Display Related Directives to this directive.

U.S. Department of Energy ORDER
Washington, D.C. DOE O 225.1A

Approved: 11-26-97

SUBJECT: ACCIDENT INVESTIGATIONS

1. OBJECTIVE. To prescribe requirements for conducting investigations of certain accidents
occurring at Department of Energy (DOE) operations and sites; to prevent the recurrence of
such accidents; and to contribute to improved environmental protection and safety and health
of DOE employees, contractors, and the public.

2. CANCELLATION.

a. DOE 225.1, ACCIDENT INVESTIGATIONS, of 9-25-95.

b. DOE 5484.1, ENVIRONMENTAL PROTECTION, SAFETY, AND HEALTH
PROTECTION INFORMATION REPORTING REQUIREMENTS, of 10-17-90,
Paragraphs 1 through 5, 6a (1) through (10), 6b, 6d, 6f (1) through (8) and the second
misnumbered 6f, and Chapters I and II.

c. Cancellation of the above Orders and paragraphs does not, by itself, modify or
otherwise affect any contractual obligation to comply with such an Order. Canceled
Orders which are incorporated by reference in a contract shall remain in effect until the
contract is modified to delete the reference to the requirements in the canceled Orders.

3. APPLICABILITY.

a. DOE Elements. Except for the exclusions in Paragraph 3c, below, this Order applies to
all DOE elements.

b. Contractors.

(1) Except for exclusions in Paragraph 3c, below, the Contractor Requirements
Document, Attachment 1, sets forth the requirements to be applied to all
contractors awarded contracts for the operation, management, maintenance,
construction, demolition, or remediation of a DOE-owned or DOE-leased facility.

(2) Contract compliance with the Contractor Requirements Document will be required
to the extent set forth in the contract. Contractors shall continue to comply with
the requirements of the paragraphs of the Order identified in Paragraph 2, above,
that are canceled by this Order until their contracts are modified to delete the
reference to the requirement of those canceled Order paragraphs.

DISTRIBUTION: INITIATED BY:
All Departmental Elements Office of Environment, Safety
and Health (2) Contract compliance with the Contractor Requirements Document will be required
to the extent set forth in the contract. Contractors shall continue to comply with
the requirements of the paragraphs of the Order identified in Paragraph 2, above,
that are canceled by this Order until their contracts are modified to delete the
reference to the requirement of those canceled Order paragraphs.

c. Exclusions. Activities conducted under the authority of the Director, Naval Nuclear
Propulsion Program, as described in Public Law 98-525.

4. REQUIREMENTS.

a. Categorization. DOE field elements shall categorize the type of investigation in
accordance with the algorithm in Attachment 2, to determine if a Type A or Type B
investigation is required. Categorization of all Type A and Type B accident
investigations shall be reported in a timely manner to the Office of the Deputy Assistant
Secretary for Oversight (EH-2). Categorization shall be made expeditiously, taking into
account that timeliness is crucial to conducting an accurate investigation, preserving the
accident scene and evidence, and identifying causal factors. (See Attachment 3 for
definitions.)

b. Notification of Other Agencies. Public law or regulation assigns other agencies
responsibility for investigating certain types of 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 field elements. The Appointing Official shall notify local agencies with
which the Department has memoranda of understanding or which have responsibilities
or interests related to the accident under investigation. Notification of other than local
agencies having agreements with Headquarters shall be made through the Office of the
Deputy Assistant Secretary for Oversight.

c. Conducting the Investigation. A Type A investigation is conducted for the more serious
accidents and is appointed and managed by the Office of the Assistant Secretary for
Environment, Safety and Health; A Type B investigation is appointed and managed at
the Field level. However, the elements of the investigation and the report format are the
same. Accident investigations categorized as either Type A or Type B shall be
conducted as follows:

(1) Appoint the Accident Investigation Board.

(a) The Appointing Official (see Paragraph 5, Responsibilities) shall formally
appoint DOE employees to a DOE Accident Investigation Board within three
calendar days of the accident categorization. If the appointment of a Type A
or Type B Accident Investigation Board is delayed beyond three calendar
days, the rationale for the delay must be documented and provided to the
Assistant Secretary for Environment, Safety and Health (EH-1). The Board
shall consist of an Accident Investigation Board Chairperson and three to six
members, at least one of whom shall be a DOE Accident Investigator. The
Appointing Official or his/her representative shall brief the Board on their
roles and responsibilities and other pertinent information within three calendar
days of their appointment.

(b) The Board appointment shall be in writing and shall include the scope of the
investigation, individuals being appointed, special provisions of the investiga-

tion, and a specified completion date for the final report (nominally 30
calendar days from date of appointment). The scope of the investigation shall
include gathering facts, analyzing causes, developing conclusions, and
developing judgments of need pertaining to DOE and contractor organiza-

tions and management systems that could have or should have prevented the
accident. The scope shall include all levels of the organization up to and
beyond the level of the Appointing Official.

1 Be a DOE senior manager with demonstrated managerial competence,
preferably a member of the Senior Executive Service, or at a senior
general service grade level determined to be appropriate by the
Appointing Official;

2 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 to be appropriate and
documented by the Appointing Official; and

3 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. This requirement is effective
October 1, 1998.

(d) DOE Accident Investigation Board members shall be DOE employees with
subject matter expertise in areas related to the accident, including knowledge
of the Department's Safety Management System Policy and integrated safety
management system. At least one member shall be a DOE Accident
Investigator. The Board may be supported by appropriate advisors and
consultants as determined by the Accident Investigation Board Chairperson.
Investigative and technical expertise may be requested from the Office of the
Deputy Assistant Secretary for Oversight.

(e) The DOE Accident Investigation Board Chairperson and members shall:

1 Report only to the Appointing Official or his/her representative identified
in the letter/memorandum of appointment during the investigation;

2 Be independent of the direct line management chain responsible for day-
to-day operation or oversight of the facility, area, or activity involved in
the accident; and

3 Not include both a supervisor and his or her subordinate.

(2) Investigate the Accident.

(a) The Board shall be responsible for conducting a thorough investigation of all
individuals, organizations, management systems, and facilities having a stake
in or potential impact on the accident, as well as the operation or oversight of
the facility, area, or activity involved in the accident, including all levels of the
organization up to and beyond the level of the Appointing Official.

(b) The Board shall determine the facts of the accident by examining the accident
scene, examining DOE and contractor documentation, interviewing witnesses
and other personnel directly associated with the accident, and performing
engineering tests and analyses as appropriate. The Board shall also examine
policies, standards, and requirements that are applicable to the accident being
investigated, as well as management and safety systems at Headquarters and
in the field that could have contributed to or prevented the accident.

(c) The Board shall analyze the facts and identify causal factors and judgments of
need. The Board shall assure that all causal factors (including root causes)
have been identified, that the conclusions are supported by the facts and
analysis, and that the judgments of need are consistent with the facts and
conclusions.

(d) The Board shall evaluate the effectiveness of safety management systems (as
defined by DOE P 450.4, SAFETY MANAGEMENT SYSTEM POLICY),
the adequacy of policy and policy implementation, and the effectiveness of
line management oversight as they relate to the accident.

(e) Prior to completion of the investigation, the Board shall conduct an internal
review of the investigation process to ensure that:

1 All of the pertinent facts, standards, and requirements relating to the
accident have been identified, a thorough analysis of them has been
conducted, and causal factors have been determined; and

2 Judgments of need have been stated and can be supported by the facts.

(3) Report Investigation Results.

(a) The Board shall report investigation results without determining individual
fault or proposing punitive measures. The report shall contain judgments of
need based upon objective analysis of the facts, root and contributing causes,
and DOE or contractor management systems that could have prevented the
accident.

(b) The Board shall offer the facts section of the draft investigation report to the
affected DOE and contractor line management to allow a review for factual
accuracy prior to completion of the report.

1 Conduct a review of the report to ensure its technical accuracy,
completeness, and internal consistency;

2 Ensure that the report includes results from an analysis of management
control and safety systems that may have contributed to the accident; and

3 Ensure that a review of the report is conducted by qualified and
authorized personnel to determine that it does not contain classified or
unclassified controlled nuclear information, or information protected by
the Privacy Act. Documentation that these reviews have been conducted
shall be retained as part of the investigation file.

(d) The Board Chairperson and Board Members shall sign and date the final
investigation report and, if appropriate, include a minority report section
should any Board member wish to offer an opinion different from that of the
Board.

(e) The Board shall submit the investigation report to the Appointing Official for
acceptance within the time frame established by the Appointing Official. Once
the accident investigation report is accepted by the Appointing Official, the
report is considered final, and the Board is released from its responsibilities.

d. Investigation Closeout. The Appointing Official shall close Type A and Type B
investigations after ensuring the following:

(1) DOE and contractor line organizations affected by the investigation have had an
opportunity to review the facts section of the draft report for accuracy and provide
their comments to the Board.

(2) A statement signed and dated by the Appointing Official is included in the final
report accepting the investigation report, including the Board's conclusions and
judgments of need.

(3) The Board Chairperson and the Head of the Field Element have conducted a
formal briefing of Headquarters and field line management, as well as the Assistant
Secretary for Environment, Safety and Health (for Type A investigations), on the
outcome of the investigation.

(4) The final report is published and distributed within seven calendar days of report
acceptance by the Appointing Official. One copy each shall be provided to the
affected Secretarial Officer(s), operations office and/or field element, and
appropriate Headquarters program office(s). One copy shall be provided to the
Assistant Secretary for Environment, Safety and Health. One copy and an
electronic version of the final report shall be provided to the Office of the Deputy
Assistant Secretary for Oversight. The final report shall also be distributed to
senior managers of organizations identified in the judgments of need with a request
for their organizations to submit corrective action plans, nominally within 30
calendar days from report acceptance by the Appointing Official.

(5) Lessons learned from the accident investigation are developed and disseminated
DOE-wide within 90 calendar days of acceptance of the investigation report by the
Appointing Official, except for delegated Type A investigations [see Paragraph
5a(5)(f)].

(6) Corrective action plans are completed, and corrective actions are implemented to
satisfy the judgments of need identified in the final investigation report.

5. RESPONSIBILITIES.

a. Assistant Secretary for Environment, Safety and Health (EH-1).

(1) Serves as Appointing Official of Type A Accident Investigation Boards, 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.

(2) Reviews all delegated Type A accident investigation reports before acceptance by
the Appointing Official and provides comments to the Appointing Official. This
review shall ensure that an objective investigation was conducted and that the
report clearly and concisely conveys the results of the investigation, including: (a)
the accident description (what happened), (b) the causal factors (why it happened),
and (c) the judgments of need (what can be done to prevent a recurrence).

(3) Grants waivers of the requirement to conduct Type A or Type B accident
investigations for accidents that meet the criteria for such investigations in the
Categorization Algorithm in Attachment 2 to this Order.

(4) Charters limited scope investigations for occurrences, incidents, or accidents based
on recommendations from the Office of the Deputy Assistant Secretary for
Oversight.

(5) Through the Office of the Deputy Assistant Secretary for Oversight (EH-2):

(a) Develops and maintains DOE accident investigation policies, procedures,
standards, and guidelines, and oversees their implementation.

(b) Recommends to the Assistant Secretary for Environment, Safety and Health
whether or not an occurrence, incident, or accident warrants a limited scope,
Type B, or Type A accident investigation. This recommendation is based on
an assessment of the significance of the occurrence, incident, or accident.

(c) Recommends to the Assistant Secretary for Environment, Safety and Health
approval or disapproval of requests for waivers of the requirement to conduct
Type A and Type B accident investigations.

(d) Analyzes accident data to assist in identifying trends and conditions
surrounding the initiation or occurrence of accidents.

(e) Performs complex-wide analyses of accidents to guide and focus oversight
efforts based on analyzed safety impact and Department-wide significance.

(f) Develops and disseminates lessons learned from all Type A and limited scope
accident investigations.

(g) Develops and disseminates information on uniform DOE accident
investigation techniques and ensures training is provided to DOE Accident
Investigation Board Chairpersons and DOE Accident Investigators.

(h) Maintains a list of prospective DOE Accident Investigation Board
Chairpersons, DOE Accident Investigators, and technical subject matter
experts.

(i) Provides investigative and technical subject matter expertise to Appointing
Officials, Board Chairpersons, and points of contact, as requested.

(j) Reviews and provides comments to Appointing Officials on corrective action
plans resulting from Type A and Type B investigations.

(k) Verifies completion of approved corrective actions and satisfaction of
judgments of need.

(l) Reviews Type B accident investigation reports and provides comments to the
Appointing Official.

b. Secretarial Officers.

(1) Cooperate with the Board during the investigation.

(2) Review draft Type A and Type B investigation reports for factual accuracy within
the time frame allowed for the investigation.

(3) Approve corrective action plans resulting from Type A and Type B investigations
for satisfaction of judgments of need identified by the Board.

c. Heads of Field Elements.

(1) Determine whether adequate protection can most effectively be achieved by
continuing to operate under the terms of existing contracts requiring compliance
with old Orders or by modifying the contract to incorporate the requirements of
revised Orders. Field elements are responsible for determining that implementation
of new rule or Order requirements will provide adequate protection prior to
requesting contract modifications that delete old Order requirements from
contracts.

(2) After incorporating this Order into contracts, ensure its implementation and
identify a single point of contact to act as liaison with the Office of the Deputy
Assistant Secretary for Oversight on matters pertaining to the DOE Accident
Investigation Program.

(3) Categorize the type of accident investigation to be conducted in accordance with
Attachment 2. The categorization of all Type A and Type B accident
investigations shall be reported in a timely manner to the Office of the Deputy
Assistant Secretary for Oversight.

(4) Serve as Appointing Officials for Type B or delegated Type A Accident
Investigation Boards.

(5) Ensure establishment of accident investigation capability by trained contractor
readiness team(s) (see Attachment 1). This includes the responsibility for
providing training required to assure readiness to assist in DOE accident
investigations.

(6) Ensure readiness teams and emergency management personnel coordinate or
integrate their activities to facilitate an orderly transition of responsibilities for the
accident scene.

(7) Provide cooperation with and assistance to DOE Accident Investigation Boards.

(8) Ensure that a sufficient number of DOE Accident Board Chairpersons and DOE
Accident Investigators are available to implement this Order for both Type A and Type
B accident investigations and, upon request, provide them to other DOE sites.

(9) Review draft Type A and Type B investigation reports for factual accuracy within
the time frame allowed for the investigation.

(10) Develop lessons learned for Type B accident investigations when serving as the
Appointing Official.

(11) Initiate actions to address applicable lessons learned from investigations conducted
at other DOE sites.

(12) Ensure that corrective action plans are:

(a) Developed to address judgments of need identified by the Board and
submitted to the responsible Secretarial Officer (program office) and to the
Office of the Deputy Assistant Secretary for Oversight, nominally within
30 calendar days of report acceptance by the Appointing Official;

(b) Submitted to the responsible Secretarial Officer for approval;

(d) Implemented and tracked to completion.

(13) Provide biannual (in January and July of each year) status reports of accident
investigation corrective actions to the Office of the Deputy Assistant Secretary for
Oversight until all corrective actions are completed.

d. Appointing Officials.

(1) Formally appoint DOE employees to Type A or Type B Accident Investigation
Boards within three calendar days of categorization of the accident. The
appointment must be in writing and shall meet the requirements of Paragraphs
4c(1)(a) and (b) of this Order.

(2) Ensure that the Board's authority is clear in investigating all potential causes of a
given accident, including individuals, organizations, and management systems up to
and beyond the level of the Appointing Official.

(3) Ensure the Board is briefed on their roles and responsibilities [stressing the Board's
authority indicated in Paragraph 5d(2)] and other pertinent information within
three calendar days of their appointment.

(4) Accept the investigation report by signing and dating a statement to this effect
which is subsequently incorporated into the final report. Once accepted, the report
is considered final and the Board is released from its responsibilities.

(5) Publish and distribute the accident investigation report within 7 calendar days of
report acceptance in accordance with the distribution indicated in Paragraph 4d(4).

(6) Develop lessons learned for dissemination throughout the Department within
90 calendar days of report acceptance.

e. Board Chairpersons.

(1) Manage the investigation process, direct the Board members in their activities, and
represent DOE in all matters regarding the accident investigation.

(2) Ensure that a thorough and competent investigation is completed.

(3) Notify the Director, Office of Enforcement and Investigation (EH-10), of any
potential Price-Anderson enforcement concerns identified during the investigation.

(4) Notify DOE, Federal, state, or local investigative or law enforcement agencies of
suspected unlawful activity identified during the accident investigation.

(5) Coordinate Board activities with all organizations having an interest in the
accident.

(6) Ensure that the Board is supported by appropriate advisors and consultants who
provide specialized expertise as deemed necessary.

6. WAIVERS. A request for waiver of any responsibility for conducting a Type A or Type B
Accident Investigation in accordance with the Accident Investigation Categorization
Algorithm (Attachment 2) 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. The request for waiver must contain the rationale for the request and shall be
submitted to the Office of the Deputy Assistant Secretary for Oversight. The Office of the
Deputy Assistant Secretary for Oversight will review waiver requests and either recommend
approval or disapproval of the requests in writing to the Assistant Secretary for
Environment, Safety and Health, who will make the final determination in writing. Copies of
the request for waiver and the approval or disapproval will be maintained both by the Office
of the Deputy Assistant Secretary for Oversight and the Head of the Field Element.

7. CONTACT. Questions concerning this Order can be directed to the Office of Oversight,
Office of Environment, Safety and Health, 301-903-3777.

BY ORDER OF THE SECRETARY OF ENERGY:

ARCHER L. DURHAM
Assistant Secretary for
Human Resources and Administration
CONTRACTOR REQUIREMENTS DOCUMENT

Type A and Type B Accident Investigations

1. In the performance of this contract, contractors shall support Type A and Type B investigations of
accidents at sites under their cognizance. Type A and Type B investigations are conducted by
formally appointed DOE Accident Investigation Boards comprised of DOE employees,
supplemented by advisors and consultants.

2. Contractors shall establish and maintain readiness to respond to accidents, mitigate the
consequences, assist in collecting and preserving evidence, and assist with the conduct of the
investigation. This shall include preserving the accident scene to the extent that it is under the
control of the contractor, documenting the accident scene through photography and other means,
providing office space and equipment for the Accident Investigation Board, meeting regularly with
the Board for discussions of issues surrounding the accident, and providing general administrative
assistance.

3. Contractors shall also prepare, implement, and track to completion approved corrective action plans
that satisfy judgments of need identified by the Accident Investigation Board.
ACCIDENT INVESTIGATION CATEGORIZATION ALGORITHM

1. INTRODUCTION. Accidents shall be analyzed and characterized expeditiously, as indicated in
Paragraph 4.a of the Order, to determine if either a Type A or Type B investigation shall be
conducted based on the criteria indicated below. Uncertainty in categorization shall be mutually
resolved by the Office of the Deputy Assistant Secretary for Oversight and the Heads of Field
Elements. All accidents not meeting the criteria for a Type A or Type B investigation shall be
categorized, investigated, and reported in accordance with the requirements of DOE O 231.1,
ENVIRONMENT, SAFETY AND HEALTH REPORTING and/or DOE O 232.1,
OCCURRENCE REPORTING AND PROCESSING OF OPERATIONS INFORMATION.
Investigations required by these Orders may provide indicators of future, more severe accidents,
which when identified and corrected early can prevent more serious accidents.

Onsite accidents meeting the Type A or Type B criteria involving Federal or contractor employees
driving government or personal vehicles while on official government business shall be investigated
unless the Head of the Field Element requests and receives a waiver from EH-1 in accordance with
the requirements of Paragraph 6 of this Order.

Offsite accidents meeting the Type A or Type B criteria involving Federal or contractor employees
driving government-owned or rented vehicles shall not be investigated unless the Head of the Field
Element determines an investigation is appropriate based on circumstances surrounding the
accident or the potential for significant lessons learned.

The following categorization criteria shall apply to any accident resulting from DOE, its
contractor, or subcontractor operations.

2. HUMAN EFFECTS.

a. Accidents Requiring Type A Investigations.

(1) Any injury or chemical or biological exposure that results in, or is likely to result in the
fatality of an employee or member of the public (fatal injury is defined as any injury that
results in death within 30 calendar days of the accident; see 49 CFR 830.2).

(2) Any accident where three or more DOE, contractor, or subcontractor employees, or
members of the public incur a serious injury (as defined in 49 CFR 830.2) that requires
hospitalization for more than 48 hours, commencing within 7 calendar days from the date
the injury was received; results in severe hemorrhages; results in severe damage to
nerves, muscles, tendons, or internal organs; results in second or third degree burns
affecting more than 9 percent of the body surface; or has a high probability of realizing a
permanent total disability due to injuries, chemical exposures, or biological exposures
received.

(3) A single individual radiation exposure (see 10 CFR 835.202, Occupational Exposure
Limits for General Employees) resulting in:

(a) A total effective dose equivalent of 25 rem or more;

(b) A dose equivalent to the lens of the eye of 75 rem or more;

(d) The sum of the deep dose equivalent for external exposure and the committed dose
equivalent to any organ or tissue other than the lens of the eye of 250 rem or more;
or

(e) A dose equivalent to the embryo or fetus of a declared pregnant worker of 2.5 rem
or more.

b. Accidents Requiring Type B Investigations.

(1) Any accident that results in the hospitalization of one or more DOE, contractor,
subcontractor employees or members of the public for five continuous calendar days or
longer due to serious injury (as defined in 49 CFR 830.2), occupational illness (except
members of the public), chemical exposure, or biological exposure.

(2) Any one accident resulting in five or more lost-workday cases.

(3) 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,
or procedures. This criterion is intended to cover injuries, illnesses, and exposures that
reveal a pattern and cause for concern.

(4) A single radiation exposure to an individual that results in:

(a) A total effective dose equivalent of at least 10 rem but less than 25 rem;

(b) A dose equivalent to the lens of the eye of at least 30 rem but less than 75 rem;

(d) The sum of the deep dose equivalent for external exposure and the committed dose
equivalent to any organ or tissue other than the lens of the eye of at least 100 rem
but, less than 250 rem; or

(e) A dose equivalent to the embryo or fetus of a declared pregnant worker of at least 1
rem but less than 2.5 rem.

3. ENVIRONMENTAL EFFECTS.

a. Accidents Requiring Type A Investigations. Release of a hazardous substance, material,
waste, or radionuclide from a DOE facility (onsite or offsite), in an amount greater than five
times the reportable quantities specified in 40 CFR Part 302, that results in serious
environmental damage.

b. Accidents Requiring Type B Investigations. Release of a hazardous substance, material,
waste, or radionuclide from a DOE facility (onsite or offsite), in an amount equal to or greater
than two times but less than five times the reportable quantities specified in 40 CFR Part 302,
that results in serious environmental damage.

4. PROPERTY EFFECTS.

a. Accidents Requiring Type A Investigations.

(1) Estimated loss of, or damage to, DOE or other property, including aircraft damage equal
to or greater than $2.5 million or requiring estimated costs equal to or greater than $2.5
million for cleaning, decontaminating, renovating, replacing, or rehabilitating structures,
equipment, or property.

(2) Any apparent loss, explosion, or theft involving radioactive or hazardous material under
the control of DOE, contractors, or subcontractors in such quantities and under such
circumstances to constitute a hazard to human health and safety or private property.

(3) Any unplanned nuclear criticality.

b. Accidents Requiring Type B Investigations.

(1) Estimated loss of, or damage to, DOE or other property of less than $2.5 million but
more than $1 million, including aircraft damage, and costs of cleaning, decontaminating,
renovating, replacing, or rehabilitating structures, equipment, or property.

(2) The operation of a nuclear facility beyond its authorized limits resulting in the
consequences identified in paragraphs 2, 3, or 4 of this attachment.

c. Cost Estimates of Accidents Requiring Type A or Type B Investigations. When estimating
the cost of an accident, the methods in DOE Guide 430.1-1, Cost Estimating Guide, should
be used.

5. OTHER EFFECTS.

a. Accidents Requiring Type A Investigations. Any accident or series of accidents for which a
Type A investigation is deemed appropriate by the Secretary or the Assistant Secretary for
Environment, Safety and Health.

b. Accidents Requiring Type B Investigations. Any accident or series of accidents for which a
Type B investigation is deemed appropriate by the Secretary; Assistant Secretary for
Environment, Safety and Health; Associate Deputy Secretary for Field Management;
Cognizant Secretarial Officer; or Head of the Field Element. This includes, for example,
Departmental cross-cutting issues and issues warranting the attention of local news or interest
groups.
DEFINITIONS

DOE Accident Investigator. 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. Effective October 1, 1998, DOE Accident Investigators must have attended an accident
investigation course of instruction that is based on current materials developed by Office of Deputy
Assistant Secretary for Oversight.

Appointing Official. A designated authority responsible for assigning Accident Investigation Boards for
Type A and Type B investigations, with responsibilities as prescribed in Paragraph 5d of this Order.

Causal Factor. An event or condition in the accident sequence necessary and sufficient to produce or
contribute to the unwanted result.

Heads of Field Elements. First-tier field managers of the operations offices, the field offices, and the
Power Marketing Administrations (Administrators). Field elements is a general term for all DOE sites
(excluding individual duty stations) located outside of the Washington, D.C. metropolitan area.

Judgments of Need. Managerial controls and safety measures necessary to prevent or minimize the
probability or severity of a recurrence of an accident.

Lesson Learned. A "good work practice" or innovative approach that is captured and shared to
promote its repeated application. A lesson learned may also be an adverse work practice or experience
that is captured and shared to avoid recurrence.

Limited Scope Investigation. An accident investigation, chartered by the Assistant Secretary for
Environment, Safety and Health, that is reduced in scope, duration, and resources from that normally
associated with a Type A or Type B investigation.

Readiness Team. Trained personnel who are available to perform initial investigative response activities
immediately following an accident.

Root Cause. The causal factor(s) that, if corrected, would prevent recurrence of the accident.