Critical Success Factors for Effective

Incident Investigation

Neil Franklin

AECI: Group SHE Manager

Process Safety Webinar Series - Part 4

30 September 2021

2

Most common causes of process safety incidents

The Italian Association

of Chemical Engineering

Online at www.aidic.it/cet

In this paper, the contributions of PSM

element to chemical process accident

are studied using major process failures

in the chemical process industry (CPI).

Around 770 major accident cases were

collected and analysed

https://www.aidic.it/cet/17/56/166.pdf

2017

0

3

2

6

11

12

19

17

9

9

6

3

2

0

0 2 4 6 8 10 12 14 16 18 20

Compliance Audits

Emergency PlannIng and Response

Contractors

Hot Work Permit

Training

Employee Participation

Process Hazard Analysis

Operatng Procedures

Mechanical Integrity

MOC

Process Safety Information

Incident investigation

PSSR

Trade Secret

Percentage contribution of PSM Element to 770 incidents

Percentage

3

On this day in history

https://processsafetyintegrity.com/incidents/

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Recent events in South Africa

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Critical Success Factors

ROLES &

RESPONSIBILITY

2

FIELD

INVESTIGATION

3

ROOT CAUSE

ANALYSIS

4

LEARNING

5

Appointing the

investigation team

Create a detailed

understand of exactly

what happened.

Create a detailed

understand of exactly

why it happened

Ensure the incident

does not repeat

HAVE A DEFINED

PROCESS

1

Define the

expectations and

outcomes

6

Have a defined process, and stick to it.

7

Field Investigation

◇Secure the scene and evidence quickly

◇Make a checklist – assign responsibilities

◇Evidence collection must start immediately BUT

take as long as needed and with repeated views of

the evidence and scene

◇ Look for multiple data sources to confirm a fact in

the sequence of events

◇Appoint one person to collate the evidence

◇Time stamps on photos are critical

Typical evidence collected:

• Interviews

• Photographs, CCTV and any other video

footage

• Process trends

• P&ID’s, MFD’s, Plot plans

• PHA’s, MOC, PSI, Maintenance reports

• Alarm printouts / Logics (Scada/DCS)

• Logbooks, Permit to work, risk assessments

etc.

• Procedures and work instructions

Organisational information

• Structure / vacancies• Training• Overtime

8

Interviews

9

Have agreed techniques – fit for purpose

Incident

description

Direct

cause

Direct

cause

Underlying

cause

Underlying

causeUnderlying

cause

Underlying

cause

Root causeRoot causeRoot causeRoot cause

Why 1

Why 2A

Why 2B

Why 3A

Why 3B

Why 3C

Why 4A

Why 4B

Why 4C

Why 4D

Why 4E

Why 4F

None of these will:

1. Do the field investigation for you;

2. Interview witnesses for you;

3. Select root causes for you;

4. Develop corrective action for you.

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Identifying the root causes and systemic weaknesses

Preventing repeats can only be done by correcting the absent or failed controls.

Review:

• PHA / Risk Assessments• Maintenance philosophy and

compliance• Procedural accuracy and compliance• Status of drawings and other PSI• Emergency Plan• Audit results

Organisational Factors

• Competency of staff• Correct leading and lagging indicators

being used• Correct performance management• Corrective action effectiveness• Institutionalising of learning

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Institutionalizing the learning

• Produce a decent report

• Share the learning in the right levels of detail to the right audience

• Hold people accountable to complete actions as part of the learning process

• Audit the implementation of actions

• Don’t rely on memories – engineer the improvements / changes

• Fix the System errors (PHA, Procedures, Training etc.) and audit this

• Conduct incident recall

Thank youAny questions?

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