Investigation and analysis of incidents

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. 

If STAMP has been used as the basis for previous safety activities, such as the original engineering process or the investigation and analysis of previous incidents and accidents, a model of the safety-control structure may already exist. If not, it must be created although it can be reused in the future. Chapters 12 and 13 provide information about the design of safety-control structures. 

Effective investigation and analysis of hazards-related incidents is an important element in a quest to achieve superior results in safety. A high quality of incident investigation and analysis not only results in risk reduction, but also serves as a positive reinforcement for the safety policies and practices that management has established. 

LuxhaJ, XT. (2003). Probabilistic Causal Analysis for System Safety Risk Assessments in Commercial Air Transport. Workshop on Investigating and Reporting of Incidents and Accidents (IRIA). Williamsburg, Virginia, USA, National Aeronautics and Space Administration (NASA). 

Investigation and analysis of hazardous incidents whether involving injury or not. 

One of the most obvious means of collecting and analyzing error data in complex, safety-critical systems is through the retrospective investigation and analysis of accidents and incidents. Accident investigation is used to reconstruct accidents and... 

Each company s management style and safety systems have strengths and weaknesses. These strengths and weakness tend to influence the types and severity of incidents that might occur. An analysis of incident investigation findings in terms of causal factors, immediate causes, contributing causes,... 

Training and documentation. Responsibilities associated with PV and QA depend on the training of manufacturing personnel and the documentation of their activities. Such activities help to form the recognized quality standard that a pharmaceutical company builds for its products. These personnel are trained to carry out the standard procedures required by GMP documentation includes the write-up/revision of these procedures. Other records document how a batch of product is manufactured, whether unusual incidents or deviations occurred, the existence of reject notices, product complaints, and the investigation and analysis (as needed) of the above abnormalities. 

Publications in the field of incident investigation and analysis often promote a particular methodology with the implicit claim that their approach is better than the methods promulgated by other organizations. Such publications are often commercial in their approach, thus tending to create a concern in the mind of the reader as to the objectivity of the materials that are presented. 

Words and phrases such as incident, accident, and near miss tend to be used quite loosely in general conversation. They also tend to have different connotations in English, American, and Canadian usage. However, in the context of formal incident investigation and analysis such words need to be tightly defined. The definitions used for these terms in this chapter are provided below. 

The definition of the word incident covers not just safety and environmental harm but also economic loss. Most of the literature to do with incident investigation and analysis focuses on safety-related events. But there is no reason why the techniques developed to investigate and understand such events could not also be used to address lost production, reduced efficiency, and unexpected equipment failure. 

The word accident should not be used during the incident investigation process because the word implies surprise and lack of controllability. There is nothing anyone can do about accidents. The whole point of an incident investigation and analysis program is that all aspects of an operation are under control of management. Only unpredictable external events such as an airplane crash alluded to above are true accidents. 

Once the incident has been evaluated, and a level of effort that is needed for the investigation and analysis has been determined, the next step is to form the investigation and analysis teams and to provide them with their terms of reference. 

An outside team can include experts on incident investigation and analysis. It is unlikely that persons working for the facility will possess such a level of expertise. 

Possibly the most important contribution that the incident owner can make to the investigation and analysis process is to create an atmosphere of seeking means of long-term improvement, rather than looking to blame someone or trying to find a quick fix. 

Most important— particularly with injury or fatality events—the investigator must never lose sight of the fact that these incidents involve real people, with real families and real friends. Incident investigation and analysis is not an intellectual exercise in which different investigators try to score points of one another or in which they show off their expertise. Incidents are about real people suffering from pain, grief, guilt, disability, and anxiety. 

The potential for litigation means that all those involved an incident investigation and analysis need to be sensitive to the legal implications of their work— particularly with respect to the secure retention of notes and other records, and the potential need to work within attomey/client privilege. 

Any documents bearing this marking must be stored and maintained in a confidential and secure location, which is not open to review by individuals outside the scope of the investigation and analysis. This privilege does not protect the disclosure of the facts involved in the incident. 

All activities required for process safety management, such as process hazard analysis, mechanical integrity, incident and near-miss investigations, and management of change... 

Measurement of Safety Performance. Accident/Incident Investigation and Analysis... 

As the actuality of incident investigation practices is considered, one can t help but feel sorry for the supervisor. It is commonly said in the literature, as Ted Ferry did in Modem Accident Investigation and Analysis An Executive Guide, that the supervisor is closest to the action, that the mishap takes place in the supervisor s domain, and that initial responsibility for investigation is very often assigned to the supervisor (p. 9). 

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