The Analysis of an Incident Investigation System

Electrical incidents provide valuable learning opportunities if root causes are identified. Incident investigations which are unable to identify all root causes and address the shortcomings in the safety management system may result in recurring incidents. It is important that the entire incident investigation programme be guided by proven techniques and executed in a well-established manner. In a white paper titled "The Development of Questions to Determine the Effectiveness of the Incident Investigation Process for Electrical Incidents", the authors analysed commonly applied incident investigation techniques and suggested six salient incident investigation process requirements irrespective of the techniques used. The paper also suggested eight latent traits, which could be used to determine the effectiveness of the incident investigation process. This paper utilises the established learning and applies it to a large steel plant. A number of serious electrical incidents, spanning many years, at different operating units were analytically reviewed. A study of the organisational policy and one completed incident investigation report is analysed to determine the effectiveness of the incident investigation process. Shortcomings in the process are discussed and possible salient practises which derogate from effective investigations are proposed. This paper forms part of a larger research project to determine the effectiveness of the application of the incident investigation process. The results and recommendations from the study aim to provide generic benchmarking of the incident investigation process, which could be used by organizations to improve its electrical safety performance.