Incident reporting systems , described

In the first of the following subsections, the data coDection approaches adopted in most CPI incident reporting systems will be described. The fact that these systems provide little support for systematically gathering data on underlying causes will provide an introduction to the later sections which emphasize causal analysis techniques. 

The initial incident report is very important. This document captures the initiator s firsthand knowledge of what occurred in the moments after the specific event. Example 5-2, Sample Toller Initial Incident Report, is an example of the data that should be documented as soon as possible. Note that it should be modified using the company s management system procedure and incident investigation procedure, which should describe the type of data needed, and level of detail desired. 

The types of data required for incident reporting and root cause analysis systems are specified. Data Collection practices in the CPI are described, and a detailed specification of the types of information needed for causal analyses is provided. 

An exceptional investigation report willfully explain the technical elements and issues associated with the incident. It will describe the management systems that should have prevented the event, and will detail the system root causes associated with human errors and other deficiencies involved in the incident. 

Such events tend to occur in liquid transfer and vaporization operations and are therefore particularly likely in users plants. A study by Euro Chlor showed that 14% of the safety incidents reported involved overloading of chlorine absorption systems [75]. Section 9.1.8.4 on liquid transfer describes some of the protective measures that can prevent this. 

Although the system is not specifically mentioned in the overall safety and health policy, in most cases, its function and responsibilities are spelled out in a safety management standard on near miss incident reporting, which is a stand-alone document. A safety standard is defined as a measurable management performance. Each element of the safety management system should have a written standard that describes the actions, duties, goals, objectives, and responsibilities for each element. 

The following document is an example of an organization s near miss incident system standard that describes the organization s commitment to near miss incident reporting and investigation, and also clearly spells out responsibilities. 

Each chapter starts with a description of the topic covered in the chapter. This is followed by a short example highlighting a reported incident involving a batch reaction system. The case study is followed by a listing of key issues and process safety practices unique to the topic. The issues and concerns presented in this book, as well as potential design solutions and sources of additional information are presented in the tables. This format concisely conveys the necessary and relevant information in a familiar and convenient format. The organization of the tables is described below. 

The critical incident technique was first described by Flanagan (1954) and was used during World War II to analyze "near-miss incidents." The war time studies of "pilot errors" by Fitts and Jones (1947) are the classic studies using this technique. The technique can be applied in different ways. The most common application is to ask individuals to describe situations involving errors made by themselves or their colleagues. Another, more systematic approach is to get them to fill in reports on critical incidents on a weekly basis. One recent development of the technique has been used in the aviation world, to solicit reports from aircraft crews in an anonjmrous or confidential way, on incidents in aircraft operations. Such data collection systems will be discussed more thoroughly in Chapter 6. 

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