If you’re covered by either OSHA’s Process Safety Management (PSM) standard or EPA’s Risk Management Program (RMP) regulations, you are required to perform incident investigations. Both standards require employers to investigate incidents that resulted in, or could reasonably have resulted in, catastrophic chemical releases.
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The requirements in the two standards are remarkably similar and not very detailed, but a new fact sheet published jointly by the two agencies urges employers to utilize a more detailed method of incident investigation than the standards require, called “root cause analysis.” Underlying their exhortation is a concern that employers are failing to get at the true causes of incidents and failing to control the risk of hazardous chemical releases as a result.
The Goal of an Investigation
The PSM and RMP standards both require employers to prepare incident investigation reports documenting:
- The date of the incident
- The date the investigation began
- A description of the incident
- The factors that contributed to the incident
- Any recommendations resulting from the investigation
Both standards state that these are minimum requirements for incident investigations. Some investigations may technically comply with the rules, yet miss important information, especially if employers stop too soon.
For example, the fact sheet describes a situation in which a worker slips on oil that has spilled on the floor, and it recommends that spills be cleaned up promptly. A traditional investigation, the agencies surmise, might determine that the solution is to clean up spills promptly. But this is merely the immediate cause of the incident, and it fails to answer the question “why was the oil on the floor in the first place?” The answer to that question might well be that the facility’s mechanical integrity program was at fault, leading to a solution that will be far more effective at preventing further incidents than one that doesn’t come into play until the oil is already spilled.
A root cause analysis, the Occupational Safety and Health Administration (OSHA) and the U.S. Environmental Protection Agency (EPA) argue, enables an employer to discover the underlying or systemic, as opposed to the generalized or immediate, causes of an incident. The immediate cause—“oil on the floor,” in OSHA’s example – is more a symptom of the real problem than its cause.
The Business Case for Root Cause Analysis
The agencies argue that identifying the root causes of incidents is more cost-effective than a traditional incident investigation, in that it is more effective at preventing similar events from happening again, reducing the risk of death or injury to workers or the community, and of environmental damage. Preventing incidents can improve process reliability, decrease production costs, and lower maintenance costs. It can also prevent or reduce costs resulting from:
- Business interruption
- Emergency response and cleanup
- Audits, inspections, and OSHA or EPA fines
- Litigation costs
- Increased insurance premiums
Tomorrow we’ll look at how to conduct a root cause analysis.