Incident Investigation

Incident investigation is a process for reporting, tracking, and investigating incidents that includes
  • A formal process for investigating incidents, including staffing, performing, documenting, and tracking investigations of process safety incidents and
  • The trending of incident and incident investigation data to identify recurring incidents. This process also manages the resolution and documentation of recommendations generated by the investigations.
At some facilities, the incidents element is used to assign blame to personnel involved in an incident. This approach results in ineffective recommendations being implemented. A more effective approach is to develop recommendations that address the systemic causes of the incidents. The incidents element is not a process to assign blame, but a process to develop effective recommendations to address the underlying, system-related causes of incidents.

Steps to conducting an effective accident investigation:

  • Provide first aid and/or medical care to the injured persons and take action to prevent further injury or damage. This is the first priority
  • Report the accident as required by company's policies.
  • Investigate the accident as soon as possible after it occurs. This allows to observe the conditions as they were at the time of the accident, prevents the disturbance of evidence, and identify witnesses.
  • Investigate the accident as soon as possible after it occurs. This allows to observe the conditions as they were at the time of the accident, prevents the disturbance of evidence, and identify witnesses.
  • Identify the causes of the accident. Note that there could be multiple causes.
  • Report findings in a written report. Prepare step-by-step account or timeline working back from the moment of the accident.
  • Develop a plan for corrective action to prevent the accident from happening again. These actions should be specific, constructive, address root causes of the accident, and address the causes described in the report.
  • Implement corrective action plan. Set a deadline for implementation of corrective actions and monitoring in place to ensure that they are completed.
  • Follow up to evaluate the effectiveness of the corrective actions taken.
  • Make adjustments as needed to continue to improve.
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