IIAR

We learn, hopefully, by our experience – in a classroom, in the field, or in our personal study. When operating an ammonia refrigeration system, we depend on education combined with experience. That education and experience can take the form of well thought-out and written operating procedures. And it’s worth asking: Are those operating procedures reviewed at least annually with the intent to correct or improve them from experience? In addition, if an incident occurs, whether it is an actual release or a close call, is it well investigated?

A few months ago, I had the opportunity to be interviewed by two criminal investigators regarding a release of ammonia. The goal of the investigators was to better understand what happened, and why it might have happened. Although the interview lasted for several hours and covered many aspects of the release, two particular areas stood out in my mind. One was “Operating Procedures,” and the second was “Incident Investigation Reports.”

From the operating procedure particular to the investigation it became clear that there could be confusion regarding what really was meant by some of the procedural steps. The criminal investigators – in the process of attempting to understand the procedure, and answer in their minds why what happened didn’t seem to match with the procedure – opened my eyes to the possible confusion of some procedural steps and statements.

Although I have been involved in procedure development and review for many years, it occurred to me that not only is it important to review procedures carefully and in detail, but also to solicit the input from other knowledgeable persons that can bring to light steps in a procedure that may be unclear or confusing. The annual review of operating procedures can sometimes become a tedious task, and one that we might quickly gloss over since the same procedures have been reviewed and certified possibly year after year. However, when something goes wrong, those procedures can be critical to the investigation of what happened and why.

This leads to the second part of my experience with this investigation, the written “Incident Investigation.” The clear and complete documentation of an incident can be extremely important. In this particular case, some of the facts were questionable and difficult to explain or justify based on the documented information.

The correct time to start the documentation of an incident is as soon as possible, and at least within 48 hours of the event. As with operating procedures, the investigation and documentation of an incident must be carefully and thoroughly done. And as appropriate recommendations develop, they must be addressed to reduce the chance of a similar event occurring in the future. The investigation of this incident impressed upon me the need to take very seriously the operating procedure review and investigation processes. I believe that many of us do work hard at our reviews and investigations, but from this particular incident I realized there is always room for improvement. A more dedicated effort at improvement of operating procedures and investigations can both help and protect employees, as well as non-employees, the public and the environment.