31.1 Preface

Chemical process incidents can be accompanied by significant consequences, both in terms of human life and in financial impact. Many major chemical process incidents are the result of a complex scenario involving simultaneous failures of multiple safeguards. A robust system for incident investigation is usually necessary to determine and understand the causes, as well as implement measures to prevent a repeat event. This chapter is intended to provide an overview of incident investigation by addressing major concepts, principles and characteristics of effective incident investigations of chemical process events. The focus is on incidents pertaining to chemical processes and their associated hazards, and the associated investigation techniques appropriate for complex systems and scenarios. This chapter is based on best practices for incident investigation, and those common concepts (i.e. tools, techniques, definitions) included in root cause investigation methodologies currently in the public domain in use in the process industry. It is not the intention to provide a stand-alone investigation methodology/guideline, nor address internal or proprietary investigation methodologies.

This chapter is based on:

• process industry best practices for incident investigation;

• investigation concepts from the Mary Kay O Connor Process Safety Center Root Cause Investigation Course;

• Ted Ferry s book on accident investigation (Ferry, 1988);

• Kuhlman s Professional Accident Investigation (Kuhlman, n.d.);

• CCPS Guidelines for Incident Investigation (second edition) (CCPS, AIChE, 2003);

• NFPA 921 Standard for investigation of fires and explosions (NFPA, Standard 921 Investigating Fires and Explosions);

• American Chemistry Council Responsible Care code (CARE ,...