Incident Investigation supervision

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. 

Supervisory factors. This classification contained six contributing factors that were further divided into two groups poor supervision and planned inappropriate operations. The poor supervision was highlighted five times in three of the six accidents/incidents investigated, and the plarmed inappropriate operations were associated with only one accident/incident. 

After the incident, an investigation team determined that the first operator had not added the initiator when required earlier in the process. When the relief operator added the initiator, the entire monomer mass was in the reactor and the reaction was too energetic for the cooling system to handle. Errors by both operators contributed to the runaway. Both operators were performing many tasks. The initiator should have been added much earlier in the process when much smaller quantities of monomer were present. There was also no procedure to require supervision review if residual monomers were detected. The lesson learned was that operators need thorough training and need to be made aware of significant hazardous scenarios that could develop. 

A process review is a formal procedure in which all factors that could lead to a reactive chemicals incident are investigated and lines of defense are identified and implemented. Process reviews are conducted on new processes and on changes in existing processes before they are put into operation. They also are conducted upon changes in supervision and periodically on existing processes. In addition, a reactive chemicals incident may trigger a process review. 

The incidence of liver damage with kava seems to be less than one case per million daily doses (15). The mechanism of the effect is currently unclear. It has been suggested that supervised, monitored, short-term medication with kava would still do more good than harm (16). However, the FDA will continue to investigate the relation, if any, between the use of dietary supplements containing kava and liver damage. 

Direct/supervise investigation of all cargo claims incidents. Analyze, and implement corrective measures (on a work process and individual driver/employee level as needed) to prevent reoccurrence of same. 

The responsibility for investigation of incidents could be assigned to any level of management. Workplace rules should be established and communicated requiring employees to report all incidents immediately to supervision. Once an incident is reported, the immediate supervisor should initiate the investigation as soon as possible, by the end of the shift when the incident occurred or no later than 24 hours after the incident was reported. Written statements should be obtained from the injured employee and witness(es) as promptly as possible following the incident. This will be discussed in more detail later in this chapter. 

Other accident analysis and investigation approaches that make explicit reference to supervision as a potential causal factor include AcciMaps (Svedung and Rasmussen, 2002), which diagrams company management and technical, operational, and management failure levels, and the Incident Cause Analysis Method (ICAM) (BHP Billiton, 2001), which addresses inadequate supervision and poor supervisor or worker ratio error modes. 

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