Standards incident investigation

Correcting the deficiencies foimd using standard incident investigation methods shoidd reduce the errors that caused a particular incident but, to reduce the precursors to error and make an organization a safer organization, a more holistic tool, such as ICAM, which looks at the full range of organizational systems, is required. 

What does the Process Safety Management standard say The regulation, 29 C.F.R. Part 1910.119, entitled Process Safety Management of Highly Hazardous Chemicals, has the following to say on Incident Investigation ... 

Naturally, while awaiting additional investigation or laboratory test results, it may be necessary for preliminary reports, status reports, and draft reports. However, the final incident investigation report must satisfy the requirements of the OSHA Process Safety Management standard. An OSHA PSM report shall, at a minimum, include ... 

Regardless of the method of investigation used for any incident, there are some mandatory OSHA requirements. The OSHA Process Safety Management (PSM) standard focuses on incidents that could reasonably have resulted or actually had resulted in a catastrophic release of highly hazardous chemicals. A major requirement is having a procedure that the employer can quickly implement. Here are a few considerations for an incident investigation procedure that addresses the major points of the PSM standard. 

In the US, a workplace study of exposure to benzidine and its congeners, such as 10b, 10c and lOd, at the chemical facility of Upjohn (previously Carwin Company), located at North Haven, Connecticut, between 1965 (when benzidine manufacture ceased) and 1989, indicated a statistically significant increase in the standardized incidence ratio125. The impact of interindividual variation in NAT2 activity on urinary metabolites and urothelial DNA adducts in workers has been examined126. Phenyl-2-naphthylamine (37), and perhaps chemicals used in its manufacture, have been implicated as possible causes of bladder cancer, based on studies of workers at a factory in North Wales. Other amines investigated... 

Incident Investigation and Root Cause Analysis is discussed in Chapter 11. The OSHA standard and guidance is to be found in paragraph (1) of the regulation. 

The existence of an indeterminate number of root causes may help explain some of the frustration that is occasionally expressed with standardized incident analysis procedures and software. In spite of their structured approach, these systems are fundamentally subjective. For example, one technique helps the investigation team list many of the possible causes that led to an event. Some of these causes are then identified as causal factors which are then developed into root causes. Yet the determination as to which causes are causal factors will necessarily depend on the... 

Access, lighting, and housekeeping standards Existing risk assessment process [hazard and operability (HAZOP), MOC, unit startups, work permitting] Recommendations from prior and current incident investigation teams... 

Of the 15 variations of incident investigation reports received, six promote an overly simplistic and inappropriate approach to causal factor determination. They reflect this instmction, although somewhat ancient, given in a publication of the American National Standards Institute, the Method of Recording Basic Facts Relating to the Nature and Occurrence of Work Injuries—Z16.2. 

I asked her what her job was. She said she was the plant manager. And I tactfully said to her that she was the problem. After brief discussion of the pattern of expected behavior with respect to incident investigation that had developed, she agreed that it was her place to set higher standards of acceptability. She also said that she knew how to do that. I suggested that she take up my principal theme, which was this ... 

The objective of this (guideline, standard, procedure) is to establish a uniform method for incident investigation that... 

Health and safety representatives who have received specific accident investigation training could be used to assist in accident and near-miss incident investigations. Since they will be conducting both formal and informal inspections, a training session in auditing techniques will help them to audit safety standards in their own areas. 

Incident investigation methods are sometimes criticized for their subjectivity. Sutton (2008) speaks about the frustration that is occasionally expressed with standardized incident analysis procedures and software. In spite of their structured approach, these systems are fundamentally subjective. ... 

Incident Investigation. Employers are required to investigate as soon as possible (but no later than 48 hours after) incidents that did result or could reasonably have resulted in catastrophic releases of covered chemicals. The standard calls for an investigation team, including at least one person knowledgeable in the process involved (a contract employee when the incident involved contract work) and others with knowledge and experience to investigate and analyze the incident, and to develop a written report on the incident. Reports must be retained for five years. 

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