PT Notes
EPA RMP Rule Amendments - Incident Investigation
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This PT Note describes amendments to EPA's Risk Management Program regulation relating to incident investigation requirements that are part of the prevention program for Program 2 and Program 3 processes.
Root Cause Analysis
EPA now requires that root causes be determined for each incident by conducting an analysis using a recognized method. The term, root cause, is defined in the amendments to mean a fundamental, underlying, system-related reason why an incident occurred.
This provision is intended to reduce the number of chemical accidents by requiring facilities to identify the underlying causes of an incident so that they may be addressed. EPA believes that identifying the root causes, rather than isolating and correcting solely the immediate cause of the incident, will help prevent similar incidents at other locations, and will yield the maximum benefit or lessons learned from the incident investigation.
While the amended rule defines ‘‘root cause’’ in the singular, it does not preclude the possibility of there being more than one root cause of an incident. Indeed, the root cause requirements in the amended rule require the owner or operator to identify ‘‘root causes.’’
With regard to selecting a recognized method to determine root causes, EPA recommends that owners and operators consult available literature on root cause investigation. For example, CCPS has published Guidelines for Investigating Chemical Process Incidents, which provides extensive guidance on incident investigations, near miss identification, root cause analysis, and other related topics.
Inclusion of Near Miss Incidents
An amendment clarifies that an existing requirement to investigate incidents that could reasonably have resulted in a catastrophic release applies to near miss incidents. EPA believes that the investigation of catastrophic release near miss events should be a high priority safety activity for regulated stationary sources because these investigations can lead to the correction of problems which could ultimately prevent much more serious and costly catastrophic release incidents.
EPA elected not to provide a regulatory definition of ‘‘near miss’’. Rather, the criterion for determining incidents that require investigation will continue to include events that ‘‘could reasonably have resulted in a catastrophic release.’’ This may be based on:
- Seriousness of the incident
- Process(es) involved, and
- Specific conditions and circumstances involved.
EPA noted that CCPS defines a ‘‘near miss’’ as an event in which an accident causing injury, death, property damage, or environmental impact, could have plausibly resulted if circumstances had been slightly different. For example, a runaway reaction that is brought under control by operators is a near miss that may need to be investigated to determine why the problem occurred, even if it does not directly involve a covered process both because it may have led to a release from a nearby covered process or because it may indicate a safety management failure that applies to a covered process at the facility. Similarly, fires and explosions near or within a covered process, any unanticipated release of a regulated substance, and some process upsets could potentially lead to a catastrophic release.
Also, EPA noted that CCPS has explained that a near miss has three essential elements:
- An event occurs, or a potentially unsafe situation is discovered
- The event or unsafe situation had reasonable potential to escalate, and
- The potential escalation would have led to adverse impacts.
EPA observed that CCPS publications contain many examples of near misses, which can be an actual event or discovery of a potentially unsafe situation. Examples of incidents that should be investigated include:
- Some process upsets, such as excursions of process parameters beyond pre-established critical control limits
- Activation of layers of protection such as relief valves, interlocks, rupture discs, blowdown systems, halon systems, vapor release alarms, and fixed vapor spray systems
- Activation of emergency shutdowns.
EPA agrees that not all excursions of process parameters outside control levels or all instances of protective device activation should necessarily be considered to be near misses. EPA expects that activation of protective devices should be investigated when the failure of such devices could have reasonably resulted in a catastrophic release. However, EPA does not agree that near miss investigations should only include situations that resulted in activation of a final safeguard or layer of protection. This may be appropriate in some cases, but in others, multiple layers of protection may quickly fail. EPA believes that owners and operators must use reasonable judgement to decide which incidents, if they had occurred under slightly different circumstances, could reasonably have resulted in a catastrophic release, and investigate those incidents.
EPA stated that near misses also should include any incidents at nearby processes or equipment outside of a regulated process if the incident had the potential to cause a catastrophic release from a nearby regulated process. An example would be a transformer explosion that could have impacted nearby regulated process equipment causing it to lose containment of a regulated substance.
EPA stated that the intent is not to include every minor incident or leak, but rather to focus on serious incidents that could reasonably have resulted in a catastrophic release, although EPA acknowledges this will require subjective judgment.
EPA plans to update existing RMP guidance to reflect the revised RMP requirements and will provide guidance to identify what types of incidents could be considered near misses.
Scope of Incidents to be Investigated
An amendment clarifies that the owner or operator must investigate an incident even if the process involving the regulated substance is destroyed or decommissioned. EPA believes that this amendment will ensure that when incidents occur, particularly incidents so severe that the owner or operator elects to decommission the process involved or where the process is destroyed in the incident, lessons are learned as a result, both for the benefit of the owner/operator, and potentially for other stationary sources with similar processes.
Incident Investigation Team
EPA now requires for Program 2 processes that an incident investigation team be established and consist of at least one person knowledgeable in the process involved and other persons with appropriate knowledge and experience to thoroughly investigate and analyze the incident. This is similar to an existing requirement for Program 3 processes.
Furthermore, EPA stated that it believes that all incident investigations, whether conducted on Program 2 or Program 3 processes, should involve a team of at least two people, particularly given the requirement under the amended rule for investigations to include analysis of root causes. However, beyond the requirements specified in the amended rule ((i.e., a team consisting of at least one person knowledgeable in the process involved and other persons with appropriate knowledge and experience), EPA does not believe it is necessary to specify additional qualification criteria for incident investigation team members.
Investigation Timeframe
EPA now requires facility owners or operators to complete incident investigation reports within 12 months unless the implementing agency approves, in writing, an extension of time. EPA believes that this timeframe will provide a reasonable amount of time to conduct most investigations, while also ensuring that investigation findings are available relatively quickly in order to assist in preventing future incidents.
For very complex incident investigations that cannot be completed within 12 months, EPA is allowing an extension of time if the implementing agency approves such an extension, in writing. EPA encourages owners and operators to complete incident investigations as soon as practicable, and believes that 12 months is typically long enough to complete even complex incident investigations. However, EPA provided flexibility for facilities to request more time to complete investigations when they consult with their implementing agency and receive written approval for an extension.
Additional Incident Investigation Reporting Requirements
- For Program 2 processes, the word ‘‘summary’’ has been changed to ‘‘report’’.
- The time and location of an incident must be specified.
- The existing requirement for a description of the incident now specifies that it be in chronological order and provide all relevant facts.
- The name and amount of the regulated substance involved in the release or near miss and the duration of the event must be provided.
- A description of the consequences, if any, of the incident including, but not limited to, injuries, fatalities, the number of people evacuated, the number of people sheltered in place, and the impact on the environment must be included.
- A description of emergency response actions taken is required.
- Additional criteria related to the factors that contributed to the incident must be provided, including the initiating event, direct and indirect contributing factors, and root causes.
- A schedule for addressing any recommendations resulting from the investigation must be included.
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