Minor incident investigations

Another application area is the use of PIFs as part of the process of incident investigation. Any investigation which seeks to establish the imderlying causes of minor or major incidents will benefit from a systematic framework for evaluating the factors which can contribute to the human contribution to such incidents. This topic will also be discussed in Chapter 6. 

Minor incidents—Infrequent occurrence of these accidents or near misses have acceptable consequences but recurring occurrences of this magnitude may warrant an investigation. 

External resources may he needed if the incident investigation work exceeds site capahilities. These resources could include corporate personnel or experts from outside the company. (The team leader may also he external if the incident is major since the leader s independence sets the tone for the investigation.) Company business unit leaders should confer with the team leader to determine whether external assistance is recommended. Factors to consider include significant offsite consequences such as environmental impact or product quality concerns. A team of trained specialists should formally investigate any process incident that could significantly affect the business. At the lower end of the scale, if a near miss or minor incident occurs that has no potential for significant consequences, local supervision or front-line personnel normally may perform the investigation without outside assistance. 

Incident investigation involves varying levels of photographic expertise. For most minor incidents, the team or a company employee can adequately meet the photographic needs. Incidents that are more serious require an experienced individual, such as a forensic specialist, who systematically documents the scene, equipment involved, damage, evidence collection, and position data. For specialized photographic needs, the services of a professional commercial photographer or other specialists are necessary and are justified. Examples of such needs include ... 

Trend analysis can be confused or invalidated by a sample that is too small. If the charting or analysis is limited only to major incidents, there will often be too few within a period to arrive at meaningful conclusions. For example, a facility with one thousand employees may experience only one or two serious incidents per year, and several years worth of data would be needed to make any meaningful statistical analysis. Minor incidents and near misses can be as useful in trend analysis and preventive prediction as major incidents. All process incidents should be reported, classified, and investigated as appropriate. The severity of an incident is frequently more a function of chance than actual fundamental system differences among accidents and near misses. 

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. 

It follows from this that as much can be learned from investigating individual minor incidents and near misses as can be learned from investigating... 

Since there are so many minor incidents, we are left with the practical problem of the time required for adequate investigation of them all. There are two ways of dealing with this problem. 

Identify patterns in minor incident occurrence and investigate groups of minor incidents which are likely to have related causes. How tWs pattern identification is carried out was described in section 2.5.6 on epidemiological analysis. 

The extent of any investigation depends on the seriousness and impact of a given incident. For a minor incident there is not likely to be formal investigation but rather a lessons learned scenario, as described below. In cases of serious injury or major laboratory or equipment damage, a more formal investigation by safety professionals will likely be conducted. In any case, we can usually learn a lot from examination of incidents, and it is not unusual to find that a similar incident has occurred in some laboratory somewhere. 

If your Trust offers Root Cause Analysis training, undertake it and apply the learning to minor incidents you spot in everyday practice. Remember, one day you may be the Si s investigating consultant, so this is all useful practice. 

The rig-move study for Statoil was based on a total of 151 reports of experienced incidents. It spans from simple Synergi reports of minor incidents and near misses, to investigated in-depth studies of more serious events. Near-miss incidents (approximately 30 reports) were excluded from the review, mainly due to the minor risk potential (personnel injuries), but also project resource limitations. 

Treating all events the same and assuming that by preventing minor incidents you proportionally reduce the likelihood of more serious events causes organizations to attack the easiest causes first. This frequently draws attention and resources away from finding and correcting the system hazards that could produce very serious outcome such as the chemical release that is overlooked because the company was too busy investigating steam tfacer bums. 

What does your company do about reporting accidents Is there an investigation associated with every accident, close call, first-aid case, and minor incident What does your company do when a serious accident occurs Is what happens when a serious incident occurs much different than when a close call or first-aid case occurs ... 

It is essential that all incidents are reported promptly, and in detail—even those that have only minor consequences or that are first aid cases or that are near misses. In the United States, incidents that meet the OSHA guidelines for recordability must also be documented and reported. (The topics of Incident Investigation and Root Cause Analysis are discussed in Process Risk and Reliability Management). 

One of the most fundamental challenges that faces investigators when dealing with large quantities of relatively minor incidents is how to identify and assess the risk of what is reported, and so properly focus attention, prioritise action and allocate resources within the organisation. In practice, the primary tool provided for this purpose in most safety information systems is a risk profile matrix, risk table or risk map. These are simplistic tables... 

From the view of both actual and potential impact, the cyclohexane release affects all business aspects. The incident is a near miss for safety, and a minor-major incident for other aspects of the business. Performing six or more investigations would be fruitless. Performing one investigation that meets the needs of all business aspeas is ideal and simpler. The near miss definition and related training will need to explain the potential impact of an... 

A standard form is a common and useful tool for the relatively minor process incident. Forms tend to steer the investigators thoughts within narrow, limited channels. Forms, therefore, may not be as useful for investigating serious process-related occurrences as they are for minor process incidents. Some companies have increased the effectiveness of reporting forms by printing memory jogger information and questions on the back of the form. Forms can be helpful for capturing cause data in a uniform manner so it can be coded for computer analysis. 

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