Guidelines for Investigating Process Safety Incidents

Front Cover

This book provides a comprehensive treatment of investing chemical processing incidents. It presents on-the-job information, techniques, and examples that support successful investigations. Issues related to identification and classification of incidents (including near misses), notifications and initial response, assignment of an investigation team, preservation and control of an incident scene, collecting and documenting evidence, interviewing witnesses, determining what happened, identifying root causes, developing recommendations, effectively implementing recommendation, communicating investigation findings, and improving the investigation process are addressed in the third edition.

While the focus of the book is investigating process safety incidents the methodologies, tools, and techniques described can also be applied when investigating other types of events such as reliability, quality, occupational health, and safety incidents.
 

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Contents

INTRODUCTION
1
OVERVIEW OF CHEMICAL PROCESS INCIDENT
13
1 Event Tree for a Processrelated Incident
15
1 Attributes of a Management System
21
5 Universal Concept for Controlling Risk
23
AN OVERVIEW OF INVESTIGATION
26
2 Schematic of an MES display
32
3
35
1 Example FactHypothesis Matrix Chemical Reduction
189
3 Rules for Causal Factor Charting
201
DETERMINING ROOT CAUSESSTRUCTURED
203
1 Example of 5 Whys Root Cause Analysis
209
1 Strengths and Weaknesses of the 5 Whys Technique
211
5 Generic Logic Tree Displaying the ANDGate
221
14 Logic Tree SlipTripFall Incident
227
18 Operator Fatality Branch
236

1 Some Characteristics of Selected Public Methodologies
44
4 Common Features of Investigation Methodologies
45
DESIGNING AN INCIDENT INVESTIGATION
47
CONTENTS xi
51
1 Suggested Training for Effective Implementation
66
2 Checklist for Developing an Incident Investigation Plan
76
INITIAL NOTIFICATION CLASSIFICATION
79
1 Common Classification Schemes
82
1 Logic Tree for Determining Incident Classification
87
3 Example of Likelihood Levels for Determining Incident
89
BUILDING AND LEADING AN INCIDENT
96
1 Investigation Team Collaboration
107
WITNESS MANAGEMENT
110
2 List of Potential Witnesses
114
4 Overview of Interview Process
122
1 Example Questions for Witnesses and Emergency Responders
128
5
134
1 Iteration between Data Analysis and Data Gathering
138
1 Scene Activities and Typical Responsibilities
142
2 Forms of Data Fragility
145
2 Examples of Paper Evidence
151
3 Asfound Position of ValvesExample Photo
155
5 Example Data Collection Form for Recording Physical
161
5 Timeline Example Based on Precise Data
169
7 Timeline Example Based on a Combination of Precise
172
1 Scientific Method Process
179
2 Strengths and Weaknesses of Logic Trees
242
22 Flowchart for Root Cause DeterminationPredefined
243
24 Incident Sequence
249
3 Strengths and Weaknesses of Predefined Trees
256
THE IMPACT OF HUMAN FACTORS
261
1 Common Human Factors Model
263
3 Incident Causation Model
272
1 Human Factors Issues
273
DEVELOPING EFFECTIVE
278
1 Incident Investigation Recommendation Flowchart
279
2 Layers of Safety
287
PREPARING THE FINAL REPORT
295
1 Sample Sections of an Incident Investigation Report
300
3 Example Checklist for Written Reports
308
IMPLEMENTING RECOMMENDATIONS
314
1 Flowchart for Implementation and Followup
316
CONTINUOUS IMPROVEMENT FOR
326
1 Requirement Compliance Checklist
327
LESSONS LEARNED
340
1 Example Safety Alert
349
APPENDIX A PHOTOGRAPHY GUIDELINES
357
APPENDIX E QUICK CHECKLIST
398
GLOSSARY
416
INDEX
437
Copyright

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About the author (2019)

The Center for Chemical Process Safety (CCPS) was founded in 1985 to develop technology and management practices that mitigate or eliminate process safety incidents in the chemical and petrochemical industries. Since that time, CCPS has published more than 100 books and held dozens of international conferences, each representing the most advanced thinking in process safety. CCPS is supported by the contributions and voluntary participation of more than 200 companies globally. CCPS is also the world's largest provider of undergraduate engineering curriculum materials through its SAChE program, with more than 160 universities participating from around the world.

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