Appendix A A-l

Appendix A: Aspects of Typical Incident Report

Documentation
1. Incident Data
All available incident data has to be catalogued and refined before the working
hypotheses can be established. Incident data will consist of:
• general description, circumstances
• written statements
• eyewitness testimonies
• laboratory tests results
• photographic evidence
• video recordings taken during dismantling of the incident site
• process flow diagrams
• utility flow diagrams
• material & energy balances
• process description
• piping & instrument drawings (P&IDs)
• piping isometrics
• piping specifications
• equipment specifications
• equipment vendor drawings
• instrument data & set point data
• control logic diagrams
• computer operating data
• pressure relief device specifications
• plot plan drawings
• operating procedures manual
• operating logs & daily operating instructions

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 A-2 Appendix A

• emergency shutdown procedures

• plant safety program (also see Appendix D)
• MSDS & safety data
• historical data on previous incidents and near misses
• records of memoranda of change for unit/facility
• data on environmental conditions

2. Studies of Human Reliability and the Role of Human Error

This is frequently an area that is studied and reported in as much detail as possible. It
should include:
• questionnaires on the level of understanding of individual roles
• an assessment of the levels of understanding of the personnel roles and tasks
performed
• the location and actions of personnel immediately before, during and after the
incident, including their communications
To determine whether or to what extent human error has played a role, some form of
human error analysis may be needed. This should culminate in some fonn of an
indication as to whether human error was probable or not probable.

3. Analysis of Loss of Containment Due to Equipment Failure

Incidents frequently occur when a loss of containment situation arises and loss of
containment usually implies some form of over-pressurization. For example, incidents
can occur when a pressure relief system and the blow-down system fail to respond
adequately. This is an area that needs analysis and clearly, should the damaged portion of
the facility be rebuilt, it will need careful redesign to prevent recurrence. Generally loss
of containment situations fall into one of three categories:
• Major, such as a rupture of an item of equipment
• Medium, such as a substantial leakage through say a pump or compressor seal
leak
• Minor, such as a flange leak.
Both medium and minor loss of containment situations can become major if fire or
explosion results, i.e., incurring knock-on or domino effects.

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Appendix A A-3

4. Contamination and Role of Contaminants

Contamination can lead to an incident as for e.g., ingress of air and oxidizing matter.
How did the contaminant initially enter the process? Did the contaminant enter with the
feed or other materials or did it ingress as a result of a partial vacuum or a reverse flow
situation or by what route? Typically if there is reverse flow or a check valve fails to
hold, e.g. ingress of nitrogen lines by hydrocarbons, contamination can result.

5. Event Sequencing
Event sequencing refers to the event versus timeline for the incident. What occurred
immediately prior to the incident? What occurred at the time of the incident? What
occurred immediately after the incident? Event sequencing could extend from hours or
even days prior to the incident to an hour or so immediately after the incident, if these
were causal. The aim will also be to compare what occurred normally (without incidents)
with what occurred when there was an incident.
Most importantly, the history of the event may be recorded on the computer systems that
are normally used for the recording and logging of data. The role of computer logging of
plant computers to determine the event-time story profile from before, during, and
immediately after the incident plays a vital role in verifying what has occurred. Specific
instruments record operating conditions such as temperatures, pressures, concentration,
flow, etc. The data obtained can be compared with the statements of eyewitnesses and
others. A table can thus be prepared that gives a sequence of events.
The event sequence should include the following:
• The date on which a specific event occurred
• The best estimated time at which the specified event occurred. Frequently this is
not known with any great accuracy, with the exception of events close to the time
of the incident, including the incident itself
• The event number. This is a provisionally assigned number in order to identify a
discrete event. As the table is revised the events can be re-numbered or,
alternatively, specific events can be renumbered where more detail is needed.
Thus an event #8 may be subdivided into event #8.1, #8.2, #8.3 and so forth.
• The action: this briefly describes what occurred with the event. As much detail as
is felt desirable.
• The reference source of the information. Did it come from recorded computer
data, from operational logs, from eyewitness testimony etc.?

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 A-4 Appendix A

• Comments column: a comments column is always useful and allows helpful

infonnation to be included with the table.
It is good if the lead investigator can create an Event Sequence Table very early on in the
proceedings and fill in the blanks on an ongoing basis. Also, when there are many
eyewitness testimonies, data from computer logs and other time related data, the lead
investigator should prepare a description of the event that links everything together in a
single document. Avoid making the table cryptic or difficult to follow and minimize the
use of acronyms. The following is a very simplified version of what may be created (they
are usually far more detailed):
Example of Event Sequence Table

Event
Date Time Action Reference Comments
#

Light ends unit taken out of Operational log for

7/10/04 1700 hrs 1
service 7/10/05

Instrument Group log

7/11/04 0800 hrs 2 PI-104 taken out of service. for 7/11/05
(Harry Long)

Following
Instrument Group log
std.
7/11/04 0830 hrs 3 PIC-I06 recalibrated for 7/11/05
procedure
(Harry Long)
IG-206

Following
Instrument Group log
Instrument loop FRC-116 std.
7/11/04 1000 hrs 4 for 7/11/05
checked out procedure
(Harry Long)
IG-693

Following
Column C-I0 1 vented, Maintenance Group log
std.
7/11/04 1200 hrs 5 steamed and opened up for for 7/11/05
procedure
inspection (Mitch McGovern)
MG-224

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 Appendix A A-S

Event
Date Time Action Reference Comments
#

Following
Column C-I0 1 closed, Maintenance Group log
std.
7/11/04 1700 hrs 6 pressured up with N2, leak for 7/11/05
procedure
tested (Mitch McGovern)
MG-921

Column C-I0 1 vented and

Operator Phil Smith
7/12/04 0800 hrs 7 pressured up to 100 psig
eyewitness testimony
with N2

Column C-I0 1 vented and

Operator Phil Smith
7/12/04 0900 hrs 8 re-pressured up to 100 psig
eyewitness testimony
with N2

Control center notified ready Operator Phil Smith

7/12/04 0930 hrs 9
to introduce feed to column eyewitness testimony

Operator Phil Smith &

Control center notifies unit
7/12/04 0950 hrs 10 Barry Brown
to open feed to column
eyewitness testimonies

Operator Phil Smith &

James Foyle opens CW to
7/12/04 1000 hrs 11 Barry Brown
EX-I02
eyewitness testimonies

Barry Brown sets FV-101 to Operator Phil Smith &

7/12/04 1005 hrs 12 lowest setting and Barry Brown
introduces feed eyewitness testimonies

Operator Phil Smith &

Explosion occurs within C-
7/12/04 1008 hrs 13 Barry Brown
101
eyewitness testimonies

Emergency Response Unit

7/12/04 1010 hrs 14 ERP team testimonies
on scene

The fire was brought under

7/12/04 1018 hrs 15 ERP team testimonies
control.

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 A-6 Aopendix A

6. Multiple Cause Determination

Provide a review of all of the multiple factors that could have played a number of roles in
the incident. Typically:
• Were there one or more failurer; in the equipment or its components?
• Of the operations carried out, which ones were correct, which ones were dubious
or ineffective, which ones were in error?
• Did the operator(s) make an incorrect analysis and, if so, why?
• If there were material failures, what were these? Were materials exposed to
excessive forces, to excessive heat, pressures, temperatures or extremely
corrosive environments?
• Was maintenance a factor? Could lack of maintenance, incorrect maintenance,
unsafe maintenance or use of incorrect parts or components have played a role?
• Could lack of understanding, knowledge or training have played a role?
• Was lack of guidance from management or incorrect instruction from
management a problem?

7. Modeling and Analysis of the Incident

Modeling and analysis of the incident can be very important since, whatever verbal and
other opinions are expressed, the laws of physics and chemistry are ultimately the true
arbiters. Modeling and analysis are the true technical audit, provided they are credible
and do not create more questions than they are supposed to answer. The value of
modeling or simulation cannot necessarily give an accurate picture of what occurred, but
it is a means oflooking at what is possible in order to determine whether it is probable.
For example, in the cases of fire and explosion understanding the mechanisms of
combustion and, possibly, decomposition chemistry, are necessary. Models help in
understanding the changes in state that result in explosions leading to blast waves or fires
resulting in thermal radiation and the ensuing impacts on targets, whether they are
human, physical objects or the environment. Also, the identification of potential ignition
mechanisms need to be addressed: they may not be fully understood or quantifiable, but
they need to be listed.
With loss of containment studies it is desirable to show how overpressure was achieved
and how this led to loss of containment of equipment. Modeling can show how failure
resulted from overstressing to the point of material(s) failure. There needs to be an

Copyright © 2006 by Dyadem Engineering Corporation

 Appendix A A-7

understanding of the mechanism of loss of containment: how did it start from the point of
over-pressurization through to leakage or rupture?
With explosions there exists the potential for random missiles: trajectories and forces
capable of producing missiles that may penetrate structures at considerable distances:
these may be computed.

8. Review of Impacts on Health (1), (2)

Impacts on health can vary greatly from little or minor injury to fatality, involving one or
more persons. The following is a list of typical injuries associated with explosions:

System Type of Injury

Auditory Eardrum rupture, ossicular disruption, cochlear damage, foreign body

Eye, Orbit, Perforated globe, foreign body, air embolism, fractures

Face

Respiratory Blast lung, haemothorax, pneumothorax, pulmonary contusion and

hemorrhage, arteriovenous fistulas (source of air embolism), airway epithelial
damage, aspiration pneumonitis, sepsis

Digestive Bowel perforation, hemorrhage, ruptured liver or spleen, sepsis, mesenteric

ischemia from air embolism

Circulatory Cardiac contusion, myocardial infarction from air embolism, shock, vasovagal
hypotension, peripheral vascular injury, air embolism-induced injury

Central Concussion, closed and open brain injury, stroke, spinal cord injury, air
Nervous embolism-induced injury
System Injury

Renal Injury Renal contusion, laceration, acute renal failure due to rhabdomyolysis,
hypotension, and hypovolemia

Extremity Traumatic amputation, fractures, crush injuries, compartment syndrome, burns,

Injury cuts, lacerations, acute arterial occlusion, air embolism-induced injury

Copyright © 2006 by Dyadem Engineering Corporation

 A-B Appendix A

The impact of exposure to toxics varies very widely, dependent on the toxic released.
Some impacts of exposure to ammonia, a commonly used industrial chemical are shown
below:

System or Area Type of Injury

of Concern

Respiratory Even fairly low concentrations of ammonia produce rapid onset of eye, nose,
and throat irritation; coughing; and bronchospasm. More severe clinical signs
include immediate laryngospasm and laryngeal edema resulting in upper
airway obstruction. Pulmonary edema can occur.

Dermal (skin) Exposure to concentrated vapor or solution can cause stinging pain, erythema,
and vesiculation, especially on moist skin areas. Skin contact with
compressed, liquid ammonia causes frostbite injury; severe burns with deep
ulcerations may result.

Ocular (eyes) Even low concentrations of ammonia produce rapid onset of eye irritation.
Contact with high gas concentrations or with concentrated ammonium
hydroxide may cause conjunctival edema and corneal erosion.

Potential Survivors of severe inhalation injury often suffer residual chronic lung
Sequelae (after disease. In cases of eye contact, ulceration and perforation of the cornea can
effects) occur after weeks or months, and blindness may ensue. Cataracts and
glaucoma have been reported in persons acutely exposed.

There needs to be a review of effects of hazards that may be caused typically by:
• Pool fires
• Jet flames
• Flash fires
• Fireballs
• Explosion (blast effects)
• Missiles generated by explosion
• Toxic effects

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 Appendix A A-9

• Corrosive chemicals exposure

9. Review of Impacts on Plant

Impacts on plant can vary greatly from nil effects with toxic releases to severe damage
caused by fire to possible demolition for explosions.
The effects of impacts to plant need to be covered:
• Any structural defonnation
• Damage to vessels, tanks and equipment
• Damage to piping
• Damage to instruments and control systems and cable trays
• Damage to piping and ducting
• Damage to electrical equipment and switchgear
• Damage to walls, ceilings and floors
• Damage to ancillary systems, e.g., drains, HVAC, lighting
• Surfaces exposed to excess heat and force and impacts from missiles

10. Hypotheses for the Incident

The main possibilities, listed as hypotheses, are needed in order to show that all
reasonable possible routes have been considered. The hypotheses description should
include:
• Assignment of a number to each hypothesis. Where there is hypothesis with
subsets or minor variations these can be labeled as say 3.1, 3.2, 3.3 etc.
• Provide an explanation for each different hypothesis
• If rejected, provide reasons for flaws or unlikelihood of hypothesis
• Identify whether hypothesis is impossible, unlikely, not plausible, plausible or
very likely
These should address all possible scenarios and the selection of the working hypotheses
(there may be more than one) should be given.

Copyright © 2006 by Dyadem Engineering Corporation

 A-10 Appendix A

11. PSM Compliance for Facility (7)

For the most part PSM (Process Safety Management) guidelines cover the entire gamut
of relevant areas. PSM is designed to adapt to the needs of most of operations involved in
the storage, transfer, use and processing of hazardous materials. PSM is a management
approach and covers a wide range of issues and organizational aspects. These are
classified into 12 elements. In summary these are:
(i) Accountability: Objective and Goals;

The key components of accountability address the following:

• Continuity of Operations
• Continuity of systems
• Continuity of organization
• Quality process
• Control of exceptions
• Alternative methods
• Management accessibility
• Communications
• Company expectations
(ii) Process Knowledge and Documentation;

Process safety infonnation is needed in the following areas:

• Chemical and occupational health hazards
• Process definition / design criteria
• Process and equipment design
• Protective systems
• Operating procedures for normal and upset conditions
• Process risk management decisions
• Company memory (management of infonnation)
(iii) Capital Project Review and Design Procedures;

The important elements of Capital project review are:

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 Appendix A A-ll

• Appropriation request procedures

• Hazard reviews
• Siting reviews
• Plot plan reviews
• Process design and review procedures
• Project management procedures and controls
(iv) Process Risk Management;

Process risk management is very important for the safe running of an organization. There
are numerous scientific techniques, which are available for hazard identification and
hazard assessment. Management must implement the remedial measures to reduce the
risks to an acceptable level. The following are the important sub elements:
• Hazard identification
• Risk analysis of operations
• Reduction of risk
• Residual risk management
• Process management during emergencies
• Encouraging client and supplier companies to adopt similar risk management
practices
• Selection of businesses with acceptable risk
(v) Management of Change;

Normally, Management of Change is required in the following areas:

• Change of Process Technology
• Change of facility
• Organizational changes that may have an impact on process safety
• Variance procedures
• Permanent changes
• Temporary changes

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 A-12 Aopendix A

(vi) Process and Equipment Integrity;

Written procedures should be used to maintain the ongoing integrity of process

equipment such as:
• Pressure vessels and storage tanks;
• Piping, instrument and electrical systems;
• Process control software;
• Relief and vent system devices;
• Emergency and fire protection systems;
• Controls including monitoring devices and sensors, alarms and interlocks and
• Rotating equipment.
As regards the above, the following are important sub-elements:
• Reliability engineering
• Materials of construction
• Fabrication and Inspection procedures
• Installation Procedures
• Preventive maintenance
• Process, hardware and systems inspection and testing (pre-startup safety review)
• Maintenance of procedures
• Alarm and instrument management
• Decommission and demolition procedures
(vii) Human Factors;

The following are the important sub-elements when assessing human factors:
• Operator - process / equipment interface
• Administrative control versus hardware control
• Human error assessment
(viii) Training and Performance;

The following are the important sub-elements of training:

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 Appendix A A-13

• Definition of skills and knowledge

• Design of operating and maintenance procedures
• Initial qualifications assessment
• Selection and development of training programs
• Measuring training and perfonnance
• Instructor program
• Records management
• Ongoing perfonnance and refresher training
(ix) Incident Investigation;
The role of Incident Investigation, although the basis for this book, is also an important
component of PSM (Process Safety Management). It gives insight into the weaknesses
and problems of the system. It provides a way to prevent occurrence of the incident in the
future. The findings of the investigation must be communicated throughout the
organization and the recommendations must be implemented. It must be remembered that
reporting and investigating near misses is also extremely important. The following are the
main sub elements of incident investigation:
• Major incidents
• Third party participation
• Follow-up and resolution
• Communication
• Incident recording, reporting and analysis
• Near-miss reporting
(x) Company Standards, Codes and Regulations;

A management system is needed to ensure that the various internal and external
published guidelines, standards are current, disseminated to appropriate people and
departments, and applied throughout the system. These guidelines can be broadly
classified as:
• External codes / regulations, e.g., OSHA 1910.119, API guidelines, CMA
Responsible care etc.
• Internal Company standards

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 ---------.
A-14 Appendix A

(xi) Audits and Corrective actions;

Traditionally, plant safety review has been conducted as a nonnal part of commissioning
by the plant manager and the plant safety officer. It is concerned with mainly checking
that the company complies with the legal and company safety requirements. Attention is
directed to features such as: access and means of escape; walkways, stairs and floors; and
fire fighting and protective equipment.
There has developed from this the more comprehensive plant safety audit. The audit is
carried out first during the plant commissioning, but is also repeated later at intervals.
Typical intervals are a year after start-up and every five years thereafter. Checklists are
prepared for these audits. It must be emphasized that the management act on any audit
made.
The following are the important sub elements:
• Process safety management systems audits
• Process safety audits
• Compliance reviews
• Internal/external auditors
• Corrective actions
(xii) Enhancement of Process Safety Knowledge

A management system for process safety should be designed for a continuous

improvement. Safety requirements are becoming more stringent, while knowledge of
systems and technology is growing, like the effect of DIERS on the design of relief
systems, the application of SIL (Safety Integrity Levels) and LOPA (Layers of Protection
Analysis). Safe operation of a plant calls for personnel to stay abreast of current
developments, and for safety infonnation to be readily accessible
The record of the Company's conformance with the accepted industry standards,
such as PSM determines the degree of diligence exercised by the Company.

12. Effectiveness of Triage (3), (4)

Triage is derived from the French trier, meaning "to sort." Surgical triage developed
from the need to prioritize the care of injured soldiers in battlefield settings. The concept
of prioritizing patients and providing immediate care to the most seriously injured was
practiced in France in the early 1800s. Over the next century, this practice was further

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Appendix A A-iS

developed in annies throughout the world. As a result, many injured persons whose
surgery might have been delayed received critical care earlier.
Disaster medical triage is a dynamic process occurring at several levels in the system to
rapidly identify patients with critical injuries from the total number of presenting
casualties. Traditionally, triage systems have attempted to sort victims into categories to
detennine treatment and transport priorities. Triage in a disaster is neither perfect nor
democratic. It lacks sensitivity and specificity; however, triage improves outcome.
Avoiding deaths in all categories requires knowledge of the resources of the local
emergency medical services system. Simple triage and rapid treatment categorizes
victims based on their ability to walk, their mental status, and the presence or absence of
ventilation or capillary perfusion.
Based upon color-coding casualties are categorized as:
• Red - Emergent. Casualties requiring immediate surgery or other life-saving
intervention, first priority for surgical teams or transport to advanced facilities,
they "cannot wait" but are likely to survive with immediate treatment.
• Yellow - Urgent. Casualties whose condition is stable for the moment but require
watching by trained persons and frequent re-triage, will need hospital care (and
would receive immediate priority care under "normal" circumstances).
• Green - Non-urgent. Casualties will require a doctor's care in several hours or
days but not immediately, may wait for a number of hours or be told to go home
and come back the next day (broken bones without compound fractures, many
soft tissue injuries).
• White - Such casualties have minor InJurIes; first aid and home care are
sufficient, a doctor's care is not required.
• Black - Dead or very severely injured and not expected to survive. They are so
severely injured that they will die of their injuries, possibly in minutes, hours or
days (large-body bums, severe trauma, lethal radiation dose), or in life-
threatening medical crisis that they are unlikely to survive given the care
available; they will require painkillers to ease their passing.
Patients who are severely injured and not expected to survive are the most difficult to
assign because of the obvious ominous implications. Note that patients placed in this
category clearly are so severely injured that no degree of medical help relieves them.
Emergency medical treatment may extend across a number of levels: local first aid (e.g.,
CPR), Company medical personnel, ambulance, hospital. It will be necessary to address

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 A-16 Appendix A

the effectiveness of the emergency team to rescue and perform procedures to save lives
and mitigate injuries is assessed.
Incident Investigator's Review of Triage and follow up:
The incident investigator, in reviewing the effectiveness of triage and follow up, may
wish to:
1. Determine the degree of injury of those affected.
2. Identify potential treatment(s) that, if effectively administered, have the potential
to treat and improve the health of the affected persons.
3. Identify and evaluate the treatment(s) actually administered in the field and
afterwards.
4. Identify and evaluate the capability of the responders (Company safety
personnel; ambulance; hospital emergency) to treat the affected persons.
In the evaluation of triage and follow up the following may be documented:
(i) Background to the Incident

Bearing in mind that the working hypotheses are important in describing and accounting
for what has occurred, a short but succinct, description of the incident is required. If
toxic, flammable, explosive or other harmful impacts occurred, these should be
referenced.
The role, speed and effectiveness of the emergency responders should be mentioned.
(ii) Degree of Injury

The most significant contributors to death and/or injury should be discussed including
how, in qualitative terms, the mechanisms of their injuries whether they arose from
toxics, blast, bums or other harmful effects. If not exactly known, a number of different,
but credible, possibilities may be enumerated.
(iii) Characteristics of Specific Agents

There may be a number of different physiological effects associated with (a) the release
of a specific substance or (b) the release or creation of toxic or harmful substances
resulting from decomposition (i.e., decomposition products) or (c) the release or creation
of toxic or harmful substances resulting from combustion in the atmosphere (i.e.,
combustion products).
The physiological impacts should be identified whether they are typically harmful to:

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 Appendix A A-17

• The respiratory system

• The digestive system
• The brain and nervous system
• The liver, kidneys, pancreas, spleen etc.
• The skin or flesh
• The eyes, olfactory or hearing system
• Other body parts or systems
In general the medical literature and use of medically correct terms should be used.
(iv) Exposure / Health Effects Modeling

A widely accepted method for modeling the probability of lethality for acute single
exposures to toxic materials or harmful agents, such as thermal radiation, lung
hemorrhage etc. is probit analysis. (See Chapter 15 for information on probit analysis).
(v) Post Accident Treatment

Information on post accident treatment in hospital mayor may not be available since
patient records are often kept confidential unless the victim or their family permits
release of information that may be deemed as confidential and sensitive. Physicians are
certainly not obligated to release such details except that some direct causes, in the case
of death, may be cited by coroners.
Immediate onsite post accident treatment may be available to the Company except once
paramedics and ambulance staff are involved confidentiality begins.
It is, nonetheless, in the best interests of the investigation to know as much about injury
details as possible, provided that that the victims and their family's rights are not
violated. Every Company, as a corollary to its Material Safety Data Sheet's hazardous
substances data should know (a) full details of toxicities, (b) toxic dose levels, (c)
treatments and agents that can counteract toxic effects. It is not reasonable to assume that
a local or nearby hospital will know absolutely everything about the effects and
treatments of possibly hundreds of chemicals that may be used or handled in the vicinity.
A responsible MSDS appendage is to research and provide qualitative and quantitative
toxics impact data on all chemicals used together with possible remediation
methodologies: this may come from qualified toxicologists and medical sources.

Copyright © 2006 by Dyadem Engineering Corporation

 A-iS Appendix A

13. Mitigation Systems Before Incident Occurred

It is important to know what mitigation is in place prior to the incident. Mitigation
systems are usually deemed to be one of two types, namely, active or passive. Active
mitigation requires some form of mechanism, either mechanical, electric, hydraulic,
pneumatic or human intervention to operate in order for mitigation to take place. Passive
mitigation requires no form of actuation in order to be effective.
Examples of active mitigation include:
• Flow, level, pressure, temperature alarms, switches and trips
• Pressure relief devices
• Fire sensors, detectors, alarms
• Fire monitors
• Sprinkler and deluge systems
• Gas sensors, detectors, alarms
• Emergency shutdown systems that include sensors, alarms, software and
hardware, e.g. PLCs, emergency shutdown valves
• Snuffmg steam
• Water curtains
• Steam curtains
• Remotely operated valves
• Shutdown procedures
Examples of passive mitigation include:
• Blow-out panels (explosion venting)
• Reduced inventories of hazardous materials
• Containment dikes
• Fireproofing of vessels, load bearing and supporting steelwork etc.
• Adequate/increased spacing
• Locating upwind of likely release points or hazardous sources
• Multiple escape routes

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Appendix A A-19

• Good roads and access

• Blast resistant buildings
It may seem preferable to depend, as much as possible, on passive as opposed to active
mitigation but, in reality, active mitigation is very often the first line of defense with
passive present should active mitigation fail. Also, very many of the active mitigation
measures are, nonetheless, often very reliable. For example pressure relief valves and
flare systems have a very high level of dependency placed upon them so that should, for
example, the emergency shutdown systems fail, the pressure relief systems will likely
cope with the load.

14. Emergency Response Time and Performance

Time is of the essence in the aftennath of an incident. In addition to triage, the emergency
response time is especially considered to ensure that all communication systems were
functional and effective. Also the efficiency of Emergency Response is extremely
critical. Minutes and possibly seconds in some instances can mean the difference between
life and death. Assessment of the Emergency Response time and perfonnance by the
investigating team should include asking the following questions:
• Was the Emergency Response Team well organized?
• How rapid was the Emergency Response?
• When the incident occurred, did the Team know what to do?
• How well did the Team communicate?
• Was the team properly equipped to handle the emergency?
• Did the team apply any emergency life saving procedures and were these
correctly applied?
• Was there a prompt response to get assistance from outside agencies (local fire
department, ambulance, paramedics, hospital, police etc.)?
• What lessons could be learned in order to benefit future emergency responses?
(For further infonnation on Emergency Response see Appendix B).

15. Recommendations for Incident Prevention

In compliance with OSHA 1910.119 requirements recommendations should be made to
minimize the chances of recurrence. As an analysis of what went wrong and caused the

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 A-20 Appendix A

incident it follows that this should be a good indicator of what needs to be changed.
Remedial measures are addressed in Chapter 19. Also see item 13 of this Appendix.

16. Refurbishing and Rebuilding Recommendations (if applicable)

Although Refurbishing and Rebuilding do not form part of the incident investigator's
mandate, they are, nonetheless, issues of possible involvement. These are discussed
further in Chapter 20.

17. Management and Planning

An incident management plan needs to be drawn up, managed and coordinated in a
timely manner especially if the production is on hold for the duration of the investigation.
Losses due to stopped production can be extremely expensive.

18. Summary Review

A summary is prepared at the very end of the investigation when all the studies have been
completed and all involved parties, especially legal, have agreed on the causal
mechanisms. Should a legal case arise at this point, all parties should have a basic
understanding of what has transpired.

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 Appendix A A-21

Ref. References and Suggested Reading

No. (Note: Internet URLs current at date of publication)

1 "Explosions and Blast Injuries: A Primer for Clinicians", CDC, Centers for Disease
Control

http://www.bt.cdc.gov/masstrauma/explosions.asp#key

2 "Medical Management Guidelines for Acute Chemical Exposures", CDC, Centers for
Disease Control

http://wonder.cdc.gov/wonder/prevg uid/pOOOOO 16/pOOOOO16.asp# head 00 50010

01000000

3 "Triage", Wikipedia

http://en .wikipedia .org/wikijTriage# Black_.2F_Expectant

4 "Triage", eMedicine.com

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