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Preface xxv Acknowledgments xxvii Acronyms and Abbreviations xxix 1 Introduction 1 1.1 Building on the Past 1 1.2 Investigation Basics 2 1.2.1 The First Step 2 1.2.2 The Second Step 4 1.2.3 The Third Step 4 1.2.4 The Fourth step 4 1.2.5 The Fifth Step 5 1.2.6 The Sixth Step 5 1.3 Who Should Read This Book? 5 1.4 The Guideline’s Objectives 6 1.5 The Guideline’s Content and Organization 6 1.6 The Continuing Evolution of Incident Investigation 11 2 Overview of Chemical Process Incident Causation 13 2.1 Stages of a Process-Related Incident 14 2.1.1 Three Phase Model of Process-Related Incidents 14 2.1.2 Event Tree 14 2.1.3 Swiss Cheese Model 16 2.1.4 Importance of Latent Failures 17 2.2 Key Causation Concepts 18 2.2.1 Loss of Containment or Energy 18 2.2.2 Management System Failure 20 2.2.3 Human Factors 21 2.2.4 Multiple Causation 22 2.2.5 Events vs Root Causes 22 2.2.6 Controlling Risk 23 2.3 Summary 24 3 An Overview of Investigation Methodologies 26 3.1 History of Investigation Methodologies and Tools 29 3.1.1 One-on-One Interview 29 3.1.2 Brainstorming 29 3.1.3 What If Analysis 30 3.1.4 5-Whys 30 3.1.5 Process of Elimination 31 3.1.6 Timelines 31 3.1.7 Sequence Diagrams 31 3.1.8 Predefined Trees 33 3.2 Tools for Use in Preparation for Root Cause Analysis 34 3.2.1 Timelines 34 3.2.2 Sequence Diagrams 35 3.2.3 Scientific Method 35 3.2.4 Causal Factor Identification 36 3.3 Structured Root Cause Analysis Methodologies 37 3.3.1 Checklists 37 3.3.2 Predefined Trees 38 3.3.3 Team-Developed Logic Trees 39 3.4 Selecting an Appropriate Methodology 43 3.4.1 Methodologies Used by CCPS Members 46 4 Designing An Incident Investigation Management System 47 4.1 System Considerations 49 4.1.1 An Organization’s Responsibilities 49 4.1.2 Workforce Responsibilities 51 4.1.3 Role of the Management System Developers 53 4.1.4 Integration with Other Functions and Teams 54 4.1.5 Involvement by Regulatory Agencies 55 4.2 Typical Management System Topics 58 4.2.1 Classifying Incidents 58 4.2.2 Specifying and Managing Documentation 59 4.2.3 Legal Considerations 60 4.2.4 Describing Team Organization and Functions 63 4.2.5 Electronic Process Data and Control Systems 64 4.2.6 Defining Training Requirements 65 4.2.7 Emphasizing Root Causes 69 4.2.8 Fostering a Blame-Free Policy 70 4.2.9 Developing Recommendations 70 4.2.10 Recommendation Responsibilities 71 4.2.11 Implementing the Recommendations and Follow-up Activities 72 4.2.12 Providing a Template for Formal Reports 73 4.2.13 Management System Review and Approval 73 4.2.14 Planning for Continuous Improvement 73 4.3 Management System 74 4.3.1 Initial Implementation- Training 75 4.3.2 Developing a Specific Investigation Plan 75 5 Initial Notification, Classification and Investigation of Process Safety Incidents 79 5.1 Internal Reporting 79 5.2 Incident Classification 81 5.2.1 Severity Classification 82 5.2.2 Local Jurisdiction 89 5.2.3 Other Options for Establishing Classification Criteria 89 5.3 Incident Notification 90 5.3.1 Corporate Notification 90 5.3.2 Agency Notification 91 5.3.3 Other Stakeholder Notification 91 5.3.4 Other Notifications 92 5.4 Type of Investigation 92 5.4.1 Which Investigation System to Use? 92 5.4.2 Investigation Approach 93 5.5 Summary 94 6 Building and Leading An Incident Investigation Team 96 6.1 Team Approach 96 6.2 Advantages of the Team Approach 97 6.3 Leading a Process Safety Incident Investigation Team 98 6.4 Potential Team Composition 100 6.5 Building a Team for a Specific Incident 104 6.5.1 Composition and Size of Investigation Team 104 6.6 Team Activities 106 6.7 Summary 108 7 Witness Management 110 7.1 Overview 110 7.1.1 Witness Issues Following a Major Occurrence 111 7.1.2 Investigation Team Priorities for Managing Witnesses 112 7.2 Identifying Witnesses 113 7.3 Witness Interviews 115 7.3.1 Human Factors Related to Interviews 115 7.3.2 Collecting Information from Witnesses 118 7.3.3 Initial Witness Statements 120 7.3.4 Conducting the Interview 121 7.4 Conducting Follow-up Activities 134 7.5 Conducting Follow-up Interviews 135 7.6 Reliability of Witness Statements 135 7.7 Summary 135 8 Evidence Identification, Collection and Management 137 8.1 Overview 137 8.1.1 Developing a Specific Plan 138 8.1.2 Investigation Environment Following a Major Occurrence 139 8.1.3 Priorities for Managing an Incident Investigation Team 141 8.2 Sources of Evidence 144 8.2.1 Types of Sources 144 8.2.2 Physical Evidence and Data 147 8.2.3 Paper Evidence and Data 149 8.2.4 Electronic Evidence and Data 152 8.2.5 Position Evidence and Data 153 8.3 Evidence Gathering 156 8.3.1 Initial Site Visit 157 8.3.2 Identifying and Documenting Evidence 159 8.3.3 Tools and Supplies 162 8.3.4 Photography and Video 164 8.4 Timelines and Sequence Diagrams 168 8.4.1 Constructing a Timeline 168 8.4.2 Constructing a Sequence Diagram 174 8.5 Summary 176 9 Evidence Analysis and Causal Factor Determination 178 9.1 Scientific Method 178 9.2 Confirmation Bias 181 9.3 Evidence Analysis 181 9.3.1 Data Organization - Timelines 182 9.3.2 Use of Protocols 182 9.3.3 Mechanical Failure Analysis 184 9.3.4 Advanced Data Systems 187 9.4 Hypothesis Formulation 187 9.4.1 Fact/Hypothesis Matrix 188 9.5 Hypothesis Testing 190 9.5.1 Engineering Analysis 190 9.5.2 Computational Modeling 191 9.5.3 Reconstruction 191 9.5.4 Test the Items under Simulated Conditions 192 9.5.5 Testing of Human Input/Performance 192 9.6 Select the Final Hypothesis 193 9.6.1 Causal Factor Identification 193 9.6.2 Causal Factor Charting 198 9.6.3 Developing a Causal Factor Chart 200 9.7 Summary 202 10 Determining Root Causes-Structured Approaches 203 10.1 Concept of Root Cause Analysis 203 10.2 Case Histories 206 10.3 Methodologies for Root Cause Analysis 208 10.3.1 5 Whys Technique 208 10.3.2 Structured Root Cause Determination 212 10.4 Root Cause Determination Using Logic Trees 214 10.4.1 Gather Evidence and List Facts 215 10.4.2 Timeline Development 215 10.4.3 Logic Tree Development 215 10.5 Building a Logic Tree 219 10.5.1 Choosing the Top Event 220 10.5.2 Logic Tree Basics 220 10.5.3 Example-Chemical Spray Injury 228 10.5.4 What to Do if the Process Stalls 232 10.5.5 Guidelines for Stopping Tree Development 232 10.6 Example Applications 235 10.6.1 Fire and Explosion Incident-Fault Tree 235 10.6.2 Data-Driven Cause Analysis 239 10.6.3 Logic Tree Summary 241 10.7 Root Cause Determination Using Predefined Trees 242 10.7.1 Scenario Determination 244 10.7.2 Causal Factors 244 10.7.3 Predefined Tree 245 10.8 Using Predefined Trees 246 10.8.1 Predefined Tree Methodology 247 10.8.2 Example-Environmental Incident 248 10.8.2 Quality Assurance 255 10.8.3 Predefined Tree Summary 255 10.9 Checklists 256 10.9.1 Use of Checklists 257 10.9.2 Checklist Summary 258 10.10 Human Factors Applications 258 10.11 Summary 259 11 The Impact of Human Factors 261 11.1 Human Factors Concepts 262 11.2 Incorporating Human Factors into the Incident Investigation Process 267 11.2.1 Human Factors Before and During the Incident 268 11.2.2 Human Factors during the Causal Analysis 269 11.2.3 Human Factors in Developing Recommendations 275 11.2.4 After the Investigation 275 11.3 Other References 276 11.4 Summary 276 12 Developing Effective Recommendations 278 12.1 Key Concepts 278 12.2 Developing Effective Recommendations 280 12.2.1 Team Responsibilities 280 12.2.2 Attributes of Good Recommendations 280 12.3 Types of Recommendations 283 12.3.1 Inherently Safer Design 284 12.3.2 Layers of Protection 285 12.3.3 Commendation/Disciplinary Action 289 12.3.4 The \"Further Action Required\" Recommendation 289 12.4 The Recommendation Process 290 12.4.1 Select Each Cause 290 12.4.2 Perform a Completeness Test 290 12.4.3 Assessing the Effectiveness 291 12.4.4 Prepare to Present Recommendations 291 12.4.5 Review Recommendations with Management 293 12.4.6 Tracking and Closure of Recommendations 293 12.5 Summary 294 13 Preparing the Final Report 295 13.1 Report Scope 295 13.2 Interim Reports 296 13.3 Writing the Report 297 13.4 Sample Report Format 299 13.4.1 Executive Summary 300 13.4.2 Introduction 301 13.4.3 Background 301 13.4.4 Sequence of Events and Description of the Incident 302 13.4.5 Findings 302 13.4.6 Causal Factors 303 13.4.7 Root Causes 304 13.4.8 Recommendations 304 13.4.9 Noncontributory Factors 306 13.4.10 Attachments or Appendices 306 13.5 Report Review and Quality Assurance 307 13.5.1 Reviewing the Report 307 13.5.2 Avoiding Common Mistakes 308 13.6 Investigation Document and Evidence Retention 310 13.7 Summary 311 14 Implementing Recommendations 314 14.1 Activities Related to Recommendation Implementation 315 14.2 Validation of Effectiveness - Case Studies 317 14.2.1 Nuclear Plant Incident 317 14.2.2 Aircraft Incident 318 14.2.3 Petrochemical Plant Incident 318 14.2.4 Challenger Space Shuttle Incident 318 14.2.5 Typical Plant Incidents 319 14.3 Practical Suggestions for Successful Recommendation Implementation 319 14.3.1 Assigning a Responsible Individual 320 14.3.2 Due Dates and Priorities to Implement Recommendations 320 14.3.3 Challenges to Resolving Recommendations 321 14.3.4 Tracking Action Items 323 14.3.5 Follow-up Verification 323 15 Continuous Improvement for the Incident Investigation System 326 15.1 Regulatory Compliance Review 327 15.2 Investigation Quality Assessment 329 15.3 Causal Category Analysis 331 15.4 Review of Near-Miss Events 334 15.5 Recommendations Review 334 15.6 Investigation Follow-up Review 336 15.7 Key Performance Indicators 337 15.8 Summary 338 16 Lessons Learned 340 16.1 Various Sources of Learning from Incidents 341 16.1.1 Internal Sources 341 16.1.2 External Sources 341 16.1.3 Cross-Industry 343 16.2 Identifying Learning Opportunities 343 16.3 Sharing and Institutionalizing Lessons Learned 345 16.4 Senior Management - Incident Sharing and Commitment 347 16.5 Examples of Sharing Lessons Learned 348 16.5.1 Creating a Process Safety Alert from a Case Study 348 16.5.2 Safety Newsletter 350 16.5.3 Videos of Incidents 355 16.5.4 Detailed Incident Reports and Databases 355 16.6 Summary 355 Appendix A. Photography Guidelines for Maximum Results 357 Appendix B. Example Protocol - Checking Position of a Chain Valve 362 Appendix C. Process Safety Events Leveling Criteria 366 Appendix D. Example Case Study 368 Appendix E. Quick Checklist for Investigators 398 Appendix F. Evidence Preservation Checklist - Prior to Arrival of the Investigation Team 404 Appendix G. Guidance On Classifying Potential Severity of a Loss of Primary Containment 406 Glossary 416 References 427 Index 437

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