Case Study Analysis Checklist Incident Investigation Guideline Investigator Name: Event Assessed: Date of Assessment:

Questions for Application of Analysis of Accident Case Studies (Chapter 15) What are the synergies or similarities between the reference case and your own operation? Are there similar chemicals used at your facility? Do you have similar processes or equipment at your facility? How does your site layout and infrastructure compare to that of the reference case? How does your operation or organization compare to that of the reference case? Are there any trends or patterns in your own operations that reflect those in the reference case? Could a similar incident occur at your facility? Why or why not? What are the potential consequences of this type of incident occurring at your facility? What is the most probable outcome? Why? Have the immediate causes of this incident ever contributed to a loss at your facility? What were the consequences? How have incidents such as these typically been dealt with at your facility? How would an investigation at your facility have likely dealt with this type of incident? Would it have drawn the same conclusions? How do the PSM systems at your facility compare to those described in the case study? Were there effective PSM initiatives or other positive factors that limited the consequences in the reference case? Does your facility or operation provide such benefits or opportunities? How effectively would your PSM systems have prevented or limited such an incident at your facility? Is there anything you could do to reduce the likelihood of a similar incident at your facility? Is there anything described in the reference case that your facility should eliminate or avoid? What direct learning can you apply to your own PSM systems or operation as a result of this incident? Is there anything you should implement at your own facility as a result of what you learned from this case? Is there anything from this incident that could influence future decisions and direction within your own organization? Is there someone else who would benefit from having this information? If so, who are they and how can you get it to them?

2003 AIChE - CCPS