Incident investigation root causes

BP (formerly BP Amoco). Incident Investigation. Root Cause Analysis Training. Comprehensive List of Causes. London, 1999. 

ABS Consulting. Incident Investigation/Root Cause Analysis Training Results Trending and Assessment. Knoxville, TN ABS Consulting, 2001. 

Personally participate in a significant incident investigation/root cause analysis. TeU my story around incidents/errors that I have been involved with and the systems improvements that could have prevented them. 

Each accident/incident should be methodically analyzed using an accident investigation/root cause analysis approach. Because many root cause analysis methods exist, it will be the investigator s responsibility to select the appropriate analysis approach (e.g., barrier analysis). Use of proper accident/incident investigation methods and tracking will lead to intervention, which will successfully prevent further occurrence of these occupational accidents and incidents. 

All loss-producing incidents and near misses investigated root-cause analyses conducted as required. 

This method identifies causal factors to accident or near-miss incidents. The root causes are the underlying contributing causes for observed deficiencies that should be documented in the findings of an investigation (Tarrents, 1980). 

Incident Investigation Previous incidents related to the chemicals or equipment involved in the new toll should be considered during the PHA and must be considered if subject to PSM/RMP compliance. In addition, procedures should be in place to describe how the client will be informed and involved in the investigation. It is veiy important to ensure that action plans addressing the root cause of past incidents were implemented. 

In addition to incident reporting systems, root cause analysis techniques can be used to evaluate the causes of serious incidents where resources are usually available for in-depth investigations. A practical example of root cause investigation methods is provided in Chapter 7. 

For a major incident investigation using a comprehensive root cause analysis system, teams will be formed to acquire information relevant to determine the structure and analyze the causes in depth. In addition to evaluations of the immediate causes, imderlying causes are likely to be evaluated by investigations in areas such as safety and quality management. Both paper- and computer-based systems will be used to acquire and record information for subsequent detailed analyses. 

The method is well-structured and provides clear, standardized procedures on how to conduct an investigation and represent the incident process. Also it is relatively easy to learn and does not require the analyst to have a detailed knowledge of the system under investigation. However, the method alone does not aid the analyst in identifying root causes of the incident, but rather emphasizes the identification of the propagation of event sequences. This is an important aspect of developing a preventive strategy. 

Workforce Support for Data Collection and Incident Analysis Systems Few of the incident investigation and data collection systems reviewed provide any guidelines with regard to how these systems are to be introduced into an organization. Section 6.10 addresses this issue primarily from the perspective of incident reporting systems. However, gaining the support and ownership of the workforce is equally important for root cause analysis systems. Unless the culture and climate in a plant is such that personnel can be frank about the errors that may have contributed to an incident, and the factors which influenced these errors, then it is unlikely that the investigation will be very effective. 

The first case study describes the application of the sequentially timed event plotting (STEP) technique to the incident investigation of a hydrocarbon leak accident. Following the analysis of the event sequence using STEP, the critical event causes are then analyzed using the root cause tree. 

This case study concerns the events leading up to the hydrocarbon explosion which was the starting point for the Piper Alpha offshore disaster. It describes the investigation of the incident using the sequentially timed events plotting (STEP) technique. Based on the STEP work sheet developed, the critical events involved in the incident are identified and analyzed in order to identify their root causes. 

The case study has documented the investigation and root cause analysis process applied to the hydrocarbon explosion that initiated the Piper Alpha incident. The case study serves to illustrate the use of the STEP technique, which provides a clear graphical representation of the agents and events involved in the incident process. The case study also demonstrates the identification of the critical events in the sequence which significantly influenced the outcome of the incident. Finally the root causes of these critical events were determined. This allows the analyst to evaluate why they occurred and indicated areas to be addressed in developing effechve error reduchon strategies. 

During facility operation, a chemical reactivity incident or near miss may occur despite all efforts to effectively manage chemical reactivity hazards. An essential element of managing chemical reactivity hazards is to appropriately report and investigate every incident or near miss involving chemical reactivity hazards. By investing the time and effort to determine the root causes and take corrective... 

Use the findings of an investigation to make effective recommendations that can reduce the likelihood of recurrence or mitigate the consequences of similar incidents (or even dissimilar incidents with common root causes). 

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. 

This chapter addresses methods and tools used successfully to identify multiple root causes. Process safety incidents are usually the result of more than one root cause. This chapter provides a structured approach for determining root causes. It details some powerful, widely used tools and techniques available to incident investigation teams including timelines, logic trees, predefined trees, checklists, and fact/hypothesis. Examples are included to demonstrate how they apply to the types of incidents readers are likely to encounter. 

This useful companion disk contains root cause analysis examples, predefined tree examples, practical checklists that can be customized, and incident evidence photograph examples. It includes a quick checklist for investigators traveling to an incident, examples of methodologies that may be usefiil in training the onsite team, and checklists and samples from the text that can be printed out at the incident site to help organize the team s work. 

One approach is to mesh all investigation and root cause analysis activities under one management system for investigation. Such a system must address all four business drivers (1) process and personnel safety, (2) environmental responsibility, (3) quality, and (4) profitability. This approach works well since techniques used for data collection, causal factor analysis, and root cause analysis can be the same regardless of the type of incident. Many companies realize that root causes of a quality or reliability incident may become the root cause of a safety or process safety incident in the future and vice versa. 

Disciplinary action may be appropriate if malicious or criminal intent is positively identified as a root cause. An example would be when an investigation reveals horseplay, practical jokes, fights, or even sabotage was among the root causes. These activities have no place in any workplace and are especially undesirable in the chemical processing industry. It is most likely that a company s employee handbook, human resources documents, or union contract addresses these situations and communicates the policy in advance of an incident. In short, the investi-... 

Every incident has one or more root causes. To understand what these are and how they interact, an investigator must use a systematic approach. As a rule, the benefits of this systematic approach result from ... 

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. 

Tool—A device or means used at a discrete stage of the incident investigation to facilitate understanding of event chronology, causal factors, and/or root causes. 

Methodology—The use of a combination of two or more incident investigation tools to analyze the evidence and determine the root causes of the incident. 

The investigation committee method is another unsuccessful approach. This unstructured approach is historically significant and was judged inadequate for investigating process safety incidents because it produced incomplete and inconsistent results. It often did not find the root cause level or all the root causes. 

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