Incident investigation procedures
“A crucial part of the process safety management program is a thorough investigation of incidents to identify the chain of events and causes so that corrective measures can be developed and implemented. Accordingly, PSM requires the investigation of each incident that resulted in, or could reasonably have resulted in, a catastrophic release of a highly hazardous chemical in the workplace.” OSHA Publication 3132
The focus of this program is to establish a program which will allow the facility to investigate ammonia releases and near misses (situations which could have potentially to have led to a release).
The Incident investigation program must be easy to use, expedient, and comprehensive enough to determine the root cause of the incident. We recommend a tiered approach based upon the incident. Six key questions should be answered: who, what, when, where, why, and how.
Depending upon the tier of the incident, everyone with any knowledge of the incident should be interviewed. A good investigation is likely to reveal several contributing factors, and generate several preventive actions.
The program will be designed to avoid laying sole blame on the employee. Even if workers openly blame themselves for making a mistake or not following prescribed procedures, the investigation must not be satisfied that all contributing causes have been identified. The error made by the employee may not be the root cause.
This program, normally consists of a written program outlining the facility policy and forms to be used for the investigation. A task flow diagram is also included to aid in training associated with the program.
If possible recommended follow-up actions should eliminate the possibility of a reoccurrences. Please note, some incident may be impossible to prevent in the future, however these incidents should not impose any safety hazards for employees.
11a. Develop the Incident Investigation Policy
Wagner-Meinert, LLC will develop a policy outlining the purpose and scope of the Incident Investigation Program as it relates to the Ammonia Refrigeration System. This policy will then be reviewed with facility personnel and finalized before being turned over to facility employees for implementation.
11b. Develop the Incident Investigation Forms
Wagner-Meinert, LLC will develop the forms (including a log) to be used to investigate incidents associated with the Ammonia Refrigeration System. The forms will then be reviewed with facility personnel and finalized before being turned over to facility employees for implementation.
The focus of this program is to establish a program which will allow the facility to investigate ammonia releases and near misses (situations which could have potentially to have led to a release).
The Incident investigation program must be easy to use, expedient, and comprehensive enough to determine the root cause of the incident. We recommend a tiered approach based upon the incident. Six key questions should be answered: who, what, when, where, why, and how.
Depending upon the tier of the incident, everyone with any knowledge of the incident should be interviewed. A good investigation is likely to reveal several contributing factors, and generate several preventive actions.
The program will be designed to avoid laying sole blame on the employee. Even if workers openly blame themselves for making a mistake or not following prescribed procedures, the investigation must not be satisfied that all contributing causes have been identified. The error made by the employee may not be the root cause.
This program, normally consists of a written program outlining the facility policy and forms to be used for the investigation. A task flow diagram is also included to aid in training associated with the program.
If possible recommended follow-up actions should eliminate the possibility of a reoccurrences. Please note, some incident may be impossible to prevent in the future, however these incidents should not impose any safety hazards for employees.
11a. Develop the Incident Investigation Policy
Wagner-Meinert, LLC will develop a policy outlining the purpose and scope of the Incident Investigation Program as it relates to the Ammonia Refrigeration System. This policy will then be reviewed with facility personnel and finalized before being turned over to facility employees for implementation.
11b. Develop the Incident Investigation Forms
Wagner-Meinert, LLC will develop the forms (including a log) to be used to investigate incidents associated with the Ammonia Refrigeration System. The forms will then be reviewed with facility personnel and finalized before being turned over to facility employees for implementation.
