Accident Reporting, Investigation and Follow-up
GOAL
Understand the causes of chemical accidents and learn lessons to improve prevention, preparedness and response in the future.
Information from reports on accidents (and significant near misses) as well as from accidents investigations is very valuable for preventing a recurrence of similar events and improving preparedness palnning. It should be recognised that the causes of accidents can be many, complex, and inter-related. (see the section on Information Management, related to using accident case histories to support accident prevention efforts).
The objective of an investigation should be to find out the root causes, not just the immediate cause, and should not be an exercise to allocate blame.
Suggested activities include:
- Establish a requirement that owners/operators promptly report on accidents and significant near misses, that meet specified criteria
- Identify what information should be reported (recognising that it is valuable to require a standardised form to facilitate the systematic collection and review of information)
- Require owners/operators to investigate the root and contributing causes (technical, organisatonal, and managerial aspects) of certain accidents (a subset of the accidents that need to be reported) and identify lessons learned
- Establish systems for the collection, review and analysis of accident and investigation reports
- Consider whether to undertake government-led investigations of certain accidents, i.e., those with the potential to identify important lessons
- Promote the sharing of information about accidents and the applications of lessons learned, both within the country and with other countries.
Relevant tools
Below is a list of tools relevant for implementing this topic :
- UNEP: A Flexible Framework for addressing Chemical Accident Prevention and Preparedness – A Guidance Document (2010)
- OECD: Guiding Principles for Chemical Accident Prevention Preparedness and Response (2nd ed, 2003)
- OECD: Addendum to the Guiding Principles (2011)
- WHO - General Information on International Health Regulations [accessed 2022]
- WHO - Manual for the Public Health Management of Chemical Incidents [2009]