Root Cause Analysis Handbook: A Guide to Efficient and Effective Incident Investigation, Third Edition

Section 10: Program Development

10.1 Introduction

This section discusses the process of developing the overall incident investigation program, as well as some issues that will affect all investigations. Topics include the following:

  • Program implementation process

  • Key considerations

    • Legal issues

    • Media concerns

    • Regulatory requirements and industry standards

    • Training guidelines

  • Management s influence on the program s success

  • Common investigation program problems and solutions

Figure 10.1 illustrates the overall incident investigation process.


Figure 10.1: Overall Incident Investigation Process

10.2 Program Implementation Process

Putting an incident investigation program in place should include the following five steps:

  1. Design the program

  2. Develop the program

  3. Implement the program

  4. Monitor the program s performance

  5. Improve the program

10.2.1 Design the Program

The first step in designing an incident investigation program or revising an existing program is to establish the goals, roles, and responsibilities for the program. In other words, decisions need to be made about what the program will accomplish and how the program will be run.

Define the Program Scope

First, decide on the scope of the program. Decide whether the program will cover all types of incidents or only a subset of these issues. Loss types to consider include:

  • Traditional occupational injuries and illnesses

  • Process safety issues

  • Equipment failures

  • Quality problems

  • Personnel safety concerns

  • Security problems

  • Reliability incidents

  • Public safety concerns

  • Environmental impact

  • Loss of revenue

  • Missed or late deliveries

  • Business interruption

  • Customer satisfaction

  • Loss of reputation

  • Motor vehicle accidents

Initially, the organization may...

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