Investigating incidents intent

There are at least a couple of conclusions we should draw from this example. If you are going to use safety alerts, even though your intentions are honorable, you may offend the injured party, the folks who took part in the investigation, and others. Be prepared for the fall-out. Also, keep in mind that you need to talk the talk and walk the walk. If an incident occurs and a corrective action is indicated, it behooves you to implement some level of corrective action. If you do not implement a sound corrective action, your company likely has an ineffective safety program to go along with a variety of outstanding lawsuits. 

Disciplinary action may be appropriate if malicious or criminal intent is positively identified as a root cause. An example would be when an investigation reveals horseplay, practical jokes, fights, or even sabotage was among the root causes. These activities have no place in any workplace and are especially undesirable in the chemical processing industry. It is most likely that a company s employee handbook, human resources documents, or union contract addresses these situations and communicates the policy in advance of an incident. In short, the investi-... 

Of course, criminal action, incompetence, or malfeasance warrants discipline. These include sabotage, horseplay, fights, and other acts of malicious intent. Discipline should be addressed by company policies, not the incident investigation. 

There has been much published on the incidence, detection and prosecution of publication fraud, rather less on fraud and misconduct in clinical research, but we should be equally concerned about research fraud. The Consensus Conference on Misconduct in Biomedical Research convened by the Faculty of Pharmaceutical Medicine and the Royal College of Physicians of Edinburgh in 1999 defined research misconduct as behavior by a researcher, intentional or not, that falls short of good ethical and scientific standards . Frank Wells, co-founder of MedicoLegal Investigations Ltd., the only specialist research fraud investigation company in Europe, prefers the generation of false data with the intention to deceive . 

In 1984, one of the most notable process incidents occurred in Bhopal, India, at a plant owned by Union Carbide. On December 3, 1984, methyl isocyanate (MIC) was vented to the atmosphere from a vent gas scrubber after a run away reaction overwhelmed the scrubber. It is reported that more than 2500 people died and 20,000 people were injured as a result of exposure to MIC. The subsequent investigation showed that the run away reaction occurred in the MIC tanks after water was reportedly intentionally added to the tank. The safety systems, a pressure relief valve, a vent gas scrubber, and a flare were reportedly poorly maintained. The relief valve worked to vent the pressure, but the scrubber was overwhelmed, and the flare was down for maintenance. This incident highlighted several loss prevention areas that needed improvement. The first was mechanical integrity. No strong preventive maintenance effort appeared to be in place. The second was emergency preparedness and response. It appears that while the plant was built 1.5 miles away from the community, zoning problems allowed the community to expand to the plant limits. It does not appear that much effort was made to work with the community on commimication/notification or evacuation needs. ... 

Before the interview starts, it must be made clear to the interviewee that the purpose of the investigation is simply to establish the facts associated with incident under investigation. It is not the intent of the interview to establish root causes or to conduct any other type of analysis. 

Far greater use is being made of incident investigation teams. Safety professionals say that the time expended by those teams is a worthwhile investment since the activity communicates management s intent to avoid hazards-related incidents. Over time, large numbers of personnel are involved. 

In a major company with exceptionally good OSHA recordable and lost workday case rates, the chief executive officer declared that results were still not acceptable and that significant reductions in injuries and illnesses were to be made. The extensive and well-qualified staff of safety professionals convinced management to use incident investigation as one means of reinforcing its intent to achieve better results. 

Incident investigation requires a particular skill to assure that injured persons and those involved with the incident will be forthcoming with the pertinent causal factors. If an impression is created that the intent is to place blame, persons involved will usually become protective of their well-being, important information may be withheld, and the probability of having a valid investigation will be diminished. 

The structure of the NPSAs Incident Decision Tree is shown in Figure 14.1. Essentially, after the incident has been investigated and some thought given to its causes, a series of questions is asked. Were the actions intentional If, yes, was there an intention to cause harm or not Is there any evidence of a medical condition Was there a departure from agreed protocols and so on. Suppose, for instance, a staff nurse gives a dose of diamorphine to an elderly patient in severe pain without waiting for a prescription to be written. Is this justified Potentially, if there is no other option. Suppose, however, she has made no attempt to contact the relevant doctor. In this case her actions were clearly intentional. 

A detailed, defined, and recorded review of an incident undertaken to identify and record the causes and contributing factors and their relationships, which led up to and caused the incident. Accident Investigation is a technique that allows an organization to learn from its experience. The intent of an incident investigation is for employers to learn from past experiences and thus avoid repeating past mistakes. See also Incident Investigation Team. 

The intent of the investigation should be to learn from the incident and help prevent similar incidents. A corrective action program should be established based on the findings of the investigation in order to analyze incidents (e.g., uncontrolled release or non-compliant pollution incident) for common root causes. The corrective action prc ram is a followup system to the incident analysis procedures. The investigation should be expedited and findings and recommendations resolved in a timely manner. 

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