Sherlock Holmes is renowned for his powers of observation and his ability to develop significant insights into the causes and perpetrators of difficult criminal cases that others miss — often figuring out what happened when no one else can. In process safety, we similarly need to determine what happened when process incidents occur so we can determine what went wrong and how future incidents can be prevented.
Incident investigations are a mechanism for learning from actual operating experience, providing continuing feedback on process safety program effectiveness, and identifying where improvements are needed. Keeping track of the types, severities, and causes of incidents can help gauge how well process safety programs are working, how they can be improved, and what lessons were learned from the incidents.
This article describes the basics of conducting an incident investigation, and explains how why tree and bow tie diagrams can improve your facility's incident investigations.