(16d) Incident Investigation – Addressing the Worst That Could Have Happened

Incident Investigation techniques typically start with a detailed description of the actual consequence and work backward toward the root causes. A lot of time is spent to qualify and quantify the actual consequence so as to appropriately apply resources to prevent recurrence. A frequent outcome of such an approach is to develop recommendations that mitigate the actual experienced effects on the person, possibly through personal protective equipment or improved operating procedures. This approach has a basic flaw in that it does not address what could have happened, specifically, the worst that could have happened. Thus, the recommendations might not address preventative safeguards or passive design necessary to eliminate the scenario altogether. By formally requiring an assessment of the worst credible consequence of the initiating event, the investigation team will then have a better perspective when considering alternative recommendations to prevent recurrence. Process Safety Management regulations already require the inclusion of actual incidents in subsequent Process Hazard Assessment (PHA). Developing the PHA scenarios concurrent with the incident investigation provides a broader perspective and assists the investigation team in culling the many potential recommendations to those which not only address the actual consequence, but also are effective against the worst credible consequence.