Reporting responsibilities, incident investigation

Recommendations concerning restart of operations are often developed before the final report is published. This is a management decision, but may or may not be part of the incident investigation scope. Nevertheless, these recommendations should be clearly written, imderstood by all, and be approved and accepted by the management organization responsible for safe operation of the facility. Restart criteria deserve special attention and are addressed in further detail later in the chapter. 

The Guidelines for Investigating Chemical Process Incidents [4] has a section on near misses. Included in that section is a discussion of the fragile balance between a managers responsibility to promote and achieve near-miss reporting of incidents and the responsibility to discipline inappropriate behavior. It is a matter of trust and openness. A single occasion of necessary discipline (if viewed as somewhat unfair) can erode some confidence and create a... 

Immediate outcome—the adverse state the system reached immediately after the active failure. Examples are release of agent, plant damage, or personal injury. Reporting and investigation flow charts supplied by the Army indicate that the severity of outcome often determines the incident s prominence for managers, the workforce, or the community, which in turn drives subsequent responses. Incidents with more salient outcomes naturally receive more scrutiny, which may bias the data set used for analysis. 

Methods, systems, and procedures for ensuring the occupational health of employees Emergency response including controls, personnel evacuation, escape, and rescue Incident investigation and reporting, corrective and follow-up action The method of performance review and audit including review in the light of external... 

No one likes to be the bearer of bad news. Nevertheless, it is the responsibility of the incident investigation team to inform management as quickly as possible about their insights regarding the incident, particularly if the news is bad or if it is possible that the incident could repeat. The team should then continue to issue interim follow-up reports. 

Management, if yon want incident investigation to be done weU, you can have it aU you need to do is hold the people who report to you responsible for doing it well. But, understand that if it s not done well at your location now, you will have to achieve a culture change to get major improvement. 

After the session, a woman approached me and said, Mr. Manuele, I think at my location, I have the kind of a culture problem you discussed because I believe that our risks are overlooked and a lot of risk taking is accepted. I say that because all of the incident investigation reports that hit my desk put the responsibility for what happened on the worker. The reports always say things like they reinstructed the worker or discussions about safety were held with the workers or the safe practice rules are being reinforced. They don t ever really analyze the situation. ... 

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. 

Most incident investigations follow formal procedures. This chapter discussed two of the most common procedures change analysis and job hazard analysis. An investigation is not complete until a final report is issued. Responsible individuals can use the information and recommendations to prevent future incidents [6]. 

Since hazards-related incidents occur during the work activity for which supervisory personnel have initial responsibility, it follows that they— those closest to operations—should have initial responsibility for incident investigation. (Of course, it would be established in an organization that employees are to report all incidents to their supervisors.)... 

Emergency Response and Incident Investigation—Emergency planning and preparedness are essential to ensure that, in the event of an incident, all necessary actions are taken for the protection of the public, the environment, and company personnel and assets. Effective incident investigation, reporting, and follow-up are necessary to provide the opportunity to learn from reported incidents and to use the information to take corrective action and prevent recurrence from the identified root causes. 

Part of the response was to set a policy under which all incidents, including near collisions, and so on, were reported and thoroughly investigated as to the root cause. I believe that the colonel told me that Simon Goldrat, a well-known Israeli quality expert, was involved with the Safety Center of the Israeli Air Force. 

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