Page 10 - Incident Investigation Key Principles

Key Principles of Process Safety for Incident Investigation
Key Principle #2: Develop and implement a written procedure to investigate process safety
incidents and near misses
Protocols for tasks such as sampling, equipment testing, and any other changes to the
site/evidence.
Obtain agreement to the protocols with relevant parties before collecting evidence.
Evidence custody transfer system, as necessary should evidence testing by an independent third
party be required.
Evidence including operating data from the data historian, security camera video, photographs,
and samples of released materials or debris, drone fly-overs, and other records [2].
Interviewing witnesses and taking their statements.
Identifying and collecting relevant records and documents.
Preserving physical evidence so that it is not compromised.
Timeline development
Methodology for conducting the root cause analysis. [15]
Incident Report including its format, content, review, and approval. The report should reside in an
archive system and have a specified retention period. In some cases, there may be a protocol for
handling confidential and privileged data.
Tracking and managing incident investigation recommendations through to their implementation.
Communication of lessons learned from the incident investigation to the affected personnel including
contractors, including information relevant to other process safety elements such as operating
procedures, training, asset integrity, etc. (See Key Principle #5).
External communications, where appropriate. For example, it may be necessary to communicate
the results of an incident investigation to external regulators based on a valid order issued by a
regulatory agency.
Monitoring and trending of process safety incidents to identify reoccurring types
Communication to the facility’s Process Hazard Analysis program manager so the incident event
scenario can be analyzed during the next revalidation.
Implement and follow the written incident investigation procedure.
Witness interviews should be conducted early, before witnesses forget details or are able to discuss
the event with others.
Incident investigation team members collect evidence, conduct interviews, perform root cause
analysis and write the incident investigation report, as assigned.
Placing and assuring that the equipment is in a safe and stable condition so that investigation
activities in the field can be performed safely
Participate in the incident investigation, as assigned. Most investigations involve interviewing
operations and maintenance personnel who were likely in the field when the incident began and
have first-hand knowledge of some of the contributing factors of the incident.
Report process safety incidents and near misses when they observe events that warrant reporting.
Understand and comply with field evidence preservation requirements when assigned to collect
evidence. Keep investigation records (e.g. witness statements, data sheets) to ensure that data is
secured.
Provide engineering support to the investigation team, such as engineering calculations, simulation, or
modeling.
 Supplemental Reading: [2] [6] [14] [16] [17]

Issued October 2023 Page 7 of 17