Incidents Incident Investigation techniques

These goals are listed in the order of importance to a company. Of greatest importance is to get near misses reported so that investigation can be used to learn from the incident. Note that incident investigation techniques are essentially the same whether applied to chemical reactivity hazards or to other hazards. 

Rohm and Haas uses Multiple-Cause, Systems-Oriented Incident Investigation techniques (MCSOII), or mac-soy. It is a direct adaptation of the Fault Tree Analysis logic and the Deming Principles of Systems and Quality. [10] The method was developed to improve the overall quality of investigations, to increase the uniformity of investigation made by various teams, and improve the usefulness of the proposed corrective actions. The quality of the mac-soy or MCSOII investigation is improved because the method [10]... 

Some Thoughts on Process Safety Incident Investigation Techniques... 

Some thoughts on process safety incident investigation techniques... 

Personnel trained in incident investigation techniques conduct all investigations. 

Incident investigation techniques Chain of custody procedures... 

The first case study describes the application of the sequentially timed event plotting (STEP) technique to the incident investigation of a hydrocarbon leak accident. Following the analysis of the event sequence using STEP, the critical event causes are then analyzed using the root cause tree. 

The results of environmental monitoring exercises will be influenced by a variety of variables including the objectives of the study, the sampling regime, the technical methods adopted, the calibre of staff involved, etc. Detailed advice about sampling protocols (e.g. where and when to sample, the volume and number of samples to collect, the use of replicates, controls, statistical interpretation of data, etc.) and of individual analytical techniques are beyond the scope of this book. Some basic considerations include the following, with examples of application for employee exposure and incident investigation. 

Many major process safety incidents were preceded by precursor occurrences. These occurrences were unrecognized or ignored because nothing bad actually happened. The lessons learned from such occurrences, typically referred to as near misses, can be extremely valuable in averting disaster. However, this benefit is only realized when they are recognized, reported, and investigation techniques are properly applied. This chapter describes near misses, discusses their importance, and presents the latest methods for helping ensure appropriate near misses are reported. 

This chapter addresses methods and tools used successfully to identify multiple root causes. Process safety incidents are usually the result of more than one root cause. This chapter provides a structured approach for determining root causes. It details some powerful, widely used tools and techniques available to incident investigation teams including timelines, logic trees, predefined trees, checklists, and fact/hypothesis. Examples are included to demonstrate how they apply to the types of incidents readers are likely to encounter. 

To be effective the investigation must apply an approach which is based on basic incident causation theories and use tested data analysis techniques. Investigating incidents to determine root causes and make recommendations can be as much an art as a science. Within the industry, best practices in incident investigation have evolved substantially in the last 20 years. This chapter provides a brief overview of some of the more relevant causation theories. 

Several theories of incident causation exist and each has associated investigation techniques. Incident investigators use their judgment to make adaptations to selected techniques based on the size and complexity of the investigation effort. Judgment based on knowledge and experience is important in determining how and why an incident occurred. 

These theories have encouraged development of techniques that support systematic incident investigation. 

This hook focuses on learning lessons from incidents to lower the risk of future major incidents. It is important to use a structured approach to incident investigation that huilds on proven and recognized techniques this makes it easier to develop consistent understanding from incidents and to communicate insights and results from investigations effectively. 

Technique—The manner in which an incident investigation tool is developed or used. 

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