This chapter describes practical considerations for writing formal incident reports, a discussion of the attributes of quality reports, and the issue of commimicating the report findings to affected persons, both internally and externally. 

The recommendations generated from an incident investigation should be properly implemented in a timely fashion to decrease the probability of... 

They ensure documentation exists explaining why a recommendation was rejected or modified after its original approval in an incident investigation report. 

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. 

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. 

The team can then recommend or implement improvements to the incident investigation work process. 

If the incident investigation team is satisfied with the root causes identified, then the investigation proceeds to the recommendation stage. If a problem or some incompleteness is noted, then an iterative loop is followed. 

The incident investigation team is responsible for developing practical recommendations and submitting them to management. It is then the responsibility of management to approve, modify, reject, communicate, implement, and follow-up on the recommendations, including ... 

Recommendations concerning restart of operations are often developed before the final report is published. This is a management decision, but may or may not be part of the incident investigation scope. Nevertheless, these recommendations should be clearly written, imderstood by all, and be approved and accepted by the management organization responsible for safe operation of the facility. Restart criteria deserve special attention and are addressed in further detail later in the chapter. 

The incident investigation team should strive to find recommendations that ... 

The decision authority and responsibility for restart rests with site and corporate management. Depending upon the scope of the investigation, the incident investigation team may be requested to assist by identifying any recommendations that should be implemented before resumption of operations. If so, then the team should clearly specify the minimum acceptable criteria recommended for safe resumption of operations. This list should be in writing and may contain a special checklist of items to be verified and completed before attempted restart. If a specific authorization or waiver of constraint is needed, this fact should be clearly indicated and communicated. 

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

At this stage of review, before writing the full incident investigation report, only the essential recommendations may have been developed. However, line management are invariably more interested in these key recommendations, and tbe other less critical recommendations may not be reviewed with management until the report has been drafted. 

This approach is not recommended for process safety incident investigation. If the team conducting the incident investigation has been chosen for their experience, technical knowledge, and skills, they are best placed to develop the recommendations to prevent a recurrence. 

The attributes of successful recommendations are addressed in detail in Chapter 10. The incident investigation team has the responsibility to develop and submit the recommendations. It is management s responsibility to act on and resolve the recommendations. Management usually determines target dates and assignment of responsibility. 

---