Professional Documents
Culture Documents
Incident Investigation
Incident Investigation
1) ESTABLISHING A SAFETY CULTURE 2) PROVIDING MANAGEMENT LEADERSHIP & COMMITMENT 3) IMPLEMENTING A COMPREHENSIVE PSRM (PROCESS SAFETY & RISK MANAGEMENT) PROGRAMME 4) ACHIEVING OPERATING EXCELLENCE THROUGH OPERATIONAL DISCIPLINE
TECHNOLOGY
FACILITIES
PERSONNEL
5) QUALITY ASSURANCE
10) CONTRACTORS
2) PROCESS HAZARD ANALYSIS 6) PRE START-UP SAFETY REVIEWS 11) INCIDENT INVESTIGATION 7) MECHANICAL INTEGRITY 3) OPERATING PROCEDURES & SAFE PRACTICES
14) AUDITING
Auditing
Technology
Personnel
Quality Assurance
Incident Investigation
Facilities
Mechanical Integrity
INCIDENT INVESTIGATION
5) Determining strengthened
.. Contd. systems to be
6) Recommend corrective & preventive actions 7) Document findings 8) Follow up & communicate the
BRIEF
LIMITED TO KNOWN FACTS (DATE, TIME, PLACE, WHAT HAPPENED, IMMEDIATE ACTION TAKEN) IT HELPS THE MANAGEMENT TO IDENTIFY INCIDENTS THAT REQUIRE A COMPREHENSIVE INVESTIGATION
3) OBTAIN EYEWITNESS ACCOUNTS ON THE SPOT, IN ONE-IN-ONE PRIVATE INTERVIEWS Audio Tapes Video Tapes
4) EXAMINE KEY EQUIPMENT ( DISASSEMBLE IT, IF APPROPRIATE)
5) REVIEW ALL POTENTIAL INFORMATION SOURCES LIKE : Drawings Logs Charts Equipment manuals Oral instructions Training records Lab tests
6) SELECT ITEMS TO PRESERVE OR COLLECT As Found condition Repair records, if applicable 7)DEVELOP CHRONOLOGY OF EVENTS 8) LIST ALL KNOWN FACTS 9) IDENTIFY ALL DEVIATIONS NORMAL CONDITIONS CIRCUMSTANCES FROM OR
3) OPERATING SYSTEMS Training Documentation Rules / Procedures Preventive maintenance Job Safety Analyses Tracking results Communication Culture
INTERVIEWING METHODS
EXAMPLES OF QUESTIONS
GENERAL QUESTIONS LIKE : WHAT HAPPENED ? DESCRIBE THE SITUATION.
SPECIFIC QUESTIONS LIKE : WHAT WERE THE READINGS OF TEMPERATURE & PRESSURE ? WHAT DAMAGE WAS DONE TO THE GLASS CONDENSER ?
EXAMPLES OF FEELINGS
ANXIOUS TENSE / WORRY PAIN / SORROW HELPLESS & LOOKING FOR HELP ANGER / RAGE FRIGHTENED
DOs OF INTERVIEWING
LISTEN EMPATHISE FIRST ASK GENERAL QUESTIONS & THEN SPECIFIC QUESTIONS BE POSITIVE ENCOURAGE ALLOW ENOUGH TIME MAKE THE PERSON FEEL COMFORTABLE
DONTs OF INTERVIEWING
PREJUDGE BLAME INTERROGATE START WITH SPECIFIC QUESTIONS INTERRUPT GET IMPATIENT
CIRCUMSTANCES THAT CONTRIBUTED TO (OR MAY REASONABLY BELIEVED TO HAVE CONTRIBUTED TO) THE OCCURRENCE OF THE INCIDENT, EVEN THOUGH A CLEAR CONNECTION CANNOT BE ESTABLISHED
ESSENTIAL FOR DEVELOPING EFFECTIVE RECOMMENDATIONS
INVESTIGATORS SHOULD NOTE THAT THERE ARE MANY KEY FACTORS WHICH ARE NOT EASILY VISIBLE
.. continued
INCIDENT INVESTIGATION / COMMUNICATION EMERGENCY PLANNING / RESPONSE QUALITY ASSURANCE MECHANICAL INTEGRITY AUDITS
ELIMINATE HAZARDS
CONTROL HAZARDS
SEVERITY
COST IMPACT ON THE ORGANISATION
DEVELOP RECOMMENDATIONS
CORRECTIVE & PREVENTIVE ACTIONS SHOULD ADDRESS KEY FACTORS & INCLUDE FOLLOWING : DESCRIPTION OF ACTION
: STEP 7 :
DOCUMENT & COMMUNICATE THE FINDINGS
TO WHOM
AREA
PLANT COMPANY
HOW
BULLETIN BOARDS
CORPORA TION
E-MAILS
: STEP 8 :
FOLLOW UP
FOLLOW-UP SYSTEM
ENSURE THAT RECOMMENDATIONS RECEIVE PROMPT ATTENTION REQUIRE WRITTEN MANAGEMENT APPROVAL WHEN RECOMMENDATIONS WILL NOT BE FOLLOWED TRACK RECOMMENDATIONS PERIODICALLY BEYOND THE 1ST YEAR TO ENSURE :* Recommendations are carried out * Good habits are established
TRACKING PROCEDURES
IDENTIFY PROBLEMS WITHIN THE PROCESS DECIDE WHAT ACTION TO TAKE ENSURE THAT ACTIONS ARE FOLLOWED THROUGH.
REPORTS
ESTABLISH A PROCEDURE FOR TRACKING RECOMMENDATIONS COMMUNICATE REPORTS ANALYSE PERFORMANCE TRENDS
THANK YOU