Incident investigation why

Thus a major accident investigation process will have to be more robust to accomplish the goals of the investigation. An investigator must collect accurate information to perform an incident investigation, find root causes, and develop effective corrective actions.

We categorize this evidence as 3 P, and an R. That is:. How do you find root causes? Investigators can fall into traps when developing corrective actions to prevent repeat incidents.

What kind of traps? Here are two examples:. What does management need from your report or presentation to be able to approve your incident investigation? Here are five critical sections for every incident investigation report:. We will investigate serious or dangerous incidents. Secure Secure the scene. Do not disturb the scene any more than is necessary to assist the injured person or to make the incident area safe. This includes any plant, substance or structure associated with the incident.

Keep people not providing immediate and urgent assistance away from the area. Collect Do not disturb the scene until you have had an opportunity to collect all the evidence. Check with one of our inspectors before removing anything from the scene for further examination and analysis.

If there has been a death or serious injury, the site should not be altered in any way without the permission of one of our inspectors or a police officer. Cooperate Co-operate with emergency services personnel, our inspectors and specialists taking evidence or measurements.

Report Analyse the investigation details gathered and write a report that can be acted upon to control the identified risks and hazards. Record physical evidence first. This evidence may be subject to rapid change or obliteration and should therefore be the first information recorded.

Take notes of the scene. Photographs, sketches and diagrams may also be useful. Careful study of these later may reveal conditions or contributing factors initially missed. Companies decide what combinations of consequences and frequencies are appropriate to trigger each type of incident feedback process: 1 formal investigation root cause analyses [RCAs] , 2 less formal investigation apparent cause analyses [ACAs] , and 3 trending of incident data with no immediate investigation performed.

The term apparent cause analysis was originally defined by the Department of Energy. Other terms that are typically applied to these different level of analyses include Level 1 and Level 2 analyses or basic and detailed analyses Ref. Personnel who have formal training in incident investigation or RCA techniques typically perform investigations and lead investigation teams.

A multidisciplinary team is appropriate for incident investigations with greater consequences and risks. An individual or a two-person investigation team may investigate incidents with lower consequences and risks. Personnel throughout the company provide assistance to the investigation team. For incidents involving significant human injuries or incidents with potential regulatory impact, the legal department will often assume overall management of the investigation.

The main products of an incident investigation system are: 1 basic data for all recorded incidents, including those that do not qualify for immediate investigation trend-only incidents , 2 analysis reports for ACAs and RCAs, 3 identification of the causes of the incidents that are investigated, and 4 implemented recommendations lessons learned and action items that will reduce the risk of similar incidents.

The results of the investigation process should be documented in a standard incident report form. Other types of work products may include up-to-date incident summary lists, action item tracking summaries, and trending data such as incident characteristics, causes, and recommendations. Data gathered during the review or generated by the investigation are usually kept at least until the action items and lessons-learned are implemented and communicated, and usually longer in accordance with company and regulatory requirements.

Outputs of the incidents element should be used to facilitate the performance improvement of other elements. In most cases, recommendations aimed at the root causes of an incident will involve modifications to other RBPS elements.

A company selects its incident investigation approach and documents the approach in its investigation procedures.