METHODOLOGY FOR INCIDENT INVESTIGATION 

METHODOLOGY FOR INCIDENT INVESTIGATION
06/09/2024	1	Final	AM	SS	YSG
Date	Rev	Remarks / Revision Summary	Prepared	Checked	Approved
			HSE RMSPL
REVISION RECORDS

 

DISCLAIMER

HSE Risk Management Services Private Limited accepts no liability or responsibility whatsoever for it in respect of any use of or reliance upon this Methodology by any third party.

Copying this Methodology without the permission of HSE Risk Management Services Private Limited is not permitted.

INTRODUCTION

Incident investigation is a critical process aimed at understanding the causes of incidents to prevent future occurrences. The primary goal is to analyze what happened, why it happened, and how to prevent it from happening again. This process helps organizations enhance safety, improve processes, and ensure compliance with regulations. Effective incident investigation goes beyond immediate responses to address underlying issues and implement lasting improvements.

OBJECTIVE OF INCIDENT INVESTIGATION

• Identify Root Causes: To understand the fundamental reasons behind the incident.
• Prevent Recurrence: To implement corrective actions that prevent similar incidents in the future.
• Enhance Safety: To improve overall safety by addressing potential hazards and risks.
• Improve Processes: To refine procedures and systems based on investigation findings.
• Ensure Compliance: To meet regulatory requirements and industry standards.
• Support Learning: To foster a culture of continuous learning and improvement within the organization.

INCIDENT INVESTIGATION METHODOLOGY

• Data Collection: Gathering relevant information and evidence related to the problem or incident, which serves as the basis for analysis such as photographs, videos, witness statements, and documents. Record initial observations and conditions.
• Data Review: Reviewing evidence, reconstruct the incident timeline, and identify key events and actions leading up to the incident.
• Preparation for the site visit:
• Material:
• Technical Information Regarding the Incident: Collect and review all pertinent technical details related to the incident.
• Evidence Collection List: Identify and organize all evidence that needs to be gathered on-site.
• Previous Inspection Reports and Certificates: Gather any previous inspection reports, test results, or certificates related to the equipment or site.
• Asset Management Guidelines: Familiarize yourself with the asset management guidelines.
• Incident History: Examine the history of previous incidents related to equipment or other factors.
• Machine:
• HAZOP, QRA, Risk Assessment, and Critical Equipment: Assess the HAZOP (Hazard and Operability Study), Quantitative Risk Assessment (QRA), risk assessments, and critical equipment involved.
• Available Barriers and Their Status: Check the status of any existing barriers and their effectiveness.

Man:

• Interview List: Prepare a list of individuals to be interviewed or questioned during the site visit.
• Competency, PSI, Training, Audit, and Monitoring: Review information on competency, Pre-Startup Safety Reviews (PSI), training records, audits, and monitoring practices.

Method:

• Relevant SOPs and Guidelines: Ensure you have access to or identify any required Standard Operating Procedures and guidelines.
• Applicable Rules, Acts, and Standards: Review the rules, acts, and standards relevant to the incident.
• Potential Causes: Develop initial hypotheses about the probable causes of the incident based on the information at hand.

Measurement:

• Evidence Collection List: Identify and organize all evidence that needs to be gathered on-site (includes measurement of evidence).
• Site visit:
• Collect and Analyze Supporting Documents: Gather and review technical information and documents related to the incident at the site.
• Interrogate Concerned Persons: Interview individuals who have relevant knowledge or involvement with the incident.
• Collect Evidence: Obtain physical and digital evidence from the incident site.
• If, after the site visit, reviewing all the evidence, and interrogating all relevant individuals, we are unable to determine the cause and reason behind the incident, we will proceed with a root cause analysis.
• Draft Report Preparation: Once the analysis is complete, a draft report is prepared to document the findings of the incident investigation process. The report typically includes an overview of the problem, a summary of the data collected and reviewed, the analysis, findings regarding causal factors and root causes, and initial recommendations for corrective actions.
• Comments Incorporation along with CRS: The draft report is then circulated for review and feedback. Comments and suggestions are incorporated into the report, and a Comment Resolution Sheet (CRS) is shared.
• Final Report: Based on the feedback received and any revisions made, a final report is prepared.

Figure 1 Steps for Incident Investigation

1. 4. PROJECT DELIVERABLES

Table 1. Incident Investigation

Sr. No.	Document Deliverable
1.	Executive Summary
2.	Incident Investigation Methodology
3.	Incident Investigation Site Visit – observation  & findings
4.	Root cause analysis if required
5.	Conclusion
6.	Comments Resolving sheets
7.	Reference
8.	List of tables
9.	List of appendixes

1.