Team investigate incidents

Figure 14.1 It is best to have a diverse team investigate incidents and to do so on location.

Employers must develop in-house capability to investigate incidents that occur in their facilities. A team should be assembled by the employer and trained in the techniques of investigation, including how to conduct interviews of witnesses, assemble needed documentation, and write reports. A multidisciplinary team is better able to gather the facts of the event and to analyze them and develop plausible scenarios as to what happened and why. Team members should be selected on the basis of their training, knowledge, and ability to contribute to a team effort to fully investigate the incident. 

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 ... 

The procedure section serves as both a job-aid for employees to use while investigating incidents and a training tool for the facility personnel whose job descriptions or special assignments include leading or participating on an investigation team. 

Establishment of criteria for selection of accidents and near accidents for team investigation. Examples are incidents (accidents and near accidents) with a potential for severe consequences, frequently recurring incidents, and incidents in new production... 

After the incident, an investigation team determined that the first operator had not added the initiator when required earlier in the process. When the relief operator added the initiator, the entire monomer mass was in the reactor and the reaction was too energetic for the cooling system to handle. Errors by both operators contributed to the runaway. Both operators were performing many tasks. The initiator should have been added much earlier in the process when much smaller quantities of monomer were present. There was also no procedure to require supervision review if residual monomers were detected. The lesson learned was that operators need thorough training and need to be made aware of significant hazardous scenarios that could develop. 

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. 

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

The personnel responsible for the collection and analysis of incident data vary in different organizations. One common practice is to assign the responsibility to an investigation team which includes the first line supervisor, a safety specialist and a plant worker or staff representative. Depending on the severity of an incident, other management or corporate level investigation teams may become involved. 

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. 

If no immediate hazards are identified during the approach to the site, the incident commander will likely approve the team to enter the site and perform the site characterization. During this stage, the team will continue field safety screening at the site and conduct a detailed site investigation. 

The first stage of the site characterization process is the customization of the generic plan developed as part of planning and preparation for responding to contamination threats. In general, the incident commander will develop the customized plan in conjunction with the site characterization team leader. The steps involved in the development of the plan include (1) perform an initial evaluation of information about the threat, (2) identify one or more investigation sites, (3) assess potential site hazards, (4) develop a sampling approach, and (5) assemble a site characterization team. 

Also note the following temperatures of interest to process safety incident investigation teams (Perry and (ireen, 1997 NFPA 422M NFPA 1997 and Avallone and Baumeister, 1996). 

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