Incident report

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. 

Example 5-2. Sample toller initial incident report... 

If yes, for each incident, attach the incident report or give the following information Description of the incident, chronology of verifiable events, other pertinent facts, root causes and contributing factors, and proposals for corrective action. 

IPRDS prepares nuclear plant data under the auspices of the ANSI/Failure and Incidents Reports Review (FIRR) Data Subcommittee. Data collection teams visit plants to e) n... 

The HAZOP team consisted of a HAZOP leader, scribe, process engineer, senior operator, and afety engineer. Previously, the HAZOP leader collected information on the process design (e.g P lDs, operating procedures, emergency procedures and incident reports) for distribution to each team men The leader sectioned the process and identified process deviations prior to the HAZOP. 

According to the incident report, there was no clear division of responsibilities between the Gas Board and the contractor who was carrying out the repairs. Where, as in this case, a special risk is likely to arise due to the nature of the work performed (and the owner of the premises has special knowledge of it), the owner must retain sufficient control of the operation to ensure that contractors e.mployees are properly protected against the risk [4],... 

Pressure can develop inside drums, and then when the lid is released, it may be forcibly expelled and injure the person releasing it. Most of the incidents reported have occurred in waste drums where chemicals have reacted together. For example, nitric acid has reacted with organic com-... 

The incident report stated that the cause of the accident was human error. Although maintenance procedures were available, they had not been used. The... 

In addition to incident reporting systems, root cause analysis techniques can be used to evaluate the causes of serious incidents where resources are usually available for in-depth investigations. A practical example of root cause investigation methods is provided in Chapter 7. 

Incident reporting systems, designed to identify underlying and direct causes for larger numbers of incidents with relatively minor causes... 

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. 

The main function of an incident reporting system (IRS) is to identify recurring trends from large numbers of incidents with relatively minor outcomes, or from near misses. One of the important characteristics of an IRS is that the time and resources required to evaluate an incident and incorporate it into the database must be minimized. This means that the designers of an IRS have to carefully evaluate the benefits and costs of requiring more comprehensive information from each incident that is to be reported. A requirement for too much information will bring the system into disrepute, and too little information will mean that the results are too general to be of any real value. 

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 amoimt of time available for the recording of data in incident reporting systems is limited, and hence the information collected is usually confined to short descriptions of the event, its actual and potential consequences and... 

Workforce Support for Data Collection and Incident Analysis Systems Few of the incident investigation and data collection systems reviewed provide any guidelines with regard to how these systems are to be introduced into an organization. Section 6.10 addresses this issue primarily from the perspective of incident reporting systems. However, gaining the support and ownership of the workforce is equally important for root cause analysis systems. Unless the culture and climate in a plant is such that personnel can be frank about the errors that may have contributed to an incident, and the factors which influenced these errors, then it is unlikely that the investigation will be very effective. 

Incident Analysis A small number of blowdown incident reports were reviewed, but these were found to contain very little information relevant to manual blowdown initiation. 

---