Investigating incidents focus

Employees in the process area where the incident occurred should be consulted, interviewed, or made members of the team. Their knowledge of the events represents a significant set of facts about the incident that occurred. The report, its findings, and recommendations should be shared with those who can benefit from the information. The cooperation of employees is essential to an effective incident investigation. The focus of the investigation should be to obtain facts, and not to place blame. The team and the investigative process should clearly deal with all involved individuals in a fair, open, and consistent manner. 

Nurturing a blame-free, open culture within an organization is essential for the success of the incident investigation process. The investigation must focus on understanding ... 

After the predefined tree has been used, a final generic cause test should be applied. The plant operating history, especially previous incidents, is considered to indicate if other generic management system problems exist. For example, repetitive failures may indicate generic causes that would not be apparent by only investigating the current incident. It is also an opportunity for a final overall review of the investigation to focus on the big picture, not just individual facts or causal factors. The team should ask, Are there any other causes that anyone has in mind that have not been included ... 

All accidents, incidents, and near misses should be investigated. The focus of the investigation should be on finding the root cause. It is critical that employers develop an effective and planned approach to accident investigation. 

Given the low incidence of severe withdrawal symptoms and the modest effects on the mesolimbic dopamine (reward) system, most investigators have found that cannabis has a low abuse or addiction potential. However, it has been argued that if cannabis is a non-addictive substance, why is its use so widespread and why are there so many longterm and heavy users Finally, contrary to the evidence that cannabis can produce chronic tolerance, some regular users report that they require less drug to achieve the same high, or sensitisation (Chapter 3). Three possible explanations may account for this. First, chronic users may focus on the effects that they wish to achieve. Second, the... 

For the purposes of this investigation-rather than adopting any single definition of a reactive chemicaT-CSB focuses on the broadest range of practices to identify reactive hazards and to manage the risk of reactive incidents. A reactive chemical may include any pure substance or mixture that has the capability to create a reactive incident. CSB defines a reactive incident as a sudden event involving an uncontrolled chemical reaction-with significant increases in temperature, pressure, or gas evolution-that has caused, or has the potential to cause, serious harm to people, property, or the environment. 

A suspected chemical contamination site that is the focus of site characterization activities could potentially become the scene of a criminal investigation. If law enforcement takes responsibility for incident command because they believe a crime has been committed, they will control the site and dictate how any additional activities, such as site characterization, are performed. In cases in which the chemical facility is still... 

Like the previous edition, the book remains focused primarily on investigating process-related incidents that present realized or potential catastrophic consequences (that is, accidents as well as near misses). However, readers will find that the methodologies, tools, and techniques described in the following chapters may also be applied when investigating other types of occurrences such as reliability, quality, and occupational health and safety incidents. 

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. 

At the base of the why tree where fundamental management systems are implicated, the process ceases. The investigation team should then focus its efforts on the rigor and quality of the management systems that could have prevented the incident. Recommendations are developed to address system deficiencies and these are tested against the why tree. An example is included on the accompanying CD ROM. 

The tool helps the investigator to understand and focus on the failed harriers, which are normally identified as causal factors. These failed harriers may need to he strengthened, replaced, or supplemented, especially where weak administrative controls are highlighted. Even successful barriers that prevented more serious consequences may require reinforcement. Therefore, barrier analysis can give the investigator valuable insights into how the incident happened and some of the multiple causes that need corrective action to prevent recurrence. 

Initial work is focused on what happened. Determination of root causes is important to prevent recurrence of the incident, but the initial focus of the investigation team is to define what happened. 

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