Abstract
Accident and incident investigations have become established procedures in the industry. These procedures have been applied with varying degree of success in many cases. The starting point of any investigation is the setting up of a committee, which is responsible for finding out how and why incidents happen. The committee uses a variety of techniques to understand the incident and attempts to reconstruct the event. The techniques include interviews with personnel, review of documentation/records, reports etc. Traditional investigations usually arrive at causes that are related to equipment, personnel or both.
However, recently published investigations go beyond the usual conclusions. Concepts like safety culture, organizational structure and employee empowerment figure prominently in these reports which normally do not find place in traditional investigations. Safety is an emergent property of a system and cannot be considered in isolation from the society and business environment in which it operates. Complexity of process systems and requirements from the society pose new challenges to process plant safety. Better understanding is required to meet these challenges. Naturally, investigations of any incident have to deal with these aspects. Recent case histories are evidence to this.
This paper will examine the basics of current investigative techniques. Further it will present the emerging research in systems theory and its application to socio-technical structures. It will outline how systems approach considers components and dynamics of their interrelationships as parts of a whole and potential for application to incident investigations.
In conclusion the paper will demonstrate that systems approach will be able to offer new insights on incident investigations and improve process safety management. To support the same reviews of investigations will be presented with systems approach methodology.
