INCIDENT INVESTIGATION & ROOT CAUSE ANALYSIS
Every Incident Has Root Causes. Most Investigations Never Find Them.
Most incident investigations stop too soon. They identify the immediate cause — the valve that failed, the operator who deviated from procedure, the alarm that was bypassed — and declare the investigation complete. The corrective actions that follow address symptoms. Every incident involves the failure of multiple independent protection layers, and each layer failure has its own root cause. Most investigations stop at the immediate cause and never trace the organizational failures across each protection layer that allowed the incident to occur. The systemic management system failures remain intact, and the next incident is a matter of time. The goal isn't just to fix what broke. It's to build an organization that learns — does not repeat the same mistakes or have repetitive incidents.
Kenan Stevick’s approach to incident investigation is different. His methodology applies the CCPS Risk Based Process Safety framework with a focus on identifying the root causes of Process Safety Management System failures — the organizational, governance, and cultural breakdowns that allowed the immediate cause to occur. This is the same analytical framework that informed a 75% Tier 1 & 2 incident reduction at Dow Chemical and that has been applied across 20 executive leadership workshops and five cases as a testifying expert.
Most all incidents are repetitive at some level. The process focuses on identifying the root causes of the PSMS failures, analyzing historical incidents, and correcting the management system to prevent future incidents — not just the incident that triggered the investigation.
services
- Incident investigation leadership and facilitation for fires, explosions, chemical releases, and near-misses
- Root cause analysis targeting management system failures, not just immediate causes
- Historical incident analysis and pattern identification across facility or corporate portfolios
- Corrective action program development — matching the fix to the right organizational level, from a single plant to enterprise-wide, so systemic causes are addressed, not just symptoms
- Incident reduction strategy development — using investigation findings to drive measurable performance improvement
- Investigation quality assessment — evaluating whether past investigations found the real root causes
- Expert support for legal and regulatory proceedings arising from incidents
Analytical Methodology
CCPS Risk Based Process Safety framework applied to organizational and management system failures. The methodology traces from immediate cause through contributing factors to the governance-level failures that created the conditions for the incident. Every investigation produces findings that are actionable at the management system level — not just at the equipment or procedure level.
track record
- Led incident reduction programs at Dow Chemical achieving 75% Tier 1 & 2 reduction (4 years) and 40% Tier 1 reduction in the preceding role
- Involved in thousands of incident investigations across 34 years at Dow
- Retained as testifying expert in five cases involving incident causation and root cause analysis
- Published: “Next Generation Root Cause Investigation and Analysis” (Global Congress of Process Safety, 2015) and “Dow Learnings & Actions from the Deep Water Horizon Accident” (Global Congress of Process Safety, 2015)
Legal Dimension
Incident investigation findings frequently become central to litigation and regulatory proceedings. Kenan’s investigations are conducted with the rigor and documentation standards required for legal defensibility — or for prosecution of claims against parties whose failures caused the incident. His experience as a testifying expert in five process safety cases informs how investigations are structured from the outset.
