ASP Exam – Incident Response, Investigations, & Disaster Planning

Following every incident and significant near miss, an incident investigation should be conducted to determine causal and contributing factors. In short, an incident investigation is a process undertaken following and HES event or incident in an effort to investigate and understand an incident,  identify health and safety management issues, and address an incidents causal factors.

Incidents should be viewed as a direct indicator that there is a shortcoming in the management process or hazards in an organization that have not been adequately addressed. The results of an investigation should be used to drive corrective actions which will prevent future incidents and will be sued in the planning process in the PDCA cycle. Beyond these items, incident investigations can be used as evidence in legal claims and assess the amount of damage and cost of an incident. Investigations should begin as soon as possible after an incident because:

• More accurate results will be obtained due to the incident being fresh in the memory of witnesses and better preserved evidence
• A message is sent to workers that management cares about safety and demonstrates a commitment to discovering the cause of an incident and improving

Tools Needed for an Investigation

Several tools may be used by an investigator to document an accident scene, including:

• Notepads or tablets for note taking (Many pieces of software are now available which can incorporate photos, document scans, etc. Directly into an investigators notes)
• Security tape or other barriers to prevent unauthorized access
• Cameras, either still or video, to document the scene
• Tape measures and marking tags
• Voice recorders for interviews
• Specimen jars and evidence collection bags (ensure proper handling protocols are followed)
• Air monitoring devices or other monitors (properly calibrated)
• Specialty items as needed

Cost of the Investigation

Incident investigations can be expensive, especially when considering the budgets constraints of smaller employers or during difficult economic times. Due to this, employers should factor in several items when considering whether or not to investigate specific incidents.

The actual and potential severity of an incident, as well as the cost of the incident should be considered. Incidents with high losses or severe actual or potential consequences should have a thorough investigation completed. Similarly, the frequency of similar events should be considered, with more frequent events demanding investigation. Generally, any public interest, potential for regulatory interest, or media involvement would be good indicators that an investigation will be necessary.

Root-Cause Analysis

Root-cause Analysis is a style of incident investigation that allows a group of investigators to identify the root cause of incidents or other problems. Although there are several different methodologies of root cause analysis in use today, one of the most common and effective methods is the “5 Why” methodology. The 5 Why methodology consists of asking 5 subsequent “Why” questions about factors that contributed to the incident. Here’s an example:

Q1: Why did the tank overflow?

A1: High level sensors did not shut down flow to the tank.

Q2: Why did the high level sensors not alarm?

A2: The high level sensors failed following a software update.

Q3: Why did the sensors fail after the update?

A3: Functionality was not checked following the software update.

Q4: Why was the system not checked following the software update?

A4: There is not a procedure requiring a check of the system following updates.

Q5: Why is there not a procedure requiring a system check following updates?

A5: No one has written a procedure because we’ve never identified this risk before.

If you’ll apply this methodology to the industry you work in or an event you’ve been made aware of recently, you should quickly see how the 5 Why root cause methodology can force an investigator to look deeper at causal factors than a simple investigation.

Other root cause methodologies focus more closely on defining the event and causal factors in a structured manner, and then analyzing those causal factors to determine a root cause using a variety of techniques. A typical sequence of investigation events is:

1. Determine a sequence of events / establish a time line
2. Define causal factors for the incident
3. Analyze causal factors to determine root causes
4. Analyze each root cause for generic (or systemic) causes
5. Develop &implement corrective actions

As with all investigations, the root cause analysis must result in one or more action items that will be implemented to prevent recurrence of an incident. In addition patterns within the incident log, incident investigations, or corrective actions may be found which can assist a company in focusing efforts in a problematic area of their operation. For example, investigation results may reveal that incidents occur more frequently during certain times of the day or days of the week, or may occur more frequently during certain types of tasks. Specific types of machinery may be involved in incidents more frequently. Identifying and addressing these patterns is critical for the overall safety of a company’s staff and will ensure continual improvement within a safety program.

Emergency, Crisis, and Disaster Response Planning

Businesses are exposed to potential emergency situations the same as we are in our daily lives, but with consequences for the business that range from inconvenience to total loss of revenue, inventory, or possibly the business itself. When a disaster occurs, people, including employees of a business, must decide how to react and what steps to take to protect themselves and the business. The largest disasters in the world have generated lessons learned that we can explore to understand how to prepare an organization for potential disasters and minimize the losses incurred during an event.

Emergency –  An event that often happens suddenly, disrupts the routine of an organization or community, and requires immediate action to prevent further damage or extended action to recover from. Lead times for an emergency may range from several weeks to none at all.

On-Scene Coordinator – The person on scene who is responsible for coordinating various agencies and internal departments to ensure all response needs are met.

Types of Emergencies

Natural Emergencies – Fires, floods, wind storms, hurricanes, extreme weather such as snow, volcanic eruptions, mud slides and avalanches and insect infestations can all cause emergencies (or not depending on the area impacted).

People – Based Emergencies – Riots and extreme protests / mob behavior, strikes and work stoppages, crowds rushing to stores for supplies preparing for an upcoming emergency or to purchase materials in short supply, events in stadiums or at sporting events.

War and Military Action – War and military actions create extreme danger for members of the general public.

Fires and Explosions – Fires and explosions, whether man made or natural, can cause extreme emergency situations.

System Failures – Runaway processes leading to release of toxic chemicals, steam, gas, or other hazardous substances, overheating in boiler processes, etc.

Traffic Problems – Accidents or abnormal traffic volumes can interrupt a communities ability to evacuate or respond to emergencies and create problems themselves as incidents may occur during the traffic event.

Planning for Emergencies

Some federal, state and local regulations require companies to develop detailed plans for emergency situations. As with most safety-related work, this process begins with a risk assessment designed to identify what emergencies could occur in the workplace, and at what frequency and severity. Detailed plans must be developed that assist workers in making strategic decisions while responding to an emergency or crisis.

Title III of the Superfund Amendments and Reauthorization Act of 1986 (SARA) requires chemical plants to develop emergency response plans for their operations and to participate in a local emergency planning process. Title III is known as the Emergency Planning and Community Right-to-Know Act (EPCRA). Each facility also maintains a chemical inventory and submits SDS sheets to local or state elements involved in the emergency planning process.

The Federal Emergency Management Agency (FEMA), Environmental Protection Agency (EPA), Nuclear Regulatory Commission (NRC) and the Department of Homeland Security (DHS) all are involved for planning for nuclear / radiation related releases and incidents.

Establishing Priorities during an Emergency

While objectives will differ for each emergency situation the basic order of priorities will be consistent in most situations:

• Safety of people
• Protection of property
• Cleanup and salvage
• Returning to normal operations

Developing Preparedness Plans

Developing Emergency Preparedness Plans are a key to planning for emergency situations. These plans may be general, strategic, or tactical in nature but should include the following:

• Actions that should be taken
• Participants that will perform the actions, possibly including an Incident Command System (ICS) structure.
• Authority given for who can proceed with actions, especially contingent actions
• Communication methods
• Resources and key information
• Supplies / equipment lists and storage areas
• Locations / facilities list and maps
• Medical service availability
• Training
• Building evacuation procedures

While preparing the plan, management should identify external resources that can be used and external agencies that must be notified of the emergency. The plan should list permitted activities and will likely contain copies of such permits to identify releases of reportable quantities. All agencies that granted the permits must be part of the plan, and contact information must remain up to date.

While developing the plan, careful consideration must be given to the size and scope of the plan While an emergency response plan may cover only a single facility, a disaster response plan may cover adjacent or adjoining facilities, including those of nearby operators and their potential to impact operations in your facility.

Site specific information needs to be maintained as facility improvements or changes are made, as local and state contacts change, and as available external resources change.

OSHA requires businesses to have a written, detailed evacuation plan that defines exit routes, specifies how emergencies are communicated, and an external muster area. Communication methods may include both alarms and verbal instructions.

In certain emergencies, personnel may need to shelter in place until an event has been contained. The buildings emergency plan should include a detailed shelter in place plan which includes the following instructions:

• How to shut down / recall elevators
• How to shut down ventilation systems
• Close and secure entrances and exits, including the building parking garages, and docks
• How to communicate the plan to all personnel in the building, including any specific procedures they may need to follow