Introduction

Accidents are significant events that trace their roots back to management system failures. They often result from a single failure. That failure however may be a symptom of deeper problems within the operation of a plant or facility. Only with a full understanding of what happened, how it happened and why it happened, can effective remedial actions be taken. Incidents are minor occurrences that can lead to an accident. This session will provide an in-depth look at the systematic process of examining and evaluating the causes of an incident so that recurrence can be prevented.

The goal of this workshop is for every attendee to leave better prepared to effectively investigate and learn from process safety incidents by being equipped with a basic understanding of:

• WHY effective incident investigation and root cause analysis (RCA) are vital,
• WHAT incident investigation skills/tools, technical competencies, and management support are required for an investigation team to be effective and efficient,
• HOW effective process safety incident investigations and RCA are done.

Learning Outcomes:

Workshop attendees will learn about proven industry practices and develop skills, in class discussions and group exercises on:

• How to set up, manage and participate in an incident investigation
• How to apply evidence preservation techniques
• How to interview witnesses and other workers
• How to collect and analyze physical parts
• How to examine records and documents
• How to apply causal analysis techniques and identify root causes\How to develop recommendations to correct deficiencies and address root causes
• How to write and compile a report
• \How to present investigation findings

Who should attend:

Those who work at, support, or regulate facilities that produce, store or use hazardous materials, and may be involved with, oversee, or review and approve incident investigation reports, should benefit from this workshop. This includes:

• Engineers and scientists (all disciplines)
• Manufacturing site process operators
• Maintenance specialists
• Environment, health, safety, and security specialists
• Facilities managers, site functional leaders, and area supervisors

Outline:

• Basic Concepts
• Secure Incident Scene–A Site Responsibility
• Establishing Investigation Team and Investigation Planning
• Positional Evidence and Preserving Evidence
• People Evidence – Interviews
• Parts and Equipment Evidence
• Failure Analysis
• Incident Sequence/Timeline and Event Analysis
• Paper Evidence
• Human Factors
• Putting It All Together and Root Cause Analysis
• Findings, Conclusions, and Recommendations