11 Incidents

“There are no accidents… there is only some purpose that we haven’t yet understood.”

– Deepak Chopra, The Return of Merlin[1]

11.1 What Are They

In the EHS realm you may encounter incidents such as:

• Employee injuries and illnesses
• Fires and explosions
• Non-compliance with, or violation of regulations, requirements and policies
• Releases or spills
• Vehicle crashes
• Near Misses

Companies may track these incidents because they may be required to report them to regulatory agencies or use the information to prevent future incidents.

11.2 Incident Terminology

Before we delve deeper into this topic, a discussion of nomenclature is prudent.  Some EHS practitioners will not use the term “accident” because they feel that every incident is preventable, and nothing truly happens by accident. The Occupational Safety and Health Administration (OSHA) evens makes this recommendation[2].  This is nearly the exact opposite theory as prescribed by Charles Perrow in his book “Normal Accidents” where he discusses that some systems are so complex and tightly coupled that it would be nearly impossible to predict and/or prevent an incident and, as the title implies, accidents are almost expected[3].  My favorite term for incident is from the well-known safety professional Todd Conklin, PhD who likes the term “deviation from expected outcome”[4].  Unfortunately, as Dr. Conklin discusses in his book “Pre-Accident Investigation”, “deviation from expected outcome” is too verbose and the acronym “DFEO” never caught on[5].  I have chosen to just use the term incident throughout since it is not controversial or verbose.

11.3 Required Reporting

11.3.1 Employee injuries and illnesses

The Occupational Safety and Health Administration (OSHA) requires reporting work-related fatalities within 8 hours and employee in-patient hospitalizations, amputations or eye loss with 24 hours of the incident[6].  The work-related concept can be confusing.  I phoned in a report after an employee suffered what appeared to be a fatal heart attack in a company lunchroom.  In this situation, I only had circumstantial information on what caused the worker’s death.  I was also uncertain how the Occupational Safety and Health Administration (OSHA) would interpret work-relatedness since the employee was on break but could have taken the break because they were not feeling well due to heart issues.  Rather than risk violating the reporting requirement, I made the call and then followed up with confirmation that they had suffered a heart attack (i.e., after checked on the medical examiner’s report).  In this instance, the Occupational Safety and Health Administration (OSHA) did not feel it was work-related.   The Occupational Safety and Health Administration (OSHA) has a whole section on determining work relatedness (29 Code of Federal Regulations (CFR) 1904.5)[7].

The Occupational Safety and Health Administration (OSHA) also requires tracking of other incidents and annual compilation of these on Occupational Safety and Health Administration (OSHA) 300 and 300A logs[8].  The Occupational Safety and Health Administration (OSHA) 300A log needs to be certified and posted at your facility[9].  Facilities with over 250 employees must submit their data to the Occupational Safety and Health Administration (OSHA) annually[10].  These incidents, which also must be work-related include:

• Death
• Days away from work (i.e., they cannot come to work because of the incident)
• Restricted work or transfer to another job (i.e., they cannot perform their normal job due to incident)
• Medical treatment beyond first aid
• Loss of consciousness
• It involves a significant injury or illness diagnosed by a physician or other licensed health care professional even if it does not meet one of the previous criteria[11].

These incidents are used to calculate several lagging safety indicators:

• Total Recordable Case Rate (TRCR)
• Days Away Restricted and Transferred (DART)[12].

The Bureau of Labor Statistics (BLS) collects some of this data and publishes the results, which allows you to compare your rates with the rest of your industry (i.e., the data is sorted by North American Industrial Classification System (NAICS))[13].

In my experience, Occupational Safety and Health Administration (OSHA) inspectors typically ask for the Occupational Safety and Health Administration (OSHA) 300 and 300A logs during inspections.  The Occupational Safety and Health Administration (OSHA) regulations require you to provide this information to authorized government employees within 4 business hours[14].

11.3.2 Non-compliance

Some regulations require reporting of violations or non-compliance.  This is a common requirement in air permits: if you have an emissions exceedance (e.g., an emissions control device such as a dust collector or oxidizer stops working), you may be required to report it to the applicable authority within a set timeframe (e.g., 24 hours).  Some air permits require periodic (every quarter, 6 months or annually) submission of a deviation report detailing non-compliance or violations.

Some states require the collection and submittal of stormwater sample results.  If you have a stormwater permit that requires stormwater sampling, you may need to compare the sample results to benchmarks or exceedance values.  I was involved in a civil lawsuit where they had alleged that our stormwater samples were a violation because they exceeded applicable benchmarks.  This was not correct, but as is common with a number of stormwater permits, we were required to take actions due to the results surpassing the benchmark values.

11.3.3 Release Reporting

The Environmental Protection Agency (EPA), Department of Transportation (DOT) and Coast Guard have several regulations that require immediate reporting of spills and releases including releases of:

• Extremely hazardous substances above a reportable quantity[15]
• Hazardous materials during transportation[16]
• Hazardous material from a railcar in the possession of the railroad or of another dangerous commodity[17]
• Hazardous substances above a reportable quantity[18]
• Hazardous substances above a reportable quantity into waters of the United States[19]
• Hazardous wastes above a reportable quantity[20]
• Oil spills into waters of the United States[21]
• Polychlorinated biphenyls that contaminate certain areas or exceed 10 pounds[22]

These reporting requirements apply even in states that have their own spill reporting regulations.  The state spill regulations sometimes overlap, and other times have additional requirements.  Even if the state regulations overlap, you still may need to report the spill to a state or other local agency.  The difference between states can be significant.  I have run across a nice Spill Reporting Matrix prepared by the Retail Compliance Center that can help identify the various spill reporting requirements[23].

To simplify the Environmental Protection Agency (EPA) and Coast Guard reporting, the federal government has established a single reporting phone number and center for handling the calls: The National Response Center (NRC) (1-800-424-8802)[24].  According to the Environmental Protection Agency (EPA) website[25]:

“The National Response Center (NRC) is a part of the federally established National Response System and staffed 24 hours a day by the U.S. Coast Guard. It is the designated federal point of contact for reporting all oil, chemical, radiological, biological and etiological discharges into the environment, anywhere in the United States and its territories. The NRC also takes maritime reports of suspicious activity and security breaches within the waters of the United States and its territories.”

The Environmental Protection Agency (EPA) has not defined “immediate” as it relates to making a spill or release report[26].   However, I report as soon as practical to avoid potential issues especially if you might need outside assistance.  Generally, I would report the spill as soon as I had the following information available:

• Material released
• Estimated quantity of the release
• Potential impacts of the release (e.g., Injuries, whether the release has reached neighborhoods, waterways, sewers, etc.)
• Specific release location (e.g., address, latitude and longitude or directions that would allow emergency responders to assist if needed)
• What you are doing to address the release and if you need assistance

The spill reporting personnel will request your contact information and may ask for additional information including, but not limited to:

• Name of the company responsible for the release (i.e., you may be calling on behalf of another company)
• Weather
• When the release started and when it was discovered
• Waterways and other environmental media that may have been impacted

I would not delay reporting to get this additional information.  In my experience, you do not always know how much material has leaked and therefore, you may not know if you are required to report.  It is not a violation to report a release that ends up being below the reporting threshold, but it is a violation if you fail to report it.  However, I know of downsides to reporting spills un-necessarily: some regulatory agencies will require formal cleanup investigations and submissions of reports that can require more time and money.  I once reported a large spill and provided our initial estimate of the quantity spilled.  After the spill, we were able to come up with an exact spill estimate that was significantly less (i.e., almost half), but still reportable.  A local paper printed a story, and they used the amount we initially reported instead of the follow-up estimate making the spill seem worse than it was.

The spill reporting agency typically provides a spill or release identification number.  If they do not, you should request this number, and you should document this number to show proof that you reported the spill, and this number may be used in future correspondence.  If they do not use a numbering system, ask for the name of the person to whom you are speaking with, and document the date and time you called them.

The burden of reporting may apply to the company that caused the spill and/or the owner of the spilled product.  This differentiation can be important during transport where your product might be spilled by the company transporting the product (e.g., a trucking company).  I once had a trucking company that did not notify us that they had spill material while transloading it onto a railcar.  My company had to pay a fine for not reporting a spill immediately even though we did not find out about it immediately.  Our contract allowed us to recuperate the funds from the trucking company, but the fine was listed under my company name.

11.4 Other Reporting

11.4.1 Department of Transportation (DOT) Accident Reporting

The various Department of Transportation (DOT) administrations require accident documentation and reporting in addition to the requirement to call the National Response Center (NRC) for hazardous material releases.  These include, but may not be limited to:

• FAA requires reporting of death or serious injury or when an aircraft receives substantial damage[27]
• FMCSA requires tracking of commercial motor vehicle and hazardous material transportation incidents and compilation of an annual accident register[28]
• FRA requires monthly reporting of certain highway-rail grade crossing incidents, rail equipment incidents and casualties[29]
• FAA requires [30]
• The Coast Guard, which is now part of the DHS,
• PHMSA requires immediate reporting of certain natural gas incidents, submission of an incident report and an annual report as well as reporting safety related conditions[31]

11.4.2 Chemical Safety Board (CSB)

The Chemical Safety Board (CSB) is a federal agency that investigates the root causes of major chemical incidents, in a non-regulatory manner (i.e., they do not issue fines and citations) to identify chemical safety changes to protect people and the environment[32].  This agency requires owners or operators to report accidental releases that result in a fatality, serious injury, or substantial property damage (i.e., a million dollars or more for on-site and off-site damages)[33].  If the release was already submitted to the National Response Center (NRC), you only need to call the Chemical Safety Board (CSB) within 30 minutes and provide the National Response Center (NRC) release identification number.  If you have not submitted a report to the NRC, but have had a release that requires reporting, you have 8 hours to submit a report directly to the Chemical Safety Board (CSB)[34].  You are required to submit certain information to the Chemical Safety Board (CSB), which is on a Chemical Safety Board (CSB) Accidental Release Form you can fill out and submit to [email protected][35].

11.4.3 Near Miss Reporting

In 1974, United Airlines started an internal awareness program that allowed anonymous reporting of incidents and safety[36].  That year, a United Airlines flight nearly crashed into Mount Weather, Virginia in route to Washington, D.C. due to confusion about approach altitudes (i.e., a near miss)[37].  The United Airlines crew reported this to the airline and the airline distributed a warning to their pilots[38].  However, because this was only reported internally within United Airlines, several months later Trans World Airlines flight 514 crashed into Mouth Weather killing 92 people[39].  After investigating the incident, the Federal Aviation Administration (FAA) created an industry-wide system for anonymously reporting safety incidents: the Aviation Safety Reporting System (ASRS)[40].

The United Airlines flight incident is an example of a “near miss” and the report an example of near miss reporting.  This is a great example of the value of near miss reporting, which could have saved 92 people if it had been distributed across the airline industry.  Therefore some companies require reporting of near misses and distribute this information, along with actual incident information, throughout their company.  Examples of near misses include:

• Unsafe conditions
• Unsafe behavior, such as a worker modifying personal protection equipment for comfort
• Minor incidents and injuries that had potential to be more serious
• Events where injury could have occurred but did not
• Events where property damage could have resulted but did not
• Events where a safety barrier was challenged, such as a worker bypassing a machine guard
• Events where potential environmental damage could have resulted but did not[41]

An interesting sidenote to the Aviation Safety Reporting System (ASRS) is that the Federal Aviation Administration (FAA) tried to develop a similar system in the late 1960’s, but the system failed[42].  When the Federal Aviation Administration (FAA) set it up again in the 1970’s they had the reporting go through a National Aeronautics and Space Administration (NASA) contractor instead of to the Federal Aviation Administration (FAA) and it was successful[43].  I think this is an important lesson on the independence of near miss incident reporting and fear of retribution holding back reporting.  A successful near miss reporting program should consider this.

11.5  Investigations

11.5.1 Why Investigate

Probably the most obvious answer to the question of why you investigate incidents is to find the cause and prevent future incidents with similar causes.  However, other reasons to investigate an incident include to:

• Fulfill a legal requirement
• Determine the cost of an incident
• Evaluate compliance with applicable regulations (e.g., occupational health and safety, criminal, etc.)
• Process workers’ compensation claims[44].

Some regulations, like the Occupational Safety and Health Administration’s (OSHA) Process Safety Management (PSM)[45] and Environmental Protection Agency (EPA) Chemical Accident Prevention Provisions (CAPP)[46] regulations require investigation of certain incidents.  The New Mexico Environment Department requires root cause investigations into air permit excursions.  Although not a requirement, the Department of Justice (DOJ) Sentencing Guidelines consider investigations part of an effective compliance program:

“Finally, a hallmark of a compliance program that is working effectively in practice is the extent to which a company is able to conduct a thoughtful root cause analysis of misconduct and timely and appropriately remediate to address the root causes.[47]”

Investigating the costs of incidents can help drive efforts to prevent them and demonstrate the need for and cost effectiveness of prevention measures.  The Occupational Safety and Health Administration (OSHA) has a “$afety Pays” website that helps with the calculations[48].

Because an incident might result in an inspection by a regulatory agency, you may want to know if the incident was caused or related to non-compliance with a regulation so you can correct it.  Even without a regulatory issue at stake, it would be hard to overlook the positive optics of finding the issue so you can prevent recurrence especially if someone was injured.

11.5.2 How to Investigate

I cannot explain how to conduct an incident investigation in one chapter: you can find entire books devoted to the subject many of which are specific to the incident type (e.g., aircraft accidents, arson investigations, vehicle/traffic accidents, etc.). Therefore, I am only going to provide a basic overview of incident investigations and suggest you work with an experienced investigator or obtain an investigation guidance book before conducting one for the first few times.

Since this chapter is on investigation, I am not going to discuss emergency response measures, but it should be obvious that the priority is to aid anyone injured and stop and contain any released materials.  The incident investigation starts after these items are addressed.  The next three sections: Preserve Evidence, Attorney-Client Privilege and Work Product Doctrine, and Gather Evidence, may not be needed on most incidents, but may be crucial for serious incidents.  I find that a lot of incident investigation guidance skips the first two steps.

11.5.2.1 Preserve Evidence

Emergency response measures should take precedent over preserving evidence (e.g., you wouldn’t second guess using the jaws of life to rescue someone in a trapped car because it might make it harder to determine the cause of the accident).

I had two employees critically injured when the rented lift they were using tipped over on uneven terrain and slingshot them into the ground.  After the incident, and without warning, the lift rental company came out to the site and took the lift.  Although we did not suspect an issue with the lift, the lift company could have been liable, and we were unable to get an independent evaluation of the lift before they could evaluate and potentially tamper with the lift.  The lesson I learned is that the incident site should be secured, access limited to necessary personnel, and nothing should be taken from the site without approval by designated personnel.  If multiple parties may be involved, such as contractors, equipment suppliers (e.g., the lift rental company), they should be consulted and a designated person from each party identified so you can coordinate efforts.

11.5.2.2 Attorney-Client Privilege and Work Product Doctrine

The first step was “preserving evidence” and not “gathering evidence.”  Before you get started with evidence gathering, interviewing and other documentation, you may want to consider whether the investigation results could be used against your company or a company employee, or potential lawsuits might be filed.  In situations where a regulatory agency or law enforcement is involved, an employee is critically injured, or multiple companies are involved, you may want to protect the investigation results by having your legal counsel spearhead the investigation: they may direct you or other company individuals to conduct the investigation or they might hire an outside company.  For more information on this, see Chapter 5 Attorney-Client Privilege and Work Product Doctrine.

11.5.2.3 Determine Who Will Be on the Investigation Team

If it is not pre-determined, you need to identify who will be part of the investigation team.  The size, background, experience and authority of the team may vary depending upon the incident.

Some incidents require outside expertise because of the complex or technical nature of the incident.  For example, fires typically involve forensic fire investigators.  If your insurance company is involved, they may hire, and/or require, an outside expert to investigate.

Depending upon your company, you may need to provide a declaration of authority or similar documentation if the individual team members do not have the authority needed to access records, enter secure incident areas, and/or to garner the cooperation needed to conduct the investigation.

You may have representatives from multiple companies if the incident involves contractors or leased or rented properties or equipment.  You may also have a regulatory agency investigating.  Both situations might require someone to coordinate their activities especially if you have your own investigation team.

11.5.2.4 Identify Witnesses

Interviewing incident witnesses can be key to understanding the incident.  Therefore, it is important to identify who witnessed the actual incident and who may have witnessed the operations, personnel, and activities before and after the incident.  The after-accident witnesses may include emergency responders and off-site medical personnel.  It is not imperative, but I prefer to not have the witnesses talk to each other before they are interviewed.

Because memories can change over time,[49] I like to have witnesses document what they saw and experienced as soon as it is appropriate.  Unfortunately, because incidents can vary significantly, I do not know of one form or set of questions that will work for every incident type.  Therefore, you may ask the witnesses to answer the “who, what, when, where and how” questions.

11.5.2.5 Gather Evidence

Evidence is the other crucial item needed for the incident investigation.  Note, some also consider witness statements as evidence.  Some of the evidence that you might need to gather includes:

• Equipment involved in the incident including health and safety, operating and storage equipment
• Equipment manuals (installation and operation)
• Maintenance and inspection logs and other documents
• Medical results (for injured employees)
• Permits
• Photos from multiple angles
• Policies and procedures
• Process control logs
• Safety data sheets
• Samples of chemicals released, including environmental samples in air, soil and water
• Sign-in logs
• Security video footage
• Strip charts
• Timeclock information
• Training presentations and records
• Weather conditions

Some of these items cannot be physically gathered, like a large tank that ruptures.  Therefore, as an alternative, you may want to block or otherwise control access so you can run tests and inspections.  I have been involved in a couple of fires where we hired a security company to guard the site during off hours.  This had less to do with intentional interference with the evidence as it did with keeping out potential thieves and people who might just be curious.

You may not need to physically gather all of this information and instead may just identify where it is located.  If you have a records retention policy, you may need to place a “hold” on these documents, so they are not deleted or disposed until the investigation, and any ensuing legal matters are resolved.

11.5.2.6 Develop the Storyline

Once you have gathered the evidence and witness statements, you can start developing a description, narrative or timeline of what happened.  A sketch or drawing of the incident can be helpful in some investigations.  You may need multiple sketches to capture the incident at different times.  Some incident investigation techniques use different illustrations to describe the incident including:

• Causal Factor Charting
• Cause and Effect Tree Analysis
• Timeline[50]

Each of these illustrations has advantages and disadvantages depending upon the type of incident[51].

11.5.2.7  Investigation Cause Traps

As discussed earlier, identifying the cause, and correcting it are one of the primary reasons why you investigate incidents.  Incident investigators often attribute incidents to three general categories:

• Equipment failure
• Human performance issues
• External events beyond the facility or operator’s control[52].

In my opinion, these are easy answers that investigators often have tunnel vision and focus on these areas and do not look for other areas and do not look beyond the obvious causes.  One incident investigation methodology, the Cause and Effect – 6M looks for causes in six different arenas all beginning with the letter “M”:

• Manpower
• Machinery
• Materials
• Measurement
• Method
• Mother Nature[53].

I like to try to find, or eliminate, incident causes in each of these arenas.

11.5.2.8 Root Cause Analysis

As I mentioned, the other issue with some investigations is they only look for the obvious cause and do not look for underlying causes.  For example, if an equipment failure occurs, the investigation does not investigate why it failed and simply replaces the equipment.  They should ask more detailed questions such as:

1. Should the facility personnel have conducted inspections or maintenance that would have identified or prevented the failure?
2. Was it the wrong equipment for the operation (e.g., not appropriate for the temperature, pressure, corrosive chemicals, etc.)?

Answering these questions may not be enough.  Depending upon the answers to these questions, you may want to continue to ask related questions such as:

1. If inspections or maintenance had not been conducted, why not?
2. Was anyone tasked with the inspections and maintenance?
3. Was inspection and maintenance conducted poorly or not as desired?
4. Were inspection and maintenance procedures developed?
5. If no inspection and maintenance was required, why not?
6. If this was the wrong equipment for the operation, why?
7. Was a mistake made in the design of the operation?
8. Was the operation changed without evaluating the impact on the equipment?
9. Did somebody replace the equipment with a different type of equipment than was originally designed?

This might seem like a lot of work, but if you just replace the equipment, you might experience the same failure.  Additionally, you might discover issues or problems that may have occurred with other equipment or operations.  For the inspections and maintenance example:

• If no one was tasked with conducting inspections and maintenance, you might have issues with your task management and/or maintenance program.
• If no inspections and maintenance were identified, you might have other equipment where these were overlooked.
• If no inspection or maintenance procedures are developed, the inspections and maintenance may not be conducted appropriately.

The example questions above are a method of evaluating incidents called Root Cause Analysis (RCA).  The founder of the Toyota car manufacturing company, Sakichi Toyado is credited with inventing Root Cause Analysis (RCA)[54].  In Root Cause Analysis (RCA), incident causes can be divided into causal factors and root causes[55].  According to TapRoot® Root Cause Analysis (RCA), a causal factor is:

“A mistake, error, or failure that directly leads to (or causes) an incident … or fails to mitigate the consequences of the original error.”[56]

The TapRoot® Root Cause Analysis (RCA) definition of a root cause is:

“The most basic management system cause (or causes) that can reasonably be identified and that management has control to fix.”[57]

In addition to TapRoot® Root Cause Analysis (RCA) other Root Cause Analysis (RCA) methodologies include:

• Pareto Chart
• Fishbone Diagram
• The 5 Whys Method
• Change Analysis
• Barrier Analysis
• Fault Tree Analysis[58], and
• Events and causal factor analysis
• Risk tree analysis
• Kepner-Tregoe problem solving[59], and
• Cause and Effect Analysis – 6M[60]

In my opinion, the formal root cause investigation methodologies help prevent tunnel vision into a single cause and obviously help identify the root causes.  Some of these Root Cause Analysis (RCA) methodologies require training and/or use software.  The benefit of the training and cost-effectiveness of the software will vary for each company depending upon the number of incidents, manpower available to investigate, etc.

A newer investigation technique is referred to as Learning Teams and a recent study showed that learning teams investigations that were process-focused identified more corrective actions and a higher number of system-focused actions than root cause analysis investigations[61]. 

11.5.2.9 Human Behavioral Performance

When investigating incidents that directly involve people you may question their actions.  The benefits of hindsight make it easy to second guess their decisions[62].  Sydney Dekker, the founder of the Safety Science Innovation Lab, uses a tunnel analogy to help understand why certain decisions may have been made during an incident:  You need to put yourself inside a tunnel where the only information available is what was available to the people involved[63].  Inside the tunnel you may better understand the decisions made and realize that the people likely did what they thought was best and prudent at the time and did not intend to make a decision that would cause an incident or make it worse.

To avoid second guessing human behavioral performance during incident investigations, you can reframe your questions accordingly:

• Ask how, not why
• Ask what, not who

11.6 Follow-Up and Corrective Actions

Following up and correcting issues (e.g., root causes) may not be part of the investigation, but it I think it can be extremely important to preventing future incidents.  To ensure the corrective actions are addressed, you should identify the person responsible for the corrective action and identify a date when it will be implemented.  Following up to verify that the corrective action was implemented is also important.

Several regulations require you to submit reports if you have certain spills or releases.  I know of several state environmental agencies that will require a follow-up report following a spill or release depending upon the material and quantity released.  This might require a subsurface investigation (e.g., soil and/or groundwater sampling) to confirm the concentrations are below applicable concentrations (e.g., preliminary remediation goals).  If not, you may be required to conduct remediation and/or additional monitoring.

Although following up on investigations is important when you identify viable corrective actions, I feel it is important to not implement a corrective action just so you can give the appearance that you did something.  Specifically, avoid knee-jerk reactions that result in employee discipline and adding additional EHS requirements.

11.6.1 Spill Prevention Control and Countermeasures (SPCC) Spill Follow-up

The last potential incident follow-up is for facilities that are subject the Environmental Protection Agency’s (EPA) Spill Prevention Control and Countermeasures (SPCC) regulation.  If you are subject to the Spill Prevention Control and Countermeasures (SPCC) regulation and have an oil spill of over 1,000 gallons or two spills of 42 gallons within a twelve-month period, you must submit the following to the Environmental Protection Agency (EPA) regional administrator with 60 days:

• Name of the facility
• Your name
• Location of the facility
• Maximum storage or handling capacity of the facility and normal daily throughput
• Corrective action and countermeasures you have taken, including a description of equipment repairs and replacements
• An adequate description of the facility, including maps, flow diagrams, and topographical maps, as necessary
• The cause of such discharge as described in § 112.1(b), including a failure analysis of the system or subsystem in which the failure occurred
• Additional preventive measures you have taken or contemplated to minimize the possibility of recurrence, and
• Such other information as the Regional Administrator may reasonably require pertinent to the Plan or discharge[64]

11.7 For Additional Information

• “The Field Guide to Understanding Human Error” Third Edition by Sidney Dekker, CRC Press, Boca Raton, Florida 2014
• “Guidelines for Investigating Process Safety Incidents”, 3rd Edition American Institute of Chemical Engineers Center for Chemical Process Safety, John Wiley and Sons, New York, New York 2019
• “OSH Answers Fact Sheets Incident Investigation” Canadian Centre for Occupational Health and Safety website (https://www.ccohs.ca/oshanswers/hsprograms/investig.html#:~:text=Reasons%20to%20investigate%20a%20workplace%20incident%20include%3A%201,criminal%2C%20etc.%29%205%20to%20process%20workers%27%20compensation%20claims

11.8 References

[1] GoodReads website, Deepak Chopra\Quotes\Quotable Quotes accessed August 10, 2022 (https://www.goodreads.com/quotes/400357-there-are-no-accidents-there-is-only-some-purpose-that)

[2] “Incident Investigation – Overview ” Occupational Safety and Health Administration (OSHA) Website, (https://www.osha.gov/incident-investigation) accessed February 2, 2022

[3] “Normal Accidents Living With High Risk Technologies” by Charles Perrow, Princeton University Press, Princeton, New Jersey, 1984

[4] “Pre-Accident Investigations, An Introduction to Organizational Safety” by Todd Conklin, CRC Press, Taylor & Francis Group.

[5] “Pre-Accident Investigations, An Introduction to Organizational Safety” by Todd Conklin, CRC Press, Taylor & Francis Group.

[6] 29 Code of Federal Regulations (CFR) 1904 Subpart E Reporting Fatality, Injury and Illness Information to the Government

[7] 29 Code of Federal Regulations (CFR) 1904.5 Determination of work-relatedness.

[8] 29 Code of Federal Regulations (CFR) 1904 Subpart C – Recordkeeping Forms and Recording Criteria

[9] 29 Code of Federal Regulations (CFR) 1904.32(a)(3) and (4)

[10] 29 Code of Federal Regulations (CFR) 1904.41(a) Basic requirements

[11] 29 Code of Federal Regulations (CFR) 1904.7(a) General Recording Details

[12] “OSHA Forms for Recording Work-Related Injuries and Illnesses” Occupational Safety and Health Administration (https://www.osha.gov/sites/default/files/OSHA-RK-Forms-Package.pdf)

[13] “Employer-Reported Workplace Injuries and Illnesses (Annual)” U.S Bureau of Labor Statistics website (https://www.bls.gov/news.release/osh.toc.htm)

[14] 29 Code of Federal Regulations (CFR) 1904.40(a) Basic requirement

[15] 40 Code of Federal Regulations (CFR) 355 Subpart C Emergency Release Notification

[16] 49 Code of Federal Regulations (CFR) 171.15 Immediate Notice of Certain Hazardous Materials Incidents

[17] 49 Code of Federal Regulations (CFR) 225.9 Telephonic Reports Of Certain Accidents/Incidents And Other Events

[18] 40 Code of Federal Regulations (CFR) 302 Designation, Reportable Quantities and Notification

[19] 40 Code of Federal Regulations (CFR) 117.21 Notice

[20] 40 Code of Federal Regulations (CFR) 302 Designation, Reportable Quantities and Notification

[21] 40 Code of Federal Regulations (CFR) 110.6 Notification

[22] 761.125(a)(1) Reporting Requirements

[23] “Spill Reporting Matrix” Retail Compliance Center website updated January 1, 2020 (https://www.rila.org/retail-compliance-center/spill-reporting#:~:text=Every%20spill%20must%20be%20reported%20within%202%20hours,cleaned%20up%20within%202%20hours%20after%20the%20discovery)

[24] United States Coast Guard National Response Center Home Page website (https://nrc.uscg.mil/Default.aspx) accessed December 22, 2021

[25] “National Response Center” Environmental Protection Agency website (https://www.epa.gov/emergency-response/national-response-center) accessed December 22, 2021.

[26] “Definition of Immediate for Emergency Planning and Community Right-To-Know Act (EPCRA) and Comprehensive Environmental Response, Compensation and Liability Act (CERCLA) Release Notification” Environmental Protection Agency Questions and Answers website (https://www.epa.gov/epcra/definition-immediate-epcra-and-cercla-release-notification) accessed December 22, 2021

[27] FAA Oder 8020.11D Chg 1: Aircraft Accident and Incident Notification, Investigation, and Reporting definition of Aircraft Accident [49 Code of Federal Regulations (CFR) 830.2]

[28] 49 Code of Federal Regulations (CFR) 390.15 Assistance in Investigations and Special Studies part (b)

[29] 49 Code of Federal Regulations (CFR) 225.11 Reporting of Accidents/Incidents

[30] 14 Code of Federal Regulations (CFR) 107.9 Accident Reporting

[31] 49 Code of Federal Regulations (CFR) 191 Transportation of Natural and Other Gas by Pipeline; Annual Reports, Incident Reports, and Safety-Related Condition Reports

[32] “About the CSB” Chemical Safety Board website accessed December 27, 2021 (https://www.csb.gov/)

[33] 40 Code of Federal Regulations (CFR) 1604.3(a) Reporting an accidental release

[34] 40 Code of Federal Regulations (CFR) 1604.3(c) Reporting an accidental release

[35] 40 Code of Federal Regulations (CFR) 1604.4 Information Required In An Accidental Release Report

[36] “Meltdown Why Our Systems Fail and What We Can Do About It” by Chris Clearfield and Andras Tilsik, Chapter 6

[37] “Meltdown Why Our Systems Fail and What We Can Do About It” by Chris Clearfield and Andras Tilsik, Chapter 6

[38] “Meltdown Why Our Systems Fail and What We Can Do About It” by Chris Clearfield and Andras Tilsik, Chapter 6

[39] “Meltdown Why Our Systems Fail and What We Can Do About It” by Chris Clearfield and Andras Tilsik, Chapter 6

[40] “Meltdown Why Our Systems Fail and What We Can Do About It” by Chris Clearfield and Andras Tilsik, Chapter 6

[41] “Near Miss Reporting Policy” Occupational Safety and Health Administration (OSHA) example policy (https://www.osha.gov/sites/default/files/2021-07/Template%20for%20Near%20Miss%20Reporting%20Policy.pdf)

[42] “Normal Accidents – Living with High-Risk Technologies” by Charles Perrow, Princeton University Press, Princeton, New Jersey, 1999, Page 168.

[43] “Normal Accidents – Living with High-Risk Technologies” by Charles Perrow, Princeton University Press, Princeton, New Jersey, 1999, Page 168.

[44] OSH Answers Fact Sheets Incident Investigation Canadian Centre for Occupational Health and Safety website accessed January 15, 2022 (https://www.ccohs.ca/oshanswers/hsprograms/investig.html#:~:text=Reasons%20to%20investigate%20a%20workplace%20incident%20include%3A%201,criminal%2C%20etc.%29%205%20to%20process%20workers%27%20compensation%20claims)

[45] 29 Code of Federal Regulations (CFR) 1910.119(m)(1) Incident Investigation

[46] 40 Code of Federal Regulations (CFR) 68.60 Incident Investigation and 68.81 Incident Investigation

[47] “How An Investigation Informs Remediation” by Thomas Fox, JDSupra website accessed January 15, 2022 (https://www.jdsupra.com/legalnews/how-an-investigation-informs-remediation-12851/#:~:text=In%20the%202020%20Update%2C%20under%20C.%20Analysis%20and,and%20appropriately%20remediate%20to%20address%20the%20root%20causes.%E2%80%9D)

[48] “Estimated Costs of Occupational Injuries and Illnesses and Estimated Impact on a Company’s Profitability Worksheet” Occupational Safety and Health Administration (OSHA) Website (https://www.osha.gov/safetypays/estimator)

[49] “Rethinking the Reliability of Eyewitness Memory” by John T. Wixted, Laura Mickes, and Ronald P. Fisher, Perspectives on Psychological Science, 2018, Vol. 13(3) page 324, 218

[50] “Root Cause Analysis Handbook – A Guide to Efficient and Effective Incident Investigation” Third Edition by ABS Consulting, Lee N. Venden Heuvel, Donald K. Lorenzo, Laura O. Jackson, Walter E. Hanson, James J. Rooney, and David A. Walker, Rothstein Associates Inc., Publisher, Brookfield, Connecticut

[51] “Root Cause Analysis Handbook – A Guide to Efficient and Effective Incident Investigation” Third Edition by ABS Consulting, Lee N. Venden Heuvel, Donald K. Lorenzo, Laura O. Jackson, Walter E. Hanson, James J. Rooney, and David A. Walker, Rothstein Associates Inc., Publisher, Brookfield, Connecticut

[52] “Root Cause Analysis Handbook – A Guide to Efficient and Effective Incident Investigation” Third Edition by ABS Consulting, Lee N. Venden Heuvel, Donald K. Lorenzo, Laura O. Jackson, Walter E. Hanson, James J. Rooney, and David A. Walker, Rothstein Associates Inc., Publisher, Brookfield, Connecticut

[53] “Cause & Effect Analysis – 6M” Posted by Allison Lynch, Edraw website, January 18, 2022 (https://www.edrawsoft.com/6m-method.html)

[54] “A Brief History of Root Cause Analysis” Bright Hub PM Project Management website  (https://www.brighthubpm.com/risk-management/123244-how-has-the-root-cause-analysis-evolved-since-inception/) accessed January 26, 2022.

[55] “Root Cause Analysis Handbook – A Guide to Efficient and Effective Incident Investigation” Third Edition by ABS Consulting, Lee N. Venden Heuvel, Donald K. Lorenzo, Laura O. Jackson, Walter E. Hanson, James J. Rooney, and David A. Walker, Rothstein Associates Inc., Publisher, Brookfield, Connecticut

[56] “What is a Causal Factor?” TapRoot® Root Cause Analysis website (What is a Causal Factor? – TapRooT® Root Cause Analysis) accessed January 26, 2022

[57] “The History of the Definition of a Root Cause” by Mark Paradies, June 20, 2018, TapRoot® Root Cause Analysis website (https://www.taproot.com/the-history-of-the-definition-of-a-root-cause/) accessed January 26, 2022

[58] “Root Analysis Methods” Invensis® Global Learning Services website (https://www.invensislearning.com/blog/root-cause-analysis-methods/) accessed January 26, 2022

[59] “Root Cause Analysis: Introduction to Root Cause Analysis: Definitions and Challenges” Tulip website (https://tulip.co/ebooks/root-cause-analysis/#:~:text=A%20causal%20factor%20is%20any%20behavior%2C%20omission%2C%20or,identifying%20a%20root%20cause%20over%20a%20causal%20factor.) accessed January 26, 2022

[60] “Cause & Effect Analysis – 6M” Posted by Allison Lynch, Edraw website, January 18, 2022 (https://www.edrawsoft.com/6m-method.html)

[61] Evaluation of Learning Teams Versus Root Cause Analysis for Incident Investigation in a Large United Kingdom National Health Service Hospita (https://www.researchgate.net/publication/340141827_Evaluation_of_Learning_Teams_Versus_Root_Cause_Analysis_for_Incident_Investigation_in_a_Large_United_Kingdom_National_Health_Service_Hospital#:~:text=The%20traditional%20approach%20to%20investigation%20is%20root%20cause,system-focused%20actions%3B%20however%2C%20this%20has%20not%20been%20evaluated.)

[62] “The Field Guide to Understanding ‘Human Error’” Third Edition by Sidney Dekker, CRC Press, Boco Raton, Florida, 2014, page 28.

[63] “The Field Guide to Understanding ‘Human Error’” Third Edition by Sidney Dekker, CRC Press, Boco Raton, Florida, 2014, page 31.

[64] 40 Code of Federal Regulations (CFR) 112.4(a) Amendment of Spill Prevention, Control, and Countermeasure Plan by Regional Administrator