Guidelines for Investigating Chemical Process Incidents provides a valuable reference tool for technical and management personnel who lead or are a part of incident investigation teams.
Guidelines for Investigating Chemical Process Incidents focuses on investigating process-related incidents with real or potential catastrophic consequences.
Guidelines for Investigating Chemical Process Incidents presents on-the-job information, techniques, and examples that support successful investigations.
The methodologies, tools, and techniques described in Guidelines for Investigating Chemical Process Incidents can also be applied when investigating other types of events such as reliability, quality, occupational health, and safety incidents.
The accompanying CD-ROM contains the text of the book for portability as well as additional supporting tools for on-site reference and trouble shooting.
Contents:
- Introduction
- Building on the Past
- Who Should Read This Book?
- The Guideline's Objectives
- The Continuing Evolution of Incident Investigation
- Designing an Incident Investigation Management System
- Preplanning Considerations
- Typical Management System Topics
- Implementing the Management System
- An Overview of Incident Causation Theories
- Stages of a Process-Related Incident
- Theories of IncidentCausation
- Investigation's Place in Controlling Risk
- Relationship between Near Misses and Incidents
- An Overview of Investigation Methodologies
- Historical Approach
- Modern Structured Approach
- Methodologies Used by CCPS Members
- Description of Tools
- Selecting an Appropriate Methodology
- Reporting and Investigating Near Misses
- Defining a Near Miss
- Obstacle to Near Miss Reporting and Recommended Solutions
- Legal Aspects
- The Impact of Human Factors
- Defining Human Factors
- Human Factors Concepts
- Incorporating Human Factors into the Incident Investigation Process
- How an Incident Evolves
- Checklists and Flowcharts
- Building and Leading an Incident Investigation Team
- Team Approach
- Advantage of the Team Approach
- Leading a Process Safety Incident Investigation Team
- Potential Team Composition
- Training Potential Team Members and Support Personnel
- Building a Team for a Specific Incident
- Developing a Specific Investigation Plan
- Team Operations
- Setting Criteria for Resuming Normal Operations
- Gathering and Analyzing Evidence
- Sources of Evidence
- Evidence Gathering
- Evidence Analysis
- Determining Root Causes--Structured Approaches
- The Management System's Role
- Structured Root Cause Determination
- Organizing Data with a Timeline
- Organizing Data with Sequence Diagrams
- Root Cause Determination Using Logic Trees--Methods A
- Logic Trees
- Fact/Hypothesis Matrix
- Case Histories and Example Applications
- Root Cause Determination Using Predefined Trees--Method B
- Causal Factor Identification
- Predefined Trees
- Checklists
- Human Factors Applications
- Developing Effective Recommendations
- Major Issues
- Developing Effective Recommendations
- Types of Recommendations
- The Recommendation Process
- Reports and Communications
- Communication Issues and Preparing the Final Report
- Interim Reports
- Writing the Formal Report
- Sample Report Format
- Capturing Lessons Learned
- Tools for Assessing Report Quality
- Legal Issues and Considerations
- Seeking Legal Guidance in Preparing Documentation
- The Importance of Document Management
- Communications and Credibility
- The Challenges and Rewards of Sharing New Knowledge
- Employee Interview and Personal Liability Concerns
- Gathering and Preserving Evidence
- Inspection and Investigation by Regulatory and Other Agencies
- Legal Issues Related to "Postinvestigation"
- Implementing the Team's Recommendation
- Three Major Concepts
- What Happens When There Is Inadequate Follow-up
- Management System Considerations for Follow-up
- Sharing Lessons Learned
- Analyzing Incident Trends
- Continuous Improvement for the Incident Investigation System
- Regulatory Compliance Review
- Investigation Quality Assessment
- Recommendations Review
- Potential Optimization Options
- Lessons Learned
- Learning Lessons from Within Your Organization
- Learning Lessons from Others
- Cross-Industry Lessons
- Trends and Statistics
- Management Application
Index
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