Incident Investigation
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OSHA’s Process Safety Management (PSM) Mandate requires that facilities investigate each incident “which resulted in, or could have reasonably resulted in a catastrophic release of highly hazardous chemical in the workplace.” The mandate language provides guidance on the required elements for the investigation, but is limited in terms of guidance for how to conduct the investigation.
One of the leading tools in incident investigation, Root Cause Analysis (RCA), provides structure to ensure that the investigation team works to identify the true cause of the incident so that effective corrective actions can be taken. Investigation teams need to be willing to look beyond the seemingly obvious immediate causes of an incident to ensure they uncover the true root cause of each incident. The purpose of the investigation is not to assign blame, but rather to identify failures in existing systems that led to the incident occurring. Corrective actions can then be identified and addressed to prevent similar incidents from occurring in the future.
AcuTech consultants have supported organizations in numerous incident investigations and are intimately familiar with the tools and approaches used in effective incident investigations. In addition, AcuTech consultants leverage their experience with continuous improvement in management systems to ensure that corrective actions follow industry best practice. AcuTech offers expertise in Root Cause Analysis, Events and Causal Factors Analysis (ECFA), expert witness services, litigation support, regulatory penalties, and third-party moderation.
- Root Cause Analysis (RCA)
- Events and Causal Factors Analysis (ECFA)
- Expert Witness
- Litigation Support
- 3rd Party Moderation
AcuTech’s consultants are well versed in codes and standards developed by industry bodies and will refer to these as well as each client’s local jurisdiction codes and standards. A sampling of the relevant codes and standards can be found below.
- Occupational Safety and Health Administration (OSHA) Standards. In the United States, OSHA sets forth regulations and standards related to workplace safety and incident investigation. These standards provide guidelines for investigating accidents and near misses in various industries, including the process industries.
- API RP 754 – Process Safety Performance Indicators for the Refining and Petrochemical Industries. This recommended practice by the American Petroleum Institute (API) provides guidance on the development and use of process safety performance indicators to measure and improve process safety performance.
- Center for Chemical Process Safety (CCPS) Guidelines. CCPS, a part of the American Institute of Chemical Engineers (AIChE), produces various guidelines and books related to process safety, including incident investigation methodologies and best practices.
- National Fire Protection Association (NFPA) Standards. NFPA develops and publishes codes and standards related to fire protection and safety, which may include guidelines for incident investigation in industries dealing with hazardous materials and processes.
- International Organization for Standardization (ISO) Standards. ISO publishes standards related to occupational health and safety management systems, such as ISO 45001. While not specific to incident investigation, these standards often include requirements or guidelines related to incident investigation as part of a broader safety management system.
- AcuTech has provided incident investigation services to many companies in the chemical, petroleum, and petrochemical industries, including full incident investigations and review of company investigations through client attorneys. We are accustomed to working under privilege and have represented clients for OSHA and other regulatory agency negotiations as well as in legal proceedings.
- AcuTech served as a peer review for the committee to develop the 2nd edition of the CCPS Guidelines on Investigating Process Safety Incidents and was on the Golden Rules of Process Safety for Key Principles: Incident Investigation (2023) project subcommittee.