Chapter 12: Investigating and Sharing Near Misses and Unfortunate Accidents

Introduction

No one rejoices when an incident occurs. An incident can bring embarrassment, equipment damage, interrupt production, create injury or worst. But often, an effective and timely incident investigation is an opportunity to acquire new insight. Within the spirit of continuous improvement, a system for investigating and sharing findings of significant incidents, near misses, and truly perilous incidents can be a key for a better tomorrow. Common sense and the OSHA Process Safety Management standard dictate there must be a practical method to investigate process safety incidents.

World-class organizations have incident investigations described as "Near Miss Reporting" or "Significant Incident Reporting," which investigates a range of abnormal incidents or injuries. They also have "Accident Investigations for OSHA Recordable Cases," which involves an injury, and "Spill/Release Notification Guidelines" for environmental insults.

For decades, most chemical manufacturers have employed a hierarchy of reviews, investigations, and reports for safety and environmental insults and incidents. It is obvious that a Process Safety Incident Investigation is the "highest level" investigation that can incorporate other more limited investigations and reports.

This chapter provides an overall view of Incident Investigation with a focus on PSM-type incidents. Look forward to a chapter that:

• provides the OSHA PSM standard for Incident Investigation

• provides the OSHA Nonmandatory Appendix C Compliance Guidelines

• discusses the cultural atmosphere surrounding incident reporting

• presents the "layered" look at investigations

• presents a view of Root Cause Analysis

• offers a practical PSM Incident Investigation procedure

• provides tips on interviewing for incident investigation.

What Does the Regulation...