Incident investigation scope

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 results of environmental monitoring exercises will be influenced by a variety of variables including the objectives of the study, the sampling regime, the technical methods adopted, the calibre of staff involved, etc. Detailed advice about sampling protocols (e.g. where and when to sample, the volume and number of samples to collect, the use of replicates, controls, statistical interpretation of data, etc.) and of individual analytical techniques are beyond the scope of this book. Some basic considerations include the following, with examples of application for employee exposure and incident investigation. 

Selecting and developing an incident investigation plan defining the scope of the investigation... 

Some items and components may require examination that is more detailed. Specific techniques for data analysis are beyond the scope of this guidebook. Entire volumes have been written on specific issues such as the fracture patterns of alloys and the corresponding clues for determining the actual cause and mechanism for the failure. Known specific materials and alloys perform and fail in consistent and predictable ways. This area of expertise is normally supplied to the incident investigation team via the use of specialists, from either within the parent organization or from outside experts or labs engaged specifically for the task. 

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 body of the report may include an introduction summarizing the occurrence or incident, the incident investigation team members, and the scope of the investigation. Background information for the facility (unit) includes such items as history, age, size, expansions, major occurrences, and technical sophistication as necessary to understand the occurrence. 

IChemE Accident Database Reports about chemical incidents around the world from official government sources, the news media, and company reports 1980-Present Scope is beyond incidents reported to or investigated by regulatory agencies or first responders Contains lessons learned from 3,000 incidents Only one-fourth of the 12,000 incidents in the database contain lessonsdeamed information... 

Background Process description, purpose, and scope of investigation, conditions preceding the incident. Historically significant issues may be discussed. 

In spectroscopic investigations, the intensity transmitted or reflected by the sample is compared with the intensity of the incident light at a given wavelength or frequency thus, with a spectrometer, intensities and wavelengths are measured simultaneously. Intensities are determined by means of an infrared detector. Clearly, the performance of the detector is just as important to the spectroscopist, as that of the source, but these and other problems of infrared technique are beyond the scope of this introduction and the reader is referred to the literature 3.3). 

Other investigators who have examined the possibility of increased skin cancer incidence in psoriasis patients (Jones et al.1985 Menter and Cram 1983 Torinuki and Tagami 1988) have concluded that coal tar treatment did not produce an increase in cancer incidence, but all of these studies are limited in scope and it is not likely that they would be sufficiently sensitive to detect a small increase in risk. Jones et al. (1985) reported no increase in cancer incidence in 719 tar-treated psoriasis patients compared with the general population. Torinuki and Tagami (1988) reported no effect of tar on cancer rates in patients treated with coal tar and UV light, but only 5 of 43 patients had a follow-up duration of >6 years and this is likely to be insufficient to detect a possible cancer effect. Menter and Cram (1983) reported their opinion that there was no increase in incidence of skin cancer in patients treated with UV light and coal tar, but this was a study of the efficacy of the treatment regime and thus, no untreated controls were included for comparison and no statistical analysis was performed. 

Incidents involving transportation, pipelines, laboratories, minerals extraction, mining, explosives manufaeturing, pyrotechnic manufacturing, or military uses are beyond the scope of this investigation, in addition to events involving simple combustion (i.e., rapid reaction of fuel [liquid, vapor, or dust] with oxygen in air). 

Create a periodic audit system on the safety of operations and the state of the plant. Audit scope might be defined by such information as the hazard analysis, identified leading indicators of risk, and past incident/accident investigations. 

Any documents bearing this marking must be stored and maintained in a confidential and secure location, which is not open to review by individuals outside the scope of the investigation and analysis. This privilege does not protect the disclosure of the facts involved in the incident. 

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