Incident investigation as a key tool in risk management

Abstract This paper details the development and implementation of Element 17 (Incident Investigation) at the Brinsa chemical plant. The authors highlight the unwavering commitment to process safety and the progress toward a robust management system at a small facility. Over 7 years of implementation, crucial support from management lines has been instrumental in achieving remarkable results. The importance of incident investigation is highlighted not only for identifying root causes and preventing future recurrences, but also as a catalyst for the continuous development and improvement of the process safety management system. The integration of this tool into the CCPS RBSP framework at Brinsa has made it possible to address not only specific safety issues but also to strengthen the safety culture and improve the response capacity to potential risks. The case study derived from Brinsa's internal investigation vividly illustrates the importance of proactively addressing plant‐specific risks. In this context, detailed instructions were developed for the safe delivery of critical equipment during major maintenance, a task that had previously raised concerns about potential chlorine exposure. The interdisciplinary and thoughtful approach applied in developing these instructions allowed for consideration of all relevant variables, from proper equipment handling to mitigating potential hazardous substance leaks. The successful testing of these instructions in 2023 not only validated their effectiveness but also demonstrated Brinsa's ongoing commitment to the safety of its operations. This study demonstrates how incident investigation, when used effectively, is not only a reactive tool, but also a fundamental pillar for proactive risk management and the promotion of a safe and resilient work environment in the chemical industry.