Incident Investigation - EN
This damage resulted from a propane vapor cloud. The emission resulted from failure of the main valve when a tank rolled over, followed by gas ignition on a heater.
DoktersAdvice is an independent firm and is able to assist customers with investigation of incidents.
Reason for investigation is to identify which elements, relevant for organizational Risk Management, could be improved.
Analysis of actual Incidents reveals the following elements:
•What happened (based on factual evidence).
•Which barriers (controls) did not function properly?
•Which causes were leading to the failing barrier?
•Which preconditions (work environment conditions) allowed the causes to happen?
•Which underlying causes (Root Causes) were leading to the working environment?
•Which organizational weaknesses (Basic Risk Factors) were involved?
Based on the analysis action points must be defined to prevent the actual incident from happening again and to prevent similar events from happening.
Incident Investigation will be carried out by an independent practitioner using the Tripod beta technology.
Small incidents in an organization may lead to serious incidents.
In order to prevent these serious incidents the analysis of small incidents may identify the underlying causes which potentially may lead to major incidents.
By defining an incident as: "anything that did not work out as intended" it is clear that all incidents should be avoided to reduce the cost of non-performance.
Behavior of people in an organization is playing a role in many incidents in organizations and should be taken into account at all times.