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    Guideline For Major Incident Investigation

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    Naga Rajan
    The document provides guidelines for major incident investigations, which involve forming an investigation team, determining the key factors that contributed to the incident, and recommending corrective actions. The team is formed based on incident severity and includes managers, HSE personnel, and others with relevant expertise. The investigation determines physical, human, and systems factors by collecting evidence, interviewing witnesses, and using root cause failure analysis techniques. This identifies circumstances that contributed to the incident. Finally, the investigation recommends corrective actions to address all key factors and strengthen relevant systems, personnel, facilities, technology, and operations.

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    Guideline For Major Incident Investigation

    Uploaded by

    Naga Rajan
    26 views3 pages
    The document provides guidelines for major incident investigations, which involve forming an investigation team, determining the key factors that contributed to the incident, and recommending corrective actions. The team is formed based on incident severity and includes managers, HSE personnel, and others with relevant expertise. The investigation determines physical, human, and systems factors by collecting evidence, interviewing witnesses, and using root cause failure analysis techniques. This identifies circumstances that contributed to the incident. Finally, the investigation recommends corrective actions to address all key factors and strengthen relevant systems, personnel, facilities, technology, and operations.

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    Guideline for Major Incident Investigation.

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    Guideline for Major Incident Investigation.docx

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    The document provides guidelines for major incident investigations, which involve forming an investigation team, determining the key factors that contributed to the incident, and recommending corrective actions. The team is formed based on incident severity and includes managers, HSE personnel, and others with relevant expertise. The investigation determines physical, human, and systems factors by collecting evidence, interviewing witnesses, and using root cause failure analysis techniques. This identifies circumstances that contributed to the incident. Finally, the investigation recommends corrective actions to address all key factors and strengthen relevant systems, personnel, facilities, technology, and operations.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    26 views3 pages

    Guideline For Major Incident Investigation

    Uploaded by

    Naga Rajan
    The document provides guidelines for major incident investigations, which involve forming an investigation team, determining the key factors that contributed to the incident, and recommending corrective actions. The team is formed based on incident severity and includes managers, HSE personnel, and others with relevant expertise. The investigation determines physical, human, and systems factors by collecting evidence, interviewing witnesses, and using root cause failure analysis techniques. This identifies circumstances that contributed to the incident. Finally, the investigation recommends corrective actions to address all key factors and strengthen relevant systems, personnel, facilities, technology, and operations.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Guideline for Major Incident Investigation

    1. Team formation
    a. Incident investigation team are performed based on the incident category.
    Category
    Category A or fatality
    B Category PFDE incidents or LWC/RWC

    C category PFDE incidents or MTC/FAC


    a.
    b.
    c.
    d.

    Team formation responsibility


    The Site chief in consultation with
    Executive Director/GMS/CHSEE
    The site chief in case of large sites or
    the Sector Chief in consultation with the
    Team Leader.
    HOD in consultation with team leader

    Senior manager form affected area- Chairman


    Minimum team size-6
    The team committee shall be trained in Root Cause Failure Analysis.
    Other members area based on the nature of the incident and could include :
    Engineering and Maintenance Personnel ( Electrical, Mechanical and
    Utility)
    HSE member
    First line supervisor from the affected area
    Involve employee / his representative
    Individuals who have firsthand knowledge of incident
    Other specialists (if required)
    2. Determining Facts
    Types of evidences
    1. Physical
    Weather
    Tools
    Personal Protective Equipment
    Machinery
    Chemicals
    2. Human
    Employees
    Supervision
    Contractors
    Vendors
    Visitors
    3. Operating systems
    Training
    Documentation
    Rules/procedures
    Preventive maintenance
    Management of Change
    Hazards analysis

    Auditing
    Communication
    Culture

    4. Gathering Information (interviewing)


    I.
    Introduction & establish report
    II.
    Judge state of mind
    III.
    Restate Purpose
    IV.
    Listen and demonstrate interest and concern
    V.
    Ask questions-what, when, where, why, who and how
    VI.
    Follow the sequence: General (open), specific, closed
    VII.
    Reflect meaning
    VIII.
    Reflect feeling
    5. Determining the key factors
    I.
    Funnel the information gathered
    II.
    Determine key factors by RCFA techniques
    III.
    RCFA (Root Cause Failure Analysis) identifies the causes of failures (i.e
    key factors) at Physical, Human and System levels.
    RFCA principles
    i.
    First find physical key factors
    ii.
    Next the human Key Factors
    iii.
    Finally the system key factors
    Key Factors
    Circumstances that contributed to or may be reasonably believed to have contributed
    to occurrence on the incident even though clear causal connection may not be found.
    6. Determining systems to be strengthened
    The key factors should identify those systems, including PSM elements that
    need to be strengthened.
    a. Personnel
    Training and performance
    Management of change-personnel
    Incident investigation and reporting
    Auditing
    Emergency planning and response
    Contractor safety and performance
    b. Facilities
    Quality assurance
    Mechanical integrity
    Pre-start up safety review
    Management of subtle changes
    c. Technology
    Process technology
    Process hazard analysis
    Operating procedures and safe practices

    Management of change-Technology
    d. Operational discipline
    Leadership by example
    Sufficient and capable resources
    Employee involvement
    Active lines of communication
    Strong team work
    Common share values
    Up to date documentation
    Practice consistent with procedures
    Absence of shortcuts
    Excellent housekeeping
    Pride in organization
    7. Recommending corrective and preventive actions
    a. Corrective and preventive actions should address all key factors and
    includes in the following
    Description of action
    Person responsible for implementation
    Completion date
    Should be acceptable to the implementing agency and affected
    plants
    Recommendation date shall be decide with meticulous planning
    Should be limited to the affected area
    Learnings from the incidents shall be taken up by the PSM
    chairman
    8. Documentation and Communication
    a. Final incident Investigation report shall be send after 7 days from the
    accident.
    b. The learning from incident should also be part of the document review of
    PSM chairman.
    9. Communication
    Shall be communicate to entire plant.
    10.Follow-up
    Incident recommendation shall be follow up by the Person in-charge appoint
    and periodic report shall be establish to the Senior Site Head.

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