Investigation of Incidents

The emergency action plan facilitates prompt evacuation of employees. Upon an alarm pcrsoimel evacuate to safe areas, cross or up wind if possible, assisting physically impaired people as necessary. Process buildings are not suitable refuges. 

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Investigations of incidents associated with tolling projects have identified that appropriate selection of a toller based upon proper equipment and expertise is important in reducing the likelihood of future process safety related incidents and environmental releases. It is likewise important to review toller safety, health, and environmental practices (current and past) in the selection process. This review can identify those practices that would need to be modified to be acceptable. Eliminating less qualified candidate firms at an early stage is a best practice. 

The client may want to reserve the right to participate in investigations of incidents or releases resulting from production, packaging. 

Obtaining the hest results from supervisors investigations of incidents that occur in the plant environment has been a goal of many safety professionals for many years, and the goal has often been quite elusive. In 1983, Plant Management became convinced of the merits of the accident causa-... 

The investigation of incidents identifies specific individuals as those accountable for the incident. Disciplinary actions are taken to teach people that this is unacceptable behavior. 

The investigation of incidents identifies the specific root causes and contributing causes for incidents. There is less emphasis on identifying the specific individuals responsible. Disciplinary actions are rare but likely if there is a history of repeated occurrences. There is usually a greater amount of explanatory detail in the incident report. There is greater tendency in a fact finding organization to report near-miss as well as minor incident events. 

The investigation of incidents goes beyond event description and emphasizes operations improvement. Individuals take initiative and pride in contributing to the improvement of the operations. Peers reinforce sharing of incident information and discuss details collabora-tively to improve their understanding of the process and appropriate operational activities. 

The investigation of incidents identifies specific individuals as those accountable for the incident. Disciplinary actions are taken to teach people that this is unacceptable behavior. In extreme cases, individuals are fired for incompetence or negligence in their duties. These organizations tend to report a small number of incidents, and the incidents reported include significant observable events such as loss of life, major equipment damage, environmental release of contaminants, or significant loss of production. 

Investigation of incidents that resulted in, or could reasonably have resulted in, a catastrophe (a major uncontrolled emission of a highly hazardous chemical, a fire, or an explosion) is required by OSHA and EPA [l(m), 2(81)]. The investigation should be initiated within 48 hours, and the investigation team should include (1) at least one person knowledgeable in the process involved, (2) a contract employee if contractors were involved, and (3) other persons having appropriate experience. 

However, investigations of incidents involving misuse of OP and CM pesticides have revealed virtually no endocrine-disrupting activity of these chemicals (Flickinger et ai, 1984), The putative endocrine-disrupting effect of OPs and CMs in wildlife is largely a prediction based on data obtained from laboratory animals. The influence of these pesticides on human health i.s also discussed here, based on observed endocrine-disrupting actions of OPs and CMs ill vitro and in laboratory animals in vivo. 

Only when a facility has conducted a large number of incident analyses is it legitimate to talk about true root causes. In one facility, it became apparent, after 25 investigations of incidents (including near misses) that the following three issues kept bubbling up. 

Investigation of incidents is well done in those entities where the culture includes management accountability for hazards-related results. 

One fundamental element of our comprehensive environment, safety, and health endeavors is the investigation of incidents that may result in harm or damage to people, property, or the environment. 

PG-05-02 " Investigation of incidents/accidents PG-04-13-ANX1 Report of investigation of accidents or incidents... 

In each incident you should ask yourself (1) What happened (2) How did it happen (3) Why did it happen This series of questions is one form of root cause analysis (RCA), a standard procedure in the investigation of incidents in business and industry. The last question is the most important one and you will find you may have to ask and answer this question several times in sequence before you come close to the real or root causes of an incident. RCA generally recommends asking Why five times to get to a fundamental, rather than superficial, cause. Root causes are the basic causes of an incident that can be reasonably identified, that can be controlled, and for which recommendations or lessons learned can be derived. Many times root causes are not immediately obvious, but can be identified from careful inquiry. Once you know the root causes you should be able to develop recommendations or steps to prevent this from happening again. 

Whittingham asserts that in some organizations, a blame culture exists whereby the focus in the investigation of incidents resulting in severe consequences is on individual human error, and the corrective action taken occurs at that level, rather than within the system that may have enabled the human error. He stresses that placing responsibility for the incident on what an individual did or did not do results in overly simplistic causal factor determination. 

In any safety>critical industry the investigation of incidents, accidents and near-misses is of paramount importance. The means to perform such investigations have developed over a number of years, and most have their roots in the analysis and investigation of failures of hardware or software systems. More recently, however, the reliability of engineered systems has been seen to improve, whereas the reliability of the other key part of any system - the human - has remained relatively unchanged. The net effect of this trend has been that failures of human performance have been elevated in importance in many industries, which in turn has prompted the development of techniques to improve the level of rigour applied to the investigation of human performance and behaviour. 

This paper focuses on the use of Human Factors analysis techniques in the investigation of incidents, and therefore concentrates on the retrospective application of these techniques. It is just as important to put in place prospective... 

The responsibility for investigation of incidents could be assigned to any level of management. Workplace rules should be established and communicated requiring employees to report all incidents immediately to supervision. Once an incident is reported, the immediate supervisor should initiate the investigation as soon as possible, by the end of the shift when the incident occurred or no later than 24 hours after the incident was reported. Written statements should be obtained from the injured employee and witness(es) as promptly as possible following the incident. This will be discussed in more detail later in this chapter. 

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