The Quality of Incident Investigation As a Contribution to Lessons Learned

A number of methodologies designed to investigate process incidents has been developed over the years. This has allowed us to make progress towards the creation of a strict process aimed at gaining a full understanding of the issue and apply it to the organizational resilience of companies engaged in activities relating to Process Safety Management.

However, based on my experience as an investigator of process and aviation incidents, I have found evidence that the process can be further improved. There are still key factors on which improvements should be focused so that organizations can get maximum benefit from hard learning.

This work aims to identify such key factors within the main steps of a typical process with an eye to facilitating a successful investigation process.

The idea is not to describe or specifically provide related information that is already freely available to all of us but to create a reflection environment in which to share those milestones that I consider to be weak links of the different stages of the incident investigation process.

Therefore, this work presents a very interesting challenge to me: trying to attract the attention and encourage the reflection of my colleagues regarding the opportunity for improvement through sound investigation. I am confident this can be achieved because all contributions to improve process incident investigations are highly valuable.