Incident Investigations to Enhance Safety Culture: Refinery Examples

The investigation of small incidents and near misses provides an opportunity for any company to change its safety culture at the grass roots level. This change is due in part to features unique to small incidents and near misses. The purpose of this paper is to outline the benefits of using small incidents and near misses to increase situational awareness and enhance safety culture. The paper will also include a refinery case study demonstrating how these small steps can make a big difference for process safety management.

Scope: The primary purpose of the investigation is to understand the underlying causes of the incident and to prevent it from happening over and over again. Events are not just human error or a result of a physical failure, each event is indicative of a fault in the system. The investigations are an important part of safety culture of company. They increase the awareness as well.

Methods, procedures, Process: The important elements of the event research are the timely research and report creation, the effective documentation of the findings and the sharing of the results. The method of the investigation is selected due to the potential risk of Incident/Near Miss/Safety Observation. In addition to the method, the assignment of team members is made by different levels of the organization depending on the level of potential risk assessment of the event.

Results, Observations, Conclusions: The current and potential evaluation of the impact of the incident to environment, human, reputation and to asset, the establishment of research teams, the appointment of root causes and actions, the automatic creation of the corrective and preventive actions or maintenance requests are made on specific investigation tab of the SAP (SAP EHSM) system. The publication of the accident research report are carried out by SAP EHSM as well.

In most of the applications Tier 1 and 2 Process Safety incidents are deeply investigated but sometimes Tier 3 and 4 incidents left behind in terms of investigation and actions completion speed. However, if you check all the Tier 3 and 4 incidents root causes comprehensively, you may see that they already call for the Tier 1 and 2 incidents. For example, you may find some corrosion reports as Tier 3 since it did not caused any Tier 1 or 2 incident. As you have investigation you will come up with some defaults due to crude oil quality or process technologies applied. Having such an investigation in the phase of Tier 3, you will be able to prevent such a big leakage. Moreover emphasizing on Tier 3 and 4 incidents investigation, gives the message that you are more proactive since you are not only dealing with the incidents only caused harm to people or asset but also potential risks. That will also help management to communicate to employees that, they are one-step ahead the incidents, which will lead employees to think potential risks in the workplace.