Incident Investigation- Addressing Common Oversights
- Type: Conference Presentation
- Conference Type:
AIChE Spring Meeting and Global Congress on Process Safety
- Presentation Date:
March 14, 2011
- Skill Level:
Principles of incident investigation may be used in daily process troubleshooting and near miss events to identify root cause. Identifying and correcting daily process issues intervenes with the natural escalation to near miss events and incident investigations.
Fundamentals of root cause analysis and incident investigation are discussed, with examples of common oversights in routine daily troubleshooting which may lead to significant incidents or repeat incidents following incomplete incident analyses.
Common oversights of incident investigations in the areas of data gathering, root cause analysis, management, communication and leadership are discussed. Data gathering topics will address collection and preservation of process data, field evidence, process sampling, and interviewing. The employment of basic statistical analysis in root cause analysis will also be examined.