Incident Investigation - hdbk11010101

DOE-HDBK-1101-96

2.11 Incident Investigation

29 CFR 1910.119 (m)

(1)

The employer shall investigate each incident which resulted in, or could reasonably have resulted in a

catastrophic release of highly hazardous chemical in the workplace.

(2)

An incident investigation shall be initiated as promptly as possible, but not later than 48 hours following the

incident.

(3)

An incident investigation team shall be established and consist of at least one person knowledgeable in the

process involved, including a contract employee if the incident involved work of the contractor, and other

persons with appropriate knowledge and experience to thoroughly investigate and analyze the incident.

(4)

A report shall be prepared at the conclusion of the investigation which includes at a minimum:

(i)

Date of incident;

(ii)

Date investigation began;

(iii)

A description of the incident;

(iv)

The factors that contributed to the incident; and,

(v)

Any recommendations resulting from the investigation.

(5)

The employer shall establish a system to promptly address and resolve the incident report findings and

recommendations. Resolutions and corrective actions shall be documented.

(6)

The report shall be reviewed with all affected personnel whose job tasks are relevant to the incident findings

including contract employees where applicable.

(7)

Incident investigation reports shall be retained for five years.

Intent

The purpose of incident investigation is to prevent recurrence of incidents having the same nature or

the root cause. Every incident that results in or could reasonably result in a catastrophic chemical

release must be investigated. The PSM Rule defines catastrophic as "a major, uncontrolled

emission, fire, or explosion, involving one or more HHCs, that presents a serious danger to

employees in the workplace" [Q87].

The incident investigation team's recommendations are to be implemented unless it can be

documented that an alternative will address the concerns at least as effectively and efficiently.

Management may reject recommendations that are erroneous, infeasible, or more costly or complex

than a equally protective measure.

Corresponding DOE Programs and Requirements

DOE incident investigations are addressed in DOE O 225.1, ACCIDENT INVESTIGATION and

DOE O 232.1, OCCURRENCE REPORTING. The Accident/Incident Reporting System and the

Occurrence Reporting and Processing System within DOE meet the intent of the incident

investigation element of the PSM Rule. Additional DOE guidance is provided in DOE-STD-1004-

92, Root Cause Analysis Guidance Document; and DOE-STD-1010-92, Guide to Good Practices for

Incorporating Operating Experiences.