California Code of Regulations › Title 19 - Public Safety › Division 5 - California Environment Protection Agency › Chapter 2 - California Accidental Release Prevention (CalARP) Program Detailed Analysis › Article 7 - Program 4 Prevention Program › Section 5110.12 - Incident Investigation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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.