Investigating incidents incident reports

C. Time lost by a supervisor to help injured worker, investigate incident, prepare reports, and adjust work and staffing. 

The initial incident report is very important. This document captures the initiator s firsthand knowledge of what occurred in the moments after the specific event. Example 5-2, Sample Toller Initial Incident Report, is an example of the data that should be documented as soon as possible. Note that it should be modified using the company s management system procedure and incident investigation procedure, which should describe the type of data needed, and level of detail desired. 

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 Major incidents Near-miss reporting Follow-up and resolution Communication Incident recording Third-party participation as needed... 

In addition to incident reporting systems, root cause analysis techniques can be used to evaluate the causes of serious incidents where resources are usually available for in-depth investigations. A practical example of root cause investigation methods is provided in Chapter 7. 

Workforce Support for Data Collection and Incident Analysis Systems Few of the incident investigation and data collection systems reviewed provide any guidelines with regard to how these systems are to be introduced into an organization. Section 6.10 addresses this issue primarily from the perspective of incident reporting systems. However, gaining the support and ownership of the workforce is equally important for root cause analysis systems. Unless the culture and climate in a plant is such that personnel can be frank about the errors that may have contributed to an incident, and the factors which influenced these errors, then it is unlikely that the investigation will be very effective. 

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. 

The Chemical Incidents Report Center (CIRC) is an incident database initiated by the U.S. Chemical Safety and Hazard Investigation Board. An online search of this database (www.chemsafety.gov/circ), as well as a more general web search, may be a good starting point for a literature survey. 

During facility operation, a chemical reactivity incident or near miss may occur despite all efforts to effectively manage chemical reactivity hazards. An essential element of managing chemical reactivity hazards is to appropriately report and investigate every incident or near miss involving chemical reactivity hazards. By investing the time and effort to determine the root causes and take corrective... 

CSB 1998. Investigation Report. "Chemical Manufacturing Incident." Report No. 1998-06-I-NJ. U.S. Chemical Safety and Hazard Investigation Board. 

IChemE Accident Database Reports about chemical incidents around the world from official government sources, the news media, and company reports 1980-Present Scope is beyond incidents reported to or investigated by regulatory agencies or first responders Contains lessons learned from 3,000 incidents Only one-fourth of the 12,000 incidents in the database contain lessonsdeamed information... 

OSHA PSM-covered facilities are required to investigate each incident which resulted in, or could reasonably have resulted in a catastrophic release of a highly hazardous chemical in the workplace (29 CFR 1910.119 [m] [1]). At the conclusion of an incident investigation, the company is required to prepare a report on the factors that contributed to the incident. At present, OSHA does not require submittal of these incident reports. However, mandatory submission of the reports would increase available data and thus improve the capability of identifying or tracking reactive incidents. 

In the case of incident investigation, a major milestone is completed when the final incident investigation report is submitted. The incident report documents the investigation team s findings, conclusions, and recommendations. This chapter describes practical considerations for writing formal incident reports, a discussion of the attributes of quality reports, and the issue of commimicating the report findings to affected persons, both internally and externally. 

In some cases, employees, rather than supervisors, lead investigations for lower level incidents. Companies have found it beneficial for employees to feel ownership of the investigation results. This philosophy helps encourage workers to report more near misses by reducing the fear caused when a supervisor leads the investigation. Most incidents are low complexity. Many of these are near misses and benefit from investigation by persons closest to the process. 

Analyze Weaknesses To learn from incidents, the final step is to recognize that the incident prediction and management systems are not perfect. Implementing practices to learn from mistakes and allowing continuous improvement to the systems to prevent incidents is essential. These practices are incident reporting and investigation processes. 

Making the employees owners of the incident reporting and investigation system. 

Incident (resources will be expended to promptly investigate these) Nonincident (report but do not investigate immediately may be trended and investigated later)... 

Consider having one incident reporting system with one approach for teaching employees the definition of a near miss and with one approach for doing incident investigations including one approach for root cause analysis. 

For improved quality of formal written incident reports, the incident investigation team should follow these guidelines ... 

Depending on the investigation team s charter, its responsibility may be complete when the recommendations were submitted in the final incident report however, the company s responsibilities are far from over. Other portions of the organization may be assigned responsibility for actual implementation and follow-up of the recommendations identified by the investigation team. 

Table 14-1 lists these requirements and provides a record of compliance for future analysis. Requiring completion of this record for each process incident investigated enhances the probability that all elements are covered. Auditing of incident reports against these requirements provides the forum for continuous improvement in meeting compliance requirements. 

A report is required at the conclusion of the investigation and the report must include -date of the incident -date the investigation began -a description of the incident -the factors that contributed to the incident -recommendations resulting from the investigation ... 

Quality Assurance in Incident Reporting and Investigation, Ujwal Ritwik... 

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