CDOIF Guidance

Safety and environmental standards for fuel storage sites

Final report

180

Investigation of incidents and near misses

285 As technical systems have become more reliable, the focus has turned to human causes of

accidents. The reasons for the failure of individuals are usually rooted deeper in the organisation’s

design, decision-making, and management functions.

286 HSG48 gives several examples of major accidents where failures of people at many levels (ie

organisational failures) contributed substantially towards the accidents. Human factors topics of

relevance to process integrity include:

ergonomic design of plant, control and alarm systems;

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style and content of operating procedures;

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management of fatigue and shift work;

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shift/crew change communications; and

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actions intended to establish a positive safety culture, including active monitoring.

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287 Investigation procedures should address both immediate and underlying causes, including

human factors.

Guidance

288 HSG65 is a suitable reference on investigation of incidents and near misses. Not all events

need to be investigated to the same extent or depth. Dutyholders need to assess each event (for

example using a simple risk-based approach) to identify where the most benefit can be obtained.

The greatest effort should concentrate on the most significant events, as well as those that had

the potential to cause widespread or serious injury or loss.

289 HSG65 Appendix 5 describes one approach that may be used as a guide for analysing the

immediate and underlying causes of effects. Various other approaches are also available, and

widely used within the industry. These include various in-house or proprietary systems.

290 Other suitable references include

Human factors in accident investigations

117

and

Guidance on

investigating and analysing human and organisational factors aspects of incidents and accidents

118

Summary

291 Dutyholders should ensure they have suitable procedures for:

identifying incident/near miss potential;

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investigating according to the identified potential;

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identifying and addressing both immediate and underlying causes;

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sharing of lessons learned;

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tracking of remedial actions.

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Audit and review

292 The terms ‘audit’ and ‘review’ are used for two different activities (see L111 and HSG65).

293 In addition to the routine monitoring of performance (ie active monitoring) the dutyholder

should carry out periodic audits of the SMS as a normal part of its business activities.

294 An audit is a structured process of collecting independent information on the efficiency,

effectiveness, and reliability of the total SMS. It should lead to a plan for corrective action. In this

context ‘independent’ means independent of the line management chain.

295 Reviews are a management responsibility. They need to take account of information

generated by the measuring (active and reactive monitoring) and auditing activities, and how to

initiate remedial actions.