Just what is an incident that requires large-scale investigation? We’re not talking about the small oil spill that’s contained and doesn’t leave plant property. We’re not talking about the minor release of an air pollutant that doesn’t jeopardize human health or the environment. We are talking about significant spills or releases of materials that leave plant property, or occur off plant property (transportation-related). We are talking about fires and/or explosions that threaten human health and/or the environment.
Once one of these types of incidents has occurred, how should you go about investigating it to provide recommendations for preventing future incidents of the same type? EES personnel have experience in this area, having participated in and led incident investigations. We can help with investigations of specific incidents, or with the development of an incident investigation/response program. As a brief aid, below is a Summary Checklist of items for an investigation team leader to consider when investigating incidents
Summary Checklist for Incident Investigation Team Leader
Initial Communications
Initial notification internal to company
Confirm legal and regulatory requirements, if any
Confirm team charter, authority, scope & reporting relationships
Team member selection & notifications
Debriefing with emergency responders & local plant management
Need for HAZWOPER rating for investigators
Initial Team Meeting
Communication protocols (internal & external to the team)
Evidence – documentation, preservation, identification, custody
Evidence – electronic
Witness interviews – identify potential witnesses
Photography (include videotaping)
Logistics – team supplies, PPE, finances, administrative needs
Special services or special technical skills
Liaison with other investigations (insurance, OSHA, EPA, State, others)
Interim report requirements, arrangements, needs of management
Special training (or refresher training), PPE, chemistry, controls, failure modes
Determine involvement of contractors
Ongoing Operations
List known facts (initial listing)
Develop initial chronology timeline
Develop initial logic diagram to identify what did or could have happened
Identify potentially credible scenarios
Identify needs for additional information needed to confirm/refute hypotheses
Apply iterative loop tool
Refine chronology, logic diagram & scenarios
Identify underlying cause
Identify potential recommendations
Analyze recommendations for Management-of-Change
Identify restart-up criteria (if applicable)
Develop draft report
Review & approval of report
Develop final report & submit to management
Specific plan for sharing results of investigation (who, what info, by when)
Critique the investigation process for potential improvements & lessons learned
Revise investigation system and retrain as necessary
Arrange for preservation or custody transfer of evidence (if needed)
Witness Interview
Identify potential witnesses
Conduct promptly
Neutral & private location
Minimize cross contamination between witnesses
Decide on documentation/recording
Establish initial rapport
Resolve distractions/concerns
Restate purpose of interview
Allow uninterrupted narrative
Use reflective listening
Use open ended questions
Keep an open mind (try to avoid screening out information that does not match the preferred scenario)
Watch body language
Explore who/what/when/where/why/how in the interactive dialog
Explore procedures, training & past incidents
Potential Sources of Evidence
Computer data
Log books
P&ID
MSDS
Operating procedures
Maintenance/testing/inspections
Training manuals
Process Hazard Analysis reports
Control logic software
Design calculations and base cases
Material balances
Process chemistry
Past incident reports
Retainer samples
Recordings of emergency and other radio communications
Observations of as-found position of valves/switches/other devices
Missile and fragmentation mapping
Damage contours
Residual inventories
Meteorological records
Dispersion calculations
Rupture disk and safety valve integrity status
We hope this information is useful to you. Remember, EES stands ready to assist you in incident investigations or in the development of incident investigation programs at your location.
Number 21