ENV-03-116 Investigating Accidents and Incidents with a Logic-Based Process

Description:

The purpose of this paper is to share the experiences of the author in selecting and implementing a successful incident investigation process at a major petroleum refinery. The process, “Behavior Justification (BJ),” is a simple logicbased tool with which incident investigators, managers and workers can evaluate the facts of any incident and arrive at the consensus root causes. In addition, investigation teams using BJ are able to complete their investigations in considerably less time than with other processes