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Incident Investigation 19 )

What the regulation says:

(m)(1) The employer shall investigate each incident which resulted in, or could reasonably have resulted in a catastrophic release of highly hazardous chemical in the workplace.

(m)(2) An incident investigation shall be initiated as promptly as possible, but not later than 48 hours following the incident.

(m)(3) An incident investigation team shall be established and consist of at least one person knowledgeable in the process involved, including a contract employee if the incident involved work of the contractor, and other persons with appropriate knowledge and experience to thoroughly investigate and analyze the incident.

(m)(4) A report shall be prepared at the conclusion of the investigation which includes at a minimum:

(m)(4)(i) Date of incident;

(m)(4)(ii) Date investigation began;

(m)(4)(iii) A description of the incident;

(m)(4)(iv) The factors that contributed to the incident;

(m)(4)(v) Any recommendations resulting from the investigation.

(m)(5) The employer shall establish a system to promptly address and resolve the incident report findings and recommendations. Resolutions and corrective actions shall be documented.

(m)(6) The report shall be reviewed with all affected personnel whose job tasks are relevant to the incident findings including contract employees where applicable.

(m)(7) Incident investigation reports shall be retained for five years.

What it means:

Incident investigation is the process of identifying the underlying causes of incidents and implementing steps to prevent similar events from occurring. The intent of an incident investigation is for employers to learn from past experiences and thus avoid repeating past mistakes. The incidents for which OSHA expects employers to become aware and to investigate are the types of events which result in or could reasonably have resulted in a catastrophic release. Some of the events are sometimes referred to as "near misses," meaning that a serious consequence did not occur, but could have.

Employers need to develop in-house capability to investigate incidents that occur in their facilities. A team needs to be assembled by the employer and trained in the techniques of investigation including how to conduct interviews of witnesses, needed documentation and report writing. A multi-disciplinary team is better able to gather the facts of the event and to analyze them and develop plausible scenarios as to what happened, and why. Team members should be selected on the basis of their training, knowledge and ability to contribute to a team effort to fully investigate the incident. OSHA states that employees of could have potentially been, or were, impacted by a release or near-miss incident must be consulted. In ammonia facilities any release, anywhere, could potentially place all employees in danger. The incident report, its findings and recommendations are to be shared with those who can benefit from the information. The cooperation of employees is essential to an effective incident investigation. The focus of the investigation should be to obtain facts, and not to place blame. The team and the investigation process should clearly deal with all involved individuals in a fair, open and consistent manner.

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