Root cause incident investigation management

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. 

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... 

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. 

One approach is to mesh all investigation and root cause analysis activities under one management system for investigation. Such a system must address all four business drivers (1) process and personnel safety, (2) environmental responsibility, (3) quality, and (4) profitability. This approach works well since techniques used for data collection, causal factor analysis, and root cause analysis can be the same regardless of the type of incident. Many companies realize that root causes of a quality or reliability incident may become the root cause of a safety or process safety incident in the future and vice versa. 

The company will learn that reporting and investigating near misses will enhance overall business performance, particularly because the near misses of a safety incident or environmental release have the same root causes as incidents that detract from quality and productivity. Safety personnel can assist in defining an appropriate near-miss reporting culture. All managers intuitively understand the return on investment from preventing incidents. The effort pays for itself directly through improvements in productivity. 

The incident investigation team s complete report is attached in the Appendix D and details of the root causes are discussed. The root causes of the incident relate to several process safety management areas ... 

After the root causes have been identified from the predefined tree, a generic cause test should be applied. By considering the plant operating history, especially other incidents that may indicate repetitive failures, the investigator may identify other generic management system problems. 

Using structured approaches such as those presented in the preceding chapter, an investigation team identifies the multiple system-related incident causes. These approaches provide the mechanism for understanding the interaction and impact of management system deficiencies. When the investigators understand what happened, how it happened, and why it happened, they can develop recommendations to correct immediate, contributing, and root causes. 

The best way to avoid claims and litigation is to prevent an incident from occurring in the first place by having adequate systems and preventive measures in place. The goal of the incident investigation is to learn the root causes of an incident in order to improve management systems, and... 

By gathering these data from each incident investigation, a database is established that will, over time, indicate the broad categories or management systems in which incident investigation findings tend to accumulate. The company can then devise and implement a more holistic approach to prevention than the one developed by addressing individual root causes. 

An exceptional investigation report willfully explain the technical elements and issues associated with the incident. It will describe the management systems that should have prevented the event, and will detail the system root causes associated with human errors and other deficiencies involved in the incident. 

The terms root cause or multiple root causes appear several times without a clear definition. When Jack Philley teaches the Investigating Process Safety Incidents course for the AIChE, he offers several clear definitions. He describes a root cause as a prime reason, underlying cause, and most often associated with breakdowns or flaws in the management systems. Furthermore, Philley s class notes point out definitions from the Department of Energy Guidelines in his handout, which states ... 

Thorough and effective analyses of workplace incidents are critical components of a comprehensive safety management system. Yet, many incident analysis processes (i.e., accident investigations) fall short. They frequently fail to identify and resolve the real root causes of injuries, process incidents and near misses. Because the true root causes of incidents are within the system, the system must change to prevent the incident from happening again. 

Plan Plant general manager decides that he will lead an incident investigation for all forklift incidents in order to get to root causes and corrective actions. 

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