Incident reviews

A recent wildland fire response led to an incident in which some firefighters were trapped, and quick action was needed to save them. The chief of the department had the incident reviewed, and the following recommendations were made ... 

Next is the process description (brief outline of basic chemistry, outline process flow diagram, batch sequencing if relevant, non-chemical process operations). An incident review is a key component, learning lessons and building on experiences culled from published information and data bases. 

Incident review (including outside incidents for information)... 

To prevent material loss due to excursions such as the previous example, robust process control systems are required throughout the supply chain from the raw materials manufacturer to the pad manufacturer and the CMP module. Invariably, incident reviews of such excursions reveal that the excursion could have been prevented or limited to only a small amount of material lost if the proper statistical process control systems had been in place. Invariably, the excursion could have been detected by careful scrutiny of an in-process parameter that was either monitored or should have been monitored by the subsupplier, pad manufacturer, and/or the CMP operation. 

Recommendation 10b. The standing incident review board recommended by the committee for each site should include a qualified member of the public who can effectively represent and communicate public interests. 

Keep records of security incidents. Review records to identify trends and potential vulnerabilities. 

The reporting system now provides a way for operators of each nuclear power plant to reflect on their own operating experience in order to identify problems, interpret the reasons for these problems, and select corrective actions to ameliorate the problems and their causes. Incident reviews serve as important vehicles for self-analysis, knowledge sharing across boundaries inside and outside specific plants, and development of problem-resolution efforts. Both INPO and the NRC issue various letters and reports to make the industry aware of incidents as part of operating experience feedback, as does IAEA s Incident Reporting System. 

Carroll, J. S. 1995. Incident reviews in high-hazard industries Sensemaking and learning nnder ambiguity and accountability. Industrial and Environmental Crisis Quarterly 9 175-197. 

Did 1 participate in any incident Reviews List injury in my Department and a brief description of the incident ... 

My area uses the new accident model form during incident reviews to brainstorm all possible... 

My area conducts incident reviews in a positive, open, no-blame environment to ensure all views and opinions are discussed... 

My area uses data from incident reviews to focus the Behaviour audits on topics of concern... 

Despite these many flaws in the official Incident Report system, the Region was able to identify and eorreet maity system safety deficiencies. Much of this success has been the result of the vigorous activity of the Regional Critical Incident Review Committee (RCIRC). As a Board of the Calgary Health Region designated (Quality... 

Employees participate in incident review to identify problems, which may help employees to identify potentially violent behavior patterns and discuss safe methods of managing difficult situations. 

An employee got his hand caught in a machine s in-running nip point while trying to make a minor machine adjustment. When the injury was investigated, the incident review team could not identify any condition that created a hazard nor why the employee would stick his hand knowingly into the moving piece of equipment. The safety rule was that all equipment should be shut down and locked out before any type of maintenance or adjustments. 

Did I participate in any other loss-producing incident reviews List loss-producing events in my department with a brief description of the injury or damage... 

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