Incident investigation reports

The major components of a compliance system are regular inspections, reporting, incident investigation, follow-up, enforcement, and recognition and reward. The system should emphasize fact finding, not fault finding. That applies to all the safety and security programs and policies described in Chapter 3. Initiation and maintenance of an effective compliance system are important to ... 

Safety meetings conducted JHAs conducted Safety inspections conducted Employees recognized Hazards reported Incident investigations Safety observations Safety training conducted... 

OSHA-reportable incidents investigated cause determination and corrections are at times inadequate. 

As mentioned earlier, determining an accident trend analysis should be relatively easy. In principle, at least, it is easy, or it should be however, a variety of obstacles will probably be encountered when trying to determine the current status of safety culture. In the initial chapters, we discussed how an OSHA log can be a guide to potential problem areas. OSHA logs, accident reports, incident investigations, accident review boards, medical records, worker interviews, OSHA citations, and other information can provide a lot of information about safety culture development. 

Severity Incident Threshold OSHA 300 Report Incident Investigation Report (HR) Internal Notification Report to OSHA within 8 hours... 

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. 

The final incident investigation report written by the assigned incident investigation team (which may include members from the client) can be written in a less structured way depending on the extent of the incident. A detailed discussion of how and why to conduct incident investigations can be found in the AIChE publication. Guidelines for Investigating Process Safety Incidents, Second Edition. 

Employees in the process area where the incident occurred should be consulted, interviewed, or made members of the team. Their knowledge of the events represents a significant set of facts about the incident that occurred. The report, its findings, and recommendations should be shared with those who can benefit from the information. The cooperation of employees is essential to an effective incident investigation. The focus of the investigation should be to obtain facts, and not to place blame. The team and the investigative process should clearly deal with all involved individuals in a fair, open, and consistent manner. 

The employer investigates incidents that result in, or could result in, a catastrophic release of highly hazardous chemicals. An incident investigation is initiated as soon as possible, but before 48 hours following the incident. An incident investigation team is established to consist of one or more experts in the process involved, and accident investigation. The report prepared at the conclusion of the investigation includes at a minimum ... 

Bhopal Methyl Isocyanate Incident Investigation Team Report, Union Carbide Corporation, Danbury, Conn., Mar. 1985. 

Incident Investigation Major incidents Near-miss reporting Follow-up and resolution Communication Incident recording Third-party participation as needed... 

Workforce Support for Data Collection and Incident Analysis Systems Few of the incident investigation and data collection systems reviewed provide any guidelines with regard to how these systems are to be introduced into an organization. Section 6.10 addresses this issue primarily from the perspective of incident reporting systems. However, gaining the support and ownership of the workforce is equally important for root cause analysis systems. Unless the culture and climate in a plant is such that personnel can be frank about the errors that may have contributed to an incident, and the factors which influenced these errors, then it is unlikely that the investigation will be very effective. 

OSHA 1910.119 does not mandate the specific type of investigation a plant must conduct when a reportable incident occurs. However, it provides stipulations that must be met for the following investigator qualifications, time requirements, report content, review process, and corrective actions. 

A number of reports have established the presence of rodenticides in predators and scavengers found dead in the field (see, for example, reports of U.K. Wildlife Incident Investigation Scheme [WHS]). Brodifacoum, difenacoum, bromodiolone, and flo-coumafen have all been found, albeit at low levels in most cases (<1 ppm in liver). Sometimes, more than one type of rodenticide has been found in one individual. The toxicological significance of these residues will be discussed in Section 11.5. 

Incident Investigation—In assessing this element, consideration must be given to major incidents, near-miss reporting, follow-up and resolution, communications, incident recording, and third-party participation as needed. 

It strongly supports reporting and investigating incidents and near misses, and emphasizes the value and necessity of communicating and sharing the lessons learned to all that could benefit. 

During facility operation, a chemical reactivity incident or near miss may occur despite all efforts to effectively manage chemical reactivity hazards. An essential element of managing chemical reactivity hazards is to appropriately report and investigate every incident or near miss involving chemical reactivity hazards. By investing the time and effort to determine the root causes and take corrective... 

These goals are listed in the order of importance to a company. Of greatest importance is to get near misses reported so that investigation can be used to learn from the incident. Note that incident investigation techniques are essentially the same whether applied to chemical reactivity hazards or to other hazards. 

OSHA PSM-covered facilities are required to investigate each incident which resulted in, or could reasonably have resulted in a catastrophic release of a highly hazardous chemical in the workplace (29 CFR 1910.119 [m] [1]). At the conclusion of an incident investigation, the company is required to prepare a report on the factors that contributed to the incident. At present, OSHA does not require submittal of these incident reports. However, mandatory submission of the reports would increase available data and thus improve the capability of identifying or tracking reactive incidents. 

The third step in incident investigation is to generate a report detailing facts, findings, and recommendations. Typically, recommendations are written to reduce risk by ... 

Many major process safety incidents were preceded by precursor occurrences. These occurrences were unrecognized or ignored because nothing bad actually happened. The lessons learned from such occurrences, typically referred to as near misses, can be extremely valuable in averting disaster. However, this benefit is only realized when they are recognized, reported, and investigation techniques are properly applied. This chapter describes near misses, discusses their importance, and presents the latest methods for helping ensure appropriate near misses are reported. 

In the case of incident investigation, a major milestone is completed when the final incident investigation report is submitted. The incident report documents the investigation team s findings, conclusions, and recommendations. This chapter describes practical considerations for writing formal incident reports, a discussion of the attributes of quality reports, and the issue of commimicating the report findings to affected persons, both internally and externally. 

The items in this list are essential to maintaining a well-designed incident investigation program. A high priority should be to promote reporting to learn from near miss incidents before a substantial loss occurs. 

They ensure documentation exists explaining why a recommendation was rejected or modified after its original approval in an incident investigation report. 

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