Abstract
A robust Process Safety system is crucial in reducing the risk of a catastrophic event to tolerable levels. Among the twenty PSM elements identified by CCPS, Incident Investigation provides an opportunity for organizations to learn valuable lessons from minor incidents that then help prevent major disasters. Choosing the right methodology for Incident Investigation facilitates the process and must be tailored to the purpose and available resources in order to be effective. Care should be exercised, however, when searching for the relationship between minor incidents and full-blown catastrophes, in order to fully exploit the potential of Incident Investigations and use their results as drivers for Process Safety risk reduction. While most organizations have Incident Investigation processes in place, statistical evidence shows that the lessons learned during investigations seldom take root, resulting in repeated accidents. This is most likely caused by the lack of implementation of the changes (or root actions) required. A particularly important role in incident investigation is played by near-misses, as they represent valuable sources of information and provide helpful opportunities for learning. A near-miss is much less grievous than a full-blown disaster: evidence is usually easier to find; people are more willing to be frank; and greater frequency means learning can happen more often and more consistently. This article discusses how thorough investigations and appropriate follow-up combined with increased attention on near-miss events can translate into safer operations and fewer tragedies.
