To learn from incidents and help prevent similar incidents, your SEMS program must establish procedures for investigation of all incidents with serious safety or environmental consequences and require investigation of incidents that are determined by facility management or BSEE to have possessed the potential for serious safety or environmental consequences. Incident investigations must be initiated as promptly as possible, with due regard for the necessity of securing the incident scene and protecting people and the environment. Incident investigations must be conducted by personnel knowledgeable in the process involved, investigation techniques, and other specialties that are relevant or necessary.
(a) The investigation of an incident must address the following:
(1) The nature of the incident;
(2) The factors (human or other) that contributed to the initiation of the incident and its escalation/control; and
(3) Recommended changes identified as a result of the investigation.
(b) A corrective action program must be established based on the findings of the investigation in order to analyze incidents for common root causes. The corrective action program must:
(1) Retain the findings of investigations for use in the next hazard analysis update or audit;
(2) Determine and document the response to each finding to ensure that corrective actions are completed; and
(3) Implement a system whereby conclusions of investigations are distributed to similar facilities and appropriate personnel within their organization.