Incident investigation team operations

The incident investigation team must evaluate potential effects of an incident on all the stakeholders interested in a facility s continued safe operation. Public perception and good will are very important. Stakeholders include ... 

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. 

Access, lighting, and housekeeping standards Existing risk assessment process [hazard and operability (HAZOP), MOC, unit startups, work permitting] Recommendations from prior and current incident investigation teams... 

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. 

The team leader s responsibilities need to be explicit. Normally a team leader chosen for more serious or more complex incident investigations will be independent from the operation or facility where the incident occurred. Actual team composition may vary significantly based on the nature of the process and the degree of technical sophistication. This flexibility of team composition is an important feature of a well-designed incident investigation management system. 

The investigation team must realize that some of the data collected will not reflect the condition of the equipment immediately after the occurrence. Emergency response activities and post-event stabilization of the system may have altered much of the data. For example, the as-found position of every valve should be recorded. However, some valves will have been operated during emergency response or mitigation activities thus, their position at the time of the incident may not be able to be determined with complete certainty. 

Finally, the investigation team considers generic causes that pertain to the overall management system for the process plant by considering the operating history and any other incidents that may have related causes. 

The operations expert is a very important team member. He will know the unit in great detail and will be able to explain how things really work around here. He will also have knowledge of past incidents, including those that were not necessarily serious enough to be reported within the Incident Investigation process, but which nevertheless can provide useful pointers to the hazards analysis team. 

Most incidents involve either an operating or maintenance technician carrying out a task incorrectly. Therefore, the investigation team will usually need to check that manuals or procedures exist, and that they are accurate and usable. 

Shift members found the injmed operator under the emergency shower. First aid type treatment was administered and the victim was rushed to a hospital where he died. Incident causes identified by the investigation team [6]... 

Case 3. A chemical company with 1,200 employees has found numerous ways to include its employees in the site s safety and health program. For example, the Safety and Health Committee, which includes equal labor and management representatives, has responsibility for a variety of activities, such as monthly plant inspections, incident investigations, and examination of any unsafe conditions in the plant. Employees are also involved in process and operations review, safety inspection, and quality teams. Two hourly employees work fulltime at monitoring the safety and health performance of on-site contractors. 

After the predefined tree has been used, a final generic cause test should be applied. The plant operating history, especially previous incidents, is considered to indicate if other generic management system problems exist. For example, repetitive failures may indicate generic causes that would not be apparent by only investigating the current incident. It is also an opportunity for a final overall review of the investigation to focus on the big picture, not just individual facts or causal factors. The team should ask, Are there any other causes that anyone has in mind that have not been included ... 

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