Sample Investigation Key Element Critique Check list Incident Investigation Guideline

Investigator Name: Event Assessed: Date of Assessment:

Investigation Key Element Critique Checklist Investigation Key Element Query

1. 2. 3. Are there written procedures or protocols for the reporting and investigating process safety incidents? Has the investigation team leader been trained (qualified) to lead investigations and in the use of appropriate investigative tools? Does the investigation team leader have independence from the issue to be investigated to the point that there is no question as to that persons objectivity? Were the necessary skills available either on the investigation team or readily available to the team when needed? Have pertinent causes and discovery processes, including data gathered, been recorded and documented? Were the proper investigative techniques applied correctly? Did the investigation go beyond the immediate or obvious causes and discover contributing causes? Was evidence gathered and preserved properly, including a documented valid chain-of-custody? Did the investigation address all facets of all causes?

Yes

No

4. 5. 6. 7. 8. 9.

10. Were the underlying root causes identified? 11. Were the management system failure(s) identified? 12. What other resources, techniques and/or tools could be used to make the next investigation better? Discuss below. 13. Were critique forms completed for each investigation? 14. Were there any legal issues from this latest investigation that were related to incident investigation reports or documentation that need to be resolved before the next major incident investigation? 15. Do we need to change any internal communication practices? 16. Do we need to change any team training or team procedures? 17. Would we do anything differently to change the litigation exposure or litigation discovery phase items? Discussion:

(See Chapter 14)

2003 AIChE - CCPS