Incident investigations

Scope

Employers covered by the PSM standard must investigate each incident that resulted in, or could reasonably have resulted in, a catastrophic release of highly hazardous chemical in the workplace. Section 1910.119(m) requires employers to start an incident investigation as promptly as possible, but no later than 48 hours after the incident.

Any employer, not just those covered by PSM, will find that management commitment to safety and health is crucial and will benefit from the investigation of incidents and near misses. Employers and employees should collaborate to identify and implement corrective actions aimed at preventing future incidents. Effective incident and near miss investigations rely on a focus on root causes rather than blaming individuals.

Regulatory citations

• 29 CFR 1910.119 — Process safety management of highly hazardous chemicals (PSM)
• Section 5(a)(1) of OSH Act — General duty clause

Key definitions

• Accident: An unexpected event that happens by chance and typically results in injury or damage.
• Incident: An unplanned or undesirable event that likely was preventable.
• Near miss: An unexpected or unintentional event that could have caused death, injury, or damage but fortunately did not.
• Root cause: The true cause of an accident or incident.

Summary of requirements

For PSM-covered facilities, the employer must:

• Form an incident investigation team as specified by the regulation.
• Promptly initiate within 48 hours an investigation of each incident that resulted in, or could reasonably have resulted in a catastrophic release of a highly hazardous chemical in the workplace.
• Write up an incident investigation report with elements listed in the regulation.
• Review the incident report with all affected personnel and contract employees.
• Set up a system to promptly address and resolve incident report findings. Document resolutions and corrective actions.
• Retain reports and other documentation for five years.

Regardless of PSM, OSHA requires all employers to provide a workplace free of recognized, serious hazards. Investigations uncover hazards and root causes of incidents so that corrective actions can be implemented to avoid incident recurrence in the future. Recommended (not required) steps might include:

• Establish an incident investigation procedure and organize an investigation team.
• Assemble an incident investigation kit.
• Conduct any incident investigation by controlling the scene, identifying/collecting evidence, determining the root cause(s), developing corrective actions, communicating findings, and implementing corrective actions.