(54n) Learn How a Robust Incident Investigation Process Can Prevent Recurrences of Major Accidents

Failure to identify the hazards and / or manage the risks of highly hazardous materials and processes is one of the primary root-causes of an incident, and failure to learn from past incidents is the leading cause of the recurrence of incidents. Industries are facing consistent challenges to identify the causes of learning failures and improving to prevent the recurrence of major accidents. What contributes most to the continuation of the learning failures? Is it the lack of process safety competency, corporate culture, or the complexity of current management systems and associated tools?

Learning from incidents is not a simple standalone process and cannot work in isolation. It is embedded into corporate policies, operating management systems, and engineering standards. Having consistency and alignment among all these systems and processes is vital in order to apply the learning. Furthermore, a strong corporate safety culture and a competent workforce is critical for developing and implementing user-friendly and fit-for-purpose processes and tools.

Commonalities in past accidents clearly indicate that there are continuing gaps in the learning process. There were several precursors before those accidents, and most importantly all accidents were preventable. Companies are facing persistent challenges in identifying and eliminating those learning gaps to prevent the recurrences of major accidents.

This paper will review the causes of the most common gaps in the incident investigation and learning process, and mutual causes of learning failures. The five steps process will be explained in details with Most Common Gaps, Best Industry Practices, Learning, and Examples. The five steps are: Incident Reporting, Incident Investigation, Writing Recommendations, Tracking Recommendations to Closure, and Learning Implementation. Improvement tips with examples of the best industry practices will be provided which will help eliminate the learning gaps. Emphasis will be given on how a good corporate safety culture, competent workforce, and user friendly, consistent processes and tools help in eliminating the mutual causes of learning failures.

The paper will conclude by explaining how a strong corporate safety culture, robust management programs, management commitment and employee involvement are the key components for the quality investigation, communication, and effective implementation of the learning from past incidents to prevent major accidents.