Guideline for Major Incident Investigation

1. Team formation
a. Incident investigation team are performed based on the incident category.
Category
Category A or fatality
B Category PFDE incidents or LWC/RWC

C category PFDE incidents or MTC/FAC

a.
b.
c.
d.

Team formation responsibility

The Site chief in consultation with
Executive Director/GMS/CHSEE
The site chief in case of large sites or
the Sector Chief in consultation with the
Team Leader.
HOD in consultation with team leader

Senior manager form affected area- Chairman

Minimum team size-6
The team committee shall be trained in Root Cause Failure Analysis.
Other members area based on the nature of the incident and could include :
Engineering and Maintenance Personnel ( Electrical, Mechanical and
Utility)
HSE member
First line supervisor from the affected area
Involve employee / his representative
Individuals who have firsthand knowledge of incident
Other specialists (if required)
2. Determining Facts
Types of evidences
1. Physical
Weather
Tools
Personal Protective Equipment
Machinery
Chemicals
2. Human
Employees
Supervision
Contractors
Vendors
Visitors
3. Operating systems
Training
Documentation
Rules/procedures
Preventive maintenance
Management of Change
Hazards analysis

Auditing
Communication
Culture

4. Gathering Information (interviewing)

I.
Introduction & establish report
II.
Judge state of mind
III.
Restate Purpose
IV.
Listen and demonstrate interest and concern
V.
Ask questions-what, when, where, why, who and how
VI.
Follow the sequence: General (open), specific, closed
VII.
Reflect meaning
VIII.
Reflect feeling
5. Determining the key factors
I.
Funnel the information gathered
II.
Determine key factors by RCFA techniques
III.
RCFA (Root Cause Failure Analysis) identifies the causes of failures (i.e
key factors) at Physical, Human and System levels.
RFCA principles
i.
First find physical key factors
ii.
Next the human Key Factors
iii.
Finally the system key factors
Key Factors
Circumstances that contributed to or may be reasonably believed to have contributed
to occurrence on the incident even though clear causal connection may not be found.
6. Determining systems to be strengthened
The key factors should identify those systems, including PSM elements that
need to be strengthened.
a. Personnel
Training and performance
Management of change-personnel
Incident investigation and reporting
Auditing
Emergency planning and response
Contractor safety and performance
b. Facilities
Quality assurance
Mechanical integrity
Pre-start up safety review
Management of subtle changes
c. Technology
Process technology
Process hazard analysis
Operating procedures and safe practices

 Management of change-Technology
d. Operational discipline
Leadership by example
Sufficient and capable resources
Employee involvement
Active lines of communication
Strong team work
Common share values
Up to date documentation
Practice consistent with procedures
Absence of shortcuts
Excellent housekeeping
Pride in organization
7. Recommending corrective and preventive actions
a. Corrective and preventive actions should address all key factors and
includes in the following
Description of action
Person responsible for implementation
Completion date
Should be acceptable to the implementing agency and affected
plants
Recommendation date shall be decide with meticulous planning
Should be limited to the affected area
Learnings from the incidents shall be taken up by the PSM
chairman
8. Documentation and Communication
a. Final incident Investigation report shall be send after 7 days from the
accident.
b. The learning from incident should also be part of the document review of
PSM chairman.
9. Communication
Shall be communicate to entire plant.
10.Follow-up
Incident recommendation shall be follow up by the Person in-charge appoint
and periodic report shall be establish to the Senior Site Head.