title: Best practices in incident investigation in the chemical process industries with examples from the industry sector and specifically from Nova Chemicals.
abstract: This paper will summarize best practices in incident investigation in the chemical process industries and will provide examples from both the industry sector and specifically from NOVA Chemicals. As a sponsor of the Center for Chemical Process Safety (CCPS), an industry technology alliance of the American Institute of Chemical Engineers, NOVA Chemicals participates in a number of working groups to help develop best practices and tools for the chemical process and associated industries in order to advance chemical process safety. A recent project was to develop an update on guidelines for investigating chemical process incidents. A successful incident investigation management system must ensure that all incidents and near misses are reported, that root causes are identified, that recommendations from incident investigations identify appropriate preventive measures, and that these recommendations are resolved in a timely manner. The key elements of an effective management system for incident investigation will be described. Accepted definitions of such terms as near miss, incident, and root cause will be reviewed. An explanation of the types of incident classification systems in use, along with expected levels of follow-up, will be provided. There are several incident investigation methodologies in use today by members of the CCPS; most of these methodologies incorporate the use of several tools. These tools include: timelines, sequence diagrams, causal factor identification, brainstorming, checklists, pre-defined trees, and team-defined logic trees. Developing appropriate recommendations and then ensuring their resolution is the key to prevention of similar events from recurring, along with the sharing of lessons learned from incidents. There are several sources of information on previous incidents and lessons learned available to companies. In addition, many companies in the chemical process industries use their own internal databases to track recommendations from incidents and to share learnings internally.
authors.affiliation: NOVA Chemicals, Inc., Moon Twp., PA 15108, USA. morrisl@novachem.com
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Morrison
mesh_terms: D000062:Accidents, Occupational / Q000145:classification / Q000517:prevention & control*; D019985:Benchmarking / Q000379:methods; D002617:Chemical Industry / Q000379:methods / Q000458:organization & administration*; D003625:Data Collection / Q000379:methods; D033161:Government Regulation; D006801:Humans; D015279:Organizational Culture; D017751:Safety Management / Q000379:methods*; D014481:United States