Investigate Cause of An Incident to Prevent Recurrence

Incident investigation is a formal process for investigating incidents, reporting and tracking. This process also includes the resolution and recommendations generated by the investigations. The results/findings of the investigation process should be documented in a standard incident report form.

Incident investigation is a way of learning from incidents that occur over the life of a facility and communicating the lessons learned to the workers. By identifying and addressing the root causes of equipment failures and personnel errors, leveraged solutions can be developed that will reduce the frequency of incidents and/or reduce the consequences of the incidents. Output of the incident investigation should be used to improve the safety performance of the plant.

Incident investigations are conducted whenever and wherever incidents occur. The investigation team will collect information at the incident scene and conduct interviews with victim and witness. Reporting to the management is important as they are the policy makers. Investigation procedure is documented as guidelines for investigator(s) to perform investigation.

The incident investigation team would perform the following general steps:

  • Scene management and assessment (secure the scene, make sure it is safe for investigators to do their job).
  • Witness management (interview victim and witnesses).
  • Investigate the incident, collect data.
  • Analyze the data, identify the root causes.
  • Report the findings and recommendations.

Personnel who have formal training in incident investigation or root cause analysis typically perform investigations and lead investigation teams. A multidisciplinary team is appropriate for incident investigations with greater consequences and risks. At some facilities, the incident investigation is used to assign blame to personnel involved in an incident. A more effective approach is to develop recommendations that address the systemic causes of the incidents.