Incident Investigation (RBPS Element 17)
Multi method root cause analysis with corrective action close out and recurrence prevention
Incident Investigation (RBPS
Element 17)
Incident Investigation is the structured learning discipline that turns every incident, near miss and significant deviation into action that prevents recurrence. The element maps to OSHA PSM 1910.119(m), which requires investigation of any incident with catastrophic release potential within 48 hours, and to CCPS RBPS Element 17. The failures are well documented. Investigations that stop at the first cause of operator error rather than reaching the latent and organisational factors, corrective actions that are filed but never close and lessons learned that never reach sister sites. Our team builds programmes that combine several root cause methods such as TapRoot, Apollo, the event and causal factor chart and MORT, just culture facilitation following James Reason and electronic action tracking that surfaces recurrence patterns across your sites.
How the study is executed
A structured, facilitated process that runs from scope definition through close out and produces defensible, actionable outputs.
Define investigation trigger per OSHA PSM (m) and corporate threshold, preserve evidence chain, secure DCS / historian / CCTV data.
Multi discipline team with independent chair, specify time bound mandate, align with just culture principles.
Apply RCA method appropriate to incident complexity, TapRoot for systematic, Apollo for human factor, ECFC for sequence, document causal chain.
Reach beyond physical / immediate causes to latent organisational and cultural factors, apply substitution test per just culture.
Per hierarchy of controls, elimination, substitution, engineering, administrative, PPE, specify monitoring KPI for effectiveness verification.
Issue investigation report, distribute across sites, integrate with API RP 754 PSE indicators, corporate HSE governance.
What the study covers in full
Outcomes of Incident Investigation (RBPS Element 17)
- Reaches the latent causes rather than closing on operator error
- A just culture that surfaces honest reporting
- Recurrence prevented through verified actions
- Lessons learned shared across sites for shared organisational learning
- Evidence that withstands an OSHA PSM (m) audit
- CCPS RBPS Element 17 evidence
- IEC 62740 cause analysis
- Factories Act 88 incident reporting met
- Near miss reporting volume rises through a just culture
- Stronger integration with management of change through investigation findings
- Better operator engagement
- Improvement in API RP 754 process safety event indicators
- A repeat incident cost avoided
- A strong position with insurers through investigation quality
- Regulator confidence
- An incident avoided at another site
Codes & standards we work to
Triggers that signal the need
Where Incident Investigation (RBPS Element 17) applies
Wellheads, separators, gas compression, FPSO topsides, produced water systems.
Distillation columns, reactors, heat exchangers, storage spheres, LPG handling.
Cryogenic exchangers, liquefaction trains, BOG compressors, storage and sendout.
Reactive systems, batch reactors, solvent handling, runaway reaction scenarios.
Boilers, HRSGs, steam headers, hydrogen systems, ammonia SCR units.
Sterile vessels, CIP/SIP, pressure fermenters, solvent recovery, spray dryers.
Tangible deliverables
- An investigation procedure with the 48 hour trigger to OSHA PSM (m)
- Guidance on selecting the root cause methodology
- Just culture facilitation training
- A corrective action tracking database
- A lessons learned sharing protocol
- An annual investigation programme review
Ready to start your project?
Speak with our team to scope an engagement tailored to your facility, regulatory context, and lifecycle stage.