#Incident investigation

Comprehensive incident management and accident investigation at industrial enterprises. Moving from mere blame-seeking to deep root-cause analysis (5W principle) and building a proactive culture. Transforming routines for 'Target Zero'.

95
items in this topic
Case
Andrey Lisitsyn
Head of Ecology and Technosphere Safety Department
Russian Railways
November 1, 2023

Creating a System of HSE Assessment Sessions for Middle Managers at JSC Russian Railways

Transition from formal training to interactive assessment sessions for middle managers using real incident analysis and business games. Implementation of a cascading training model by preparing over 800 internal moderators and using virtual 3D classrooms and VR simulators.

Incident investigation HSE TOP 100 VR
Case
Irina Feygina
Leading occupational safety specialist
Krastsvetmet
October 24, 2023

Automation of Industrial Safety Processes

Comprehensive automation of industrial safety processes based on 1C. Implementation includes digitizing personal training cards, medical examination referrals, PPE lifecycle tracking using barcoding, as well as risk assessment and incident investigation processes. A "Safety Pyramid" dashboard integrated with Power BI was developed for data visualization.

Incident investigation HSE TOP 100 Risk assessment
Case
Aleksandr Isakov
Chief Expert, Contractor Management Group
SIBUR
October 18, 2023

Contractor HSE Management System

A comprehensive contractor HSE management system covering about 40,000 workers at production and construction sites. The practice includes shifting focus to preventive work before site admission, dividing contractors into production and construction perimeters, introducing a penalty forgiveness mechanism, and focusing on auditing the internal management system during incident investigations.

Incident investigation HSE TOP 100 Risk assessment
Case
Vyacheslav Pachin
Head of HSE Service
GC "Agropromkomplektatsiya"
July 18, 2023

HSE Incident Investigation: Goals, Objectives, Methods

Implementing a systemic approach to investigating all incidents, including micro-injuries, focusing on finding root causes instead of assigning blame. The practice involves the sequential application of analytical tools (5W1H, 4M analysis, "5 Whys") by cross-functional working groups and mandatory horizontal scaling of corrective measures to adjacent departments.

Incident investigation HSE TOP 100 Risk assessment
Case
Aleksandr Pivikov
Director of Production Safety
OTEKO
December 15, 2022

First Steps in Safety

Building an HSE management system from scratch in a large company. Implementing daily safety audits with management participation, automating incident tracking (including off-the-job injuries), and creating an institute of internal trainers.

Incident investigation Safety culture Safety leadership
Case
+2
5 speakers
December 13, 2022

Leaders on What Matters Most

Building a safety culture through the personal leadership of the CEO. Practices include implementing Process Safety Management (PSM), an uncompromising attitude towards violations and incident concealment, and the top executive's personal involvement in incident investigations and new initiatives.

Incident investigation HSE TOP 100 Vision Zero
Case
Vladislav Melnikov
Director of Health, Safety and Safety
KAMA
November 17, 2022

HSE System Maturity Analysis. Next Steps for System Development

Comprehensive launch of an industrial safety system from scratch at an enterprise with a long history. Includes maturity assessment, organizational structure revision, budget defense, audit implementation, incident investigation, PPE accounting automation, and personnel involvement in risk assessment.

Incident investigation HSE TOP 100 Safety culture
Case
Elena Zelentsova
Project Manager for HSE Training Programs Development
NLMK
August 26, 2022

Evaluating the Effectiveness of Implementing HSE Tools at NLMK PJSC

A system for evaluating the effectiveness of implementing proactive HSE tools (safety contacts, behavioral dialogues, registration of unsafe acts and conditions) by internal auditors. The evaluation covers four areas: integration into the management system, competencies, practical application, and impact on behavioral attitudes, followed by the development of a corrective action plan.

Incident investigation HSE TOP 100 Safety leadership
Case
Aleksandr Pivikov
Director of Production Safety
OMK
June 13, 2022

Contractor Management

A comprehensive contractor management system that includes creating an internal supervising service, automating control and admission processes (ASMS), mandatory testing before issuing work permits, and integrating safety metrics into project manager KPIs. The practice also covers the operation of a special contractor committee, the distribution of targeted fines, and the formation of a reliability rating.

Incident investigation HSE TOP 100 Safety leadership
Case
Ekaterina Kuznetsova
Acting Director of Occupational Safety Research Center
VNII Labor of the Ministry of Labor of Russia
May 31, 2022

Example of an HSE Management System Training Module

A methodology for teaching the basics of the HSE management system and risk assessment by transferring industrial processes to understandable everyday situations. Baking a pie is used as an example to analyze hazard identification, risk assessment, development of control measures, and a systematic approach to incident investigation.

Incident investigation HSE TOP 100 Vision Zero
Case
Aleksandr Pivikov
Director of Production Safety
OMK
March 10, 2022

Managing Lies

Transition from reactive safety indicators to proactive metrics by excluding occupational injuries from managers' KPIs. Implementation of an integral Safety System Development Index that accounts for domestic injuries, audit quality, and near-miss registration, using an in-house IT solution.

Incident investigation Safety culture Safety leadership
Case
Denis Karpenko
HSE IT Project Manager
NLMK
March 10, 2022

Unified Digital HSE Space

Creating a unified digital HSE space in a large industrial company. Implementation of incident investigation, inspection modules, electronic permit-to-work, and a hazard reporting service with an escalation system.

Incident investigation Employee engagement Safety audit
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