Investigating incidents approach

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. 

Above described results and discussions were summarized into the integrated approach to the incident investigation. The approach is represented by the flowchart in Fig. 6. 

This paper describes the development of a tool set for incident investigation that incorporates the use of a suite of tools to assess human error, violations and safety culture as an integral part of the investigation. This approach helps to overcome issues associated with a delay in the investigation of human factors that can occur if such techniques are applied in a stand-alone context. This approach also has the benefit of collecting data on the human aspects of safety as a whole, rather than independently conducting several forms of analysis. This allows the complex relationships between people, the organisation, the environment and the task to be captured. 

The potential severity of anaphylaxis during anesthesia underscores the interest of developing a rational approach to reduce its incidence by identifying potential risk factors before surgery. Recommendations concerning the identification of population at risk of peroperative anaphylaxis, who would benefit from preoperative investigation, have been proposed [10]. 

If no immediate hazards are identified during the approach to the site, the incident commander will likely approve the team to enter the site and perform the site characterization. During this stage, the team will continue field safety screening at the site and conduct a detailed site investigation. 

The first stage of the site characterization process is the customization of the generic plan developed as part of planning and preparation for responding to contamination threats. In general, the incident commander will develop the customized plan in conjunction with the site characterization team leader. The steps involved in the development of the plan include (1) perform an initial evaluation of information about the threat, (2) identify one or more investigation sites, (3) assess potential site hazards, (4) develop a sampling approach, and (5) assemble a site characterization team. 

This chapter provides an overview of a management system for investigating process safety incidents. It opens with a review of management responsibilities and presents the important features that a management system must address to be effective. It examines systematic approaches that help implement incident investigation teams, root cause determinations, recommendations, follow-up, and documentation. 

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. 

One approach is to mesh all investigation and root cause analysis activities under one management system for investigation. Such a system must address all four business drivers (1) process and personnel safety, (2) environmental responsibility, (3) quality, and (4) profitability. This approach works well since techniques used for data collection, causal factor analysis, and root cause analysis can be the same regardless of the type of incident. Many companies realize that root causes of a quality or reliability incident may become the root cause of a safety or process safety incident in the future and vice versa. 

An example of a typical approach for writing an incident investigation management system is presented on pages 30-31. It addresses all of the items described previously. 

Every incident has one or more root causes. To understand what these are and how they interact, an investigator must use a systematic approach. As a rule, the benefits of this systematic approach result from ... 

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. 

The investigation committee method is another unsuccessful approach. This unstructured approach is historically significant and was judged inadequate for investigating process safety incidents because it produced incomplete and inconsistent results. It often did not find the root cause level or all the root causes. 

The team reviews causal factors against investigative checkiists to determine why that factor existed at the time of the incident. A combined what if/pheckfist approach may be used. 

Analysis, that can assist with the identihcation of causal factors. The concepts of incident causation encompassed in these tools are fundamental to the majority of investigation methodologies. (See Chapter 3 for information about the Domino Theory, System Theory, and HBT Theory.) The simplest approach involves reviewing each unplanned, unintended, or adverse item (negative event or undesirable condition) on the timeline and asking, Would the incident have been prevented or mitigated if the item had not existed If the answer is yes, then the item is a causal factor. Generally, process safety incidents involve multiple causal factors. 

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