Incident investigation required

Incident investigation requires a particular skill to assure that injured persons and those involved with the incident will be forthcoming with the pertinent causal factors. If an impression is created that the intent is to place blame, persons involved will usually become protective of their well-being, important information may be withheld, and the probability of having a valid investigation will be diminished. 

Integrated approach to the incident investigation requires certain modifications of the meanings of terms predefined tree, Root Cause Map and root cause. The modifications are specified below ... 

Proper incident investigation requires a well-trained process leader. 

Incident investigation requirements Mechanical integrity requirements Standard operating procedures Process safety information Management of change Required employee participation Required hot work permits Contractor requirements... 

Amendments to the Clean Air Act require employer-employees consultation to develop and implement PSM program elements and hazard assessments. Section 304 requires employee training and education on the findings of PSM incident investigations. 

Where regulations related to process safety exist, they must be understood and PSM system design must be consistent with them. For example, some countries may require that operators participate in hazard analyses and incident investigations. Where there are no process safety-related regulations, you have complete flexibility in system design. 

Three major themes have been emphasized in this chapter. The first is that an effective data collection system is one of the most powerful tools available to minimize human error. Second, data collection systems must adequately address underlying causes. Merely tabulating accidents in terms of their surface similarities, or using inadequate causal descriptions such as "process worker failed to follow procedures" is not sufficient to develop effective remedial strategies. Finally, a successful data collection and incident investigation system requires an enlightened, systems oriented view of human error to be held by management, and participation and commitment from the workforce. 

Do all of the required action items uncovered in reactive chemistry testing, hazard analyses and lessons learned from previous incident investigations. 

OSHA PSM-covered facilities are required to investigate each incident which resulted in, or could reasonably have resulted in a catastrophic release of a highly hazardous chemical in the workplace (29 CFR 1910.119 [m] [1]). At the conclusion of an incident investigation, the company is required to prepare a report on the factors that contributed to the incident. At present, OSHA does not require submittal of these incident reports. However, mandatory submission of the reports would increase available data and thus improve the capability of identifying or tracking reactive incidents. 

On the other hand, there are a number of elements of fire prevention that overlap with elements of other programs. For example. Incident Investigation, Management of Change (MOC), Process Safety Information (PSI), and Process Hazard Analysis (PHA) input required for fire prevention can be derived from these same elements of the Process Safety Management (PSM) program. 

Most facilities already have an established Incident Investigation Program as part of the Process Safety Management program. These existing Incident Investigation Programs should incorporate fire prevention requirements. 

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. 

This section lists sources used to develop the incident investigation management system corporate guidance, regulatory requirements, and other reference materials such as this hook. 

Investigating a catastrophic incident normally requires a team of experienced, highly skilled specialists who represent not only process safety hut also specialized technologies such as ... 

Figure 7-1 offers a typical checklist to use during the planning stage of an investigation of a major complex incident. Low complexity incident investigations do not always call for a formal plan. Some simple investigations may require only 1 to 2 hours to complete. 

In addition to the incident investigation team, there will be others with stakes in the data. Additional samples and copies of photographs will often be required. 

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