Incident investigation team training requirements

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. 

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. 

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