Incident investigation team

The final incident investigation report written by the assigned incident investigation team (which may include members from the client) can be written in a less structured way depending on the extent of the incident. A detailed discussion of how and why to conduct incident investigations can be found in the AIChE publication. Guidelines for Investigating Process Safety Incidents, Second Edition. 

The employer investigates incidents that result in, or could result in, a catastrophic release of highly hazardous chemicals. An incident investigation is initiated as soon as possible, but before 48 hours following the incident. An incident investigation team is established to consist of one or more experts in the process involved, and accident investigation. The report prepared at the conclusion of the investigation includes at a minimum ... 

Bhopal Methyl Isocyanate Incident Investigation Team Report, Union Carbide Corporation, Danbury, Conn., Mar. 1985. 

Also note the following temperatures of interest to process safety incident investigation teams (Perry and (ireen, 1997 NFPA 422M NFPA 1997 and Avallone and Baumeister, 1996). 

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. 

Chapter 7 provides details on the training, selection, and organization of incident investigation teams. 

Complex Incidents Investigation Team Leader Training... 

Conforming to certain expected conventions and meeting normal patterns of actions and habits can enhance human performance. The incident investigation team should be alert for built-in design deviations from normal conventions. These deviations are often an underlying cause for human error. 

Leading a Process Safety Incident Investigation Team... 

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. 

This chapter addresses typical data gathering needs of major investigations. A team may need to augment the activities in this chapter for the unique circumstances of the incident. Performing the activities oudined in this chapter plus special activities provides the incident investigation team with the data needed to complete the next step—systematic determination of the multiple root causes of the incident. However, data gathering and analysis typically involve much iteration as shown in Figure 8-1. 

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

A witness may have several motives for purposely modifying statements. Witnesses have information that the incident investigation team needs in order to imderstand the incident and determine the causes. They may choose not to tell the incident investigation team all of the relevant information they have. Sometimes witnesses will purposely modify their testimony or withhold information during interviews. AVhat are some of their motives for doing this Usually they are the same as those for not reporting near misses. The most significant of these influences is fear of punishment. 

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. 

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. 

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