Management incident investigation design

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... 

The team leader s responsibilities need to be explicit. Normally a team leader chosen for more serious or more complex incident investigations will be independent from the operation or facility where the incident occurred. Actual team composition may vary significantly based on the nature of the process and the degree of technical sophistication. This flexibility of team composition is an important feature of a well-designed incident investigation management system. 

Experienced incident investigators know that such specific failures are but the immediate causes of an incident, and that underlying each such immediate cause is a management system failure, such as faulty design or inadequate training.. . . ... 

Audit findings can be incorporated into a facility s overall hazard management system. Items for the system can come from hazards analyses, incident investigations, and audits. The system will be designed such that managers can choose not to follow up on a finding. However, if they do so, they must clearly justify that decision. 

Furthermore, whatever the particular safety process — management involvement, safety in the design stages, employee training, hazards communication, incident investigation, use of personal protective equipment, behavior modification, and so on—its fundamental purpose is to avoid, eliminate, or control hazards. 

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