{"id":18723,"date":"2020-04-14T12:19:00","date_gmt":"2020-04-14T10:19:00","guid":{"rendered":"https:\/\/pre.grupo-tema.com\/sin-categorizar\/incident-investigation-practical-recommendations\/"},"modified":"2025-11-25T09:51:27","modified_gmt":"2025-11-25T08:51:27","slug":"incident-investigation-practical-recommendations","status":"publish","type":"post","link":"https:\/\/www.grupo-tema.com\/en\/blog-en\/incident-investigation-practical-recommendations\/","title":{"rendered":"Incident Investigation Practical Recommendations"},"content":{"rendered":"\n
S. Palumbo, A. Tom\u00e1s<\/h6>\n\n

Accident vs. Incident<\/h3>\n\n

Incident Investigation is a powerful method of identifying the causes, as well as the sequence of events leading to an unsafe condition. If the unsafe condition has developed into a scenario with an impact on people, the environment, equipment or reputation of a company, it is referred to as an “accident”. If this scenario has only generated the potential to cause damage, it is referred to as an “incident”. <\/p>\n\n

In an incident or near-miss (near-miss<\/em>) there may be hidden consequences greater than those manifested, which is why it is preferred to speak of incident investigation rather than accident investigation.<\/p>\n\n

\"\"<\/figure>\n\n

Fig.1: “Iceberg Theory”, Bird and Germain, 1985.<\/p>\n\n

It is known that behind every fatality there are ten severe incidents, thirty minor incidents and six hundred “near misses”. At the bottom of the pyramid are the so-called unsafe acts<\/em> or unsafe conditions that are, in fact, the origin of the incidental scenarios, often in the form of hidden causes. <\/p>\n\n

Preventing and mitigating these minor cases is the best way to avoid more severe events.<\/p>\n\n

<\/h3>\n\n

2. Pre-organization of the incident investigation<\/h3>\n\n

An efficient incident investigation occurs when the evidence, testimonies and data collected accurately describe what happened. To reduce the risk of losing information, it is necessary to start this process as early as possible. <\/p>\n\n

In a real accident situation, immediate action is taken to restore the safety conditions of the personnel and the facility. In this phase there are many professional figures involved (emergency manager, rescue team, process supervisors, first aid personnel, etc.) and the incident investigation is not usually activated immediately. <\/p>\n\n

\"\"<\/figure>\n\n

Fig.2: “Explosion and fire shut Irving Oil refinery in Canada” by tonynetone is licensed under CC BY 2.0<\/p>\n\n

The only way to achieve both objectives, immediate response to restore the situation and investigation of the accident, is to have a structure and procedures defined in advance. The recipe for positive success includes prior definition of roles, availability of resources and detailed steps to be followed by all involved in the investigation. <\/p>\n\n

These accident response measures are fundamental points in a Process Safety Management System (PSMS<\/em>) in which guidelines are established to ensure the identification of industrial risks, the management of these risks and continuous improvement through learning based on what has occurred.<\/p>\n\n

3. When to conduct an incident investigation<\/h3>\n\n

In the event of a process incident, the first step is to evaluate whether or not an investigation is necessary. Historically, cases involving material damage (to people or facilities) were investigated, basing the evaluation only on the severity of the event. Currently, the criteria justifying an investigation are broader and include: <\/p>\n\n

    \n
  • Near-misses<\/em>.<\/li>\n\n\n\n
  • Potential risk situations.<\/li>\n\n\n\n
  • Legal requirements.<\/li>\n\n\n\n
  • Similar incidents occurred at other facilities.<\/li>\n<\/ul>\n\n
    \"\"<\/figure>\n\n

    Fig 3: Example of an Incident Report<\/p>\n\n

    It is recommended that each company establishes incident categories in advance. Incident event levels, identified by the term Tier<\/em> (i.e. Tier 1, Tier 2, etc.), are numerically ordered by severity and describe the relevance of the occurrence (TIER 1 = A loss of containment of a mass of toxic substances greater than xx grams). The TIER concept was first introduced in 2011 in IOGP Report 456, Process Safety – Recommended Practice of KPI<\/em>, based on previous studies conducted by CCPS(Center for Chemical and Process Safety<\/em>) and API(American Petroleum Institute<\/em>). <\/p>\n\n

    It is important to emphasize that, depending on the category of the incident, a more or less detailed investigation method will be required, and the resources involved must be adapted to the complexity of the scenarios and the final objectives pursued.<\/p>\n\n

    To ensure the success of the investigation, it is important not to lose sight of the fact that the sooner potential hazards are identified, the less likely it is that the company will be exposed to risks. The achievement of a shorter analysis time cannot be subordinated to the quality of the results. <\/p>\n\n

    4. Questions to be answered in an investigation<\/h3>\n\n

    There are elements in the incident investigation that cannot be omitted; they are the ones that make it possible to answer the five fundamental questions(5W<\/em>):<\/p>\n\n

    \"\"<\/figure>\n\n
      \n
    1. When?<\/em> – When?<\/li>\n\n\n\n
    2. Where?<\/em> – Where?<\/li>\n\n\n\n
    3. Who? – Who? <\/li>\n\n\n\n
    4. What? <\/li>\n\n\n\n
    5. Why? <\/li>\n<\/ol>\n\n

      These questions should be used as a guideline for the research, while the answers should be given once all the evidence has been collected, so as not to deviate the analysis by leading to incorrect or partial results.<\/p>\n\n

      The answers to questions 1 to 4 define the incident’s Sequence of Events, while the answer to question 5 is the actual investigation, using different methods, among which Root Cause Analysis (RCA<\/em>) stands out as one of the most complete.<\/p>\n\n

      To simplify the realization of both the Sequence of Events and the Root Cause Analysis, there are digital solutions that allow the construction of the database, the logical organization of the elements of the investigation and the optimized visualization of the results, such as Incident XP<\/em> from CGE Risk Management Solutions<\/em>.<\/p>\n\n

      5. Resources required<\/h3>\n\n

      According to PSMS guidelines, the company has to instruct and train its employees and keep them informed of the results of incident investigations.<\/p>\n\n

      Under the PSMS, the Process Safety Committee, an independent team that must include not only management but also a technical team, is responsible for authorizing the investigation of the incident and appointing a leader for the investigation who will also manage the resulting recommendations. This leader will be responsible for selecting the members of the investigation team. <\/p>\n\n

      Members of the research team may include:<\/p>\n\n

        \n
      • Operators and Operation Managers.<\/li>\n\n\n\n
      • Security managers.<\/li>\n\n\n\n
      • External experts.<\/li>\n\n\n\n
      • Local authorities (if and when required by law).<\/li>\n\n\n\n
      • Personnel from areas that have been affected by the event (i.e. electrical, controls, chemical, instrumentation specialists, etc.).<\/li>\n\n\n\n
      • Research leader (it is recommended that he\/she be an expert in the selected research technique).<\/li>\n<\/ul>\n\n

        The incident investigation team aims to gather evidence and testimonies to identify the causes of the event.<\/p>\n\n

        Examples of evidence are:<\/p>\n\n

          \n
        • Photographs.<\/li>\n\n\n\n
        • Documentation.<\/li>\n\n\n\n
        • Operating procedures.<\/li>\n\n\n\n
        • Operating journals.<\/li>\n\n\n\n
        • Computer data from the monitoring and control system.<\/li>\n<\/ul>\n\n

          6. Errors in data collection<\/h3>\n\n

          To preserve the evidence of the incident it is necessary to confine the area as soon as possible and restrict access to it. The preservation of the area is, in case of an accident involving damage to personnel or facilities, a legal requirement. A modification of the incident area may lead to erroneous conclusions or to the loss of fundamental evidence in the search for the causes of the incident. Another source of errors comes from the testimonies of the personnel present at the time of the incident, in case they are not properly interviewed. In this regard, it is important to bear in mind that they are one of the most vulnerable sources, not only to the way of investigating, but also to the passage of time. There is a risk that they may influence each other or feel intimidated, so it is necessary to explain thoroughly that the purpose of the questions is to understand the causes of the incident, to avoid its occurrence in the future, and not to look for those responsible who may be subject to possible sanctions. Interviews should be conducted by personnel who empathize with the interviewees and take into consideration their emotional states. It can be very useful to repeat the sequence of events in the area of the incident. <\/p>\n\n

          7. Data analysis<\/h3>\n\n

          Once the preliminary research data are available, it is necessary to organize them for analysis. It is not uncommon that, once analyzed, findings are identified that require further research to complete the information picture. <\/p>\n\n

          The first step is to identify the sequence of events, constructing a timeline where the evidence found is put in chronological order; it is recommended to use both classic methods, such as the use of Post-It notes, and the most modern digital systems to be able to insert at each point of the line evidence collected later.<\/p>\n\n

          Methodologies for defining the sequence of events are:<\/p>\n\n

            \n
          • STEP – Sequential Timed Events Plotting.<\/li>\n\n\n\n
          • ECFC – Events and Causal Factors Charting.<\/li>\n\n\n\n
          • MTO Analysis – Man-Technology-Organization Analysis.<\/li>\n<\/ul>\n\n
            \"\"<\/figure>\n\n

            Fig 4: Example of STEP methodology application.<\/p>\n\n

            After the sequence of events, the causes are evaluated. The most commonly used methods in this phase are: <\/p>\n\n

              \n
            • RCA – Root Cause Analysis:\n
                \n
              • 5-Whys analysis.<\/li>\n\n\n\n
              • BowTie analysis.<\/li>\n\n\n\n
              • Fishbone diagrams (Ishikawa diagrams).<\/li>\n<\/ul>\n<\/li>\n\n\n\n
              • Fault Tree Analysis.<\/li>\n\n\n\n
              • Event Tree Analysis (Event Tree Analysis).<\/li>\n\n\n\n
              • SCAT – Systemic Causal Analysis Technique.<\/li>\n\n\n\n
              • Barrier Failure Analysis.<\/li>\n\n\n\n
              • Tripod Beta by Shell.<\/li>\n\n\n\n
              • Change Analysis.<\/li>\n\n\n\n
              • AEB – Accident Analysis and Barrier Function.<\/li>\n\n\n\n
              • MORT – Management Oversight and Risk Tree.<\/li>\n\n\n\n
              • ECFA – Events and Causal Factors Analysis.<\/li>\n\n\n\n
              • Acci-Map.<\/li>\n<\/ul>\n\n

                Since research is an iterative process where data are frequently reviewed, details are added and the structure is reorganized, it is advisable to use commercial software that simplifies this work and facilitates the understanding of the causal tree developed.<\/p>\n\n

                \"\"<\/figure>\n\n

                Fig 5: Example of Barrier Failure Analysis (Incident XP, GCE).<\/p>\n\n

                \"\"<\/figure>\n\n

                Fig 6: Example Tripod Beta (Incident XP, GCE)<\/p>\n\n

                8. Errors in data analysis<\/h3>\n\n

                Data analysis can be successful only if the method selected is commensurate with the complexity of the situation and the availability of the evidence collected. There is a risk that a method that is too complex may lead to losing sight of the central point of the analysis. Similarly, a method that is too simple may fail to consider key factors in the causes of events. <\/p>\n\n

                The results of the analysis can lead to three types of identified causes:<\/p>\n\n

                  \n
                1. Objective evidence.<\/li>\n\n\n\n
                2. Speculation.<\/li>\n\n\n\n
                3. Assumptions.<\/li>\n<\/ol>\n\n

                  The difference between them is that in the first case there is direct evidence of what is sustained, in the second case there are indications that lead to consider it probable that a certain event has occurred, while in the last case there is no confirmation of the facts and hypotheses are established. Obviously, the more objective evidence is brought to the study, the closer we will be to reality. In all cases, it is good practice to specify for each cause to which category it belongs. <\/p>\n\n

                  9. Research Report<\/h3>\n\n

                  The purpose of the Incident Investigation Report is to describe what happened, both the sequence of events and the causes, and it must define the barriers to be implemented to avoid the main event and the measures to be taken to ensure its effectiveness.<\/p>\n\n

                  The information that needs to be included in an incident investigation report is:<\/p>\n\n

                    \n
                  • Title of the incident.<\/li>\n\n\n\n
                  • Incident identification code.<\/li>\n\n\n\n
                  • Location.<\/li>\n\n\n\n
                  • Date\/Time of Incident.<\/li>\n\n\n\n
                  • Date\/Time when the incident is discovered.<\/li>\n\n\n\n
                  • Date of initiation of the investigation.<\/li>\n\n\n\n
                  • Research team.<\/li>\n\n\n\n
                  • Type of incident (Health\/Environment\/Property)<\/li>\n\n\n\n
                  • Incident Description.<\/li>\n\n\n\n
                  • Timeline of events.<\/li>\n\n\n\n
                  • Collected information and testimonials.<\/li>\n\n\n\n
                  • Root Cause Analysis.<\/li>\n\n\n\n
                  • Preventive and corrective actions.<\/li>\n<\/ul>\n\n

                    The recommendations issued from the report must meet the “SMART” criteria:<\/p>\n\n

                      \n
                    • Specific<\/strong>– Specific<\/strong>: that responds to the function for which it has been proposed.<\/li>\n\n\n\n
                    • Measurable<\/strong>– Measurable<\/strong>: that its effectiveness can be measured and evaluated.<\/li>\n\n\n\n
                    • Achievable<\/strong>– Achievable: that is possible to achieve with the available resources.<\/li>\n\n\n\n
                    • Relevant<\/strong>– Important<\/strong>: having a significant priority in relation to other options.<\/li>\n\n\n\n
                    • Time<\/strong>bound – Limited in time<\/strong>: that can be carried out in a defined time.<\/li>\n<\/ul>\n\n

                      10. Errors in the report<\/h3>\n\n

                      The Incident Investigation Report is a formal document intended for a multidisciplinary audience, not always of a technical nature.<\/p>\n\n

                      It is a common mistake to make excessively complex incident reports. It is essential that the clarity of the presentation is ensured by an understandable wording, as well as by providing, as far as possible, diagrams and graphical representations. Another common mistake in the report is to indicate recommendations that have not been agreed with the stakeholders, thus not respecting the SMART criteria indicated above. <\/p>\n\n

                      On the other hand, it is not uncommon to find actions that are too generic, that do not have deadlines<\/em> or where it is not clear who is responsible for their implementation.<\/p>\n\n

                      All these gray areas generate conflicts, distrust and, as a final effect, delay in the implementation of measures to protect the facility and prevent the occurrence of the same incident.<\/p>\n\n

                      11. Conclusions<\/h3>\n\n

                      Incident investigation is the method of analysis that allows us to know the causes that give rise to an undesired event. To guarantee the success of this task, it is essential to plan the investigation process in advance, as well as to assign roles to those responsible for its development. <\/p>\n\n

                      It is equally important to carry out the research immediately and to select interview personnel who empathize with the testimonies and take into consideration their emotional states, in order to ensure the reliable collection of information.<\/p>\n\n

                      During the investigation, information may arise that alters the postulated sequence of events. Therefore, to manage all the information derived from this process, it is advisable to use specific software developed for this purpose, which incorporates the causes, the existing barriers and the sequence of failures.<\/p>\n\n

                      A relevant point that should not be neglected at the end of an investigation is the communication of the results to the personnel of the facility and at all levels. The knowledge of the causes, and in particular of the hidden causes, generates a positive circle of prevention scenarios that transcends in the safety of the facilities. <\/p>\n","protected":false},"excerpt":{"rendered":"

                      S. Palumbo, A. Tom\u00e1s Accident vs. Incident Incident Investigation is a powerful method of identifying the causes, as well as the sequence of events leading to an unsafe condition. If the unsafe condition has developed into a scenario with an impact on people, the environment, equipment or reputation of a company, it is referred to […]<\/p>\n","protected":false},"author":1,"featured_media":18258,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[394],"tags":[],"class_list":["post-18723","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-blog-en"],"_links":{"self":[{"href":"https:\/\/www.grupo-tema.com\/en\/wp-json\/wp\/v2\/posts\/18723","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.grupo-tema.com\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.grupo-tema.com\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.grupo-tema.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.grupo-tema.com\/en\/wp-json\/wp\/v2\/comments?post=18723"}],"version-history":[{"count":1,"href":"https:\/\/www.grupo-tema.com\/en\/wp-json\/wp\/v2\/posts\/18723\/revisions"}],"predecessor-version":[{"id":18725,"href":"https:\/\/www.grupo-tema.com\/en\/wp-json\/wp\/v2\/posts\/18723\/revisions\/18725"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.grupo-tema.com\/en\/wp-json\/wp\/v2\/media\/18258"}],"wp:attachment":[{"href":"https:\/\/www.grupo-tema.com\/en\/wp-json\/wp\/v2\/media?parent=18723"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.grupo-tema.com\/en\/wp-json\/wp\/v2\/categories?post=18723"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.grupo-tema.com\/en\/wp-json\/wp\/v2\/tags?post=18723"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}