How can you develop a process safety incident investigation report that avoids common mistakes?

1 Define the scope

The first step in developing a process safety incident investigation report is to define the scope of the investigation. This means setting the boundaries, objectives, and criteria for the investigation, as well as the roles and responsibilities of the team members. The scope should be based on the severity, complexity, and potential impact of the incident, and should be agreed upon by all the stakeholders. A well-defined scope will help you focus on the relevant facts and issues, avoid distractions and biases, and ensure consistency and completeness.

2 Collect and analyze the data

The next step is to collect and analyze the data related to the incident. This includes gathering physical evidence, documents, records, interviews, observations, and measurements. The data should be verified, validated, and organized in a logical and chronological order. The analysis should aim to identify the sequence of events, the deviations from normal conditions, the contributing factors, and the root causes of the incident. The analysis should also consider the human, technical, organizational, and external aspects of the incident, and use appropriate tools and methods, such as causal analysis, fault tree analysis, or event tree analysis.

3 Generate and evaluate the findings

The third step is to generate and evaluate the findings of the investigation. The findings are the conclusions and interpretations derived from the data and analysis. They should be clear, concise, and factual, and should answer the questions of what, how, and why the incident occurred. The findings should also be evaluated against the scope, objectives, and criteria of the investigation, and should be supported by sufficient and credible evidence. The evaluation should also identify any gaps, uncertainties, or conflicts in the findings, and propose ways to address them.

4 Develop and prioritize the recommendations

The fourth step is to develop and prioritize the recommendations of the investigation. The recommendations are the actions and improvements suggested to prevent or mitigate similar incidents in the future. They should be specific, realistic, and measurable, and should address the root causes and contributing factors of the incident. The recommendations should also be prioritized based on their urgency, feasibility, and effectiveness, and should be aligned with the plant's policies, standards, and goals. The prioritization should also consider the costs, benefits, and risks of implementing the recommendations.

5 Write and review the report

The fifth step is to write and review the report of the investigation. The report is the document that summarizes and communicates the results of the investigation to the relevant audiences. The report should be structured, coherent, and consistent, and should include the following sections: executive summary, introduction, background, methodology, data collection, data analysis, findings, recommendations, references, and appendices. The report should also be clear, concise, and accurate, and should use appropriate language, tone, and format. The report should also be reviewed by the team members, the stakeholders, and the experts, and should be revised and refined based on their feedback and comments.

6 Share and learn from the report

The sixth and final step is to share and learn from the report of the investigation. The report should be disseminated and presented to the relevant audiences, such as the plant management, the employees, the regulators, and the industry peers. The report should also be discussed and debated, and the feedback and suggestions should be collected and considered. The report should also be used as a learning opportunity, and the lessons learned should be incorporated into the plant's training, procedures, and culture. The report should also be followed up and monitored, and the implementation and effectiveness of the recommendations should be evaluated and reported.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?