The first basic step to any investigation is to understand the story. Any incident is nothing but a story. It must be having its sequence which is required to be understood in a way that you remember it. Move the story repeatedly in your mind to make sure you can tell this to any of your team members helping you with the investigation or when you are with the people during the interview sessions. Sequence requires logic, and here itself the basic question of WHY would start coming in. Logic comes from defined operating and maintaining procedures & practices having strong basis. Where things have been performed and acted upon without logic indicates that the established protocols might not have been followed. And where everything has made all sense, you can park that still to check for any improvement gaps afterwards. You start taking notes when you start understanding the story, connecting the logic, and initiating your WHYs.<\/p>\n\n\n\n
Step 2: Follow the story<\/strong><\/p>\n\n\n\n With the understanding of the story in your mind, this is the time to follow the story to perform the incident investigation. Whatever has been told to you is required to be lived by you. If you will not live the story in the field, with the people involved, you might end up with a basic version of events and may not be the actual ones. Following the story will start providing you with initial findings. You pass by all those recorders which recorded the events shared with you to be sure about what happened without a gap. Incomplete or incorrect story cannot provide you with the right ground of performing the investigation. There are highly likely chances of concluding something which may not apply any significant improvement in the right area of concern. There are cases whereas a result of incident investigation, heavy budget was spent to address an identified cause which was not the one direct or even contributing. Example include upgrading the piping material to specialized alloy rather than re-assessing the feed variance during certain events.<\/p>\n\n\n\n Step 3: Verify & re-verify<\/strong><\/p>\n\n\n\n This step relates to following the story. The sequence is required to be supported with sufficient evidence, and that evidence should be in compliance with defined operation & maintenance procedures. So, everything once found is required to be verified. This would trigger to spot for the evidence, and to make sure WHY such an action was taken or WHY such event happened. Verification would include human interaction as well where a series of interviews would be conducted with a single purpose to verify each & every step of the story. And it is always recommended that this step is done twice. Conduct a preliminary set of interviews and then go back with all the notes taken. Come back again to have yet another session. This should be true not only with the interviews but with dealing of other hard & soft evidence. There should not be any doubt when we start analyzing the collected data, and that is the reason we verify & re-verify.<\/p>\n\n\n\n Step 4: Analyze the data<\/strong><\/p>\n\n\n\n Keep things graphical. Make drawings, even while note taking have some shapes drawn, let the manual process charts jump into the work. This would enable having a mind map of the entire process. They tend to remain with you most of the times, and it becomes easily when you finally draft the slides or a report. Key to analyzing the data is to connect whatever you have collected on a bigger scale. Zoom out and see what is happening actually. Have a Heli view of the situation, make sure that you see it from there, take yourself completely outside, and then bring back in to a level that consider yourself in the role of each & every person who was participating in controlling or mitigating the incident while on the field or in the control room. That would enable you to understand that what he was equipped with and what was lacking. Similar kind of analysis is required to be run on procedural side of the things. Were they covering the scenarios which were there in real-time. There have been scenarios where the procedure itself was not covering a scenario which happened or personnel were not adequately trained how to handle if a particular scenario happens. After this zooming out, and in to the events is done with looking into the collected data, you would start collecting the causes.<\/p>\n\n\n\n Step 5: Call the causes<\/strong><\/p>\n\n\n\n When you start calling the causes during the analysis, it is important to flag them with elimination sense. Apply this in a way that you ask yourself and the team that eliminating this cause would prevent the incident next time or would just play a role to eliminate or mitigate. Later would call for a contributory cause however formal will be a direct cause. Direct causes, if more than one, should have percentage contribution assigned. This percentage contribution could come with a careful definition of direct causes. For example, incorrect installation of a gasket, and its poor storage both were identified as the direct causes for a flange leak. Now, assess through quantitative data analysis, how many times incorrect installation alone would cause a leak alone, and similarly in how many instances, poor storage conditions would result in a leak. This may require looking into the past leak data analysis, incident reports etc. Then only, risk assignment can be done with the identified causes. Human factors are required to be assessed with expected & achieved competency. All other causes should be contributing to making the system robust, applied with updates or modifications to bring improvements.<\/p>\n\n\n\n Step 6: Issue the recommendations<\/strong><\/p>\n\n\n\n Careful analysis of the causes identified, and an application of elimination sense would provide you with meaningful and applied recommendations. Make sure that nothing is generated which is good-to-have. Always look that how you can minimize the recommendations rather than issuing a big set. Connect each of them to the finding and the cause. Recommendation should be agreed with the Action Party for its risk level, target date, budget, and requirements of resources.<\/p>\n\n\n\n Incident investigation would always remain a pivotal program to learn, apply, and remember what exactly happened, how, and why. This opportunity should never be missed out as it promotes process safety culture in hydrocarbon industry, and if followed properly serves as a legacy which newcomers would always carry forward.<\/p>\n","protected":false},"excerpt":{"rendered":" In a hydrocarbon processing facility, incident investigation is a key area to master for all involved. 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