Incidents investigation and analysis

Rothblum, A., et al. Human Factors in Incident Investigation and Analysis. 2nd International Workshop on Human Factors in Offshore Operations, 2002. 

The regulation makes it clear that the investigation is a team effort and that the team members must be properly qualified to participate. The team must include someone who understands the process and someone who is trained in incident investigation and analysis. Contract workers must be involved where appropriate. 

Publications in the field of incident investigation and analysis often promote a particular methodology with the implicit claim that their approach is better than the methods promulgated by other organizations. Such publications are often commercial in their approach, thus tending to create a concern in the mind of the reader as to the objectivity of the materials that are presented. 

Manage an incident investigation and analysis as a project with a schedule, budget, and predefined deliverables. 

Words and phrases such as incident, accident, and near miss tend to be used quite loosely in general conversation. They also tend to have different connotations in English, American, and Canadian usage. However, in the context of formal incident investigation and analysis such words need to be tightly defined. The definitions used for these terms in this chapter are provided below. 

The definition of the word incident covers not just safety and environmental harm but also economic loss. Most of the literature to do with incident investigation and analysis focuses on safety-related events. But there is no reason why the techniques developed to investigate and understand such events could not also be used to address lost production, reduced efficiency, and unexpected equipment failure. 

The word accident should not be used during the incident investigation process because the word implies surprise and lack of controllability. There is nothing anyone can do about accidents. The whole point of an incident investigation and analysis program is that all aspects of an operation are under control of management. Only unpredictable external events such as an airplane crash alluded to above are true accidents. 

An outside team can include experts on incident investigation and analysis. It is unlikely that persons working for the facility will possess such a level of expertise. 

Most important— particularly with injury or fatality events—the investigator must never lose sight of the fact that these incidents involve real people, with real families and real friends. Incident investigation and analysis is not an intellectual exercise in which different investigators try to score points of one another or in which they show off their expertise. Incidents are about real people suffering from pain, grief, guilt, disability, and anxiety. 

The potential for litigation means that all those involved an incident investigation and analysis need to be sensitive to the legal implications of their work— particularly with respect to the secure retention of notes and other records, and the potential need to work within attomey/client privilege. 

Guidelines For Managing Process Safety Risks During Organizational Change TABLE A.9 Incident Investigation and Analysis (Continued)... 

Measurement of Safety Performance. Accident/Incident Investigation and Analysis... 

Effective investigation and analysis of hazards-related incidents is an important element in a quest to achieve superior results in safety. A high quality of incident investigation and analysis not only results in risk reduction, but also serves as a positive reinforcement for the safety policies and practices that management has established. 

When designing an incident investigation and analysis process, a determination must be made concerning the causation model on which the process is to be based. What the designer of the process believes are the facts about incident causation has to be established before an instmctional guide can be written or a training program developed. Consider these extremes. 

Help in crafting an incident investigation and analysis system can be found in... 

Rothblum, A.M., Wheal, D. et al. (2002). Human Factors In Incident Investigation And Analysis. 2nd International Workshop On Human Factors In Offshore Operations (HFW2002), Houston, Texas, USA, US Coast Guard. 

Dorart, J.A. and van der Graaf, G.C. (1996). Tripod-beta incident investigation and analysis, hr Proceedings ofthe Third International Conference on Health, Safety and Environment New Orleans, LA Society of Petroleum Engineers. 

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