Investigating team

After the incident, an investigation team determined that the first operator had not added the initiator when required earlier in the process. When the relief operator added the initiator, the entire monomer mass was in the reactor and the reaction was too energetic for the cooling system to handle. Errors by both operators contributed to the runaway. Both operators were performing many tasks. The initiator should have been added much earlier in the process when much smaller quantities of monomer were present. There was also no procedure to require supervision review if residual monomers were detected. The lesson learned was that operators need thorough training and need to be made aware of significant hazardous scenarios that could develop. 

The final incident investigation report written by the assigned incident investigation team (which may include members from the client) can be written in a less structured way depending on the extent of the incident. A detailed discussion of how and why to conduct incident investigations can be found in the AIChE publication. Guidelines for Investigating Process Safety Incidents, Second Edition. 

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 ... 

The investigating team was charged to realisticaHy assess the risk at individual installations before considering interactions that may arise from fires, explosions and the release of airborne toxic substances and other interactions between installations. 

For probabilities and consequences, the investigating team used data they had and information from many sources, including ... 

Quantitative assessment requires historical data which may be suspect for two reasons. There is the possibility that there are latent accidents not in the database. It is possible that past accidents have been rectified and will not recurr. In the absence of data, judgment based on experience and speculation must be used. Notwithstanding this weakness, the quantitative approach was adopted, d he investigating team identified situations that could cause a number of public casualties. R vents limited to the employees or which might cause single off-site casualties were not included in the assessment. 

Bhopal Methyl Isocyanate Incident Investigation Team Report, Union Carbide Corporation, Danbury, Conn., Mar. 1985. 

The personnel responsible for the collection and analysis of incident data vary in different organizations. One common practice is to assign the responsibility to an investigation team which includes the first line supervisor, a safety specialist and a plant worker or staff representative. Depending on the severity of an incident, other management or corporate level investigation teams may become involved. 

EMSL, Environmental Monitoring Support Laboratory EPIC, Environmental Photographic Information Center DOA, Department of Agriculture DOI, Department of Interior FIT, Field Investigation Team TAT, Technical Assistance Team. 

Some of the Farben prosecution staff as well as some members of the Farben investigating teams have reviewed this book and made helpful suggestions. The following persons in particular devoted much time and effort to suggesting material and reviewing the manuscript Belle Mayer Zeck, Emanuel Minskoff, Drexel Sprecher, Joseph Friedman, Bernard Bernstein, Ansel Luxford, and John Pehle. Valuable data were supplied by Jerry Weiss, William Acton, and Beniamin Ferencz. 

Every member of an investigation team learns about problems that precipitate accidents. This new knowledge helps every team member avoid similar situations in the future. If the investigation is appropriately reported, many others will also benefit. 

Investigation team Choose team as quickly as possible. Experience and affiliation are proportional to the magnitude of the accident. 

Set objectives and delegate responsibilities Based on (1) and (2), define the objectives and subobjectives of the investigation (the investigation team does this). Delegate responsibilities to team members with suggested completion times. 

The accident investigation report is written using the principles of technical documentation. Items 1-4 are objective and should not include the authors opinions. Items 5-7 appropriately contain the opinions of the authors (investigation team). This technical style allows readers to develop their own independent conclusions and recommendations. As a result of these criteria, the accident investigation report is a learning tool, which is the major purpose of the investigation. 

Layered events and recommendations are developed primarily by experienced personnel. For this reason some experienced personnel are always assigned to investigation teams. Inexperienced team members learn from the experienced personnel, and often they also make significant contributions through an open and probing discussion. 

The investigation team found that the reaction accelerated beyond the heat-removal capacity of the reactor. The resulting high temperature led to a secondary runaway decomposition reaction, causing an explosion that blew the hatch off the reactor and allowed the release of the contents from the vessel. 

In 1995, an outbreak of Ebola VHF affected more than three hundred people in and around the city of Kikwit in the Democratic Republic of the Congo (the former Zaire) and approximately 80 percent of the victims died. An international investigation team worked with local authorities to introduce VHF isolation precautions as well as standard precautions. When the types of precaution featured in the manual mentioned above were installed in Kikwit, no further nosocomial (hospital) transmission of the Ebola virus was documented. 

The list of RMP-regulated chemicals has not been revised since the October 1997 recommendation by the OSHA-EPA joint chemical accident investigation team to review the lists of substances subject to the PSM Standard and RMP regulation to determine whether reactive chemicals should be added. 

Given the disparity in success between raw and purified NaNT solutions described in the previous section, it was hypothesized that an impurity in the raw NaNT solution was contributing towards varying DBX-1 reaction results including the inability to produce DBX-1 at all. NaNT synthesis has never been optimized for scale-up nor have adequate analytical methods been developed to analyze NaNT. The investigating teams from Nalas Engineering and Pacific Scientific utilized various analytical methods to identify impurities in the NaNT solutions that impeded the reaction to DBX-1. 

Also note the following temperatures of interest to process safety incident investigation teams (Perry and (ireen, 1997 NFPA 422M NFPA 1997 and Avallone and Baumeister, 1996). 

Form accident investigation team Operations Manager... 

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. 

Once the likely causes of an incident have been identified, investigation teams evaluate what can be done to help prevent recurrence. The incident investigation recommendations are the product of this evaluation. This chapter addresses types of recommendations, some attributes of good recommendations, methods to document and present recommendations, and management s responsibilities. 

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. 

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