Guidelines for Investigating Chemical Process Incidents, 2nd Edition

Preface.

Acknowledgments.

1. Introduction.

1.1 Building on the Past.

1.2 Who Should Read This Book?

1.3 The Guideline’s Objectives.

1.4 The Continuing Evolution of Incident Investigation.

2. Designing an Incident Investigation Management System.

2.1 Preplanning Considerations.

2.1.1 An Organization’s Responsibilities.

2.1.2 The Benefit of Management’s Commitment.

2.1.3 The Role of the Developers.

2.1.4 Integration with Other Functions and Teams.

2.1.5 Regulatory and Legal Issues.

2.2 Typical Management System Topics.

2.2.1 Classifying Incidents.

2.2.2 Other Options for Establishing Classification Criteria.

2.2.3 Specifying Documentation.

2.2.4 Describing Team Organization and Functions.

2.2.5 Setting Training Requirements.

2.2.6 Emphasizing Root Causes.

2.2.7 Developing Recommendations.

2.2.8 Fostering a Blame-Free Policy.

2.2.9 Implementing the Recommendations and Follow-Up Activities.

2.2.10 Resuming Normal Operation and Establishing Restart Criteria.

2.2.11 Providing a Template for Formal Reports.

2.2.12 Review and Approval.

2.2.13 Planning for Continuous Improvement.

2.3 Implementing the Management System.

2.3.1 Initial Implementation—Training.

2.3.2 Initial Implementation—Data Management System.

References.

3. An Overview of Incident Causation Theories.

3.1 Stages of a Process-Related Incident.

3.1.1 Three Phases of Process-Related Incidents.

3.1.2 The Importance of Latent Failures.

3.2 Theories of Incident Causation.

3.2.1 Domino Theory of Causation.

3.2.2 System Theory.

3.2.3 Hazard-Barrier-Target Theory.

3.3 Investigation’s Place in Controlling Risk.

3.4 Relationship between Near Misses and Incidents.

Endnotes.

4. An Overview of Investigation Methodologies.

4.1 Historical Approach.

4.2 Modern Structured Approach.

4.3 Methodologies Used by CCPS Members.

4.4 Description of Tools.

4.4.1 Brainstorming.

4.4.2 Timelines.

4.4.3 Sequence Diagrams.

4.4.4 Causal Factor Identification.

4.4.5 Checklists.

4.4.6 Predefined Trees.

4.4.7 Team-Developed Logic Trees.

4.5 Selecting an Appropriate Methodology.

Endnotes.

5. Reporting and Investigating Near Misses.

5.1 Defining a Near Miss.

5.2 Obstacle to Near Miss Reporting and Recommended Solutions.

5.2.1 Fear of Disciplinary Action.

5.2.2 Fear of Embarrassment.

5.2.3 Lack of Understanding: Near Miss versus Nonincident.

5.2.4 Lack of Management Commitment and Folow-through.

5.2.5 High Level of Effort to Report and Investigate.

5.2.6 Disincentives for Reporting Near Misses.

5.2.7 Not Knowing Which Investigation System to Use.

5.3 Legal Aspects.

Endnotes.

6. The Impact of Human Factors.

6.1 Defining Human Factors.

6.2 Human Factors Concepts.

6.2.1 Skills-Rules-Knowledge Model.

6.2.2 Human Behavior.

6.3 Incorporating Human Factors into the Incident Investigation Process.

6.3.1 Finding the Causes.

6.4 How an Incident Evolves.

6.4.1 Organizational Factors.

6.4.2 Unsafe Supervision.

6.4.3 Preconditions for Unsafe Acts.

6.4.4 Unsafe Acts.

6.5 Checklists and Flowcharts.

Endnotes.

7. Building and Leading an Incident Investigation Team.

7.1 Team Approach.

7.2 Advantage of the Team Approach.

7.3 Leading a Process Safety Incident Investigation Team.

7.4 Potential Team Composition.

7.5 Training Potential Team Members and Support Personnel.

7.6 Building a Team for a Specific Incident.

7.6.1 Minor Incidents.

7.6.2 Limited Impact Incidents.

7.6.3 Significant Incidents.

7.6.4 High Potential Incidents.

7.6.5 Catastrophic Incidents.

7.7 Developing a Specific Investigation Plan.

7.8 Team Operations.

7.9 Setting Criteria for Resuming Normal Operations.

8. Gathering and Analyzing Evidence.

8.1 Overview.

8.1.1 Developing a Specific Plan.

8.1.2 Investigation Environment Following a Major Occurrence.

8.1.3 Priorities for Managing an Incident Investigation Team.

8.2 Sources of Evidence.

8.2.1 Types of Sources.

8.2.2 Information from People.

8.2.3 Physical Evidence and Data.

8.2.4 Paper Evidence and Data.

8.2.5 Electronic Evidence and Data.

8.2.6 Position Evidence and Data.

8.3 Evidence Gathering.

8.3.1 Initial Site Visit.

8.3.2 Evidence Management.

8.3.3 Tools and Supplies.

8.3.4 Photography and Video.

8.3.5 Witness Interviews.

8.4 Evidence Analysis.

8.4.1 Basic Steps in Failure Analysis.

8.4.2 Aids for Studying Evidence.

8.4.3 New Challenges in Interpreting Evidence.

8.4.4 Evidence Analysis Methods.

8.4.5 The Use of Test Plans.

Endnotes.

9. Determining Root Causes—Structured Approaches.

9.1 The Management System’s Role.

9.2 Structured Root Cause Determination.

9.3 Organizing Data with a Timeline.

9.3.1 Developing a Timeline.

9.3.2 Determining Conditions at the Time of Failure.

9.4 Organizing Data with Sequence Diagrams.

9.5 Root Cause Determination Using Logic Trees—Methods A.

9.5.1 Gather Evidence and List Facts.

9.5.2 Timeline Development.

9.5.3 Logic Tree Development.

9.6 Logic Trees.

9.6.1 Choosing the Top Event.

9.6.2 Logic Tree Basics.

9.6.3 Example—Chemical Spray Injury.

9.6.4 What to Do If the Process Stalls.

9.6.5 Guidelines for Stopping Tree Development.

9.7 Fact/Hypothesis Matrix.

9.7.1 Application of Fact/Hypothesis Matrix.

9.8 Case Histories and Example Applications.

9.8.1 Fire and Explosion Incident—Fault Tree.

8.1.2 Data Driven Cause Analysis.

9.9 Root Cause Determination Using Predefined Trees—Method B.

9.9.1 Evidence Gathering.

9.9.2 Timeline Development.

9.9.3 Scenarios Determination.

9.9.4 Causal Factors.

9.9.5 Predefined Tree.

9.10 Causal Factor Identification.

9.10.1 Identifying Causal Factors.

9.10.2 Barrier Analysis.

9.10.3 Change analysis.

9.10.4 Quality Assurance.

9.10.5 Causal Factor Summary.

9.11 Predefined Trees.

9.11.1 Background—MORT.

9.11.2 Using Predefined Trees.

9.11.3 Example—Environmental Incident.

9.11.4 Quality Assurance.

9.11.5 Predefined Tree Summary.

9.12 Checklists.

9.12.1 Use of Checklists.

9.12.2 Checklist Summary.

9.13 Human Factors Applications.

9.14 Conclusion.

Endnotes.

10. Developing Effective Recommendations.

10.1 Major Issues.

10.2 Developing Effective Recommendations.

10.2.1 Team Responsibilities.

10.2.2 Attributes of Good Recommendations.

10.3 Types of Recommendations.

10.3.1 Inherent Safety.

10.3.2 Hierarchies and Layers of Recommendations.

10.3.3 Commendation/Disciplinary Action.

10.3.4 The “No-Action” Recommendation.

10.3.5 The Incompletely Worded Recommendation.

10.4 The Recommendation Process.

10.4.1 Select One Cause.

10.4.2 Develop and Examine Preventive Actions.

10.4.3 Perform a Completeness Test.

10.4.4 Establish Criteria to Resume Operations.

10.4.5 Prepare to Present Recommendations.

10.4.6 Review Recommendations with Management.

10.5 Reports and Communications.

Endnotes.

11. Communication Issues and Preparing the Final Report.

11.1 Interim Reports.

11.2 Writing the Formal Report.

11.2.1 General Guidance.

11.3 Sample Report Format.

11.3.1 Executive Summary.

11.3.2 Introduction.

11.3.3 Background.

11.3.4 Sequence of Events and Description of the Incident.

11.3.5 Evidence and Cause Analysis.

11.3.6 Findings and Recommendations.

11.3.7 Noncontributory Factors.

11.3.8 Attachments or Appendices.

11.3.9 Criteria for Restart.

11.4 Capturing Lessons Learned.

11.4.1 Internal.

11.4.2 External.

11.5 Tools for Assessing Report Quality.

11.5.1 Checklist.

11.5.2 Avoiding Common Mistakes.

12. Legal Issues and Considerations.

12.1 Seeking Legal Guidance in Preparing Documentation.

12.1.1 Use and Limits of Attorney—Client Privilege.

12.1.2 Recording the Facts.

12.2 The Importance of Document Management.

12.3 Communications and Credibility.

12.4 The Challenges and Rewards of Sharing New Knowledge.

12.5 Employee Interview and Personal Liability Concerns.

12.6 Gathering and Preserving Evidence.

12.7 Inspection and Investigation by Regulatory and Other Agencies.

12.8 Legal Issues Related to “Postinvestigation”.

12.9 Summary.

Endnotes.

13. Implementing the Team’s Recommendation.

13.1 Three Major Concepts.

13.2 What Happens When There Is Inadequate Follow-up?

13.2.1 Nuclear Plant Incident.

13.2.2 Aircraft Incident.

13.2.3 Petrochemical Plant Incident.

13.2.4 Challenger Space Shuttle Incident.

13.2.5 Typical Plant Incidents.

13.3 Management System Considerations for Follow-up.

13.3.1 Understanding Responsibilities.

13.3.2 Formally Accepting Recommendations.

13.3.3 Assigning a Responsible Individual.

13.3.4 Determining Action Item Priority.

13.3.5 Implementing the Action Items.

13.3.6 Documenting Recommendation Decisions—the Audit Trail.

13.3.7 Tracking Action Items.

13.3.8 Revising the Incident Investigation Management System.

13.4. Sharing Lessons Learned.

13.4.1 Performing the Follow-Up Audit.

13.4.2 Internal Sharing.

13.4.3 External Sharing.

13.5 Analyzing Incident Trends.

Endnotes.

14. Continuous Improvement for the Incident Investigation System.

14.1 Regulatory Compliance Review.

14.2 Investigation Quality Assessment.

14.3 Recommendations Review.

14.4 Potential Optimization Options.

14.4.1 Follow Up.

14.4.2 Causal Category Analysis.

Endnotes.

15. Lessons Learned.

15.1 Learning Lessons from Within Your Organization.

15.2 Learning Lessons from Others.

15.3 Cross-Industry Lessons.

15.4 Trends and Statistics.

15.5 Management Application.

15.6 Case Studies.

15.6.1 Esso Longford Gas Plant Explosion.

15.6.2 Union Carbide Bhopal Toxic Gas Release.

15.6.3 NASA Challenger Space Shuttle Disaster.

15.6.4 Tosco Avon Oil Refinery Fire.

15.6.5 Shell Deer Park Olefins Plant Explosion.

15.6.6 Texas Utilities Concrete Stack Collapse.

15.6.7 Three Mile Island Nuclear Accident.

15.6.8 Concorde Air Crash.

References.

Appendix A. Relevant Organizations.

Appendix B. Professional Assistance Directory.

Appendix C. Photography Guidelines for Maximum Results.

Appendix D. Example Case Study—Fictitious NDF Company Incident.

Appendix E. Example Case Study—More Bang for the Buck: Getting the Most from Accident Investigations.

Appendix F. Selected OSHA and EPA Incident Investigation Regulations.

Appendix G. Quick Checklist for Investigators.

Appendix H. Additional Resources.

Appendix I. Contents of CD-ROM.

Glossary.

Index.