1: Accident Investigations
Select and complete accident investigations and recommend actions with a high potential for protecting workers, the public,
and the environment.
Other Information:
Key Results: - Deploy to accidents that score high on selection criteria - Investigate selected accidents and produce written
investigative products that contain significant new findings - Where appropriate, issue significant safety recommendations
with a high potential for preventing or reducing the impact of future accidents - Reduce the time to complete investigation
products Key Strategies: Resources, Skills, and Technology Needed - Develop, revise, and periodically review selection criteria
and other tools necessary to improve and expedite investigations - Incorporate new components into investigative analysis
(e.g. human factors, safety culture, and organizational performance) - Ensure adequate emphasis in all investigations on the
impact of chemical accidents on the public and on community preparedness and response issues - Improve planning to tailor
the scope, detail, and resources of investigations to the importance of the safety issues - Develop and implement criteria
for continuing or curtailing investigations - Improve capacity to conduct industry surveys to define the extent of risks -
Identify potential recommendation targets and assess the magnitude of the safety issues at an early stage of the investigation
- Improve the monitoring of emerging chemical safety issues Metrics: - Number of significant safety recommendations issued
- Cost and average duration of completed investigations - Surveys of stakeholders on impact and significance of investigative
products - Adherence to incident selection criteria and scoping criteria Discussion: Chemical accidents cause fatalities and
injuries to workers and the public and produce extensive property damage and harm the environment. The CSB investigates major
accidents to determine their root causes and recommends actions to prevent future accidents. CSB has substantially increased
the number of accident investigations it conducts each year. In FY 2002, the agency issued only four accident investigation
reports. Four years later, in FY 2006, the agency completed seven investigation reports. The CSB only has the resources to
conduct investigations of a small percentage of the chemical accidents that occur each year in the United States. In a 2006
report to Congress, the CSB noted that over a 12-month period, the agency screened some 645 chemical accidents, an average
of almost two a day. The consequences of 18 of these accidents — including deaths, injuries, property damage, public impact,
or environmental harm — were serious enough to rate “medium” to “high” priority in the agency’s scoring system for chemical
accidents. The CSB deployed to seven accident sites during the same period, and five investigations were carried forward.
To make the greatest impact within resource constraints, CSB focuses its investigative resources on those cases that have
the potential for helping to improve safety on a widespread basis. An example is the CSB’s investigation of the 2005 refinery
disaster in Texas City that killed 15 workers and injured approximately 180 others. Even before this investigation was completed,
it commanded worldwide attention as the CSB publicized its preliminary findings and early recommendations through seven news
conferences, a major public meeting, and numerous speaking engagements around the country. The CSB’s three urgent safety recommendations
issued in 2005 from the Texas City investigation are already prompting major changes throughout the industry. For example,
new policies are being implemented in the U.S. and overseas for placing temporary structures such as trailers away from hazardous
areas of petrochemical facilities. However, the majority of accidents that occur do not command national attention, and investigative
recommendations from those accidents have more limited scope. Approximately 6% (24) of CSB’s recommendations have the potential
to impact serious and widespread risks by affecting national regulations, voluntary standards, model codes, or other activities
of national significance. Another 32% could impact important risks in contexts such as large cities or major corporations.
The remaining 62% have focused on individual sites or smaller firms or have called on organizations to communicate CSB findings.
In smaller cases where significant national recommendations are not warranted, the CSB will focus on completing investigations
quickly and efficiently and with a limited commitment of resources. The Board recognizes, however, that even smaller accidents
can offer significant and important lessons for industry and will use the outreach program to publicize the findings from
those cases. Often, it is only a few fortunate circumstances that differentiate between a smaller accident and a catastrophic
one. The keys to achieving Goal 1 include a highly disciplined use of the agency’s selection criteria for accident deployments
and — even more importantly — a careful scoping of resources and effort after the initial details of an accident are revealed.
CSB investigations continue to highlight the key role that organizational behavior and human factors play in causing major
accidents. The study of human factors can range from examining the interface between humans and equipment to investigating
how organizational and staffing decisions impact safety performance. Almost all major U.S. chemical accidents involve hazards
that are known among safety experts and have been previously described in the technical literature. Accident investigations
from many sectors — including the manned space program and the nuclear energy sector — have focused on the role of organizational
safety culture in setting the stage for disasters. To better address these issues, the CSB will include organizational and
human factors components in its investigative analysis, alongside the existing rigorous technical analyses. Baseline Statistics:
During FY 2006, the agency issued a total of seven investigation reports (two full investigations, three case studies, and
two safety bulletins). During the period from 1998 to 2006, the CSB issued a total of 383 safety recommendations, of which
approximately 36% addressed significant risks at the national, state, or large municipal or corporate level. The average duration
of the last eight completed investigations has been 15 months, at an average total cost of $159,000. During the period from
July 2004 to June 2005, the agency initiated five accident investigations; all five scored at least “medium” in the agency’s
selection criteria. During the same period, resource constraints prevented the agency from deploying investigators to eight
other accidents that scored “medium” or above.
Objective(s):
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