Management incident investigation

What interpretation can be given to the foregoing For this important aspect of safety management—incident investigation—a champion at the senior executive level is needed to drive improvement. In every company with which I am familiar that has achieved stellar safety results, incident experience is regularly reviewed at... 

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. 

Incident investigation The management process by which underlying causes of undesirable events are uncovered and necessary steps are taken to prevent similar occurrences. 

Incident investigations are a part of process safety management. In investigations, lessons are learned as to how inherently safer technology could have prevented or mitigated the results. How can these learnings be disseminated such that future incidents in similar processes are avoided ... 

Pre-Startup Safety Review Mechanical Integrity Hot Work Permit Management of Change Incident Investigation Emergency Planning and Response Compliance Audits Trade Secrets... 

Management of change p Process and equipment integrity K Incident investigation p ... 

For a major incident investigation using a comprehensive root cause analysis system, teams will be formed to acquire information relevant to determine the structure and analyze the causes in depth. In addition to evaluations of the immediate causes, imderlying causes are likely to be evaluated by investigations in areas such as safety and quality management. Both paper- and computer-based systems will be used to acquire and record information for subsequent detailed analyses. 

With regard to evaluating these factors, it is recommended that structured checklists be used, such as those provided by the HFAM method described in Chapter 2. These checklists provide an explicit link between the direct causal factors and management policies. Figure 2.12 shows how these checklists could be used to investigate possible procedures deficiencies, and the policies that led to the deficiencies, as part of the incident investigation. Similar checklists can be used to investigate possible culture problems (e.g., inappropriate trade-offs between safety and production) that could have been implicated in an accident. 

Three major themes have been emphasized in this chapter. The first is that an effective data collection system is one of the most powerful tools available to minimize human error. Second, data collection systems must adequately address underlying causes. Merely tabulating accidents in terms of their surface similarities, or using inadequate causal descriptions such as "process worker failed to follow procedures" is not sufficient to develop effective remedial strategies. Finally, a successful data collection and incident investigation system requires an enlightened, systems oriented view of human error to be held by management, and participation and commitment from the workforce. 

The assessment should also seek out systems for measuring performance. Remember that there is a need to measure both PSM and ESH performance, as well as the effectiveness of the processes in place. It is likely that at least some PSM and ESH performance measures will be in place, such as injury rates, number of incident investigations, regulatory infractions and insurance premiums. Your questions should probe for issues that managers track, but perhaps only informally, that could provide new measures of performance. 

The objective of incident investigation is to prevent recurrence of similar events. This is accomplished by establishing a management system for investigation that ensures ... 

Incident investigations. See Investigations Incompatible materials hazards identification, 82-83, 84 NOAA Worksheet, 77 screening methods, 58-63 Information handoff, management practices, 117... 

Near-miss incidents, investigations, 112-113 New management, chemical reactivity hazard management, 28... 

On the other hand, there are a number of elements of fire prevention that overlap with elements of other programs. For example. Incident Investigation, Management of Change (MOC), Process Safety Information (PSI), and Process Hazard Analysis (PHA) input required for fire prevention can be derived from these same elements of the Process Safety Management (PSM) program. 

Most facilities already have an established Incident Investigation Program as part of the Process Safety Management program. These existing Incident Investigation Programs should incorporate fire prevention requirements. 

These four steps will result in the greatest positive effect when they are performed in an atmosphere of openness and trust. Management must demonstrate by both word and deed that the primary objective is not to assign blame, but to understand what happened for the sake of preventing future incidents. This book helps organizations define and refine their incident investigation systems to achieve positive results effectively and efficiently. 

Identify the essential features of a management system designed to foster and support high quality incident investigations. 

Chapter 2—Designing an Incident Investigation Management System... 

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. 

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. 

Like all of the elements of process safety management, the incident investigation element continues to evolve. The AIChE Center for Chemical Process Safety assists this evolution hy providing interested parties with information to help them in safely operating process facilities. To this purpose, CCPS and the contributing authors offer this second edition of the Guidelines for Investigating Chemical Process Incidents. 

The incident investigation management system should be described in a written document that defines the roles, responsibilities, protocols, and specific activities to be carried out by personnel performing an incident investigation. 

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