Learning from experience involves monitoring, and acting on, internal and external sources of information. Despite a company’s best efforts, operations do not always proceed as planned, so organizations must be ready to turn their mistakes – and those of others – into opportunities to improve process safety efforts.

1. KEY PRINCIPLES
ESSENTIAL
FEATURES
WORK ACTIVITIES ELEMENT METRICS WAYS TO IMPROVE EFFECTIVENESS MANAGEMENT REVIEW
1. Establish and implement written procedures to report on,
collect data related to, investigate, and learn from incidents
2. Assign a job function as the champion of the incidents
element
3. Assign an incident investigation coordinator
4. Define the technical scope of the incidents element by
specifying the risk and consequence thresholds that trigger
different levels of investigations.
5. Communicate the technical scope of the incidents element by
providing facility-specific examples of the types of incidents that
are investigated, and the appropriate level of effort for each type
or level of analysis.
6. Identify facility-specific examples of near miss incidents and
train workers to appropriately report near misses.
7. Provide awareness training and refresher training on incidents
element processes to all employees and contractors, focusing on
the appropriate reporting of incidents, including near misses,
and the basic approach of the incident investigation program.
8. Provide RCA and forensics training to incident investigation
leaders, focusing on the skills needed to lead an investigation
team and the use of RCA techniques.
9. Provide RCA review training to managers responsible for
championing, guiding, and reviewing incident investigations,
focusing on the essential elements and products of an RCA
10. Establish a formal investigation review process for teams to
use at the conclusion of each investigation.
11. Establish and collect incident investigation performance
metrics.
12. Perform self-assessments of the management systems and
practices for the incidents element.
13. Perform management reviews of the incident investigation
process.
Monitor All Sources
of Potential
Incidents
14. Perform active assessments of data, such as logs, data
trends, and emergency response actuations, that could identify
near misses and incident precursors.
• Ratio of accident to near miss reports by shift,
department, or unit
Use the risk matrices used for proactive risk
assessments to classify the actual and
potentiallosses from incidents.
Ensure that All
Incidents Are
Reported
15. Identify and eliminate barriers for reporting incidents. • Number of incidents reported per unit time. Focus on near miss reporting.
16. Initiate investigations as promptly as possible, but within a
specified time following the incident.
Use a standard method for estimating the
potential consequences of an incident.
17. Establish time limits for notifying the appropriate personnel
of incidents.
Use the investigation program to investigate
abnormally positive incidents
Collect Appropriate
Data During the
Investigation
18. Develop a list of information, data, interviews, and records
that incident investigators typically consider collecting during
investigations.
19. Develop a formal interface between the emergency element
and the incidents element.
20. Use consistent and effective methods, such as interviewing
techniques and test plans, to collect data.
21. Use consistent and effective methods to preserve data.
Use Appropriate
Techniquesfor Data
Analysis
22. Provide data collection guidance and methods for performing
incident investigations to facilitate rigorous analysis of the data
collected. Guidance and methods address the following key
issues:
Investigate Causes
to an Appropriate
Depth
23. Analyze each incident in accordance with the analysis level
defined in the investigation program.
Demand Technical
Rigor in the
Investigation
Process
24. Ensure that the investigation team approaches the
investigation with an open mind and considers all evidence.
Provide
Investigation
Personnel with
Appropriate
Expertise and Tools
25. Assign personnel who have expertise in investigation
methodologies to perform investigations.
Develop Effective
Recommendations
26. Develop appropriate recommendations for each cause.
Prepare Incident
Investigation
Reports
27. Provide specifications for the content of reports. Use a two-phase report review process.
Provide Clear
Linking Between
Causes and
Recommendations
28. Require the investigation team to specifically show the
relationship between the incident, the causes, and the
recommendations identified.
Provide ready access to incident investigation
data and recommendation status.
29. Establish a system to promptly address and resolve the
incident report recommendations. Resolutions and
recommendations are documented and tracked. A database is
usually required to track the status of each recommendation.
30. Review the status of each action item on a periodic basis,
including review and approval of changes to the implementation
plans and schedules.
Communicate
Findings lnternally
31. Review incident investigation reports with all affected
personnel whose job tasks are relevant to the incident findings,
including contract employees where applicable.
32. Review incident investigation reports with all relevant
facilities.
33. Share findings and lessons learned with industry peer
groups, respecting business confidentiality.
34. Assess incidents and incident recommendations from other
facilities for their impact on the reader's facility.
Maintain lncident
lnvestigation
Records
35. Develop a document retention policy with regard to data
logs and summaries, investigation reports, and investigation
files.
• Number of times presentations and review dates are
revised.
Perform proactive assessments of the
effectiveness of recommendations.
36. Use an incident database to trend incident characteristics
and track recommendations.
37. Populate the database established in work activity 36 from
all sources (see work activity 14).
38. Perform a periodic analysis of the incident database to
identify adverse trends.
39. Periodically report adverse trends to management.
40. Perform an analysis of historical incident data during each
incident investigation to determine any prior similar instances.
Perform pilot testing. Normally,
Adopt a commercially available investigation
method and/or software.
Use software to manage the information
generated by the incidents element.
Integrate health, safety, environmental,
reliability, quality, security, and customer
service investigations.
Initiate
Investigations
Promptly
• Average time to initiate investigation.
17- I N C I D E N T I N V E S T I G A T I O N
17-INCIDENTINVESTIGATION
17-INCIDENTINVESTIGATION
19.3.1MaintainaDependableIncidentReportingand
InvestigationPractice
19.3.2IdentifyPotentialIncidentsforInvestigation
Develop a formal restart policy that involves
the investigation team
Ensure recommendations can be resolved.
Use an incident scoring system to determine
the level of effort expended during the
investigation and in communicating the
results.
Develop a library of generic analyses.
• Average time to complete investigation reports
• Examine the current status of actions to
address management system issues for the
incidents
element that were identified by the audits
element, or other RBPS element.
L E A R N F R O M E X P E R I E N C E
19.3.5FollowThroughonResults
oflnvestigations
19.3.6TrendDatato
IdentifyRepeat
Incidentsthat
Warrant
Investigation
Interface with the
Emergency
Management
Element
• Average effort expended per investigation.
19.3.3UseAppropriateTechniquestoInvestigate
Incidents
19.3.4
Document
Incident
Investigation
Results
17- I N C I D E N T I N V E S T I G A T I O N
lmplement the
Program
Consistently Across
the Company
Define an
Appropriate
Scopefor the
lncident
lnvestigation
Element
Involve Competent
Personnel
Monitor Incident
Investigation
Practices for
Effectiveness
• Number of quali.fied investigation leaders.
• Facility performance.
Losses typically decrease over time. However,
• Repeat causes.
Analyze lncident
Trends
• Number of investigations triggered by trend analysis.
Use a software program toperform trend
investigation data.
• For significant lessons that were
communicated to other units and facilities,
review what actions (if any) were
implemented.
• Identify lessons that should be
communicated to other units at the facility or
other facilities within the company.
Resolve
Recommendations
Communicate
Findings Externally
• Number of lessons learned communications.
• Average time to resolve recommendations.
• Number of times recommendation completion dates are
revised.
• Review the list of ongoing incident
investigations, with particular focus on the
level of effort applied to completing the
investigation; determine if the level of effort
appears to coincide with the level of risk
associated with the incident.
• Review the timeliness of completion of
recommendations. If recommendations are not
completed in a timely manner, determine the
causes of the delays in implementation.
• Review the list of all open recommendations
and how the number of open
recommendations is changing with time.
• Select a group of incident investigation
reports representing a range of severity,
different units, and so forth, and for each
investigation report
• Review a list of major incidents that have
occurred at the facility since the last
management review for this element.
Log All Reported
Incidents
Use a software program to track the status of
recommendations.
Prioritize recommendations.
Track recommendations to completion.
• Ratio oflow!moderate!high level of effort investigations

2. KEY PRINCIPLES
ESSENTIAL
FEATURES
WORK ACTIVITIES ELEMENT METRICS WAYS TO IMPROVE EFFECTIVENESS MANAGEMENT REVIEW
1. Establish and implement procedures to develop and maintain
process safety management perfor- mance and efficiency
metrics.
• The use of metrics for each operating area.
2. Assign an owner of the metrics system to monitor the
program's effectiveness on a routine basis.
Determine
Triggersfor Metrics
Collection and
Reporting
3. Determine when metrics data are gathered.
4. Determine the facility areas in which the metrics element
should be applied.
5. Determine the RBPS elements for which metrics would be
useful.
6. Determine whether performance indicators, efficiency
indicators, or both are desired.
7. Define the metrics roles and responsibilities for various groups
of personnel.
8. Provide training on the metrics system.
9. Provide detailed training to those who are assigned specific
roles within the metrics system.
10. Maintain records of metrics system data.
11. Establish and collect metrics data on the metrics element.
12. Provide input to interna! audits of metrics practices.
13. Develop appropriate metrics for each selected RBPS
element.
• Number of metricsfor which data are collected.
14. Ensure that an appropriate means exists for collecting data
on selected RBPS elements.
• The refresh ratefor metrics.
Collect and Refresh
Metrics
15. Collect and refresh metrics data at appropriate intervals. • Staff-hours required to develop metries.
16. Summarize metrics data in a useful format.
17. Communicate metrics data.
18. Establish action limits for the metrics.
• Percentage of management personnel that use metrics
for decision making.
• Percentage of employees who have seen metrics.
19. Create a communication process for the RBPS health status
and for potential corrective actions/ adjustments to the RBPS
elements.
• Frequency of metrics use in management review
meetings.
• The number of problems avoided/ discovered through
the use of metrics.
Establish Consistent
Implementation
Ensure that the
Scope of Metrics Is
Appropriate
lnvolve Competent
Personnel
18- M E A S U R E M E N T A N D M E T R I C S
18-MEASUREMENTANDMETRICS
18-MEASUREMENTANDMETRICS
20.3.1MaintainaDependablePractice20.3.2ConductMetricsAcquisition
• Evidence that metrics use has caused improvement.
Changes
18- M E A S U R E M E N T A N D M E T R I C S
L E A R N F R O M E X P E R I E N C E
• Resource utilization on the collection and
refreshing of metrics.
Use Metrics to
lmprove RBPS
Elements
Use existing RBPS element software and
databases to gather RBPS metrics
20.3.3Use
MetricstoMake
Corrective
Action
Decisions
• Number of RBPS elements for which metrics are
maintained.
Use existing data collection systems to gather
RBPS metrics.
lmplement
Appropriate
Element Metrics
Summarize and
Communicate
Metrics in a Useful
Format
• The number of metrics communications tools developed
Coordinate data collection with the facility
reliability effort as much as possible
Keep Metrics
Practices Effective • Results of audits or management reviews indicating that
metrics are in consistent use.
• The number of audit findings dealing with the metrics
element
• Number of people trained on metrics element.
• Employee opinions about the use of key
process safety performance metrics. Are
workers aware of the metrics, or know where
to find information about them?
• Employee opinions on the effectiveness of
new employee and contractor training on
metrics.
• Any incidents or trends that found metrics
failure to be a root cause or contributing
factor.
• Status of corrective actions and whether they
are overdue.
• Any recent audit findings that addressed the
metrics element.
• Frequency of metrics updates.
• Data collection methods.

3. KEY PRINCIPLES
ESSENTIAL
FEATURES
WORK ACTIVITIES ELEMENT METRICS WAYS TO IMPROVE EFFECTIVENESS MANAGEMENT REVIEW
1. Develop an audits program that addresses issues such as: the
scope of application, scheduling, team staffing, recommendation
resolution, and documentation of audits.
2. Establish an audits element owner.
3. Define roles and responsibilities for the audits element.
4. Develop audit protocols.
5. Define the skills needed for the audit team members.
6. Provide the required training to the audit team members.
7. Ensure appropriate objectivity for audit teams.
8. Establish baseline schedules for audits.
9. Identify triggers for additional audits.
Prepare for the
Audit
10. Review audit protocols.
Determine the Audit
Scope and Schedule
11. Confirm the audit schedule and define the scope.
Assemble the Team
12. Select team members, assign RBPS management system
elements to the respective team mem- bers, and confirm their
availability.
Assign
Responsibilities
13. Assign audit responsibilities to audit team members based
on expertise, experience, and interest.
Gather Advanced
Information
14. Assemble and distribute to the team members information
that will assist in their advance preparation for the audit.
Plan Onsite
Activities
15. Plan audit activities and prepare the onsite agenda.
16. Conduct the audit kick-off meeting.
17. Gather audit data though records sampling and reviews,
observations, and interviews.
18. Assess RBPS implementation strengths, weaknesses, and
gaps relative to established require- ments.
19. Report preliminary audit observations and findings in
periodic meetings during the audit.
20. Conduct an audit close-out meeting.
21. Prepare a draft report and forward it to the appropriate
facility personnel for review.
22. Issue the final report and forward it to the appropriate
facility personnel.
23. Develop an action plan to address report findings; assign
responsibilities and establish deadlines.
24. Follow up to resolve, and document resolution of, audit
recommendations.
25. Maintain required documentation of the audit, including
resolution of recommendations
26. Monitor RBPS performance over time.
27. Identify continuing RBPS management system or
performance weaknesses.
28. Implement RBPS management system enhancements to
address weaknesses.
29. Identify RBPS management system strengths.
30. Disseminate information on RBPS management system best
practices to other facilities.
• Percentage of recommendations that are rejected by
thefacility management.
Avoid making audits a competition.
Make appropriate use of written audit protocols
to help ensure comprehensive audits.
Standardize audit procedures.
21.3.3UseAuditsto
EnhanceRBPS
Effectiveness
Ensure that resources to support the audits
program are properly budgeted
Provide for a high level review of audit results.
Prioritize follow-up activities.
19- A U D I T I N G
19-AUDITING
19-AUDITING
21.3.1Maintaina
DependablePractice
21.3.2ConductElementWorkActivities
• Percentage of near miss and incident investigations
identifying RBPS management system weaknesses that
were not detected by prior audits
Pay careful attention to audit logistics.
Give proper consideration to audit team
composition.
19- A U D I T I N G
L E A R N F R O M E X P E R I E N C E
Monitor RBPS
Maturation over
Timefor Each Facility
Share Best Practices
• Percentage of auditfindings that are repeat findings. A
• Trends in the number or significance of findings over a
series of audits of the same facility.
• Confirm that recommendation action items
are closed out only upon the implementation of
the action explicitly recommended.
Document the Audit
Properly train audit team members.
Conduct the Audit
Be discriminating in the scheduling of audits.
Ensure Consistent
Implementation
Involve Competent
Personnel
Identify When
Audits Are Needed
• Number of previous audits conducted by each audit
team member.
• Percentage of audits havingfew significantfindings.
• Percentage of audits completed according to schedule.
• Evaluate whether the scope of the audit
program covers every relevant facility and
activity, consistent with the organization's
scope of application for the RBPS management
system
• Evaluate whether the established frequencies
for the audit(s) reflect (1)the perceived risk
associated with the activities and facilities
being audited and (2) past audit results and
incident histories.
• Determine whether audits are conducted
according to schedule.
• Evaluate whether the audit team staffing is
appropriate.
• Review the audit report(s) and determine if
the documentation is sufficient to establish a
basis for evaluating the quality of the audit.
Address Audit
Findings and
Recommendations
• Interval between completion of onsite work and
completion of the audit report.
• Number of person-days required to complete an audit.
• Number or percentage of unresolved audit
recommendations.
• Average and maximum number of days overdue for
open recommendations.
• Evaluate whether the action items proposed
to address the audit findings are appropriate to
correct the deficiencies detailed by the report
findings or recommendations.
• Determine whether responsibilities for the
resolution of audit recommendations are
clearly as- signed and deadlines established.
• Determine whether recommendation action
item deadlines are consistently met. If not,
what is done in lieu of the required activity?
Ensure that an adequate amount of
representative data is reviewed.
Establish an integrated corrective action
tracking system
Make maximum use of computer databases
when performing records reviews.

4. KEY PRINCIPLES
ESSENTIAL
FEATURES
WORK ACTIVITIES ELEMENT METRICS WAYS TO IMPROVE EFFECTIVENESS MANAGEMENT REVIEW
1. Develop a written policy for managing the management
review element.
2. Include specific roles and responsibilities in the management
system governing the management review element.
3. Develop management review protocols.
4. Establish baseline schedules for reviews.
Validate Program
Effectiveness
5. Identify measures by which the effectiveness of management
reviews will be judged.
Prepare for the
Review
Work activities 6 through 9 address this essential feature.
Determine the
Review Scope
6. Establish the scope of the review.
Schedule the Review 7. Confirm the review schedule.
Gather Information 8. Gather information necessary for the review.
10. Conduct the review meeting.
11. Assess RBPS implementation strengths, weaknesses, and
gaps relative to established require- ments.
Document the
Review
12. Document the review and forward it to the appropriate
facility personnel.
13. Develop an action plan to address review findings; assign
responsibilities and establish deadlines.
14. Followup to resolve review recommendations, and document
resolution.
15. Identify relevant metric(s) for each RBPS element. • The type and number of findings in audits.
16. Trend RBPS performance over time.
17. Identify continuing RBPS management system or
performance weaknesses.
18. Implement management system enhancements to address
weaknesses.
Conduct Field
lnspections
19. Periodically spot check work practices in the field to verify
that they are consistent with RBPS element requirements.
22.3.3Monitor
Organizational
Performance
Establish Standards
for Performance
• The number of repeatfindings in reviews.
• Changes in performance goals
Define Roles and
Responsibilities
20- M A N A G E M E N T R E V I E W A N D C O N T I N U O U S I M P R O V E M E N T
MANAGEMENTREVIEWANDCONTINUOUS
IMPROVEMENT
20-MANAGEMENTREVIEWANDCONTINUOUS
IMPROVEMENT
22.3.1Maintain
aDependable
Practice
22.3.2ConductReviewActivities
Prepare a
Presentation
Address Review
Findings/Recommen
dations
• The time required to resolve deficiencies identified by
management reviews.
• The number of deficiencies identified by management
reviews.
• Number of management reviews per time period.
Establish an integrated corrective action
tracking system.
Provide workers with advance notice of special
areas of inquiry.
Lookfor trends across different elements
Make appropriate use of written protocols to
help ensure comprehensive reviews.
M A N A G E M E N T R E V I E W A N D C O N T I N U O U S I M P R O V E M E N T
L E A R N F R O M E X P E R I E N C E
Strive to
Continuously
Improve
• Percentage of reviews delegated to subordinates.
• The number of incidents attributed to RBPS element
failures
Provide an anonymous employee-reporting
program.
Avoid making reviews a competition.
The overall design and conduct of
management reviews has been described
in this chapter. Like all other elements,
the management review element should
be subject to review periodically to
ensure that the program is working
properly. However, rather than have the
management reviewers attempt to review
themselves, this review can best be
conducted as part of the periodic external
audit program. Any weaknesses revealed
should be resolved as an audit finding.