Document 2RQKO1VBXBRQVOZN2r25k2JZL

ABD00003400 APPENDIX 4A INCIDENT INVESTIGATION GUIDELINE OSHA 1910.119 Appendix "E" A. Incident Reporting 1. Employees will be encouraged through training programs, bulletin board postings, and safety talks to report all incidents that are unusual or out of the ordinary. 2. Incident investigations will focus on finding the facts not the guilty. B. Pre-Planning 1. Establish an Incident Review Committee to track incident reports through their life cycle, to determine the adequacy of recommendations, and to insure that recommendations are completed. 2. Use the Georgia Gulf Incident Investigation Procedure to start collecting facts and related information on the reported incident. 3. Start the investigation as quickly as possible to prevent loss of relevant information and loss or blurring of people's recollections. C. Management Responsibilities 1. Provide medical, safety and health help to personnel involved m the incident. 2. Bring the incident under control as quickly and safely as possible. 3. Direct investigation activities in a way that will preserve relevant information and evidence. D. Initial Response 1. Secure and barricade the incident area after control is established. 2. Promptly establish the investigating team. 3 Start collecting information at the incident scene as quickly as possible before it has time to disappear or diminish PSCODE 1 8/8/91 ABD00003401 E Incident Investigation Team 1 The team membership will vary depending on the type, location and significants of the incident. 2. A typical team will be composed of two (2) to five (5) people. 3. The team members will normally be selected from the following a. Supervisor from unit involved. b. Engineer from unit involved. c. Safety supervisor. d. Environmental Manager. e. Technician from unit involved. f. Personnel from an area not involved in the incident. g. Manager of the unit involved. F. Determining the Facts 1. Visit the incident as quickly as possible before the physical evidence is disturbed. 2. Prepare visual aids such as photographs, field sketches, missile projection maps, etc. 3. Take samples of spills, residues, vapors, etc. and note any condition which may have affected the samples 4. Obtain information from eyewitnesses if possible through private interviews. 5. Obtain information from other people who have information relevant to the incident through private interviews. 6. Observe the disassembly of key mechanical equipment. 7. Review all sources of potentially useful information such as a Operating logs b. Recorder charts c. Computer records d. As-built drawings e. Operating and maintenance procedures f. Work order records (changes) g. Employee experience and training h. Design data (process and equipment) l. etc. PSCODE 2 8/8/91 ABD00003402 3. Determine which incident related items should be preserved 9 Carefully document the sources of information contained in the incident report. Report only facts - not hearsay or speculation G. Determine the Cause 1. Establishing the basic cause of the incident is crucial to the development of effective recommendations for correction and preventing a recurrence 2 Sort out the facts, inferences, and judgements using cause and effect relationships such as those outlined below a. Develop the chronology of events which occurred before, during and after the incident. b. List conditions or circumstances which deviated from normal no matter how insignificant they may seem. c. List all hypotheses of the causes of the incident based on these deviations. d. A "Cause Tree" approach can sometimes be helpful in depicting the many different failures that led to the incident. H. Recommending Corrective and Preventive Actions 1. Develop the recommendations for corrective action. 2. Name the person or position responsible for completing the recommendations. 3. Determine the timing (schedule) for completing the recommendations. 4. Determine if operation can be safely restarted prior to completion of the recommendations. I. Follow-Up System 1. Develop and implement a system to insure that all recommendations are completed and that no open recommendations go uncompleted. PSCODE 3 8/8/91 ABD00003403 J. Communicating Results 1 Document the findings of the incident investigation including all back-up information. This should include a. Description of the incident including location, date and time. b. Facts collected during investigation. c. Statement of causes. d. Recommendations for corrective and preventive action. 2. Review of incident investigation results with appropriate operating, maintenance, and other personnel who work in the area where the incident occurred. 3. Communicate the results within the Georgia Gulf Corporation. 4. Make results of investigation known to other companies with similar units, 5. Retain Incident Investigation reports for five (5) years. PSCODE 4 8/8/91