(66b) Using Feedback to Improve the Quality of Your Incident Investigations

Trevor Kletz once explained that it was relatively easy for him to create his monthly Lessons Learned Bulletins, because ICI had a requirement that investigation reports be complete and well-written. As a result, he could easily understand what had happened and could explain it in simple language. Several years ago, Honeywell’s Performance Materials & Technologies division embarked on a specific effort to improve the quality of our incident investigations, and of the learnings flowing from them. The purpose was – and remains – to reduce the number of process safety events by learning from smaller events and applying those lessons broadly. One important aspect of this broader program was to provide a “critique” of several important aspects of the investigations of our process safety incidents. The aspects we chose to focus on first included things like “was a proper team formed to examine the aspects of the incident” and “did the team collect the right information, including creating a timeline of the events leading up to the incident”, “did they identify the cause(s)” plus several others. The degree to which the investigation complies with each criterion is evaluated by a team of seasoned professionals, and an Investigation Maturity Index is fed back to the investigators as well as reported upwards to leadership.

In this paper we will explain the criteria we use, the work process of the evaluation team as well as some of the insights and improvements we have made as a result.