Page 78 - Root Cause Failure Analysis

Regulatory Compliance Issues 69
QuaNfied investigator

The regulation clearly defines the investigating team:

. . . at least one person knowledgeable in the process involved, including a contract
employee if the incident involved work of the contractor, and other persons with
appropriate knowledge and experience to thoroughly investigate and analyze the
incident.

Time Requirements
OSHA regulations define specific time requirements for investigating any release or
potential release of any chemical that is within the scope of 29 CFX 1910. The regula-
tion states:

An incident investigation shall be initiated as promptly as possible, but not later
than 48 hours following the incident.

In part, the reason for this quick response to an incident is to assure that all pertinent
evidence and facts can be preserved to facilitate the investigation.

Report Content
The regulation also defines specific topics that must be addressed in the report. These
include

Date of the incident,
Date the investigation began,
A complete description of the incident,
Contributing factors, and
Any recommendations resulting from the investigation.

Review Process
The regulation states:

The report must be reviewed with all affected personnel whose job tasks are rele-
vant to the incident findings, including contract employees where applicable.

The intent of this clause is to ensure that all affected employees understand why the
incident occurred and what actions could prevent a recurrence. While the regulation
does not specifically define the methods to comply with this requirement, it is impera-
tive that the review be prompt and complete. In almost all cases, the review requires
personal meetings, either individually or in small groups, to thoroughly review the
incident and recommend corrective actions.