(41l) No Objections! : This Is the Legal Standard for Your Incident Investigations

Many investigators of process safety incidents use propriety root cause analysis tools and/or the 5 Whys method. A few of these techniques may use a relatively rudimentary approach to identifying one or more potential scenarios that may have caused the incident, and then try to eliminate scenarios until only one is left.

However, many of the techniques do not identify and eliminate multiple scenarios before commencing the root cause analysis. Such an approach can lead to ‘confirmation bias’ where the investigator(s) only collect evidence to prove their belief. Indeed, the author has conducted investigations in parallel with government agencies that thought they knew on the first few days of the investigation what caused the incident. Whereas the author conducted a more thorough investigation gathering evidence for multiple potential scenarios that resulted in a very different conclusion and root cause(s).

This paper presents a systematic analytical process that can be applied to incident investigations and provides organization and objective evaluation of hypotheses (i.e., scenarios) to determine the real root causes.