Should “All” Small Incidents be Investigated?

Many recent incidents such as DuPont Corporation Toxic Chemical Releases in Belle, West Virginia and Exxon Mobil’s Refinery explosion in Torrance, California, bring our attention to the importance of investigating near-miss incidents. Small (Near-miss) incident investigations offer opportunities for improvement that are often overlooked for a number of reasons, including:

• equating 'small' with unimportant or uninteresting
• considering 'small' incident investigations as not delivering value (often with reason)
• lack of corporate commitment to properly investigating and data-managing small incidents data
• common superficial trending of small incidents data without any form of data quality control
• an insistence on blaming things and procedures in investigations instead of identifying human actions as causes
• no commitment to actual investigations of small incidents, coupled with poor methodology and a lack of quality control

In this paper, the authors will elaborate on the above mentioned reasons supported with examples and identify the lessons learned. In an attempt to promote a dialogue for future discussion, an approach of risk ranking the incidents will be proposed. This approach will assist in deciding which incidents need to be investigated for root causes to prevent impending high risk incidents.