Training incident investigation team

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

Complex Incidents Investigation Team Leader Training... 

Examples of mechanisms used to trigger employee involvement include establishing safety committees attended by employees and management representatives as well as unit safety meetings, training, involvanent in incident investigation teams and others. 

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. 

Personnel with proper training, skills, and experience are critical to the successful outcome of an incident investigation. This chapter describes team composition as a function of incident type, complexity, and severity as well as suggested training topics. It also provides team leaders with a high-level overview of the basic team activities typically required in the course of conducting an investigation. 

The procedure section serves as both a job-aid for employees to use while investigating incidents and a training tool for the facility personnel whose job descriptions or special assignments include leading or participating on an investigation team. 

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. 

Some organizations establish a highly trained and specialized corporate incident investigation staff as a preparatory measure for rare major catastrophic incidents. The ability to deploy the trained team quickly is essential. The faster the team is in place, the higher the quality of the data they collect. 

The regulation makes it clear that the investigation is a team effort and that the team members must be properly qualified to participate. The team must include someone who understands the process and someone who is trained in incident investigation and analysis. Contract workers must be involved where appropriate. 

Employers should have trained inhouse teams for investigation of unusual incidents. These include accidents and near misses that could have had harmful consequences. The objective of an incident investigation is to learn from experience, and this requires publication and dissemination of a clear report of the findings. Multidisciplinary teams are better able to gather and analyze the facts of an event. The knowledge of employees who work in the area where an incident occurred is a substantial asset. They should be consulted, interviewed, or made part of the investigating team. 

A reasonably independent well-trained review team must be assembled to investigate near misses and incidents. The size and diversity of the team and the depth of the investigation should be gaged from the actual and potential consequences to actual and potential consequence of the incident [11]. See Chapter 14 for some incident investigation concepts and techniques. 

As with hazards analysis, the key to successful incident investigation is having a team leader who has extensive industrial experience and who is properly trained in conducting investigations. Such people are hard to find. 

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. 

This useful companion disk contains root cause analysis examples, predefined tree examples, practical checklists that can be customized, and incident evidence photograph examples. It includes a quick checklist for investigators traveling to an incident, examples of methodologies that may be usefiil in training the onsite team, and checklists and samples from the text that can be printed out at the incident site to help organize the team s work. 

The composition and mandate of a team will vary depending on the specific incident. Within a large organization or a company with several very different processes, it may not be practical or desirable to preselect one team to investigate all incidents. Personnel should be selected to participate in investigations based on tbeir specific skills, experience, availability, and tbe team roles tbat need to be filled for a particular investigation. Over time, tbis approach will produce a pool of trained and experienced employees familiar with the investigation process. 

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