111: Problem/Incident Reporting/Identification Issue
Definition/Typical Issues
Are personnel failing to report incidents that have significant impacts on health, safety, reliability, quality, or security? Are personnel unaware of the types of incidents that should be reported? Are personnel not familiar with the methods for incident reporting? Are employees punished for reporting problems?
Was there a failure to identify chronic problems? Was there a failure to use a database to analyze the historical data to identify recurring problems? Were the historical data misinterpreted?
Was there a failure to identify a similar past incident?
Note 1: Coding under the Rewards/Incentives Issue (#211) node may also be appropriate.
Examples
Example 1
- An engineer noted oil dripping from a pump seal. The process for reporting and documenting the problem required a lot of forms to be filled out. The engineer did not want to take the time to complete the forms. As a result, he did not report the problem and the pump subsequently failed.
Example 2
- A manager noted a problem with one of the facility's security systems. However, when the manager reported the problem to the security supervisor, he was told that it wasn't important and the security supervisor did not record the issue. As a result, a significant security vulnerability was not addressed.
Example 3
- An operator reported a problem with the drying oven he was using. The temperature control system had malfunctioned and a batch of product had been damaged. Company policy required individuals who reported problems to help personnel correct the situation. As a result, the operator was required to work overtime to assist with the repairs, and he missed the college basketball championship game on television. The next time the operator discovered a problem near the end of his shift, he did not report it because he did not want to stay over past his shift.
Example 4
- A valve failed, resulting in a process upset. Shift employees had noticed problems with the valve prior to the incident and had expressed concern to the first-line supervisors, but the problem had not been recognized by management and corrected.
Typical Recommendations
- Develop incident reporting guidelines.
- Provide training to personnel on the types of incidents that should be reported.
- Provide process-specific examples of incidents that should be reported.
- Ensure that the incident-reporting process is as simple as possible.
- Define the technical scope of the incident investigation program by specifying the risk and consequence threshold that trigger different levels of investigations.
- Identify and eliminate barriers for reporting of incidents.
- Assess incidents and incident recommendations from other facilities for their impact on your facility.
- Use an incident database to trend incident characteristics and track recommendations.
- Perform a periodic analysis of the incident database to identify adverse trends.
- Perform an analysis of historical incident data during each incident investigation to identify any prior similar instances.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 80 | Problem Reporting LTA |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 90 | Problem Reporting Issue |