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Incident investigation team development

After the most likely scenario has been identified and the logic tree developed, the incident investigation team now reaches the stage of searching out the system-related multiple causes. An accompanying challenge is deciding when to stop further development of each branch of the tree. [Pg.214]

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 ... [Pg.253]

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. [Pg.275]

In summary, developing the recommendations is a responsibility of the incident investigation team. Implementing the recommendations is a management responsibility. The inclusion of the elements of the recommendation in daily work practice is the responsibility of each individual affected by the recommended action. [Pg.311]

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. [Pg.130]

The first stage of the site characterization process is the customization of the generic plan developed as part of planning and preparation for responding to contamination threats. In general, the incident commander will develop the customized plan in conjunction with the site characterization team leader. The steps involved in the development of the plan include (1) perform an initial evaluation of information about the threat, (2) identify one or more investigation sites, (3) assess potential site hazards, (4) develop a sampling approach, and (5) assemble a site characterization team. [Pg.114]

At the base of the why tree where fundamental management systems are implicated, the process ceases. The investigation team should then focus its efforts on the rigor and quality of the management systems that could have prevented the incident. Recommendations are developed to address system deficiencies and these are tested against the why tree. An example is included on the accompanying CD ROM. [Pg.55]

Unlike the procedure followed in developing logic trees, the investigation team does not construct the tree. Rather they apply each causal factor to each branch of the predefined tree in turn, and those branches that are not relevant to the incident are discarded. This prescriptive approach offers consistency and repeatability by presenting different investigators with the same standard set of possible root causes for each incident. [Pg.233]

While the use of predefined trees does not directly challenge the investigation team to think laterally of other possible causes, many predefined trees present a wide range of causal factors, some of which the team may not have otherwise considered. It is therefore possible, but unlikely, that the incident could involve a novel root cause that was not previously experienced by those who developed the predefined tree. The addition of a final test based on another tool, such as brainstorming, can overcome this apparent weakness. [Pg.234]

Using structured approaches such as those presented in the preceding chapter, an investigation team identifies the multiple system-related incident causes. These approaches provide the mechanism for understanding the interaction and impact of management system deficiencies. When the investigators understand what happened, how it happened, and why it happened, they can develop recommendations to correct immediate, contributing, and root causes. [Pg.251]

This approach is not recommended for process safety incident investigation. If the team conducting the incident investigation has been chosen for their experience, technical knowledge, and skills, they are best placed to develop the recommendations to prevent a recurrence. [Pg.265]

Rohm and Haas uses Multiple-Cause, Systems-Oriented Incident Investigation techniques (MCSOII), or mac-soy. It is a direct adaptation of the Fault Tree Analysis logic and the Deming Principles of Systems and Quality. [10] The method was developed to improve the overall quality of investigations, to increase the uniformity of investigation made by various teams, and improve the usefulness of the proposed corrective actions. The quality of the mac-soy or MCSOII investigation is improved because the method [10]... [Pg.296]

The existence of an indeterminate number of root causes may help explain some of the frustration that is occasionally expressed with standardized incident analysis procedures and software. In spite of their structured approach, these systems are fundamentally subjective. For example, one technique helps the investigation team list many of the possible causes that led to an event. Some of these causes are then identified as causal factors which are then developed into root causes. Yet the determination as to which causes are causal factors will necessarily depend on the... [Pg.451]

Incident Investigation. Employers are required to investigate as soon as possible (but no later than 48 hours after) incidents that did result or could reasonably have resulted in catastrophic releases of covered chemicals. The standard calls for an investigation team, including at least one person knowledgeable in the process involved (a contract employee when the incident involved contract work) and others with knowledge and experience to investigate and analyze the incident, and to develop a written report on the incident. Reports must be retained for five years. [Pg.281]

Employers must develop in-house capability to investigate incidents that occur in their facilities. A team should be assembled by the employer and trained in the techniques of investigation, including how to conduct interviews of witnesses, assemble needed documentation, and write reports. A multidisciplinary team is better able to gather the facts of the event and to analyze them and develop plausible scenarios as to what happened and why. Team members should be selected on the basis of their training, knowledge, and ability to contribute to a team effort to fully investigate the incident. [Pg.242]

A sample appears in Figure 9-22 on page 219 for a fictitious incident. Developing the matrix is not a one-time exercise, but is usually prepared over the course of the investigation. Gradually, some hypothesis will emerge as more likely and others will become less probable. It is very helpful to others to keep unlikely scenarios on the matrix and document why the scenario was ruled out. Seeing why their pet theory was ruled out can help people accept the team s conclusions. [Pg.217]


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See also in sourсe #XX -- [ Pg.253 ]




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