Investigating incidents

Checks on environmental policy, organization and responsibilities, legislation, training records, emergency plans, performance targets, means of investigating incidents and written work instructions. 

Employers must develop in-house capability to investigate incidents that occur in their facilities. A team should be assembled by the employer and trained in the techniques of investigation, including how to conduct interviews of witnesses, assemble needed documentation, and write reports. A multidisciplinary team is better able to gather the facts of the event and to analyze them and develop plausible scenarios as to what happened and why. Team members should be selected on the basis of their training, knowledge, and ability to contribute to a team effort to fully investigate the incident. 

The employer investigates incidents that result in, or could result in, a catastrophic release of highly hazardous chemicals. An incident investigation is initiated as soon as possible, but before 48 hours following the incident. An incident investigation team is established to consist of one or more experts in the process involved, and accident investigation. The report prepared at the conclusion of the investigation includes at a minimum ... 

Incident investigation Incident investigation needs are very simiiar... 

Investigate Chemical Reactivity Incidents Incident Investigation Incident Investigation Monitoring Performance... 

It strongly supports reporting and investigating incidents and near misses, and emphasizes the value and necessity of communicating and sharing the lessons learned to all that could benefit. 

Facilities typically investigate incidents to determine their causes and prevent their recurrence. An incident is an unusual or unexpected event, which either resulted in, or had the potential to result in ... 

The procedure section serves as both a job-aid for employees to use while investigating incidents and a training tool for the facility personnel whose job descriptions or special assignments include leading or participating on an investigation team. 

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. 

The historical approach to investigating incidents has been an informal, one-on-one interview typically comprising the person involved in the incident with his or her immediate supervisor. This tool when used alone has... 

Unger, L.. and Paradise, M. TapRooT —A Systematic Approach for Investigating Incidents. Paper, Process Plant Safety Symposium. Houston, TX, 1992. 

Having peers help investigate incidents involving peers. 

Historically, companies and agencies that investigate incidents have overlooked human factor causes almost entirely. Material deficiencies in incidents (for example, equipment malfunction or a deficiency in the structural integrity of the vessel) can often he identified easily (for example, a shaft is broken). However, the real difficulty in incident investigation is to answer why these deficiencies occurred, and the answer is often related to human behavior. For instance, the shaft may have broken because of com-... 

Even for experienced investigators, preparing to investigate a significant incident can be hectic in the mobilization period following the event. This checklist is intended to be used as a quick reminder of some key considerations for people on their way to an investigation. Incidents are unique and have unique requirements but the information included should be adequate reminders for most incidents. 

Jack Philley began his article, Investigate Incidents with Multiple Root Cause, as follows ... 

Philley, Jack, Investigate Incidents with Multiple Root Causes, Hydrocarbon Processing, Sept. 1992, pp. 77-80. 

After the incident has been declared under control and acute emergency conditions no longer exist, post-incident activity and stabilization should commence. Activity during this period may include cleanup and disposal, accident investigation/incident reconstruction, site restoration, and emergency plan evaluation. 

The board has legal authority to investigate incidents, but its remit is limited to finding out what happened, and to helping ensure that lessons learned are spread across the process industries. 

Oscar Wilde s comment A tmth ceases to be a truth as soon as two people perceive it was presented in Chapter 1. His comment very much applies to the process of investigating incidents. Facts are never truly objective each person has their own perception of what they perceive to be the same reality. For example, when asked what happened in the case of the example, one person may say The pump seal failed, another may state Hydrocarbon vapors were released to the atmosphere. Both persons are correct but their statements reflect their different views of reality. Therefore, it is very difficult to develop a truly general incident analysis whose conclusions are independent of the profiles of the persons conducting that analysis. 

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