Section 5110.12 - Incident Investigation(a) The owner or operator shall develop, implement, and maintain effective written procedures for promptly investigating and reporting any incident that results in or could reasonably have resulted in a major incident.(b) The written procedures shall include an effective method for conducting a thorough root cause analysis.(c) The owner or operator shall initiate the incident investigation as promptly as possible, but no later than 48 hours following an incident.(d) An incident investigation team shall be established and shall, at a minimum, consist of a person with expertise and experience in the process involved, a person with expertise in the owner or operator's root cause analysis method, and a person with expertise in overseeing the investigation and analysis. The owner or operator shall provide for employee participation in this process, pursuant to section 5110.13. If the incident involved the work of a contractor, an employee and employee representative of that contractor, if applicable, shall also be included on the investigation team.(e) The incident investigation team shall implement the owner or operator's root cause analysis method to determine the underlying causes of the incident. The analysis shall include identification of management system causes, including organizational and safety culture causes.(f) The team shall review the related DMRs that were performed pursuant to section 5110.8(e) and incorporate the applicable findings from these DMRs into the incident investigation.(g) The incident investigation team shall develop recommendations to address the findings of the investigation. Recommendations shall include interim actions that will reduce the risk of a recurrence or similar incident until final actions can be implemented. For recommendations that result from the investigation of a major incident, an HCA shall be performed pursuant to section 5110.16. The owner or operator shall append the HCA report to the final investigation report.(h) The owner or operator shall submit a written report for major incidents to the UPA within 90 calendar days of the incident, unless the owner or operator can demonstrate that additional time is needed due to the complexity of the investigation. In such cases the owner or operator shall prepare a status report within 90 calendar days of the incident and every 30 calendar days thereafter until the investigation is complete. The owner or operator shall submit a final report within five (5) months of the incident.(i) The investigation report shall include: (1) Date and time of the incident;(2) Date and time the investigation began;(3) A detailed description of the incident;(4) The factors that caused or contributed to the incident, including direct causes, indirect causes and root causes, determined through the root cause analysis;(5) A list of any DMR(s), PHA(s), HCA(s), and Safeguard Protection Analyses (SPA(s)) that were reviewed as part of the investigation;(6) Interim recommendations to prevent a recurrence or similar incident;(7) Recommendations for permanent corrective actions.(j) The UPA shall make reports from investigation of major incidents available to the public by posting the final report on the Unified Program Agency's website within 30 calendar days of receipt.(k) The report shall be provided to and, upon request, reviewed with employees whose job tasks are affected by the incident. Investigation reports shall also be made available to all operating, maintenance, and other personnel, including employees of contractors where applicable, whose work assignments are within the facility where the incident occurred or whose job tasks are relevant to the incident findings. Investigation reports shall be provided upon request to employee representatives, and where applicable, contractor employee representatives.(l) The owner or operator shall follow the corrective action work process documented in subsections 5110.19(d) and (e), when resolving the investigation team's findings and recommendations, determining action items for implementation, tracking to completion, and documentation of closeout. The corrective action plan shall include review, and revalidation as necessary, of the appropriate portions of all relevant PHAs and DMRs.(m) Incident investigation reports shall be retained for the life of the process unit.(n) If the UPA chooses to perform an independent Process Safety Culture Assessment (PSCA), Incident Investigation, evaluation of the ARP management system or Human Factors Analysis after a major incident pursuant to section 5140.3, the owner or operator shall assist the UPA in conducting the independent analysis.Cal. Code Regs. Tit. 19, § 5110.12
Note: Authority cited: Section 8585, Government Code; and Sections 25531 and 25534.05, Health and Safety Code. Reference: Section 8585, Government Code; Section 25531, Health and Safety Code; and Section 68.81, Part 68, Title 40, Code of Federal Regulations.
1. Change without regulatory effect renumbering section 2762.9 to new section 5110.12, including amendment of subsections (d), (f)-(g), (l) and (n), filed 3-6-2024 (Register 2024, No. 10).