We investigate accidents to avoid repeating them in the future by identifying the mistakes or contributing factors that led to the accident. Further, investigating accidents is important to defend against claims as it helps determine liability and establish a factual basis for any legal or insurance proceedings. Additionally, investigating accidents helps us find the root cause, which allows us to address the underlying issues and prevent similar accidents from occurring.

The ECF technique is a structured approach to map out the sequence of events leading to an incident or near miss. It identifies key events, decisions, and conditions that contributed to the outcome, providing clarity on what went wrong and when.

Management plays a key role by providing resources for thorough investigations, fostering an open reporting environment, and ensuring corrective actions are implemented. Leadership commitment to addressing systemic issues is essential for long-term safety improvements.

The 5-Why methodology involves asking “Why?” repeatedly (typically five times) to drill down into the underlying reasons behind an incident. This iterative questioning process moves beyond symptoms to uncover fundamental issues.

By analyzing incidents and near misses, organizations gain valuable insights into vulnerabilities in their systems. Sharing lessons learned with employees and updating policies and procedures based on findings can enhance overall safety performance.

During an investigation, it is vital to gather witness statements to allow for different perspectives and testimonies that can contribute to the overall understanding of the incident. It is crucial to take photos as visual evidence can provide valuable information and help in recreating the scene. Moreover, collecting any physical evidence is essential as it can provide tangible proof and support during the investigation process. Finding the root cause and sharing the findings to prevent future accidents is important in order to learn from the incident and implement the necessary changes to avoid similar occurrences in the future.

An Incident investigation is a complex task that requires a multidisciplinary approach involving individuals with expertise in various fields related to process safety management, engineering, and industrial processes. Broadly speaking, the following individuals could be involved in accident investigations: managers, safety officers, technicians, engineers, operational specialists, union representatives, etc.

The individual tasked with conducting the incident investigation not only profoundly influences its effectiveness, but also greatly impacts the safety of employees to prevent the accident from reoccurring. Ultimately, defining the qualifications of a capable individual remains one of the most difficult and underestimated aspects of an incident investigation.

There are a number of steps involved in the investigation of a combustible dust, flammable liquid, and gaseous fire or explosion incident. The success of the investigation will be dependent on upfront planning, accurate documentation, the experience of the investigation team, the support of upper management, and the availability of the necessary resources. Below are the common steps used to investigate an incident:

• Step 1 – Recognition of when an incident has occurred so that the incident investigation team can be activated
• Step 2 – Assembling a qualified team that will determine and analyze the facts of the incident
• Step 3 – Gathering information, including interviewing personnel who have knowledge of the incident, documenting of the incident scene and taking photographs, collection of evidence, analyzing data, and developing and testing of the hypotheses
• Step 4 – Determining root causes and causal factors.
• Step 5 – Preparing the investigation report which provides details regarding the circumstances surrounding the incidents, including facts, findings, and recommendations to prevent future occurrences.
• Step 6 – Implementing recommendations and communication of the incident investigation team’s conclusions to the affected parties.

Our expert consultants apply a practical strategy that draws on our decades of plant experience and in-depth understanding of published industry norms to investigate incidents involving combustible dust, flammable liquids, and gases at your facility.

Root causes frequently point to systemic issues within management systems, such as inadequate training, poor maintenance, or unclear procedures. While individual mistakes might trigger incidents, these mistakes often result from organizational gaps rather than personal negligence.