§ 68.60 Incident investigation.

(a) The owner or operator shall investigate each incident which resulted in, or could reasonably have resulted in a catastrophic release. (b) An incident investigation shall be initiated as promptly as possible, but not later than 48 hours following the incident. (c) An incident investigation team shall 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. (d) A report shall be prepared at the conclusion of the investigation which includes at a minimum: (1) Date of incident; (2) Date investigation began; (3) A description of the incident; (4) The factors that contributed to the incident; and, (5) Any recommendations resulting from the investigation. (e) The owner or operator shall promptly address and resolve the investigation findings and recommendations. Resolutions and corrective actions shall be documented. (f) The findings shall be reviewed with all affected personnel whose job tasks are affected by the findings. (g) Incident investigation reports shall be retained for five years. (h) The owner or operator shall ensure the following are addressed when the incident in paragraph (a) of this section meets the accident history reporting requirements under § 68.42: (1) The report shall be completed within 12 months of the incident, unless the implementing agency approves, in writing, to an extension of time; and (2) The report in paragraph (d) of this section shall include factors that contributed to the incident including the initiating event, direct and indirect contributing factors, and root causes. Root causes shall be determined by conducting an analysis for each incident using a recognized method.