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DOE G 225.1A-1
November 26, 1997/Rev. 1
IMPLEMENTATION GUIDE
FOR USE WITH
DOE ORDER 225.1A,
ACCIDENT INVESTIGATIONS
ASSISTANT SECRETARY FOR
ENVIRONMENT, SAFETY AND HEALTH
FINAL GUIDE FOR UNLIMITED USE AND DISTRIBUTION IMPLEMENTATION GUIDE
FOR USE WITH
DOE ORDER 225.1A,
ACCIDENT INVESTIGATIONS
ASSISTANT SECRETARY FOR
ENVIRONMENT, SAFETY AND HEALTH This page intentionally left blank. FOREWORD
This Department of Energy (DOE) Guide for implementation of DOE O 225.1A, ACCIDENT
INVESTIGATIONS, has been revised to be consistent with Revision A to the Order. The Guide
has been approved by the Assistant Secretary for Environment, Safety and Health and is available
for use by all Departmental elements and their contractors.
Significant revisions to the Order and Guide include provisions for the following:
Notifying other Federal agencies and Departmental elements of accidents in accordance
with regulatory requirements.
Documenting reviews of investigation reports for classification and personal privacy
considerations.
Clarifying responsibilities for training readiness teams and developing lessons learned.
Submitting and approving requests for waivers of the requirement to conduct Type A or
Type B accident investigations.
Further defining roles and responsibilities of appointing officials.
The Assistant Secretary for Environment, Safety and Health (EH-1) delegating Type A
accident investigations to the heads of field elements.
Establishing time frames for appointing accident investigation boards, publishing reports,
releasing the board, and submitting corrective action plans.
Deleting the Safety Management Template and incorporating doctrine from the DOE Plan
for the Development and Implementation of Integrated Safety Management and its
supporting policy and guidance.
Revising the algorithm for categorizing Type A and Type B accident investigations to
clarify the definitions of fatalities, injuries, and illnesses.
Chartering of limited scope investigations for occurrences, incidents, or accidents.
Establishing a requirement for field elements to ensure orderly transition of responsibilities
for the accident scene from emergency management to accident investigation personnel.
Broadening and clarifying the responsibility of the Office of the Deputy Assistant
Secretary for Oversight for the DOE Accident Investigation Program.
Clarifying the processing of the accident investigation report and supporting records under
the Freedom of Information Act (FOIA) to include categorizing the accident investigations
as a law enforcement activity.
Clarifying the requirements for EH conducting quality reviews of accident investigation
reports.
Changing the characterization of the EH assessment of corrective action plans from
"concurrence" to "review."
DOE used the work of individuals within the Department and its contractor community, as well as
private industry, to develop its accident investigation program. Portions of their work and ideas
are incorporated herein.
Beneficial comments (recommendations, additions, deletions, consolidations, and any pertinent
data that may improve this document) should be sent to the Office of Security Evaluations, Office
of the Deputy Assistant Secretary for Oversight, Assistant Secretary for Environment, Safety and
Health.
CONTENTS
Section Page
FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . .iii
CHAPTER I: INTRODUCTION. . . . . . . . . . . . . . . . . . .I-1
CHAPTER II: APPLICATION. . . . . . . . . . . . . . . . . . II-1
CHAPTER III: GENERAL INFORMATION . . . . . . . . . . . . .III-1
1.0 OBJECTIVES OF THE ACCIDENT INVESTIGATION PROGRAM .III-1
2.0 OVERALL MANAGEMENT OF THE PROGRAM. . . . . . . . .III-1
3.0 ROLES AND RESPONSIBILITIES . . . . . . . . . . . .III-2
4.0 THE ACCIDENT INVESTIGATION CYCLE . . . . . . . . .III-3
5.0 EFFECTS OF CANCELLATION OF DOE 5484.1. . . . . . .III-4
6.0 DETERMINING TYPE OF INVESTIGATION TO BE CONDUCTED.III-5
7.0 DELEGATIONS, WAIVERS, AND DELAYS . . . . . . . . .III-6
8.0 CONDUCTING LIMITED SCOPE INVESTIGATIONS. . . . . .III-6
9.0 NOTIFYING OTHER FEDERAL AGENCIES OR
DEPARTMENTAL ELEMENTS. . . . . . . . . . . . . . .III-8
10.0 BOARD STAFFING, QUALIFICATIONS, AND TRAINING . . III-10
11.0 POINTS OF CONTACT. . . . . . . . . . . . . . . . III-11
12.0 DOCUMENTATION AND THE ACCIDENT INVESTIGATION FILEIII-13
CHAPTER IV. GUIDELINES. . . . . . . . . . . . . . . . . . . IV-1
1.0 SITE READINESS AND INITIAL INVESTIGATIVE ACTIONS . IV-1
1.1 READINESS TO CONDUCT ACCIDENT INVESTIGATIONS. IV-1
1.2 PRESERVING THE ACCIDENT SCENE . . . . . . . . IV-3
1.3 COLLECTING AND CONTROLLING EVIDENCE . . . . . IV-4
1.4 OBTAINING INITIAL WITNESS STATEMENTS. . . . . IV-4
1.5 DOCUMENTING THE ACCIDENT. . . . . . . . . . . IV-5
1.6 RESTORING OPERATIONS AND OTHER CONSIDERATIONS IV-5
2.0 THE ACCIDENT INVESTIGATION BOARD . . . . . . . . . IV-6
2.1 THE ROLE OF THE APPOINTING OFFICIAL . . . . . IV-6
2.2 ACCIDENT INVESTIGATION BOARD ROLES AND
RESPONSIBILITIES. . . . . . . . . . . . . . . IV-8
3.0 GATHERING INFORMATION/FACTS. . . . . . . . . . . .IV-16
3.1 REVIEWING STANDARDS AND REQUIREMENTS. . . . .IV-16
3.2 GATHERING PHYSICAL EVIDENCE . . . . . . . . .IV-17
3.3 GATHERING DOCUMENTARY AND ELECTRONIC SYSTEMS
EVIDENCE. . . . . . . . . . . . . . . . . . .IV-19
3.4 CONDUCTING INTERVIEWS . . . . . . . . . . . .IV-20
3.5 EXAMINING ORGANIZATIONAL CONCERNS,
MANAGEMENT SYSTEMS, AND LINE MANAGEMENT
OVERSIGHT . . . . . . . . . . . . . . . . . .IV-21
4.0 DETERMINING FACTS AND ANALYZING INFORMATION. . . .IV-23
4.1 DETERMINING FACTS . . . . . . . . . . . . . .IV-23
4.2 ANALYZING FACTS . . . . . . . . . . . . . . .IV-25
4.3 DETERMINING CAUSAL FACTORS. . . . . . . . . .IV-25
4.4 DESCRIPTION OF ANALYTICAL TECHNIQUES. . . . .IV-26
5.0 DETERMINING CONCLUSIONS AND JUDGMENTS OF NEED. . .IV-30
5.1 ARRIVING AT CONCLUSIONS . . . . . . . . . . .IV-30
5.2 STATING JUDGMENTS OF NEED . . . . . . . . . .IV-31
6.0 REPORTING. . . . . . . . . . . . . . . . . . . . .IV-32
6.1 PREPARING THE REPORT. . . . . . . . . . . . .IV-32
6.2 REPORT CONTENT. . . . . . . . . . . . . . . .IV-33
7.0 CLOSING THE INVESTIGATION. . . . . . . . . . . . .IV-38
7.1 BRIEFINGS . . . . . . . . . . . . . . . . . .IV-38
7.2 APPOINTING OFFICIAL'S REPORT ACCEPTANCE . . .IV-39
8.0 POST-INVESTIGATION ACTIVITIES. . . . . . . . . . .IV-39
8.1 CORRECTIVE ACTION PLANS . . . . . . . . . . .IV-39
8.2 TRACKING AND VERIFYING CORRECTIVE ACTIONS . .IV-40
8.3 LESSONS LEARNED . . . . . . . . . . . . . . .IV-41
APPENDICES
1. DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . .1-1
2. SAMPLE CONTENT--MEMORANDUM ESTABLISHING
AN ACCIDENT INVESTIGATION BOARD . . . . . . . . . . . . 2-1
3. MODEL OPENING STATEMENT . . . . . . . . . . . . . . . . 3-1
TABLES
Table 1. Investigation Categorization Algorithm Summary. III-7
Table 2. Typical Investigation Schedule. . . . . . . . . IV-13
Table 3. Accident Investigation Analytical Techniques. . IV-27
FIGURES
Figure 1. Example report disclaimer . . . . . . . . . . . .IV-33
Figure 2. Example acceptance statement. . . . . . . . . . .IV-33 CHAPTER I
INTRODUCTION
DOE Order (DOE O) 225.1A, ACCIDENT INVESTIGATIONS, prescribes requirements and
responsibilities related to the Department's accident investigation program. The purpose of the
Guide is to explain the requirements addressed in the Order and provide guidance regarding
acceptable methods for implementing those requirements. The approach to investigations
described in the Guide is similar to and consistent with methods used by other government
agencies and private industry. It provides an organized and proven methodology for effectively
and efficiently conducting Type A and Type B accident investigations.
The Guide contains general guidelines for categorizing accidents, establishing accident
investigation boards, and conducting and reporting Type A and Type B accident investigations,
investigation closure, and post-investigative activities. Roles and responsibilities for appointing
officials, board chairpersons, board members, and field points of contact are also addressed.
Accident investigation methods, reflected in this Guide and DOE O 225.1A, involve streamlining
and simplifying the process. The investigative process and the resulting report development
should be conducted in a timely and efficient manner. The focus is on what happened, why it
happened, and how similar accidents can be prevented. Emphasis should be placed on the
possible contributory roles of management systems as root causes of accidents, where
appropriate, and on the application of or failure to apply the components of DOE's safety
management system. This system is described in DOE Policy (DOE P) 450.4, SAFETY
MANAGEMENT SYSTEM POLICY, THE DOE PLAN FOR THE DEVELOPMENT AND
IMPLEMENTATION OF INTEGRATED SAFETY MANAGEMENT, and DOE P 411.1,
SAFETY MANAGEMENT FUNCTIONS, RESPONSIBILITIES AND AUTHORITIES
POLICY. Accident investigation reports are designed to concisely convey key information in an
easily understandable format, providing useful information and insight that can help prevent future
accidents. In addition, training to support the process is streamlined. The DOE workbook
Conducting Accident Investigations provides more details on the accident investigation process
and has been distributed throughout DOE. This Guide and the workbook replace all previously
distributed Manuals and guidance on accident investigations.
Appendix 1 to this Guide provides definitions of key terms. Appendix 2 provides a sample
memorandum for the appointing official's use. Appendix 3 provides a model opening statement
for use in conducting accident investigation interviews. CHAPTER II
APPLICATION
This Guide applies to DOE for the conduct, support, and followup of Type A and Type B
accident investigations. To the extent the requirements of DOE O 225.1A are incorporated into
appropriate contractual documents, DOE contractors and subcontractors will also find it useful in
meeting support requirements for accident investigations. Its most widespread application is for
use by appointing officials, accident investigation board chairpersons, board members, and
designated Headquarters and field points of contact who must implement the requirements of
DOE O 225.1A in conducting or supporting Type A or Type B accident investigations. DOE and
DOE contractor managers and site readiness teams will find the Guide useful in understanding
DOE's accident investigation approach and their associated responsibilities. It is also useful to
DOE contractors and subcontractors who support accident investigations and DOE line
management who must develop corrective action plans for followup to investigations.
The Guide discusses information on the Department's expectations in meeting DOE O 225.1A;
the Guide does not introduce or impose any new requirements. Users of this Guide have the
latitude to choose whether and how to apply the procedures, methodologies, and techniques
discussed in the Guide. Alternative approaches and methods that implement the requirements of
DOE O 225.1A are acceptable; however, this Guide provides proven methods for successfully
conducting and reporting effective, comprehensive investigations.
Though the Guide deals solely with Type A and Type B accident investigations, much of the
guidance can also be applied effectively to investigations of accidents and occurrences not
requiring Type A or Type B investigations. These occurrences make up the majority of accidents
in DOE. Well-planned and well-executed investigations of these events (including formerly
designated Type C accident investigations) can result in more effective reporting, discovery of
contributing and root causes, and identification and resolution of systemic problems, the
correction of which might prevent more serious occurrences and lead to improved environment,
safety, and health conditions throughout the Department. CHAPTER III
GENERAL INFORMATION
1. OBJECTIVES OF THE ACCIDENT INVESTIGATION PROGRAM
The objectives of the accident investigation program are
Contribute to improved environmental protection and enhanced safety and health
of DOE employees, contractors, and the public.
Prevent the recurrence of accidents.
Reduce accident fatality rates and promote a downward trend in the number and
severity of accidents.
Preventing accidents and reducing lost time and fatalities due to accidents are line
management's responsibility. The accident investigation program provides useful, timely,
and needed information to managers in the DOE complex to assist them in meeting these
responsibilities.
To accomplish these objectives, the accident investigation process must enable the
Department to respond with speed, accuracy, focus, and brevity. The results of accident
investigations can help managers eliminate underlying causes and prevent similar accidents
across the complex. However, to achieve maximum benefit, accident investigations need
to be convened rapidly, staffed and supported adequately, focused on pertinent and
essential facts and causation, conducted accurately and thoroughly, concluded quickly,
and reported clearly and concisely. Analytical techniques used to draw conclusions and to
establish causes must be valid, appropriate, and easy to use. Finally, sound judgments of
need promote better safety practices, address systemic problems, and, when implemented,
help prevent future occurrences.
2.0 OVERALL MANAGEMENT OF THE PROGRAM
DOE O 225.1A, Paragraph 5a(5), delegates implementation responsibility for the program
to the Office of the Deputy Assistant Secretary for Oversight (EH-2). The DOE Accident
Investigation Program Manager (referred to throughout the Guide as the "program
manager") is assigned responsibilities for day-to-day management of the program by the
Deputy Assistant Secretary for Oversight. Accident Investigation Program Manager responsibilities include, but are not limited to:
Developing Departmental policy and maintaining program guidance.
Coordinating the program with Headquarters and field element points of contact.
Maintaining program-related resource databases.
Providing or identifying acceptable program-related training materials to points of
contact.
Analyzing and trending data from past accidents.
Reviewing and providing comments on corrective action plans.
Assisting in developing and disseminating lessons learned to the Department for
Type A and limited scope accident investigations.
Assisting in the selection, appointment, support, training, qualification, and other
activities of Type A accident investigation boards appointed by the Assistant
Secretary for Environment, Safety and Health.
Evaluating requests for waivers for Type A and Type B investigations, as well as
making recommendations on their approval to the Assistant Secretary for
Environment, Safety and Health.
Recommending to the Assistant Secretary for Environment, Safety and Health the
need to conduct a limited scope accident investigation, as appropriate.
3.0 ROLES AND RESPONSIBILITIES
DOE O 225.1A establishes requirements and responsibilities for the Assistant Secretary
for Environment, Safety and Health, Secretarial Officers, heads of field elements,
appointing officials, accident investigation boards, and DOE contractors, who must
collectively implement the DOE accident investigation program. Responsibilities for
appointing officials are discussed in detail in Section IV, Paragraph 2.1, of this Guide.
One of the most important responsibilities of appointing officials is to ensure that boards
understand they have the authority and responsibility to review management systems,
policies, and line management oversight processes up to and beyond the level of the
appointing official as possible root causes of the accident. This emphasis should be
included in the briefing given to the board before they begin the investigation.
The Assistant Secretary for Environment, Safety and Health, through the Office of the
Deputy Assistant Secretary for Oversight, assesses the significance of occurrences,
incidents, and accidents in terms of their potential impact on Department-wide safety.
This assessment may include an evaluation of the hazards involved, potential Department-
wide implications of lessons learned, potential for safety improvement, potential presence
of previously unrecognized hazards, potential public concern, and accident complexity, to
determine the benefit to the Department in conducting a limited scope, Type A, or Type B
accident investigation.
Significant responsibilities of heads of field elements include acting as the appointing
official for Type B and delegated Type A accident investigations and maintaining a cadre
of qualified accident investigation board chairpersons and accident investigators. In
addition, heads of field elements must ensure that DOE and contractor organizations
under their purview are trained and are prepared to effectively carry out initial
investigative actions, such as preserving the accident scene and other evidence, obtaining
initial witness statements, and assisting accident investigation boards, as well as
developing and implementing corrective action plans to address judgments of need
identified by accident investigation boards.
The accident investigation board should ensure that its activities include gathering
appropriate factual information and sufficient data to determine the impact of policy,
organizational structure, management systems, and line management oversight processes
on the accident. Data analysis should address these considerations as possible root or
contributing causes to the accident. The board chairperson is responsible for ensuring the
investigation is objective and is broad enough to identify and report on root causes.
4.0 THE ACCIDENT INVESTIGATION CYCLE
The concept for Type A accident investigations calls for a nominal 30-day investigation
cycle that begins with the date of board appointment and ends with submission of the
accident investigation report to the Assistant Secretary for Environment, Safety and
Health. While the nature and complexity of the circumstances surrounding an accident
will ultimately dictate the length of the investigative process (some will require less time,
some more), the typical accident investigation should be no more than four weeks. Week
one (on site) will be spent collecting data about the accident, with priority given to
conducting interviews. Any testing requirements (engineering, physical, chemical,
metallurgical, toxicological, destructive, nondestructive) will be identified and conducted
as needed. Some analysis of collected information will occur, as will some preliminary
writing. Week two (on site) will also be devoted primarily to data collection, with
additional emphasis and time devoted to information analysis and preliminary writing.
Week three (on site) will be devoted primarily to data analysis and writing a final draft
report; followup data collection as necessary; and a review of the factual portion of the
draft report by site DOE and contractor line management personnel. Also, the Office of
Oversight will review the report and provide comments to the board chairperson on behalf
of the Assistant Secretary for Environment, Safety and Health. After this review and
resolution of comments, all board members will sign the report. By the end of the week,
the board may brief the responsible line managers at the site of the accident on the
conclusions of the investigation. This briefing is at the discretion of the board chairperson.
Week four (at Headquarters, with selected personnel only) will be devoted to final report
editing and formatting. After the report is prepared, it will be submitted for acceptance to
the Assistant Secretary for Environment, Safety and Health.
It is expected that similar processes will be used for delegated Type A and Type B
investigations. These processes may be modified to meet the needs of the field appointing
official. The nominal 30-day life cycle is still appropriate. The Office of Oversight will
also review and comment on delegated Type A reports as the designee of the Assistant
Secretary for Environment, Safety and Health, as prescribed by DOE O 225.1A,
Paragraph 5a(2). This review will occur before report acceptance by the appointing
official. Comments are provided to the appointing official.
The nominal time frame for the investigation cycle for limited scope investigations
approved in accordance with DOE O 225.1A, Paragraph 5a(4), is expected to be
approximately 10 to 14 days, including the time for investigation and preparing the final
report.
5.0 EFFECTS OF CANCELLATION OF DOE 5484.1
The requirements of DOE 5484.1, ENVIRONMENTAL PROTECTION, SAFETY, AND
HEALTH PROTECTION INFORMATION REPORTING REQUIREMENTS,
Paragraphs 1 through 5; 6a(1) through (10); 6b; 6d; 6f(1) through (8); and the second
misnumbered 6f, and Chapters I and II were canceled by DOE O 225.1A, ACCIDENT
INVESTIGATIONS. The requirements of Chapter II, Paragraph 1e, and Chapters III,
IV, and V were canceled by DOE O 231.1, ENVIRONMENT SAFETY AND HEALTH
REPORTING.
DOE O 225.1A eliminates the requirement for Type C investigations previously defined in
DOE 5484.1, Change 7. However, Type C investigations, while not mandatory, will be
conducted when requirements from DOE 5484.1 remain specified in existing contracts.
Under DOE O 225.1A, it is anticipated that contracts will be modified to meet the new
Order. After the contracts have been modified, if an incident does not meet the criteria for
a Type A or Type B investigation, it may have to be reported and investigated in
accordance with the Occurrence Reporting and Processing System (ORPS) or the
Computerized Accident and Incident Reporting System (CAIRS), as appropriate, in
accordance with DOE O 232.1, OCCURRENCE REPORTING AND PROCESSING OF
OPERATIONS INFORMATION, or DOE O 231.1 respectively. DOE O 232.1 canceled
DOE 5000.3B, OCCURRENCE REPORTING AND PROCESSING OF OPERATIONS
INFORMATION, but has no linkage, either by reference or requirements, to
DOE O 225.1A or DOE 5484.1.
6.0 DETERMINING TYPE OF INVESTIGATION TO BE CONDUCTED
Attachment 2 to DOE O 225.1A, ACCIDENT INVESTIGATION CATEGORIZATION
ALGORITHM, contains the criteria for determining whether an accident investigation
should be categorized as Type A or Type B. These criteria are summarized in Table 1.
Standard cost-estimating guides and escalation factors, as described in DOE G 430.11,
COST ESTIMATING GUIDE, should be used for estimating the monetary loss in the
category of Property Effects.
The heads of DOE field elements are responsible for promptly reporting and categorizing
all accidents to determine whether a Type A or Type B investigation is required.
Not properly categorizing an accident investigation can result in wasted resources (over-
categorization) or the failure to prevent similar or more serious accidents because of
unresolved or unidentified causes (under-categorization). Therefore, it is important for
heads of field elements to make accurate categorizations. It is often difficult to categorize
accidents since there may be varying interpretations of terminology. The use of best
judgment in applying categorization is acceptable, provided that the rationale is
documented. Uncertainty as to proper categorization should be mutually resolved by the
heads of field elements and the Office of the Deputy Assistant Secretary for Oversight on
behalf of the Assistant Secretary for Environment, Safety and Health.
This categorization and subsequent initiation of a Type A or Type B investigation should
be made expeditiously, taking into account that timeliness is crucial to conducting an
accurate investigation, preserving the accident scene evidence, and identifying causal
factors.
DOE O 225.1A, ACCIDENT INVESTIGATIONS, provides for limited scope
investigations. Limited scope investigations are chartered by the Assistant Secretary for
Environment, Safety and Health based on recommendations from the Office of the Deputy
Assistant Secretary for Oversight. Recommendations will be based on an assessment of
the significance of an occurrence, incident or accident, taking into account such factors as
the significance of the hazards involved, potential for improvements in safety, implications
of lessons learned, presence of new information, accident complexity, and potential for
public concern.
7.0 DELEGATIONS, WAIVERS, AND DELAYS
The Assistant Secretary for Environment, Safety and Health (EH-1), who serves as the
appointing official for Type A accident investigations, may delegate this responsibility to
the head of a field element, subject to conditions specified in the memorandum of
delegation and board appointment.
Under certain conditions, it may be desirable not to conduct a Type A or Type B accident
investigation, although the criteria (see Table 1) for such an investigation may be met. A
request for waiver of any responsibility for conducting a Type A or Type B accident
investigation may be prepared by the head of a field element when it is determined that
there would be no substantial lessons learned from conducting the investigation. It is
anticipated that written requests for waiver will be submitted in a timely manner (i.e., no
longer than 5 calendar days after categorization of the accident). The request for waiver
must contain the rationale and shall be submitted to EH-1 for approval through the Office
of the Deputy Assistant Secretary for Oversight who will review requests for waiver and
either recommend approval or disapproval of the request in writing. Copies of the waiver
request and the approval or disapproval will be maintained both by Office of the Deputy
Assistant Secretary for Oversight and the head of the field element.
The categorization of certain accidents for investigation purposes may be difficult if the
extent of injuries or damages cannot be assessed initially. If the appointment of a Type A
or Type B accident investigation board is delayed beyond 3 calendar days after accident
categorization, the rationale for the delay must be documented and provided to the
Assistant Secretary for Environment, Safety and Health.
8.0 CONDUCTING LIMITED SCOPE INVESTIGATIONS
Limited scope investigations are conducted for certain occurrences, incidents, or
accidents, in accordance with DOE O 225.1A, Paragraph 5a(4), and Section III,
Paragraph 6.0, of this Guide, when the Assistant Secretary for Environment, Safety and
Health determines that a formal but less resource-intensive investigation is warranted.
The Assistant Secretary is the appointing official for limited scope investigations. The
letter of appointment for these investigations will establish and specify the authority of the
board, the scope of the investigation, and the time period for conducting the investigation.
It is anticipated that limited scope investigations will be conducted by a smaller board (one
to three individuals) and completed during a short time period (nominal time frame for the
investigation cycle is expected to be approximately 10 to 14 days, including the time for
investigation and preparing the final report) using the same principles employed Table 1. Investigation Categorization Algorithm Summary.
Categorization
Criteria
Type of Investigation
Type A
Type B
Human Effects
Any fatal or likely to be fatal
injury (49 CFR 830.2)
chemical exposure
biological exposure
Any one accident requiring
hospitalization of three or more
individuals incurring a serious injury
(serious injury is defined in 49 CFR
830.2 as any injury that requires
hospitalization for more than 48 hours,
commencing within seven days from
the date the injury was received;
results in severe hemorrhages, nerve,
muscle, or tendon damage; involves
severe damage to an internal organ; or
involves second- or third-degree burns
affecting more than nine percent of the
body surface); or with a high
probability of realizing a permanent
total disability due to injuries,
chemical exposures, or biological
exposures received.
One individual radiation exposure (see
10 CFR 835.202) of
25 rem or more total
75 rem or more to the eye
250 rem or more to skin or
extremity (shallow dose)
250 rem or more for external
exposure (deep dose) or to organ or
tissue (committed dose) for other
than lens of the eye
2.5 rem or more dose to embryo or
fetus of pregnant woman
Any accident that results in the hospitalization
of one or more DOE, contractor, or
subcontractor employees, or members of the
public for five continuous days or longer due
to
serious injury
occupational illness (except members of the
public)
chemical exposure
biological exposure
Any one accident resulting in five or more lost
workday cases
A series of accidents involving five or more
lost-workday cases occurring within a one-
year time period that involve identical or
similar
facilities
systems
equipment
materials
procedures
A single radiation exposure to an individual
that results in:
10 rem but <25 rem total dose
30 rem but <75 rem dose to the lens of the
eye
100 rem but <250 rem shallow dose to skin
or an extremity
100 rem but <250 rem sum of deep dose
and dose to organ or tissue (other than lens
of the eye)
1 rem but <2.5 rem dose to embryo or fetus
of declared pregnant woman
Environmental
Effects
Any release greater than five times the
reportable limits in 40 CFR Part 302
of a hazardous substance, material,
waste, or radionuclide resulting in
serious environmental damage
Any release over two times but less than five
times the reportable limits in 40 CFR 302 of
hazardous substance, material, waste, or
radionuclide resulting in serious
environmental damage
Table 1. Investigation Categorization Algorithm Summary (continued).
Property Effects
Loss or damage* of > $2.5 million in
property, including costs for
cleaning
decontaminating
renovating
replacing or
rehabilitating
structures, equipment, or property
Apparent loss, explosion, or theft
involving radioactive or hazardous
material in quantities or circumstances
likely to constitute a hazard to health,
safety, or property
Any unplanned nuclear criticality
*When estimating loss or damage, follow
the methods in DOE G 430.1-1, COST
ESTIMATING GUIDE.
Loss or damage* of over $1 million but
less than $2.5 million in property,
including costs for
cleaning
decontaminating
renovating
replacing or
rehabilitating
structures, equipment, or property
The operation of a nuclear facility beyond
its authorized limits resulting in the
consequences identified in columns 2, 3, or
4 of this table
*When estimating loss or damage, follow
the methods in DOE G 430.1-1, COST
ESTIMATING GUIDE.
Other Effects
Any accident or series of accidents
deemed appropriate by the Secretary or
the Assistant Secretary for Environment,
Safety and Health
Any accident or series of accidents deemed
appropriate by the
Secretary;
Assistant Secretary for Environment,
Safety and Health;
Associate Deputy Secretary for Field
Management;
Cognizant Secretarial Officer; or
Heads of field elements
for Type A and Type B investigations. Facts should be determined and analyzed, and
causal factors determined to explain why the accident occurred. The results of the
investigation should be documented in a report consistent with the format in Section IV,
Paragraph 6.2, of this Guide, abbreviated in length, while summarizing the elements
generally included in Type A and Type B investigation reports.
9.0 NOTIFYING OTHER FEDERAL AGENCIES OR DEPARTMENTAL
ELEMENTS
DOE O 225.1A requires that other Federal agencies be notified whenever an accident
occurs at a DOE facility requiring such notification by public law, regulation, or
memoranda of understanding. Public law or regulation assigns other agencies
responsibility for investigating certain accidents that could occur at DOE facilities, or as a
result of DOE activities. In some cases, DOE may have a memorandum of understanding
with another agency to this effect. The appointing official shall determine whether
applicable memoranda of understanding have been executed through Headquarters or in
the field. Notification of agencies having agreements with Headquarters shall be made by
coordinating through the Office of the Deputy Assistant Secretary for Oversight. The
appointing official shall notify local agencies with which the Department has memoranda
of understanding and which have responsibilities or interests related to the accident under
investigation. The following should be considered for notification:
The National Transportation Safety Board for accidents meeting the criteria of
49 CFR Part 830.
The DOE Nuclear Emergency Search Team for assisting in locating lost nuclear
materials. These include accidents involving aircraft, rail transportation, and motor
vehicles.
The Nuclear Regulatory Commission (NRC) for accidents meeting the criteria for
facilities licensed under the NRC or agreement states. These include nuclear reactors,
nuclear materials processing facilities, and nuclear materials storage facilities.
The Mine Safety and Health Administration for mining or tunnel accidents meeting
the criteria of 30 CFR Part 55, 30 CFR Part 56, or 30 CFR Part 57. These include
accidents at the Waste Isolation Pilot Project (WIPP) facility, the former
Superconducting Super Collider Project, or the Weeks Island Salt Dome crude oil
storage facility.
The Occupational Safety and Health Administration (OSHA) for accidents meeting
the criteria of 29 CFR Part 1960. These cover a broad range of construction,
operations, and maintenance activities at DOE facilities.
The Environmental Protection Agency for accidents involving pollution of air, water,
or land under the Comprehensive Environmental Response, Compensation and
Liability Act, Section 104 and the Clean Air Act, Sections 103, 112, 114, and 307.
Federal Communications Commission for accidents involving licensed
radiofrequency transmitting facilities.
United States Coast Guard for water transportation-related accidents.
Food and Drug Administration for accidents related to food and drug services.
The Defense Nuclear Facilities Safety Board for accidents occurring at or affecting
defense nuclear facilities.
10.0 BOARD STAFFING, QUALIFICATIONS, AND TRAINING
Federal employees acting as board chairpersons or members may be subject to the
Department's Technical Qualification Program (see DOE O 360.1, TRAINING). It is a
local decision whether Federal staff at Headquarters or in the field, who may be board
chairpersons or members, fall under this program. If so, the necessary competencies
should be determined and added to the pertinent qualification standard in the employees'
organizations; board chairpersons or members should also demonstrate acceptable
experience, education, and skills to meet qualification standards in accordance with local
procedures, as applicable.
The board must be familiar with accident investigation techniques and must have sufficient
skills and knowledge, either through board members or advisors and consultants, to
evaluate: (1) the effectiveness of management systems, as defined in DOE P 450.4,
SAFETY MANAGEMENT SYSTEM POLICY (there should be requisite knowledge on
the board of the Department's integrated safety management system and its components);
(2) the adequacy of DOE policy and policy implementation; and (3) how line management
oversight responsibilities are executed, all as related to the accident.
Board chairpersons must:
be senior DOE managers;
have demonstrated managerial competence and preferably be a member of the
Senior Executive Service or at a Senior General Service Grade level determined to
be appropriate by the appointing official; and
be knowledgeable of DOE accident investigation techniques and experienced in
conducting accident investigations through participation in at least one Type A or
Type B investigation, or have equivalent accident investigation experience as
determined and documented by the appointing official.
Effective October 1, 1998, accident investigation board chairpersons must have attended
an accident investigation course of instruction that is based on current materials developed
by the Office of the Deputy Assistant Secretary for Oversight. For additional information
on this subject, contact the program manager.
Board members must be:
DOE employees
Subject matter experts in areas related to the accident.
At least one board member must be a DOE accident investigator and must have
participated in at least one Type A or Type B accident investigation. At least one board
member or consultant/advisor must be knowledgeable in evaluating management systems
(i.e., have demonstrated understanding and experience in applying and evaluating safety
management system components as defined in DOE P 450.4, SAFETY MANAGEMENT
SYSTEM POLICY, DOE P 411.1, SAFETY MANAGEMENT FUNCTIONS,
RESPONSIBILITIES, AND AUTHORITIES POLICY, and their accompanying
implementation guidance). These skills may reside in a single board member.
The term "DOE accident investigator," as defined and used in DOE O 225.1A and this
Guide, signifies an individual who understands DOE accident investigation techniques and
has experience in conducting investigations through participation in at least one Type A or
Type B investigation. This individual's knowledge may be demonstrated through
experience, training, education, or qualification; and, effective October 1, 1998, must have
attended an accident investigation course of instruction that is based on current materials
developed by the Office of the Deputy Assistant Secretary for Oversight.
The program manager will keep the field and Headquarters points of contact apprised of
the availability of appropriate training to support the accident investigation program.
Training will be necessary in the following areas:
basic accident investigation techniques,
board chairperson skills,
analytical techniques, and
readiness team actions.
The program manager, in coordination with field and program office points of contact,
may schedule and offer training courses or distribute training materials, as required, or
may identify courses available from universities, commercial sources, or other government
agencies that meet the Department's needs. Therefore, points of contact should
coordinate their program-related training needs with the program manager and provide
feedback and recommendations to the program manager on training from these various
sources.
Field elements, through their points of contact, are responsible for providing training
required to assure readiness to conduct accident investigations.
11.0 POINTS OF CONTACT
Points of contact have important roles in supporting accident investigations. There should
be at least one point of contact for each field element and one for each site and facility that
reports directly to a cognizant secretarial officer or Headquarters element. The principal
responsibilities of the points of contact are to assure that all of the requirements of DOE O
225.1A are understood by the field element or other organization for which they work and
that the Order's requirements can be carried out by DOE and contractor staff. They act as
liaison with the program manager on matters pertaining to the DOE accident investigation
program. In addition, they ensure that DOE and contractor personnel are trained in
accident investigations and readiness in sufficient numbers to meet site needs for
responding to, or assisting with, accident investigations; that appropriate equipment to
support investigations is procured and available for use; and that DOE and contractor staff
are trained to operate it. They also maintain a current list of DOE and contractor
personnel trained in accident investigations and readiness.
It is anticipated that points of contact will assist heads of field elements in implementing
DOE O 225.1A, as well as assist accident investigation boards. This includes
responsibilities such as those described in Section IV, Paragraphs 1.1 through 1.6, of this
Guide and
Maintaining a state of readiness to conduct accident investigations throughout the
field element and its operational facilities.
Overseeing accident response activities of site readiness teams.
Ensuring readiness teams and emergency management personnel coordinate or
integrate their activities to facilitate an orderly transition of responsibilities for the
accident scene.
Communicating and transferring information to the board chairperson prior to and
subsequent to his/her arrival on site.
Coordinating corrective action planning and followup with the head of the field
element and coordinating comment resolution by reviewing parties.
Assisting heads of field elements in tracking implementation of corrective action
plans.
Facilitating distribution of lessons learned.
Providing other DOE sites with DOE accident investigation board chairpersons
and investigators on request.
A significant responsibility for the points of contact is to assure that contractors are aware
of and trained in the requirements for supporting accident investigations and that the
contractors are prepared to support the process by assisting in the functions discussed in
Section IV, Paragraphs 1.1 through 1.6, of this Guide.
12.0 DOCUMENTATION AND THE ACCIDENT INVESTIGATION FILE
Permanent records must be maintained for Type A and Type B accident investigations in
accordance with DOE record retention requirements. Investigation records are retained
for ten years following the date of the final report. Accident investigation reports do not
contain all records and backup data associated with the investigation; therefore, the
records that form the basis for the facts in the report should be kept in an investigation file
for future reference. Examples of the type of records that should be retained in the file
include: witness statements; stenographic transcripts of interviews; videotapes;
photographs; analytical test results; policies and procedures pertinent to the investigation
or referenced in the report; daily logs; training records; job or work records; and
checklists. Documentation showing that the report was subjected to reviews for classified
and Privacy Act information, shall be retained in the investigation file.
If the appointment of a Type A or Type B accident investigation board is delayed beyond
3 calendar days from the time of the categorization of the accident, the rationale for the
delay must be documented and maintained in the accident investigation file.
In the event that a request for waiver of responsibility for conducting a Type A or Type B
accident investigation is prepared and submitted to EH-1 for approval, copies of the
waiver and the approval or disapproval shall be maintained as part of the accident
investigation files.
If the Assistant Secretary for Environment, Safety and Health delegates the responsibility
for a Type A accident investigation to the head of a field element, a copy of the
memorandum of delegation shall be maintained in the accident investigation file.
Any reports developed as a result of the requirements of DOE O 231.1,
ENVIRONMENT, SAFETY AND HEALTH REPORTING, DOE O 232.1,
OCCURRENCE REPORTING AND PROCESSING OF OPERATIONS
INFORMATION, or DOE O 151.1, COMPREHENSIVE EMERGENCY
MANAGEMENT SYSTEM, related to a Type A or Type B accident investigation, shall
be maintained as part of the accident investigation file. CHAPTER IV
GUIDELINES
1.0 SITE READINESS AND INITIAL INVESTIGATIVE ACTIONS
This section addresses how field readiness for accident investigations and initial actions
after an accident can meet the intent of DOE O 225.1A.
1.1 READINESS TO CONDUCT ACCIDENT INVESTIGATIONS
Readiness to conduct accident investigations means preparing in advance of the accident
to
Preserve the integrity of the accident scene and various types of evidence.
Initiate data collection activities.
Obtain witness statements.
Document the accident scene through photographs or video.
Readiness teams should coordinate their actions with or be integrated with emergency
management personnel, in accordance with the requirements of DOE O 151.1,
COMPREHENSIVE EMERGENCY MANAGEMENT SYSTEM. A well-trained
readiness team that participates in the initial response to an accident can greatly assist in
securing, preserving, and documenting the accident scene, collecting and controlling
evidence, identifying witnesses, and taking initial statements. In addition, they can provide
valuable assistance to the accident investigation board when it assembles on site. Their
composition, location, equipment, and other characteristics should be determined by the
field elements and their contractors. The performance and equipment for the team should
be documented in procedures and periodically tested. Heads of field elements are
responsible for providing the training required to assure readiness to conduct
investigations.
When an accident occurs, initial actions include taking charge of the accident scene
quickly, initiating any required emergency response, assisting injured parties, ameliorating
the accident conditions, preserving and controlling evidence and the accident scene for
later investigation, and restoring operations if there is no danger to workers or the public.
Each field element should maintain readiness capability to respond to accidents in this
manner. To ensure the needed rapid-response capability, heads of field elements and
designated points of contact should ensure that sufficient numbers of initial responders and
prospective accident investigation board personnel are trained and available; adequate
procedures for initial response have been established; equipment is available and
functional; and the necessary infrastructure can be quickly assembled to respond to the
accident and support the accident investigation.
Coordinated activities by the readiness team and emergency management personnel
include the following:
Mitigating the consequences of the accident.
Reporting and categorizing events expeditiously, taking into account the urgency
for investigative accuracy; preserving the accident scene and evidence; and
returning to normal operations in accordance with DOE O 225.1A and DOE O
232.1, OCCURRENCE REPORTING AND PROCESSING OF OPERATIONS
INFORMATION.
Determining the medical condition and fitness-for-duty status of those injured in
the accident and others who are directly involved in the accident as soon as
possible after the accident including requesting an autopsy and promptly collecting
biological specimens, if appropriate.
Taking initial witness statements in writing as soon as possible after an accident
occurs.
Preserving the accident scene until it is examined and released by the board.
Creating a photographic and/or videotape record of the accident scene as soon as
possible after the accident occurs.
Identifying, collecting, inventorying, and protecting pertinent physical evidence
until it is turned over to the board.
Establishing and maintaining a chain of custody for photographs, videotapes, and
physical and documentary evidence until it is turned over to the board.
Making sure all documentation pertinent to the accident, including medical
records, in the possession of contractors and subcontractors is available to the
board immediately upon the board's arrival at the site.
Transferring responsibility for the accident scene, evidence, and documentation to
the board when it arrives at the scene.
Briefing the board on the day of their arrival at the accident site. This briefing
should include, as a minimum:
a description of the accident;
emergency response actions taken;
the status of evidence and the accident scene;
the DOE and contractor organizations having line management, project
management, and oversight responsibilities related to the accident; and
organization charts showing both line and project management structure
for these responsibilities.
Assisting with the investigation as requested by the board chairperson.
Managers, through points of contact, should evaluate the need for site- or organization-
specific training to ensure that sufficient numbers of staff are available to perform these
functions. Contracts that address accident readiness by contractors should be modified to
include these provisions under DOE O 225.1A, if they are not adequately addressed in
existing contracts. The benefits of incorporating initial investigative or investigative
support actions into emergency preparedness plans and drills should also be considered.
1.2 PRESERVING THE ACCIDENT SCENE
Preserving an accident scene and evidence is important to the ensuing investigation.
Important evidence must be collected quickly, or it may be lost or lose its value to the
investigation. Site procedures should specify the DOE or contractor official who will
control the scene and access to it. Generally, an accident scene should be isolated as soon
as possible until it is turned over to the accident investigation board. This action prevents
the scene from being disturbed or altered, prevents evidence from being removed from or
relocated at the scene, and protects people from hazards that may remain after an
accident. An accident scene can be protected in a number of ways, including: cordoning
off the area with rope, tape, or barricades; locking doors and gates; posting warning signs;
using a log to document who enters the area and their justification for entry; and posting
guards to control and limit access. Special controls and coordination with local security
operations are necessary if the accident scene or evidence contains classified or
unclassified controlled nuclear information material. The accident investigation board may
require that the same or different preservation and control procedures be kept in place
until it has concluded the examination and documentation of the scene.
There may be circumstances where an accident scene must be preserved for investigation
by an agency other than DOE. This could include the National Transportation Safety
Board (e.g., for aircraft or railway accidents), OSHA, law enforcement agencies, or other
agencies that may exercise jurisdiction to conduct investigations. In the event that an
accident scene must be preserved to satisfy the investigative needs of these agencies, the
scene should be cordoned off, access to it controlled, and otherwise secured, as indicated
above, until the agency having jurisdiction arrives and takes control of the scene.
1.3 COLLECTING AND CONTROLLING EVIDENCE
There are three types of evidence: physical, human (given through witness statements or
interviews), and documentary (including photographic media). The collection and control
of physical evidence is an important element of preserving the accident scene and an
important role of readiness teams. Some physical evidence can safely be left intact at a
protected accident scene. However, other evidence may be located remotely from the
scene, may have been removed during emergency response or casualty evacuation
activities, or may be too perishable to safely remain at the scene. Such evidence should be
protected from damage or contamination and safely stored for delivery and transfer to the
board. It may not be apparent whether some items are evidence that is, whether they are
significant to the investigation. When in doubt, it is best to be conservative in treating
items as evidence. It is easy to discard items later that are not needed but difficult or
impossible to recover needed items that were not preserved. Additional information
concerning collecting and controlling evidence is contained in Section IV, Paragraphs
3.2.2, 3.2.3, and 3.3, of this Guide.
Physical and documentary evidence should be preserved and secured as it is collected.
These steps are necessary to prevent alteration and to establish the accuracy and validity
of collected evidence. Evidence should be stored in a secured area and access to the
evidence limited to those who have a need to examine and use it during the accident
investigation. No evidence should be released without the authorization of the board
chairperson.
1.4 OBTAINING INITIAL WITNESS STATEMENTS
Statements from witnesses should be taken as soon as possible, preferably before they
leave the accident scene. Quickly identifying witnesses (e.g., victims, eyewitnesses, and
other participants) and taking witness statements are important, because the first
statements of witnesses are more accurate and have greater credibility than those made
later. Other persons, such as emergency response personnel, persons who arrived at the
scene shortly after the accident, and anyone else who would be expected to provide
material information about the accident should be identified, located, and asked to provide
a statement.
While the board will conduct formal interviews later, initial statements help preserve early
impressions and observations and help the board focus its efforts. A standardized witness
statement form should be used to obtain initial statements. Use of a form provides
necessary information about the witnesses and where they can be contacted later, ensures
that a consistent set of questions is presented to all witnesses, and provides an opportunity
for persons who have just witnessed or been associated with an accident to record what
they know in a structured manner. More information concerning witness interviewing is
provided in Section IV, Paragraph 3.4, of this Guide.
1.5 DOCUMENTING THE ACCIDENT
Documenting the accident means making a record of the accident scene and collecting
records of conditions before, during, and after the accident. Since the accident
investigation board may not arrive at the accident site until 2 or 3 calendar days after the
accident, it is important for readiness or other personnel to document thoroughly the
condition and status of the accident scene just after the accident has occurred (see also
Section IV, Paragraph 3.2.1, of this Guide).
1.6 RESTORING OPERATIONS AND OTHER CONSIDERATIONS
Accident investigation needs, particularly such immediate needs as preservation of
evidence, will always be overridden by life- and property-saving considerations and
sometimes by risk reduction and programmatic considerations, such as restoration of
operations. Initial investigations by readiness teams normally do not commence until the
accident scene has been released by the emergency response organization. Casualties are
treated and removed, fires extinguished, roads cleared, and services and operations
restored or resumed, although all of these activities may alter the accident scene. Care
must be taken by readiness teams so that their activities do not interfere with emergency
response actions.
Even given the secondary nature of preserving evidence when compared with taking
emergency actions, much can be done concurrently, or soon after emergency actions are
taken, to preserve the accident scene and relevant evidence and records. Training
emergency response and readiness team personnel in the need for and methods of evidence
preservation, as well as prior planning and coordination, facilitates the ability of both
groups to conduct their activities in a way that will enhance, rather than degrade,
preservation of important evidence and the accident scene.
Evidence of suspected criminal behavior, Price-Anderson enforcement issues, or fraud, waste,
and abuse should be handled in the manner indicated in Section IV, Paragraph 2.2.1, of this
Guide and reported to the head of the field element and the appointing official.
Upon arrival on site, the Board Chairperson will inspect and formally accept custody of
the accident scene from local authorities. While in possession of the accident scene, the
Board Chairperson will have the authority and responsibility for making decisions on
restoring operations following an accident that will affect the accident scene, or impact the
preservation of evidence. This decision is coordinated in advance with the head of the
field element or his/her designee and is made after balancing such factors as operational
needs, mission objectives, and risk to workers, the public, and the environment against the
need to conduct a comprehensive investigation. Care must be given to this decision, since
once evidence is lost it cannot be recovered.
2.0 THE ACCIDENT INVESTIGATION BOARD
2.1 THE ROLE OF THE APPOINTING OFFICIAL
2.1.1 Establishing the Board's Authority
Authority to appoint accident investigation boards and to assign individuals to conduct
accident investigations resides with the appointing official. The Assistant Secretary for
Environment, Safety and Health is the appointing official for Type A and limited scope
accident investigations. Heads of field elements are the appointing officials for delegated
Type A and Type B accident investigations. Each Type A, Type B, and limited scope
accident investigation board must be established in writing by the appointing official within
3 calendar days of the categorization of the accident. The written authorization includes
the scope of the investigation, the names of the individual board members being appointed,
a specified completion date for the final report (nominally 30 calendar days from the date
of appointment), and any special provisions deemed appropriate. The scope of the
investigation must include gathering facts; analyzing the facts and evidence; developing
conclusions regarding causal factors; and identifying judgments of need for DOE and
contractor organizations and management systems that could have or should have
prevented the accident. The scope of the investigation includes reviewing all levels of the
organization up to and beyond the level of the appointing official. An example of an
appointment memorandum is provided in Appendix 2.
DOE heads of field elements are responsible for determining whether an accident meets
the criteria for a Type A or Type B investigation. This determination must be made using
the Accident Investigation Categorization Algorithm contained in Attachment 2 to DOE O
225.1A (see Section III, Paragraph 6.0, of this Guide). The appointing official for Type A
accident investigations is the Assistant Secretary for Environment, Safety and Health,
unless this responsibility is specifically delegated to the head of a field element, subject to
conditions specified in the memorandum of delegation and board appointment. The head
of the field element with cognizance over the site or facility where the accident occurred is
the appointing official for Type B investigations.
2.1.2 Selecting Board Members
Appointing officials select DOE accident investigation boards consisting of a chairperson
and three to six members who meet the qualifications and criteria indicated in Section III,
Paragraph 10.0, and in Section IV, Paragraph 2.1.4, of this Guide. The board shall be
supported by appropriate advisors and consultants.
The program manager maintains a list of trained and experienced chairpersons, members,
and consultants, including their areas of expertise. Appointing officials and the points of
contact may contact the program manager for assistance in identifying candidate
chairpersons or members. It is recommended that appointing officials select DOE
accident investigators to fill as many board member positions as possible.
2.1.3 Briefing the Board
The appointing official or his/her representative must conduct a briefing for all board
members within 3 calendar days of their appointment (preferably prior to their departure
for the accident site) to ensure they clearly understand their roles and responsibilities. This
briefing may be done in person or via videoconference or teleconference. However, if it is
impractical to brief the entire board, the board chairperson will receive the briefing. The
chairperson should then convey the contents of the briefing to the other board members
prior to commencing the investigation. The briefing should include the following subjects:
Scope of the investigation.
Emphasize that: the board is empowered to examine DOE and contractor
organizations and management systems as possible root causes of the accident, the
board is required by DOE O 225.1A to do so, and they are to fully report the
findings.
Confirmation that the board has the authority to investigate up to and beyond the
level of the appointing official when reviewing specific management systems and
organizations.
Avoiding conflicts of interest for board members.
Skills and qualifications of board members.
Application of the principles in DOE P 450.4, SAFETY MANAGEMENT
SYSTEM POLICY, DOE P 411.1, SAFETY MANAGEMENT FUNCTIONS,
RESPONSIBILITIES AND AUTHORITIES POLICY, and draft DOE M 411.1-
1, MANUAL OF SAFETY MANAGEMENT FUNCTIONS,
RESPONSIBILITIES AND AUTHORITIES to the investigative process.
Special concerns of the appointing official based on site accident patterns or other
considerations.
2.1.4 Avoiding Undue Influence and Conflict of Interest
Board chairpersons and members report only to the appointing official or his/her
representative during the investigation. During the investigation, board members and
advisors are relieved of their normal duties. The appointing official is responsible for
avoiding undue influence and conflict of interest in selecting board chairpersons and
members. Care must be taken in selecting board members who are not in the direct line
management chain responsible for day-to-day operations or for line management oversight
of the facility, area, or activity involved in the accident. In addition, the board must not
include both a supervisor and his or her subordinate(s).
2.2 ACCIDENT INVESTIGATION BOARD ROLES AND RESPONSIBILITIES
The accident investigation board has several major functions:
Conducting a comprehensive investigation within the defined scope, collecting all
pertinent information, and determining the facts relevant to the accident
Analyzing the facts and determining causal factors that contributed to the accident,
with particular emphasis on determining the root causes of the accident
Identifying judgments of need that must be addressed to prevent recurrence of the
accident
Reporting the essential facts and results of the investigation clearly and concisely
Maintaining appropriate communications with interested organizations throughout
the investigation
Ensuring the quality and accuracy of all its activities.
2.2.1 Board Chairperson
The board chairperson manages board activities and is responsible to the appointing
official for all aspects of the investigation. The chairperson maintains control of the
accident scene until it is no longer needed for the investigation. The chairperson will not
normally conduct investigative activities, but rather will direct the overall effort, keeping it
focused and on schedule, and will maintain communications and coordination with
interested managers and organizations that are legitimate stakeholders, such as unions or
the surrounding community. The chairperson represents the Department in all matters
pertaining to the investigation.
If suspected unlawful activity is revealed during the investigation, the chairperson has the
responsibility to notify appropriate DOE, other Federal, state, or local investigative or law
enforcement authorities (e.g., Federal Bureau of Investigation) or, in the case of fraud,
waste, and abuse, the DOE Office of the Inspector General. The board chairperson shall
notify the Director, Office of Enforcement and Investigation (EH-10), of any potential
Price-Anderson enforcement concerns identified during the investigation.
2.2.2 Board Members
Board members are primarily responsible for collecting and analyzing information,
reaching conclusions regarding causal factors, identifying judgments of need, and writing
the report. Board members should use a broad range of investigative and analytical
techniques to make these determinations.
2.2.3 Advisors and Consultants
The board chairperson may require the assistance of advisors and consultants during the
investigation. Advisors and consultants may be DOE employees, DOE contractors or
subcontractors, or outside personnel, and may include persons from the accident site.
They should be free from involvement in issues leading to the accident and not have any
conflicts of interest that would bias their judgment, as determined by the board
chairperson. Potential conflicts of interest should be referred to the field element's office
of chief council, or the board's legal advisor for resolution, and the results documented in
the accident investigation records. Advisors and consultants are normally used to provide
the board with specialized expertise. They may be site personnel with knowledge of site
processes or activities, or of the accident itself, and may possess expertise in accident
investigation and analytical techniques, law, medicine, metallurgy, chemistry, electricity,
transportation, work planning and control, conduct of operations, or other specialized
disciplines. Advisors and consultants may be used to facilitate investigative activities or
conduct specific tasks (e.g., to review medical or contractual aspects of the accident).
Alternatively, they may be integrated into a broader spectrum of the board's activities,
participating throughout the investigation. By definition, advisors and consultants, can
advise and consult, but cannot dictate the board's results or the report contents; those are
responsibilities of the board. The need for consultants and advisors will be dictated by the
nature of the accident and the direction of the investigation. The program manager
maintains a listing of potential subject matter experts who can be called upon for
participation as required.
Labor union representatives should be permitted to observe and advise the board. They
may be present at interviews of bargaining unit employees, unless an employee requests
otherwise, and at open meetings of the board.
2.2.4 Support Functions
Appointing officials should assure that a board has sufficient administrative support
personnel to expedite the investigative and report-writing processes, freeing members
from administrative burdens and allowing them to concentrate on data collection and
analytical tasks. The following support positions are recommended.
Administrative Coordinator. An individual familiar with the administrative and
logistical needs and processes for an accident investigation should provide daily
coordination of those matters. Other functions to be performed include tracking
and controlling documentation, tracking appointments, assigning administrative
tasks and priorities, and coordinating report production.
Analyst. An individual trained in and knowledgeable of the various analytical
techniques that can be used to support the accident investigation process (see
Section IV, Paragraph 4.4 of this Guide). Board members have the responsibility
for collecting and analyzing information; however, a dedicated analyst can
recommend the proper analytical tools based on the type and complexity of the
accident, and process the information using the tools selected, allowing the board
members to concentrate on the results.
Technical Writer/Editor. Use of a technical writer or editor can facilitate the
report-writing process. While board members have the primary writing
responsibilities, a dedicated writer or editor can focus on the responsibilities for
editing the report and managing report preparation, which will result in a more
cohesive and readable report.
Typist/Text Processor. A board usually needs at least one typist to perform
general secretarial and administrative tasks, such as filing, typing or text
processing, and answering telephones. Often these personnel can be provided by
the facility where the investigation is being conducted.
Court Reporters. Using a court reporting service enhances the interview process
by increasing the timeliness and accuracy of interview transcripts. The use of court
reporters provides all members of the board the opportunity to review interviews
in which they did not participate and provides a transcript that can be used to
reconstruct or develop the chronology of events preceding the accident. When an
investigation requires numerous interviews, use of court reporters is essential and
can help prevent the investigation from getting behind schedule in its early stages,
when most of the interviewing takes place and when the information elicited during
interviews is needed. This service is generally available commercially in most
areas.
2.2.5 Managing the Accident Investigation
The accident investigation is managed as a project--a complex project that must remain
focused while confronted with a significant workload, finite time constraints, sensitive
issues, and a dependence on the cooperation of others. Consequently, the investigation
process (and the board) needs to be well managed and closely controlled in order to be
successful and efficient.
2.2.5.1 Role of the Chairperson
The board chairperson manages all aspects of the investigation. Some of the chairperson's
first decisions and actions will greatly influence the tone, tempo, and degree of difficulty
associated with the entire investigative process. A day planner format or similar tool
should be used to identify the detailed list of actions that the chairperson should complete
throughout an investigation. The program manager has copies of this tool for use by
board chairpersons.
An investigation is complex, and it requires management of several very different,
interrelated activities. First, the investigative process itself needs to be managed:
information must be collected, processed, and integrated; facts must be analyzed;
conclusions related to causal factors must be drawn; causal factors and judgments of need
must be identified; and a report must be prepared. To manage this aspect of the
investigation, the chairperson organizes work assignments for the board, establishes
deadlines, requires feedback, seeks and obtains ongoing information about progress and
status, and makes adjustments as necessary. The chairperson keeps the board focused on
essential activities and ensures that all efforts are directed appropriately and not wasted on
irrelevant or inconsequential pursuits. While the chairperson's responsibilities may
preclude participation in the detailed investigative tasks, he/she should remain fully
informed of those activities and be the driving force behind all decisions concerning the
investigation.
Concurrently, the chairperson manages the administrative, logistical, and budgetary
activities of the board. Support of various kinds is obtained and coordinated when
needed. If administrative and logistical support functions are not well managed, the
productivity, efficiency, and accomplishments of the board can be degraded.
No less important is the chairperson's need to manage relationships among the board
members and between the board and organizations external to the board. In the stressful
situation created by the board's intense deliberations, it is essential that the board
chairperson understand group dynamics to manage the individual personalities of the
board members. Care must be taken to ensure that strong-willed personalities do not
dominate and influence the objectivity of the investigation and that all viewpoints are
heard and analyzed.
The board may call upon a number of organizations for support, including administrative
or logistical, technical, or merely cooperation in facilitating the investigation. One of the
chairperson's important functions is to manage the board's relationship with these parties.
Interested parties may include the appointing official, site contractor organizations, DOE
field staff, employees and their organizations, unions, local community groups, and the
media. Dealing with injured parties and their families (except on matters directly related
to the investigation, such as conducting interviews or taking witness statements) is
generally the responsibility of the head of the field element or contractor management.
However, contingent upon the circumstances, the chairperson should consider contacting
the family to explain the purpose of the investigation. Coordination with the field or
contractor management should be accomplished prior to such contact.
2.2.5.2 Investigation Schedule
The length of each particular investigation is dictated in part by the nature and complexity
of the circumstances surrounding the accident. Most accident investigations, however,
can be completed in a 30-day period, organized generally as indicated in Table 2. Plans
for managing the investigative process should be based on this 30-day schedule. As
circumstances require, the chairperson and appointing official can establish a different time
frame, and the schedule can be modified accordingly. Keeping the length of the
investigation (including submission of the final report) to a minimum, consistent with
thoroughness and accuracy, is an important consideration.
2.2.5.3 Control Measures
As with any project, an accident investigation requires the use of management controls to
ensure that necessary activities are completed properly and on time. Although not unique
to accident investigations, the following common control methods are typically used by
the chairperson.
Task assignments and due dates. Each specific task should be assigned to an
individual or team so that responsibility is clearly understood. Due dates, including
intermediate milestones, if appropriate, should be assigned.
Daily meetings. The board should meet at least once daily to exchange necessary
information and keep the chairperson fully informed of progress and status. On
the third day of the investigation, the interview and investigation schedule should
be reassessed.
Table 2. Typical Investigation Schedule.
Time Frame
Activities
Week 1 (onsite)
Board arrives; data collection and interviews;
identification and initiation of physical testing
requirements; initial data analysis; preliminary writing.
Week 2 (onsite)
Continued data collection; additional emphasis on data
analysis; initial report preparation.
Week 3 (onsite)
Primarily devoted to data analysis and report preparation;
follow-up data collection; factual accuracy review of
draft report by site DOE and contractor managers;
completion of final draft report; briefing of local DOE
and contractor managers; departure from site.
Week 4
Selected personnel only: final report editing and
formatting; submission of report to appointing official.
Progress reports. At the daily meetings or whenever appropriate, individuals and
teams should provide the chairperson with verbal or written progress reports,
identifying potential problems and their solutions. The chairperson may be
requested to prepare periodic status reports. These reports may be necessary as
background for press releases, briefings, or to dispel rumors, and to keep
Headquarters apprised of the investigation's progress.
Accountability controls. Logbooks or some other method should be used to
maintain control and accountability of items of physical evidence, documents,
photographs, and other material pertinent to the investigation.
Correspondence controls. Appropriate measures should be employed to track
incoming and outgoing correspondence.
Information release. The chairperson establishes and strictly enforces a specific
policy regarding what information can be released, and by whom, to persons or
organizations outside the board. The chairperson coordinates approved press
releases with the local field and contractor public relations representatives to
assure consistency and that releases are only made after review and concurrence by
the board chairperson.
2.2.5.4 Administration and Logistics
Administrative and logistical arrangements and decisions should be made quickly and
executed immediately so that start-up time is kept to a minimum once the board arrives
on-site. Inadequate or slowly developing administrative and logistical support can
severely hinder an investigation. The chairperson, assisted by the administrative
coordinator and others, as appropriate, should make necessary decisions and arrange for
all support. Normal support requirements include:
Office/work space
Site-specific security, safety, and health training, as required
A dedicated conference room suitable for board meetings and briefings
Telephones, including speaker phones, as required (may include a publicized
"hotline" number) and FAX machines
Computers/printers and software for word processing, graphics, and analytical
programs
Copy machine (preferably dedicated)
Document shredder
Hotel selection and reservations
Rental car allotments
Security badges and passes
Property permits for cameras, recorders, other equipment
Office supplies and consumables
After-hours access to site and work space
Administrative and logistical support personnel
Court reporters
2.2.5.5 Quality Control
Formal quality control for all accident investigations is necessary because of the gravity
and sensitivity of the work performed by accident investigation boards, as well as the need
for accuracy, thoroughness, and perspective. While the chairperson may implement any
quality control measures deemed necessary or helpful (see Section IV, Paragraph 6.3, of
this Guide for more specific guidance on quality control), the following procedures are
typically used:
When the board develops conclusions from analytical results, they make a
thorough effort to ensure that all verified facts, results from the analysis of those
facts, and resulting conclusions are both consistent and logical.
When essential portions of the draft report are complete, the board conducts a
verification analysis of the report to ensure that facts in the report are consistent
with the best information available, that each section of the report is consistent
with other sections, and that the analyses, conclusions, and judgments of need in
the report accurately reflect the consensus of the board.
The board provides the facts section of the draft report to the affected DOE and
contractor managers for factual accuracy review and validation, as indicated in
Section IV, Paragraph 6.4, of this Guide.
The Office of the Deputy Assistant Secretary for Oversight, on behalf of the
Assistant Secretary for Environment, Safety and Health, conducts a review of
Type A and limited scope accident investigation reports, to include investigations
delegated to the head of a field element. This occurs before acceptance by the
appointing official. Comments are provided to the appointing official (see Section
IV, Paragraph 6.5 of this Guide). This review provides a quality check by staff not
associated with the accident or the investigation and provides unbiased insight into
the validity of the board's conclusions. A similar review is conducted for Type B
accident investigations, except that the review may not be conducted prior to
acceptance of the report by the appointing official.
2.2.5.6 Minority Opinions
The final accident investigation report is a consensus document that must be signed by the
board chairperson and each board member. If all board members cannot agree, the
dissenting member(s) must sign the report but may, at their discretion, prepare a minority
report that will become an official part of the final report. The board chairperson should
make a concerted effort to understand the logic underlying the differing opinions and to
consider what changes might resolve the conflict. If the conflict cannot be resolved, it is
the board member's right to prepare a minority opinion, and it is the board chairperson's
responsibility to accept the opinion and include it in the final report. The minority opinion
addresses issues in conflict and is limited to this scope.
2.2.5.7 Freedom of Information and Privacy Acts
Information that is generated or obtained as part of an investigation by the board may be
subject to disclosure under the Freedom of Information Act (FOIA) and the Privacy Act.
The FOIA provides that any person may obtain access to agency records unless those
records are protected from release by one of nine exemptions. Some of the FOIA
exemptions protect classified information, deliberative materials, and personal information
whose disclosure could cause an unwarranted invasion of privacy. The FOIA also
protects from disclosure "information compiled for law enforcement purposes" if its
disclosure could reasonably be expected to "interfere with enforcement proceedings."
Accident investigations are considered a law enforcement activity and records generated
as part of these investigations may be protected from disclosure. This type of information,
however, may not be protected from disclosure after implementation of corrective
measures, if disclosure of the information would not interfere with an active investigation.
The FOIA further protects information compiled for law enforcement purposes if
disclosure would "constitute an unwarranted invasion of personal privacy," or "disclose
the identity of a confidential source." This information may continue to be protected after
implementation of any corrective measures in response to the accident.
The Privacy Act protects from disclosure, records maintained in a system of records that
are retrieved by a personal identifier. Generally, information in a system of records cannot
be disclosed without the prior written consent of the individual to whom the records
pertain, unless the information falls within one of the exceptions in the Act. A "record"
subject to the Privacy Act is any information about an individual that identifies the
individual by name, or other device particular to the individual.
A "system of records" is a group of records from which information is retrieved by a
person's name or other identifying device. Accordingly, accident investigation records
that are retrieved by name or other personal identifier are deemed to be maintained in a
system of records subject to the Privacy Act. For example, if witness interview transcripts
or medical records of an individual injured in the accident that are part of an accident
investigation are retrieved by a personal identifier, the records are subject to the Privacy
Act. However, if the records are kept in a manner that requires identification of a
particular accident as a prerequisite to finding information about any individual, the
records are deemed not to be in a "system of records" and the Privacy Act does not apply.
If any questions arise concerning disclosure of accident investigation records or the
applicability of the FOIA or the Privacy Act, the chairperson should obtain guidance from
the Department's FOIA/Privacy Act attorney in the appropriate headquarters or field
office.
3.0 GATHERING INFORMATION/FACTS
3.1 REVIEWING STANDARDS AND REQUIREMENTS
The board should identify DOE Orders and Standards; Federal and State regulations;
other external regulatory requirements; and site-specific policies, requirements, or
guidelines applicable to the accident. This is necessary to establish the requirements
governing work at the site where the accident occurred, determine what role they played
in the accident, and ensure that policy issues are adequately addressed during the
investigation. Review of applicable safety analysis reports, standards requirements
identification documents, and other requirements documents may be helpful in identifying
this information.
3.2 GATHERING PHYSICAL EVIDENCE
Physical evidence should be gathered and a record made of all facts from all sources,
including witness statements and interview transcripts, as soon as they become available.
A good method for displaying the facts is to list them on removable, adhesive-backed
notes that can be placed on a wall, so they can be used to develop the events and causal
factors chart.
3.2.1 Recording the Accident Scene
Photographs, videotapes, and sketches should be used for recording and documenting the
accident scene. The readiness team should document the accident scene initially (even
though the board may wish to record the scene later as well). It is important to record the
location, orientation, and subject matter for each photograph. Photographic coverage
should be detailed, complete, and, if necessary, should include standard references to help
establish distance, perspective, color, and date. Photographs (digitized photographs are
preferred) should be taken of obstructions, equipment, parts, material, debris, spills and
stains, and anything else that may contribute to or affect the accident scene.
Videotapes should cover the overall accident scene and should focus on specific locations
or items of significance. A thorough videotape may relieve the board from making
repeated visits to the accident scene; this may be important if the scene is difficult to
access or it presents hazards of any kind. If evidence must be moved, its exact location
and orientation at the scene should first be recorded in detail, perhaps using sketches with
measured distances and directions from reference objects that will remain at the scene.
The original location of evidence can also be marked (using paint, tape, chalk, etc.) before
it is removed.
A documented chain of custody on still video camera disks and prints should be
maintained (see Section IV, Paragraph 3.2.3, of this Guide).
Color film pictures are preferred. These pictures should be carefully logged on an
accepted form with information recording the exact time, location, direction, and other
pertinent data. Photographic aids that record the date and time on the negative should be
avoided, because these images may obscure important details in the photo or video.
Reference aids such as rulers, grids, and color charts should be included in the
photographs when there is any chance for distorted interpretation; size, color, and exact
location are critical. Videotapes are of particular value at accident scenes where
progression of events is critical, such as fires. Other specialized photographic techniques
may be desirable in certain circumstances. These special techniques are used to identify
foliage changes, internal conditions, and other effects not visible to normal sight. They
include aerial, micrographic, ultraviolet, infrared, false color, motion pictures, stereo,
x-rays, and thermal scanners.
3.2.2 Handling and Preserving Physical Evidence
Physical evidence should be gathered and assigned to categories, and a record should be
made of all facts from all sources, including the witness statements and interview
transcripts as soon as they become available. Care should be taken in the event
pathogenic contamination of physical evidence occurs (e.g., in the case of blood). Such
material may require autoclaving or other sterilization. Work practice controls, as defined
by 29 CFR 1910.1030, should be used. Actions taken to mitigate bloodborne pathogen
hazards resulting from the accident should be documented. Potential exposures to team
members should be investigated and referred to the appropriate medical personnel for
immediate treatment. 29 CFR 1910.1030 details controls that should be followed for
exposure to blood or other potentially infectious materials. In addition, a record must be
established and maintained for each investigation team member who has an occupational
exposure (see 29 CFR 1910.20 and 1910.30).
Physical evidence is fragile: physical objects can be removed, broken, lost, misplaced,
cleaned up, destroyed, distorted, or overlooked. When physical evidence is identified, it is
collected and secured or the area in which it is located is secured to preserve integrity of
the evidence. Materials can be bottled, bagged, or boxed, and their locations recorded or
photographed. The accident scene can be roped or taped off, doors locked, and guards
posted, or it can be preserved by other means.
3.2.3 Preserving the Chain of Custody
A strict chain of custody (documentation showing physical custody) should be maintained
on all evidence. Security and custody of evidence are necessary to prevent alteration and
to establish the accuracy and validity of the physical material, photographs, and documents
collected.
To establish a chain of custody for evidence:
The evidence should be photographed/videotaped in its original location as it was
found immediately after the accident
The photographs/videotapes should be time- and date-stamped and inventoried and
should be treated as other physical evidence, using the chain-of-custody principles
described below
A decision should be made about what evidence is to be removed from the scene
The person collecting the evidence should prepare an inventory of the items and
sign a chain-of-custody document stating at a minimum:
What items were removed from the scene
When the items were removed from the scene
Who removed the items from the scene
Location of the items at the time of inventory
Evidence should be controlled by signature transfer (signatures of the recipient and
the person relinquishing custody) and made available to those who have need to
examine and use the evidence during the accident investigation
Secure storage and access control to evidence must be maintained throughout the
investigation
The accident investigation board chairperson should determine the disposition of
evidence at the conclusion of the investigation.
3.2.4 Testing Physical Evidence
Testing and analyzing physical evidence may be important tools in identifying contributing
and root causes of an accident. Testing is generally divided into nondestructive and
destructive testing and must be properly sequenced to assure that all nondestructive
testing and analysis are performed prior to the start of destructive testing. A simple test
and analysis plan may help avoid problems. Testing need not be performed by an
independent off-site laboratory if the tests are straightforward and are witnessed by a
board member. Decisions on performing testing and analysis should be made early in the
investigation so that the results are available in time to meet the board's schedule.
3.3 GATHERING DOCUMENTARY AND ELECTRONIC SYSTEMS EVIDENCE
Preserving documentary evidence, data, and information is an important consideration.
This evidence might be on paper, videotape, magnetic tape, or computer media, either in
an area of close proximity to the accident or in files at other locations. Such evidence may
include items such as permits, reports, analyses, logbooks, work process documentation,
instrument charts, as-built drawings, entry control records, maintenance tags, and process
records. Documents or paper evidence can be overlooked, misplaced, or taken.
Documents can be altered, disfigured, misinterpreted, or electronically sanitized.
Computer software and disks can be erased by exposure to magnetic fields.
Documentary evidence that could be altered in any way should be collected, catalogued,
and secured (in locked containers, if necessary).
3.4 CONDUCTING INTERVIEWS
Human evidence can be extremely delicate. Eyewitnesses can forget, overlook, or fail to
recall evidence of critical value to the investigation. Individuals naturally begin to
rationalize the circumstances of traumatic accidents after the event. Therefore, to
preserve accuracy, the preferred approach is to obtain and record initial eyewitness
statements before the participants and witnesses leave the accident site. This step should
be taken as part of the initial response efforts discussed in Section IV, Paragraph 1.4, of
this Guide.
After the board arrives, a witness interviewing schedule should be established, and
interviewing should begin as soon as practical. A neutral location free from distractions
(phones, noise, etc.) should be reserved for these interviews. Each board member is
responsible for assuring that the interviews are effective and productive. Court reporters
should be used to document key interviews to ensure accuracy and expeditious availability
of transcripts to the board. Recording should commence at the opening statement (see
Appendix 3). In some cases, those being interviewed may request the presence of an
attorney or union representative during the interview. Unless directed to do otherwise by
DOE legal counsel, this request should be honored. The transcript should then be
reviewed for accuracy by the board and the witness, and discrepancies should be resolved.
The transcript should be read by all board members and placed in the investigation files.
3.4.1 Who to Interview
The board should develop a strategy and the sequence of interviews prior to scheduling
interviews with the following types of individuals:
witnesses to a specific event,
co-workers,
supervisors,
managers,
injured parties,
emergency response personnel,
individuals first on the scene,
medical personnel/physicians, and
other organizational personnel
3.4.2 Interviewing Techniques
Care needs to be exercised in interviewing witnesses to minimize hearsay and
collaboration. It also may be necessary to conduct followup interviews of witnesses for
clarifying and corroborating information. A board member should be present at key
interviews and control the interviews. Good interviewing techniques that will aid in this
effort include the following:
Plan the interview. Determine ahead of time what information is needed and what
questions need to be asked.
Establish rapport before the interview starts. Create an environment in which the
witness will be more comfortable. Do not treat the interview like an interrogation.
Provide a standard opening statement to ensure consistency for all interviews. A
model opening statement is included in Appendix 3 that addresses privacy and
freedom of information concerns.
Before asking specific questions, ask the interviewee to provide a description of
the events in his/her own words. Do not interrupt during this description.
Ask open-ended questions (i.e., questions that cannot be answered by "yes" or
"no" responses).
Be unbiased and nonjudgmental. Do not ask leading questions or questions that
suggest a certain point of view; the witness may believe that a decision has already
been made and any contrary information will not be taken seriously.
Schedule effectively. Schedule time between interviews to reflect on the
information obtained and to decide whether any new information has affected the
questions planned for the next witness.
3.5 EXAMINING ORGANIZATIONAL CONCERNS, MANAGEMENT
SYSTEMS, AND LINE MANAGEMENT OVERSIGHT
Accident investigations must thoroughly examine organizational concerns, management
systems, and line management oversight processes to determine whether deficiencies in
these areas were root causes of the accident. This examination focuses on management
systems, not on individuals. To find out why management systems were not effective in
preventing the conditions leading to the accident, investigators should examine the
components of the Department's integrated safety management system as defined in
DOE P 450.4, SAFETY MANAGEMENT SYSTEM POLICY, DOE P 411.1, SAFETY
MANAGEMENT FUNCTIONS, RESPONSIBILITIES, AND AUTHORITIES
POLICY, and their accompanying implementation guidance. The safety management
system consists of six components: the objective, guiding principles, core functions,
mechanisms, responsibilities, and implementation. These components provide a
framework that can be used to verify whether the safety management system contributed
to the accident.
Review of management issues should focus initially on the following components of safety
management and how they may have contributed to the accident. However, the review
should not be limited to these components alone and should be expanded by board
members as appropriate. Consideration of issues such as maintenance, work planning and
controls, etc., may also be appropriate.
The objective of integrated safety management is to assure that the Department and
contractors systematically integrate safety into management and work practices at all
levels so that missions are accomplished while protecting the public, the workers, and the
environment. This is accomplished through effective integration of safety management
into all facets of work planning and execution.
The guiding principles of safety management are the fundamental policies that guide
Department and contractor actions, from development of safety directives to performance
of work. They provide the essential criteria for evaluating line management's performance
in ensuring effective safety management. They are:
1. Line Management Responsibility for Safety. Line management is directly
responsible for the protection of the public, the workers, and the environment.
2. Clear Roles and Responsibilities. Clear and unambiguous lines of authority and
responsibility for ensuring safety are established and maintained at all
organizational levels within the Department and its contractors.
3. Competence Commensurate with Responsibilities. Personnel shall possess the
experience, knowledge, skills, and abilities that are necessary to discharge their
responsibilities.
4. Balanced Priorities. Resources shall be effectively allocated to address safety,
programmatic, and operational considerations. Protecting the public, the workers,
and the environment shall be a priority whenever activities are planned and
performed.
5. Identification of Safety Standards and Requirements. Before work is performed,
the associated hazards shall be evaluated and an agreed-upon set of safety
standards and requirements shall be established that, if properly implemented, will
provide adequate assurance that the public, the workers, and the environment are
protected from adverse consequences.
6. Hazard Controls Tailored to Work Being Performed. Administrative and
engineering controls to prevent and mitigate hazards shall be tailored to the work
being performed and associated hazards.
7. Operations Authorization. The conditions and requirements to be satisfied for
operations to be initiated and conducted shall be clearly established and agreed
upon.
The core functions for integrated safety management provide the necessary structure for
any work activity that could potentially affect the public, the workers, and the
environment. The functions are applied as a continuous cycle, with the degree of rigor
appropriate to address the type of work activity and the hazards involved. This
framework can be useful during an accident investigation to determine whether the work
activity and its hazards were appropriately analyzed and the appropriate controls were
implemented during work performance. The five core functions are:
1. Define the Scope of Work. Missions are translated into work, expectations are
set, tasks are identified and prioritized, and resources are allocated.
2. Analyze the Hazards. Hazards associated with the work are identified, analyzed,
and categorized.
3. Develop and Implement Hazard Controls. Applicable standards and requirements
are identified and agreed upon, controls to prevent/mitigate hazards are identified,
the safety envelope is established, and controls are implemented.
4. Perform Work within Controls. Readiness is confirmed and work is performed
safely.
5. Provide Feedback and Continuous Improvement. Feedback information on the
adequacy of controls is gathered, opportunities for improving the definition and
planning of work are identified and implemented, line and independent oversight is
conducted, and, if necessary, regulatory enforcement actions occur.
Additional information on implementing the Department's safety management system is
included in DOE P 450.4, DOE P 411.1, and their implementation guidance.
4.0 DETERMINING FACTS AND ANALYZING INFORMATION
4.1 DETERMINING FACTS
The first step in an accident investigation is to determine the facts or "what happened."
Identifying all the relevant facts through the investigative process enables the board to
satisfy this requirement. As facts are gathered and reviewed, first impressions should notguide the investigation; rather, the board should review all facts in the totality of the
accident's circumstances to ensure that only factual information is considered in
determining what actually occurred. Facts should be constantly reviewed for relevance
and accuracy, then validated. Not all information can be established as factual with
complete certainty; therefore, the board's report should identify areas of uncertainty
revealed during the investigation.
The investigation determines facts in a logical manner by:
Establishing a clear chronological description of the accident (what happened and
how)
Stressing aspects of the accident that may have a bearing on causal considerations
Establishing accurate, complete, and substantive information that can be used to
support the analysis and conclusions of the investigation
Resolving matters of speculation and disputed facts through analysis, testing, and
board discussions.
Care must be taken to ensure that relevant facts are not overlooked and are objectively
considered during the investigation. Investigators' preconceived notions, press accounts,
and other publicized information may bias the investigation. Investigators should examine
evidence critically and establish an objective and independent account of the accident.
Examples of information to include in the determination of facts are:
Pertinent background information on the site or facility (e.g., facility description
and its mission, location, and history)
Description of the injury, exposure, property damage, or costs
Physical evidence, including meteorological conditions at the time of the accident
(if relevant)
Chronology of pertinent events/causal factors
Physical hazards and safety controls present or absent at the time of the accident
Technical data on operations or processes impacting the accident
Related events that are not part of the causal sequence but that provide revealing
information about how or why the accident occurred
Description of organizational, procedural, policy, or safety management processes
relating to the accident, such as quality assurance procedures, safety practices,
work planning procedures, and hazards analyses.
One procedure that has been used in the past with success in organizing factual material is
to place removable, adhesive-backed notes on a wall in a large room to form an events and
causal factors chart. The analytical tools used later in the investigation will help the board
validate and analyze the facts on this chart. This procedure will also help the board
develop a logical flow and chronology of events surrounding the accident, which all board
members can review at any time. The events and causal factors chart is constantly
updated so board members can keep current with new information. The chart is also
helpful in conducting the associated analyses and in preparing the report.
4.2 ANALYZING FACTS
Analyzing facts provides another key element of information for the investigation "how
the accident happened." Analysis focuses on the facts connected to the accident and the
conditions leading up to the accident, and also identifies the causal factors that allowed the
accident to occur. The board thoroughly documents the methodology it uses to arrive at
its understanding of the facts, conditions, and circumstances. Analytical tools can be used
to chart events, analyze the relationships of causes to events, assist investigators in
reaching conclusions about the causal factors, and help develop judgments of need.
Proper investigation and analyses should be performed in a cost-effective manner but not
at the expense of rigorous and comprehensive investigation and review of management or
other system failures.
Most analyses are performed using tools such as change analysis, barrier analysis, events
and causal factors analysis, and root cause analysis. Further descriptions of these
techniques are provided in Section IV, Paragraph 4.4, of this Guide. The results of
applying each technique should be identified in the report. If the board arrives at different
conclusions from each type of analysis, the report should explain how the results fit
together.
A root cause analysis should be conducted for each accident investigation. The
methodology used is not as important as the results. In an accident investigation, it is
important to look beyond the errors and failures that immediately precipitated the
accident. The investigator must identify system deficiencies at the work and management
levels to determine the underlying oversights, omissions, performance errors, and accepted
risks that are the root causes. These causes may lie in the organizational structure, safety
management systems, or line management oversight processes related to the accident.
4.3 DETERMINING CAUSAL FACTORS
A key element of the investigation is determining the causal factors or "why the accident
happened." The causal factors of an accident are events and conditions in the accident
sequence necessary and sufficient to produce or contribute to the unwanted result. Causal
factors generally consist of a series of relatively simple and explicit statements that
summarize the causes and their contributing factors, including any systemic factors. There
are three types of causal factors: direct, contributing, and root causes. Direct cause is
defined as the immediate events or conditions that cause the accident. Contributing causes
are conditions or events that collectively increase the likelihood of an accident but that
individually did not cause the accident. Root causes are conditions or events that, if
corrected or eliminated, would prevent recurrence of the accident.
DOE O 225.1A requires that causal factors, including root causes, be identified during an
accident investigation. Contributing and root causes should always be identified in order
to complete the causal factors analysis. If the accident investigation board is unable to
identify the root causes of the accident, a statement to that effect should be included in the
report.
Identifying the direct cause of an accident is optional. While it may not be necessary to
identify the direct cause in order to complete the causal factors analysis, the direct cause
should be identified when it facilitates understanding why the accident occurred or when it
is useful in developing lessons learned from the accident.
4.4 DESCRIPTION OF ANALYTICAL TECHNIQUES
A suite of analytical techniques available to support the accident investigation process is
listed in Table 3. Change analysis, barrier analysis, root cause analysis, and events and
causal factors charting and analysis are all considered core analytical techniques for
accident investigations. They are easy to learn and use, are efficient, and meet the needs
of DOE's accident investigation program. While many techniques could be used on most
accidents, those used must be suitable for the type and complexity of the accident. For
example, causation for a complex accident could not be determined through the use of
only one technique, such as barrier analysis.
In general, the core analytical techniques should be used for Type A and Type B accident
investigations to assure that all of the contributing and root causes are identified. These
techniques have been used successfully in the past for both Type A and Type B
accident investigations, although other techniques can be used if they yield similar results.
For complex accidents, more rigorous techniques, such as those that employ complicated
analytical trees, may be necessary to assure that accident causation is identified. Two
examples are Management Oversight and Risk Tree (MORT) and Project Evaluation Tree
(PET).
Other analytical techniques could be used, if needed, for specific situations such as
scientific modeling (e.g., for incidents involving criticality and atmospheric dispersion),
material and structural analysis, human factors analysis, software hazards analysis,
common cause failure analysis, or sneak circuit analysis. In certain situations, an
integrated accident event matrix may be developed to determine the actions and
interactions of personnel around the time of the accident. The application of analytical
techniques for a given accident is determined by the board chairperson, in consultation
with board members and advisors/consultants who have expertise in available techniques.
Table 3. Accident Investigation Analytical Techniques.
Core Analytical Techniques
For the basic accident with few system failures, these analytical techniques may
be used:
Barrier Analysis
Change Analysis
Root Cause Analysis (manual or automated)
Events and Causal Factors Charting and Analysis
Complex Analytical Techniques
For complex accidents with multiple system failures, the analytical techniques
may include fault or analytic tree analysis, and the core analytical techniques
listed above.
Specific Analytical Techniques
This pool of analytical techniques should be used to select techniques for specific
investigations (depending on the nature and complexity of the accident) as
determined by subject matter experts and the board chairperson.
Human Factors Analysis
Integrated Accident Event Matrix
Failure Modes and Effects Analysis
Software Hazards Analysis
Common Cause Failure Analysis
Sneak Circuit Analysis
72-Hour Profile
Materials and Structural Analysis
Scientific Modeling (e.g., for incidents involving
criticality and atmospheric dispersion)
Following is a brief discussion of techniques that are used in most accidents. Further
details are available in the DOE workbook Conducting Accident Investigations.
4.4.1 Barrier Analysis
The basic premise of barrier analysis is that there is energy flow associated with all
accidents. This energy may be kinetic, potential, electromagnetic, thermal, steam, other
pressurized gases or liquids, or a myriad of other types of energy. It is the isolation,
shielding, and control (barriers) of this energy (hazard) from people, property, or the
environment (targets) that prevents accidents. Barriers generally fall in the following
categories: equipment, design, administrative (procedures and work processes),
supervisory/management, warning devices, knowledge and skills, and physical. Therefore,
identifying the energy sources and the failed or deficient barriers and controls in an
accident investigation provides the means for identifying the causal factors of the accident.
If barriers were installed and one failed partially or totally, an investigator would examine
the secondary safety systems, if any, that were in place to mitigate the failure. The
investigator would also determine what events led up to and through the failure sequence,
paying particular attention to changes made in the system. To accomplish this, the entire
sequence of events can be broken down into a logical flow from the beginning to the end
of an accident. Questions are asked about the practicality of the barriers and controls
selected, why they failed, or why none were selected for use.
The principal benefits of barrier analysis are that it identifies safety system elements that
failed, and the results can be succinctly presented. Another benefit of barrier analysis is
that the results can easily be presented graphically. A graphical flowchart (diagram) can
clearly and concisely portray the energy flows and failed or unused barriers that led to the
accident. Thus, barrier analysis is valuable in understanding the accident and the sequence
of events that led to it.
4.4.2 Change Analysis
Change analysis is a systematic approach to problem-solving that can help identify
accident causes. Change analysis is a simple, straightforward process that is relatively
quick and easy to learn and apply.
Change is a necessary ingredient for progress; however, changes to systems and their
impact also contribute to errors, loss of control, and accidents. The purpose of change
analysis is to identify and examine all changes systematically and to determine the
significance or impact of the changes. The use of this technique in accident investigation
is particularly well-suited for finding quick answers and identifying causal factors that are
not otherwise obvious.
It has been demonstrated that, when problems arise for any functional system that has
been operating satisfactorily (i.e., up to some standard), changes and differences
associated with personnel, plant and hardware, or procedures and managerial controls are
actual causal factors in creating these problems. Change can be thought of as stress on a
system that was previously in a state of dynamic equilibrium. Change can also be viewed
as anything that disturbs the planned or normal functioning of a system.
Accident investigators need to carefully evaluate all the changes identified during the
investigation. Did the change really cause the result, or did the change merely bring an
existing system deficiency to light? The investigation must focus on the systemic
deficiencies that allowed the accident to happen and not just accept the changes identified
as being the sole cause of the accident. Often, change analysis will lead to further insight
into areas that must be explored by other analytical techniques.
4.4.3 Events and Causal Factors Charting and Analysis
Identifying systemic causal factors requires understanding the sequence of events over
time and the interaction of those events and their causal factors. This sequence proceeds
from an initiating event through the final loss-producing occurrence. A meticulous tracing
of unwanted energy transfers and their relationships to each other and to the people, plant,
procedures, and controls involved in an accident will usually reveal a definable sequence
for an accident.
Two basic principles are helpful in defining and understanding these sequences of events,
causal factors, and energy transfers:
Accidents result from a set of successive events that produce unintentional harm
(i.e., personal injury, property damage)
The accident sequence occurs during the conduct of some work activity (i.e., a
series of events directed toward some anticipated or intended outcome other than
injury or damage).
Events and causal factors charting is an integral and important part of the DOE accident
investigation process. It is used in conjunction with other key tools (such as root cause
analysis, change analysis, and barrier analysis) to achieve optimal analytical results in
accident investigation.
An events and causal factors chart is a graphic representation that produces a picture of
the accident: both the sequence of events that led to the accident and the conditions that
were causal factors.
Events and causal factors analysis is an effective means of integrating other analytical
techniques into a concise and complete investigative summary. Events and causal factors
analysis depicts, in logical sequence, the necessary and sufficient events and conditions for
accident occurrence. It provides a systematic accident analysis tool to aid in collecting,
organizing, and depicting accident information; validating information from other
analytical techniques; writing and illustrating the accident investigation report; and briefing
management on the results of the investigation.
For additional information on events and causal factors charting and analysis, refer to
Section 7.3.1 of the DOE workbook Conducting Accident Investigations.
4.4.4 Root Cause Analysis
DOE O 225.1A requires that root causes of each accident be identified. Root cause
analysis is used in accident investigations to identify those deficiencies, including
management systems factors, that, if corrected, would prevent recurrence of the accident
(i.e., the root cause[s] of an accident).
Root causes of an accident can be determined using numerous automated and manual
techniques. A manual version of root cause analysis such as compliance/noncompliance
or tier diagramming is acceptable. Commercially available automated techniques are
widely used in the DOE complex. Whatever technique is used, investigators should assure
that actual root causes are determined, not just contributing causes. The contributing
causes are important; however, the need to find concise and justified root causes should be
the main intent of using these analytical techniques.
4.4.5 Analytical Trees
An analytical tree is a graphical representation of an accident using a deductive approach
(general to specific). The tree starts with the event (accident) and branches out as specific
details are developed. The bottom branches of the tree can be used to identify the causal
factors. There are many acceptable equivalent methods of using analytical trees, such as
fault trees (computerized and manual versions), of which MORT and PET are two
examples. Additional information on the application of analytical trees to accident
investigations can be found in Section 7.4 of the DOE workbook Conducting Accident
Investigations.
5.0 DETERMINING CONCLUSIONS AND JUDGMENTS OF NEED
5.1 ARRIVING AT CONCLUSIONS
Conclusions are significant deductions derived from the investigation's analytical results.
They are derived from and supported by the facts and the results from testing and the
various analyses conducted. Conclusions are statements that answer two of the questions
the accident investigation addresses: what happened and why it happened. Conclusions
may include concise recapitulations of the causal factors (direct, contributing, and root
causes) of the accident, as determined by analysis of the facts. An example of a
conclusion is, "XYZ contractor failed to adequately implement a medical surveillance
program, thereby allowing an individual with medical restrictions to work in violation of
those restri