Incident investigation responsibility

Pre-Startup Safety Review Mechanical Integrity Hot Work Permit Management of Change Incident Investigation Emergency Planning and Response Compliance Audits Trade Secrets... 

The regulation states An incident investigation shall be initiated as promptly as possible, but not later than 48 hours following the incident. In part, the reason for this quick response to an incident is to assure that all pertinent evidence and facts can be preserved to facilitate the investigation. 

VII Recovery Procedures Procedures that explain the necessary actions following the response to the emergency. These include Incident investigation, employee support, community coordination, critiques, decontamination and recovery operations. 

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. 

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. 

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. 

Making initial notification in a timely manner can present serious challenges immediately following an incident. The incident investigation management system should address how to handle these communications and how to coordinate with facility emergency response plans. A checklist with prearranged names, titles, and phone numbers should be developed and kept up to date for this use. 

The team leader s responsibilities need to be explicit. Normally a team leader chosen for more serious or more complex incident investigations will be independent from the operation or facility where the incident occurred. Actual team composition may vary significantly based on the nature of the process and the degree of technical sophistication. This flexibility of team composition is an important feature of a well-designed incident investigation management system. 

This group must be familiar with the concepts, policies, extent of commitment from upper-level management, and specific assignments of responsibility associated with process safety incident investigation. 

The Center for Chemical Process Safety (CCPS) conducted a survey of its membership and other processing companies in preparation for this revised edition. Based on the responses, some general observations can be made about incident investigations ... 

The organization s incident investigation management system should specify the team leader s responsibilities and authority. Upon selection of the team leader, the leader and senior management should review and agree on all assigned responsibilities. The agreed responsibilities should... 

Specific job related responsibilities associated with incident investigation... 

The team leader is responsible to plan and direct the team activities. The specific plan for the team should include a designated mechanism for documenting the team activities, deliberations, decisions, commimications, and a record of documents requested, received, or issued. The primary objectives of a process safety incident investigation plan are to ... 

One of the most critical issues is clearly establishing which groups have responsibility for which activities and areas. These responsibilities may change during the investigation. The incident investigation team leader must ensure that these responsibilities are clear to all groups to avoid duplication of effort or omission of critical activities. 

Emergency response, manufacturing, and incident investigation team... 

The normal practice is to designate a single person on the incident investigation team to coordinate photography. This person works closely with the team member responsible for documentation and record keeping and coordinates with other groups outside the team. 

The next item in the loop is a decision point for possibly introducing the use of inductive reasoning methods into the deliberations. If the deductive process continues to indicate progress, then additional facts are procured or the logic tree is restructured. For example, one witness stated a particular valve was open, yet the post-incident inspection found it to be closed. The team must be careful to ensure that the valve is closed because of the actions taken prior to the incident, and not as a result of post-event response activities. The position of this particular valve may be a critical item in determining which of two scenarios is the more probable case. The incident investigation team would then initiate a short-term action item to conduct a mini-investigation to resolve this question. 

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. 

AAdienever an investigation reveals an employee action worthy of commendation, the incident investigation team should point this out in their comments. Cool rational actions in the middle of an emergency often limit the consequences of an incident. Those employees who demonstrate this type of response should he recognized and commended. 

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. 

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. 

---