DOE Workbook

CONDUCTING ACCIDENT
INVESTIGATIONS

REVISION 2

May 1, 1999

U.S. Department of Energy

Washington, D.C. 20585

DISTRIBUTION STATEMENT
Approved for public release; distribution is unlimited.
 Table of Contents

TABLE OF CONTENTS

Foreword

Introduction
˜ ˜ ˜

Part I C The Context of DOE

Context DOE==s
Accident Investigation Program
Section 1 C Accidents: General Principles

1.1 The Nature of Accidents ........................................................................................................ 1-1

1.2 Human Factors Considerations .............................................................................................. 1-1

1.2.1 Human-Machine Interface .......................................................................................... 1-2

1.2.2 Human Capabilities .................................................................................................... 1-3
1.2.3 Equipment/Design Considerations ............................................................................. 1-4
1.2.4 Physical Work Environment ....................................................................................... 1-4
1.2.5 Organizational Work Environment ............................................................................. 1-6

Key Points to Remember .............................................................................................................. 1-8

Section 2 C DOE=s Accident Investigation

Program
2.1 Overall Management of the Program ..................................................................................... 2-1
2.2 Roles and Responsibilities of Key Participants ..................................................................... 2-1
2.2.1 Appointing Officials and Line Management Participants .......................................... 2-2
2.2.2 The Accident Investigation Board .............................................................................. 2-3

2.3 Site Readiness ........................................................................................................................ 2-6

2.3.1 Readiness C What Is It? ............................................................................................. 2-6

2.3.2 Establishing Written Procedures and Responsibilities ............................................... 2-8
2.3.3 Maintaining Resources to Support Accident Investigations ...................................... 2-8
2.3.4 Training for Site Readiness ........................................................................................ 2-8
2.3.5 Conducting Periodic Practices and Evaluations ......................................................... 2-9

2.4 Accident Investigation Process Overview ............................................................................. 2-9

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2.5 Waivers ................................................................................................................................ 2-11

2.6 Limited Scope Accident Investigations ............................................................................... 2-12

Key Points to Remember ............................................................................................................ 2-13

˜ ˜ ˜

Part II C The Accident

Investigation Process
Section 3 C Appointing the Investigation
Board
3.1 Establishing the Accident Investigation Board and Its Authority ......................................... 3-1
3.2 Briefing the Board .................................................................................................................. 3-2

Key Points to Remember .............................................................................................................. 3-3

Section 4 C Implementing Site Readiness

4.1 Immediate Post-Accident Actions ......................................................................................... 4-1
4.2 Preserving and Documenting the Accident Scene ................................................................. 4-2

4.2.1 Securing and Preserving the Scene ............................................................................. 4-2

4.2.2 Documenting the Scene .............................................................................................. 4-3

4.3 Collecting, Preserving, and Controlling Evidence ................................................................. 4-3

4.4 Obtaining Initial Witness Statements ..................................................................................... 4-4
4.5 Transferring Information to the Board ................................................................................... 4-5

Key Points to Remember .............................................................................................................. 4-7

Section 5 C Managing the

Accident Investigation
5.1 Project Planning ..................................................................................................................... 5-1

5.1.1 Collecting Initial Site Information .............................................................................. 5-1

5.1.2 Determining Task Assignments .................................................................................. 5-1
5.1.3 Preparing a Schedule .................................................................................................. 5-2
5.1.4 Acquiring Resources .................................................................................................. 5-3
5.1.5 Addressing Potential Conflicts of Interest.................................................................. 5-3
5.1.6 Establishing Information Access and Release Protocols ........................................... 5-3

5.2 Managing the Investigation Process ...................................................................................... 5-6

5.2.1 Taking Control of the Accident Scene........................................................................ 5-6

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5.2.2 Initial Meeting of the Investigation Board ................................................................. 5-6

5.2.3 Promoting Teamwork ................................................................................................. 5-7
5.2.4 Managing Information Collection .............................................................................. 5-9
5.2.5 Coordinating Internal and External Communication ................................................. 5-9
5.2.6 Managing the Analysis ............................................................................................. 5-11
5.2.7 Managing Report Writing ......................................................................................... 5-12
5.2.8 Managing Onsite Closeout Activities ....................................................................... 5-13
5.2.9 Managing Post-Investigation Activities ................................................................... 5-13

5.3 Controlling the Investigation Process .................................................................................. 5-14

5.3.1 Monitoring Performance and Providing Feedback ................................................... 5-14

5.3.2 Controlling Cost and Schedule ................................................................................. 5-14
5.3.3 Assuring Quality ....................................................................................................... 5-15

Key Points to Remember ............................................................................................................ 5-16

Section 6 C Collecting Data

6.1 Collecting Human Evidence .................................................................................................. 6-2

6.1.1 Locating Witnesses ..................................................................................................... 6-2

6.1.2 Conducting Interviews ................................................................................................ 6-2

6.2 Collecting Physical Evidence ................................................................................................ 6-6

6.2.1 Documenting Physical Evidence ................................................................................ 6-7

6.2.2 Inspecting Physical Evidence ..................................................................................... 6-9
6.2.3 Removing Physical Evidence ................................................................................... 6-10

6.3 Collecting Documentary Evidence ...................................................................................... 6-10

6.4 Examining Organizational Concerns, Management Systems, and Line Management
Oversight ............................................................................................................................. 6-11
6.5 Preserving and Controlling Evidence .................................................................................. 6-12

Key Points to Remember ............................................................................................................ 6-17

Section 7 C Analyzing Data

7.1 Determining Facts .................................................................................................................. 7-1

7.2 Determining Causal Factors ................................................................................................... 7-2

7.2.1 Direct Cause ............................................................................................................... 7-2

7.2.2 Contributing Causes ................................................................................................... 7-3
7.2.3 Root Causes ................................................................................................................ 7-4
7.2.4 The Importance of Causal Factors .............................................................................. 7-5

7.3 Using the Core Analytical Techniques .................................................................................. 7-5

7.3.1 Events and Causal Factors Charting ........................................................................... 7-5

7.3.2 Barrier Analysis .......................................................................................................... 7-8

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7.3.3 Change Analysis ....................................................................................................... 7-15

7.3.4 Events and Causal Factors Analysis ......................................................................... 7-21
7.3.5 Root Cause Analysis ................................................................................................. 7-25

7.4 Using Advanced Analytic Methods ..................................................................................... 7-39

7.4.1 Analytic Trees........................................................................................................... 7-40

7.4.2 Management Oversight and Risk Tree Analysis (MORT) ....................................... 7-44
7.4.3 Project Evaluation Tree (PET) Analysis .................................................................. 7-47

7.5 Other Analytic Techniques .................................................................................................. 7-52

7.5.1 Time Loss Analysis .................................................................................................. 7-52

7.5.2 Human Factors Analysis ........................................................................................... 7-52
7.5.3 Integrated Accident Event Matrix ............................................................................ 7-53
7.5.4 Failure Modes and Effects Analysis ......................................................................... 7-53
7.5.5 Software Hazards Analysis ....................................................................................... 7-54
7.5.6 Common Cause Failure Analysis ............................................................................. 7-54
7.5.7 Sneak Circuit Analysis ............................................................................................. 7-54
7.5.8 Materials and Structural Analysis ............................................................................ 7-54
7.5.9 Design Criteria Analysis........................................................................................... 7-54
7.5.10 Accident Reconstruction .......................................................................................... 7-54
7.5.11 Scientific Modeling .................................................................................................. 7-54

Key Points to Remember ............................................................................................................ 7-56

Section 8 C Developing Conclusions

and Judgments of Need
8.1 Conclusions ............................................................................................................................ 8-1
8.2 Judgments of Need ................................................................................................................. 8-2
8.3 Minority Opinions .................................................................................................................. 8-4

Key Points to Remember .............................................................................................................. 8-5

Section 9 C Reporting the Results

9.1 Writing the Report ................................................................................................................. 9-1
9.2 Report Format and Content .................................................................................................... 9-1

9.2.1 Disclaimer ................................................................................................................... 9-3

9.2.2 Appointing Official=s Statement of Report Acceptance ............................................. 9-3
9.2.3 Table of Contents ........................................................................................................ 9-4
9.2.4 Acronyms and Initialisms ........................................................................................... 9-4
9.2.5 PrologueCInterpretation of Significance ................................................................... 9-5
9.2.6 Executive Summary .................................................................................................... 9-5
9.2.7 Introduction ................................................................................................................ 9-6
9.2.8 Facts and Analysis ...................................................................................................... 9-6
9.2.9 Conclusions and Judgments of Need ........................................................................ 9-12
9.2.10 Minority Report ........................................................................................................ 9-13
9.2.11 Board Signatures ...................................................................................................... 9-13

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9.2.12 Board Members, Advisors, Consultants, and Staff .................................................. 9-13

9.2.13 Appendices ............................................................................................................... 9-13

9.3 Performing Quality Review and Validation of Conclusions ................................................ 9-13

9.4 Conducting the Factual Accuracy Review ........................................................................... 9-16
9.5 Review by the Assistant Secretary for Environment, Safety and Health ............................ 9-16
9.6 Submitting the Report .......................................................................................................... 9-17

Key Points to Remember ............................................................................................................ 9-18

˜ ˜ ˜
Appendices
Appendix A C Glossary
Appendix B C References
Appendix C C Specific Administrative Needs
Appendix D C Safety Management System
Appendix E C Subject Index

˜ ˜ ˜
List of Tables
Table 1-1. Human capabilities contribute to work performance ................................................ 1-4
Table 1-2. Equipment design can affect human performance .................................................... 1-5

Table 2-1. Appointing officials and line management participants in accident

investigations have clearly defined responsibilities ................................................. 2-2
Table 2-2. The accident investigation board has these major responsibilities ........................... 2-3
Table 2-3. The timeline for a Type A or Type B accident investigation requires conducting
multiple simultaneous tasks .................................................................................... 2-11

Table 3-1. Board members must meet these criteria .................................................................. 3-2

Table 4-1. Several types of witnesses should provide preliminary statements .......................... 4-5

Table 5-1. These activities should be included on an accident investigation schedule ............. 5-2
Table 5-2. The chairperson establishes protocols for controlling information .......................... 5-5
Table 5-3. The chairperson should use these guidelines in managing information
collection activities ................................................................................................. 5-10
Table 5-4. The Price-Anderson Amendments Act of 1988 ...................................................... 5-11

Table 6-1. These sources are useful for locating witnesses ....................................................... 6-3
Table 6-2. It is important to prepare for interviews ................................................................... 6-3
Table 6-3. Group and individual interviews have different advantages .................................... 6-4
Table 6-4. Interviewing do=s ....................................................................................................... 6-5
Table 6-5. Interviewing don=ts .................................................................................................... 6-6
Table 6-6. Use these universal precautions when handling potential bloodborne pathogens .... 6-8
Table 6-7. These are typical questions for addressing the five core functions
of integrated safety management ............................................................................ 6-13
Table 6-8. These are typical questions for addressing the seven
guiding principles of integrated safety management .............................................. 6-14
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Table 7-1. Case study introduction ............................................................................................ 7-3

Table 7-2. Benefits of events and causal factors charting .......................................................... 7-6
Table 7-3. Guidelines and symbols for preparing an events and causal factors chart ............... 7-8
Table 7-4. Sample barrier analysis worksheet ......................................................................... 7-16
Table 7-5. Sample change analysis worksheet ......................................................................... 7-22
Table 7-6. Case Study: Change analysis summary .................................................................. 7-23
Table 7-7. Tier diagram worksheet for a contractor organization ............................................ 7-28
Table 7-8. Example tier diagram approach .............................................................................. 7-30
Table 7-9. Compliance/noncompliance root cause model categories ...................................... 7-38
Table 7-10. MORT color coding system .................................................................................... 7-47

Table 8-1. These guidelines are useful for writing judgments of need ...................................... 8-3
Table 8-2. Case Study: Judgments of need ................................................................................ 8-4

Table 9-1. Useful strategies for drafting the investigation report .............................................. 9-2
Table 9-2. The accident investigation report should include these items .................................. 9-2
Table 9-3. Facts differ from analysis ....................................................................................... 9-10

˜ ˜ ˜

List of Figures
Figure 1-1. Human-machine “activity model” ........................................................................... 1-2

Figure 2-1. The process used to conduct an accident investigation involves

many activities....................................................................................................... 2-10
Figure 2-2. The three primary activity phases in an accident investigation overlap
significantly ........................................................................................................... 2-11

Figure 5-1. A typical schedule of accident investigation activities covers 30 days .................. 5-4

Figure 7-1. Simplified events and causal factors chart .............................................................. 7-7
Figure 7-2. Sample of an events and causal factors chart (in progress) .................................... 7-9
Figure 7-3. Barriers are intended to protect personnel and property against hazards ............. 7-13
Figure 7-4. Barriers to protect workers from hazards .............................................................. 7-14
Figure 7-5. Summary results from a barrier analysis reveal the types of
barriers involved .................................................................................................... 7-17
Figure 7-6. Summary results from a barrier analysis can highlight the role of the
core functions in an accident ................................................................................. 7-18
Figure 7-7. The change analysis process is relatively simple .................................................. 7-20
Figure 7-8. Events and causal factors analysis; driving events to causal factors .................... 7-24
Figure 7-9. Grouping root causes on the events and causal factor chart ................................. 7-25
Figure 7-10. Identifying the linkages on the tier diagram .......................................................... 7-35
Figure 7-11. The analytic tree process begins with the accident as the top event ..................... 7-40
Figure 7-12. Analytic trees are constructed using symbols ....................................................... 7-43
Figure 7-13. The layout of an analytic tree shows logical relationships ................................... 7-45
Figure 7-14. A completed analytic tree shows the flow of lower-tier elements
to the top event ...................................................................................................... 7-46
Figure 7-15. The initial MORT chart uses logic symbols .......................................................... 7-48
Figure 7-16. The accident description can be shown on a MORT chart ................................... 7-49
Figure 7-17. Management system factors can be shown on a MORT chart .............................. 7-50
Figure 7-18. This branch of the PET chart deals with procedures ............................................ 7-51
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Figure 7-19. Time loss analysis can be used when emergency response
is in question ............................................................................................................................... 7-53

Figure 8-1. Facts, analyses, and causal factors are needed to support judgments of need ........ 8-3

˜ ˜ ˜

List of Forms and Tools

Accident Investigation Equipment Checklist ............................................................................. 2-15

Accident Investigation AGo Kit@ Contents.................................................................................. 2-20
Accident Investigation Preliminary Interview List ...................................................................... 4-9
Accident Investigation Witness Statement Form ....................................................................... 4-10
Accident Investigation Startup Activities List ........................................................................... 5-19
Accident Investigation Information Request Form .................................................................... 5-22
Individual Conflict of Interest Certification Form ..................................................................... 5-23
Accident Investigation Interview Schedule Form ...................................................................... 6-19
Accident Investigation Interview Form ...................................................................................... 6-20
Model Opening Statement .......................................................................................................... 6-21
Accident Investigation Physical Evidence Log Form ................................................................ 6-22
Accident Investigation Site Sketch ............................................................................................. 6-23
Accident Investigation Site Map ................................................................................................ 6-24
Accident Investigation Position Mapping Form ......................................................................... 6-25
Accident Investigation Sketch of Physical Evidence Locations and Orientations ..................... 6-26
Accident Investigation Photographic Log Sheet ........................................................................ 6-27
Accident Investigation Sketch of Photography Locations and Orientations .............................. 6-28
Barrier Analysis Worksheet ........................................................................................................ 7-58
Change Analysis Worksheet ....................................................................................................... 7-59
PET Analysis Worksheet ............................................................................................................ 7-60

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Contents-vii
Foreword

A
s part of its continuing effort to enhance the quality and consistency of oversight
activities, the Office of the Deputy Assistant Secretary for Oversight initiated an
extensive review of all aspects of the Accident Investigation Program. As a result, this
workbook has been revised to improve the Accident Investigation Program.

Substantive Workbook Changes

Section 1

• Section 1.2.4, “Broad Environmental Factors,” is retitled “Physical Work Environment,” and
a new section 1.2.5, “Organizational Work Environment,” was added. The seven guiding
principles from DOE Policy 450.4, Safety Management System Policy, are summarized and
described as characteristics of the organizational work environment that are necessary to
prevent accidents.

Section 5

• Added a new Section 5.1.5 entitled, “Addressing Potential Conflicts of Interest.” This
section describes the steps for resolving and documenting the resolution of any potential
conflict of interest concerns regarding board members, advisors, and consultants.
Additionally, a new “Conflict of Interest Certification Form” was added to the end of
Section 5.

• Section 5.2.5, “Coordinating Internal and External Communication,” was revised by adding
a bullet at the top of the second column on page 5-11 regarding the required notifications
when a potential Price-Andersen Amendments Act non-compliance is identified during an
investigation.

Section 6

• Table 6-4, “Interviewing Do’s,” was revised by adding a bullet under “Create a Relaxed
Atmosphere,” which states, “Conduct the interview in a neutral location that was not
associated with the accident.” This reminder was added based on lessons learned from
investigations conducted since the last revision of the workbook.

• Section 6.4, “Examining Organizational Concerns, Management Systems, and Line

Management Oversight,” was revised to more clearly describe using DOE Policy 450.4 as a
framework for investigating management systems. The typical questions for addressing the
five core functions in Table 6-7 were revised and Table 6-8, “Typical Questions for
Addressing the Seven Guiding Principles of Integrated Safety Management,” was added.
These tables illustrate how lines of inquiry can be developed that are specific to the accident
and involve the principles and core functions of integrated safety management.

Accident Investigation Workbook/Rev 2

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Section 7

• Moved Section 7.5, “Determining Causal Factors,” to the front of Section 7 to become
Section 7.2, because it provides definitions of the terms that are used throughout the
remainder of the section.

• Revised the text of Section 7.2.3, “Root Causes,” to more clearly incorporate safety
management considerations. The root cause examples in the text and in the text box for this
section were revised to more directly pertain to integrated safety management principles and
core functions.

• Added a new Section 7.2.4, “Importance of Causal Factors.” This section emphasizes the
importance of identifying causal factors in the management systems failures that lead to the
accident. It also stresses the importance of assigning responsibility for the root cause(s) at
the appropriate line management and oversight levels.

• Extensively revised Section 7.3.2, “Barrier Analysis,” to illustrate applying integrated safety
management core functions and principles in conducting a barrier analysis. Major changes
include:
— Combining administrative and management barriers on Figure 7-4 into one class of
barriers entitled, “Management Barriers”
— Adding guidance regarding the types of information that might be needed to analyze
safety management barriers at the activity, facility/corporate, and institutional levels
— Simplifying Table 7-4, “Sample Barrier Analysis Worksheet”
— Revising the Basic Barrier Analysis Steps text box to be consistent with revised Table 7-4
— Revising Figure 7-5 to highlight physical vs. management barriers and adding Figure 7-6
to show how the five core functions can be used to organize and present the results of a
barrier analysis in the investigation report.

• Revised Section 7.3.3, “Change Analysis,” by deleting the old Table 7-3, “Considerations for
Completing the Change Analysis Worksheet,” and adding text to clarify the change analysis
process. This includes revising the Note in the last paragraph of the section to incorporate an
example of the compounding effects of incremental change.

• Revised Section 7.3.5, “Root Cause Analysis,” Section 7.3.5.1, “Tier Diagraming,” and
Table 7-8, “Example Tier Diagram Approach,” to emphasize the use of the core functions
and guiding principles of integrated safety management as a framework for identifying the
underlying management system deficiencies as potential root cause(s).

• Section 9.5, “Review by the Assistant Secretary for Environment, Safety and Health” (part of
Report Writing), was revised to clarify that Type B accident investigation reports will be
reviewed by EH-2, with comments incorporated prior to report publication and distribution
by the appointing official.

Accident Investigation Workbook/Rev 2

ii
Introduction

T
he purpose of this workbook is requirements of DOE Order 225.1A are
to provide those responsible for acceptable.
conducting accident investigations
with practical, detailed advice on conducting This workbook is divided into two parts.
these investigations. The material in this Part I covers background information those
workbook parallels information in the U.S. involved in accident investigations need to
Department of Energy (DOE) Implementa- know before they begin an investigation.
tion Guide for Use with DOE Order 225.1A Included in Part I are:
(which explains how to meet the require-
ments and responsibilities of DOE Order n Accidents: General Principles
225.1A, Accident Investigations). The (Section 1)
workbook provides more in-depth guidance,
as well as specific tools and techniques, that n DOE’s Accident Investigation Program
will facilitate the investigation process. It is (Section 2).
designed primarily for use by DOE accident
investigation boards (board chairpersons Part II describes the detailed, step-by-step
and board members) and their support staff DOE process for conducting accident
(consultants, advisors, and administrative investigations, including specific tools and
staff). However, field and program office techniques that have proven effective on
points of contact for accident investigations previous investigations. Part II covers:
will also find this workbook useful in
preparing for and supporting accident n Appointing the Investigation Board
investigations. (Section 3)

This workbook is intended to: n Implementing Site Readiness (Section 4)

n Provide more detailed information and n Managing the Accident Investigation

guidance for the subjects addressed in (Section 5)
the Implementation Guide for Use with
DOE Order 225.1A n Collecting Data (Section 6)

n Serve as a reference source for conduct- n Analyzing Data (Section 7)

ing investigations
n Developing Conclusions and Judgments
n Support training in accident investiga- of Need (Section 8)
tion processes.
n Reporting the Results (Section 9).
The workbook does not introduce or impose
any requirements not addressed in DOE A glossary and list of references are in-
Order 225.1A. Users have the latitude to cluded in Appendices A and B. Appendices
choose whether and how to apply the C and D list specific administrative needs
procedures, methodologies, and techniques and components of DOE’s Safety Manage-
presented here. Alternative approaches and ment System Evaluation Factors. Appendix
methods that effectively implement the E is a subject index.

Accident Investigation Workbook/Rev 2

1
 Part I —

The Context of DOE's

Accident Investigation Program

Section 1 — Accidents: General Principles

Section 2 — DOE's Accident Investigation Program

Contents

Section 1 C Accidents:
General Principles

1.1 The Nature of Accidents ..................................................................................... 1-1

1.2 Human Factors Considerations ........................................................................... 1-1

1.2.1 Human-Machine Interface ......................................................................... 1-2

1.2.2 Human Capabilities ................................................................................... 1-3
1.2.3 Equipment/Design Considerations ............................................................ 1-4
1.2.4 Physical Work Environment ...................................................................... 1-4
1.2.5 Organizational Work Environment ............................................................ 1-6

Key Points to Remember ........................................................................................... 1-8

List of Tables

Table 1-1. Human capabilities contribute to work performance ............................. 1-4

Table 1-2. Equipment design can affect human performance ................................. 1-5

List of Figures

Figure 1-1. Human-machine “activity model” .......................................................... 1-2

 Part I Section 1 — Accidents: General Principles

1
Accidents: General Principles
1.1 The Nature of management, line management oversight,
and communications. In a work
Accidents environment, several barriers may be used in
an effort to prevent accidents. Accidents

A
ccidents are unplanned and occur when one or more barriers in a work
unintentional events that result in system, including procedures, standards, and
harm or loss to personnel, property, requirements intended to control the actions
production, or nearly anything that has some of workers, fail to perform as intended. The
inherent value (i.e., targets). These losses barriers may not exist, may not be adhered
increase an organization’s operating costs to, or simply may not be comprehensive
through higher production costs, decreased enough to be effective. Personal
efficiency, and the long-term effects of performance and environmental factors may
decreased employee morale and unfavorable also reduce protection.
public opinion.
A certain level of risk is inherent in every
Accidents are rarely simple and almost activity. Accepting some level of risk is
never result from a single cause. Most necessary, but to protect against unwanted
accidents involve multiple, interrelated loss (e.g., injury, property damage,
causal factors. Accidents can occur production downtime), risks must be
whenever significant deficiencies, controlled, transferred, or eliminated.
oversights, errors, omissions, Understanding how to prevent or control
or unanticipated changes are present. Any accidents requires an understanding of the
one of these conditions can be a precursor sequence of events leading to an accident in
for an accident; the only uncertainties are order to identify and implement
when the accident will occur and how countermeasures that contain risks within
severe its consequences will be. acceptable limits.
To conduct a complete accident
investigation, the factors contributing to an
1.2 Human Factors
accident, as well as the means to prevent Considerations
accidents, must be clearly understood.
Management prevents or mitigates accidents Human factors focus on people and their
by identifying and implementing the interaction with equipment, facilities,
appropriate controls and barriers. Controls procedures, and environments in work and
help to prevent errors or failures that could daily activities and how these considerations
result in an accident; barriers help to affect accidents. The human factors
mitigate the consequences of potential framework can be used by the investigator
errors or failures. Barriers to protect targets to:
against loss can be physical barriers, such
as machine guards and railings, or n Identify the multiple, interrelated factors
management barriers, such as work that may contribute to an accident
procedures, hazard analysis, requirements

Accident Investigation Workbook/Rev 2

1-1
Section 1 — Accidents: General Principles Part I

n Trace non-human causes back to the equipment or machine, and the

potential human contributors. environment.

These considerations should be assessed Human factors analysis starts by looking at

during the data collection process to ensure the immediate context of human-machine
that they are considered as part of the performance. It then addresses how human
overall analysis of an accident. capabilities, equipment considerations, and
Understanding human factors as they relate the environment can affect human-machine
to accidents requires knowing how the performance. The human factors framework
human-machine interface operates in the consists of five key areas that should be
workplace, the capabilities people bring to a addressed in any accident investigation:
task, and how the primary elements of the
work setting affect human performance. n Human-machine interface
n Human capabilities
In most accidents, human performance is n Equipment/design considerations
likely to be a significant causal factor. For n Physical work environment
example, an accident may be caused by a n Organizational work environment.
worker failing to follow safety procedures
when operating equipment. In another 1.2.1 Human-Machine
situation, an accident may occur as a result
Interface
of an equipment malfunction, which upon
further investigation is found to result from
In every accident, there is a human
a poorly constructed control device. In the
consideration, or a human-made object, or
first case, human error on the part of the
both. Generally, any accident can be
equipment operator is a causal factor in the
attributed to a human activity or response.
accident. In the latter case, human error on
Figure 1-1 shows the relationship among
the part of the equipment designer is a
humans and machines. This relationship
causal factor in the accident. In both cases,
provides a human-machine “activity model”
human performance is an important causal
that can be used to examine the immediate
factor. An investigation of both accidents
work activity and to examine potential
would involve examining human activities,
causal factors of the accident.
Hum an M achine

Inform ation
Displays
Perception
Hum an-M achine Interface

Inform ation M achine

Processing and Status
Decision-M aking

Action Planning
and Execution Controls

Figure 1-1. Human-machine “activity model.”

Accident Investigation Workbook/Rev 2

1-2
Part I Section 1 — Accidents: General Principles

Before examining factors that may Persons in this occupation who lack high
contribute to accidents, it is important to levels of these capabilities have a greater
understand the process people use to propensity to cause accidents.
perform a task or activity. As shown in
Figure 1-1, humans perform the following Table 1-1 lists human capabilities that
activities to complete a task: contribute to the actions described in the
“activity model.” These are only a sample
n Information perception: Perceiving of capabilities that contribute to effective
information means that the human has performance. Many other capabilities can
detected some type of signal; this may affect performance, depending on specific
be visual, auditory, or tactile. For task requirements:
example, operators perceive information
from annunciator panels. The activity n Experience, knowledge, and training:
of monitoring displays and perceiving For any task or work activity, human
information serves as a trigger to an performance is generally enhanced if the
action.
person has previous experience in
performing the task, has knowledge of the
n Information processing and decision-
making: This activity involves input, and understands the meaning of
processing the information to determine various indicators and the implications of
its meaning and formulating an various actions. This knowledge and
appropriate response. For example, experience can be gained through formal
operators must continually process the training, education, and on-the-job
meaning of the information provided by training.
machine displays and determine the
appropriate action. Often, determining n Physical aptitude, fitness, and behavior:
the appropriate action requires effective A worker’s capability to perform
sharing of information and collective effectively may be reduced by: (a) recent
decision-making in order to formulate injuries or surgery or temporary physical
the most appropriate action. limitations; (b) seasonal allergies or other
temporary disorders; (c) changes in visual
n Action planning and execution: When capacity (e.g., decreased visual acuity due
a decision is made, the human then to aging, color vision, and night
plans and executes the course of action. adaptation) or changes in work that
In the case of operators, the action might demand greater visual abilities; (d)
need to be coordinated among many hearing loss due to noise exposure; and
operators. The action is executed by
(e) physical and neurological effects due,
manipulating controls that initiate a
for example, to exposure to toxic
change in the status of the machine.
The machine, in turn, responds by materials.
providing feedback via displays
indicating the new status of the plant. n Stress: Workers may experience stress
because of work-related or personal
1.2.2 Human events. Sources of stress may stem from:
(a) drug use—which can impair motor
Capabilities
and cognitive functions—including
taking prescription or over-the-counter
Determining whether worker capabilities
medications to alleviate a condition or
match work requirements is another human
injury (e.g., taking antihistamines for
factors consideration. For example, military
allergies); (b) alcohol consumption,
and commercial aircraft pilots are selected,
which can reduce sensory perception
in part, for their quick response time,
resulting in loss of physical coordination;
problem-solving abilities, and visual acuity.

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Section 1 — Accidents: General Principles Part I

Table 1-1. Human capabilities contribute to work performance.

Work Activity Human Capability Specific Examples

Information Perception Perpetual Processes Vision

Hearing
Pain

Information Processing and Cognitive Processes Short-Term Memory

Decision-Making Long-Term Memory
Problem Solving

Action Planning and Execution Motor Processes Repetitive Movements

Tracking Movements
Manual Dexterity
Muscular Strength
Reaction Time

and (c) smoking, which can cause There are two main sources of human error:
muscular deterioration and weakness design flaws and improper maintenance.
among other things. When an accident involves some type of
equipment, it is useful to examine the
n Fatigue: A worker may become fatigued equipment to determine whether the design
due to disruptions in sleep patterns is compatible with human capabilities and
resulting from social, familial, or work consistent with commonly accepted
factors such as an excessive workload for operating practices and norms. Equipment
an extended period. design features that can impact human-
machine interaction are shown in Table 1-2.
n Work or shift changes: Changes in Accident investigations involving equipment
working hours (from day to evening) can should also include a review of the
alter a worker’s effectiveness until he/she equipment’s technical manuals to ensure
has adjusted to the change in schedule. that operation and maintenance are
congruent with design specifications.
1.2.3 Equipment/
Design Considerations Work
1.2.4 Physical W ork
Environment
Equipment can also contribute to an
accident in two main ways. One way is for Environmental factors can influence human-
an equipment malfunction to directly cause machine performance and thereby contribute
the accident. A second way is for the to an accident. The physical work
equipment to contribute to a human error environment is the setting in which the
that then causes the accident. Even if accident occurred.
equipment malfunction rather than human
error appears to be the direct cause of an Many physical work environment
accident, it is important to trace the requirements are specified in Occupational
equipment malfunction back to potential Safety and Health Administration (OSHA)
sources of human error. regulations. Environmental factors that may
influence the effective performance of both
humans and equipment include:
Accident Investigation Workbook/Rev 2
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Part I Section 1 — Accidents: General Principles

Table 1-2. Equipment design can affect human performance.

Features Interaction Characteristics

Large Equipment n Equipment to carry or house humans should be designed with

specified size, stature, and sitting height limitations.
n A proper field of view should be provided.

Control Replacement n Control knobs and dials should be positioned so that an

and Operations operator can easily reach and operate them.
n Controls should be placed in an arrangement that logically
reflects the normal sequence of operations.
n Control operation should be compatible with widely accepted
standards or norms (e.g., knobs turn clockwise to increase
power and counterclockwise to decrease power).

Visual Displays n Information presented in visual displays should be easy to

perceive, process, and interpret.
n Coded information should be compatible with widely accepted
standards or norms (e.g., color-coded indicators, such as red
for danger, yellow for caution).

Audio Indicators n Audio alarms should be easily interpreted and distinguishable

from other audio indicators.
n Audio alarms should be compatible with widely accepted
standards or norms, so that high frequency and rates indicate
urgency.

n Illumination: The level of lighting must n Thermal conditions: Worker

be sufficient for workers to have a good performance is influenced by
view of their work environment, the temperature extremes, which can often
equipment, and the materials they are influence worker concentration
working with. (information processing and decision-
making). Extreme temperatures may
n Noise: High levels of noise can distract also affect human control responses by
workers from concentrating on the task requiring additional clothing or gear for
they are performing. In addition, high protection. In addition, equipment may
levels of extraneous noise can interfere have limited operating conditions under
with audio indicators that workers rely extreme temperatures. Therefore, it
on to signal actions or activities. is important to identify the limits of
equipment and machines under extreme
n Vibration and motion: High levels of temperatures.
vibration and motion can interfere with
human task performance, especially n Altitude and depth: Humans can
tasks that require fine motor movement. experience physical functioning
Vibration can also interfere with problems when performing at high
equipment performance, causing altitudes and extreme depths; in general,
unexpected performance decrements in humans also experience cognitive
equipment that is normally considered functioning decrements under both these
highly reliable. conditions.

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Section 1 — Accidents: General Principles Part I

Humans and equipment are limited in their They translate and communicate safety
capacity to perform effectively under goals to their subordinates. Managers
extreme or unusual environmental and workers are held accountable for
conditions. When investigating an accident, safety performance through a variety of
it is important to characterize the means, such as safety performance
environmental conditions at the time of the evaluation in annual performance
accident and the potential human or machine appraisals, and establishing meaningful
performance decrements that could result. consequences for safety successes and
failures.
1.2.5 Organizational n Competence is commensurate with job
Work Environment responsibilities. All personnel in the
organization have the experience,
Organizational factors can contribute to knowledge, skills, and abilities to
accidents. Effective safety management perform their technical work and to
systems are critical to establish a work perform it safely. Competence to
environment in which safe operations are perform work safely means that
assured. managers and workers are aware of the
hazards associated with the work
Experience in DOE facilities and in other activities for which they are responsible
industries in which safe operations are and of the hazard controls that are
required has enabled DOE to identify the necessary to protect the public, workers,
characteristics of organizations that are and the environment from harm.
Training programs are strong and kept
necessary to prevent accidents. These
current.
characteristics are defined in DOE Policy
450.4, Safety Management System Policy, n Priorities must be balanced. Decisions
and include: regarding resource investments achieve
a balance between mission and safety
n Line management is directly responsible goals. Schedule pressures are not
for the protection of the public, workers, allowed to compromise safety in work
and the environment. Direct activities. Safety programs and
responsibility means that senior initiatives are not eroded by budget cuts
managers set clear policies that are or staff reductions.
implemented throughout all levels of the
organization and are clearly n Safety standards and requirements are
communicated and understood. implemented. Managers and workers
Managers create a safety culture by ensure that all safety standards and
emphasizing safety in each management requirements are met when work is
decision. Workers are empowered to performed. Changes to standards and
raise issues, design safe work processes, requirements lead to changes in safety
and to stop work or refuse unsafe work management policies and procedures.
assignments. Changes in mission, functions, and work
activities are analyzed to detect any new
n Lines of authority and responsibility for hazards. Required hazard controls are
ensuring safety at all organizational identified and implemented.
levels must be clearly defined.
Managers and workers at all levels
n Hazard controls are tailored to the work
understand that they are responsible for
being performed. The scope and
assuring the safety of any work
purpose of work activities are defined in
activities within their span of control.
advance. Hazards are identified,

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Part I Section 1 — Accidents: General Principles

analyzed, categorized, and then In addition, safe and efficient organizations

controlled. Workers’ knowledge of any use operational experience to improve their
hazards is used in planning for the job, performance. Safety performance is
and their experience in performing the evaluated and the results are used to
work is captured and institutionalized in enhance operations. Systems are created to
procedures and training programs. gather safety performance information from
systematic measurements, from external and
n Operations are authorized. Work self-assessments, and from analyses of local
activities are planned and performed in incidents and near-misses. Any deficiencies
accordance with the work plan. The in safety management are immediately
scope, purpose, and staffing corrected. Lessons learned at other facilities
requirements of work activities are and in other industries are examined for
defined in advance. Work is authorized applicability to the local work environment.
only when the work plan has been
reviewed and accepted, and work is then Comparing the organizational work
performed within the controls. Hazard environment in which the accident occurred
controls are implemented and workers to these critical organizational
are informed of the work to be characteristics is likely to provide important
performed and the hazard controls information for understanding the accident.
required.

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Section 1 — Accidents: General Principles Part I

KEY POINTS TO REMEMBER

A
ccidents are unplanned and unintentional events that result in harm or loss to
personnel, property, production, or anything that has some value. Barriers
(physical and management) should exist to prevent accidents or mitigate their
consequences. Accidents occur when one or more barriers in a work system fail to
perform or do not exist.

Human factors are important in assessing the causes of accidents. Two basic
principles are important in assessing the role of human factors in an accident:

n Nearly every accident has more than one cause

n Human error can be identified as a causal factor in nearly every accident.

The major human attributes that affect work performance are:

n Experience, knowledge, and training

n Physical aptitude, fitness, and behavior
n Stress
n Fatigue
n Work or shift changes.

In conducting the investigation, it is helpful to consider how the following factors

contributed to the accident.

n Human-machine interface: The immediate activity involving the human and the
machine/equipment that preceded and continued through the accidental event.
n Human capabilities: The capabilities of the worker or person directly involved in
the accident.
n Equipment/design considerations: Equipment can contribute to accidents by
either directly causing the accident or contributing to human errors that cause
accidents. Even if equipment malfunction is the direct cause of the accident,
equipment malfunctions can often be traced back to human error (poor design or
maintenance).
n Physical work environment: The environmental conditions at the work site
(extreme temperatures, poor lighting, high noise levels, or vibration) can impair
human performance.
n Organizational work environment: Organizational factors such as line manage-
ment responsibility for safety, personnel competence, safety prioritization, and
hazard analysis and requirements, as well as other management system character-
istics, directly impact safe operations.

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Contents

Section 2 C DOE=s Accident

Investigation Program

2.1 Overall Management of the Program .................................................................. 2-1

2.2 Roles and Responsibilities of Key Participants .................................................. 2-1
2.2.1 Appointing Officials and Line Management Participants ......................... 2-2
2.2.2 The Accident Investigation Board ............................................................. 2-3

2.3 Site Readiness...................................................................................................... 2-6

2.3.1 Readiness C What Is It? ............................................................................ 2-6

2.3.2 Establishing Written Procedures and Responsibilities .............................. 2-8
2.3.3 Maintaining Resources to Support Accident Investigations ..................... 2-8
2.3.4 Training for Site Readiness ....................................................................... 2-8
2.3.5 Conducting Periodic Practices and Evaluations ........................................ 2-9

2.4 Accident Investigation Process Overview ........................................................... 2-9

2.5 Waivers .............................................................................................................. 2-11

2.6 Limited Scope Accident Investigations ............................................................. 2-12

Key Points to Remember ......................................................................................... 2-13

List of Tables

Table 2-1. Appointing officials and line management participants in accident

investigations have clearly defined responsibilities ............................... 2-2
Table 2-2. The accident investigation board has these major responsibilities ........ 2-3
Table 2-3. The timeline for a Type A or Type B accident investigation
requires conducting multiple simultaneous tasks ................................. 2-11

List of Figures

Figure 2-1. The process used to conduct an accident investigation involves

many activities ...................................................................................... 2-10
Figure 2-2. The three primary activity phases in an accident investigation overlap
significantly .......................................................................................... 2-11

List of Forms and Tools

Accident Investigation Equipment Checklist ........................................................... 2-15

Accident Investigation AGo Kit@ Contents ............................................................... 2-20
 Part I Section 2 — DOE’s Accident Investigation Program

2
DOE’s Accident
Investigation Program

A
primary mission of DOE is to conclusions and to establish causes must be
operate its programs and facilities valid, appropriate, and easy to use. Finally,
with a high level of safety. The sound judgments of need promote better
accident investigation process has been safety practices, address systemic problems,
designed to evaluate management systems and when implemented, help prevent future
and determine causal factors to prevent occurrences without determining individual
accident recurrence. fault or proposing punitive measures.

Specifically, the objectives of DOE’s 2.1 Overall

accident investigation program are to
Management of
prescribe requirements for conducting
investigations that will: the Program

n Contribute to improved environmental The DOE Accident Investigation Program

protection and enhanced safety and Manager (referred to throughout the
health of DOE employees, contractors, workbook as the “Program Manager”) in the
and the public Office of Oversight administers the program
on behalf of the Assistant Secretary for
n Prevent the recurrence of accidents Environment, Safety and Health (EH-1).
The Program Manager is the central focal
n Reduce accident fatality rates and point for field and program office points of
promote a downward trend in the contact for program administration and
number and severity of accidents. training coordination.

To accomplish these objectives, the accident 2.2 Roles and

investigation process must respond with Responsibilities of
speed, accuracy, focus, and brevity. The
results of accident investigations can help
Key Participants
managers eliminate underlying causes,
prevent similar accidents, and enhance A number of groups and individuals play
safety across the DOE complex. To achieve important roles in DOE’s accident
maximum benefit, accident investigations investigation program. These persons
need to be convened rapidly, staffed and include appointing officials, line
supported adequately, focused on pertinent management, the accident investigation
and essential facts and causation, conducted board, advisors and consultants to the board,
accurately and thoroughly, concluded and administrative support staff.
quickly, and reported clearly and concisely.
Analytical techniques used to draw

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Section 2 — DOE’s Accident Investigation Program Part I

2.2.1 Appointing Table 2-1 lists the primary responsibilities of

Officials and Line the appointing official for an accident
Management investigation, heads of field elements, and
Participants for field and program office points of
contact.

Table 2.1. Appointing officials and line management participants in

accident investigations have clearly defined responsibilities.

Participants Major Responsibilities

Appointing n Formally appoints the accident investigation board in writing within three days of
Official accident categorization
n Establishes the scope of the board’s authority, including the review of manage-
ment systems, policy, and line management oversight processes as possible
causal factors
n Briefs board members within three days of their appointment
n Ensures that notification is made to other agencies, if required by memoranda of
understanding, law, or regulation
n Emphasizes the board’s authority to investigate the causal roles of organizations,
management systems, and line management oversight up to and beyond the level
of the appointing official
n Accepts the investigation report and the board’s findings
n Publishes and distributes the accident investigation report within seven calendar
days of report acceptance
n Develops lessons learned for dissemination throughout the Department
n Closes the investigation after the actions in DOE Order 225.1A, Paragraph 4d, are
completed

Heads of Field n Maintain a cadre of qualified1 accident investigation board chairpersons and DOE
Elements accident investigators
n Ensure that DOE and contractor organizations are prepared to effectively accom-
plish initial investigative actions and assist accident investigation boards
n Categorize the accident investigation in accordance with the algorithm provided in
Attachment 2 of DOE Order 225.1A
n Report accident categorization and initial actions taken by site readiness teams to
the Office of the Deputy Assistant Secretary for Oversight (EH-2)
n Serve as the appointing official for Type B and delegated Type A accident investi-
gations
n Ensure that readiness teams and emergency management personnel coordinate
their activities to facilitate an orderly transition of responsibilities for the accident
scene
n Develop lessons learned for Type B accident investigations
n Develop and submit (nominally within 30 days of report acceptance by the
appointing official) corrective action plans to address judgments of need identified
by accident investigation boards to the responsible Secretarial Officer and to the
Office of the Deputy Assistant Secretary for Oversight.
n Provide biannual status reports of accident investigation corrective actions to the
Office of the Deputy Assistant Secretary for Oversight until all corrective actions
are completed

1
Federal employees serving as board chairpersons or DOE accident investigators shall 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.

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Part I Section 2 — DOE’s Accident Investigation Program

Table 2-1. Appointing officials and line management participants in accident

investigations have clearly defined responsibilities. (Continued)

Participants Major Responsibilities

Field and n Maintain a state of readiness to conduct investigations throughout the field
Program element, their operational facilities, and the site readiness teams
Office Points n Ensure that sufficient numbers of site DOE and contractor staff understand and
of Contact are trained to conduct or support investigations
n Procure appropriate equipment to support investigations
n Maintain a current list of DOE and contractor staff trained in conducting or
supporting investigations
n Oversee the activities of the site readiness team
n Assist readiness teams in coordinating investigation activities with accident
mitigation measures taken by emergency response personnel
n Communicate and transfer information on accidents to the head of the field
elements, cognizant secretarial officer, or Headquarters element to whom they
report
n Communicate and transfer information to the accident investigation board
chairperson before and after his/her arrival on site
n Coordinate corrective action planning and follow-up with the head of the field
element and coordinate comment resolution by reviewing parties
n Assist heads of field elements in tracking implementation of corrective action
plans
n Facilitate distribution of lessons learned identified from accident investigations
n Serve as liaison to the Program Manager on accident investigation matters

2.2.2 The Accident and prepare a report. The board’s overall

Investigation Board responsibilities are listed in Table 2-2.
Responsibilities for those individuals who
When an accident occurs, the board must be comprise the investigation board are de-
rapidly assembled to collect the facts, scribed below.
conduct the investigation, reach conclusions,

Table 2-2. The accident investigation board has these major responsibilities.

Participants Major Responsibilities

Accident n Conducts a comprehensive investigation within the defined scope and allotted
Investigation time frame, collects all pertinent information, and determines the facts
Board relevant to the accident
n Analyzes facts and determines causal factors
n Analyzes the causal role of organizations, management systems, and
oversight up to and beyond the level of the appointing official
n Identifies judgments of need that must be addressed to prevent recurrence of
the accident
n Reports the essential facts and results of the investigation in a concise and
understandable manner
n Maintains appropriate communications with interested organizations
throughout the investigation
n Ensures the quality and accuracy of its activities
n Assists the appointing official in closing the investigation, if requested

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Section 2 — DOE’s Accident Investigation Program Part I
2.2.2.1. Board • Remaining continuously informed of
Chairperson the investigation’s progress and
status
The board chairperson manages the
investigation by coordinating the efforts of n Ensuring that the board is supported by
the board members, advisors/consultants, appropriate advisors and consultants
and support staff. The board chairperson is with specialized expertise, as needed
responsible to the appointing official for all
aspects of the investigation. The n Resolving potential conflicts of interest
chairperson maintains control of the for board members, advisors, and
accident scene until it is no longer needed consultants
for the investigation. The chairperson does
not normally conduct investigative n Serving as the point of contact with the
activities, but rather directs the overall appointing official and DOE
effort, keeping it focused and on schedule. management at the site, facility, or area
where the accident occurred, and
If unlawful activity is revealed during the representing DOE in all matters
investigation, the chairperson notifies DOE pertaining to the investigation
and appropriate Federal, state, or local
authorities, or in the case of fraud, waste, or n Coordinating with, and communicating
abuse, the DOE Office of the Inspector board activities to, interested managers
General. If any potential Price-Anderson and organizations who are stakeholders
enforcement concerns are revealed, the with a legitimate interest in the accident
chairperson notifies the Director, Office of
Enforcement and Investigation (EH-10), the n Ensuring an effective and efficient
DOE Site Manager, and the contractor as investigation that thoroughly examines
soon as practical. all potential causal factors, including
management systems, within the allotted
The chairperson’s specific roles and time frame
responsibilities include:
n Generating a quality report of the
n Taking control of the investigation from investigation
the site readiness team
n Following report acceptance by the
n Providing leadership and managing appointing official, conducting a
board activities by: briefing, together with the head of the
field element, to Headquarters and field
• Establishing and communicating line management, as well as to the
the roles and responsibilities of Assistant Secretary for Environment,
board members, advisors, Safety and Health (for Type A
consultants, and support staff investigations), on the outcome of the
investigation.
• Building effective team
relationships with and among board 2.2.2.2 Board Members
members
Board members are primarily responsible for
• Planning, scheduling, and collecting and analyzing information,
coordinating activities reaching conclusions regarding causal
factors, identifying judgments of need, and
• Establishing and meeting deadlines writing the report. Board members apply
investigative and analytical techniques to
make these determinations.
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Part I Section 2 — DOE’s Accident Investigation Program

2.2.2.3 Advisors and 2.2.2.4 Support Staff

Consultants Roles

Advisors and consultants are used at the The investigation board uses support staff to
discretion of the chairperson whenever the handle administrative functions or to
circumstances of an accident require provide expertise not available from
specialized expertise or special knowledge members, consultants, and advisors. The
of the accident itself is required. These following support positions are
individuals may include: recommended:

n Legal advisor—helpful in dealing with n Administrative coordinator. This

legal issues that may arise, including individual should be familiar with the
liability issues and concerns related to administrative and logistical needs and
the Freedom of Information and Privacy processes of an accident investigation and
Acts. DOE counsel from the operations be able to provide daily coordination of
or field office having cognizance over these matters. Other functions include
the site, area, or facility involved tracking and controlling documentation,
generally fulfills this role. If this is not tracking appointments, assigning
feasible, an attorney from the Office of administrative tasks and priorities, and
General Counsel can assist the board. coordinating report production (a detailed
list of responsibilities is included in
n Medical advisor—a key person in any Appendix C).
investigation involving an injury, illness,
or fatality. The board may obtain advice n Analyst. An individual trained in and
from a physician to clarify medical knowledgeable of the various analytical
issues early in the investigation. techniques that can be used to support
the accident investigation process (see
n Technical experts—provide valuable Section 7 of this workbook). Board
expertise during investigations members have the responsibility for
involving technical information about collecting and analyzing information;
operations, policy, hazards, failure however, a dedicated analyst can
modes, component testing, and systems. recommend the proper analytical tools
based on the type and complexity of the
n Professional/technical photographer— accident and process the information
critical for providing an accurate using the tools selected, allowing the
photographic record of evidence and the board members to concentrate on the
accident scene, using techniques not results of the analysis.
commonly known to investigators.
n Technical writer/editor. This person
n Site personnel—may contribute specific can facilitate the report writing process.
knowledge of processes or activities in While board members have primary
areas such as metallurgy, chemistry, writing responsibilities, use of a
electrical operations, or conduct of dedicated writer focuses responsibility
operations. for assembling the report, facilitates
report preparation, and results in a more
n Union advisor—can provide cohesive and readable report.
information on work practices, facilitate
interviews with union members, and n Typist/text processor. A board usually
convey to workers the board’s desire to needs at least one typist to perform
assure that the accident is thoroughly general secretarial and administrative
investigated. tasks, such as filing, word processing,
Accident Investigation Workbook/Rev 2
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Section 2 — DOE’s Accident Investigation Program Part I

and answering telephones. These n Respond to and mitigate the

personnel can often be provided by the consequences of an accident
facility where the investigation is being
conducted. n Preserve the accident scene and collect
and control critical initial evidence —
n Court reporters. Using a court physical, human (given through witness
reporting service increases the timeliness statements or interviews), and
and accuracy of interview transcripts. documentary (including photographic
The use of court reporters gives all media)
members of the board the opportunity to
review interviews in which they did not n Assist the accident investigation board
participate and provides a transcript for with investigations.
reconstructing or developing the
chronology of events preceding the To implement these requirements, the site’s
accident. When an investigation point of contact and designated readiness
requires numerous interviews, use of teams normally:
court reporters is essential and can help
prevent the investigation from getting n Assist the head of the field element in
behind schedule in its early stages, when categorizing accident severity by using
most of the interviewing takes place and the accident categorization algorithm in
when the information from interviews is Attachment 2 to DOE Order 225.1A and
needed. This service is available Table 1 of the Implementation Guide for
commercially in most areas. Use with DOE Order 225.1A

2.3 Site Readiness n Assist in reporting events (in accordance

with DOE Order 225.1A and DOE
DOE Order 225.1A and its Attachment 1, Order 232.1, Occurrence Reporting and
Contractor Requirements Document, Processing of Operations Information)
establish requirements and responsibilities
for heads of field elements and contractors n Assist in restoring operations, if
to: requested

n Support Type A, Type B, and limited n Document the accident scene through
scope accident investigations photography or other means

n Establish and maintain readiness to n Provide facilities, equipment, supplies,

respond to accidents. tools, and general administrative and
logistical support for accident
Site readiness is an important, ongoing part investigations
of DOE’s accident investigation program.
This section addresses responsibilities of n Conduct initial investigative activities
points of contact and heads of field
elements, as well as activities needed to n Provide sufficient numbers of DOE
implement those responsibilities, in meeting board chairpersons and accident
site readiness requirements. investigators and, if requested, provide
them to other DOE sites
2.3.1 Readiness —
What Is It? n Transfer control and custody for the
accident scene and evidence to the board
Readiness to conduct accident investigations chairperson when he/she arrives at the
means preparing in advance to: site.
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Part I Section 2 — DOE’s Accident Investigation Program

Readiness teams coordinate their actions accident and support the accident
with or are integrated with emergency investigation.
management personnel. The team’s
composition, location, equipment, and other Managers, through points of contact,
characteristics are determined by field evaluate the need for site- or organization-
elements and their contractors. The specific training to ensure that sufficient
operation of equipment for the team should numbers of staff are available to perform
be documented in procedures and its these functions.
performance should be periodically tested.
In determining the number and
A well trained readiness team that qualifications of potential accident
participates in the initial response to an investigation board members, consideration
accident can provide valuable assistance to should be given to the need for supporting
the accident investigation board when it other Departmental elements by providing
assembles on site. DOE and contractor chairpersons and board members. Contracts
managers should ensure that accident that address accident readiness by
responders and readiness teams can contractors should be modified to include
complete the immediate and near-term steps these provisions under DOE Order 225.1A,
that will facilitate the investigation. When if they are not adequately addressed in
an accident occurs, immediate actions existing contracts. The benefits of
include taking charge of the accident scene incorporating initial investigative or
quickly, initiating any required emergency investigative support actions into emergency
response, assisting injured parties, preparedness plans and drills should also be
ameliorating the accident conditions, and considered. It is important to ensure
preserving and protecting evidence and the coordination between readiness teams and
accident scene for later investigation. Each emergency management personnel to
field element is responsible for maintaining facilitate an orderly transition of
a readiness capability to respond to responsibilities for the accident scene.
accidents in this manner.
An important element in establishing site
To ensure the capability for the necessary readiness is to ensure that both the DOE
rapid response, heads of field elements and field element and contractors work together
designated points of contact should ensure to ensure that the site has a well coordinated
that: and effective capability for responding to
accidents. This capability includes:
n Sufficient numbers of readiness team
personnel and prospective accident n Clearly documented and coordinated
investigation board personnel are procedures, roles, responsibilities,
trained and available authorities, and accountabilities

n Adequate procedures for initial response n Adequate resources to support

have been established investigations

n Equipment is available and functional n Focused training for the field or

program office points of contact and the
n The necessary infrastructure can be site readiness team
quickly assembled to respond to the
n Periodic practice and evaluation.

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Section 2 — DOE’s Accident Investigation Program Part I

2.3.2 Establishing involved in the emergency response

Written Procedures function. Field elements are also
and Responsibilities responsible for assuring that DOE and
contractor organizations have mechanisms
DOE field elements should have clearly in place to provide enough qualified
documented and integrated procedures, roles, personnel to serve as accident investigation
responsibilities, authorities, and board chairpersons and members to support
accountabilities in their implementation DOE accident investigations at other sites.
directives for establishing and maintaining site
readiness. In addition, their contractors They also assure that other resources are
establish and document their own procedures readily accessible. These resources include
to identify their organizations’ operations in reference documents, site references, office
response to an accident or incident. Both equipment, tools, measurement devices, office
field- and organization-specific site readiness supplies, and protective gear. The Accident
programs should: Investigation Equipment Checklist (provided
at the end of this section) is a tool that field
n Contain appropriate detail regarding the elements can use to assure that adequate
specific responsibilities and activities resources to support accident investigations
that make up the accident response are readily available at the site.
approach
TIP
n Provide clearly formulated guidelines
To determine the necessary number of trained
that address decisions involving
site readiness personnel, consider both the
tradeoffs between accident mitigation/
site’s readiness needs and the site’s obligation
restoration of operations and accident
to supply accident investigators and accident
scene/evidence preservation
investigation chairpersons to other DOE sites.
n Be consistent with DOE orders

n Be coordinated with the emergency 2.3.4 Training

response program for Site Readiness

n Be adequately communicated to the Site readiness requires formal training for

people responsible for taking or the points of contact and site readiness team
directing action in response to accidents. members. In addition, training for
emergency response teams should ensure
Site readiness procedures should cover the that when they respond to an accident, they
activities indicated in Section 2.3.1. consider the need to preserve the accident
scene and evidence. Line managers and
2.3.3 Maintaining supervisors also need instruction in accident
Resources to Support response; if they are present at an accident
scene, these persons can be very useful in
Accident Investigations
providing background about the event (e.g.,
people involved, witnesses present,
Sufficient resources to support an onsite
equipment involved, material involved, and
accident investigation should be in place or
environmental factors).
readily available.
The field element is responsible for
The specific composition of the site
identifying the minimum site- and
readiness team is determined by the field
organization-specific training requirements
elements and their contractors. Ideally, the
to support the site readiness capability.
team should include individuals currently
Accident Investigation Workbook/Rev 2
2-8
Part I Section 2 — DOE’s Accident Investigation Program

Managers within affected organizations then available to control and limit injuries and
develop appropriate training based on these losses and to prevent emergency teams,
requirements and site-specific needs. rescuers, and investigative readiness teams
from causing additional injury or loss or
Field elements or program offices are becoming casualties themselves.
responsible for coordinating with the Program
Manager to assure that DOE and contractor Site readiness personnel who are prospective
staff are trained in accident investigation DOE accident investigators and chairpersons,
techniques and readiness. In particular, the as well as the field or program office point of
field or program office point of contact verifies contact, should attend an accident investigation
that site readiness personnel responding course of instruction that is based on current
immediately following an accident have been materials developed by the Office of the
trained in: Deputy Assistant Secretary for Oversight and
must have the appropriate qualifications
n Initial reporting and categorization of through experience in conducting comparable
events (in accordance with DOE Order investigations.
225.1A and DOE Order 232.1)
2.3.5 Conducting
n Photographing and videotaping the Periodic Practices and
accident scene Evaluations
n Identifying, collecting, controlling, and To be effective, site readiness plans and
preserving evidence and information procedures should be practiced and evaluated
periodically. Because of the need for
n Performing other initial investigative coordinated efforts, the benefits of
functions, such as taking witness statements incorporating the site readiness actions into
and determining the fitness-for-duty status of emergency preparedness plans/procedures, as
all individuals injured in the accident well as combining drills for site readiness and
emergency preparedness, should be
n Transferring responsibility for the accident considered. Readiness teams can be evaluated
scene, evidence, and documentation to the during drills by having appropriate team
accident investigation board. members demonstrate tasks and functions
such as:
In addition to needing to know how, when,
where, and to whom to report an accident and n Collecting and storing evidence
how to summon emergency help, those
responding to an accident must know what n Identifying witnesses and taking
actions they can take, and what actions require statements
skilled and qualified emergency response
professionals. Emergency personnel who n Preparing an information transition plan
direct and coordinate emergency response and for a board chairperson.
rescue operations need to know what
equipment, materials, and protective gear are
required; how and where they are obtained;
2.4 Accident
and what training or qualifications are required Investigation
for their use. They also need to know the Process Overview
risks, hazards, or peculiarities of the operation,
process, or facility involved, as well as what The major activities between the accident and
specialized knowledge, skills, procedures, and the end of the accident investigation are shown
equipment are needed to handle them safely. in Figure 2-1. They are discussed in detail in
They must know what means are needed and Part II of this workbook.
Accident Investigation Workbook/Rev 2
2-9
Section 2 — DOE’s Accident Investigation Program Part I

Accident Occurs

Initial Reporting
and
Categorization

Readiness Team Responds

Secures Scene
Takes Witness Statements
Preserves Evidence

Appointing Official
Selects Board
Chairperson and Members

Board Arrives
at Accident Scene

Board Chairperson
Takes Responsibility
for Accident Scene

Board Activities

Collect, Preserve, Integrate, Organize, Evaluate Develop Conclusions

and Analyze Evidence Conduct Requirements
and Verify Causal and Determine Verification Analysis
Evidence to Determine Factors Judgments of Need
Causal Factors

Prepare Draft Report

Site Organizations
Conduct Factual
Accuracy Review

Board Members
Finalize Draft
Report

Board Chairperson
Conducts
Closeout Briefing

Appointing Official
Accepts Report

Figure 2-1. The process used to conduct an accident investigation involves many activities.

Accident Investigation Workbook/Rev 2

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Part I Section 2 — DOE’s Accident Investigation Program

A nominal 30-calendar-day time frame, Table 2-3. The time line for a Type A or
beginning with the date of the board Type B accident investigation requires
appointment and ending with submission of conducting multiple simultaneous tasks.*
the accident report, has been established by
Time Frame Activities
DOE as a target for completing Type A and
Type B accident investigations. The time Week 1 Collecting evidence,
line and schedule of activities, illustrated in conducting interviews,
Table 2-3, is flexible and depends on conducting tests (engineering,
chemical, nondestructive, etc.),
specific accident circumstances, such as the initiating analysis, and
accident’s severity and complexity. The beginning development of the
appointing official should attempt to identify report.
any circumstances that may prolong this 30-
Week 2 Further collection of data, more
day time line and make appropriate
in-depth analysis, and report
adjustments to the completion date. The writing by the board.
board chairperson should be aware of
potential delays and make adjustments as Week 3 Additional interviews, data
early as possible. Figure 2-2 demonstrates analysis, and report writing.
Additional data collection as
how the three primary activity phases of an needed to fill gaps identified in
accident investigation overlap during the analyses. Factual accuracy
accident investigation cycle. check by site DOE and
contractor line management.
2.5 Waivers At end of the week, the board
briefs site DOE and contractor
line management on facts,
In some instances when an accident meets conclusions, and judgments of
the criteria for a Type A or Type B need.
investigation, it nevertheless may be
desirable not to conduct a Type A or Type B Week 4 Report completion, editing,
investigation if the head of the field element and formatting; report review
determines that the investigation would lead by Office of Oversight; report
to no significant lessons learned. In such a submittal to the appointing
official.
case, the head of the field element submits a
request for waiver, within five calendar days
after the accident is categorized, to the * Limited scope investigations are permitted, if no substantial
lessons learned would be expected from conducting a full
Office of the Deputy Assistant Secretary for
scope investigation. For limited scope investigations, these
Oversight. activities are expected to be completed within 10-14 days, as
discussed in Section 2.6 of this workbook.

Analysis of
Collection of Evidence Evidence and Facts; Development of
and Facts Development of Judgments of Need;
Conclusions Writing the Report

Week 1 Week 2 Week 3 Week 4

Figure 2-2. The three primary activity phases in an accident investigation overlap significantly.

Accident Investigation Workbook/Rev 2

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Section 2 — DOE’s Accident Investigation Program Part I

The Office of the Deputy Assistant board members. The requirements for
Secretary for Oversight will review waiver selecting board chairpersons and board
requests and either recommend approval or members are identical to those for Type A
disapproval of the requests in writing to the and Type B accident investigation boards.
Assistant Secretary for Environment, Safety Limited scope investigations are expected to
and Health, who will make the final be completed within 10 to 14 days of board
determination in writing. appointment.

2.6 Limited Scope The process for conducting limited scope

Accident investigations uses the same principles as
those described previously for Type A and
Investigations Type B accident investigations. The limited
scope investigation may have an abbreviated
Limited scope investigations may be scope, as determined by the charter. Facts
conducted when chartered by the Assistant are collected and analyzed using the
Secretary of Environment, Safety and analytical techniques described in Section 7
Health, as prescribed in DOE Order 225.1A, of this workbook (although the processes for
when it is determined that a formal but less using them are abbreviated); causal factors
resource-intensive investigation is are identified; judgments of need are
warranted. developed; and a report is written and
submitted to the appointing official.
Limited scope investigation boards consist
of a board chairperson and one to three

Accident Investigation Workbook/Rev 2

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Part I Section 2 — DOE’s Accident Investigation Program

KEY POINTS TO REMEMBER

D
OE’s accident investigation program provides timely, useful, and needed information
regarding the causal factors of accidents in order to prevent future accidents from
similar causes.

The Accident Investigation Program Manager in the Office of Oversight administers the
accident investigation program. The Program Manager also coordinates accident
investigation training.

Each person involved in the accident investigation process plays a specific role:

n The Assistant Secretary for Environment, Safety and Health (EH-1) serves as appointing
official for Type A accident investigation boards (unless this responsibility is
specifically delegated to the head of a field element), reviews all delegated Type A
accident investigation reports, grants waivers of the requirement to conduct Type A or
Type B accident investigations, and charters limited scope investigations.
n The appointing official establishes the board’s authority; selects the board chairperson
and board members; briefs the board before they begin their investigation activities;
accepts the report; and closes the investigation.
n Heads of field elements serve as appointing officials for Type B accident investigation
boards and ensure that DOE and contractor organizations in the field maintain
investigative site readiness and develop and implement corrective action plans.
n Field or program office points of contact ensure that sites can effectively respond to,
conduct, or assist with accident investigations; serve as a liaison to the Program Manager
on accident investigation matters; and assist in distributing lessons learned.
n Board chairpersons have overall responsibility for the investigation and are accountable
to the appointing official.
n Board members perform accident investigation activities—gather information, analyze
data, and report findings.

The field or program office point of contact is responsible for ensuring that the site can
support accident investigation activities. To prepare for these activities, points of contact
should:

n Assure that site readiness personnel are trained to respond to accidents, preserve and
collect evidence, and take witness statements
n Periodically verify readiness by conducting drills to practice readiness skills.

The accident investigation cycle has a nominal 30-calendar-day time line for completion.
However, individual investigation schedules may vary, depending on an accident’s
complexity.

Accident Investigation Workbook/Rev 2

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Section 2 — DOE’s Accident Investigation Program Part I

This page intentionally left blank.

Accident Investigation Workbook/Rev 2

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Part I Section 2 — DOE’s Accident Investigation Program

Accident Investigation
Equipment Checklist (page 1 of 5)

(√ ) Checklist Notes
DOCUMENT PACKET
DOE Order 225.1A, Accident Investigations
Implementation Guide for Use with DOE Order 225.1A
Accident Investigation Preliminary Interview List
Witness Statement Form
Change Analysis Form
Barrier Analysis Form
Chairperson Day Planner

SITE DOCUMENTS
Organization charts
Facility maps
Applicable blueprints and as-built drawings
Policies and procedures manuals
ES&H manuals
Training manuals
Phone books (local, facility, and Headquarters)

Accident Investigation Workbook/Rev 2

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Section 2 — DOE’s Accident Investigation Program Part I

Accident Investigation
Equipment Checklist (page 2 of 5)

(√ ) Checklist Notes
OFFICE SUPPLIES
18 In/Out baskets
Adhesive notes (assorted sizes & colors)
Adhesive flags (assorted colors)
Chart paper (1/4" grid)
12 hard-bound journals
2 boxes suspension folders
12 letter-size expandable files
3 boxes computer disks
1 box full-page dividers
8 calendars
3 boxes pens, red
3 boxes pens, black
4 heavy black markers
1 box yellow highlighters
1 box pencils (hard)
12 boxes paper clips
12 boxes binder clips (assorted)
1 box rubber bands (assorted)
1 heavy-duty stapler
1 box heavy-duty staples
1 heavy-duty staple remover
4 boxes staples
8 desk staplers
8 staple removers
8 tape dispensers/tape

Accident Investigation Workbook/Rev 2

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Part I Section 2 — DOE’s Accident Investigation Program

Accident Investigation
Equipment Checklist (page 3 of 5)

(√ ) Checklist Notes
OFFICE SUPPLIES (cont’d)
4 scissors
2 three-hole punch
2 clipboards
12 three-ring binders - (1", 2", 3")
2 boxes manila file folders
Assorted file folder labels
Overnight mailing supplies
12 phone message pads
6 bottles all-purpose whiteout
Assorted envelopes (9"x12", 5"x7", 10"x13")
DOE-HQ memorandum letterhead
24 ruled notepads
12 steno pads
3" x 5" index cards
Return address labels
Packing boxes
5 boxes double-pocket portfolio (assorted colors)
Nylon filament tape
OFFICE EQUIPMENT
Telephones
Answering machine or voice mail capability
Computers/software Provided by EH-21 for Type A
investigations
Letter-quality printers Provided by EH-21 for Type A
investigations
Camera with flash Contained in Type A “Go Kit”
Film

Accident Investigation Workbook/Rev 2

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Section 2 — DOE’s Accident Investigation Program Part I

Accident Investigation
Equipment Checklist (page 4 of 5)

(√ ) Checklist Notes
OFFICE EQUIPMENT (cont’d)
Portable cellular phone
50 3.5" formatted diskettes with labels
Pagers (beepers)
Fax machine
Cassette tape recorder, cassettes, and batteries
High-speed photocopier (multifunction)
Document shredder
Electric pencil sharpener
TOOLS
Flashlight or lantern (explosion-proof)
Spare batteries and bulb for flashlight
Steel tape measure - 100-foot
Scale - 12-inch ruler
Scissors (heavy-duty)
Compass - professional type (e.g. MILSPEC
Lensatic or surveyor’s)
Magnifying glass
Inspection mirrors - large & small dental
Toothbrush - natural bristle
Twine - 300-ft package wrapping
Cardboard tags, string
Masking tape (2-inch)
SPECIAL DEVICES

Engineer’s scale
Metric conversions

Accident Investigation Workbook/Rev 2

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Part I Section 2 — DOE’s Accident Investigation Program

Accident Investigation
Equipment Checklist (page 5 of 5)

(√ ) Checklist Notes
SPECIAL DEVICES (cont’d)
Calculators
Calipers, inside and outside diameter
PERSONAL PROTECTION EQUIPMENT
Hard hats
First aid kit
Glasses, other eye protection
Gloves, leather or canvas
Ear plugs, other hearing protection
Vest, orange flagperson’s
Steel-toed boots or shoes
Dust masks, respirators

This list is not exhaustive or limiting. Use this checklist as a starting point and add or delete
items as needed.

Accident Investigation Workbook/Rev 2

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Section 2 — DOE’s Accident Investigation Program Part I

Accident Investigation
“Go Kit” Contents (page 1 of 2)

(√ ) Description Quantity
SUITCASE 1 OF 3
Bushnell 10 x 50 Binoculars 1

Gerber Multi-Plier Tool 1

30’ Steel Tape Measure 1

100’ Steel Tape Measure 1

Two-Wheel Rolatape 1

NiteTracker Rechargeable Spotlight 1

Replacement Bulbs for NiteTracker 2

Kodak DC50 Zoom digital camera (S/N EKA63701001 & 1

EKKA62501451

Energizer Hi Energy Lithium AA batteries (camera) 12

Film cards for camera 5

Camera connector cables 2 sets

AC Adapter (NiteTracker) 1

DC Adapter (NiteTracker) 1

Evidence Tags (packs) 2

Evidence/Security tape (108’) 2

Inspection Mirror 2

Tweezer (metal) 2

Tweezer (metal) 2

Tweezer (metal) 2

Tweezer (disposable) 24

Accident Investigation Workbook/Rev 2

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Part I Section 2 — DOE’s Accident Investigation Program

Accident Investigation
“Go Kit” Contents (page 2 of 2)

(√ ) Description Quantity
Suitcase 2 of 3
Bushnell 7 x 35 Binoculars 1
Super Sabrelite Flashlight 10
Duracell “C” size Battery Pack (10-battery pack) 3 packs
Latex Exam Gloves: Small (box) 1
Latex Exam Gloves: Medium (box) 1
Latex Exam Gloves: Large (box) 1
Latex Exam Gloves: X-Large (box) 1
Nuisance Odor Masks 10
Vionex Skin Wipes (50/box) 1

Suitcase 3 of 3

Minolta Freedom Action Zoom Camera 1

Kodak film 100, 12 exp 2 rolls
Kodak film 200, 12 exp 2 rolls
Kodak film 400, 12 exp 1 roll
Kodak film 400, 24 exp 1 roll
Camera battery, C123A 3
Evidence bags - paper, style 86 38
Evidence bags - paper, style 25 29
Evidence bags - paper, style 12 25
Evidence bags - paper, style 4 60
Evidence bags - zip lock plastic, 9 x 12 50
Evidence bags - zip lock plastic, 5 x 8 50
Evidence bags - zip lock plastic, 4 x 6 50
Evidence bags - zip lock plastic, 3 x 5 50

Accident Investigation Workbook/Rev 2

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 Part II —
The Accident Investigation Process

Section 3 — Appointing the Investigation Board

Section 4 — Implementing Site Readiness

Section 5 — Managing the Accident Investigation

Section 6 — Collecting Data

Section 7 — Analyzing Data

Section 8 — Developing Conclusions and

Judgments of Need

Section 9 — Reporting Results

Contents

Section 3 C Appointing
the Investigation Board
3.1 Establishing the Accident Investigation Board and Its Authority ....................... 3-1
3.2 Briefing the Board ............................................................................................... 3-2

Key Points to Remember ........................................................................................... 3-3

List of Tables

Table 3-1.Board members must meet these criteria ................................................... 3-2

 Part II Section 3 — Appointing the Investigation Board

3
Appointing the
Investigation Board

B
efore an accident investigation can selecting these individuals, the appointing
actually begin, the appointing official follows the criteria defined in DOE
official must conduct a number of Order 225.1A, which are shown in
activities, including selecting and briefing Table 3-1.
the investigation board. These activities are
discussed below. DOE Order 225.1A establishes some
additional restrictions concerning the
3.1 Establishing selection of board members and chairper-
the Accident sons. No member shall have:

Investigation Board # A supervisor-subordinate relationship

and Its Authority with another board member

Upon notification of an accident requiring # Any conflict of interest or direct or line

a Type A or Type B investigation, the management responsibility for day-to-
appointing official selects the accident day operation or management of the
investigation board chairperson and three to facility, area, or activity involved in the
six other board members, one of whom must accident.
be a DOE accident investigator. The
appointing official for a Type A accident Consultants, advisors, and support staff can
investigation is the Assistant Secretary for be assigned to assist the board where
Environment, Safety and Health (EH-1), necessary, particularly when DOE employ-
unless this responsibility is delegated to the ees with necessary skills are not available.
head of the field element. The appointing For example, advisory staff may be neces-
official for Type B accident investigations is sary to provide knowledge of management
the head of the field element. Limited scope systems or organizational concerns or
investigations are chartered by the Assistant expertise on specific DOE policies. A
Secretary for Environment, Safety and dedicated and experienced administrative
Health. A list of prospective chairpersons coordinator (see Appendix C) is recom-
who meet minimum qualifications is mended. The Program Manager can help
available from the Program Manager. The identify appropriate personnel to support
Program Manager also maintains a list of accident investigation boards.
qualified board members, consultants,
advisors, and support staff, including The appointing official must appoint the
particular areas of expertise for potential accident investigation board within three
board members or consultants/advisors. calendar days after the accident is catego-
The selected chairperson can help identify rized by issuing an appointment memoran-
and select board members and others dum. If the board appointment is delayed
needed to conduct the investigation. In beyond three calendar days, the rationale for
the delay must be provided to the Assistant

Accident Investigation Workbook/Rev 2

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Section 3 — Appointing the Investigation Board Part II

Table 3-1. Board members must meet these criteria.

Role Qualifications

Chairperson n Senior DOE manager

n Preferably a member of the Senior Executive Service or at a senior
general service grade level deemed appropriate by the appointing
official
n Demonstrated managerial competence
n Knowledgeable of DOE accident investigation techniques
n Experienced in conducting accident investigations through participation
in at least one Type A or Type B investigation, or equivalent experience
n Effective October 1, 1998, has participated in an accident investigation
course sponsored by the Deputy Assistant Secretary for Oversight

Board n DOE employee

Members n Subject matter expertise in areas related to the accident, including
knowledge of the Department’s safety management system policy and
integrated safety management system
n At least one board member must be a DOE accident investigator, having
participated in at least one Type A or Type B accident investigation

Board Member n Knowledgeable in evaluating management systems, the adequacy of

or Advisor/ policy and its implementation, and the execution of line management
Consultant oversight
n Industry working knowledge in the analytical techniques used to
determine accident causal factors

Secretary for Environment, Safety and 3.2 Briefing

Health (EH-1).
the Board
The appointment memorandum establishes The appointing official is responsible for
the board=s authority and includes the scope briefing all board members as soon as
of the investigation, the names of the possible (within three days) after their
individuals being appointed to the board, a appointment to ensure that they clearly
specified completion date for the final report understand their roles and responsibilities.
(nominally 30 calendar days), and any This briefing may be given via videoconfer-
special provisions deemed appropriate. ence or teleconference. If it is impractical to
brief the entire board, at least the board
The scope of the investigation includes: chairperson should receive the briefing and
then convey the contents of the briefing to
# Gathering facts the other board members before starting the
investigation. The briefing emphasizes:
# Analyzing facts and evidence

# Developing conclusions # The scope of the investigation

# Identifying judgments of need related to # The board=s authority to examine

DOE and contractor organizations and DOE and contractor organizations and
management systems that could or management systems, including line
should have prevented the accident management oversight, as possible root
causes of an accident, up to and beyond
# Reviewing all levels of the organization the level of the appointing official
up to and beyond the level of the
appointing official.
Accident Investigation Workbook/Rev 2
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Part II Section 3 — Appointing the Investigation Board

# The necessity for avoiding conflicts of # Pertinent accident information and

interest special concerns of the appointing
official based on site accident patterns
# Evaluation of the effectiveness of or other considerations.
management systems, as defined by
DOE Policy 450.4 (Safety Management
System Policy)

KEY POINTS TO REMEMBER

# Upon notification of an accident requiring an investigation, the appointing official
selects the board chairperson and board members and briefs them before they
begin the investigation.

# Board chairpersons and members must meet the experience and qualification
criteria defined in DOE Order 225.1A.

# The appointing official establishes the board=s authority in a written appointment

memorandum.

# The scope of the investigation includes identifying causal factors and developing
conclusions and judgments of need related to DOE and contractor organizations
and management systems, including line management oversight, up to and beyond
the level of the appointing official.

Accident Investigation Workbook/Rev 2

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Contents

Section 4 C Implementing
Site Readiness
4.1 Immediate Post-Accident Actions ....................................................................... 4-1
4.2 Preserving and Documenting the Accident Scene............................................... 4-2

4.2.1 Securing and Preserving the Scene ........................................................... 4-2

4.2.2 Documenting the Scene ............................................................................. 4-3

4.3 Collecting, Preserving, and Controlling Evidence .............................................. 4-3

4.4 Obtaining Initial Witness Statements .................................................................. 4-4
4.5 Transferring Information to the Board ................................................................ 4-5

Key Points to Remember ........................................................................................... 4-7

List of Tables

Table 4-1. Several types of witnesses should provide preliminary statements ....... 4-5

List of Forms and Tools

Accident Investigation Preliminary Interview List .................................................... 4-9

Accident Investigation Witness Statement Form ..................................................... 4-10
 Part II Section 4 — Implementing Site Readiness

4
Implementing Site Readiness

T
his section addresses actions to is responsible for notifying and providing
be taken by field element readiness critical information to the following indi-
teams immediately following an viduals: the head of the field element; the
accident. All of these actions occur before cognizant secretarial officer or responsible
the DOE accident investigation board official at the appropriate Headquarters
chairperson arrives on site. element; the Accident Investigation Program
Manager; the board chairperson (after
Many immediate post-accident activities are appointment); the emergency operations
concurrent with emergency actions taken to center; and the emergency response team.
save lives and limit losses and hazards. The point of contact then:
Emergency action considerations—
particularly lifesaving and life-protecting n Coordinates with the emergency
activities—always take first priority, even if response team to preserve the accident
property or evidence is destroyed, distorted, scene
or broken in the process. The adverse
effects of tradeoffs that must be made during n Begins legal negotiations for temporary
emergency response can be minimized control of the area if the accident occurs
through advance preparation and planning to on public property or on property owned
ensure proper coordination of emergency by a private party
actions with initial investigative activities.
n Establishes an accident investigation
It is important, therefore, that the head of the “command center” (a large, dedicated
field element ensure that readiness teams conference room to be used exclusively
and emergency response personnel by the accident investigation board)
coordinate their activities for optimal
emergency and initial investigative n Initiates collection and control of
response. Following these initial actions, evidence and documentation of the
the field or program office point of contact accident scene and scenario
is responsible for ensuring a smooth
transition of initial investigative activities to
n Manages identification of witnesses and
the accident investigation board chairperson,
collection of witness statements
including transferring evidence and other
information relevant to the accident.
n Determines which contractor and line
organizations are affected by the
4.1 Immediate accident
Post-Accident
Actions n Provides input into decisions made by
line managers regarding mitigation
Immediately after an accident occurs, the actions and the restoration of operations,
field or program office point of contact as appropriate.

Accident Investigation Workbook/Rev 2

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Section 4 — Implementing Site Readiness Part II

Each site readiness team member has n Locking doors and gates
responsibility for supporting some portion
of these activities, particularly those n Posting warning signs
described in the sections that follow.
n Posting security personnel to control
4.2 Preserving and access
Documenting the
Accident Scene n Taking photographs and narrated
videotape recordings of the accident
The effectiveness of an accident scene, especially of any evidence that
investigation depends on immediate easily can be destroyed (e.g., tire tracks,
preservation of the accident scene and the fluids on the ground).
physical, human, and documentary evidence
related to the accident. Because the accident
investigation board may not arrive until two TIP
or three days after the accident, the site Securing a frequently used or public area
readiness team preserves and documents the may require additional efforts. Security
condition and status of the accident scene. personnel can be posted around the area to
This encompasses assessing the medical help secure the accident scene long enough
condition and fitness-for-duty status of the for the site readiness team to complete a
injured or others involved in the accident thorough walk-through and document the
(including requesting an autopsy, as scene, if long-term access controls are not
appropriate), and preserving and recording feasible.
the accident scene by means of written
documentation, sketches, video, and
photographs (including the location of To effectively preserve the accident scene,
equipment, parts, materials, debris, spills the first member of the site readiness team
and stains, injured parties and witnesses, to arrive is responsible for performing a
and other pertinent items). Procedures to be walk-through to:
used by the site readiness team in
preserving, collecting, and documenting n Characterize the accident scene
evidence for the board are discussed below.
n Identify key human, physical, and
4.2.1 Securing and documentary evidence
Preserving the Scene
n Identify changes made to the scene
The accident scene should be secured because of accident mitigation activities
immediately following an accident. This
can be achieved in several ways, including: n Define the physical characteristics of the
accident scene (e.g., “injured person is
n Removing and excluding all persons four feet from equipment, lying face
from the accident scene except essential down”).
emergency responders
This initial information should be
n Cordoning the area with rope, tape, or documented through notes or diagrams
barricades labeled as “initial walk-through.”

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Part II Section 4 — Implementing Site Readiness

Details on documenting the accident scene

TIP using photographs, videotapes, position
If the accident occurs in an area that makes maps, and sketches are provided in Section
securing the accident scene difficult, the 6 of this workbook.
walk-through may be the sole opportunity to
collect and preserve important evidence. 4.3 Collecting,
Preserving, and
4.2.2 Documenting the Controlling
Scene Evidence
Designated site readiness team members are There are three types of evidence: physical,
responsible for recording the accident scene human (given through witness statements or
as it exists after the accident. Effective interviews), and documentary (including
documentation methods include: photographic media). Physical evidence at
an accident scene may include solids,
n Photographs liquids, and gases. Documentary evidence
includes all the documentation developed by
n Videotapes the site readiness team, as well as accident-
related paper and electronic information,
n Initial position maps such as logbooks, instrument charts, as-built
drawings, engineering analyses, vendor
information, correspondence, and computer
n Sketches.
software.
Because a professional photographer or
Most physical evidence can safely be left
videographer may not be available, it is
intact at a protected accident scene to await
important that designated site readiness
examination by the investigation board.
team members be familiar with these
However, some evidence may be too perish-
techniques so that they can capture the
able to remain safely at the scene, and some
initial state of the accident scene. Site
may have been removed during emergency
readiness team members need to be aware of
response or casualty evacuation. Perishable
what documentary evidence is needed for
evidence includes artifacts that may provide
successful accident investigations. A
information about the accident and are
sufficient number of qualified readiness
located at the scene, but that may be cor-
team members should be available on site to
rupted, moved, or lost if left at the scene.
perform these functions at all times. If
For example, fluids emanating from equip-
necessary, initial photographs and video-
ment or vehicles involved in an accident
tapes can be supplemented later with
may quickly evaporate or be absorbed by
professional photographs and videotapes.
surrounding materials. Therefore, fluid
samples should be taken quickly.
Sketches and position maps can be used to
note items removed from the scene prior to
Before any evidence is removed from the
photographing and videotaping. These
accident scene, site readiness team members
sketches and maps should include measured
should preserve its integrity by:
distances and directions from reference
objects that will remain at the scene. The
original location of evidence should be
n Recording the exact location and
marked at the accident scene (using paint, orientation of evidence at the scene,
tape, chalk, or other appropriate media) using measurements, logs, sketches,
before evidence is removed. photography, and video

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Section 4 — Implementing Site Readiness Part II

n Establishing secure storage locations for

evidence TIP
Quickly identify witnesses and take their
n Establishing and maintaining a strict statements (e.g., from injured parties,
chain of custody (documentation eyewitnesses, and other participants)
showing physical custody) for each item because witnesses’ initial statements are
of evidence more accurate and have greater credibility
than those made later.
n Ensuring that access to evidence is
limited only to those who are
investigating the accident until transfer identified, located, and asked to provide
of the evidence to the accident statements. Early statements form the basis
investigation board. for documenting the accident sequence and
identifying potential interviewees for the
Tools to use in collecting, preserving, and more extensive and formal interviews to be
controlling evidence are discussed in conducted later by the accident investigation
Section 6 of this workbook. board. Guidance on gathering witness
statements is provided below.

TIP If accident circumstances prevent the site

Be conservative in determining whether readiness team from taking witness
items are evidence. It is easy to discard statements at the scene, names and contact
items that are not needed later on, but it information for all witnesses should be
may be difficult or impossible to recover recorded. The Accident Investigation
discarded items intact. Preliminary Interview List (see end of this
section) can be used to record this
information. To preserve initial
observations, witnesses to the accident
4.4 Obtaining Initial should be: (1) informed not to talk about the
Witness Statements accident except to accident response and
investigative personnel, and (2) isolated to
Human evidence (evidence given through the extent possible before and while giving
witness statements or interviews) also must their initial statements. Usually, witnesses
be immediately preserved by identifying and can be categorized as shown in Table 4-1,
isolating witnesses. A witness is anyone with initial statements taken in the order in
who either directly observed or was affected which the categories are listed.
by the accident, or who was directly or
indirectly involved in the process, Some witnesses may leave the accident
equipment, or system affected. Statements scene before they are identified. To ensure
from witnesses must be taken as soon as that all witnesses are identified:
possible, preferably before they leave the
accident scene, to ensure that initial n Ask witnesses to list or recall others at
observations and impressions are not lost or the scene
altered.
n Make a public request for information
Other persons, such as emergency response via local media and site notification and
personnel, persons who arrive at the scene communication systems.
shortly after the accident, and anyone else
who might be expected to provide material A standardized witness statement form, such
information about the accident, should be as the Accident Investigation Witness

Accident Investigation Workbook/Rev 2

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Part II Section 4 — Implementing Site Readiness

Table 4-1. Several types of witnesses should provide preliminary statements.

Type of Witness Relationship to the Accident

Principal Witnesses n Those directly involved in or who sustained injury from the
accident

Eyewitnesses n Participants
n Observers of the accident or events immediately preceding,
during, or following the accident

Emergency Response n Those arriving at the scene shortly after the accident
Personnel and Site
Readiness Team Members

Other Potential Witnesses n Those in the vicinity of the accident

n Those with knowledge of preceding events or conditions,
such as shift workers on duty prior to the shift during which
the accident occured; the shift change-over team leader; or
security personnel who may have conducted a recent walk-
through
n Persons with work tasks related to the process, equipment,
or facility involved
n Equipment and facility designers, operators, procurement
specialists, and safety and quality personnel

Statement Form (see the end of this section), 4.5 Transferring

may be used for gathering initial witness
Information to the
statements. Using a standard form helps
ensure consistency in the type of Board
information obtained from each witness and
helps investigators obtain the information in The field or program office point of contact
a structured manner. The questions on this ensures the orderly transfer of information
form are open-ended to ensure that wit- by:
nesses are not constrained from conveying
their observations and impressions. n Identifying and reporting the accident to
the Program Manager
Asking witnesses to sketch or diagram the
accident setting also may help capture some n Briefing the board chairperson and
of this information. The site readiness team continuing to transfer important infor-
should encourage witnesses to revisit the mation to the chairperson prior to his/
accident scene to help clarify or recall her arrival on site
information.
n Continuing communication with the
Finally, any behavioral observations that Program Manager
may impact the witness’ statement should be
noted. n Providing a detailed, well-structured
briefing to the chairperson upon his/her
arrival on site and to the entire board
when they are assembled on site

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Section 4 — Implementing Site Readiness Part II

n Transferring documentary evidence, n Identifying information about similar

along with the secured accident scene types of accidents
and other evidence, to the accident
investigation board. n Identifying and contacting appropriate
board members
Information should be summarized and
organized in a structured manner to provide n Identifying and contacting consultants
a clear description of the accident scene and and advisors
scenario. The point of contact also conducts
verbal briefings and faxes accident docu- n Scoping and planning the accident
mentation materials to both the Program investigation before the board arrives on
Manager and the chairperson. Early access site.
to information allows these persons to start:

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Part II Section 4 — Implementing Site Readiness

KEY POINTS TO REMEMBER

# The site readiness team is responsible for a number of initial investigative
activities immediately following an accident, including preserving evidence and
documenting the accident scene.

# To facilitate optimal accident response, the site readiness team should maintain
close coordination or integration with emergency response personnel and the
emergency operations center.

# Emergency response actions take precedence over initial investigative actions. To

minimize the loss of evidence, advance planning and coordination with emergency
response personnel are necessary.

# The site readiness team should collect, document, and control perishable evidence
that cannot remain at the accident scene.

# Initial witness statements should be taken as soon as possible after the accident to
ensure maximum accuracy and credibility.

# Procedures should be in place for transferring information collected by the site

readiness team to the board chairperson.

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Section 4 — Implementing Site Readiness Part II

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Accident Investigation Workbook/Rev 2

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 Part II

Accident Investigation Preliminary Interview List

Interviewee/Title Reason for Interview Phone Location/Shift/Company Affiliation Notes

Accident Investigation Workbook/Rev 2

4-9
Section 4 — Implementing Site Readiness
Section 4 — Implementing Site Readiness Part II

Accident Investigation
Witness Statement Form (page 1 of 2)

Name: Job Title:

Telephone No.: Supervisor:
Work Location:
Location of Accident:
Accident Time and Date:
Please fully describe the accident sequence from start to finish (use additional paper as needed):

Please fully describe the work and conditions in progress leading up to the accident (use additional
paper as needed):

Note anything unusual you observed before or during the accident (sights, sounds, odors, etc.):

What was your role in the accident sequence?

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Part II Section 4 — Implementing Site Readiness

Accident Investigation
Witness Statement Form (page 2 of 2)

What conditions influenced the accident (weather, time of day, equipment malfunctions, etc.)?

What do you think caused the accident?

How could the accident have been prevented?

Please list other possible witnesses:

Additional comments/observations:

Signature: Date/Time:
Accident Investigation Workbook/Rev 2
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Contents

Section 5 C Managing the

Accident Investigation
5.1 Project Planning .................................................................................................. 5-1

5.1.1 Collecting Initial Site Information ............................................................. 5-1

5.1.2 Determining Task Assignments ................................................................. 5-1
5.1.3 Preparing a Schedule ................................................................................. 5-2
5.1.4 Acquiring Resources.................................................................................. 5-3
5.1.5 Addressing Potential Conflicts of Interest ................................................. 5-3
5.1.6 Establishing Information Access and Release Protocols ........................... 5-3

5.2 Managing the Investigation Process .................................................................... 5-6

5.2.1 Taking Control of the Accident Scene ....................................................... 5-6

5.2.2 Initial Meeting of the Investigation Board ................................................ 5-6
5.2.3 Promoting Teamwork ................................................................................ 5-7
5.2.4 Managing Information Collection ............................................................. 5-9
5.2.5 Coordinating Internal and External Communication ................................. 5-9
5.2.6 Managing the Analysis ............................................................................ 5-11
5.2.7 Managing Report Writing ........................................................................ 5-12
5.2.8 Managing Onsite Closeout Activities ...................................................... 5-13
5.2.9 Managing Post-Investigation Activities .................................................. 5-13

5.3 Controlling the Investigation Process ................................................................ 5-14

5.3.1 Monitoring Performance and Providing Feedback .................................. 5-14

5.3.2 Controlling Cost and Schedule ................................................................ 5-14
5.3.3 Assuring Quality ...................................................................................... 5-15

Key Points to Remember ......................................................................................... 5-16

List of Tables

Table 5-1. These activities should be included on an accident investigation

schedule .................................................................................................. 5-2
Table 5-2. The chairperson establishes protocols for controlling information ....... 5-5
Table 5-3. The chairperson should use these guidelines in managing
information collection activities ........................................................... 5-10
Table 5-4. The Price-Anderson Amendments Act of 1988 ................................... 5-11

List of Figures

Figure 5-1. A typical schedule of accident investigation activities covers 30 days . 5-4

List of Forms and Tools

Accident Investigation Startup Activities List ......................................................... 5-19

Accident Investigation Information Request Form .................................................. 5-22
Individual Conflict of Interest Certification Form ................................................... 5-23
 Part II Section 5 — Managing the Accident Investigation

5
Managing the
Accident Investigation
5.1.1 Collecting Initial

T
he accident investigation is a
complex project that involves a Site Information
significant workload, time
constraints, sensitive issues, cooperation Following appointment, the chairperson is
between team members, and dependence on responsible for contacting the site to obtain
others. To finish the investigation within the as many details on the accident as possible.
time frame required, the board chairperson The field or program office point of contact
must exercise good project management or the site readiness team leader is usually
skills and promote teamwork. The designated as the liaison with the board.
chairperson’s initial decisions and actions The chairperson needs the details of the
will influence the tone, tempo, and degree of accident to determine what resources, board
difficulty associated with the entire member expertise, and technical specialists
investigation. This section provides the will be required. Furthermore, the
board chairperson with techniques and tools chairperson should request background
for planning, managing, and controlling the information, including site history, site
investigation. maps, and organization charts. The
Accident Investigation Information Request
5.1 Project Form (provided at the end of this section)
Planning can be used to document and track these and
other information requests throughout the
Project planning must occur early in the investigation.
investigation. The chairperson should begin
developing a plan for the investigation 5.1.2 Determining
immediately after his/her appointment. The Task Assignments
plan should include a preliminary report
outline, specific task assignments, and a A useful strategy for determining and
schedule for completing the investigation. It allocating tasks is to develop an outline of
should also address the resources, logistical the accident investigation report, including
requirements, and protocols that will be content and format, and use it to establish
needed to conduct the investigation. tasks for each board member. This outline
helps to organize the investigation around
The chairperson’s initial planning activities important tasks and facilitates getting the
are shown in the Accident Investigation report writing started as early as possible in
Startup Activities List, provided at the end the investigation process. Board members,
of this section. The chairperson and advisors, and consultants are given specific
administrative coordinator can use this list assignments and responsibilities based on
to organize the initial investigative their expertise in areas such as management
activities. systems, work planning and control,
occupational safety and health, training, and

Accident Investigation Workbook/Rev 2

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Section 5 — Managing the Accident Investigation Part II

any other technical areas directly related to direction from the appointing official. The
the accident. These assignments include chairperson should establish significant
specific tasks related to gathering and milestones, working back from the
analyzing facts, conducting interviews, appointing official’s designated completion
determining causal factors, developing date. Table 5-1 shows a list of typical
conclusions and judgments of need, and activities to schedule.
report writing. Assigning designated board
members specific responsibilities ensures The schedule developed by the board
consistency during the investigation. chairperson should include the activities to
be conducted and milestones for their
5.1.3 Preparing completion. A sample schedule is included
a Schedule as Figure 5-1. The Accident Investigation
Day Planner: A Guide for Accident
The chairperson also prepares a detailed Investigation Board Chairpersons, available
schedule using the generic four-week from the Program Manager, can assist in the
accident investigation cycle and any specific development of this schedule.

Table 5-1. These activities should be included on an accident investigation schedule.

Interviews/Evidence Collection and Preliminary Analysis

Obtain needed site and facility background information, policies, procedures, and training records
Assign investigation tasks and writing responsibilities
Initiate and complete first draft of accident chronology and facts
Select analytical methods (preliminary)
Complete interviews
Complete first analyses of facts using selected analytical tools; determine whether additional tools are
necessary
Obtain necessary photographs and complete illustrations for report

Internal Review Drafts

Complete first draft of report elements, up to and including facts and analysis section
Complete development and draft of direct, contributing, and root causes
Complete development and draft of judgments of need
Complete first draft of report for internal review
Complete draft analyses
Complete second draft of report for internal review

External Review Drafts

Complete Classification/Privacy Act reviews

Conduct factual accuracy review and revise report based on input
Complete report review by Office of Oversight
Complete final draft of report
Prepare outbrief materials
Brief relevant site and field office managers on findings
Leave site
Complete final production of report

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Part II Section 5 — Managing the Accident Investigation

5.1.4 Acquiring memorandum signed by the board

Resources chairperson with written concurrence from
the Program Manager. If the chairperson
From the first day, the chairperson and relies on the advice of legal counsel, the
administrative coordinator begin acquiring chairperson shall seek appropriate legal
resources for the investigation. This counsel concurrence through the Program
includes securing office space, a dedicated Manager. The memorandum will become
conference room or “command center,” part of the board’s permanent record.
office supplies, computers (available
through the Program Manager for Type A 5.1.6 Establishing
investigations), a secured area for document Information Access
storage, tools, and personal protective and RRelease
elease Protocols
equipment, if necessary. The site’s accident
readiness function should provide many of Information access and other control
these resources. The Accident Investigation protocols maintain the integrity of the
Equipment Checklist (see Section 2) is investigation and preserve the privacy and
designed to help identify resource needs and confidentiality of interviewees and other
track resource status. The Program Manager parties. The Freedom of Information Act
retains an investigation “go kit” (see (FOIA) and Privacy Act apply to information
Section 2) containing many of these generated or obtained during a DOE
resources for Type A investigations. accident investigation. These two laws
dictate access to and release of government
In addition, the board chairperson assures records.
that contracting mechanisms exist and that
funding is available for the advisors and
consultants required to support the TIP
investigation. These activities are When in doubt about releasing or protecting
coordinated with the Program Manager. information under the Freedom of
Information Act or Privacy Act, consult with
5.1.5 Addressing a specialist at the field office or
Potential Conflicts of Headquarters.
Interest

The board chairperson is responsible for The FOIA provides access to Federal agency
resolving potential conflicts of interest records except those protected from release
regarding board members, advisors, and by exemptions. Anyone can use the FOIA
consultants. Each board member, advisor, to request access to government records.
and consultant should certify that he or she Therefore, the board must ensure that the
has no conflicts of interest by signing the information it generates is accurate,
Individual Conflict of Interest Certification relevant, complete, and up-to-date. For this
Form (provided at the end of this section). reason, court reporters should be used to
If the chairperson or any individual has con- record interviews, and interviewees should
cern about the potential for or appearance of be allowed to review and correct transcripts.
conflicts of interest, the chairperson should
inform the Program Manager and seek legal The Privacy Act protects government
counsel input, if necessary. The decision to records on citizens and lawfully admitted
allow the individual to participate in the permanent residents from release without
investigation, and any restrictions on his or the prior written consent of the individual to
her participation, shall be documented in a whom the records pertain.

Accident Investigation Workbook/Rev 2

5-3
 Days

5-4
-3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Preliminary

Accident occurs
Board chair/members designated
Admin. coord. arrives on site
Board chair/members arrive on site

Investigation

Site tour and briefing

Interviews/evidence collection and
preliminary analysis

Report Writing

Outline prepared
Writing assigned

Internal Review Drafts

1st Draft
Section 5 — Managing the Accident Investigation

2nd Draft (analysis)

3rd Draft (causes)
4th Draft (judgments of need)
Draft for internal review
(Integrate text and pictures)
Conduct verification analysis

External Review Drafts

Factual accuracy check

Quality review by EH-2
Prepare draft final report

Briefings

Prepare outbrief materials

Conduct outbrief (site)

Submit to Appointing
Official
Conduct Management
Briefings (occurs after
30 day cycle)
Begin Task Duration of Task
Part II

Accident Investigation Workbook/Rev 2

Figure 5-1. A typical schedule of accident investigation activities covers 30 days.
Part II Section 5 — Managing the Accident Investigation

Specifically, the board is responsible for: A sample statement that addresses the
provisions of both the FOIA and the Privacy
n Informing interviewees why information Act and their pertinence to interviews for
about them is being collected and how it DOE accident investigations is provided at
will be used the end of Section 6. This statement should
be read at the beginning of all interviews.
n Ensuring that information subject to the
Privacy Act is not disclosed without the The chairperson should obtain guidance
consent of the individual, except under from a legal advisor or the FOIA/Privacy
the conditions prescribed by law. Act contact person at the site, field office, or
Information that can normally be Headquarters regarding questions of
disclosed includes name, present and disclosure, or the applicability of the FOIA
past positions or “grade” (e.g., GS-13), or Privacy Act.
annual salaries, duty station, and
position description. Therefore, the The chairperson also is responsible for
board should not request this establishing other protocols relating to
information unless it is relevant to the information access and release. These
investigation. protocol concerns are listed in Table 5-2.

Table 5-2. The chairperson establishes protocols for controlling information.

Protocol Considerations

Information Keep all investigative evidence and documents locked in a secure area
Security accessible only to board members, advisors, and support staff.

Press Releases n Determine whether there is a DOE-designated contact to handle press

releases; if so, work with that person.
n The board is not obligated to release any information. However,
previous chairpersons have found that issuing an early press release
can be helpful.
n The initial press release usually contains a general description of the
accident and the purpose of the investigation.
n The board chairperson should review and approve all press releases.

Lines of Establish liaison with field element management and with the operating
Communication contractor at the site, facility, or area involved in the accident to set up
clear lines of communication and responsibility.

Format of n Determine the amount and format of information to be released to the

Information site contractor(s), union advisor, and local DOE office for internal
Releases purposes.
n Never release verbatim interview transcripts or tapes due to the
sensitivity of raw information.
n Do not release preliminary results of analyses. These results can be
taken out of context and lead to premature conclusions by the site and
the media.
n Consult with the appointing official before releasing any information.

Approvals for Assure that board members, site contractors, and the local DOE office do
Information not disseminate information concerning the board’s activities, findings, or
Releases products before obtaining the chairperson’s approval. Brief the board on
what they can reveal to others.

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Section 5 — Managing the Accident Investigation Part II

5.2 Managing activities or procedures, or for recovery,

the Investigation rehabilitation, or mitigation activities.
These functions are the responsibility of
Process line management.

As an investigation proceeds, the 5.2.2 Initial Meeting of

chairperson uses a variety of management the Investigation Board
techniques, including guiding and directing,
monitoring performance, providing feedback The chairperson is responsible for ensuring
on performance, and making decisions and that all board members work as a team and
changes required to meet the investigation’s share a common approach to the
objectives and schedule. Because these investigation. As one of the board’s first
activities are crucial, the chairperson may onsite activities, the chairperson typically
designate an individual to oversee holds a meeting to provide all board
management activities in case the members, advisors, consultants, and support
chairperson is not always immediately staff with an opportunity to introduce
available. themselves and to give the chairperson an
opportunity to brief the board members on:
5.2.1 TTaking
aking Control
of the Accident Scene n The scope of the investigation,
including all levels of the organizations
Before arriving at the site, the chairperson involved up to and beyond the level of
communicates with the point of contact or the appointing official
the appropriate site readiness designee to
assure that the scene and evidence are n An overview of the accident
properly secured, preserved, and investigation process, with emphasis on:
documented and that preliminary witness
information has been gathered. At the • Streamlined process and limited
accident scene, the chairperson should: time frame to conduct the
investigation (if applicable)
n Obtain briefings from all persons • The schedule and plan for
involved in managing the accident completing the investigation
response
• The need to apply the components
n Obtain all information and evidence of DOE’s integrated safety
gathered by the site readiness team management system during the
investigation as the means of
n Make a decision about how secure the evaluating management systems
accident scene must remain during the
initial phases of the investigation. If • Report-writing process.
there are any concerns about loss or
contamination of evidence, play it safe n Potential analytical and testing
and keep the scene restricted from use. techniques to be used

n Assume responsibility only for activities n The roles, responsibilities, and

directly related to the accident and assignments for the chairperson, the
investigation. The chairperson and board members, and other participants
board members should not take
responsibility for approving site n Information control and release
protocols

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Part II Section 5 — Managing the Accident Investigation

n Administrative processes and logistics. decisions and provide a higher quality

investigation than the same group working
At the meeting, the chairperson clearly individually), while allowing individual
communicates expectations and provides actions and decisions. It is important that
direction and guidance for the investigation. the chairperson set the ground rules and
In addition, at the meeting the chairperson provide guidance to the board members and
should distribute copies of local phone other participants in:
directories and a list of phone and fax
numbers for pertinent individuals at DOE n Member relationships: Friendship is
Headquarters. The board should also be not required, but poor relationships can
briefed on procedures for: impede the board’s ability to conduct a
high-quality investigation. The
n Handling potential conflicts of interest chairperson can encourage positive
resulting from using contractor-provided relationships by focusing attention on
support and obtaining support from each member’s strengths and
other sources downplaying weaknesses. The
chairperson can facilitate this by
n Storing investigative materials in a arranging time to allow team members
secured location and disposing of to get to know one another and learn
unneeded yet sensitive materials about each other’s credentials, strengths,
and preferences. Effective interpersonal
n Using logbooks, inventory, checkout relationships can save time and promote
lists, or other methods to maintain high-quality performance.
control and accountability of physical
evidence, documents, photographs, and n Communication processes: It is the
other material pertinent to the chairperson’s responsibility to make
investigation sure that all members get a chance to
speak and that no one member
n Recording and tracking incoming and dominates conversations. The
outgoing correspondence chairperson should establish
communication guidelines and serve as
n Accessing the board’s work area after an effective role model in terms of the
hours. following:

• Be clear and concise; minimize the

5.2.3 Promoting
tendency to think out loud or tell
Teamwork
“war stories”
The board must work together as a team to
• Be direct and make your perspective
finish the investigation within the time
clear
frame established by the appointing official.
To make this happen, the board chairperson
• Use active listening techniques,
should ensure that strong-willed
such as focusing attention on the
personalities do not dominate and influence
speaker, paraphrasing, questioning,
the objectivity of the investigation and that
and refraining from interrupting
all viewpoints are heard and analyzed.
• Pay attention to non-verbal
The chairperson must capitalize on the
messages and attempt to verbalize
synergy of the team’s collective skills and
what you observe
talents (i.e., the team is likely to make better

Accident Investigation Workbook/Rev 2

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Section 5 — Managing the Accident Investigation Part II

• Attempt to understand each chairperson should pay attention to and

speaker’s perspective note processes that seem to work well,
and ask the group to suggest alternatives
• Seek information and opinions from to processes that are unsatisfactory.
others, especially the less talkative
members
TIP
• Postpone evaluation until all ideas Teams are more effective than individuals,
and arguments have been heard because team members have a clear
purpose, capitalize on each other’s
• Encourage diverse ideas and strengths, coordinate their efforts, and help
opinions each other. Teamwork promotes a higher
quality investigation.
• Suggest ideas, approaches, and
compromises
To control team dynamics, the chairperson
• Help keep discussions on track needs to be aware that groups go through
when they start to wander. predictable stages as they progress from
meeting one another to becoming a high-
n Decision processes: The chairperson performance team:
should gain agreement in advance
regarding how particular decisions will n Forming: At this stage, team members
be made. Decisions can be made by get acquainted, understand their
consensus, by vote, by the chairperson, purposes, and define their roles and
or by an expert. Each method has responsibilities. Members are typically
strengths and weaknesses, and the very polite at this stage, and conflict is
method used should be the one that rare. Little work is accomplished during
makes the most sense for the particular this stage, as the team is still in the
decision and situation. Team members planning phase. The chairperson can
should be aware of which method will speed this stage by formally organizing
be used.
the group; by defining goals, roles, and
responsibilities; and by encouraging
n Roles and responsibilities: Team members to become comfortable with
members should clearly understand both
one another.
the formal and informal roles and
responsibilities of each board member,
n Storming: Team members begin to
consultant, and support person.
Clarifying these roles helps avoid realize the sheer amount of work to be
duplication of effort and omission of done and may get into conflict regarding
critical tasks, and reduces power roles, planned tasks, and processes for
struggles and other conflicts. Board accomplishing the work. There may be
chairpersons should avoid the power struggles. The team focuses
temptation to reassign tasks when team energy on redefining work processes.
members encounter problems. The chairperson can speed this phase
by encouraging open discussion of
n Group processes: For an effective methods and responsibilities and
investigation, group processes must be promoting non-defensive, solution-
efficient. Time and energy may be focused communication.
needed to develop these processes. The

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Part II Section 5 — Managing the Accident Investigation

n Norming: The team develops norms 5.2.4 Managing

about roles, planned tasks, and Information Collection
processes for working together. Power
issues are settled. Team members start Upon arrival at the accident site, the board
to become productive and assist one begins to collect evidence and facts and to
another. The chairperson can speed conduct interviews. Table 5-3 provides
this stage by formalizing new norms, guidelines to assist the chairperson in
methods, and responsibilities and by monitoring this process.
encouraging relationship development.
5.2.5 Coordinating
n Performing: The team settles into clear Internal and External
roles, understands the strengths of Communication
different members, and begins to work
together effectively. The chairperson The board chairperson is responsible for
can help maintain this stage by coordinating communication both internally
encouraging open communication, a (with the appointing official, board
“learning from mistakes” philosophy, members, advisors, consultants, and support
and recognizing progress. staff) and externally (relevant DOE
Headquarters managers, local DOE field
office site managers, site contractor[s], the
TIP media and the public).
Understanding the four typical stages of
team development can help the chairperson Maintaining effective communications
manage team interactions and promote team includes:
processes throughout the accident
investigation. n Conducting daily board meetings to:

• Review and share the latest

The chairperson sets the stage for effective information and evidence
teamwork at the very first board meeting.
At this meeting, the chairperson should • Discuss how new information may
encourage the team to define their goals and contribute to analyses
tasks, clarify their roles and responsibilities,
agree on team processes, and become • Review latest analytical findings
acquainted with each other’s strengths. and potential causal factors and
discuss how new information may
affect these analyses
TIP
Many board members may have never • Note information gaps and prioritize
worked on an effective team. The directions to pursue
chairperson needs to focus on effective team
activities, because the members may not • Serve as a checkpoint to ensure that
immediately see the value of teamwork or board members are completing their
may be caught up in their own tasks to the tasks, acting within scope, and not
exclusion of the team. pursuing factual leads of limited
potential value.

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Section 5 — Managing the Accident Investigation Part II

n Obtaining regular verbal or written local field office, and contractors;

progress reports from board members calling the appointing official on a pre-
and identifying solutions to potential determined basis; and providing written
problems status reports to the appointing official

n Using a centralized, visible location for n For Type A investigations, providing

posting assignments and progress daily status updates to the Deputy
reports to keep everyone informed and Assistant Secretary for Oversight
up-to-date
n Coordinating external communications
n Conducting meetings with site managers with the public and media through the
and contractor(s) to exchange informa- field office public relations/media
tion and to summarize investigation representative to ensure that the
status Department’s interests are not
compromised
n Conducting weekly conference calls
with managers from Headquarters, the

Table 5-3. The chairperson should use these guidelines in

managing information collection activities.

n Review and organize witness statements, facts, and background information provided by the site
readiness team or other sources and distribute these to the board.

n Organize a board walk-through of the accident scene, depicting events according to the best
understanding of the accident chronology available at the time. This can help the board visualize
the events of the accident.

n Assign an administrative coordinator to oversee the organization, filing, and security of collected
facts and evidence.

n Develop draft of objectives and topical areas to be covered in initial interviews and oversee
development of a standardized list of initial interview questions to save interviewing time and
promote effective and efficient interviews.

n If deemed appropriate, issue a site or public announcement soliciting information concerning the
accident.

n Ensure that witnesses are identified and interviews scheduled.

n Ensure that board members preserve and document all evidence from the accident scene.

n Make sure all board members enlist the aid of technical experts when making decisions about
handling or altering physical evidence.

n Establish a protocol agreeable to the board for analyzing and testing physical evidence.

n Identify and initiate any necessary physical tests to be conducted on evidence.

n Assess and reassess the need for documents, including medical records, training records,
policies, and procedures, and direct their collection. Use the Accident Investigation Information
Request Form provided at the end of the section to document and track information requests.

n Emphasize to board members that to complete the investigation on schedule, they must prioritize
and may not have time to pursue every factual lead of medium to low significance. The board
chairperson must emphasize pursuits that will lead to the development of causal factors and
judgments of need.

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Part II Section 5 — Managing the Accident Investigation

n Ensuring that in both internal and n Coordinating board activities with all
external communications (press organizations having an interest in the
conferences, briefings), the facts accident (e.g., agencies notified by the
presented are sufficiently developed and appointing official or the Deputy
validated, and that no speculation, Assistant Secretary for Oversight under
hypotheses, or conjecture is expressed; DOE Order 225.1A, Paragraph 4.b.).
consulting with the appointing official
prior to disseminating any information
about the investigation TIP
Meetings that maximize efficiency have a set
n Notifying DOE and appropriate Federal, length of time and follow a planned, well-
state, or local authorities of unlawful focused agenda.
activities, or in the case of fraud, waste,
or abuse, the DOE Office of the
Inspector General 5.2.6 Managing the
Analysis
n Notifying the Director, Office of
Enforcement and Investigation (EH-10), The chairperson is responsible for ensuring
the DOE Site Manager, and the that events and causal factors charting and
contractor of any potential Price- application of the core analytical techniques
Anderson enforcement concerns begin as soon as initial facts are available.
identified during the investigation as This will help to identify information gaps
soon as practical (Table 5-4 provides early, drive the fact collection process, and
additional detail) identify questions for interviews. The use of

Table 5-4. The Price-Anderson Amendments Act of 1988.

The Price-Anderson Amendments Act of 1988 provides indemnification (government acts as an

insurer against findings of liability from nuclear activities of contractors acting within the scope of their
contracts) to DOE contractors who manage and operate nuclear facilities for DOE. The Act subjects
DOE indemnified contractors, subcontractors, and suppliers to potential civil and criminal penalties
for violations of DOE rules, regulations, and orders relating to nuclear safety requirements. DOE's
enforcement procedural rules and policy are published in 10 CFR Part 820.

Some examples of nuclear safety noncompliances that should be reported as potential enforcement
items are:

• Any single, unplanned occupational exposure to an individual that exceeds 100 millirem Total
Effective Dose Equivalent
• Any single occurrence of personal contamination of clothing (excluding personal protective
clothing) that is greater than 100 times the levels specified in 10 CFR Part 835, Appendix D
• An aggregate of related nuclear safety noncompliances indicative of a programmatic breakdown
• A number of nuclear safety-related noncompliances with common root causes occurring at the
same site
• Intentional violations involving the failure to perform activities that fulfill nuclear safety
requirements, coupled with alteration, concealment, or destruction of documents pertaining to
those activities.

For further information, review DOE Handbook 1089, Guidance for Identifying, Reporting, and
Tracking Nuclear Safety Noncompliances, contact the Field Office Price-Anderson Coordinator, or
contact the DOE Office of Enforcement and Investigation (EH-10).

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Section 5 — Managing the Accident Investigation Part II

accident investigation analysis software can n The causal factors, conclusions, and
be a helpful tool for identifying information judgments of need are supported by the
gaps and organizing causal factors during facts and analysis
the analyses. Another technique is to use
multicolored adhesive notes on a wall to n Significant facts and analyses do not
portray elements of the events and causal result in a “dead end”; rather, they are
factors chart. A wall-size chart makes it linked to causal factors and judgments
easier for all board members to observe of need.
progress, provide input, and make changes.
5.2.7 Managing
As the board proceeds with the analyses, Writing
Report Writing
the chairperson should monitor and discuss
progress to ensure that:
Many investigation boards have found
report writing to be the most difficult part
n Several board members and/or advisors of the investigation, often requiring several
work collectively (not one person in iterations. Report quality is crucial, because
isolation) to produce a quality result the report is the official record of the
investigation. Efforts to conduct a quality
investigation lose integrity if the report is
TIP poorly written or fails to adequately convey
Delegating responsibility for complex a convincing set of supporting facts and
analyses to a single individual can produce clear conclusions. To manage the reporting
inferior results. Analyses are strengthened process, the chairperson should:
by input from the entire board and its
advisors. n Develop a report outline as soon as
possible to facilitate writing
assignments and minimize overlap in
n If analysis and information-gathering content between sections
functions (e.g., interviewing) are
assigned to separate groups of board n Begin writing the accident chronology,
members, these groups should interact background information, and facts as
regularly to improve coordination, soon as information becomes available
strengthen the analytical process, and
maintain appropriate focus
n Continuously identify where sections
should be added, moved, or deleted
n Analyses are iterative (i.e., analyses are
repeated, each version producing results
n Adhere to required format guidelines
that approximate the end result more
and promote ongoing clarification of
closely); several iterations of analyses
format, content, and writing styles
will be needed as new information
becomes available
n Quickly identify strong and weak
writers and pair them, when possible,
n The analyses address organizational
to avoid report writing delays
concerns, management systems, and line
management oversight functions that
may have contributed to the accident’s
n Encourage authors to consult with one
causes another frequently to become familiar
with the content of each section and to
reduce redundancy

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Part II Section 5 — Managing the Accident Investigation

n If possible, use a technical writer to the accident occurred. Accident

evaluate grammar, format, technical investigation participants (chairperson,
content, and linkages among facts, board members, and any consultants and
analyses, causes, and judgments of need. advisors deemed appropriate by the
This is important when several authors chairperson) may attend the briefing. The
have contributed to the report. The briefing covers:
technical writer focuses on producing
a clear, concise, logical, and well- n The scope of the investigation, as
supported report and ensures that the provided in the appointment letter
report reads as if one person wrote it.
n The investigation’s participants,
It is possible to have serious disagreements including any subject matter experts
among board members regarding the or other consultants
interpretation of facts, causal factors,
conclusions, and judgments of need. The n A brief summary of the accident
board chairperson should make a concerted (what happened)
effort to reach consensus among board
members on accident causes, conclusions, n Causal factors (why it happened)
and judgments of need. When board
members cannot reach agreement and the n Judgments of need (what needs to be
chairperson cannot resolve the difference,
corrected)
the dissenting board member(s) may opt to
produce a minority report.
n Organizations that should be responsible
for corrective actions.
5.2.8 Managing
Onsite Closeout Other briefings may be provided by the
Activities board chairperson and board members, as
deemed appropriate by the appointing
The investigative portion of the process is official. These may include briefing DOE
considered complete and board members and contractor line management at the site
are released when the appointing official of the accident.
formally accepts the final report. The
chairperson is responsible for final editing 5.2.9 Managing Post-
and production of the report, with assistance Investigation Activities
from selected board members and
administrative support staff. In the case of The chairperson is also responsible for
Type A investigations, the chairperson must ensuring that all information resulting from
coordinate with the Program Manager for the investigation is carefully managed and
final report production (e.g., graphics, controlled. To this end, the chairperson
duplicating, binding). takes the following actions:
A briefing on the investigation’s outcome to
n Controlling the release of information
DOE Headquarters (including the Assistant
to the public: The chairperson should
Secretary for Environment, Safety and
instruct board members not to
Health for Type A accident investigations)
communicate with the press or other
and field line management with cognizance
external organizations regarding the
over the site of the accident is required by
investigation. External communications
DOE Order 225.1A. This briefing is
are the responsibility of the board
conducted by the board chairperson and the
chairperson until the final report is
head of the field element of the site at which

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Section 5 — Managing the Accident Investigation Part II

released. The board chairperson should n Is the investigation on schedule?

work closely with a person designated
by the site to release other information, n Is the investigation within scope?
such as statements to site employees and
the public. n Are board members, advisors,
consultants, and support staff focused
n Archiving materials: One of the final and effective?
activities of the board is to place
investigation documents and evidence in n Are additional resources needed?
long-term storage. For Type A
investigations, these materials are n Are daily board meetings still necessary
archived by the Program Manager. All and productive, or should the interval
factual material and analysis products between them be increased?
are included, such as logbooks, board
meeting minutes, field notes, sketches, The chairperson must be informed on the
witness statements (including interview status of the accident investigation and must
tapes, if used), photographs, location be prepared to make decisions and provide
and custody of any physical evidence, timely feedback to board members, site
personnel, and other parties affected by the
analysis charts, and the various forms
accident. Frequently, decisions must be
completed during the investigation.
made when there is not time to reach
Medical or personnel records subject to
consensus among the board members.
the Privacy Act may be returned to their
When this occurs, the chairperson informs
original location. The administrative
the board members of the decision and the
coordinator arranges for archiving and
reason for the urgency. Intermediate
for shipping materials to the archive
milestone revisions can then be made, if
repository during the onsite phase of the
events or practical considerations so dictate.
investigation.
5.3.2 Controlling Cost
5.3 Controlling the and Schedule
Investigation Process
Cost and schedule must be controlled to
Throughout the investigation, the board ensure that planning and execution activities
chairperson is responsible for controlling are within the established budget and
board performance, cost, schedule, and milestones.
quality of work. Techniques for imple-
menting these controls are described below. n Cost Control: The board chairperson is
responsible for preparing a cost estimate
5.3.1 Monitoring for the activities to be conducted during
Performance and the investigation and assuring that funds
Providing Feedback are available to support the investigation
process, including costs associated with
The chairperson uses daily meetings to travel, advisors, and consultants. If
monitor progress and to measure necessary, the chairperson may issue a
performance against the schedule of activity
memo authorizing costs incurred by
milestones. Board members are given
board members, including additional
specific functions or activities to perform
travel expenses, hotel rates over per
and milestones for completion. The
diem, and incidental expenses. Control
chairperson assesses the progress and status
can be exercised over costs by using
of the investigation periodically by asking
advisors and consultants only when
such questions as:

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Part II Section 5 — Managing the Accident Investigation

required and by limiting travel (such as 5.3.3 Assuring Quality

trips home for the weekend) during the
onsite investigation. During Type B Formal quality control measures are
investigations, the board chairperson necessary because of the seriousness and
should coordinate with the appropriate sensitivity of the accident investigation
designee of the head of the field element board’s work and because of the need for
to ensure that the costs are being accuracy, thoroughness, and perspective.
tracked. The Program Manager is the The chairperson has the prerogative to
point of contact for these concerns implement any quality assurance measures
during Type A investigations. A method deemed necessary. At a minimum, the
for estimating costs should be agreed chairperson must ensure that the report is
upon early in the investigation, and the technically accurate, complete, and
estimate should be reviewed each week internally consistent. When analytical
to ensure that the cost of the work is not results are developed into conclusions, all
exceeding the estimate, or that any cost verified facts, the results of analyses of
growth is justified and can be funded. those facts, and the resulting conclusions
must be both consistent and logical.
n Schedule Control: Progress against the
scheduled milestones can be assessed When essential portions of the draft report
during daily progress meetings with the are complete, the chairperson conducts a
board and its staff. As problems arise, requirements verification analysis to ensure
the schedule may be adjusted or that the facts are consistent with the best
resources applied to offset variances. information available, that all report sections
Because of the relatively short time are consistent, and that analyses, causes, and
frame involved, the chairperson must judgments of need logically flow from the
identify and resolve problems facts. Section 9 provides further detail on
immediately to maintain the schedule, or assuring report quality.
re-evaluate it with the appointing
official as circumstances require.

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Section 5 — Managing the Accident Investigation Part II

KEY POINTS TO REMEMBER

During the accident investigation, the board chairperson is responsible for managing
all aspects of the process, including planning, organizing, directing, and controlling
the investigative process:

# Completing initial activities prior to arriving on site is critical to ensuring an efficient

and effective investigation.
.
# Planning and organizing includes using project management techniques to organize the
process and team, establishing a schedule, planning, and assigning specific tasks and
completion milestones, acquiring resources, and establishing information access and
release protocols.

# Directing the investigative process involves developing the board into a team, leading
communications, conducting feedback and decision-making activities, evaluating and
modifying group processes, and managing investigative activities.

# Controlling the investigative process includes monitoring performance, providing

feedback, controlling costs and schedule, and providing quality assurance.

Teamwork is important in assuring that the investigation is completed on schedule with high
quality. By understanding the four stages of team development (forming, storming, norming,
and performing) the chairperson can facilitate quick progression to the fourth stage. The
chairperson promotes effective teamwork by assuring a clear understanding of roles and
responsibilities, encouraging effective communications, providing clear explanations of
expectations, obtaining agreement on decision-making methods and group processes, and
working with board members to resolve potential problems.

The board chairperson has responsibility for representing DOE on all matters pertaining to
board activities and the investigation by communicating with other DOE organizations and
individuals, as well as external parties. These include the appointing official, DOE
Headquarters managers, field managers, site managers, contractors, the media, unions, and
other stakeholders with legitimate interests.

External communications should be coordinated through a field office public relations/media

representative to preserve the interests of the Department. Moreover, prior to any public
address, facts pertaining to the investigation must be sufficiently developed and validated.

For all Type A investigations, the board chairperson provides daily status updates to the
Deputy Assistant Secretary for Oversight.

Information must be controlled to maintain the integrity of the investigation and preserve the
privacy of those involved. Consequently, evidence, interview transcripts, personnel records,
analytical and test results, and other material should be locked in a secured area to which
only the board has access. Freedom of Information Act and Privacy Act restrictions apply to
most investigative materials. Coordinating press releases, developing protocols for access to
and release of information, and presenting awareness briefings to the board are common
ways to help control sensitive investigation information.

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Part II Section 5 — Managing the Accident Investigation

KEY POINTS TO REMEMBER (Continued)

The onsite phase of the investigation is considered complete when:

# The board has reviewed the draft report for internal consistency, and site
management and contractors have reviewed it for factual accuracy

# The appointing official accepts the report.

The typical contents of a closeout briefing include:

# The scope of the investigation

# The investigation’s participants

# A summary of what happened

# The accident’s causal factors

# Judgments of need

# Organizations that should be responsible for corrective actions.

The chairperson is responsible for ensuring that certain post-investigation activities are
completed. These include final editing and distribution of the report, briefings requested
by Department officials, and archiving investigative files.

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Part II Section 5 — Managing the Accident Investigation

Accident Investigation Startup

Activities List (page 1 of 3)

Name of Designated Lead

Description of Activity
HQ Site Other

Board Chairperson Responsibilities:

Attend briefing by appointing official

Assist in selecting, notifying, and

briefing board members and
consultants/advisors

Identify all appropriate site authorities

Obtain details of accident from site

readiness team leader and other site
parties

Ensure that adequate evidence preser-

vation and collection activities were
initiated

Begin identifying and collecting

background and factual information

Ask the Program Manager to search for

information about similar accidents

Review all forwarded site and board

member information

Reassign normal business commitments

Establish a preliminary accident

investigation schedule, including
milestones and deadlines

Contact selected board members,

consultants/advisors, and site personnel

Arrange travel for self and expedite

board travel arrangements

Establish administrative support

Determine that logistical support for the

accident investigation is established

Travel to site

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Section 5 — Managing the Accident Investigation Part II

Accident Investigation Startup

Activities List (page 2 of 3)

Name of Designated Lead

Description of Activity
HQ Site Other
Administrative Coordinator
Responsibilities:
Make hotel selection and reserve a
block of rooms for the accident investi-
gation board

Determine site/field office points of

contact for administrative and logistical
support

Arrange for local court reporter support

for interviews

Arrange for office/work space and

furnishings for the accident investigation
board

Arrange for a large, dedicated confer-

ence room that can be locked when not
in use by the accident investigation
board

Arrange for several small, hard-walled

offices to be used when conducting
interviews

Arrange for security badges/passes for

members of the accident investigation
board

Arrange for property permits for

personal equipment (cameras, laptops,
etc.) for members of the accident
investigation board

Arrange for specific security, access,

safety, and health training, as required

Arrange for dedicated telephone

services and a fax machine

Arrange for a dedicated, high-speed

copy machine that has collating and
stapling capability

Obtain office supplies and consumables

for use by the accident investigation
board

Arrange after-hours access to site and

work space, and assume responsibility
for all keys/cards provided by the site

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Part II Section 5 — Managing the Accident Investigation

Accident Investigation Startup

Activities List (page 3 of 3)

Name of Designated Lead

Description of Activity
HQ Site Other

Prepare and maintain the interview

schedule

Create and maintain accident

investigation files

Arrange for an area central to work

space to locate documents, lockable file
cabinets, high-speed copy machine,
large-volume document shredder(s),
and fax machine

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Section 5 — Managing the Accident Investigation Part II

Accident Investigation
Information Request Form

Date of Request ___________ Page _____ of _____

Requested From: Requested By:

Contact Person: Location:

Phone Number: Phone Number:

Fax Number: Fax Number:

Information Requested How Transmitted Date Received

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Part II Section 5 — Managing the Accident Investigation

Accident Investigation Individual

Conflict of Interest Certification
Form

I certify that all work to be performed by me in support of the DOE accident investigation identified
as:
_______________________________________________________________________________
(include the accident site name and date)

has been reviewed and does not present a conflict of interest concern.

I have no past, present, or currently planned interests that either directly or indirectly may relate to
the subject matter of the work to be performed that may diminish my capacity to give impartial,
technically sound, objective assistance and advice. Additionally, I have performed no services that
might bias my judgment in relation to the work to be performed, or which could be perceived to
impair my objectivity in performing the subject work.

____________________________________ ____________________________________
(Print name) (Signature)

BOARD POSITION: __ Member __ Advisor __ Consultant

(Federal employee)

CONTRACT NO. (if applicable):___________________________________________________

DATE: ________________________________________________________________________

The original of this form remains with the accident investigation files. One copy will be sent to the:

DOE Accident Investigation Program Manager

Office of Oversight
Environment, Safety & Health
Department of Energy
(phone) 301-903-5605
(fax) 301-903-4120

NOTE: Statements or entries generally:

Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and
willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact, or makes any false,
fictitious, or fraudulent statements or representations, or makes or uses any false writing or document knowing
the same to contain any false, fictitious, or fraudulent statement or entry, shall be fined not more than $10,000
or imprisoned not more than five years, or both. (18 USC 1001)

Accident Investigation Workbook/Rev 2

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Contents

Section 6 C Collecting Data

6.1 Collecting Human Evidence ................................................................................ 6-2

6.1.1 Locating Witnesses .................................................................................... 6-2

6.1.2 Conducting Interviews ............................................................................... 6-2

6.2 Collecting Physical Evidence .............................................................................. 6-6

6.2.1 Documenting Physical Evidence ............................................................... 6-7

6.2.2 Inspecting Physical Evidence .................................................................... 6-9
6.2.3 Removing Physical Evidence .................................................................. 6-10

6.3 Collecting Documentary Evidence .................................................................... 6-10

6.4 Examining Organizational Concerns, Management Systems, and Line
Management Oversight ..................................................................................... 6-11
6.5 Preserving and Controlling Evidence ................................................................ 6-12

Key Points to Remember ......................................................................................... 6-17

List of Tables

Table 6-1. These sources are useful for locating witnesses ..................................... 6-3
Table 6-2. It is important to prepare for interviews ................................................. 6-3
Table 6-3. Group and individual interviews have different advantages .................. 6-4
Table 6-4. Interviewing do=s .................................................................................... 6-5
Table 6-5. Interviewing don=ts ................................................................................. 6-6
Table 6-6. Use these universal precautions when handling potential
bloodborne pathogens ............................................................................ 6-8
Table 6-7. These are typical questions for addressing the five core functions
of integrated safety management .......................................................... 6-13
Table 6-8. These are typical questions for addressing the seven
guiding principles of integrated safety management ............................ 6-14

List of Forms and Tools

Accident Investigation Interview Schedule Form .................................................... 6-19

Accident Investigation Interview Form ................................................................... 6-20
Model Opening Statement ....................................................................................... 6-21
Accident Investigation Physical Evidence Log Form .............................................. 6-22
Accident Investigation Site Sketch .......................................................................... 6-23
Accident Investigation Site Map .............................................................................. 6-24
Accident Investigation Position Mapping Form ...................................................... 6-25
Accident Investigation Sketch of Physical Evidence Locations and Orientations .. 6-26
Accident Investigation Photographic Log Sheet ...................................................... 6-27
Accident Investigation Sketch of Photography Locations and Orientations ........... 6-28
 Part II Section 6 — Collecting Data

6
Collecting Data

C
ollecting data is a critical part of the Three key types of evidence are collected
investigation. Although initial during the investigation:
information is collected by the site
readiness team, the detailed information # Human or testamentary evidence
collected by the accident investigation board includes witness statements and
is the foundation for the entire investigation, observations
including the analyses and conclusions.
These in turn become the basis for # Physical evidence is matter related to
identifying preventive measures to preclude the accident (e.g., equipment, parts,
recurrences. Consequently, it is important debris, hardware, and other physical
to ensure that all relevant information is items)
collected and that the information is
accurate. # Documentary evidence includes paper
and electronic information, such as
Gathering and analyzing information is an records, reports, procedures, and
interdependent process that takes place documentation.
throughout the first three weeks of the
investigation cycle. As preliminary analysis The investigation board expands and builds
is conducted on the initial evidence, gaps on results from the site readiness team's
will become apparent, requiring the board to initial activities. Therefore, the board
collect additional evidence. Generally, chairperson must obtain a timely assessment
many data collection and analysis iterations of what has been done and determine the
occur before the board can be certain that all board’s immediate actions. It may be
pertinent evidence has been gathered and helpful for the board chairperson to
analyses are finalized. designate one board member to oversee
evidence collection.
Upon arrival of the accident investigation
board, the point of contact briefs the board Collecting evidence can be a lengthy, time-
members on all actions taken by the site consuming, and piecemeal process.
readiness team and other emergency Witnesses may provide sketchy or
response personnel. It is important that the conflicting accounts of the accident.
board become familiar with the initial Physical evidence may be badly damaged or
investigative actions conducted prior to completely destroyed. Documentary
their arrival. At this time, all evidence the evidence may be minimal or difficult to
site readiness team has collected, including access. Thorough investigation requires that
lists of witnesses, witness statements, and board members be diligent in pursuing
other important documents, are also turned evidence and adequately explore leads, lines
over to the board. of inquiry, and potential causal factors until
they gain a sufficiently complete
understanding of the accident.

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Section 6 — Collecting Data Part II

The process of collecting data is iterative. up interviews with persons previously not
Preliminary analysis of the initial evidence interviewed, and additional lines of
identifies gaps that will direct subsequent questioning.
data collection. Generally, many data
collection and analysis iterations occur 6.1.1 Locating
before the board can be certain that all Witnesses
analyses can be finalized. The process of
data collection also requires a tightly Principal witnesses and eyewitnesses are
coordinated, interdependent set of activities identified and interviewed as soon as
on the part of several investigators. possible. Principal witnesses are persons
who were actually involved in the accident;
eyewitnesses are persons who directly
TIP observed the accident or the conditions
It may be helpful for the board chairperson immediately preceding or following the
to designate one board member to oversee accident. General witnesses are those with
evidence collection. knowledge about the activities prior to or
immediately after the accident (the previous
shift supervisor or work controller, for
The process of pursuing evidentiary material example). One responsibility of the site
involves: readiness team and other initial responders
is to identify witnesses, record initial
# Collecting human evidence (locating statements, and provide this information to
and interviewing witnesses) the investigation board upon their arrival.
Prompt arrival by board members and
# Collecting physical evidence expeditious interviewing of witnesses helps
(identifying, documenting, inspecting, ensure that witness statements are as
and preserving relevant matter) accurate, detailed, and authentic as possible.

# Collecting documentary evidence Table 6-1 lists sources that investigators can
use to locate witnesses.
# Examining organizational concerns,
management systems, and line 6.1.2 Conducting
management oversight Interviews
# Preserving and controlling evidence. Witness testimony is an important element
in determining facts that reveal causal
6.1 Collecting factors. It is best to interview principal
Human Evidence witnesses and eyewitnesses first, because
they often provide the most useful details
Human evidence is often the most insightful regarding what happened. If not questioned
and also the most fragile. Witness promptly, they may forget important details.
recollection declines rapidly in the first 24
hours following an accident or traumatic
event. Therefore, witnesses should be TIP
located and interviewed immediately and The investigator should first get an overview
with high priority. As physical and of the accident and then expand information
documentary evidence is gathered and with careful questioning.
analyzed throughout the investigation, this
new information will often prompt follow-

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6.1.2.1 Preparing for interview. Interviews can be conducted after

Interviews the board has established the topical areas to
be covered in the interviews and after the
Much of the investigation’s fact-finding board chairperson has reviewed with the
occurs in interviews. Therefore, to elicit the board the objectives of the interviews and
most useful information possible from strategies for obtaining useful information.
interviewees, interviewers must be well Table 6-2 provides guidelines for interview
prepared and have clear objectives for each preparation.

Table 6-1. These sources are useful for locating witnesses.

Site readiness team members and emergency response personnel can name the person
who provided notification of the incident and those present on their arrival, as well as the
most complete list available of witnesses and all involved parties.
Principal witnesses and eyewitnesses are the most intimately involved in the accident and
may be able to help develop a list of others directly or indirectly involved in the accident.
First-line supervisors are often the first to arrive at an accident scene and may be able to
recall precisely who was present at that time or immediately before the accident. Supervisors
can also provide the names and phone numbers of safety representatives, facility designers,
and others who may have pertinent information.
Local or state police, firefighters, or paramedics, if applicable.
Nurses or doctors at the site first aid center or medical care facility (if applicable).
Staff in nearby facilities (those who may have initially responded to the accident scene;
staff at local medical facilities).
News media may have access to witness information and photographs or videos of the post-
accident scene.
Maintenance and security personnel may have passed through the facility soon before or
just after the accident.

Table 6-2. It is important to prepare for interviews.

Identify all interviewees using the Accident Investigation Preliminary Interview List (provided
in Section 4). Record each witness’ name, job title, reason for interview, phone, work schedule,
and company affiliation; take a brief statement of his or her involvement in the accident.
Schedule an interview with each witness using the Accident Investigation Interview
Schedule Form (provided at the end of this section). Designate one person to oversee this
process. Previous boards have found it useful to make the administrative coordinator
responsible for scheduling initial and follow-up interviews and written statement verifications.
Assign a lead interviewer from the board for each interviewee. Having a lead interviewer can
help establish consistency in depth and focus of interviews.
Develop sketches and diagrams to pinpoint locations of witnesses, equipment, etc., based
on the initial walk-through and site readiness team input.
Develop a standardized set of interview questions. Charts may be used to assist in
developing questions. The Accident Investigation Interview Form (provided at the end of this
section) can aid in recording pertinent data.
Discuss interviewing objectives and plan strategies to ensure that all board members use
consistent interviewing methods. To enhance the quality of information obtained, everyone
should have some training on correct interviewing techniques.
Determine the appropriate means of documenting interviews (handwritten notes, court
reporter, etc.) in light of the circumstances. Experience indicates that a court reporter generally
is preferable.

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People’s memories, as well as their new information from every witness may be
willingness to assist an investigative board, small. Sometimes, group interviews can
can be affected by the way they are corroborate testimony given by an
questioned. Based on the availability of individual, but not provide additional
witnesses, board members’ time, and the details. The board should use their
nature and complexity of the accident, the collective judgment to determine which
board chairperson and members must technique is appropriate. Advantages and
determine who to interview, in what order, disadvantages of both techniques are listed
and what interviewing techniques to employ. in Table 6-3. These considerations should
Some methods that previous accident be weighed against the circumstances of the
investigation boards have found successful accident when determining which technique
are described below. to use.

Interviewing: Do’s and Don’ts. Table 6-4

TIP lists actions that promote effective
A witness interview is not an interrogation. interviews, and Table 6-5 lists actions to
Investigators should convey the sense of a avoid while conducting interviews.
cooperative, informal meeting.
It is important to create a comfortable
atmosphere in which interviewees are not
Individual vs. Group Interviews. rushed to recall their observations.
Depending on the specific circumstances Interviewees should be told that they are a
and schedule of an accident investigation, part of the investigation effort and that their
investigators may choose to hold either input will be used to prevent future
individual or group interviews. Generally, accidents and not to assign blame. Before
principal witnesses and eyewitnesses are and after questioning, interviewees should
interviewed individually to gain independent be notified that follow-up interviews are a
accounts of the event. However, a group normal part of the investigation process and
interview may be beneficial in situations that further interviews do not mean that their
where a work crew was either involved in or initial statements are suspect. Also, they
witness to the accident. Moreover, time may should be encouraged to contact the board
not permit interviewing every witness whenever they can provide additional
individually, and the potential for gaining information or have any concerns.

Table 6-3. Group and individual interviews have different advantages.

Individual Interviews Group Interviews

Advantages # Obtain independent stories # More time-efficient

# Obtain individual perceptions # All interviewees supplement story; may get
# Establish one-to-one rapport more complete picture
# Other people serve as “memory joggers”

Disadvantages # More time-consuming # Interviewees will not have independent stories

# May be more difficult to # More vocal members of the group will say
schedule all witnesses more and thus may influnce those who are
quieter
# “Group think” may develop; some individual
details may get lost
# Contradictions in accounts may not be
revealed

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Table 6-4. Interviewing do’s.

Create a Relaxed Atmosphere

√ Conduct the interview in a neutral location that was not associated with the accident.

√ Introduce yourself and shake hands.

√ Be polite, patient, and friendly.

√ Treat witnesses with respect.

Prepare the Witness

√ Describe the investigation’s purpose: to prevent accidents, not to assign blame.

√ Explain that witnesses may be interviewed more than once.

√ Use the Model Opening Statement to address FOIA and Privacy Act concerns.

√ Stress how important the facts given during interviews are to the overall investigative process.

Record Information

√ Rely on a court reporter to provide a detailed record of the interview.

√ Note crucial information immediately in order to ask meaningful follow-up questions.

Ask Questions
√ Establish a line of questioning and stay on track during the interview.

√ Ask the witness to describe the accident in full before asking a structured set of questions.

√ Let witnesses tell things in their own way; start the interview with a statement such as "Would you
please tell me about...?"

√ Ask several witnesses similar questions to corroborate facts.

√ Aid the interviewee with reference points; e.g., "How did the lighting compare to the lighting in this
room?"

√ Keep an open mind; ask questions that explore what has already been stated by others in
addition to probing for missing information.

√ Use visual aids, such as photos, drawings, maps, and graphs to assist witnesses.

√ Be an active listener, and give the witness feedback; restate and rephrase key points.

√ Ask open-ended questions that generally require more than a "yes" or "no" answer.

√ Observe and note how replies are conveyed (voice inflections, gestures, expressions, etc.).

Close the Interview

√ End on a positive note; thank the witness for his/her time and effort.

√ Allow the witness to read the interview transcript and comment if necessary.

√ Encourage the witness to contact the board with additional information or concerns.

√ Remind the witness that a follow-up interview may be conducted.

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Table 6-5. Interviewing don’ts.

√ DO NOT rush the witness while he/she is describing the accident or answering questions.

√ DO NOT judge, display anger, refute, threaten, intimidate, or blame the witness.

√ DO NOT suggest answers.

√ DO NOT make promises that cannot be kept (for example, unrestricted confidentiality).

√ DO NOT use inflammatory words ("violate," "kill," “lie," "stupid," etc.).

√ DO NOT omit questions during the interview because you think you already know the answer.

√ DO NOT ask questions that suggest an answer, such as "Was the odor like rotten eggs?"

Before each interview, interviewees should # The amount of time between the
be apprised of Freedom of Information Act accident and the interview. People
(FOIA) and Privacy Act concerns as they normally forget 50 to 80 percent of the
pertain to their statements and identity. A details in just 24 hours.
model opening statement that addresses
FOIA and Privacy Act provisions can be # Contact between this witness and others
found at the end of this section. Inter- who may have influenced how this
viewees should be aware that information witness recalls the events.
provided during the investigation may not be
precluded from release under FOIA or the # Signs of stress, shock, amnesia, or other
Privacy Act. For further information consult trauma resulting from the accident.
Section IV, Paragraph 2.2.5.7 of the Details of unpleasant experiences are
Implementation Guide for Use with DOE frequently blanked from one’s memory.
Order 225.1A (DOE G225.1-1). If any
Investigators should note whether an
questions arise concerning the disclosure of
interviewee displays any apparent mental or
accident investigation records or the
physical distress or unusual behavior; it may
applicability of the FOIA or the Privacy Act,
have a bearing on the interview results.
guidance should be obtained from the FOIA/
These observations can be discussed and
Privacy Act attorney at either Headquarters
their impact assessed with other members of
or the field. Most sites have FOIA/Privacy the board.
Act specialists who can be consulted for
further guidance.
6.2 Collecting
Following these guidelines will help ensure Physical Evidence
that witness statements are provided freely
and accurately, subsequently improving the
TIP
quality and validity of the information
To ensure consistent documentation, control,
obtained.
and security, it may be useful to designate a
single board member or the administrative
6.1.2.2 Evaluating the
coordinator to be in charge of handling
Witness's State of Mind evidence.
Occasionally, a witness's state of mind may
affect the accuracy or validity of testimony Following the leads and preliminary
provided. In conducting witness interviews, evidence provided by the initial findings of
investigators should consider: the site readiness team, the board proceeds
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Part II Section 6 — Collecting Data

in gathering, cataloging, and storing

physical evidence from all sources as soon TIP
as it becomes available. The most obvious Significant physical evidence is often found
physical evidence related to an accident or in obscure and seemingly insignificant
accident scene often includes solids such as: places, such as hinges and supports.

# Equipment
# Tools Physical evidence should be systematically
# Materials collected, protected, preserved, evaluated,
# Hardware and recorded to ultimately determine how
# Plant facilities and why failures occurred and whether use,
# Pre- and post-accident positions of abuse, misuse, or nonuse was a causal
accident-related elements factor.
# Scattered debris
# Patterns, parts, and properties of 6.2.1 Documenting
physical items associated with the Physical Evidence
accident.
Evidence should be carefully documented
Less obvious but potentially important
at the time it is obtained or identified. The
physical evidence includes fluids (liquids
Accident Investigation Physical Evidence
and gases). Many DOE facilities use a
Log Form (provided at the end of this
multitude of fluids, including chemicals,
section) can help investigators document
fuels, hydraulic control or actuating fluids,
and track the collection of physical
and lubricants. Analyzing such evidence
evidence. Additional means of documenting
can reveal much about the operability of
equipment and other potentially relevant physical evidence include sketches, maps,
conditions or causal factors. photographs, and videotape.

Care should be taken if there is the potential Sketching

6.2.1.1 Sketching and
for pathogenic contamination of physical Mapping Physical
evidence (e.g., blood); such material may Evidence
require autoclaving or other sterilization.
Specialized technicians experienced in fluid Sketching and mapping the position of
sampling should be employed to help the debris, equipment, tools, and injured persons
board collect and analyze fluid evidence. If may be initiated by the site readiness team
required, expert analysts can be requested to and expanded on by the accident
perform tests on the fluids and report results investigation board. Position maps convey a
to the board. visual representation of the scene
immediately after an accident. Evidence
When handling potential bloodborne may be inadvertently moved, removed, or
pathogens, universal precautions such as destroyed, especially if the accident scene
those listed in Table 6-6 should be observed can only be partially secured. Therefore,
to minimize potential exposure. All human sketching and mapping should be conducted
blood and body fluids should be treated as if immediately after recording initial witness
they are infectious. The precautions in statements.
Table 6-6 should be implemented for all
potential exposures. Exposure is defined as Precise scale plottings of the position of
reasonable anticipated skin, eye, mucous elements can subsequently be examined to
membrane, or parenteral contact with blood develop and test accident causal theories.
or other potentially infectious materials.

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Table 6-6. Use these universal precautions when handling potential bloodborne pathogens.

Personal protective equipment should be worn when exposure to bloodborne pathogens is likely.
Hands and other skin should be washed with soap and water immediately or as soon as feasible after
removal of gloves or other personal protective equipment.
Handwashing facilities should be provided that are readily accessible to employees.
When provision of handwashing facilities is not feasible, appropriate antiseptic hand cleanser in
conjunction with clean cloth, paper towels, or antiseptic towelettes should be used. Hands should be
washed with soap and water as soon as possible thereafter.
Mucous membranes should be flushed with water immediately or as soon as feasible following contact
with blood or other potentially infectious materials.
Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed except
by approved techniques.
Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in
appropriate containers until properly reprocessed.
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited
in work areas where there is a reasonable likelihood of occupational exposure.
Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets, or on countertops or
benchtops where blood or other potentially infectious materials are present.
All procedures involving blood or other potentially infectious materials shall be performed in such a
manner as to minimize splashing, spraying, spattering, and generation of droplets of these
substances.
Mouth pipetting or suctioning of blood or other potentially infectious materials is prohibited.
Specimens of blood or other potentially infectious materials shall be placed in a container to prevent
leakage during collection, handling, processing, storage, transport, or shipping.
Equipment, which may become contaminated with blood or other potentially infectious materials, shall
be examined prior to servicing or shipping and shall be decontaminated as necessary.

The Accident Investigation Site Sketch, can identify, record, or preserve physical
Accident Investigation Site Map, Accident accident evidence that cannot be effectively
Investigation Position Mapping Form, and conveyed by words or collected by any other
Accident Investigation Sketch of Physical means.
Evidence Locations and Orientations
(provided at the end of this section) are Photographic coverage should be detailed
useful for drawing sketches and maps and and complete, including standard references
recording positions of objects. to help establish distance and perspective.
Videotapes should cover the overall accident
6.2.1.2 Photographing scene, as well as specific locations or items
and Videotaping Physical of significance. A thorough videotape
Evidence allows the board to minimize trips to the
accident scene. This may be important if the
TIP scene is difficult to access or if it presents
Photography and videography can be used hazards. The Accident Investigation
in a variety of ways to emphasize areas or Photographic Log Sheet (provided at the
items of interest and display them for better end of this section) can be used to record
understanding. These are best performed by photograph or videotape subjects, dates,
specialists, but should be supervised and times, and equipment settings and positions.
directed by an investigator.
Good photographic coverage of the accident
Photography is a valuable and versatile tool is essential, even if photographs or video
in accident investigation. Photos or videos stills will not be used in the investigation

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report. However, if not taken properly, Sheet can be used for this purpose.
photographs and videos can easily The Accident Investigation Sketch of
misrepresent a scene and lead to false Photography Locations and Orientations
conclusions or findings about an accident. (provided at the end of this section) is
Therefore, whenever possible, accident helpful when reviewing photos and
photography and videotaping should be analyzing information.
performed by professionals. Photographic
techniques that avoid misrepresentation, 6.2.2 Inspecting
such as the inclusion of rulers and particular Physical Evidence
lighting, may be unknown to amateurs but
are common knowledge among professional Following initial mapping and photographic
photographers and videographers. recording, a systematic inspection of
physical evidence can begin. The inspection
One of the first responsibilities of the board involves:
chairperson should be to acquire a technical
photographer whose work will assist the # Surveying the involved equipment,
board. Five possible sources include: vehicles, structures, etc., to ascertain
whether there is any indication that
# In-plant photo lab component parts were missing or out
# Other DOE or DOE contractor photo of place before the accident
labs
# Commercial photographers; industrial, # Noting the absence of any parts of
medical, aerial, legal, portrait, and guards, controls, or operating indicators
scientific photographers (perhaps the (instruments, position indicators, etc.)
best to assist in accident investigation among the damaged or remaining parts
are industrial, legal, or scientific at the scene
photographers)
# A member of the investigation board # Identifying as soon as possible any
# Security personnel. equipment or parts that must be cleaned
prior to examination or testing and
Even if photos are taken by a skilled transferring them to a laboratory or to
photographer, the investigation board should the care of an expert experienced in
be prepared to direct the photographer in appropriate testing methodologies
capturing certain important perspectives or
parts of the accident scene. Photographs of # Noting the routing or movements of
evidence and of the scene itself should be records that can later be traced to find
taken from many angles to illustrate the missing components
perspectives of witnesses and injured
persons. In addition, board members may # Preparing a checklist of complex
wish to take photos for their own reference. equipment components to help ensure a
If available, digital photography will thorough survey.
facilitate incorporation of the photographs
into the investigation report. However, if These observations should be recorded in
this is not practical, high-quality 35mm notes and photographs so that investigators
photographs can be scanned for avoid relying on their memories. Some
incorporation in the report. investigators find a small cassette tape
As photos are taken, a log should be recorder useful in recording general
completed noting the scene/subject, date, descriptions of appearance and damage;
time, direction, and orientation of photos, as however, the potential failure of a recorder,
well as the photographer’s name. The inadvertent tape erasure, and limitations of
Accident Investigation Photographic Log verbal description suggest that verbal
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Section 6 — Collecting Data Part II

recorded descriptions should be used in methods for preserving and packaging

combination with notes, sketches, and evidence and specimens that must be
photographs. transported for testing.

Removing
6.2.3 Removing When preparing to remove physical
Physical Evidence evidence, these guidelines should be
followed:
Following the initial inspection of the scene,
investigators may need to remove items of # Normally, extraction should not start
physical evidence. To ensure the integrity until witnesses have been interviewed,
of evidence for later examination, the since visual reference to the accident
extraction of parts must be controlled and site can stimulate one’s memory
methodical. The process may involve
simply picking up components or pieces of # Extraction and removal or movement of
damaged equipment, removing bolts and parts should not be started until position
fittings, cutting through major structures, or records (measurements for maps,
even recovering evidence from beneath piles photographs and videotape) have been
of debris. Before evidence is removed from made
the accident scene, it should be carefully
packaged and clearly identified. The # Be aware that the accident site may be
readiness team or a pre-assembled unsafe due to dangerous materials or
investigator’s kit can provide general- weakened structures
purpose cardboard tags or adhesive labels
for this purpose. # Locations of removed parts can be
marked with orange spray paint or wire-
Equipment or parts thought to be defective, staffed marking flags; the marking flags
damaged, or improperly assembled should can be annotated to identify the part
be removed from the accident scene for removed and to allow later measurement
technical examination. The removal should
be documented using position maps and # Care during extraction and preliminary
photos to display the part in its final, post- examination is necessary to avoid
accident position and condition. If improper defacing or distorting impact marks and
assembly is suspected, investigators should fracture surfaces
direct that the part or equipment be
photographed and otherwise documented as # The board chairperson and investigators
each subassembly is removed. should concur when the parts extraction
work can begin, in order to assure that
Items that have been fractured or otherwise board members have completed all
damaged should be packaged carefully to observations requiring an intact accident
preserve surface detail. Delicate parts site.
should be padded and boxed. Both the part
and the outside of the package should be 6.3 Collecting
labeled. Greasy or dirty parts can be Documentary
wrapped in foil and placed in polyethylene
Evidence
bags or other nonabsorbent materials for
transport to a testing laboratory, command
Documentary evidence can provide
center, or evidence storage facility. If
important data and should be preserved and
uncertainties arise, subject matter experts
secured as methodically as physical
can advise the board regarding effective
evidence. This information might be in the
form of paper, photos, videotape, magnetic
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Part II Section 6 — Collecting Data

tape, or electronic media, either at the site or # Follow-on documentation that describes
in files at other locations. actions taken in response to the other
types of documentation.
Some work/process/system records are
retained only for the workday or the week. Collectively, this evidence gives important
Once an accident has occurred, the board clues to possible underlying causes of
must work quickly to collect and preserve errors, malfunctions, and failures that led to
these records so they can be examined and the accident.
considered in the analysis.
6.4 Examining
Accident investigation preplanning should
Organizational
include procedures for identifying records to
be collected, as well as the people Concerns, Manage-
responsible for their collection. Because ment Systems, and
records are usually not located at the scene Line Management
of the accident, they are often overlooked in
the preliminary collection of evidence.
Oversight
DOE Order 225.1A requires that the
Documents often provide important
investigation board “examine policies,
evidence for identifying causal factors of an
standards, and requirements that are
accident. This evidence is useful for:
applicable to the accident being
investigated, as well as management and
# Thoroughly examining the policies,
safety systems at Headquarters and in the
standards, and specifications that
field that could have contributed to or
molded the environment in which the
prevented the accident.” Additionally, DOE
accident occurred
Order 225.1A, Paragraph 4.c.(2)(b) and (d),
requires the board to “evaluate the
# Indicating the attitudes and actions of
effectiveness of management systems, as
people involved in the accident
defined by DOE Policy 450.4 (Safety
Management System Policy), the adequacy
# Revealing evidence that generally is not
of policy and policy implementation, and the
established in verbal testimony.
effectiveness of line management oversight
as they relate to the accident.” Therefore,
Documentary evidence generally can be
accident investigations must thoroughly
grouped into four categories:
examine organizational concerns,
management systems, and line management
# Management control documents that
oversight processes to determine whether
communicate management expectations
deficiencies in these areas contributed to
of how, when, where, and by whom
causes of the accident. The investigation
work activities are to be performed
board should consider the full range of
management systems from the first-line
# Records that indicate past and present
supervisor level, up to and including site and
performance and status of the work
Headquarters, as appropriate. It is important
activities, as well as the people,
to note that this focus should not be directed
equipment, and materials involved
toward individuals.
# Reports that identify the content and
In determining sources and causes of
results of special studies, analyses,
management system inadequacies and the
audits, appraisals, inspections, inquiries,
failure to anticipate and prevent the
and investigations related to work
conditions leading to the accident,
activities
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Section 6 — Collecting Data Part II

investigators should use the framework of on the specific characteristics of the

DOE’s integrated safety management system accident. The answers to the questions may
established by the Department in DOE be used to determine the facts of the
Policy 450.4. This policy lists the objective, accident, which, along with the analytical
guiding principles, core functions, tools described in Section 7, will enable the
mechanisms, responsibilities, and board to determine whether deficiencies
implementation means of an effective safety found in management systems and line
management system. management oversight are causal factors for
the accident.
The safety management system elements
described in DOE Policy 450.4 should be 6.5 Preserving
considered when deciding who to interview, and Controlling
what questions to ask, what documents to
collect, and what facts to consider pertinent Evidence
to the investigation. Even more importantly,
these elements should be considered when Preserving and controlling evidence are
analyzing the facts to determine their essential to the integrity and credibility of
significance to the causal factors of the the investigation. Security and custody of
accident. evidence are necessary to prevent its
alteration or loss and to establish the
In many accidents, deficiencies in accuracy and validity of all evidence
implementing the five core safety collected.
management functions defined in DOE
Policy 450.4 cause or contribute to the The point of contact is responsible for
accident. The five core functions are: (1) assuring that a chain of custody is
define the scope of work; (2) identify and established for all evidence removed from
analyze the hazards associated with the the accident scene before the board arrives.
work; (3) develop and implement hazard
controls; (4) perform work safely within the The board chairperson is responsible for
controls; and (5) provide feedback on establishing an evidentiary custody protocol
adequacy of the controls and continuous to ensure that all evidence is well
improvement in defining and planning the documented at the accident scene and
work. Table 6-7 contains a list of typical carefully controlled when it is removed and
questions board members may ask to stored after the board arrives. Evidence
determine whether any deficiencies in the control procedures similar to the following
implementation of the core functions guidelines will help assure that evidence is
affected the accident sequence. not adulterated, corrupted, or lost and that
subsequent engineering tests, if conducted,
Table 6-8 contains a list of typical questions and other analytical results are valid.
board members may ask to determine
whether line management deficiencies # Evidence should be photographed and/
affected the accident. These questions are or videotaped in its original location
based on the seven guiding principles of immediately following the accident,
DOE Policy 450.4. provided it does not interfere with
rescue or amelioration activities
The questions in Tables 6-7 and 6-8 are
provided in Appendix D to facilitate use by # A log should be maintained stating the
the board. These are not intended to be location, date, and time that photos and
exhaustive. Board members should adapt videos are taken. The Accident
these questions or develop new ones based Investigation Photographic Log Sheet

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Table 6-7. These are typical questions for addressing the five core
functions of integrated safety management.

Function #1: Define the scope of work.

n Were the purpose and scope of the work to be performed clearly defined so that workers
could identify any unanticipated conditions and actions that would be outside the autho-
rized work scope?
n Were expectations regarding the removal or control of hazards clearly defined and
communicated to the workers?
n Were the required safety support activities identified?
n Were roles, responsibilities, and authorities for the work activity defined and executed
appropriately?
n Were the worker qualifications required to safely perform the work identified?
n Were the design, operation, and configuration of equipment known and considered in
work planning?
n Were the characteristics of the work environment known and considered in work
planning?

Function #2: Identify and analyze the hazards.

n Were the type and magnitude of all possible hazards clearly understood by line
management, supervisors, and workers?
n Were the hazards analyzed and potential consequences documented?
n Did the workers provide input to the hazard analysis?
n Did the workers receive any feedback regarding their input?
n Were the standards and requirements associated with the hazards identified?

Function #3: Develop and implement hazard controls.

n Were required physical and engineering hazard controls evaluated for likely effectiveness
under the expected work conditions?
n Were the required administrative controls, such as technical procedures and safety
support personnel, in place?
n Were the workers qualified and given hazard- or activity-specific training?
n Was a proper review, approval, and configuration control process in place?

Function #4: Perform work within controls.

n Was the readiness to perform the work checked and confirmed prior to starting work?
n Was appropriate authorization received to start work?
n Was the work performed as planned (i.e., by the intended workers using the pre-
approved procedures with the required level of supervision and safety support present
with effective hazard controls in place)?
n Were the workers empowered to stop work if unanticipated or unsafe conditions arose?

Function #5: Provide feedback and continuous improvement.

n Was there a system to collect and use feedback from workers on workplace hazards?
n Were workers aware of any hazards affecting the work activity that were not addressed in
planning for it?
n Was management aware of the hazard(s) identified by the workers?
n Were there any lessons learned locally, from audit or evaluation results or from external
operating experience, that applied to the work activity but were not addressed in planning
for it?

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Section 6 — Collecting Data Part II

Table 6-8. These are typical questions for addressing the seven guiding principles
of integrated safety management.

Guiding Principle #1: Line management is directly responsible for the protection of the
public, workers, and the environment.

n Did DOE assure and contractor line management establish documented safety policies
and goals?
n Was integrated safety management policy fully implemented down to the activity level at
the time of the accident?
n Was DOE line management proactive in assuring timely implementation of integrated
safety management by line organizations, contractors, subcontractors, and workers?
n Were environment, safety and health (ES&H) performance expectations for DOE and
contractor organizations clearly communicated and understood?
n Did line managers elicit and empower active participation by workers in safety
management?

Guiding Principle #2: Clear lines of authority and responsibility for ensuring safety
shall be established and maintained at all organizational levels within the Department
and its contractors.

n Did line management define and maintain clearly delineated roles and responsibilities for
ES&H to effectively integrate safety into sitewide operations?
n Was a process established to ensure that safety responsibilities were assigned to each
person (employees, subcontractors, temporary employees, visiting researchers, vendor
representatives, lessees, etc.) performing work?
n Did line management establish communication systems to inform the organization, other
facilities, and the public of potential ES&H impacts of specific work processes?
n Were managers and workers at all levels aware of their specific responsibilities and
accountability for ensuring safe facility operations and work practices?
n Were individuals held accountable for safety performance through performance
objectives, appraisal systems, and visible and meaningful consequences?
n Did DOE line management and oversight hold contractors and subcontractors
accountable for ES&H through appropriate contractual and appraisal mechanisms?

Guiding Principle #3: Personnel shall possess the experience, knowledge, skills, and
abilities that are necessary to discharge their responsibilities.

n Did line managers demonstrate a high degree of technical competence and

understanding of programs and facilities?
n Did line management have a documented process for assuring that DOE personnel,
contractors, and subcontractors were adequately trained and qualified on job tasks,
hazards, risks, and Departmental and contractor policies and requirements?
n Were mechanisms in place to assure that only qualified and competent personnel were
assigned to specific work activities, commensurate with the associated hazards?
n Were mechanisms in place to assure understanding, awareness, and competence in
response to significant changes in procedures, hazards, system design, facility mission,
or life cycle status?
n Did line management establish and implement processes to ensure that ES&H training
programs effectively measure and improve performance and identify training needs?
n Was a process established to ensure that (1) training program elements were kept
current and relevant to program needs, and (2) job proficiency was maintained?

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Part II Section 6 — Collecting Data

Table 6-8. These are typical questions for addressing the seven guiding principles
of integrated safety management.

Guiding Principle #4: 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.

n Did line management demonstrate a commitment to ensuring that ES&H programs had sufficient
resources and priority within the line organization?
n Did line management clearly establish that integrated safety management was to be applied to all
types of work and address all types of hazards?
n Did line management institute a safety management system that provided for integration of ES&H
management processes, procedures, and/or programs into site, facility, and work activities in
accordance with the Department of Energy Acquisition Regulation (DEAR) ES&H clause (48 CFR
970.5204-2)?
n Were prioritization processes effective in balancing and reasonably limiting the negative impact of
resource reductions and unanticipated events on ES&H funding?

Guiding Principle #5: Before work is performed, the associated hazards shall be evaluated and
an agreed-upon set of safety standards shall be established that, if properly implemented, will
provide adequate assurance that the public, the workers, and the environment are protected
from adverse consequences.

n Was there a process for managing requirements, including the translation of standards and
requirements into policies, programs, and procedures, and the development of processes to tailor
requirements to specific work activities?
n Were requirements established commensurate with the hazards, vulnerabilities, and risks
encountered in the current life cycle stage of the site and/or facility?
n Were policies and procedures, consistent with current DOE policy, formally established and
approved by appropriate authorities?
n Did communication systems assure that managers and staff were cognizant of all standards and
requirements applicable to their positions, work, and associated hazards?

Guiding Principle #6: Administrative and engineering controls to prevent and mitigate hazards
shall be tailored to the work performed and associated hazards.

n Were the hazards associated with the work activity identified, analyzed, and categorized so that
appropriate administrative and engineering controls could be put in place to prevent or mitigate
the hazards?
n Were hazard controls established for all stages of work to be performed (e.g., normal operations,
surveillance, maintenance, facility modifications, decontamination, and decommissioning)?
n Were hazard controls established that were adequately protective and tailored to the type and
magnitude of the work and hazards and related factors that impact the work environment?
n Were processes established for ensuring that DOE contractors and subcontractors test,
implement, manage, maintain, and revise controls as circumstances change?
n Were personnel qualified and knowledgeable of their responsibilities as they relate to work
controls and work performance for each activity?

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Section 6 — Collecting Data Part II

Table 6-8. These are typical questions for addressing the seven guiding principles
of integrated safety management. (Continued)

Guiding Principle #7: The conditions and requirements to be satisfied for operations to
be initiated and conducted shall be clearly established and agreed upon.

n Were processes in place to assure the availability of safety systems and equipment
necessary to respond to hazards, vulnerabilities, and risks present in the work
environment?
n Did DOE and contractor line management establish and agree upon conditions and
requirements that must be satisfied for operations to be initiated?
n Was a management process established to confirm that the scope and authorization
documentation is adequately defined and directly corresponds to the scope and
complexity of the operations being authorized?
n Was a change control process established to assess, approve, and reauthorize any
changes to the scope of operations ongoing at the time of the accident?

can be used for this purpose. Avoid n Secure storage should be obtained
using photographic attachments that immediately, and access to evidence
digitally record the date and time on the controlled throughout the investigation.
negative because these images become a
permanent part of the photo and may n Access to the room or suite of offices
obscure evidence or important details in used by the investigation board should
the photo or video. The computerized/ be restricted. No one other than board
printed date on the back of photos members, advisors, and support staff
provided by film processors should be should have access to the board’s office
used in conjunction with, not in lieu of, space; this includes janitorial staff.
a photo log, because the date on photos
gives the day the film was processed, n The board chairperson should determine
not the day the photos were taken. the disposition of evidence at the
conclusion of the investigation.
# Board members should prepare and sign
an inventory of all evidentiary items Documentary evidence can easily be
collected, including statements overlooked, misplaced, or taken.
regarding: Documents can be altered, disfigured,
misinterpreted, or electronically corrupted.
• Items removed from the scene Computer software and disks can be erased
• Date and time items were removed by exposure to magnetic fields. As with
• Person who removed items other evidence collected during the
• Location where those items will be investigation, documentary evidence should
stored. be collected, inventoried, controlled, and
secured (in locked containers, if necessary).
n Evidence should be controlled by
signature transfer (signatures of the
recipient and the person relinquishing TIP
custody) and made available only to Protect all records relating to the accident
those who need to examine and use the until investigation activities or analysis of
evidence during the accident those records determines that they are not
investigation. The Accident relevant to the accident.
Investigation Physical Evidence Log
Form may be used for this purpose.

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Part II Section 6 — Collecting Data

KEY POINTS TO REMEMBER

n Gather as much evidence as quickly as possible. It is easier to discount an item
later than to capture or reconstruct it later.

n Assess initial response activities performed by the site readiness team to

determine any gaps or immediate concerns. Formulate initial plans for evidence
collection based on this assessment.

n Three types of evidence are gathered during accident investigations:

• Human or testamentary evidence (witness statements and observations)
• Physical evidence (matter related to the accident such as equipment, parts,
fluids, debris, hardware, and other physical items)
• Documentary evidence (paper and electronic information).

n Develop and implement effective procedures to preserve and control evidence

because they are necessary to ensure the accuracy and validity of the evidence and
essential to the integrity and credibility of the investigation.

n The five major steps in gathering evidence are:

• Collecting human evidence (locating and interviewing witnesses)
• Collecting physical evidence
• Collecting documentary evidence
• Examining organizational concerns, management systems, and line
management oversight
• Preserving and controlling evidence.

n Identify witnesses as quickly as possible to obtain witness statements. Sources for

locating witnesses include site readiness and emergency response personnel,
principal witnesses, eyewitnesses, first line supervisors, police, firefighters,
paramedics, nurses or doctors, news media, and maintenance and security
personnel.

n Promoting effective interviews includes careful preparation, creating a relaxed

atmosphere, preparing the witness for the interview, recording the interview
(preferably by using a court reporter to document the interview), asking open-
ended questions, and evaluating the witness’s state of mind.

n Do not rush witnesses while they are describing the accident; do not be
judgmental, hostile, or argumentative; do not display anger, suggest answers,
threaten, intimidate, or blame the witness; do not make promises of
confidentiality, use inflammatory words, ask questions that suggest an answer, or
omit questions because you think you know the answer.

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Section 6 — Collecting Data Part II

KEY POINTS TO REMEMBER (Continued)

n Mapping and photographing the accident scene are important, because precise
visual representations of the accident scene and pinpointing the location of
evidence before it is moved are necessary to ensure that the board has the means
to develop and test causal theories.

n Remove evidence carefully, tagging and packaging it to preserve its integrity.

n Before removing evidence from the accident scene, follow these guidelines:
• If possible, removal should not begin until witnesses have been interviewed
• Extraction and removal or movement should not be started until the scene and
the location of evidence has been documented
• Exercise caution and be alert for unsafe conditions or weakened structures
• The location of removed material can be marked with paint or flags
• Avoid defacing or distorting impact marks and fracture surfaces
• The board should concur on removal

n Follow precautions when handling potential bloodborne pathogens.

• Documentary evidence is generally grouped into four categories:
• Management control documents
• Records that indicate past and present status of work activities
• Reports of studies, analyses, audits, etc.
• Follow-on documentation that describes actions taken in response to other
types of documentation.

n Consider the role of management systems when collecting and reviewing

evidence, and gather all evidence that could reveal deficiencies in safety
management.

n Use the guiding principles and core functions of the integrated safety management
system to form questions that will guide evidence collection and analysis of all
levels of management systems, from the first line supervisor up to and including
Headquarters.

n Establish a chain of custody for evidence and ensure that it is strictly maintained
throughout the investigation.

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 Part II

Accident Investigation Preliminary Interview List

Date/time of Location of Board member(s) Individual to be Title/position of

interview interview interviewing interviewed interviewee Notes

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Section 6 — Collecting Data
Section 6 — Collecting Data Part II

Accident Investigation Interview Form

Interviewee: Interviewer:
Title/Position: Title/Position: Page __ of __

Others present: Date:

Time:

Initial Questions:

Follow-Up Questions:

Observations of Interviewee:

Notes:

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Part II Section 6 — Collecting Data

MODEL OPENING STATEMENT

[To be recorded]

Let the record reflect that this interview has commenced at (time, date. and place).
I’m (state interviewer’s name(s) and employment affiliation(s). i.e., I’m Joe Smith of the Idaho
Operations Office of the Department of Energy. With me are (name and organization of other
Department personnel). For the record, please state your full name, company affiliation, job
title, or position.

Read into record the names and employment of any additional persons present (other than the
recorder).

The Department has established an accident investigation board to determine the facts that led
to the (accident date) accident at (place of accident). The principal purpose of this
investigation is to determine the facts surrounding the accident so that proper remedial
measures can be instituted to prevent the recurrence of accidents. We have authority to
conduct this investigation under the Department of Energy Organization Act, which
incorporates provisions of the Atomic Energy Act of 1954 authorizing investigations of this
type.

Your appearance here to provide information is entirely voluntary, and you may stop testifying
and leave at any time. However, you should understand that giving false testimony in this
investigation would be a felony under 18 U.S. Code Section 1001. Do you understand that?

You have the right to be accompanied by an attorney or a union representative. (If witness has
attorney or a union representative, put the name of such person into the record.) “Let the
record reflect that Mr./Mrs./Ms. is accompanied by” (as his/her attorney or union
representative).

We would like to record this interview to ensure an accurate record of your statements. A
transcript of this discussion will be produced, and you will have an opportunity to review the
transcript for factual accuracy and corrections. If you do not wish to have the session
recorded. we will not do so. Do you have any objection to having the session recorded?

We will attempt to keep your testimony confidential but we cannot guarantee it. At a later
date, we may have to release your testimony pursuant to a request made under the Freedom of
Information Act, a court order, or in the course of litigation concerning the accident, should
such litigation arise. Do you want your testimony to be considered confidential? (wait for
answer--if answer to preceding question is affirmative).

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 Section 6 — Collecting Data
6-22

Accident Investigation Physical Evidence Log Form

Acknowledgements of Transfer

Original Inventoried & Tagged by: Released by: Received by:

Tag Evidence Location Storage Name/Signature/ Name/Signature/ Name/Signature/
Number Description Reference Location Date/Time Date/Time Date/Time
Accident Investigation Workbook/Rev 2

Part II
Attach copy of Accident Investigation Sketch of Physical Evidence Locations
 Part II

Accident Investigation Site Sketch

Board Member: Date:

Title: Time:

Accident Investigation Workbook/Rev 2

Sketch
Orientation

6-23
Section 6 — Collecting Data

Attach copy of Accident Investigation Position Mapping Form

6-24
Accident Investigation Site Map

Board Member: Date:

Title: Time:
Section 6 — Collecting Data

Sketch
Orientation
Part II

Accident Investigation Workbook/Rev 2

Attach copy of Accident Investigation Position Mapping Form
 Accident Investigation Workbook/Rev 2

Part II
Accident Investigation Position Mapping Form

Board Member: Date:

Title: Time:

Code # Object Reference Point Distance Direction

Section 6 — Collecting Data

6-25

Attach copy of Accident Investigation Site Map and Accident Investigation Site Sketch
6-26
Accident Investigation
Sketch of Physical Evidence Locations and Orientations

Board Member: Date:

Title: Time:
Section 6 — Collecting Data

Sketch
Orientation
Part II

Accident Investigation Workbook/Rev 2

Attach copy of Accident Investigation Physical Evidence Log Form
Part II Section 6 — Collecting Data

Accident Investigation
Photographic Log Sheet

Photographer: Location:
Camera Type: Date:
Lighting Type: Time:
Film Roll No:

Date Time Direction Distance

Photo of of Lens of from
No. Scene/Subject Photo Photo f/R Camera Subject

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6-28
Accident Investigation
Sketch of Photography Locations and Orientations

Board Member: Date:

Title: Time:
Section 6 — Collecting Data

Sketch
Orientation
Part II

Accident Investigation Workbook/Rev 2

Attach copy of Accident Investigation Position Mapping Form
Contents

Section 7 C Analyzing Data

7.1 Determining Facts ............................................................................................... 7-1

7.2 Determining Causal Factors ................................................................................ 7-2

7.2.1 Direct Cause ........................................................................................... 7-2

7.2.2 Contributing Causes ............................................................................... 7-3
7.2.3 Root Causes ............................................................................................ 7-4
7.2.4 The Importance of Causal Factors ......................................................... 7-5

7.3 Using the Core Analytical Techniques ................................................................ 7-5

7.3.1 Events and Causal Factors Charting ....................................................... 7-5

7.3.2 Barrier Analysis ...................................................................................... 7-8
7.3.3 Change Analysis ................................................................................... 7-15
7.3.4 Events and Causal Factors Analysis ..................................................... 7-21
7.3.5 Root Cause Analysis ............................................................................ 7-25

7.4 Using Advanced Analytic Methods .................................................................. 7-39

7.4.1 Analytic Trees ...................................................................................... 7-40

7.4.2 Management Oversight and Risk Tree Analysis (MORT) ................... 7-44
7.4.3 Project Evaluation Tree (PET) Analysis .............................................. 7-47

7.5 Other Analytic Techniques ................................................................................ 7-52

7.5.1 Time Loss Analysis .............................................................................. 7-52

7.5.2 Human Factors Analysis ...................................................................... 7-52
7.5.3 Integrated Accident Event Matrix ........................................................ 7-53
7.5.4 Failure Modes and Effects Analysis ..................................................... 7-53
7.5.5 Software Hazards Analysis .................................................................. 7-54
7.5.6 Common Cause Failure Analysis ......................................................... 7-54
7.5.7 Sneak Circuit Analysis ......................................................................... 7-54
7.5.8 Materials and Structural Analysis ........................................................ 7-54
7.5.9 Design Criteria Analysis ...................................................................... 7-54
7.5.10 Accident Reconstruction ...................................................................... 7-54
7.5.11 Scientific Modeling .............................................................................. 7-54

Key Points to Remember ......................................................................................... 7-56

List of Tables

Table 7-1. Case study introduction ....................................................................... 7-3

Table 7-2. Benefits of events and causal factors charting .................................... 7-6
Table 7-3. Guidelines and symbols for preparing an events and causal factors
chart ..................................................................................................... 7-8
Table 7-4. Sample barrier analysis worksheet .................................................... 7-16
Contents

Section 7 (Cont’d)

List of Tables (Cont’d)

Table 7-5. Sample change analysis worksheet ................................................... 7-22

Table 7-6. Case Study: Change analysis summary ............................................. 7-23
Table 7-7. Tier diagram worksheet for a contractor organization ...................... 7-28
Table 7-8. Example tier diagram approach ........................................................ 7-30
Table 7-9. Compliance/noncompliance root cause model categories ................ 7-38
Table 7-10. MORT color coding system .............................................................. 7-47

List of Figures

Figure 7-1. Simplified events and causal factors chart .......................................... 7-7
Figure 7-2. Sample of an events and causal factors chart (in progress) ................ 7-9
Figure 7-3. Barriers are intended to protect personnel and property against
hazards .............................................................................................. 7-13
Figure 7-4. Barriers to protect workers from hazards .......................................... 7-14
Figure 7-5. Summary results from a barrier analysis reveal the types of
barriers involved ............................................................................... 7-17
Figure 7-6. Summary results from a barrier analysis can highlight the role
of the core functions in an accident .................................................. 7-18
Figure 7-7. The change analysis process is relatively simple .............................. 7-20
Figure 7-8. Events and causal factors analysis; driving events to causal factors 7-24
Figure 7-9. Grouping root causes on the events and causal factor chart ............. 7-25
Figure 7-10. Identifying the linkages on the tier diagram ..................................... 7-35
Figure 7-11. The analytic tree process begins with the accident as the top event . 7-40
Figure 7-12. Analytic trees are constructed using symbols ................................... 7-43
Figure 7-13. The layout of an analytic tree shows logical relationships ............... 7-45
Figure 7-14. A completed analytic tree shows the flow of lower-tier elements
to the top event .................................................................................. 7-46
Figure 7-15. The initial MORT chart uses logic symbols ..................................... 7-48
Figure 7-16. The accident description can be shown on a MORT chart ............... 7-49
Figure 7-17. Management system factors can be shown on a MORT chart .......... 7-50
Figure 7-18. This branch of the PET chart deals with procedures ........................ 7-51
Figure 7-19. Time loss analysis can be used when emergency response is
in question ......................................................................................... 7-53

List of Forms and Tools

Barrier Analysis Worksheet ..................................................................................... 7-58

Change Analysis Worksheet .................................................................................... 7-59
PET Analysis Worksheet ......................................................................................... 7-60
 Part II Section 7 — Analyzing Data

7
Analyzing Data
7.1 Determining
C
areful and complete analysis of the
data collected following an accident
Facts
is critical to the accurate
determination of an accident’s causal
Immediately following any serious accident,
factors. The results of comprehensive
much of the available information may be
analyses provide the basis for corrective and
conflicting and erroneous. The volume of
preventive measures.
data expands rapidly as witness statements
are taken, emergency response actions are
The analysis portion of the accident
completed, evidence is collected, and the
investigation is not a single, distinct part of
accident scene is observed by more
the investigation. Instead, it is the central
individuals.
part of the iterative process that includes
collecting facts and determining causal
The principal challenge of the investigation
factors. Well chosen and carefully
board is to distinguish between accurate and
performed analytical methods are important
erroneous information in order to focus on
for providing results that can aid
areas that will lead to identifying the
investigators in developing an investigation
accident’s causal factors. This can be
report that has sound judgments of need.
accomplished by:

TIP n Understanding the activity that was

Each board should determine which analytic being performed at the time of the
techniques to use based on the accident’s accident
complexity and severity. Alternative
approaches and methods to those presented in n Personally conducting a walk-through of
this workbook are acceptable, provided that the accident scene
they meet the requirements of DOE Order
225.1A and are demonstrably equivalent. n Challenging “facts” that are inconsistent
with other evidence (e.g., physical)
Caution must be taken in applying analytic
n Corroborating facts through interviews
methods. First, no single method will
provide all the analyses required to
n Testing or inspecting pertinent
completely determine the multiple causal
components to determine failure modes
factors of an accident. Several techniques
and physical evidence
that can complement and cross-validate one
another should be used to yield optimal
n Reviewing policies, procedures, and
results. Second, analytic techniques cannot
work records to determine the level
be used mechanically and without thought.
of compliance or implementation.
The best analytic tools can become
cumbersome and ineffective if they are not
applied to an accident’s specific
circumstances and adapted accordingly.
Accident Investigation Workbook/Rev 2
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Section 7 — Analyzing Data Part II

TIP
7.2 Determining
Prevention is at the heart of the entire Causal Factors
investigation process; therefore, any
accident investigation must focus on fact- TIP
finding, not fault-finding. The process of determining causal factors
seeks to answer the questions — what
happened and why did it happen?
Fact-finding begins during the collection
of evidence. All sources of evidence
(e.g., accident site walk-throughs, witness Causal factors are the events and conditions
interviews, physical evidence, policy or that produced or contributed to the
procedure documentation) contain facts that, occurrence of the accident. There are three
when linked, create a chronological depiction types of causal factors:
of the events leading to an accident. Facts are
not hypotheses, opinions, analysis, or n Direct cause
conjecture. However, not all facts can be n Contributing causes
determined with complete certainty, and such n Root causes.
facts are referred to as assumptions.
Assumptions should be reflected as such in 7.2.1 Direct Cause
the investigation report and in any closeout
briefings. The direct cause of an accident is the
immediate events or conditions that caused
Board members should immediately begin the accident. The direct cause should be
developing a chronology of events as facts stated in one sentence, as illustrated in the
and evidence are collected. Facts should be examples below.
reviewed on an ongoing basis to ensure
relevance and accuracy. Facts and evidence
EXAMPLES:
later determined to be irrelevant should be ACCIDENT DIRECT CAUSES
removed from the accident chronology but
retained in the official investigation file for n The direct cause of the accident was
future consideration. contact between the chisel bit of the air-
powered jackhammer and the 13.2 kV
energized electrical cable in the sump pit
Contradictory facts can be resolved in closed being excavated.
board meetings, recognizing that the
determination of significant facts is an n The direct cause of the accident was the
inadvertent activation of electrical circuits
iterative process that evolves as gaps in
that initiated the release of CO2 in an
information are closed and questions occupied space.
resolved. The board revisits the prescribed
scope and depth of their investigation often
during the fact-finding and analysis process. Identifying the direct cause of an accident is
Doing so ensures that the investigation optional. While it may not be necessary to
adheres to the parameters prescribed in the identify the direct cause in order to complete
board’s appointment memorandum. the causal factors analysis, the direct cause
should be identified when it facilitates
Causal factors of an accident are identified by understanding why the accident occurred or
analyzing the facts. Judgments of need, and when it is useful in developing lessons
the subsequent corrective actions, are based learned from the accident.
on the identified causes of the accident.
Therefore, the facts are the foundation of all
other parts of the investigative process.

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Part II Section 7 — Analyzing Data

7.2.2 Contributing Contributing causes may be longstanding

Causes conditions or a series of prior events that,
alone, were not sufficient to cause the
Contributing causes are events or conditions accident, but were necessary for it to occur.
that collectively with other causes increased Contributing causes are the events and
the likelihood of an accident but that conditions that “set the stage” for the accident
individually did not cause the accident. and, if allowed to persist or re-occur, increase
the probability of future accidents.

Table 7-1. Case study introduction.

CASE STUDY

This section of the workbook begins with a case study of an electrical accident. It is
selectively referenced throughout this and subsequent sections to illustrate the
process of determining facts and the use of six analytic techniques: four core
techniques commonly used in DOE accident investigations, and two tree-based
techniques. In this workbook, particular emphasis is placed on these techniques
because they can be used in most accident investigations. However, for extremely
complex accidents, additional, more sophisticated techniques may be needed that
require specialized training. Training for these techniques is beyond the scope of this
workbook and can be obtained through government, private, and university sources.

ACCIDENT DESCRIPTION

The accident occurred at approximately 9:34 a.m. on January 17, 1996, in Building
XX, during the excavation of a sump pit in the floor of the building. Workers were
attempting to correct a waste stream outfall deficiency. Two workers arrived at the job
site at approximately 8:40 a.m. and resumed the excavation work begun the previous
day. The workers were employed by WS, the primary subcontractor for construction
and maintenance. They used a jackhammer, pry bar, and shovel to loosen and
remove the rubble from the sump pit. At about 9:34 a.m., at a depth of 39 inches,
Worker A, who was operating the jackhammer, pierced the conduit containing an
energized 13.2 kV electrical cable. He was transported to the local medical center,
where cardiac medications were administered.

ACCIDENT FACTS

Using the case study accident, the following three factual statements were derived
during the investigation:

n The injured worker had not completed safety training prior to the accident, as
required by WS Environment, Safety, and Health Manual Procedure 12340.

n Design drawings for the project on which the injured employee was working did
not comply with the requirements of DOE Order 6430.1A, General Design Criteria,
and did not show the location of the underground cable.

n A standing work order system, without a safety review, was used for nonroutine,
nonrepetitive tasks.

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Section 7 — Analyzing Data Part II

EXAMPLES: n Ensure that hazard controls are tailored

ACCIDENT CONTRIBUTING CAUSES to the work being performed
n Ensure that work is properly reviewed
n Failure to implement safety
procedures in effect for the project and authorized.
contributed to the accident.

n Failure to erect barriers or post

warning signs contributed to the TIP
accident. Even though the board should avoid placing
n The standing work order process was individual blame for an accident, the board
used by facility personnel as a has an obligation to seek out and report all
convenient method of performing work causal factors, including deficiencies in
without a job ticket and work package,
allowing most work to be field- management, safety, or line management
directed. oversight systems.
n Inadequate illumination in the area of
the platform created visibility problems
that contributed to the fall from the Root cause statements, as shown in the
platform.
examples below, should identify the DOE
and contractor line organizations responsible
Root
7.2.3 Root Causes for the safety management failures. Root
cause statements should also identify the
Root causes are the causal factors that, if specific management system(s) that failed.
corrected, would prevent recurrence of the
same or similar accidents. Root causes may
EXAMPLES:
be derived from or encompass several ACCIDENT ROOT CAUSES
contributing causes. They are higher-order,
fundamental causal factors that address n Contractor management and the DOE field
office failed to clearly define responsibilities
classes of deficiencies, rather than single for safety reviews of planned work. The lack
problems or faults. Correcting root causes of clarity in roles and responsibilities for
would not only prevent the same accident safety reviews was a root cause of the
accident.
from recurring, but would also solve line
management, oversight, and management n Contractor management allowed the
system deficiencies that could cause or standing work order process, intended for
routine work, to be used to accomplish non-
contribute to other accidents. They are routine, complex modification and
identified using root cause analysis (see construction work. DOE field office oversight
failed to detect and ensure correction of this
Section 7.3.5). practice. Misuse of the standing work order
process was a root cause of the accident.
In many cases, root causes are failures to
n Contractor management systems were
properly implement the principles and core ineffective in translating lessons learned
functions of integrated safety management. from past occurrences into safer day-to-day
operations at the facility. The failure to
Root causes can include failures in implement lessons learned was a root cause
management systems to: of the accident.

n Assessments performed by the DOE

n Define clear roles and responsibilities program office failed to identify that some
for safety safety standards were not addressed by
contractor safety management systems.
n Ensure that staff are competent to Implementation of these requirements would
perform their responsibilities have prevented the accident.
n Ensure that resource use is balanced to
meet critical mission and safety goals
n Ensure that safety standards and
requirements are known and applied to
work activities
Accident Investigation Workbook/Rev 2
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Part II Section 7 — Analyzing Data

7.2.4 The Importance

TIP
Factors
of Causal Factors
The purpose of any analytic technique in an
accident investigation is to answer the
The primary purpose of any accident
question — “How did it happen?” It is the
investigation is to help line management
job of the board to apply whatever
prevent recurrence of accidents by
techniques can help them determine the
identifying all of an accident’s causal
causal factors of an accident.
factors. The board is responsible for
identifying the local causal factors that, if
corrected, would prevent another accident Following are descriptions of and
from occuring when the same work activity instructions for using these four core
is performed again. However, more is analytic techniques:
required than simply detecting and removing
immediate hazards. The board is also n Events and causal factors charting and
responsible for identifying and describing analysis
any failures in management systems and
n Barrier analysis
oversight processes that allow hazards to
exist that could lead to other accidents at
n Change analysis
other facilities and DOE sites. Modern
accident investigation theory indicates that n Root cause analysis.
generally the root causes of accidents are
found in management system failures, not in
7.3.1 Events and
the most directly related causal factor(s) in
terms of time, location, and place.
Factors
Causal F actors
Charting
Generally, the higher the level in the
management and oversight chain at which a Accidents rarely result from a single cause.
root cause is found, the broader the scope of Events and causal factors charting is useful in
the activities that the root cause can affect. identifying the multiple causes and graphically
Because these higher-level root causes, if depicting the triggering conditions and events
not corrected, have the largest potential to necessary and sufficient for an accident to
cause other accidents, it is incumbent on a occur.
board to ensure that the investigation is not
ended until the root causes are identified. If For purposes of this workbook, events and
a board cannot identify root causes, this causal factors charting and events and causal
should be stated clearly in the investigation factors analysis (see Section 7.3.4) are
report, along with an explanation. considered one technique. They are addressed
separately because they are conducted at
7.3 Using the Core different stages of the investigation. Events
and causal factors charting is a graphical
Analytical display of the accident’s chronology and is
Techniques used primarily for compiling and organizing
evidence to portray the sequence of the
accident’s events. It is a continuous process
DOE accident investigation boards
performed throughout the investigation.
commonly use four techniques to analyze
Events and causal factors analysis is the
the factual information they have collected,
application of analysis to determine causal
to identify conditions and events that
factors by identifying significant events
occurred before and immediately following
and conditions that led to the accident. As the
an accident, and to determine an accident’s
results of other analytical techniques (e.g.,
causal factors.
change analysis and barrier analysis) are
Accident Investigation Workbook/Rev 2
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Section 7 — Analyzing Data Part II

completed, they are incorporated into the Constructing the Chart. Constructing the
events and causal factors chart. After the chart events and causal factors chart should
is fully developed, the analysis is performed to begin immediately. However, the initial
identify causal factors. chart will be only a skeleton of the final
product. Many events and conditions will
Events and causal factors charting is possibly be discovered in a short amount of time,
the most widely used analytic technique in and therefore, the chart should be updated
DOE accident investigations, because the almost daily throughout the investigative
events and causal factors chart is easy to data collection phase. Keeping the chart
develop and provides a clear depiction of the up-to-date helps ensure that the
data. By carefully tracing the events and investigation proceeds smoothly, that gaps
conditions that allowed the accident to occur, in information are identified, and that the
board members can pinpoint specific events investigators have a clear representation
and conditions that, if addressed through of accident chronology for use in
corrective actions, would prevent a recurrence. evidence collection and witness
The benefits of this technique are highlighted interviewing.
in Table 7-2.
Investigators and analysts can construct
an events and causal factors chart using
TIP
either a manual or computerized method.
To identify causal factors, board members
Accident investigation boards often use
must have a clear understanding of the
both techniques during the course of the
relationships among the events and the
investigation, developing the initial chart
conditions that allowed the accident to
manually and then transferring the
occur. Events and causal factors charting
resulting data into computer programs.
provides a graphical representation of these
relationships.

Table 7-2. Benefits of events and causal factors charting.

The benefits of events and causal factors charting include:

n Illustrating and validating the sequence of events leading to the accident and the conditions
affecting these events

n Showing the relationship of immediately relevant events and conditions to those that are associated
but less apparent — portraying the relationships of organizations and individuals involved in the
accident

n Directing the progression of additional data collection and analysis by identifying information gaps

n Linking facts and causal factors to organizational issues and management systems

n Validating the results of other analytic techniques

n Providing a structured method for collecting, organizing, and integrating collected evidence

n Conveying the possibility of multiple causes

n Providing an ongoing method of organizing and presenting data to facilitate communication among
the investigators

n Clearly presenting information regarding the accident that can be used to guide report writing

n Providing an effective visual aid that summarizes key information regarding the accident and its
causes in the investigation report.

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Part II Section 7 — Analyzing Data

The manual method employs removable from left to right, the primary chain of
adhesive notes to chronologically depict events that led to an accident. Secondary
events and the conditions affecting these and miscellaneous events are then added
events. The chart is generally constructed to the events and causal factors chart,
on a large conference room wall or many inserted where appropriate in a line above
sheets of poster paper. Accident events the primary sequence line. Conditions
and conditions are recorded on removable that affect either the primary or secondary
adhesive notes and affixed sequentially to events are then placed above or below
the wall in the board’s conference room or these events. Figure 7-1 illustrates the
“command center.” Because the exact basic format of the events and causal
chronology of the information is not yet factors chart. Guidelines for constructing
known, using removable adhesive notes the chart are shown in Table 7-3.
allows investigators to easily change the
sequence of this information and to add A sample summary events and causal
information as it becomes available. factors chart (Figure 7-2) uses data from
Different colored notes or inks can be the case study accident. It illustrates how
used to distinguish between events and data may become available during an
conditions in this initial manual accident investigation, and how a chart
construction of the events and causal would first be constructed and
factors chart. subsequently updated and expanded.

If the information becomes too unwieldy Depending on the complexity of the

to manipulate manually, the data can be accident, the chart may result in a very
entered into a computerized analysis large complex sequence of events
program. Using specialized analytical covering several walls in the “command
software, investigators can produce an center.” For the purpose of inclusion in
events and causal factors graphic, as well the investigation report and closeout
as other analytical trees or accident briefings, the chart is generally
models. summarized. Note that “assumed
conditions” appear in the final chart.
Whether using a manual or a These are conditions the board presumed
computerized approach, the process affected the accident sequence, but the
begins by chronologically constructing, effect could not be substantiated with
evidence.

Figure 7-1. Simplified events and causal factors chart.

C o nd ition

C o nd ition

S ec o nd a ry
E v en ts S ec o nd a ry S ec o nd a ry
S eq u e nc e E v en t 1 E v en t 2

P rim a ry
E v en ts E v en t 1 E v en t 2 E v en t 1 A c cid e nt
S eq u e nc e E v en t

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Section 7 — Analyzing Data Part II

7.3.2 Barrier Analysis A hazard is the potential for an unwanted

energy flow to result in an accident or
Barrier analysis is based on the premise other adverse consequence. Energy flow
that hazards are associated with all is the transfer of energy from its source to
accidents. Barriers are developed and another destination. This transfer of
integrated into a system or work process to energy can be either wanted or unwanted.
protect personnel and equipment from For example, the flow of electricity
hazards (see Figure 7-3). For an accident to through an electrical cable to a piece of
occur, there must be: equipment is a desired energy flow. A
worker coming into contact with that
n A hazard, which comes into contact electricity is an undesired energy transfer.
with As used here, energy is defined broadly
and could be, for example, kinetic,
n A target, because biological, acoustical, chemical,
electrical, mechanical, potential,
n Barriers or controls were unused or electromagnetic, thermal, or radiation.
failed.

Table 7-3. Guidelines and symbols for preparing an events and causal factors chart.

Symbols # G — Events
# " — Accidents
# — Conditions
# ::: — Presumptive events
# — Presumptive conditions or assumptions
# v — Connect events
# - -> — Connect conditions
# Í — Transfers one line to another
# LTA— Less than adequate; a judgment of the board

Events # Are active (e.g., “crane strikes building”)

# Should be stated using one noun and one active verb
# Should be quantified as much as possible and where applicable (e.g.,
“the worker fell 26 feet,” rather than, “the worker fell off the
platform”)
# Should indicate the date and time of the event, when they are known
# Should be derived from the event or events and conditions
immediately preceding it.

Conditions # Are passive (e.g., “fog in the area”)

# Describe states or circumstances rather than occurrences or events
# As practical, should be quantified
# Should indicate date and time if practical/applicable
# Are associated with the corresponding event.

Primary Event Encompasses the main events of the accident and those that form the
Sequence main events line of the chart.

Secondary Encompasses the events that are secondary or contributing events and
Event those that form the secondary line of the chart.
Sequence

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Part II Section 7 — Analyzing Data

Figure 7-2. Sample of an events and causal factors chart (in progress).

Legend
Sta ge 1:
(Fa cts ava ilable at the tim e of bo ard’s arrival on site) Event

C ond ition

W orke r Accident
Pipe fitte rs arrive
Co ncre te slab is strikes 13 .2 kV
o n site to be gin
wo rk pre para tio ns cut an d rem o ve d p rim ary feede r Transfer
1 /10 /9 6 cab le
9 :34 a .m .
LTA Less Than
Adequ ate

Sta ge 2:
(Fa cts and co nditions known after reviewing witness statem ents and condu cting w alk-throu gh)

Pre lim ina ry

d rawing s place Po te ntial for 1 3.2 kV Po te ntial for 1 3.2 kV
sum p at basem e nt still e xists still e xists
e ntry d o orwa y

Pipe fitte rs arrive W orke r W orke r p ulls la b orer

Pipe fitte rs id en tify Co ncre te slab is W orke r slu m ps into uprigh t p ositio n
o n site to be gin strikes 13 .2 kV
n ee d to relocate cut an d rem o ve d forw ard o ver (jackh a m m e r still
wo rk pre para tio ns p rim ary feede r
sum p 1/10 /9 6 jackham m er p ositioned o n
1 /10 /9 6 cab le
9 :34 a .m . w o rke r)

Sta ge 3:
(A dditional facts ob tained from interviews and docum ent reviews. N ote few conditions have been determ in ed thu s far.)
Pre lim ina ry
d rawing s place
sum p at basem e nt
e ntry d o orwa y

W S pip efitte r Pipe fitte rs arrive

Pipe fitte rs receive Pipe fitte rs id en tify Fa cility m an ag e r is
forem a n (acting ) o n site to be gin W S perfo rm s
wo rk pa ckage n ee d to relocate n ot aw a re of A
re ce ive s w ork wo rk pre para tio ns safe ty che cklist
sum p 1/10 /9 6 b asem e nt w ork
p acka g e 1 /10 /9 6
1 /16 /9 6

W S doe s no t
h ave pro ced ure s of Po te ntial for 1 3.2 kV Po te ntial for 1 3.2 kV
PP E re qu ire m en ts still e xists still e xists
for jackha m m e ring

Fo re m an inqu ire s Dirt is rem ove d by W orke r W orke r p ulls la b orer

Co ncre te slab is m asonry crew w ith W orke r slu m ps into uprigh t p ositio n
a bo ut excavatio n strikes 13 .2 kV
A cut an d rem o ve d jackham m er, forw ard o ver (jackh a m m e r still
p erm it re quire m en ts p rim ary feede r
sho ve l, an d pry ba r jackham m er p ositioned o n
1 /16 /9 6 cab le
1 /17 /9 6 8:40 a.m . 9 :34 a .m . w o rke r)

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Section 7 — Analyzing Data Part II

Figure 7-2. (Continued)

S ta ge 4:
(Fa cts a nd co nditions known after interview s, reviews o f docum entary evidence)

W S wo rk Prelim inary Legend

Pipefitter goes
on annual leave and package does not draw ings place
identify underground sum p at basem ent E vent
acting pipefitter
forem an assigned utilities entry doorw ay
Cond ition
Pipefitters arrive
W S pipefitter foreman (acting) receives Pipefitters receive on site to begin A ccident
w ork package w ork package w ork preparations A
1/10/96 Transfer

LTA Less Than

A dequ ate

C onceptual
Approval given by draw ings do not Pipefitters verbally
eng ineering firm clearly identify com m unicate the
oversight und erground scope of w ork
location

Pipefitters identify W S pipefitters W S pipefitters W S electrician

A nee d to relocate request sum p area m ark sum p goe s to building to
location above note location of A
sum p 1/10/96 relo cation above
grade utility sum ps 1/11/96

W S safety
inspections at
fire station raise
W S checklist W S checklist concerns about
doe s not address all W ork control LTA doe s not address all requirem ents for
safety and health safety and health excava tion perm its
concerns concerns

Facility m anager is Forem an inquires

W S perform s not aw are of C oncrete slab is abo ut excavation
A safety check list basem ent work cut and rem oved A
perm it requirem ents
1/16/96 1/16/96

M ultiple indications M ultiple indications

give perception give perception
pow er is off pow er is off

W S does not
have procedures of Potential for 13.2 kV Potential for 13.2 kV
PPE re quirem ents still exists still exists
for jackham m ering

D irt is rem oved by W orker W orker pulls laborer

m asonry crew w ith W orker slum ps into upright position
strikes 13.2 kV
jackham m er, forw ard over (jackham m er still
A prim ary feeder
shovel, and pry bar jackham m er positioned on
cable
1/17/96 8:40 a.m . 9:34 a.m . w orker)

Accident Investigation Workbook/Rev 2

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Part II Section 7 — Analyzing Data

Figure 7-2. (Continued)

S ta ge 5:
(In form ation know n at the end of the in ve stig ation, edite d to includ e o nly m ajor eve nts and conditio ns)

W S electricians Legend
m ak e design
W ork control LTA E vent
decision on wo rk
package
P HA is not C ond ition
W S work control perform ed as
bypasses
supervisory review
required by W S A ccident
procedures

P ipefitter goes W S work P relim inary Transfer

M as on forem an drawings place
on a nnual leave and package doe s n ot
m ay not have seen sum p at basem ent LTA
acting pipefitter identify underground
sum p w ork package
Less Than
forem an assigned utilities entry doorw ay
A dequate

P ipefitters arrive
W S pipefitter forem an (a cting) receives P ipefitters receive on s ite to begin
w ork package w ork package w ork preparations A
1/10 /96

W ork control LTA

N o docum entation
available for lateral
relocation of sum p

O versight routinely S um p relocation P ipefitters do n ot

approves deviations m ay not have been provide draw ings,
inform ally by phone fully considered w ork plans, or
perm its

C onceptual
A pproval given by drawings do not P ipefitters verbally
engineering firm clearly identify com m unicate the
oversight underground scope of w ork
location

P ipefitters iden tify W S pipefitters W S pipefitters W S electrician

need to relocate request sum p area m ark sum p goes to building to
A A
sum p 1/10/96 relocation ab ove location above note location of
grade utility sum ps 1/11/96

Accident Investigation Workbook/Rev 2

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 Section 7 — Analyzing Data Part II

Figure 7-2. (Continued)

Stage 5 C ontinued:
(Inform ation know n at the end of the investigation, edited to include only m ajor events and conditions)

Legend
Event

W ork c o ntrol LTA C ondition

Accident
A cting p ipe fitte r
E lectrica l sa fety forem a n do es n ot
re qu ire m en ts LTA
Transfer
k no w o f ind oo r
e xcava tio n
re qu ire m en t LTA Less Than
Adequate
Train in g LTA P ipe fitte rs do
n ot kn ow of in do or
e xcava tio n
P ipe fitte rs fore m an re qu ire m en t
O S H A req uirem e nts m ay n ot ha ve M anage m e nt LTA
a re n o t m et in fo rm ed fa cility U tility spe cialist
m anage r d oe s no t k no w o f
in d oo r e xc av atio n
S ite fo rm a l
re qu ire m en t
E vac u ation p erm it M anage m e nt LTA ele ctric al s afety
is no t ide ntified p rog ram is no t W S s afety
e sta b lish ed in s pe ctio ns a t
fire s tatio n rais e
W S c he cklist W S c he cklist c on cern s ab ou t
d oe s no t a dd re ss a ll W ork c o ntrol LTA d oe s no t a dd re ss a ll re qu ire m en ts fo r
s afe ty a nd h ea lth s afe ty a nd h ea lth e xcava tio n pe rm its
c on cern s c on cern s

Fa c ility m an ag e r is Fo re m a n in qu ire s
W S p erform s n ot aw a re of C o nc re te slab is a bo ut ex cav atio n
A s afe ty c he cklis t b as em e nt w ork c ut an d rem o ve d A
p erm it re qu ire m en ts
1 /16/9 6 1 /16/9 6

M aso n m a y no t
h av e be en aw are o f
P PE re qu ire m ents

M ultiple ind ic atio ns M ultiple ind ic atio ns

OSHA
g iv e pe rce ption g iv e pe rce ption
im p le m en tation LTA
p ow e r is o ff p ow e r is o ff

W S d oe s no t
h av e pro ce dure s of P o te ntial fo r 1 3.2 k V P o te ntial fo r 1 3.2 k V
P PE re qu ire m ents s till e x is ts s till e x is ts
for jac kha m m e rin g

D irt is rem ove d by W orke r W orke r p ulls la b ore r

m aso nry c rew w ith s trik e s 13 .2 kV W orke r s lu m ps in to u prigh t p os itio n
A p rim ary fee de r forw a rd ov er A
ja c kh am m er, (jac kha m m e r still
s ho vel, an d pry b a r c ab le ja c kh am m er p os ition ed o n
1 /17/9 6 8:4 0 a.m . 9 :34 a .m . w o rker)

Accident Investigation Workbook/Rev 2

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Part II Section 7 — Analyzing Data

Figure 7-3. Barriers are intended to protect personnal property against hazards.

Hazard Barrier Target

A target is a person or object that a hazard place or was required to keep them apart.
may damage, injure, or fatally harm. Obvious physical barriers are those placed
directly on the hazard (e.g., a guard on a
A barrier is any means used to control, grinding wheel); those placed between a
prevent, or impede the hazard from reaching hazard and target (e.g., a railing on a
the target. second-story platform); or those located on
the target (e.g., a welding helmet).
Investigators use barrier analysis to identify Management system barriers may be less
hazards associated with an accident and the obvious, such as the exposure limits
barriers that should have been in place to required to minimize harm to personnel or
prevent it. This analysis addresses: the role of supervision in ensuring that work
is performed safely. The investigator must
n Barriers that were in place and how they understand each barrier’s intended function
performed and location, and how it failed to prevent the
n Barriers that were in place but not used accident.
n Barriers that were not in place but were
required To analyze the performance of physical
n The barrier(s) that, if present or barriers, investigators may need several
strengthened, would prevent the same or different types of data, including:
a similar accident from occurring in the
future. n Plans and specifications for the
equipment or system
Figure 7-4 shows types of barriers that may n Procurement and vendor technical
be in place to protect workers from hazards. documentation
n Installation and testing records
When analyzing barriers, investigators n Photographs or drawings
should first consider how the hazard and n Maintenance histories.
target could come together and what was in
Accident Investigation Workbook/Rev 2
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Section 7 — Analyzing Data Part II

Figure 7-4. Barriers to protect workers from hazards.

Types of Barriers

Physical Barriers Management Barriers

Conduit Hazard Analyses

Equipment and Knowledge/Skills

Engineering Design
Line Management Oversight
Fences
Requirements Management
Guard Rails
Supervision
Masonry
Training
Protective Clothing
Work Planning
Safety Devices
Work Procedures
Shields

Warning Devices

To analyze management barriers, n The work package and procedures that

investigators may need to obtain information were used during the activity.
about barriers at three organizational levels
responsible for the work: the activity, The investigator may also need information
facility, and institutional levels. For about safety management systems at the
example, at the activity level, the facility level. This kind of information
investigator will need information about the might include:
work planning and control processes that
governed the work activity, as well as the n The standards and requirements that
relevant safety management systems. This applied to the work activity, such as
information could include: occupational exposure limits or relevant
Occupational Safety and Health
n Organizational charts defining Administration regulations
supervisory and contractor management n The facility technical safety
roles and responsibilities for safety requirements and safety analysis report
n Training and qualification records for n Safety management documentation that
those involved in the accident defines how work is to be planned and
n Hazard analysis documentation performed safely at the facility
n Hazard control plans n The status of integrated safety
n Work permits management implementation.

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Part II Section 7 — Analyzing Data

The third type of information the In the tabular format, individual barriers
investigator may need would be information and their purposes are defined. Each is
about the institutional-level safety considered for its effectiveness in isolating,
management direction and oversight shielding, and controlling an undesired path
provided by senior line management of energy.
organizations. This kind of information
might include: Figure 7-5 provides an example of a barrier
analysis summary. This format is
n Policy, orders, and directives particularly useful for illustrating the results
n Budgeting priorities of the analysis in a clear and concise form.
n Resource commitments. Figure 7-6 provides an example of a barrier
analysis summary that highlights the five
The investigator should use barrier analysis core functions of integrated safety
to ensure that all failed, unused, or management. These summary charts are an
uninstalled barriers are identified and that effective graphic in closeout briefings and in
their impact on the accident is understood. the final report.
However, the investigator must cross-
validate the results with the results of other 7.3.3 Change Analysis
core analytic techniques to identify which
barrier failures were contributory or root Change is anything that disturbs the
causes of the accident. “balance” of a system operating as planned.
Change is often the source of deviations in
Constructing a Worksheet. A barrier system operations. Change can be planned,
analysis worksheet is a useful tool in anticipated, and desired, or it can be
conducting a barrier analysis. A blank unintentional and unwanted. Workplace
worksheet is provided at the end of this change can cause accidents, although
section. Table 7-4 illustrates a worksheet change is an integral and necessary part of
that was partially completed using data from daily business. For example, changes to
the case study. Steps used for completing standards or directives may require facility
this worksheet are provided below. policies and procedures to change, or
turnover/retirement of an aging workforce
will change the workers who perform
TIP certain tasks. Change can be desirable, for
Although a barrier analysis will identify the example, to improve equipment reliability or
failures in an accident scenario, the failures to enhance the efficiency and safety of
may not all be causal factors. The barrier operations. Uncontrolled or inadequately
analysis results directly feed into the events analyzed change can have unintended
and causal factors chart and subsequent consequences, however, and result in errors
causal factors determination. or accidents.

Analyzing the Results. The results of TIP

barrier analysis are first derived and Change analysis is particularly useful
portrayed in tabular form, then summarized in identifying obscure contributing causes of
graphically to illustrate, in a linear manner, accidents that result from changes in
the barriers that were unused or that failed a system.
to prevent an accident. Results from this
method can also reveal what barriers should
have or could have prevented an accident.

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Section 7 — Analyzing Data Part II

Table 7-4. Sample barrier analysis worksheet.

Hazard: 13.2 kV electrical cable Target: Acting pipefitter

What were the How did each How did the barrier
barriers? barrier perform? Why did the barrier fail? affect the accident?

Engineering Drawings were Engineering drawings and Existence of electrical

drawings incomplete and did construction cable unknown
not identify specifications were not
electrical cable at procured
sump location
Drawings used were
preliminary

No as-built drawings were

used to identify location of
utility lines

Indoor excavation Indoor excavation Pipefitters and utility Opportunity to identify

permit permit was not specialist were unaware existence of cable
obtained of indoor excavation missed
permit requirements

Personal Personal No hazard controls were Pipefitter not protected

protective protective required for from electric shock
equipment equipment was jackhammering
not used

Basic Barrier Analysis Steps

Step 1: Identify the hazard and the target. Record them at the top of the worksheet. “13.2 kV
electrical cable. Acting pipefitter.”

Step 2: Identify each barrier. Record in column one. “Engineering drawings. Indoor
excavation permit. Personal protective equipment.”

Step 3: Identify how the barrier performed (What was the barrier’s purpose? Was the barrier
in place or not in place? Did the barrier fail? Was the barrier used if it was in place?)
Record in column two. “Drawings were incomplete and did not identify electrical cable
at sump location. Indoor excavation permit was not obtained. Personal protective
equipment was not used.”

Step 4: Identify and consider probable causes of the barrier failure. Record in column three.
“Engineering drawings and construction specifications were not procured. Drawings
used were preliminary, etc.”

Step 5: Evaluate the consequences of the failure in this accident. Record evaluation in
column four. “Existence of electrical cable unknown.”

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Part II Section 7 — Analyzing Data

Figure 7-5. Summary results from a barrier analysis reveal the types of barriers involved.

Target Worker

Roles and responsibilities unclear

Work scope not documented
Hazard unknown
Hazard unanalyzed
Standards/requirements not identified
Workers uninformed
Reviews bypassed
Management
Procedures incomplete
Barriers
Training incomplete
Required authorizations not received
Procedures not followed
Supervision ineffective
Stop work not used
Oversight ineffective
No electrical safety program

Design preliminary
No as-built drawings
Physical
Electrical conduit breached
Barriers
13.2 kV cable insulation breached
Personal protective equipment not used

Hazard 13.2 kV energized electrical cable

Accident Investigation Workbook/Rev 2

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Section 7 — Analyzing Data Part II

Figure 7-6. Summary results from a barrier analysis can highlight the role
of the core functions in an accident

Target Worker

Roles and responsibilities unclear

Work Design preliminary
Scope No as-built drawings
Work scope not documented

Hazard unknown
Hazard unanalyzed
Hazard Standards/requirements not identified
Analysis Workers uninformed
Reviews bypassed

Electrical conduit breached

Hazard 13.2 kV cable insulation breached
Controls Procedures incomplete
Training incomplete

Required authorizations not received

Work Procedures not followed
Within Personal protective equipment not used
Supervision ineffective
Controls
Stop work not used
Oversight ineffective

Feedback Lessons learned in electrical safety not applied

Hazard 13.2 kV energized electrical cable

Accident Investigation Workbook/Rev 2

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Part II Section 7 — Analyzing Data

Change analysis examines planned or n A model or ideal situation

unplanned changes that caused undesired (i.e., as designed or engineered).
outcomes. In an accident investigation, this
technique is used to examine an accident by Generally, it is recommended that boards
analyzing the difference between what has compare the accident sequence to the same
occurred before or was expected and the situation in an accident-free state—the
actual sequence of events. The investigator operation prior to the accident—to
performing the change analysis identifies determine differences and thereby identify
specific differences between the accident- accident causal factors. In order for the
free situation and the accident scenario. comparison to be effective, investigators
These differences are evaluated to determine must have sufficient information regarding
whether the differences caused or this baseline situation.
contributed to the accident. For example,
why would a system that operates correctly
TIP
99 times out of 100 fail to operate as
In change analysis, differing events and
expected one time?
conditions are systematically reviewed and
analyzed to determine potential causes.
Conducting Change Analysis. Change
analysis is relatively simple to use. As
illustrated in Figure 7-7 it consists of six The following data sources can be a starting
steps. The last step, in which investigators point for acquiring a good working
combine the results of the change analysis knowledge of the system, facility, or process
with the results from other techniques, is under study prior to the accident or event;
critical to developing a comprehensive however, the list of input requirements
understanding of the accident. should be tailored to fit the specific
circumstances and needs of the
When conducting a change analysis, investigation:
investigators identify changes as well as the
results of those changes. The distinction is n Blueprints
important, because identifying only the n Equipment description documents
results of change may not prompt n Drawings
investigators to identify all causal factors of n Schematics
an accident. n Operating and maintenance procedures
n Roles and responsibilities
The results of a change analysis can stand n Job/task descriptions
alone, but are most useful when they are n Personnel qualifications
combined with results from other n Results of hazard analysis
techniques. For example, entering change n Performance indicators
analysis results into the events and causal n Personnel turnover statistics.
factors chart helps to identify potential
causal factors. A sample change analysis worksheet is
presented at the end of this section for
To conduct a change analysis, the analyst reference. This worksheet may be modified
needs to have a baseline situation. This as necessary to meet specific requirements.
baseline situation can be:
To develop the information needed to conduct
n The same situation but before the a change analysis, it is useful for the board to
accident (e.g., previous shift, last week, list any changes they identify from their
or last month) information-gathering activities on a poster
board set up in the board’s common meeting

Accident Investigation Workbook/Rev 2

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Section 7 — Analyzing Data Part II

Figure 7-7. The change analysis process is relatively simple.

Describe
accident
situation

A nalyze
Identify differences for
Com pare
differences effect on
accident

Describe
com parable
accident-free Input results
situation into events
and causal
factors chart

room. At the beginning of the investigation, n Where an event or condition occurred

the board members should simply note the in the accident situation versus where an
changes they identify as they find them and event or condition occurred in the
not worry about analyzing the significance of baseline situation
the changes. Often, in the early stages of an
investigation, there is insufficient information n Who was involved in planning,
to determine whether a change is important or reviewing, authorizing, performing, and
not. supervising the work activity in the
accident versus the accident-free situation
As the investigation progresses, it will
become clear that some of the changes noted n How the work was managed and
on the poster board are insignificant and can controlled in the accident versus the
be crossed off the list. The remaining accident-free situation.
changes that seem to be important for
understanding the accident can then be Reviewing the worksheet may also prompt
organized by entering them into the change the investigators to identify additional
analysis worksheet. changes that were not originally listed.

Board members should first categorize the To complete the remainder of the worksheet,
changes according to the questions shown in first describe each event or condition of
the left-hand column of the worksheet. That interest in the column labeled, “Accident
is, the board should determine if the change Situation.” Then describe the related event or
pertained to, for example, a difference in: condition that occurred (or should have
occurred) in the baseline situation in the
n What events, conditions, activities, or column labeled, “Prior, Ideal, or Accident-
equipment were present in the accident Free Situation.” The difference between the
situation that were not present in the events and conditions in the accident and the
baseline (accident-free, prior, or ideal) baseline situations should be briefly described
situation (or vice versa) in the column labeled, “Difference.” As a
group, the board should then discuss the effect
n When an event or condition occurred or that each change had on the accident and
was detected in the accident situation record the evaluation in the final column of
versus the baseline situation the worksheet.
Accident Investigation Workbook/Rev 2
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Part II Section 7 — Analyzing Data

Table 7-5 shows a partially completed of root cause analysis depends on the results
change analysis worksheet containing of the events and causal factors analysis.
information from the case study to Therefore, the events and causal factors
demonstrate the change analysis approach. analysis must be complete and thorough.
The worksheet allows the user to compare
the “accident situation” with the “accident- Events and causal factors analysis requires
free situation” and evaluate the differences deductive reasoning to determine which
to determine each item’s effect on the events and/or conditions contributed to the
accident. accident.

A change analysis summary, as shown in Getting started. Before starting to analyze

Table 7-6, is generally included in the the events and conditions noted on the chart,
accident investigation report. It contains a an investigator must first ensure that the
subset of the information listed in the chart contains adequate detail. Both a
change analysis worksheet. The differences change analysis and a barrier analysis
or changes identified can generally be should be conducted and the results
described as causal factors and should be incorporated into the chart before the
noted on the events and causal factors chart analysis begins. Also, the board members
and used in the root cause analysis, as must resolve any obvious gaps in data
appropriate. before this analysis begins.

Note: A potential weakness of change By the time the board is ready to conduct a
analysis is that it does not consider the preliminary analysis of the chart, a great
compounding effects of incremental change deal of time will have been devoted to
(for example, a change that was instituted adding, removing, and rearranging events
several years earlier coupled with a more and conditions on the chart. In all
recent change). To overcome this weakness, likelihood, the chart will be lengthy,
investigators may choose more than one possibly containing 100 events or more.
baseline situation against which to compare Given the magnitude of data, one can
the accident scenario. For example, become overwhelmed with where to begin
decreasing funding levels for safety training identifying causal factors. It is easiest and
and equipment may incrementally erode most efficient to begin with the event on the
safety. Comparing the accident scenario to chart that immediately precedes the accident
more than one baseline situation (for and work backwards.
example, one year ago) and five years ago
and then comparing the one- and five-year Conducting the Analysis. Examine the first
baselines with each other can help identify event that immediately precedes the
the compounding effects of changes. accident. Evaluate its significance in the
accident sequence by asking, “If this event
7.3.4 Events and had not occurred, would the accident have
Factors
Causal F actors occurred?” If the answer is, “The accident
Analysis would have occurred whether this event
happened or not” (e.g., worker punched in to
The following describes the process for work at 0700), then the event is not
using the events and causal factors chart to significant. Proceed to the next event in the
determine the causal factors of an accident. chart, working backwards from the accident.
This process is an important first step in
later determining the root causes of an If the answer to the evaluation question is,
accident. The results of this analysis can be “The accident would not have occurred
used with a tier diagram (see Section without this event,” then determine whether
7.3.5.1) if desired. The quality and accuracy the event represented normal activities with
Accident Investigation Workbook/Rev 2
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 Table 7-5. Sample change analysis worksheet.

Section 7 — Analyzing Data

7-22

Prior, Ideal, or Accident-Free

Factors Accident Situation Situation Difference Evaluation of Effect

WHAT 1. Design and ES&H reviews 1. Project design and ES&H review 1. Environmental Group 1. Design and ES&H
Conditions, were not performed. are performed by appropriate assumed design role and reviews were not
occurrences, activities, 2. Established review process groups to ensure adequate removed ES&H review from performed, contributing
equipment was bypassed. review and the safety and health task. to the accident.
3. Hazards associated with the of employees. 2. Environmental Group 2. Construction packages
work being performed were 2. Construction packages are approved work packages. were not approved by
not identified. No review approved by facilities project 3. No preliminary hazard facilities group.
of as-built drawings. delivery group. analysis was performed on 3. Hazards were not
No excavation permit. 3. A preliminary hazard analysis is construction task. identified, contributing
No underground utility performed on all work. to the accident.
survey.

WHEN
Occurred, identified,
facility status, schedule

WHERE Sump location was placed above Sump is placed in a non-hazardous Inadequate design allowed sump Sump location was placed
Physical location, a 13.2 kV electrical line. location. to be located above a 13.2 kV above an electrical line,
environmental line. which was contacted by a
conditions worker jackhammering in
the area.

WHO Environmental Group assumed Environmental Group serves as an Support organization took Lack of oversight on project.
Accident Investigation Workbook/Rev 2

Staff involved, training, line responsibility for project. oversight/support organization to responsibility of line function for
qualification, assist line management in project. project management.
supervision

HOW Management allowed Management assures that work is Hazards analysis was not Hazards were not identified,
Control chain, Environmental Group to oversee performed by qualified groups. conducted. contributing to the accident.
hazard analysis construction tasks.
monitoring

OTHER

Part II
NOTE: The factors in this worksheet are only guidelines but are useful in directing lines of inquiry and analysis.
Part II Section 7 — Analyzing Data

the expected consequences. If the event was n Why did these conditions exist?
intended and had the expected outcomes, n How did these conditions originate?
then it is not significant. However, if the n Who had responsibility for the
event deviated from what was intended or conditions?
had unwanted consequences, then it is a n Are there any relationships between
significant event. what went wrong in this event chain and
other events or conditions in the
Carefully examine the events and conditions accident sequence?
associated with the significant event by n Is the significant event linked to other
asking a series of questions about this event events or conditions that may indicate a
chain, such as: more general or larger deficiency?

n Why did this event happen? The significant events, and the events and
n What events and conditions led to the conditions that allowed the significant
occurrence of the event? events to occur, are the accident’s causal
n What went wrong that allowed the event factors.
to occur?

Table 7-6. Case Study: Change analysis summary.

Prior or Ideal Condition Present Condition Difference (Change)

Environmental Group Environmental Group Support organization takes

serves as an oversight/ assumed line responsibility responsibility for a line function.
support organization to for project.
assist line management in
project.

Project design and ES&H Environmental Group Design and ES&H reviews
reviews are performed by assumed design role and were not performed.
appropriate groups to removed ES&H review
ensure adequate review from task.
and the safety and health
of employees.

Work is stopped when Work continued. No opportunity to analyze and

unexpected conditions are control hazards of different
found. work conditions.

A preliminary hazard No preliminary hazard Hazards associated with the

analysis is performed on analysis was performed on work being performed were not
all work. maintenance task. identified. No review of as-built
drawings. No excavation
permit. No underground utility
survey.

Sump is placed in a non- Sump was located above a Inadequate design allowed
hazardous designated 13.2 kV electrical line. sump to be located above a
location. 13.2 kV line.

Accident Investigation Workbook/Rev 2

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Section 7 — Analyzing Data Part II

Repeat this questioning process for every indicate that the electrical hazard was not
event in the chart. As a causal factor is identified in the hazard analysis for the
identified, write a summary statement that activity. In such a case, the investigator can
describes the causal factor on an adhesive write up a causal factor concerning the
note of a unique color and place the note hazard analysis, place it on the chart, and
above the event chain from which it was connect it with an arrow to the two event
derived, as shown in Figure 7-8, when chains from which it was derived (see
constructing the chart manually. If a Figure 7-9). Alternatively, the investigator
computer graphics program is used to can record the same causal factor twice and
construct the chart, use a hexagon to place it above each of the applicable event
represent causal factors. chains.

Sometimes events and conditions from TIP

several different event chains are related and Not all event chains will produce causal
suggest a larger, more significant causal factors. However, it is important to prepare
factor. For example, in two side-by-side a complete set of events in order to
event chains, the conditions “procedure did understand the circumstances leading up to
not address electrical hazard” and “electrical the accident and to assure that all
hazard not discussed in pre-job brief” may significant events have been identified.

Figure 7-8. Events and causal factors analysis; driving events to causal factors.

Event Chain

Accident Investigation Workbook/Rev 2

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Part II Section 7 — Analyzing Data

Figure 7-9. Grouping root causes on the events and causal factors chart.

Legend
R O OT C AU S E R O OT C AU S E
- M anag em e nt - S afety P olic y Even t
R espon sibility im plem e ntatio n

C on dition

Accide nt
Work R ST resists X YZ Work Work
H isto ry of consid ers restrictions restrictions
restrictions im plem e nting
safety no t safety contrac t no t no t Tra nsfer
prob lem s im plem e nted require me nts term ina tion prom ulga ted im plem e nted
8/96
R oo t C ause

P ro cedure D oes no t E xtent o f

P.E . was told im plem e nt Failure to
com p liance P.E . suffered im plem e nt m edical
and by do ctor contrac tual from ad vanced prob lem not
abou t respons ib ility & safety
enforce m ent diabetes know n by
restrictions acc oun tability respons ib ilities
prob lem s m anag em ent

R ST ta ske d to X YZ directs
im ple m ent me dica l R ST m anag er
R ST begin s S afety violatio ns R ST receives X YZ steps up replacem ent o f coun sels P.E . O n
s urve illanc e R ST S afety A
constru ction o n in prog ram letter of P.E .’s sev erity of safety pro gra m an d work eating habits
B A-R E 9/2 3/93 identified 11 /94 wo rk restriction s enforce m ent re stric tions
S upe rinten dent 12/9 5
1/10 /96 5/95 11/29 /95

After these steps have been completed for underlying deficiencies in a safety
each event on the chart, the process should management system that, if corrected,
be repeated with all board members to would prevent the same and similar
ensure that nothing has been overlooked and accidents from occurring.
that consensus has been reached.
Root cause analysis is a systematic process
When the board is satisfied that all causal that uses the facts and results of the core
factors have been identified on the chart, analytic techniques to determine the most
efforts can then be focused on initiating the important reasons for the accident. Root cause
root cause analysis. analysis is not an exact science and therefore
requires a certain amount of judgment. The
7.3.5 RRoot
oot Cause intent of the analysis is to identify and address
Analysis only those root causes that can be controlled
within the system being investigated,
excluding events or conditions that cannot be
TIP reasonably anticipated and controlled, such as
Root cause analysis should be conducted for some natural disasters. The core analytic
every occurrence, regardless of severity or techniques—events and causal factors,
complexity. Minor incidents often analysis, barrier analysis, and change
foreshadow more serious events. analysis—provide answers to an investigator’s
questions regarding what, when, where, who,
and how. Root cause analysis is primarily
Accidents are symptoms of larger problems performed to resolve the question, “Why?”
within a safety management system.
Although accidents generally stem from Once several (or all) of the recommended
multiple causal factors, correcting only the core analytic techniques have been
local causes of an accident is analogous to performed, the accident investigation board
treating only symptoms and ignoring the should have a broad understanding of the
“disease.” To identify and treat the true accident’s events and conditions, along with
ailments in a system, the root causes of an a fairly extensive list of suspected causal
accident must be identified. Root cause factors. A root cause analysis is performed
analysis is any technique that identifies the to refine the list of causal factors and

Accident Investigation Workbook/Rev 2

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Section 7 — Analyzing Data Part II

categorize each according to its significance It is important that the accident investigation
and impact on the accident. board work together to determine the root
causes of an accident. One of the board’s
There may be more than one root cause of primary responsibilities is to identify an
a particular accident, but probably not more accident’s causal factors so that judgments
than three or four. If more are thought to of need can be prepared and appropriate
exist at the conclusion of the analysis, the corrective measures can be developed and
board should re-examine the list of causal implemented. Therefore, all board members
factors to determine which causes can be must participate in the root cause analysis; it
further combined to reflect more cannot be left solely to a single member of
fundamental (root) causes. This section the board.
provides some examples of root cause
analysis and discusses analytical tools that Root cause analysis can be performed
can help accident investigators determine using computerized or manual techniques.
the root causes of an accident. Regardless of the method, the intent is to
use a systematic process for identifying root
causes.
TIP
In any accident, there may be a series of
Manual methods include tier diagramming
causal factors, one leading to another. One
and compliance/noncompliance. Each is
of the most important responsibilities of the
effective as a systematic method for
investigation board is to pursue each factor
identifying root causes. However, the
in the series until the board is assured that
compliance/noncompliance method reflects
actual root causes are identified.
the limited applicability of certain
techniques and underscores the need for the
Conducting the analysis. To initiate a root board to select analytic methods
cause analysis, the facts surrounding the commensurate with the accident’s scope,
accident must be known. In addition, the complexity, and severity.
facts must be analyzed using other analytic
methods to ascertain an initial list of causal Computerized techniques can be somewhat
factors. A rather exhaustive list of causal more sophisticated and generally speed the
factors must be developed prior to the process of root cause identification. It is
application of root cause analysis to ensure important to note, however, that
that final root causes are accurate and computerized techniques are dependent on
comprehensive. the quality and quantity of data input.
Moreover, at least one member of the board
should be very familiar with the software
TIP
package, including its limitations. An
If a root cause analysis is attempted before
overview of these methods is provided
all the significant facts are known or the full
below.
spectrum of causal factors is determined, it
is likely that the systemic root causes will
7.3.5.1 Tier
not be discovered.
Diagraming

The board should examine the evidence Tier diagraming is a technique used to
collected from the accident scene, witness identify both the root causes of an accident
statements, interviews, and facility and the levels of line management that have
documents. It should then determine the responsibility and authority to correct
whether additional information will be the accident’s causal factors.
needed for the particular root cause
technique they are performing.
Accident Investigation Workbook/Rev 2
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Part II Section 7 — Analyzing Data

The board uses tier diagrams to fundamental organizational deficiencies

hierarchically categorize the causal factors (root causes)
derived from the events and causal factors
analysis. A different diagram is developed n Provides a structured and repeatable
for each organization responsible for the approach for assigning management or
work activities associated with the accident. oversight responsibility for each causal
Each diagram is divided into several tiers, factor
depending on the number of management
levels in the organization under n Requires the board to assign
consideration. responsibility for causal factors, from
which appropriate judgments of need
The first diagram should focus on the can later be developed
organization to which the persons (or
equipment) directly involved in the accident n Assists the board in visually and
belonged, usually a contractor or physically organizing significant causal
subcontractor organization. The tiers for the factor data.
first diagram should represent levels of
organizational responsibility ranging from Before initiating a root cause analysis using
the worker level to senior management, as the tier diagram method, the investigator
shown in the example tier diagram should be satisfied with the results of the
worksheet in Table 7-7. If the accident events and causal factors analysis. In
occurred during subcontractor activities, the addition, the board must have a solid
first diagram would be composed of the tiers understanding of the line and oversight
within the subcontractor’s organization. A organizations responsible for the activities
second diagram should then be developed to associated with the accident.
represent the contractor organization for
which the subcontractor was working. A Getting started. Once the events and causal
third diagram should be developed to factors analysis is complete, a number of
represent the DOE line and oversight causal factors are noted on the events and
organizations responsible for the causal factors chart. These will be the input
contractor’s (and subcontractor’s) activities. to the tier diagrams and root cause analysis.
Provided below are step-by-step instructions
In a series of steps, causal factors from the for completing the root cause analysis using
events and causal factors chart are evaluated. tier diagraming. Guidelines and other
Each causal factor is assigned to a level of reminders follow the instructions.
management responsibility in the tier
diagram(s). Linkages among causal factors Step 1. Identify significant events/
are then identified and possible root causes are conditions. Review the causal factors listed
developed. Review of the integrated safety on the events and causal factors chart to
management core functions and guiding focus only on significant events or
principles assists in this synthesis. conditions (i.e., causal factors).

Tier diagraming is helpful in identifying and Step 2. Assign letter designators. Starting
analyzing root causes because it: at the beginning of the chart, assign a letter
to each causal factor (A, B, C…) on an
n Helps the board organize and categorize adhesive note. Place the same letter
the causal factors identified on the designator on the actual chart where that
events and causal factors chart causal factor is affixed.

n Provides a structured method for linking Later, the analyst will remove the adhesive
causal factors into higher-level, notes and place them on the tier diagram.
Accident Investigation Workbook/Rev 2
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 Section 7 — Analyzing Data
7-28

Table 7-7. Tier diagram worksheet for a contractor organizaiton.

Tier Causal Factors Root Causes

(Optional column)

Tier 5: Senior
Management

Tier 4: Middle
Management

Tier 3: Lower
Management

Tier 2:
Supervision
Accident Investigation Workbook/Rev 2

Tier 1: Worker
Actions

Tier 0: Direct
Cause

Part II
Part II Section 7 — Analyzing Data

By noting where the causal factor Step 7. Evaluate other tiers. Continue a
originated, the analyst can easily return to similar line of inquiry about the causal
the event chain if a question arises during factor at each successive tier until satisfied
the root cause analysis. that the causal factor is placed in the tier
commensurate with the highest level of
Step 3. Develop tier diagram framework. responsibility or authority for it. Again, as a
Using Table 7-7 as a model, create a tier causal factor is moved to higher tiers, note
diagram with the number of tiers the letter designation in the tier from which
commensurate with the line organization it is moved. For example, if responsibility
being examined. The grid can be drawn on for causal factor “A” is found to reside with
large butcher paper, a white board, or any upper management, the letter “A” should
other large surface for displaying to the appear in Tiers 1 through 4, with the actual
board members. For the purposes of this adhesive note placed in Tier 5. If
section, a typical contractor organization responsibility for the causal factor lies with
with six tiers (0-5) is assumed. A review of DOE line management or oversight, move
organizational charts, work control logs, and the adhesive note to the tier diagram(s) for
other such documentary evidence may be the DOE organizations involved.
helpful in completing this step.
Step 8. Repeat for each causal factor.
Step 4. Begin with Tier 0. Remove the Repeat steps 5 through 7 for each causal factor
“direct cause statement” adhesive note and previously placed in Tier 1 of the diagram.
place it in Tier 0, “direct cause.” Remove
all other causal factor adhesive notes and Step 9. Identify linkages. After arranging
place them in Tier 1, “worker actions.” all the causal factors on the tier diagrams,
examine the causal factors to determine
Step 5. Evaluate Tier 1. Beginning with whether there is linkage between two or
causal factor “A,” ask whether the “worker more of them. For example, are two or
actions-Tier 1” is the organizational level three causal factors similar enough to
responsible for this causal factor; that is, can indicate poor conduct of operations? Or
this causal factor be attributed to the perhaps several causal factors are related to
worker(s) involved in the accident? Use the a lack of worker training. If linkages exist,
sample questions listed in Table 7-8 as group the adhesive notes at the highest level
guidance in completing this step. These where a linkage occurs (see Figure 7-10).
questions were derived from the integrated For example, if causal factors “B” and “F”
safety management framework and reflect in Tier 3 are related to causal factor “H” in
the typical responsibilities for developing Tier 4, remove “B” and “F” (noting their
and implementing safety management location), and affix them to “H” in Tier 4.
systems that are associated with each of the Next, if one of the causal factors statements
management levels. accurately describes the commonality
among the grouped causal factors, let that
Step 6. Evaluate Tier 2. If the causal causal factor represent the grouping. If not,
factor can be attributed to the worker, ask write a causal factor statement that captures
whether the causal factor is solely the common theme of all the causal factors
attributable to the “worker actions” tier. Did in that particular grouping. This statement
the worker’s supervisor have any becomes a potential root cause.
responsibility for this causal factor? If not,
leave the causal factor in Tier 1. If the Table 7-8 and Appendix D provide typical
supervisor had any responsibility for this questions to assist the board in identifying
causal factor, write a letter “A” in Tier 1 and safety management deficiencies that may have
physically move the causal factor adhesive played a role in the accident. If there are two
note to Tier 2. or more causal factors from the tier diagram
Accident Investigation Workbook/Rev 2
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 Section 7 — Analyzing Data
7-30

Table 7-8. Example tier diagram approach.

Tier Typical Integrated Safety Management Sample Questions to Assist in Assigning Causal Factors to
Responsibilities Management Levels

Tier 5: Senior • Develop safety policy • Did senior management establish safety policies and goals?
Management • Communicate policy and • Were ES&H performance expectations for subcontractor
expectations organizations clearly communicated and understood?
• Prioritize activities and allocate • Was senior management proactive in assuring timely
resources implementation of integrated safety management by line
• Oversee compliance with contract organizations, subcontractors, and workers?
terms and conditions • Did senior management define and maintain clearly delineated
• Monitor safety performance roles and responsibilities for ES&H to effectively integrate
safety into sitewide operations?
• Was senior management involved in the sitewide prioritization
of work?
• Was a process established to ensure that safety responsibilities
were assigned to each person (employees, subcontractors,
temporary employees, visiting researchers, vendor
representatives, lessees, etc.) performing work?
Accident Investigation Workbook/Rev 2

• Did senior management hold line managers accountable for

safety performance through performance objectives, appraisal
systems, and visible and meaningful consequences?
• Did senior management institutionalize the stop-work authority
philosophy?

Part II
 Accident Investigation Workbook/Rev 2

Part II
Table 7-8. Example tier diagram approach. (Continued)

Tier Typical Integrated Safety Management Sample Questions to Assist in Assigning Causal Factors to
Responsibilities Management Levels

Tier 4: Middle • Same as Senior Management with • Did management implement policy through plans and programs
Management smaller span of control, e.g., a development?
facility, rather than an entire site • Was management aware of the status of plans and program
• Develop plans and programs to implementation?
implement policy • When problems occurred, did management request feedback on
• Oversee problem identification/ the nature of problems?
corrective action processes • Did management have a system for monitoring and measuring
• Solicit and respond to feedback and organizational performance?
lessons learned • Was stop-work authority communicated to the organization?
• Was management involved in the development and
implementation of corrective actions?

Section 7 — Analyzing Data

7-31
 Section 7 — Analyzing Data
7-32

Table 7-8. Example tier diagram approach. (Continued)

Tier Typical Integrated Safety Management Sample Questions to Assist in Assigning Causal Factors to
Responsibilities Management Levels

Tier 3: Lower • Develop procedures to implement • Were required procedures developed and kept current to assure
Management plans and programs a safe worker environment?
• Ensure hazard awareness and • Did management implement required programs for worker
communication safety?
• Oversee work planning and execution • Was management aware of problems regarding procedure
• Solicit and use worker input implementation and compliance?
• Implement corrective actions • Was management involved in the work planning, control, and
execution process?
• Did management have a system for eliciting feedback on
• work-related hazards?
• Did management take timely corrective actions when problems
occurred or were identified?
• Did management have a system for identifying and
disseminating work process lessons learned?
Accident Investigation Workbook/Rev 2

• Was stop work authority defined for first line supervisors and
their staff?

Part II
 Accident Investigation Workbook/Rev 2

Part II
Table 7-8. Example tier diagram approach. (Continued)

Tier Typical Integrated Safety Management Sample Questions to Assist in Assigning Causal Factors to
Responsibilities Management Levels

Tier 2: • Control the work scope • Were the supervisor’s work instructions adequate to allow the
Supervision • Identify hazards work to be performed safely?
• Implement hazard controls • Was the work environment safe?
• Authorize job/tasks • Were required procedures provided or communicated to the
• Provide feedback and lessons learned worker by supervision?
• Did the supervisor provide feedback to management on prior
incidents and/or safety concerns?
• Did the supervisor discuss job hazards with the worker prior to
starting work?
• Did the supervisor implement timely corrective actions based on
previous incidents?
• Did the supervisor confirm the readiness to perform work prior to
the execution of work?
• Did the supervisor provide the worker with the proper tools and
equipment to perform the work safely?

Section 7 — Analyzing Data

• Did the supervisor define stop-work authority for workers?
7-33
 Section 7 — Analyzing Data
7-34

Table 7-8. Example tier diagram approach. (Continued)

Tier Typical Integrated Safety Management Sample Questions to Assist in Assigning Causal Factors to
Responsibilities Management Levels

Tier 1: Worker • Maintain technical competence • Were the worker’s knowledge, skills, and abilities adequate to
Actions • Perform work within controls perform the job safely?
• Identify hazards and report incidents • Did the worker understand the work to be performed?
• Stop work, if necessary • Were communications adequate to inform the worker of any
hazards?
• Was the worker knowledgeable of the type and magnitude of
hazards associated with the work?
• Was the work covered by procedures?
• Was the worker trained on the procedures?
• Did the worker have the right tools and equipment to perform the
job safely?
• Did the worker have stop-work authority?
• Did the worker understand she/he had stop-work authority?
Accident Investigation Workbook/Rev 2

Tier 0: Direct
Cause

Part II
Part II Section 7 — Analyzing Data

Figure 7-10. Identifying the linkages on the tier diagram.

Accident Investigation Workbook/Rev 2

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Section 7 — Analyzing Data Part II

that relate to deficiencies in implementing a factors chart. These should be added to both
specific core function or guiding principle, the events and causal factors chart and the tier
consider developing a potential root cause diagram to assure that they are consistent and
statement that describes the underlying reflect all of the causal factors as a basis for
management system deficiency in terms of the root cause analysis.
core function or guiding principle. For
example, several causal factors related to Step 11. Simplify root cause statements.
deficiencies in skills, abilities, or knowledge There may be more than one root cause of a
may indicate that line management has failed particular accident, but probably not more
to assure that worker competence is than three. If there are more than that at the
commensurate with their responsibilities, end of the tier diagram analysis, the board
reflecting a failure to implement Guiding should re-examine the list of root causes to
Principle #3. determine which ones can be further
combined to reflect more fundamental
The board members should continue to deficiencies.
examine all of the causal factors until they
are satisfied that all applicable linkages When the board is satisfied that the root
have been made. causes have been accurately identified and
the number of root causes is not excessive,
Step 10. Identify root causes. Evaluate each the root cause analysis is complete. The
of the causal factor statements that now appear board should capture the essence of the root
on the charts. Compare each statement to the cause analysis for the accident investigation
definition of a root cause to determine whether report, noting the direct, contributing, and
it appears to be a root cause of the accident. root causes of the accident in order to
This step will generally involve a great deal of develop judgments of need.
discussion among board members.
Guidelines and Reminders:
TIP
n Root causes may be found in any tiers
If a causal factor does not meet the criteria
of any diagrams. However, they are
for a root cause; do nothing, it remains a
generally found in higher tiers because
contributing cause of the accident.
that is where managers are most
responsible for directing and overseeing
If a causal factor (singly or representing a activities.
group) meets the criteria for a root cause,
denote it as such either using the letters n The root cause of an accident can be
“RC” (root cause) or by some other means. found at the worker level of the tier
You may find that you need to create a root diagram if, and only if, the following
cause statement based on one or more conditions are found to exist:
causal factors. If so, write a summary
causal factor statement and place it on the • Management systems were in place
appropriate tier. The board may choose to and functioning, and provided
add a third column, “Root Causes,” to the management with feedback on system
tier diagram (Figure 7-10). The advantage implementation and performance
of adding this column is that moving the
root cause statements makes them stand out, • Management took appropriate
along with the associated level of actions based on the feedback
management responsibility.
• Management, including supervision,
The root cause analysis may reveal causal could not reasonably have been
factors that are not on the events and causal expected to take additional actions
Accident Investigation Workbook/Rev 2
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Part II Section 7 — Analyzing Data

based on their responsibilities and The basic steps for applying the compliance/
authorities. noncompliance technique are:

n Root causes can be found at more than n Have a complete understanding of the
one level of an organization. For facts relevant to the event
example, one root cause may be
attributable to Tier 3, while two other n Broadly categorize the noncompliance
root causes are attributable to Tier 5. event

n Root causes are generally attributable to n Determine why the noncompliance

an action or lack of action by a occurred (i.e., the subcategory or
particular group or individual in the line underlying cause).
organization.
For example, investigators may use this
n Each “corporate” organization is technique to determine whether an injured
considered separately for its worker was aware of particular safety
responsibility in the accident. For requirements, and if not, why he or she was
example, in DOE, a management and not (e.g., the worker didn’t know the
operating (M&O) contractor would be requirements, forgot, or lacked experience).
considered as one organization, and If the worker was aware but was not able to
DOE would be considered as a second comply, a second line of questioning can be
organization. Consequently, the results pursued. Perhaps the worker could not
of one tier diagram may be the input of comply because the facility did not supply
another. For example, if the upper personal protective equipment. Perhaps the
management of an M&O contractor was worker would not comply in that he or she
responsible for a particular root cause, refused to wear the safety equipment. Lines
DOE may share responsibility for that of inquiry are pursued until investigators are
particular root cause—there may be a assured that a root cause is identified.
deficiency in the directives given from
DOE, insufficient oversight, or some Lines of questioning pertaining to the three
other DOE responsibility that was compliance/noncompliance categories
inadequately fulfilled. follow. However, it should be noted that
these are merely guides; an accident
7.3.5.2 Compliance/ investigation board should tailor the lines
Noncompliance of inquiry to meet the specific needs and
circumstances of the accident under
The compliance/noncompliance technique investigation.
is useful when investigators suspect
noncompliance to be a causal factor. This n Don’t Know: Questions focus on
technique compares evidence collected whether an individual was aware of or
against three categories of noncompliance had reason to be aware of certain
to determine the root cause of a procedures, policies, or requirements
noncompliance issue. As illustrated in Table that were not complied with.
7-9, these are: “Don’t Know,” “Can’t
Comply,” and “Won’t Comply.” Examining n Can’t Comply: This category focuses
only these three areas limits the application on what the necessary resources are,
of this technique; however, in some where they come from, what it takes to
circumstances, an accident investigation get them, and whether personnel know
board may find the technique useful. what to do with the resources when they
have them.

Accident Investigation Workbook/Rev 2

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 Section 7 — Analyzing Data
Table 7-9. Compliance/noncompliance root cause model categories
7-38

Don’t Know Can’t Comply Won’t Comply

Never This is often an indication of Scarce Lack of funding is a common No An investigator may have to
knew poor training or failure in a resources rebuttal to questions regarding reward determine whether there is
work system to disseminate noncompliance. However, a benefit in complying with
guidance to the working level. resource allocation requires requirements or doing a job
decision-making and priority- correctly. Perhaps there is
setting at some level of no incentive to comply.
management. Boards should
consider this line of inquiry
when examining root causes
pertaining to noncompliance
issues.

Forgot This is usually a local, Don’t This issue focuses on lack of No This issue focuses on
personal error. It does know how knowledge (i.e., the know-how penalty whether sanctions can
not reflect a systemic to get a job done). force compliance, if
deficiency, but may indicate a enforced.
need to increase frequency of
training or to institute
refresher training.
Accident Investigation Workbook/Rev 2

Tasks This is often a result of lack of Impossibility This issue requires Disagree In some cases, individuals
implied experience or lack of detail in investigators to determine refuse to perform to a
guidance. whether a task can be standard or comply with a
executed. Given adequate requirement that they
resources, knowledge, and disagree with or think is
willingness, is a worker or group impractical. Investigators
able to meet a certain will have to consider this in
requirement? their collection of evidence
and determination of root

Part II
causes.
Part II Section 7 — Analyzing Data

n Won’t Comply: This line of inquiry condition that has existed over time. In
focuses on conscious decisions to not selecting the “condition” option, he or she
follow specific guidance or perform to a would be prompted through a series of
certain standard. questions designed to prevent a mishap
occurrence; the “event” option would
By reviewing collected evidence, such as initiate a process of investigating an
procedures, witness statements, and accident that has already occurred.
interview transcripts, against these three
categories, investigators can pursue
TIP
suspected compliance/noncompliance issues
Analytical software packages can help the
as causal factors.
board:
Although the compliance/noncompliance
n Remain focused during the investigation
technique is limited in applicability, by
n Identify interrelationships among data
systematically following these or similar
n Eliminate irrelevant data
lines of inquiry, investigators may identify
n Identify causal factors (most
causal factors and judgments of need.
significantly, root causes).
7.3.5.3 Automated
Techniques The graphics design features of many of
these software packages can also be quite
Several root cause analysis software packages useful to the accident investigation board.
are available for use in accident investigations. With little input, these software packages
Generally, these methods prompt the allow the user to construct preliminary trees
investigator to systematically review or charts; when reviewed by investigators,
investigation evidence and record data in the these charts can illustrate gaps in
software package. These software packages information and guide them in collecting
use the entered data to construct a tree model additional evidence.
of events and causes surrounding the accident.
In comparison to the manual methods of root It is worth underscoring the importance
cause analysis and tree or other graphics of solid facts collection. While useful,
construction, the computerized techniques are an analytic software package cannot replace
quite time-efficient. However, as with any the investigative efforts of the board. The
software tool, the output is only as good as the quality of the results obtained from a
input; therefore, a thorough understanding of software package is highly dependent on the
the accident is required in order to use the skill, knowledge, and input of the user.
software effectively.
7.4 Using
Many of the software packages currently
available can be initiated from both PC-
Advanced Analytic
based and Macintosh platforms. The Methods
Windows-based software packages contain
pulldown menus and employ the same use The four core techniques can be effectively
of icons and symbols found in many other applied to many investigations, but the
computer programs. In a step-by-step analysis of more complex accidents may
process, the investigator is prompted to have to be supplemented with more
collect and enter data in the templates sophisticated techniques. These techniques
provided by the software. For example, an require in-depth knowledge and specialized
investigator may be prompted to select expertise beyond the scope of this
whether a problem (accident or component workbook. However, several are discussed
of an accident) to be solved is an event or briefly here to ensure awareness of their
Accident Investigation Workbook/Rev 2
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Section 7 — Analyzing Data Part II

applicability to the accident investigation paths, and can lead to neutral, negative, or
process. The chairperson, board members, positive conclusions regarding accident
and any subject matter experts should severity.
determine which methods to employ, based on
their familiarity with various methods and the
TIP
severity and complexity of the accident.
An analytic tree enables the user to:
7.4.1 Analytic Trees n Systematically identify the possible
paths from events to outcome
Analytic tree analyses are well defined, useful
n Display a graphical record of the
methods that graphically depict, from
analytical process
beginning to end, the events and conditions
n Identify management system weaknesses
preceding and immediately following an
and strengths.
accident. An analytic tree is a means of
organizing information that helps the
investigator conduct a deductive analysis of The analytic tree process begins by clearly
any system (human, equipment, or defining the accident; “branches” of the tree
environmental) to determine critical paths of are constructed using logic symbology.
success and failure. Results from this analysis Following is a summary overview of the
identify the details and interrelationships that approach to constructing an analytic tree,
must be considered to prevent the oversights, which is illustrated in Figure 7-11. It should
errors, and omissions that lead to failures. In not be inferred that this is the only way to
accident investigations, this type of analysis construct or use analytic trees, since a
can consist of both failure paths and success variety of analytic tree methods is available.

Figure 7-11. The analytic tree process begins with the accident as the top event.
Step 1

Define Top
Event (Accident)

Step 2 Step 3

Understand Consider Possible

System (Accident) Accident Scenarios

Step 4

Construct
Tree

Steps 5 & 6 Step 7

Validate and Add to Tree as

Evaluate Tree New Data Are
Available

Step 8

Identify
Causal Factors

Accident Investigation Workbook/Rev 2

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Part II Section 7 — Analyzing Data

As the events at the bottom branches of Step 5. It is important for each board
the tree become more specific, the causal member to validate the analytical tree for
factors of the accident are developed. When completeness, logic, and accuracy. As new
the event at the bottom contains no other facts and evidence are discovered, the tree
events that allowed it to occur, a decision must be updated to reflect these changes.
must be made regarding whether the event is The validation process should begin as soon
a causal factor or is not relevant to the as the tree is constructed. The purpose of
outcome of the accident (top event). When this validation review is to confirm that:
processed through the logic gate, each
bottom tier should be necessary and n The tree meets its intended objectives
sufficient to lead directly to the failure or
success of the event on the next higher tier. n The management systems are fully and
clearly described
The steps required to prepare an analytic
tree are described below. n Inputs to logic gates are necessary and
sufficient to logically produce the stated
Step 1. Define the top event as the accident. output events.
As in events and causal factors analysis, the
event should be defined as a single, discrete Step 6. Each relationship between events
event, such as “worker strikes 13.2 kV should be evaluated to determine the causal
primary feeder cable.” factors of the accident (top event). As these
tiers flow down to the end events, the
Step 2. Acquire a working knowledge of the specific events of the analytic tree will be
accident effects, the work situation, and the developed and will help describe why
upstream processes that preceded them. A the top event occurred, by organizing the
comprehensive understanding of the accident’s evidence in a way that helps the
management system is also needed to board identify the accident’s causal factors.
develop the tree. Though the chart is highly structured,
identifying root causes is not a mechanical
Step 3. Based on the facts, postulate the process. Considerable reasoning and
possible scenarios by which the accident judgment are required from the board to
occurred. All accidents are complex events determine root and contributing causes.
that become interrelated to produce the
unwanted event (accident). This step should Step 7. Add to the analytic tree as new
force the investigator to analyze the facts of evidence is acquired and new possible
the accident and try to visualize all possible scenarios are developed. The tree must be
scenarios. As the investigation continues a working analytical tool that will have
and as new evidence is introduced, a several iterations before the final tree is
different scenario could develop. Before developed. If new possible scenarios are
the tree is constructed, it is important to introduced, do not reject the scenario if it
visualize it using different possible does not fit the tree. It might be necessary
scenarios consistent with the facts. to construct a new tree for a new scenario.
It is important that all possible scenarios be
Step 4. Construct the analytic tree, starting considered; they should be rejected only
with the top event and using the proper logic because they do not fit the facts, not because
gates and symbols. The tiers beneath the top they are improbable.
event should explain the reason for failure
or success of that event. The proper use of Step 8. Through the iterative process of
symbols and transfers is crucial to fact-finding and analysis identify the causal
understanding this graphic model. factors.

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Section 7 — Analyzing Data Part II

The basic conventions for constructing an number of digits in the decimal event
analytic tree are to: numbering system should correspond to
the tier on which the event is located.
n Use common and accepted graphic (For example, the fourth tier will
symbols for events, logic gates, and contain four digits.) This system for
transfers. (Figure 7-12 displays the numbering will uniquely describe an
symbols used in analytic trees.) event and systematically trace its
development through sub-branches and
n The analytic tree should be constructed branches to the first-tier event. Each
as simply as the accident allows. The successively higher-level event can be
tree should flow logically from the top identified by dropping the last digit from
event to the more specific events. If an the number. For example:
event occurs that has no relevance to the
accident, a diamond symbol should note Top Event
that there is no further development of 1 First Tier
this event. 1.1 Second Tier
1.1.1 Third Tier
n Keep the tree logical. The tree should 1.1.1.1 Fourth Tier
be validated at each level to ensure that 1.1.1.1.1 Fifth Tier
each contributing event logically proceeds
to the top event. The lower-tier input n A modified decimal system for
events should be only those that are numbering events can be adapted for
necessary and sufficient to produce the transfer symbols, beginning with the
next tier event. It is important for events letter designation for the transfer. If the
to logically flow to other events that are transfer letter is A, then the
supported by the facts. corresponding numbers could be
A.1.3.2. The numbering system is the
n Use the proper logic gate that describes same as the decimal system, with an
the relationship between the events. The alphabetic symbol as the first digit
proper selection and use of the logic corresponding to the transfer. The
gates will identify the interaction fourth subtier that is transferred would
between lower-tier events and the top be labeled as shown below:
event.
D Transfer
n The event descriptions should be D.2 First Subtier
simple, clear, and concise. The D.2.2 Second Subtier
descriptions should be sufficiently D.2.2.1 Third Subtier
detailed and logical that they can be D.2.2.1.2 Fourth Subtier
understood without referring to another
section. n Use transfers to avoid duplication of
identical branches or segments of the
n The final analytic tree should be limited tree and to reduce single-page tree
in the number of tiers placed on a single complexity. Whenever two or more gate
page. For legibility and readability, it is output events have identical details in
best that only four or five tiers be placed the substructures contributing to their
on a single page. occurrence, that substructure should be
constructed under only one of the output
n Use a common numbering system for events; it should then be transferred to
the events. Each event is identified by the others through the use of transfer
the decimal numbering system. The symbols. The event must be identical

Accident Investigation Workbook/Rev 2

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Part II Section 7 — Analyzing Data

Figure 7-12. Analytic trees are constructed using symbols.

R ectangle (G en eral Basic E ven t) - T he prim ary bu ildin g b lo ck for

analytic trees. E ven t resulting from th e co m b ination of m o re
b asic events acting thro ug h lo gic gates.

C ircle (B asic Event) - T he sym b ol u sed for the bottom tier of the
tree to indicate develop m ent is com plete. Event is no t
d ep end ent on other events.

D iam ond (U ndevelo ped E vent) - A n event that is n ot fu rth er

d evelop ed either becau se it is of insufficient consequ ence or
b ecause in fo rm atio n is unavailable.

H ouse or Scroll (E xtern al even t) - A n even t th at is norm ally

expected to occur. The ho use is used for analytic trees, and the
scro ll is used fo r M O R T.

Triangle - Transfer sym bol.

AND A ND G ate - A ll inputs are required to produce output.

O R G ate - On ly one or any com bination of inp uts is required to

OR g en erate ou tput event.

Ellip se (Con ditio nin g Even t) - A pp lies condition s or co nstrain ts

to b asic log ic gates or o utput events.

Accident Investigation Workbook/Rev 2

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Section 7 — Analyzing Data Part II

to be transferrable. Transfers should factors chart, which must be filled in by

also be used below the bottom-tier investigators, the MORT chart contains
events on a page to indicate continuance generic questions that investigators attempt to
of sub-branches of those events on other answer using available factual data. This
pages. Whenever there is insufficient enables the investigator to focus on potential
space on a page to develop a branch key causal factors. The MORT chart’s size
below an event at any level, a transfer can make it difficult to learn and use
immediately below that event indicates effectively. For complex accidents involving
that the branch is developed on another multiple systems, such as nuclear systems
page. failures, MORT can be a valuable tool but
may be inappropriate for relatively simple
n Do not number or letter logic gates; accidents. MORT requires extensive training
use numeric and alphanumeric decimal to effectively perform an in-depth causal
identification designations only for analysis of complex accidents. If needed, the
events. MORT analysis is usually performed by board
members with substantial previous experience
n Follow the left-to-right convention of in using the MORT techniques.
indicating time sequencing or order of
performance for related events on a
single tier. It should also be apparent The benefits of MORT are that it:
that a higher-tier event has greater
significance (more impact on the top n Uses the analytic tree method to
event) and occurs later than the more systematically dissect an accident
detailed contributory events located on
lower tiers within its branch. n Serves as a detailed road map by
requiring investigators to examine all
Figure 7-13 shows an example format for possible causal factors (e.g., assumed
the layout of an analytic tree. Although risk, management controls or lack of
each accident will dictate its own shape, this controls, and operator error)
example displays all elements in an analytic
tree. Figure 7-14 is an example of a n Looks beyond immediate causes of an
completed analytic tree for a grinding wheel accident and instead stresses close
accident. The lowest tier shows that the tool scrutiny of management systems that
rest was not set correctly, the operator did allowed the accident to occur
not wear goggles, and the machine guard
was removed for convenience. This n Permits the simultaneous evaluation of
example displays how the lower-tier multiple accident causes through the
elements contribute (flow) to the top event. analytic tree.

7.4.2 Management In evaluating accidents, MORT provides

Oversight and Risk a systematic method (analytic tree) for
Tree Analysis (MORT) planning, organizing, and conducting a
comprehensive accident investigation.
MORT—a comprehensive analytical tree Through MORT analysis, investigators
technique—was originally developed for DOE identify deficiencies in specific control
to help conduct nuclear criticality and factors and in management system factors.
hardware analysis. It was later adapted for use These factors are evaluated and analyzed to
in accident investigations and risk identify the causal factors of the accident.
assessments. Basically, MORT is a graphical
checklist, but unlike the events and causal Detailed knowledge and understanding of
management and operating systems is a
Accident Investigation Workbook/Rev 2
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Part II Section 7 — Analyzing Data

Figure 7-13. The layout of an analytic tree shows logical relationships.

TO P EVEN T
(A C CID ENT)

AN D

1 2 3

AN D

2.1 2.2 2.3 2.4

A OR B AN D

2.2.1 2.2.2 2.2.3 2.4.1 2.4.2

OR AN D

2.2.1.1 2.2.1.2 2.2.3.1 2.2.3.2

prerequisite to a comprehensive MORT expected” event distinguishes events that

analysis. Therefore, it is most effective if are typically a part of any system, such as
investigators have collected substantial change and normal variability. The
evidence before initiating the MORT “satisfactory” event describes events that
process. The management system data may be accident causal factors but are a
required include procedures, policies, necessary part of the operation, such as
implementation plans, risk assessment “functional” (part of the system) and people
program, and personnel. Information about or objects in the energy channel. In
the facility, operating systems, and addition to using the traditional transfer
equipment is also needed. This information symbol (triangle), the MORT chart includes
can be obtained through reviews of physical capital letters as drafting breaks and small
evidence, interview transcripts, management ovals as risk transfers.
systems, and policies and procedures.
The first step of the process is to obtain the
The symbols used on the MORT chart are MORT charts and select the MORT chart for
similar to those used for other analytical the safety program area of interest evaluating
trees. The symbols that differ for the each event. Next, the investigators work their
MORT chart are the scroll (“normally way down through the tree, level by level,
expected” event) and the oval proceeding from known to unknown. Events
(“satisfactory” event). The “normally should be coded in a specific color relative to

Accident Investigation Workbook/Rev 2

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Section 7 — Analyzing Data Part II

Figure 7-14. A completed analytic tree shows the flow of lower-tier elements to the top event.

W heel Fragm en t
Im pacts
O perator’s Eye

AND

1 2 3
A brasive
W heel O perator’s
G rinder E ye Exposed
D isintegrated O perating

OR AND

1.1 1.2 3.1 3.2

S tress Lim it O perator’s Eye O perator in
W heel E xceeded N ot P rotected Front of W heel
S tru ck B y
O bject
OR OR

1.2.1 1.2.2 3.1.1 3.1.2

To ol Im pressed W heel M achine E ye
D id N ot
A t E xcessive O verspeed S hield
A ngle W ear
R em oved
G og gles
OR OR OR

1.2.1.1 1.2.1.2 1.2.2.1 1.2.2.2 3.1.2.1 3.1.2.2

H eld A t To ol R est N ot R em oved
S et C orrectly W rong S peed
W rong For
P art N ot Inadequate
A ngle O perator
C orrect D esign
C onvenience

the significance of the event (accident). The When the appropriate segments of the tree
color-coding system used in MORT analysis is have been completed, the path of cause and
shown in Table 7-10. An event that is effect (from lack of control by management,
deficient, or less than adequate (LTA) in to basic causes, contributory causes, and
MORT terminology, is marked red. The root causes) can easily be traced back
symbol is circled if suspect or coded in red if through the tree. This becomes a matter of
confirmed. An event that is satisfactory following the red events through the various
is marked green in the same manner. logic gates. The tree highlights quite clearly
Unknowns are marked in blue, being circled where controls and corrective actions are
initially and colored in if sufficient data do not needed and can be effective in preventing
become available, and an assumption must be recurrence of the accident.
made to continue or conclude the analysis.
Figures 7-15 through 7-17 show three
It is not useful to start on the first day by MORT charts. Figure 7-15 displays the
marking everything as needing more injury, damage, other costs, performance
information (color-coded blue). Instead, start lost, or degraded event. Figure 7-16
marking the first MORT chart with red and describes the incident, barriers, and persons
black for events where there is sufficient or objects. Figure 7-17 is an evaluation of
evidence. Ideally, all blue blocks eventually the management system factors.
are replaced by one of the other colors;
however, this may not always be possible.

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Part II Section 7 — Analyzing Data

Table 7-10. MORT color coding system.

Color Code Significance

Red The event is less than adequate. Corrective actions are needed.
All events colored red must be documented and supported with
facts and analyzed as potential causal factors of the accident.

Green The event is satisfactory and adequate. Credible evidence must

support this event to ensure that no corrective actions need to be
identified for this event.

Blue The event has insufficient evidence or information to evaluate.

Additional facts or evidence must be collected to analyze this event.

Black The event is not applicable or relevant to the accident. The event
does not need any further investigation.

7.4.3 Project Evaluation of procedures requires procedural

Evaluation Tree (PET) instructions, reviews and safety evaluations,
Analysis work plans, work package instructions, and
other data. Personnel evaluation requires job
PET is an efficient means of performing an descriptions, organizational charts, training
in-depth analysis of an operation, project, or records, course curricula, course materials,
system. This analytical tree method is best interviews, and other data. If the accident was
suited for performing hazard and accident facility- or hardware-related, then drawings,
analyses, but it can also be used to identify procurement documents, specifications, test
preventive measures. PET was developed to plans, system safety plans, hazard analyses,
capture the philosophy and methodology of and budget data are required to conduct a
MORT, but eliminate the complexity of the comprehensive PET analysis. The scope and
more than 1,500 logic gates in MORT. depth of the accident investigation dictate the
input requirements.
Using PET in an accident investigation
requires detailed information regarding TIP
the various components of the system, The key benefits of the PET analysis are that
operation, or accident situation, such as it:
procedures, personnel, facilities, and
equipment. Using logic symbology, an n Provides a simplified approach that
analyst traces each component of a system applies the tenets of MORT
through the tree’s branches to evaluate each
element as a potential causal factor. n Categorizes information into three main
branches—procedures, personnel, and
PET is structured for evaluation and analysis plant or hardware—enabling
of procedures, personnel, and facilities/ investigators to examine the factors that
hardware. (An example of a PET chart used impact an accident relatively simply
to analyze procedures is shown in Figure 7- and quickly.
18.) PET analysis requires detailed
information on these three dimensions.
Accident Investigation Workbook/Rev 2
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Section 7 — Analyzing Data Part II

Figure 7-15. The initial MORT chart uses logic symbols.

DRAW ING B REAK.

INJURIE S, DA MAGE ,
TRA NSFE R TO SECTION OF
OTHE R COSTS, FUTURE TREE IN DICATED BY
PER FO RM ANCE LOST UNDE SIRED SYM BOL IDENTIFICATION
OR DE GRADED EVEN TS 1 LETTE R-NUM BER.

OVER SIGHTS ASS UME D

AND RISK S
OM M ISSION S

S/M R

RISK 1 RISK 2 RISK 3 RISK 4 RISK N

W H AT HAPPE NED? W H Y?

SPEC IFIC M ANAG EM ENT

CONTR OLS SYSTEM
FACTOR S LTA FACTOR S LTA

S M

RISK
ACCIDENT AM ELIORAT ION POL IC Y IM PL EM ENTATION ASS ESSM ENT
LTA LTA LTA SYSTEM LTA

SA1 SA2 MA1 M A2 M A3

A B C C

Accident Investigation Workbook/Rev 2

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 Figure 7-16. The accident description can be shown on a MORT chart.
Part II

ACC IDENT

SA1

PERS ON S,
C26 OB JE CTS IN
IN CIDEN T S D7 BARR IER S LTA E NERGY
MB3
CH ANNEL

Accident Investigation Workbook/Rev 2

SB1 SB2 S B3

ON EN ERGY O N PER SONS , SEPAR AT E NON - FUNCT IONAL

BETW EE N
SO URCE OBJECTS T IM E, SPACE FUN CTION AL

Aa1 A a2 A a3 A a1 Aa2
1 a3 1 a3 1 a3

RE PEAT REPEAT REPE AT

SB2
BARR IERS
LTA

CON SEQ UENT PR ECEDE NT

UNWAN TED UNWAN TED HOME BARR IER D ID NOT USE C ONTROL
ENERGY FLOW ENER GY FL OW (S) POSSIB LE FAIL ED CONTROL
IM PR A CTICA L
LTA
S D3 Ab1 A b3
SC1 Ab 2
RISK 2 A b2 A b1 RIS K 4
ADM IN EVASIV E
CONT ROL ACTIO N LTA
CONSEQUE NT
LTA
U NWANTE D Ab4
EN ERGY F LOW TA SK
Ab3
DID NOT PE RFORM ANCE
P ROVID E ERR ORS
UNWANT ED Ac2
B ARRIE RS LTA EN ERGY Ac1 1b 3

FLOW (S) RISK 3 SD5

J
SD 7 SD8
CON TROL
CO NTROL
IM PRAC TIC AL
FACILITY HIGH ER LTA
TECH N ICA L
FUNCTIO N AL M AINTE NANC E IN SPECTIO N SUPER VISION S UPERVISIO N Ac2
INFO RM ATION
O PERA BILITY LTA LTA LTA SER VIC ES A c1 RISK 5
SYSTEM S LTA
LTA LTA
SD1 SD2 SD3 S D4 SD 5 S D6

7-49
D E F G H I
Section 7 — Analyzing Data
Section 7 — Analyzing Data Part II

Figure 7-17. Management system factors can be shown on a MORT chart.

M AN AG EM ENT
SYS TEM FA CTO R S
LTA

IM PLEM EN TATION RIS K

PO LICY ASS ESSM ENT
LTA
LTA LTA

MA1 M A2
M A3

TEC HNIC AL HA ZAR D SAF ETY

G OA LS INF OR M ATIO N AN ALYSIS PRO G RAM
LTA SYS TEM S LTA PRO CE SS LTA REV IEW LTA

M B1 M B2 M B3 M B4
D L M N

STA FF VIGOR
M ETH OD S AC CO UNT -
RES PO NS- DIR EC TIV ES BU DG ETS AN D
CR ITERIA AB ILITY
IBILITY LTA LTA EXA MP LE
AN ALYSIS LTA
LTA LTA
LTA
A a1 A a3 Aa5 Aa7

LIN E INF OR -
RES PO NS- M AT ION
IBILITY FLO W
LTA LTA M AN AG EM ENT
SERVICES LTA
Aa2 Aa4

A a6 DEL AYS
506 I

Accident Investigation Workbook/Rev 2

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Part II Section 7 — Analyzing Data

Figure 7-18. This branch of the PET chart deals with procedures.

PR OCED URES

VALI- CU R- USED W R ITER UPDATE

CO NTENTS CR ITERIA
DATED RENT QU ALIFI- PR OVISION S
CATIO NS

F IT U S EA B L E R E QU IR E D CHANGE
N E ED E D SC OP E L EV EL W H EN W HO
C O N TR O L

BY
PE O PL E O R G A N I- B Y TA S K M A N A GE -
UNDER- AVA ILA B L E
Z ATIO N MENT
STA N D A B L E O T H ER

FA C IL I- BY
H IG H ER BY
T IES / T EC H
HQS SU PER -
HARD- D ATA
R E GS LOCA- VISIO N
WA R E N U M B ER
T IO N

BY
HQS O T H ER
LANGUAG E
F O R M AT G R A PH IC S

F IT
F IT
O R G A N I-
U S ER
Z ATIO N

C O N SIS TEN T EM ER - W ORK-

C O VE R T EC H N I-
G EN C Y ARO UND
ALL C A L LY
TA SK S PR OC E D PR OC E D -
C O R R EC T
-U R E URE

IN T ER N A L EX TER N A L

Accident Investigation Workbook/Rev 2

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Section 7 — Analyzing Data Part II

The first step is to organize the data into The list of techniques provided in this
procedures, personnel, and facilities/ workbook is not exhaustive. Other analytic
hardware. These data are then techniques that may yield important results
systematically evaluated using the for a particular investigation may be
appropriate PET chart. The next step is to necessary and used at the board’s discretion.
color-code the events. Red is used for
events that are less than adequate (LTA), 7.5.1 Time Loss
green for events that are satisfactory Analysis
(adequate), black for events that are not
relevant to the accident, and blue for areas Time loss analysis evaluates emergency
that need additional investigation or analysis response performance. The basic
to reach a decision. (This color-coding assumption of this technique is that every
system is the same system used for MORT.) accident sequence has a natural progression
that would occur without outside
After the chart is completed and the events intervention by emergency response
are color-coded, PET worksheets should be personnel (e.g., a fire would eventually burn
used to evaluate each red item. A PET out without the aid of firefighters).
analysis worksheet is provided at the end of
this section. This worksheet is similar to the With this technique, the natural course of
barrier analysis and change analysis accident events is plotted graphically against
worksheets. It provides the basis for the time. A second line is plotted that shows the
narrative summary of the analysis. positive effect of emergency responders on
the natural course of events (i.e., decreasing
7.5 Other Analytic the end-time of the accident). A second line
Techniques also can be plotted that displays emergency
response actions that made the natural
Other analytic techniques may be used for course of events worse or prolonged the
specific investigations, depending on the end-time of the accident (for example, by
nature and complexity of the accident. contributing to additional injuries). This
Ultimately, the analytic techniques used in any technique begins with the accident,
investigation should be determined by the compares actual events and processes with
board chairperson with input from the board an ideal response process, and continues
members and advisors/consultants. To until loss ceases.
conduct an effective and timely investigation,
the choice normally should be limited to the Time loss analysis is not widely used in
techniques discussed above. However, if accident investigations; however, it can be
warranted by the circumstances of the accident useful in cases where additional response
investigation, experts in various analytic activities could have decreased the severity
methods may be called upon to use other of the accident or where investigators
analytic techniques. It is also important for suspect that emergency response actions
investigators to understand that many of these were less than sufficient. Figure 7-19
analytical processes may have been completed displays a time loss analysis chart.
prior to the accident and may be included in
authorization basis documentation (e.g., safety 7.5.2 Human
analysis reports). This information is useful to Factors Analysis
the board in developing and understanding its
own analysis of the accident. Following are Human factors analysis identifies elements
brief descriptions of additional analytic that influence task performance, focusing on
techniques that might be used. operability, work environment, and
management elements. Humans are often

Accident Investigation Workbook/Rev 2

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Part II Section 7 — Analyzing Data

Figure 7-19. Time loss analysis can be used when emergency response is in question.

Natural
course of
fire

Loss Lim it of
actual fire
dam age

Water
dam age

Tim e
9:00 9:05 9:10 9:15 9:20
Fire Operator Autom atic Em ergency Fire
begins becom es sprinkler response departm ent
aw are of system team arrives
fire and response arrives
responds

the weakest link in a system and can be the more specific about the timing of accident
system component most likely to fail. Often events; it is a simple and effective way to
machines are not optimally designed for develop the accident scenario around the
operators, thereby increasing the risk of facts related to key personnel and
error. High-stress situations can cause appropriate tasks.
personnel fatigue and increase the likelihood
of error and failure. Therefore, methods that 7.5.4 F ailure Modes
Failure
focus on human factors are useful when and Effects Analysis
human error is determined to be a direct or
contributing cause of an accident. This method is most often used in the
hazard analysis of systems and
7.5.3 Integrated subsystems; it is primarily concerned with
Accident Event Matrix evaluating single-point failures,
probability of accidents or occurrences,
An integrated accident event matrix and reliability of systems and subsystems.
illustrates the time-based interaction This technique examines a system’s
between the victim and other key individual subsystems, assemblies, and
personnel prior to the accident and components to determine the variety of
between the emergency responders and ways each component could fail and the
the victim after the accident. It analyzes effect of a particular failure on other
at what time key personnel performed equipment components or subsystems. If
certain tasks both before and after the possible, the analysis should include
accident. This technique complements quantified reliability data.
the events and causal factors chart, but is

Accident Investigation Workbook/Rev 2

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Section 7 — Analyzing Data Part II

Software
7.5.5 Sof tware 7.5.8 Materials and
Hazards Analysis Structural Analysis

This analytic technique is used to locate Materials and structural analysis is used to
software-based failures that could have test and analyze physical evidence. This
contributed to an accident. This technique technique has made significant contributions
may be increasingly important in the future to developing credible scenarios and
as more operations and systems associated determining the cause of several accidents.
with an accident become computerized and It is used whenever hardware, material
therefore dependent on software. failure, or structural integrity is a possible
issue, but the cause of the failure is
7.5.6 Common Cause unknown.
Failure Analysis
7.5.9 Design Criteria
Common cause failure analysis evaluates Analysis
multiple failures that may be caused by a
single event shared by multiple components. This method involves the systematic review
Common causes of failures in redundant of standards, codes, design specifications,
systems are analyzed to determine whether procedures, and policies relevant to the
the same failure contributed to the accident. accident. This tool is useful in identifying
The general approach to common cause whether codes exist, how standards or codes
failure analysis is to identify critical systems were circumvented, and codes or standards
or components and then use barrier analysis that should be in place to prevent
to evaluate the vulnerability to common recurrence. It can be used similarly to
environmental hazards, unwanted energy change analysis to examine the accident to
flows, and barrier failures. This method is determine whether work processes deviated
useful for accidents in which multiple from existing standards, codes, or
barriers failed and a common cause failure procedures (i.e., was a piece of equipment
contributed to the accident. used properly as designed and specified?).

7.5.7 Sneak Circuit 7.5.10 Accident

Analysis Reconstruction

A sneak circuit is an unanticipated energy Although not widely used in DOE accident
path that can enable a failure, prevent a investigations, accident reconstruction may
wanted function, or produce a mistiming be useful when accident scenes yield
of system functions. Sneak circuit analysis sketchy, inconclusive evidence. This
is mainly performed on electronic circuitry, method uses modeling to reconstruct the
but it can also be used in situations accident-related equipment or systems
involving hydraulic, pneumatic, mechanical, (i.e., from accident to pre-accident state).
and software systems. It identifies ways in Good reconstruction can be more accurate
which built-in design characteristics enable than witness statements, because it applies
an undesired function to occur or prevent the laws of physics and engineering.
desired functions from occurring. Its
importance lies in the distinction from 7.5.11 Scientific
component failure. Sneak circuit failure Modeling
results from circuit design. Sneak circuit
analysis generally employs inductive Scientific modeling models the behavior of
reasoning and is difficult to employ without a physical process or phenomenon. The
the appropriate proprietary software. methods, which range from simple hand
Accident Investigation Workbook/Rev 2
7-54
Part II Section 7 — Analyzing Data

calculations to complex and highly accident investigations. It is only performed

specialized computer models, cover a for accident scenarios involving complex
wide spectrum of physical processes physical processes (e.g., nuclear criticality,
(e.g., nuclear criticality, atmospheric fires, “runaway” chemical reactions and
dispersion, groundwater and surface water explosions) and is not normally needed for
transport/dispersion, nuclear reactor physics, typical occupational and industrial
fire modeling, chemical reaction modeling, accidents. When scientific modeling is
explosive modeling). For example, several deemed appropriate, it should be performed
computer models have been developed to at the direction of technically competent
predict the concentrations of hazardous personnel (e.g., specialists, consultants, or
materials in the air at downwind locations board members who have the requisite
from a release. Such modeling is useful in technical backgrounds and familiarity with
characterizing the consequences of an the models being used).
accidental release of a hazardous material to
the atmosphere. Similarly, nuclear All scientific models have inherent
criticality models (e.g., the SCALE package assumptions and uncertainties that limit
or the KENO code) can analyze scenarios their accuracy. The board should recognize
that could lead to a critical configuration. In such limitations when considering the
the event of a nuclear criticality, such results of scientific models during the
models could be useful in understanding accident investigation process. Sometimes
how the event occurred and what factors the facility in which an accident occurred
were important to the accident scenario may choose to perform scientific modeling
(e.g., the presence of “moderating” or and may provide those results to the board.
“reflecting” materials, such as water, can be In reviewing such results, the board should
very important). validate whether it is appropriate to obtain
independent expertise to interpret the results
Although useful in some circumstances, and determine the validity of the modeling
scientific modeling is not necessary for most assumptions.

Accident Investigation Workbook/Rev 2

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Section 7 — Analyzing Data Part II

KEY POINTS TO REMEMBER

Determining Facts

n Begin defining facts early in the collection of evidence.

n Develop an accident chronology (e.g., events and causal factors chart) while
collecting evidence.
n Set aside preconceived notions and speculation.
n Allow the discovery of facts to guide the investigative process.
n Consider all information for relevance and possible causation.
n Continually review facts to verify accuracy and relevance.
n Retain all information gathered, even that which is removed from the accident
chronology.
n Establish a clear description of the accident.

Analytical techniques are used to determine the causes of an accident. There are three
types of causal factors: the direct cause, contributing causes, and root causes.

Conducting the Analysis

Four core analytic techniques are generally used in DOE accident investigations:

n Events and causal factors charting and analysis: used to trace the sequence of
events and conditions surrounding an accident, as well as to determine the causal
factors
n Barrier analysis: used to examine the effectiveness of barriers (management and
physical) intended to protect persons, property, and the environment from unwanted
energy transfers
n Change analysis: used to examine planned or unplanned changes in a system and
determine their significance as causal factors in an accident
n Root cause analysis: used to identify the causal factors, including management
systems, that, if corrected, would prevent recurrence of the accident.

Each of these techniques has strengths and limitations that should be reviewed before
applying it to any given accident. However, the use of the core analytical techniques
should be sufficient for most accident investigations. Other techniques are available for
complex accidents or when there are special circumstances or considerations. Some of
these techniques are MORT, PET, materials and structural analysis, design criteria
analysis, integrated accident event matrix, and scientific modeling. Other techniques are
available for complex accidents or special accident circumstances.

Accident Investigation Workbook/Rev 2

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Part II Section 7 — Analyzing Data

KEY POINTS TO REMEMBER (CONTINUED)

The following should be considered when performing analyses:

n Chart events in chronological order, developing an events and causal factors chart as
initial facts become available.
n Stress aspects of the accident that may be causal factors.
n Establish accurate, complete, and substantive information that can be used to
support the analysis and determine the causal factors of the accident.
n Stress aspects of the accident that may be the foundation for judgments of need and
future preventive measures.
n Resolve matters of speculation and disputed facts through board discussions.
n Document methodologies used in analysis; use several techniques to explore various
components of an accident.
n Qualify facts and subsequent analysis that cannot be determined with relative
certainty.
n Conduct preliminary analyses; use results to guide additional collection of evidence.
n Analyze relationships of event causes.
n Clearly identify all causal factors.
n Examine management systems as potential causal factors.
n Consider the use of analytic software to assist in evidence analysis.

Accident Investigation Workbook/Rev 2

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 Section 7 — Analyzing Data
7-58

Barrier Analysis Worksheet

Hazard: Target:

What were the barriers? How did each Why did the barrier fail? How did the barrier
barrier perform? affect the accident?
Accident Investigation Workbook/Rev 2

Part II
 Accident Investigation Workbook/Rev 2

Part II
Change Analysis Worksheet

Factors What were the How did each Why did the barrier fail? How did the barrier
barriers? barrier perform? affect the accident?

WHAT
Conditions, occurrences,
activities, equipment

WHEN
Occurred, identified,
facility status, schedule

WHERE
Physical location,
environmental
conditions

WHO
Staff involved, training,
qualification, supervision

Section 7 — Analyzing Data

HOW
Control chain, hazard
analysis monitoring

Other

NOTE: The factors in this worksheet are only guidelines but are useful in directing lines of inquiry and analysis.
7-59
 Section 7 — Analyzing Data
7-60

PET Analysis Worksheet

Prepared by:
Date:
Accident Investigation:
Final
Item Pet Responsible Completion
Item No. Evaluated Event Color Problem/Comments Person/Agency Status Date
Accident Investigation Workbook/Rev 2

Part II
Contents

Section 8 C Developing
Conclusions and Judgments
of Need

8.1 Conclusions ......................................................................................................... 8-1

8.2 Judgments of Need .............................................................................................. 8-2
8.3 Minority Opinions ............................................................................................... 8-4

Key Points to Remember ........................................................................................... 8-5

List of Tables

Table 8-1. These guidelines are useful for writing judgments of need ................... 8-3
Table 8-2. Case Study: Judgments of need .............................................................. 8-4

List of Figures

Figure 8-1. Facts, analyses, and causal factors are needed to support judgments
of need .................................................................................................... 8-3
 Part II Section 8 — Developing Conclusions and Judgments of Need

8
Developing Conclusions and
Judgments of Need

C
onclusions and judgments of need
are key elements of the investigation n Be used to highlight positive aspects of
that must be developed by the board. performance revealed during the investi-
gation, where appropriate.
8.1 Conclusions
When developing conclusions, the board
Conclusions are significant deductions should:
derived from the investigation’s analytical
results. They are derived from and must be n Organize conclusions sequentially,
supported by the facts plus the results of preferably in chronological order, or in
testing and the various analyses conducted. logical sets (e.g., hardware, procedures,
people, organizations)
Conclusions may:
n Base conclusions on the facts and the
n Include concise statements of the causal subsequent analysis of the facts
factors of the accident determined by
analysis of facts n Include only substantive conclusions
that bear directly on the accident, and
n Be statements that alleviate potential that reiterate significant facts and
confusion on issues that were originally pertinent analytical results leading to the
suspected causes accident’s causes

n Address significant concerns arising out n Keep conclusions as short as possible

of the accident that are unsubstantiated and, to the extent possible, limit refer-
or inconclusive ence citations (if used) to one per
conclusion.

EXAMPLE: CONCLUSIONS

# XYZ contractor failed to adequately implement a medical surveillance program, thereby allowing
an individual with medical restrictions to work in violation of those restrictions. This was a
contributing factor to the accident.
# Welds did not fail during the stam line rupture.
# Blood tests on the injured worker did not conclusively establish his blood alcohol content at the
time of the accident.
# The implementation of comprehensive response procedures prevented the fire from spreading
to areas containing dispersible radioactive materials, averting a significant escalation in the
consequences of the fire.

Accident Investigation Workbook/Rev 2

8-1
Section 8 — Developing Conclusions and Judgments of Need Part II

An interactive process is the preferred

TIP approach for generating judgments of need.
The process of determining conclusions That is, board members should work to-
seeks to answer the questions—what hap- gether to review causal factors and then
pened and why did it happen? begin generating a list of judgments of need.
These judgments should be linked directly
to causal factors, which are derived from
8.2 Judgments of facts and analyses.
Need
One method for ensuring that all significant
facts and analytical results are addressed in
Judgments of need are the managerial
the judgments of need is to develop displays
controls and safety measures determined
linking judgments of need with facts,
by the board to be necessary to prevent or
analyses, and causal factors. Previous
minimize the probability or severity of a
boards have found it useful to display these
recurrence. Judgments of need should be
elements on the walls of the board’s confer-
linked to causal factors and logically flow
ence room. Figure 8-1 demonstrates how
from the conclusions. They should be:
this information can be arranged to provide
an ongoing assessment of linkages among
n Stated in a clear, concise, and direct
the four elements. It portrays the concept of
manner
requirements verification analysis described
in Section 9 of this workbook. Using this
n Based on the facts/evidence
approach, the board can identify gaps in the
data where a clear, logical flow among the
n Stated so that they can be the basis for
four elements is missing. The board can use
corrective action plans.
this information to determine whether
judgments of need are supported by linkages
Judgments of need:
connecting the facts, results from analyses,
and causal factors.
n Should not be prescriptive corrective
action plans or recommendations, nor
should they suggest punitive actions
TIP
If a judgment of need cannot be clearly
n Should not include process issues
linked to causal factors derived from
(e.g., evidence control, preservation
analysis of facts, exclude it from the report.
of the accident scene, readiness) unless
these issues have a direct impact on the
accident. These concerns should be
Once the board has identified the judgments
noted in a separate memorandum to the
of need derived from their investigation
appointing official, with a copy to site
activities, the members can begin writing
management and the Assistant Secretary
statements documenting these judgments.
for Environment, Safety and Health.
Table 8-1 presents guidance on writing these
statements.
TIP
Table 8-2 provides samples of well-written
Board members should work together to
judgments of need for the case study electri-
derive judgments of need to assure that the
cal accident. Information in this table
merits and validity of each are openly
demonstrates the relationships among
discussed and that each one flows from the
significant facts, analysis, causal factors,
facts and analyses.
and judgments of need.

Accident Investigation Workbook/Rev 2

8-2
Part II Section 8 — Developing Conclusions and Judgments of Need

Fact

Analysis
Fact
Causal Factor Judgment
Analysis
Fact of Need

Analysis Causal Factor

Fact Judgment
of Need
Fact Analysis Causal Factor
Judgment
Fact Analysis Causal Factor
of Need

Fact Analysis Causal Factor

Judgment
Analysis Causal Factor of Need
Fact

Fact Analysis

Fact

Figure 8-1. Facts, analyses, and causal factors are needed to support judgments of need.

Table 8-1. These guidelines are useful for writing judgments of need.

Clearly identify organizations that need to implement actions to prevent recurrence of the accident.
Where applicable, specify whether the judgment of need applies to a DOE Headquarters or field
element, contractor, subcontractor, or some combination of these.

Avoid generic statements and focus on processes and systems, not individuals.

Focus on causal factors.

Be specific and concise; avoid vague, generalized, broad-brush, sweeping solutions introduced by
"should."

Do not tell management how to do something; simply identify the need.

Present judgments of need in a manner that allows a specific organization to translate them into
corrective actions sufficient to prevent recurrence.

Accident Investigation Workbook/Rev 2

8-3
Section 8 — Developing Conclusions and Judgments of Need Part II

Table 8-2. Case Study: Judgments of need.

Significant Facts Causal Factors Judgments of Need

Safety training for the accident Training implementation was WS management needs to
victim as required by WS informal and was not based on evaluate the effectiveness of
ES&H Manual Procedure 1234 appropriate structured develop- implementation of the training
was not completed prior to the ment and measurement of program by observing and
accident. learning. This programmatic measuring workplace perfor-
deficiency was a contributing mance.
cause to the accident.

The standing work order Using the standing work order XYZ management needs to
system normally used for process, normally used for assure that the standing work
nonroutine, nonrepetitive tasks routine tasks, to accomplish order system is used only on
was used to authorize the nonroutine, complex modifica- routine, repetitive, and
work involved in the accident. tion and construction work, was noncomplex tasks where no
a root cause of the accident. significant risks or hazards have
been identified or could reason-
ably be encountered.

Judgments of need form the basis for n Disagrees on the linkages among facts,
corrective action plans, which are the analyses and causal factors.
responsibility of line management and
should not be directed by the board. If Even when new facts are collected and new
the board finds a need to make specific analyses are conducted, board members may
recommendations, they should appear in a still strongly disagree on the interpretation
separate communication and not in the body of facts, the conclusions, or the judgments
of the report or in the transmittal letter to the of need. Board members should make these
appointing official. differences known to the chairperson as
soon as they arise.
8.3 Minority Opinions
Every effort should be made to resolve a
During the process of identifying judgments board member’s dissenting opinion by
of need, board members may find that they collecting additional facts, if possible, and
disagree on the interpretation of facts, conducting additional analyses.
analytical results, causal factors, conclu-
sions, or judgments of need. This disagree- When board members still disagree, it is
ment can occur because the board: recommended that the chairperson:

n Has too few facts or has conflicting n Obtain a detailed briefing from those not
information from different sources; in agreement and consider the facts,
when this occurs, additional information analyses, causal factors, and conclusions
may be needed to resolve these conflicts that each used.

n Needs to evaluate the analyses con- n Monitor the differences between those
ducted and consider using different not in agreement by holding meetings to
analytical techniques discuss any new information collected

Accident Investigation Workbook/Rev 2

8-4
Part II Section 8 — Developing Conclusions and Judgments of Need

or new analyses conducted; more position and indicate whether there is a

common ground may be found as this need to present a minority opinion in the
information emerges. accident investigation report.

n Work with the board to identify areas of Note that the board is not required to reach
mutual agreement and areas of disagree- consensus, but is encouraged to work
ment as the end of the investigation diligently to resolve differences of opinion.
approaches. However, if one or more board members
disagree with the interpretation of facts,
n Openly discuss his or her position causal factors, conclusions, or judgments of
concerning the causal factors, conclu- need endorsed by the remainder of the
sions, and judgments of need with the board, the minority board member or
board and achieve consensus. At this members should document their differences
point, board members who disagree with in a minority report. This report is described
the consensus should describe their in Section 9.

KEY POINTS TO REMEMBER

C
onclusions are significant deductions derived from the investigation’s analyti-
cal results. They are derived from and supported by the facts plus the results of
testing and various analyses conducted.

# Judgments of need are the managerial controls and safety measures necessary to
prevent or minimize the probability or severity of an accident’s recurrence.

# To ensure that a clear and comprehensive list of judgments of need is presented,

the board should link each judgment of need with causal factors, analyses, and
facts. If the linkage is weak at any point, the judgment of need should be excluded
from the list.

# As the board generates the judgments of need, differing opinions may emerge. If
these differences cannot be resolved at the end of the investigation, the board
member(s) whose opinion(s) differs from the majority should prepare a report
describing those differences (i.e., the minority report). This circumstance gener-
ally arises as a result of: (1) insufficient or conflicting factual information, (2)
inconclusive or conflicting analytical results, (3) disagreement as to the interpreta-
tion of facts, causal factors, conclusions, or judgments of need, or (4) unclear
linkage among facts, analyses, and causal factors.

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Contents

Section 9 C Reporting the Results

9.1 Writing the Report ............................................................................................... 9-1

9.2 Report Format and Content ................................................................................. 9-1

9.2.1 Disclaimer .............................................................................................. 9-3

9.2.2 Appointing Official=s Statement of Report Acceptance ......................... 9-3
9.2.3 Table of Contents ................................................................................... 9-4
9.2.4 Acronyms and Initialisms ....................................................................... 9-4
9.2.5 PrologueCInterpretation of Significance ............................................... 9-5
9.2.6 Executive Summary................................................................................ 9-5
9.2.7 Introduction ............................................................................................ 9-6
9.2.8 Facts and Analysis .................................................................................. 9-6
9.2.9 Conclusions and Judgments of Need ................................................... 9-12
9.2.10 Minority Report .................................................................................... 9-13
9.2.11 Board Signatures .................................................................................. 9-13
9.2.12 Board Members, Advisors, Consultants, and Staff .............................. 9-13
9.2.13 Appendices ........................................................................................... 9-13

9.3 Performing Quality Review and Validation of Conclusions ............................. 9-13

9.4 Conducting the Factual Accuracy Review ........................................................ 9-16
9.5 Review by the Assistant Secretary for Environment, Safety and Health .......... 9-16
9.6 Submitting the Report ....................................................................................... 9-17

Key Points to Remember ......................................................................................... 9-18

List of Tables

Table 9-1. Useful strategies for drafting the investigation report............................ 9-2
Table 9-2. The accident investigation report should include these items ................ 9-2
Table 9-3. Facts differ from analysis ..................................................................... 9-10
 Part II Section 9 — Reporting the Results

9
Reporting the Results

T
he purpose of the investigation report investigation will be judged primarily by the
is to clearly and concisely convey the report, which will provide the affected site and
results of the investigation in a the DOE complex as a whole with the basis
manner that will help the reader understand for developing the corrective actions
what happened (the accident description and necessary to prevent or minimize the severity
chronology), why it happened (the causal of a recurrence, as well as lessons learned.
factors), and what can be done to prevent a
recurrence (the judgments of need).
Investigation results are reported without TIP
attributing individual fault or proposing Many previous boards have conducted
punitive measures. thorough and competent accident
investigations, yet failed to communicate the
The investigation report constitutes an results effectively in the report. As a result,
accurate and objective record of the accident the causes, judgments of need, and lessons
and provides complete and accurate details learned often appear unsupported or are
and explicit statements of: lost in a mass of detail.

# The board=s investigation process

The report writing process is interactive, yet
# Facts pertaining to the accident, includ- focused. Guidelines for drafting a report,
ing relevant management systems provided in Table 9-1, will help the board
involved work within the investigation cycle and
schedule to maximize their efficiency and
# Analytical methods used and their effectiveness in developing a useful report.
results
Senior DOE management is placing
# Conclusions of the board, including the increasingly greater emphasis on generating
causal factors of the accident concise (nominally less than 50 pages), yet
thorough investigation reports. This
# Judgments of need for corrective actions approach requires board members to
to prevent recurrence of the accident. communicate the significant facts, analyses,
causal factors, conclusions, and judgments
When completed, this report is submitted to of need with as little extraneous narrative as
the appointing official for acceptance and possible. Inherent in this approach is the
dissemination. need for reports to provide helpful and
useful information to line managers to assist
them in enhancing their safety programs.
9.1 Writing the
Report 9.2 Report Format
and Content
The investigation report is the official record
of the investigation; its importance cannot be
The investigation report should consist of
overemphasized. The quality of the
the elements listed in Table 9-2. Although
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Section 1 — Accidents: General Principles Part II

Table 9-1. Useful strategies for drafting the investigation report.

n Establish clear responsibilities for writing each section of the report.

n Establish deadlines for writing, quality review, and production, working back from the scheduled
final draft report due date.

n Use an established format (as described in Section 9.2). Devise a consistent method for
referencing titles, acronyms, appendices, and footnotes to avoid last-minute production
problems.

n Use a single point of contact, such as the administrative coordinator, to control all electronic
versions of the report, including editing input, and to coordinate overall report production.

n Start writing as soon as possible. Write the facts as bulleted statements as they are
documented. Write the accident chronology as soon as possible to minimize the potential for
forgetting the events and to save time when generating the first draft.

n Begin developing illustrations and photograph captions early. These processes take more time
than generally anticipated.

n Allow time for regular editorial and board member review and input. Don’t wait until the last few
days on site for the board to review each other’s writing and the entire draft report. This step is
important for assuring that primary issues are addressed and the investigation remains focused
and within scope.

n Use a zip drive to save the report during text processing — the file is extremely large.

n Use a technical writer or editor early in the process to edit the draft report for readability,
grammar, content, logic, and flow.

n Share information with other board members.

n Plan for several revisions.

Table 9-2. The accident investigation report should include these items.

n Disclaimer
n Appointing Official’s Statement of Report Acceptance
n Table of Contents, including list of exhibits, figures, and tables
n Acronyms and Initialisms
n Glossary of Technical Terms (if necessary)
n Prologue—Interpretation of Significance
n Executive Summary
n Introduction—Scope of Investigation, Description of the Accident, Brief Description of Site,
Facility, or Area where the Accident Occurred
n Facts and Analysis
n Conclusions and Judgments of Need
n Minority Report (if necessary)
n Board Signatures
n Board Members, Advisors, Consultants, and Staff
n Appendices

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Part II Section 9 — Reporting the Results

DOE Order 225.1A does not specifically implies liability. It should be worded
require some of these elements or prescribe exactly as the example below, with the
any specific order of presentation within the substitution of the appointing official and
report, a certain level of consistency in designated type of accident investigation
content and format among reports facilitates (i.e., A or B) relevant to the given accident.
extraction and dissemination of facts,
conclusions, judgments of need, and lessons 9.2.2 Appointing
learned. Official=s Statement of
Report Acceptance
The following are brief descriptions and
acceptable examples of the elements of a After reviewing the draft final report, the
typical accident investigation report. appointing official signs and dates a
statement indicating that the investigation
9.2.1 Disclaimer has been completed in accordance with
procedures specified in DOE Order 225.1A
The accident investigation report disclaimer and that the findings of the accident
should appear on the back of the title page investigation board have been accepted. An
of the report. The disclaimer is a statement example of this statement is provided below.
that the report neither determines nor

EXAMPLE: DISCLAIMER

This report is an independent product of the Type A accident investigation board appointed by
[Name], Assistant Secretary for Environment, Safety and Health (EH-1).

The board was appointed to perform a Type A investigation of this accident and to prepare an
investigation report in accordance with DOE Order 225.1A, Accident Investigations.

The discussion of facts, as determined by the board, and the views expressed in the report do not
assume and are not intended to establish the existence of any duty at law on the part of the U.S.
Government, its employees or agents, contractors, their employees or agents, or subcontractors at
any tier, or any other party.

This report neither determines nor implies liability.

EXAMPLE: APPOINTING OFFICIAL’S ACCEPTANCE STATEMENT

On [Date], I established a Type [A] Accident Investigation Board to investigate the [Fall] at the
[Facility] at the [Site] that resulted in the [Fatality of a construction worker]. The Board’s
responsibilities have been completed with respect to this investigation. The analysis, identification
of direct, contributing, and root causes, and judgments of need reached during the investigation
were performed in accordance with DOE Order 225.1A, Accident Investigations. I accept the
findings of the Board and authorize the release of this report for general distribution.

Signed,

[Name]
Assistant Secretary
Environment, Safety and Health

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Section 1 — Accidents: General Principles Part II

9.2.3 Table of 9.2.4 Acronyms

Contents and Initialisms

In addition to a table of contents for the Use of acronyms and initialisms* is common
report body, a list of exhibits, figures, and among DOE staff and contractors; however,
tables and a list of appendices should be to people outside the Department who may
included. Typically, the table of contents read the report, use of such terms without
lists the headings within the report down to adequate definition can be frustrating and
the third level. An example is provided hinder understanding. This element of the
below for reference. report assists readers by identifying, in
alphabetical order, terms and acronyms used

* An acronym is a term that is pronounceable formed from the initial letters or parts of a compound expression, such as FORTRAN
(formula translation). An initialism is an unpronounceable abbreviation pronounced as letters formed from the initial letters of a
compound expression, such as EPA (Environmental Protection Agency).

EXAMPLE: TABLE OF CONTENTS

ACRONYMS AND INITIALISMS ......................................................................................................... iii

PROLOGUE ......................................................................................................................................... v
EXECUTIVE SUMMARY .................................................................................................................... vii
1.0 INTRODUCTION ......................................................................................................................... 1
1.1 BACKGROUND .................................................................................................................... 1
1.2 FACILITY DESCRIPTION ..................................................................................................... 1
1.3 SCOPE, CONDUCT, AND METHODOLOGY ....................................................................... 2
2.0 FACTS AND ANALYSIS .............................................................................................................. 5
2.1 ACCIDENT DESCRIPTION AND CHRONOLOGY .............................................................. 5
2.1.1 Background and Accident Description ...................................................................... 5
2.1.2 Chronology of Events ................................................................................................ 9
2.1.3 Accident Response and Investigative Readiness ..................................................... 9
2.2 PHYSICAL HAZARDS, CONTROLS, AND RELATED FACTORS ...................................... 11
2.2.1 Work Controls ........................................................................................................... 11
2.2.2 Personnel Performance ........................................................................................... 13
2.2.3 Management Systems ............................................................................................. 15
2.3 BARRIER ANALYSIS ......................................................................................................... 22
2.4 CHANGE ANALYSIS .......................................................................................................... 24
2.5 CAUSAL FACTORS ANALYSIS ......................................................................................... 25
3.0 CONCLUSIONS AND JUDGMENTS OF NEED ........................................................................ 29
4.0 BOARD SIGNATURES .............................................................................................................. 32
5.0 BOARD MEMBERS, ADVISORS, CONSULTANTS, AND STAFF ............................................. 33

Appendix A. Appointment of Type A Accident Investigation Board ................................................ A-1

Appendix B. Performance of Barriers ............................................................................................. B-1
Appendix C. Change Analysis ....................................................................................................... C-1
Appendix D. Root Cause Analysis ................................................................................................. D-1

EXHIBITS, FIGURES AND TABLES

Exhibit 1-1 Area Enclosure ............................................................................................................ 3

Exhibit 2-1 View Looking South ..................................................................................................... 5

Figure 2-1 Summary Events Chart and Accident Chronology .................................................... 10

Figure 2-2 Barrier Analysis Summary ......................................................................................... 23
Figure 2-3 Events and Causal Factors Chart ............................................................................. 26

Table 3-1 Conclusions and Judgments of Need ....................................................................... 29

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Part II Section 9 — Reporting the Results

EXAMPLE: ACRONYMS AND INITIALISMS

CFR Code of Federal Regulations

DOE U.S. Department of Energy
EH DOE Office of Environment, Safety and Health
EM DOE Office of Environmental Management
ES&H Environment, Safety and Health
M&O Management and Operating
OSHA Occupational Safety and Health Administration

in the report. Acronyms and initialisms The executive summary should include a
should be kept to a minimum (see example brief account of:
above). Proliferation of acronyms makes it
difficult for managers and those unfamiliar # Essential facts pertaining to the
with the site, facility, or area involved to occurrence and major consequences
read and comprehend the report. Acronyms (what happened)
or initialisms should not be used for organi-
zational elements in the field or position # Conclusions that identify the causal
titles. If necessary, a glossary of technical factors, including organizational,
terms should follow this section. management systems, and line
management oversight deficiencies, that
9.2.5 PrologueC allowed the accident to happen (why it
Interpretation of happened)
Significance
# Judgments of need to prevent recurrence
The prologue is a one-page synopsis of the (what must be done to correct the
significance of the accident with respect to problem and prevent it from recurring at
management concerns and the primary the affected facility and elsewhere in the
lessons learned from the accident. DOE complex).

The executive summary should be written

TIP for the senior manager or general reader
The prologue should interpret the accident’s who may be relatively unfamiliar with the
significance as it relates to the affected site, subject matter. It should contain only
other relevant sites, field offices within the information discussed in the report, but
DOE complex, and DOE Headquarters. should not include the facts and analyses in
their entirety.

9.2.6 Executive
Summary TIP
The Executive Summary should not include
The purpose of the executive summary is to a laundry list of all the facts, conclusions,
convey to the reader a reasonable under- and judgments of need. Rather, to be
standing of the accident, its causes, and the effective, it should summarize the important
actions necessary to prevent recurrence. facts; causal factors; conclusions; and
Typical executive summaries are two to five judgments of need.
pages, depending on the complexity of the
accident.

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Section 1 — Accidents: General Principles Part II

9.2.7 Introduction methodology employed in conducting

the investigation.
This section of the report, illustrated in the
example that follows, normally contains TIP
three major subsections: Site and facility diagrams and organiza-
tional charts for relevant management
systems may be appropriate in either the
# A brief background description of the
Introduction or the Facts and Analysis
accident and its results, and a statement
section. However, include this information
regarding the authority to conduct the only when it is needed to clarify the
investigation accident's context and the role of related
organizations.
# A facility description defining the area
or site and the principal organizations Facts
9.2.8 Facts and
involved, to help the reader understand
Analysis
the context of the accident and the
information that follows
This section of the report states the facts
related to the accident and the analysis of
# Descriptions of the scope of the
those facts. It focuses on the events
investigation, its purpose, and the
connected to the accident; the factors that

EXAMPLE: PROLOGUE

INTERPRETATION OF SIGNIFICANCE

The fatality at the [Site] on [Date] resulted from failures of Department of Energy (DOE), contractor,
and subcontractor management, and the fatally injured worker. The subcontractor, the employer of
the fatally injured worker, had a poor record of serious safety deficiencies and had never accepted
the higher levels of safety performance required by the Department’s safe work ethic.

Although all the appropriate contractual and procedural requirements were in place, the
subcontractor failed to implement them and continued to allow violations of Occupational Safety and
Health Administration regulations invoked by DOE orders. These serious deficiencies were
recognized by the prime contractor, which was instituting progressively stronger sanctions against
the subcontractor. However, because of the subcontractor’s recalcitrance and the imminent danger
conditions represented by the subcontractor’s frequent violations of fall protection requirements,
more aggressive measures, such as contract cancellation, could have been taken earlier.

The prime contractor’s oversight was narrowly focused on selected aspects of the subcontractor’s
safety performance and did not identify the subcontractor’s failure to implement its own procedures,
or institute appropriate fall protection measures. Thus, the implications and frequency of imminent
danger hazards were not fully appreciated. Departmental oversight focused on the subcontractor’s
performance and did not identify the gaps in the prime contractor’s oversight focus. As a result,
hazards were not identified and barriers were not in place to prevent the accident, which could have
been avoided.

This fatality highlights the importance of a complete approach to safety that stresses individual and
line management responsibility and accountability, implementation of requirements and procedures,
and thorough and systematic oversight by contractor and Department line management. All levels
of line management must be involved. Contractual requirements and procedures, implementation of
these requirements, and line management oversight are all necessary to mitigate the dangers of
hazards that arise in the workplace. Particular attention must be paid to individual performance and
changes in the workplace. Sound judgment, constant vigilance, and attention to detail are
necessary to deal with hazards of immediate concern. When serious performance deficiencies are
identified, there must be strong, aggressive action to mitigate the hazards and re-establish a safe
working environment. Aggressive actions, up to and including swift removal of organizations that
exhibit truculence toward safety, are appropriate and should be taken.

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Part II Section 9 — Reporting the Results

allowed those events to occur; and the # Brief descriptions of and results from
results of the various analytical techniques analyses that were conducted
used to determine the direct, contributing, (e.g., barrier analysis, change analysis,
and root causes of the accident, including events and causal factors analysis, and
the role of management and safety system root cause analysis).
deficiencies. This section should logically
lead the reader to the conclusions and Photographs, evidence position maps, and
judgments of need. It includes subsections diagrams, which may provide perspectives
dealing with: that written narrative cannot capture, should
be included in the Facts and Analysis
# Accident description and chronology, section, as determined by the board.
including a description of the responses
to the accident Accident Description and Chronology.
A subsection describing the accident and
# Hazards, controls, and management chronology of events should be first in the
systems pertinent to the accident Facts and Analysis section of the report.

EXAMPLE: EXECUTIVE SUMMARY

INTRODUCTION

A fatality was investigated in which a construction subcontractor fell from a temporary platform in the
[Facility] at the [Site]. In conducting its investigation, the accident investigation board used various
analysis techniques, including events and causal factors charting and analysis, barrier analysis,
change analysis, and root cause analysis. The board inspected and videotaped the accident site,
reviewed events surrounding the accident, conducted extensive interviews and document reviews,
and performed analyses to determine the causal factors that contributed to the accident, including
any management system deficiencies. Relevant management systems and factors that could have
contributed to the accident were evaluated using with the components of the Department’s inte-
grated safety management system, as described in DOE Policy 450.4.

ACCIDENT DESCRIPTION

The accident occurred at approximately [Time] on [Date] at the [Facility], when a construction worker,
employed by [Subcontractor], fell from a temporary platform. The platform had been installed to
catch falling tools and parts, but it was also used as a work platform for personnel activities when
100 percent fall protection was used. The worker was transported by helicopter to the medical
center, where he died at [Time] from severe head and neck injuries.

DIRECT AND ROOT CAUSES

The direct cause of the accident was the fall from an unprotected platform.

The contributing causes of the accident were: (1) the absence of signs and barricades in the
vicinity of the platform, (2) visibility problems created by poor illumination in the area of the platform,
and (3) lack of implementation of job safety analysis, work controls, and the medical surveillance
program.

The root causes of the accident were: (1) failure by [Subcontractor] to implement requirements and
procedures that would have mitigated the hazards, and (2) failure by [Subcontractor] to effectively
implement components of the Department’s integrated safety management policy mandating line
management responsibility and accountability for safety performance.

CONCLUSIONS AND JUDGMENTS OF NEED

Conclusions of the board and judgments of need as to managerial controls and safety measures
necessary to prevent or mitigate the probability of a recurrence are summarized in Table 1.

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Section 1 — Accidents: General Principles Part II

This section includes: and pertinent information is documented. It is

reasonable for the board to begin preparing a
# Background information about systems draft of the accident description and
and any activities and events preceding chronology during the first few days on site.
the accident, including scheduled As additional information is collected, new
maintenance and system safety analysis findings can be used to augment the initial
writing.
# Chronological description of the events
leading up to and including the Description and Analysis of Facts.
accident itself Subsections on the facts surrounding the
accident, and the analysis of those facts,
# A summary events chart, identifying should follow the accident description and
the major events from the events and chronology subsection. These sections must
causal factors chart. provide the full basis for stating the
accident’s causes and judgments of need.
This is typically one of the first sections
written, as soon as evidence is collected

EXAMPLE: EXECUTIVE SUMMARY (Continued)

Table 1. Conclusions and Judgments of Need

Conclusions Judgments of Need

# Comprehensive safety requirements None

existed, were contractually invoked, and
were appropriate for the nature of [Facility]
construction work.

# [Subcontractor] failed to follow procedures [Subcontractor] line management and

required by its contract and by its ES&H safety personnel need to implement
Program Plan, including: existing safety requirements and proce-
- [Subcontractor] failed to adequately dures.
implement fall protection requirements
contained in its ES&H Program Plan for
the [Facility] project, including enforce-
ment of a three-tiered approach to fall
protection. The third tier (choice of last
resort) requires anchor points, lanyards,
shock absorbers, and full-body harness.
- The worker was not wearing any fall
protection equipment and did not obtain a
direct reading dosimeter before entering
the radiological control area.

# [Subcontractor] and [Contractor] did not [Subcontractor] and [Contractor] need to

fully implement the hazard inspection ensure that an adequate hazard analysis
requirements of the [Facility] contract and is performed prior to changes in work tasks
[Subcontractor's] ES&H Program Plan, and that affect the safety and health of
therefore did not sufficiently identify or personnel.
analyze hazards and institute protective
measures necessary due to changing
conditions.

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Part II Section 9 — Reporting the Results

In writing the report, it is important to leading to a logical interpretation of those

clearly distinguish facts from analysis. Facts facts and supportable conclusions. The
are objective statements that can be verified analysis should include a brief statement of
by physical evidence, by direct observation, the impact of the factual circumstances on
through documentation, or from statements the accident. Table 9-3 illustrates this
corroborated by at least one witness or distinction.
interviewee other than the one making the
statement. Analysis is a critical review and Following are some guidelines for
discussion of the implications of the facts, developing this portion of the report:

EXAMPLE: INTRODUCTION

1.0 INTRODUCTION

1.1 BACKGROUND

On [Date], at approximately [Time], a construction subcontractor working at the [Site] fell approxi-
mately 17 feet from a temporary platform. The platform was built to catch falling tools and parts in
the [Facility]. The worker was transported by helicopter to the medical center, where he died from
severe head and neck injuries.

On [Date], [Appointing Official Name and Title] appointed a Type A accident investigation board to
investigate the accident, in accordance with DOE Order 225.1A, Accident Investigations.

1.2 FACILITY DESCRIPTION

Contractor activities at [Site] are managed by the DOE XXX Operations Office. The facility in which
this accident occurred is under the programmatic direction of the Office of Environmental Manage-
ment (EM).

[Provide a brief discussion of site, facility, or area operations and descriptive background that
sheds light on the environment or location where the accident occurred.]

1.3 SCOPE, CONDUCT, AND METHODOLOGY

The board commenced its investigation on [Date], completed the investigation on [Date], and
submitted its findings to the Assistant Secretary for Environment, Safety and Health on [Date].

The scope of the board's investigation was to review and analyze the circumstances to determine
the accident's causes. During the investigation, the board inspected and videotaped the accident
site, reviewed events surrounding the accident, conducted interviews and document reviews, and
performed analyses to determine causes.

The purposes of this investigation were to determine the nature, extent, and causation of the
accident and any programmatic impact, and to assist in the improvement of policies and practices,
with emphasis on safety management systems.

The board conducted its investigation, focusing on management systems at all levels, using the
following methodology:

# Facts relevant to the accident were gathered

# Relevant management systems and factors that could have contributed to the accident were
evaluated in accordance with the components of DOE's integrated safety management
system, as described in DOE Policy 450.4
# Events and causal factors charting and analysis, along with barrier analysis and change
analysis, was used to provide supportive correlation and identification of the causes of the
accident.

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Section 1 — Accidents: General Principles Part II

Table 9-3. Facts differ from analysis.

Facts Analysis

# At 9:30 a.m. the outside temperature was # Meteorological conditions at the time of
36° F and the sky was clear. the accident did not contribute to the
accident.

# In September 1995, the Environmental # The alternate work authorization process

Group implemented its own alternate work was not adequate to assure worker
authorization process. This process did not safety.
include a job hazards analysis prior to
construction activities.

# The subsections should be organized Analysis section should describe the formal
logically according to relevant analytical methods used during the
investigation topics, such as: investigation, as well as the results. For
example, if barrier analysis, change analysis,
• Physical hazards and events and causal factors analysis were
• Conduct of operations performed during an investigation, each of
• Training these methods and the results are briefly
• Work planning and control summarized. There always should be a
• Organizational concerns subsection that includes a discussion of the
• Management systems root cause analysis. If necessary, detailed
• Maintenance supporting documentation for analyses
• Personnel performance performed during the investigation is
• Other topics specific and relevant to included in one or more appendices.
the investigation.
TIP
# For each subsection, list relevant facts in Avoid lengthy narratives. It is more
the form of bulleted statements. important to lay out the facts in a clear,
concise manner that is understandable to
# For each subsection, provide an analysis the reader. Precede the bulleted facts with a
of what the facts mean in terms of their statement identifying them as facts. Include
impact on the accident and its causes. only facts—not conjecture, assumptions,
This narrative should be as concise as analysis, or opinions.
possible and may reference the more
detailed analyses discussed later in the Causal Factors Analysis. Three types of
report (e.g., barrier analysis, change causal factors are identified using analytic
analysis, events and causal factors methods: direct cause, contributing causes,
charting and analysis, and root cause and root causes. A narrative showing how
analysis). All facts included in the report these are presented in the report is provided
should be addressed. on page 9-12. A figure (a summary events
and causal factor chart) showing the logical
Generally the facts are presented as short sequence of the events and causal factors for
statements, and the analysis of the facts the accident is included in the report. Each
provides a direct link between the facts and causal factor is generally a brief, explicit
causal factors. See the example on the next statement that summarizes the cause and any
page. of its contributing factors. The causal factors
that are identified in the report must be fully
Brief Descriptions and Results from supported by the facts and analysis
Analyses. Subsections in the Facts and
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Part II Section 9 — Reporting the Results

EXAMPLE: DESCRIPTION AND ANALYSIS OF FACTS

2.0 FACTS AND ANALYSIS

2.2 PHYSICAL HAZARDS, CONTROLS, AND RELATED FACTORS
2.2.1 Physical Barriers

Facts related to physical barriers on the day of the accident are as follows:

# There were no general barriers, warning lines, or signs to alert personnel on top of the con-
struction materials to the fall hazards in the area. There were no other safety barriers for the
platform.
# The platform was intended to catch falling tools or parts, but it was also used as a work
platform for personnel with 100 percent fall protection.
# There were no static lines or designated (i.e., engineered) anchor points for personnel to
connect fall protection equipment in the vicinity of the platform.
# Lighting in the area of the platform was measured at 2 foot-candles.

Following is the analysis of these facts.

Occupational Safety and Health Standards for the Construction Industry (29 CFR 1926) requires
that, when working from an area greater than six feet in height or near unprotected edges or sides,
personal protection in the form of a fall protection system be in place during all stages of active
work. Violations of fall protection requirements usually constitute an imminent danger situation.
Lighting in the area was less than the minimum of 5 foot-candles prescribed by the OSHA stan-
dards (29 CFR 1925.56). This level of illumination may have contributed to the accident, taking into
consideration the visual adjustment when moving from a brighter area to a progressively darker
area, as was the case in the area where the accident occurred. There were no permanently
installed fall protection systems, barriers, or warnings; each subtier contractor was expected to
identify the fall hazards and provide its own fall protection system as they saw fit. The combination
of these circumstances was a contributing cause of the accident.

EXAMPLE: DESCRIPTION AND RESULTS FROM ANALYSES

2.0 FACTS AND ANALYSIS

2.3 CHANGE ANALYSIS

Change analysis was performed to determine points where changes are needed to correct
deficiencies in the safety management system and to pinpoint changes and differences that may
have had an effect on the accident.

Changes directly contributing to the accident were failure to execute established procedures for fall
protection, signs and barricades, and Job Safety Analysis/Construction Safe Work Permit; unsafe
use of the temporary platform; insufficient lighting in the platform area; and unenforced work
restrictions for the construction worker. No job safety analysis was performed and/or Construction
Safe Work Permit obtained for work on the platform, leading to a failure in the hazard analysis
process and unidentified and uncorrected hazards in the workplace. Deficiencies in the
management of the safety program within [Subcontractor] are also related to failures in the medical
surveillance program.

Changes brought about by [Subcontractor] management failures resulted in a deficient worker

safety program. Management failed to implement the contractual safety requirements necessary to
prevent the accident and avoid deficiencies in the worker safety program.

[Contractor's] progressive approach to improving [Subcontractor's] compliance with safety

requirements was successful to a degree, but failed to prevent recurrence of imminent danger
situations.

Accident Investigation Workbook/Rev 2

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Section 1 — Accidents: General Principles Part II

described in the report. If they are not, the of need (discussed in Section 8 of this
board risks reaching erroneous conclusions workbook). The conclusions can be listed
and producing insufficient or unnecessary using bulleted statements, tables, or
judgments of need that will affect the diagrams with limited narrative, as long as
report’s credibility. the meaning is clear. Judgments of need may
be presented in the same manner.
9.2.9 Conclusions and
Judgments of Need Judgments of need are identified actions
required to prevent future accidents.
This section of the report lists the board’s Examples of well-written judgments of need
conclusions in the form of concise are shown on page 9-14.
statements, as well as the board’s judgments

EXAMPLE: CAUSAL FACTORS ANALYSIS

2.5 CAUSAL FACTORS ANALYSIS

The direct cause of the accident was the fall from an unprotected platform. However, there were
also contributing causes and root causes.

Contributing causes for the accident were:

# Job safety analysis, work controls, and medical surveillance program not implemented
# Insufficient illumination in the area of the temporary platform
# Failure to remove the temporary platform
# Absence of warning signs and barricades.

Another possible contributing factor was impaired judgment of the worker who fell from the
platform. This cause could not be substantiated.

Root causes of the accident were:

# Failure by [Subcontractor] to implement requirements and procedures that would have

mitigated the hazards. The implementation of comprehensive and appropriate requirements
is part of the third of DOE's safety management principles. [Subcontractor] failed to implement
its medical surveillance program and to enforce work restrictions for the worker. A hazard
analysis, required by DOE Order 5480.9A and the ES&H Program Plan, was not conducted;
consequently, the hazards associated with the platform were not identified, and no
countermeasures were implemented. The absence of fall protection, physical barriers, and
warning signs in the vicinity of the platform, along with inadequate lighting, violated DOE
requirements that invoke Federal safety standards. Finally, failure to ensure that
comprehensive requirements are fully implemented represents a fundamental flaw in the
safety management program of [Subcontractor] and exhibits failure to meet part of the
management requisites for the fifth of DOE's safety management principles requiring that
comprehensive and appropriate requirements be established and effectively implemented to
counteract hazards and assure safety.

# Failure by [Subcontractor] to implement the principle of line management responsibility

and accountability for safety. Line management responsibility and accountability for safety is
the first of DOE's safety management principles. [Subcontractor] has clear safety policies and
well defined responsibilities and authorities for safety. However, [Subcontractor] line
management failed to appropriately analyze and manage hazard mitigation and, when faced
with adverse consequences for poor safety performance, has refused to accept accountability.
[Subcontractor] consistently failed to implement effective safety policies and practices as
reflected in DOE policies and industry standards. [Subcontractor] did not meet contractual
requirements for safety and its own safety policy. Finally, [subcontractor] failed to ensure that
findings resulting from reviews, monitoring activities, and audits were resolved in a timely
manner. [Subcontractor's] approach and numerous safety program failures reflect less than
full commitment to safety and directly led to the accident.

Accident Investigation Workbook/Rev 2

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Part II Section 9 — Reporting the Results

Report
9.2.10 Minority Report be omitted. All appendices should be
referenced in the report.
If used, this section contains the opinions of
any board member(s) that differ from the 9.3 Performing
majority of the board. The minority report Quality Review
should:
and Validation of
# Address only those sections of the Conclusions
overall report that warrant the dissenting
opinion Before releasing the report outside the
investigation team, the board reviews it to
# Follow the same format as the overall ensure its technical accuracy, thoroughness,
report, addressing only the points of and consistency, and to ensure that
variance organizational concerns, safety management
systems, and line management oversight
# Not be a complete rewrite of the overall processes are properly analyzed as possible
report. causes of the accident. The following are
further considerations for quality review of
9.2.11 Board Signatures the report.

The accident investigation board Structure and Format—The report should

chairperson and members must sign and date be reviewed to ensure that it follows the
the report, even if there is a minority format and contains the information outlined
opinion. The signature page identifies the in Section 9.2, which ensures compliance
name and position of each board member with the intent of Paragraph 4.c(3) of DOE
and the accident investigation board Order 225.1A. Variation in the format is
chairperson, as shown on page 9-15. It also acceptable, as long as it does not affect the
indicates whether each board member is a report’s quality or conflict with the
DOE accident investigator. requirements of the order.

9.2.12 Board Technical and Policy Issues—All technical

Members, Advisors, requirements applicable to the investigation
Consultants, and Staff should be reviewed by appropriate subject
matter experts to assure their accuracy.
This section lists the names of the board Likewise, a knowledgeable board member
members, advisors, and staff, indicating or advisor should review whether policy,
their employers and their positions with requirements, and procedures were
respect to the accident investigation. followed. A board member or advisor
knowledgeable in such policy and
requirements should also review the report
9.2.13 Appendices
to determine whether these requirements
were adequately considered.
Appendices are added, as appropriate, to
provide supporting information, such as the
accident investigation board’s appointment Requirements Verification Analysis—
letter and results from detailed analyses Requirements verification analysis should
conducted during the investigation. be conducted on the draft report after all the
Generally, the amount of documentation in analytical techniques are completed. This
the appendices should be limited. If there is analysis ensures that all portions of the
any doubt about the benefit of including report are accurate and consistent, and
material as an appendix, it should probably verifies that the conclusions are consistent
with the facts, analyses, and judgments of
Accident Investigation Workbook/Rev 2
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Section 1 — Accidents: General Principles Part II

EXAMPLE: CONCLUSIONS AND JUDGMENTS OF NEED

3.0 CONCLUSIONS AND JUDGMENTS OF NEED

This section of the report identifies the conclusions and judgments of need determined by the
Board, as a result of using the analysis methods described in Section 2.0. Conclusions of the
Board consider significant facts, causal factors, and pertinent analytical results. Judgments of need
are managerial controls and safety measures believed necessary to prevent or mitigate the
probability or severity of a recurrence. They flow from the causal factors and are directed at guiding
managers in developing follow-up actions. Table 3-1 identifies the conclusions and the
corresponding judgments of need identified by the Board.

Table 3-1. Conclusions and Judgments of Need

CONCLUSIONS JUDGMENTS OF NEED

# Comprehensive safety requirements existed, None

were contractually invoked, and were
appropriate for the nature of construction
work.

# [Subcontractor] failed to follow procedures [Subcontractor] line management and safety

required by its contract and by its ES&H personnel need to implement existing safety
Program Plan, including: requirements and procedures.
# [Subcontractor] failed to adequately imple-
ment fall protection requirements contained
in its ES&H Program Plan for the project,
including enforcement of a three-tiered
approach to fall protection. The third tier
(choice of last resort) requires anchor points,
lanyards, shock absorbers, and full-body
harness.

# A temporary platform, used as a work [Subcontractor] and [Contractor] need to ensure

surface for personnel activities when that safety personnel inspect changing work
employing 100 percent fall protection, did conditions for previously unidentified safety and
not have guardrails and was left in place health hazards, and implement protective
without barriers or other warning devices. measures.
- [Subcontractor] failed to post adequate
warning signs and establish barriers on
the stack to warn personnel that they
were approaching within six feet of the
edge of a fall hazard, as required by
OSHA regulations and [Subcontractor's]
ES&H Program Plan.
- [Contractor] failed to recognize that
warning signs and barriers were not in
place in the work area near the plat-
form.

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Part II Section 9 — Reporting the Results

EXAMPLE: BOARD SIGNATURES

4.0 BOARD SIGNATURES

Signed Date Dated

[Name], Board Chairperson
DOE Accident Investigator
U.S. Department of Energy, EH-21

Signed Date Dated

[Name], Board Member
DOE Accident Investigator
U.S. Department of Energy, Rocky Flats Field Office

Signed Date Dated

[Name], Board Member
DOE Accident Investigator
U.S. Department of Energy, Oak Ridge Operations Office

Signed Date Dated

[Name], Board Member
OSHA Accident Investigator
U.S. Department of Energy, Idaho Operations Office

Signed Date Dated

[Name], Board Member
U.S. Department of Energy, Idaho Operations Office

EXAMPLE: PARTICIPANTS

5.0 BOARD MEMBERS, ADVISORS, CONSULTANTS, AND STAFF

Chairperson [Name], DOE (EH-21)

Member [Name], DOE-Oak Ridge Operations Office
Member [Name], DOE-Rocky Flats Field Office
Member [Name], DOE-Idaho Operations Office
Member [Name], DOE-Idaho Operations Office

Advisor [Name], DOE (EH-21)

Advisor [Name], DOE (EH-21)
Advisor [Name], DOE-Albuquerque Operations Office
Advisor [Name], DOE-Idaho Operations Office
Advisor [Name], Consultant

Medical Advisor [Name], M.D., Consultant

Legal Advisor [Name], DOE-Idaho Operations Office

Administrative Coordinator [Name], DOE (EH-21)

Technical Writer [Name], XYZ Corporation

Technical Editor [Name], XYZ Corporation

Administrative Support [Name], DOE-Rocky Flats Field Office

[Name], DOE-Idaho Operations Office

Accident Investigation Workbook/Rev 2

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Section 1 — Accidents: General Principles Part II

need. The requirements verification analysis protect the integrity of the investigation and
determines whether the flow from facts to prevent a premature reaction to preliminary
analysis to causal factors to judgments of analyses. However, other portions of the
need is logical. That is, the judgments of report may be provided at the discretion of
need are traced back to the supporting facts. the board chairperson. The review is
The goal is to eliminate any material that is important for ensuring an accurate report
not based on facts. and verifying that all affected parties agree
on the facts surrounding the accident. This
is consistent with the approach of
TIP identifying system deficiencies so that
One approach to requirements verification corrective actions can be taken, rather than
is to cut a copy of the draft report apart; fixing blame. It also supports and is
compare the facts, analysis, causal factors, consistent with the DOE management
and judgments of need on a wall chart; and philosophy of openness in the oversight
validate the continuity of facts through the process.
analysis and causal factors to the judgments
of need. This method also identifies any Some boards have conducted this review in
misplaced facts, insufficient analyses, and the board’s dedicated conference room. This
unsupported conclusions or judgments of allows representatives of affected
need. organizations to review the draft description
of the facts and to ask follow-up questions
of board members, while ensuring that
Classification and Privacy Review—A dissemination of the draft document remains
review should be completed by an closely controlled.
authorized derivative classifier to ensure
that the report does not contain classified or Comments and revisions from DOE and
unclassified controlled nuclear information contractor management are incorporated
(UCNI). An attorney should also review the into the draft final report, as appropriate.
report for privacy concerns. These reviews
are conducted before the report is Review
9.5 Review by the
distributed for the factual accuracy review. Assistant Secretary for
Documentation that these reviews have been Environment, Safety
completed should be retained in the and Health
permanent investigation file.
DOE Order 225.1A requires review of Type
9.4 Conducting the A, limited scope, and Type B accident
investigation reports by the Assistant
Factual Accuracy Secretary. Type A and limited scope
Review accident investigation reports are reviewed
by the Assistant Secretary as the appointing
When the accident investigation report has official. Responsibility for review of
been drafted in its final form, but before it is delegated Type A and Type B accident
submitted to the appointing official for investigation reports has been delegated to
acceptance, the facts presented in the Facts the Deputy Assistant Secretary for Oversight
and Analysis section of the report should be (EH-2). Delegated Type A and Type B
reviewed by affected DOE and contractor accident investigation reports are reviewed
line management to validate the factual prior to acceptance by the appointing
accuracy of the report contents. Generally, official. Comments are provided to the
only the “facts” portion should be appointing official for incorporation prior to
distributed for this review, in order to report publication and distribution.

Accident Investigation Workbook/Rev 2

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Part II Section 9 — Reporting the Results

Coordination for these reviews should be provides the draft final report to the
made with the Program Manager. Board appointing official for acceptance. If the
chairpersons should plan and schedule appointing official determines that the board
sufficient time for this review to maintain has met its obligation to conduct a thorough
the appropriate investigation cycle. investigation of the accident, that the report
fully describes the accident and its causal
9.6 Submitting the factors, and that it provides judgments of
Report need sufficient to prevent recurrence, the
report is formally accepted. The statement
Once the report has been finalized, the of report acceptance from the appointing
accident investigation board chairperson official is included in the final report
(see Section 9.2.2).

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Section 1 — Accidents: General Principles Part II

KEY POINTS TO REMEMBER

n Begin writing the report as soon as initial evidence is collected.

n Keep pace with writing as the investigation proceeds to avoid having to do all the
writing during the third and fourth weeks.

n The primary portions of the report include:

• Prologue—Interpretation of Significance
• Executive Summary
• Introduction
• Facts and Analysis
• Conclusions and Judgments of Need
• Minority Report (if applicable)
• Board Signatures
• Appendices.

n Provide a concise, yet clear discussion of the facts and analyses of the investiga-
tion.

n Clearly distinguish between facts and analysis.

n Ensure that the facts and analyses logically lead the reader to the conclusions and
judgments of need determined by the board.

n Describe judgments of need so that they can be translated into corrective actions.

n Include appendices as needed, but do not bury important facts in appendices.

n Quality reviews of the report prior to finalization include processes for reviewing
structure and format, technical and policy issues, and a requirements verification
analysis.

n The factual accuracy of the report is reviewed by submitting it to affected DOE

and contractor line management to validate the factual content. This ensures an
accurate report and that all affected parties agree on the facts surrounding the
accident. Comments and revisions are incorporated as appropriate.

n Requirements verification analysis is conducted on the draft report to ensure that

all portions of the report are accurate and consistent. It also verifies that the
conclusions are consistent with the facts, analyses, and judgments of need and that
the flow from facts to analysis to causal factors to judgments of need is logical.
Judgments of need are traced back to the supporting facts. One method of doing
this is to create a wall chart using the applicable portions of the report to depict
the flow visually.

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Part II Section 9 — Reporting the Results

KEY POINTS TO REMEMBER (Continued)

n Submit the draft report for review and comment to the Office of Oversight before
submitting it to the appointing official for acceptance in Type A investigations.

n Submit the draft report for review and comment to the Office of Oversight prior to
report publication and dissemination for Type B and delegated Type A investigations.

Accident Investigation Workbook/Rev 2

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Section 1 — Accidents: General Principles Part II

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Accident Investigation Workbook/Rev 2

9-20
Appendix A

Glossary
 Appendix A — Glossary

A
Glossary
Accident: An unwanted transfer of energy or Appointing Official: A designated authority
an environmental condition that, due to the responsible for assigning accident
absence or failure of barriers or controls, investigation boards for Type A and Type B
produces injury to persons, damage to investigations, with responsibilities as
property, or reduction in process output. prescribed in DOE Order 225.1A, Paragraph
5.d.
Accident Investigation: The systematic
appraisal of unwanted events for the purpose Barrier: Anything used to control, prevent,
of determining causal factors, subsequent or impede energy flows. Common types of
corrective actions, and preventive measures. barriers include equipment, administrative
procedures and processes, supervision/
Accident or Emergency Response Team: A management, warning devices, knowledge
team or teams of emergency and accident and skills, and physical objects.
response personnel for a particular site. This
team may be composed of a number of Barrier Analysis: An analytical technique
teams from the site, such as local police and used to identify energy sources and the failed
firefighter units, emergency medical or deficient barriers and controls that
personnel, and hazardous material teams. contributed to an accident.

Analysis: The use of methods and Board Chairperson: The leader who
techniques for arranging data to: (a) assist manages the accident investigation process,
in determining what additional data are represents DOE in all matters regarding the
required; (b) establish consistency, validity, accident investigation, and reports to the
and logic; (c) establish necessary and appointing official for purposes of the
sufficient events for causes; and (d) guide accident investigation.
and support inferences and judgments.1
Board Members: A group of three to six
Analytical Tree: Graphical representation of DOE staff assigned to investigate an accident.
an accident in a deductive approach (general This group reports to the board chairperson
to specific). The structure resembles a tree— during the accident investigation.
that is, narrow at the top with a single event
(accident) and then branching out as the tree Causal Factor: An event or condition in the
is developed, and identifying root causes at accident sequence necessary and sufficient to
the bottom branches. produce or contribute to the unwanted result.
Causal factors fall into three categories:
_________________________________
1
n Direct cause
Ferry, Ted S., Modern Accident Investigation and Analysis,
2nd Edition, John Wiley & Sons, New York, New York, 1988.

Accident Investigation Workbook/Rev 2

A-1
Appendix A — Glossary

n Contributing cause Controls: Those barriers used to control

wanted energy flows, such as the insulation
n Root cause. on an electrical cord, a stop sign, a
procedure, or a safe work permit.
Cause: Anything that contributes to an
accident or incident. In an investigation, the Direct Cause: The immediate events or
use of the word “cause” as a singular term conditions that caused the accident.
should be avoided. It is preferable to use it in
the plural sense, such as “causal factors,” DOE Accident Investigator: An individual
rather than identifying “the cause.” who understands DOE accident investigation
techniques and has experience in conducting
Chain of Custody: The process of investigations through participation in at least
documenting, controlling, securing, and one Type A or Type B investigation.
accounting for physical possession of Effective October 1, 1998, DOE accident
evidence, from initial collection through investigators must have attended an accident
final disposition. investigation course of instruction that is
based on current materials developed by the
Change: Stress on a system that was Office of Deputy Assistant Secretary for
previously in a state of equilibrium, or Oversight.
anything that disturbs the planned or normal
functioning of a system. DOE Operations: Activities funded by DOE
for which DOE has authority to enforce
Change Analysis: An analytical technique environmental protection, safety, and health
used for accident investigations, wherein protection requirements.
accident-free reference bases are established,
and changes relevant to accident causes and DOE Site: A tract either owned by DOE,
situations are systematically identified. In leased, or otherwise made available to the
change analysis, all changes are considered, Federal government under terms that afford
including those initially considered trivial or DOE rights of access and control
obscure. substantially equal to those it would possess if
it held the fee (or pertinent interest therein) as
Conclusions: Significant deductions derived agent of and on behalf of the government.
from analytical results. Conclusions are One or more DOE operations/program
derived from and must be supported by the activities carried out within the boundaries of
facts, plus results from testing and analyses the described tract.
conducted. Conclusions are statements that
answer two questions the accident Energy: The capacity to do work and
investigation addresses: what happened and overcome resistance. Energy exists in many
why did it happen? Conclusions include forms, including acoustic, potential, electrical,
concise recapitulations of the causal factors kinetic, thermal, biological, chemical, and
(direct, contributing, and root causes) of the radiation (both ionizing and non-ionizing).
accident determined by analysis of facts.
Energy Flow: The transfer of energy from its
Contributing Cause: An event or condition source to some other point. There are two
that collectively with other causes increases types of energy flows: wanted (controlled—
the likelihood of an accident but that able to do work) and unwanted (uncon-
individually did not cause the accident. trolled—able to do harm).

Accident Investigation Workbook/Rev 2

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 Appendix A — Glossary

Event: An occurrence; something significant Investigation Report: A clear and concise

and real-time that happens. An accident written account of the investigation results.
involves a sequence of events occurring in
the course of work activity and culminating Judgments of Need: Managerial controls
in unintentional injury or damage. and safety measures necessary to prevent or
minimize the probability or severity of a
Events and Causal Factors Chart: recurrence of an accident.
Graphical depiction of a logical series of
events and related conditions that precede the Lessons Learned: A “good work practice”
accident. or innovative approach that is captured and
shared to promote its repeated application. A
Eyewitness: A person who directly observed lesson learned may also be an adverse work
the accident or the conditions immediately practice or experience that is captured and
preceding or following the accident. shared to avoid recurrence.

Fatal Injury: Any injury that results in death Limited Scope Investigation: An accident
within 30 calendar days of the accident. investigation chartered by the Assistant
Secretary for Environment, Safety and
Field Element: A general term for all DOE Health that is reduced in scope, duration, and
sites (excluding individual duty stations) resources from that normally associated with
located outside the Washington, D.C., a Type A or Type B investigation.
metropolitan area.
Occurrence: An event or condition that
General Witness: A person with knowledge adversely affects or may adversely affect
about the activities prior to or immediately DOE or contractor personnel, the public,
after the accident (the previous shift property, the environment, or DOE mission.
supervisor or work controller, for example).
Occurrence Reporting and Processing
Hazard: The potential for energy flow(s) System (ORPS): The reporting system
to result in an accident or otherwise adverse established and maintained for reporting
consequence. occurrences related to the operation of DOE
facilities.
Heads of Field Elements: First-tier field
managers of the operations offices, the field Point of Contact: A DOE staff member
offices, and the power marketing who is assigned the role of liaison with the
administrations (administrators). Accident Investigation Program Manager in
the Office of Security Evaluations (EH-21),
Human Factors: The study of human who administers the accident investigation
interactions with products, equipment, program. In this role, the point of contact
facilities, procedures, and environments used ensures that site readiness teams are trained
in work and everyday living. The emphasis in collecting and maintaining initial accident
is on human beings and how the design of investigation evidence and that their activities
equipment influences people. are coordinated with accident and emergency
response teams.
Investigation: A detailed, systematic search
to uncover the “who, what, when, where, Principal Witness: A person who was
why, and how” of an occurrence and to actually involved in the accident.
determine what corrective actions are needed
to prevent a recurrence.

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Appendix A — Glossary

Readiness Team: Trained personnel who are Root Cause: The causal factor(s) that, if
available to perform initial investigative corrected, would prevent recurrence of the
response activities immediately following an accident.
accident. They are responsible for initiating
the accident investigation, maintaining the Root Cause Analysis: Any methodology
integrity of evidence before the accident that identifies the causal factors that, if
investigation board arrives, and supporting corrected, would prevent recurrence of the
the board after its arrival. accident.

Requirements Verification Analysis: A Target: A person, object, or animal upon

validation technique that determines whether which an unwanted energy flow may act to
the logical flow of data from analysis to cause damage, injury, or death.
conclusions and judgments of need is based
on facts. This technique is conducted after
all the analyses are completed.

Accident Investigation Workbook/Rev 2

A-4
Appendix B

References
 Appendix B — References

B
References
a. DOE Order 225.1A, Accident Investigations.

b. Implementation Guide for Use with DOE Order 225.1A (DOE G 225.1-1).

c. DOE Order 232.1, Occurrence Reporting and Processing of Operations

Information, September 25, 1995.

d. DOE Order 360.1, Training, May 31, 1995.

e. DOE Policy 450.4, Safety Management System Policy, October 15, 1996.

f. DOE Guide 450.4-1, Integrated Safety Management System Guide, Revision 0;

Volumes 1 and 2, November 26, 1997.

g. DOE Policy 450.6, Secretarial Policy Statement Environment, Safety and

Health, April 14, 1998.

h. General Technical Qualification Standard, Section 5.1, August 26, 1994.

i. Department-Wide Area Qualification Standard—Occupational Safety

Qualification Standard Competencies, Section 1.4, May 1995.

j. Ferry, Ted S., Modern Accident Investigation and Analysis, 2nd Edition, John
Wiley & Sons, New York, New York, 1988.

k. Stephenson, Joe, System Safety 2000: A Practical Guide for Planning,

Managing, and Conducting System Safety Programs, Van Nostrand Reinhold,
New York, New York, 1991.

l. Center for Chemical Process Safety, Guidelines for Investigating Chemical

Process Incidents, American Institute of Chemical Engineers, New York, New
York, 1992.

Accident Investigation Workbook/Rev 2

B-1
 Appendix C

Specific Administrative Needs

 Appendix C — Specific Administrative Needs

C
Specific Administrative Needs
Roles and Responsibilities of
The Administrative Coordinator
The onsite administrative coordinator assists n Selecting a hotel and reserving a block of
the board chairperson and board members rooms
in the day-to-day activities of the accident
investigation. This includes serving as a n Obtaining office supplies and
central point of contact for the board, making consumables for use by board members
arrangements for office facilities and equip- and support staff
ment, managing report production, and
maintaining investigation records. n Arranging for after-hours access to the
site and work space
Generally, the administrative coordinator
(working closely with the board chairperson)
n Serving as the custodian for all keys
is responsible for:
provided by the site
n Arranging for appropriate onsite office/ n Determining site/field office contact for
work space and furnishings (including a
administrative and logistical support
large conference room that can be locked
when not in use by the board, several
n Preparing and maintaining interview
small, hard-walled offices for conducting
schedules (if requested by board
interviews, a central area to locate a
chairperson)
library of documents collected, and
several lockable file cabinets)
n Creating and maintaining onsite accident
investigation files
n Arranging for local court reporter(s)
n Maintaining chain of custody for evi-
n Arranging for security badges/passes for
dence (if requested by board chairperson)
board members and property permits for
personal equipment (cameras, computers,
etc.) n Attending daily board meetings and
taking notes to assist the chairperson
n Arranging for specific security, access,
safety, and health training, as required n Tracking action items and follow-up
activities to completion
n Arranging for telephone service and
dedicated fax machine n Coordinating report preparation and
production activities on site and at
Headquarters
n Arranging for a dedicated, high-speed
copy machine that has collating and
stapling capability n Arranging for shipment of files and
records to Headquarters for archiving
at the end of the investigation.
Accident Investigation Workbook/Rev 2
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 Appendix D

Safety Management System

 Appendix D — Safety Management System

D
Safety Management System
Board members should use the framework of DOE’s integrated safety management system,
contained in DOE Policy 450.4, to determine the effectiveness of management systems, the
adequacy of policy and policy implementation, and the effectiveness of line management over-
sight as they relate to the accident. The following two tables contain typical questions board
members may ask to evaluate the core functions and guiding principles of integrated safety
management.

Table D-1. These are typical questions for addressing the five core functions of
integrated safety management.

Function #1: Define the scope of work.

n Were the purpose and scope of the work to be performed clearly defined so that workers
could identify any unanticipated conditions and actions that would be outside the authorized
work scope?
n Were expectations regarding the removal or control of hazards clearly defined and
communicated to the workers?
n Were the required safety support activities identified?
n Were roles, responsibilities, and authorities for the work activity defined and executed
appropriately?
n Were the worker qualifications required to safely perform the work identified?
n Were the design, operation, and configuration of equipment known and considered in work
planning?
n Were the characteristics of the work environment known and considered in work planning?

Function #2: Identify and analyze the hazards.

n Were the type and magnitude of all possible hazards clearly understood?
n Was the accident potential analyzed?
n Were the consequences of potential accidents described and understood by line
management, supervisors, and workers?
n Did the workers provide input to the hazard analysis?
n Did the workers receive any feedback regarding their input?
n Were the standards and requirements associated with the hazards identified?

Function #3: Develop and implement hazard controls.

n Were required physical and engineering hazard controls evaluated for likely effectiveness
under the expected work conditions?
n Were the required administrative controls, such as technical procedures and safety
support personnel, in place?
n Were the workers qualified and given hazard- or activity-specific training?
n Was a proper review, approval, and configuration control process in place?

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Appendix D — Safety Management Program

Table D-1. These are typical questions for addressing the five core functions
of integrated safety management. (Continued)

Function #4: Perform work within controls.

n Was the readiness to perform the work checked and confirmed prior to starting work?
n Was appropriate authorization received to start work?
n Was the work performed as planned (i.e., by the intended workers using the pre-approved
procedures with the required level of supervision and safety support present with effective
hazard controls in place)?
n Were the workers empowered to stop work if unanticipated or unsafe conditions arose?

Function #5: Provide feedback and continuous improvement.

n Was there a system to collect and use feedback from workers on workplace hazards?
n Were workers aware of any hazards affecting the work activity that were not addressed in
planning for it?
n Was management made aware of the hazard(s) identified by the workers?
n Were there any lessons learned locally, from audit or evaluation results or from external
operating experience, that applied to the work activity but were not addressed in planning for
it?

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 Appendix D — Safety Management System

Table D-2. These are typical questions for addressing the seven guiding principles
of integrated safety management.

Guiding Principle #1: Line management is directly responsible for the protection of the
public, workers, and the environment.

n Did DOE assure and contractor line management establish documented safety policies and
goals?
n Was ISM fully implemented down to the activity level at the time of the accident?
n Was DOE line management proactive in assuring timely implementation of ISM by line
organizations, contractors, subcontractors, and workers?
n Were ES&H performance expectations for DOE and contractor organizations clearly
communicated and understood?
n Did line managers elicit and empower active participation by workers in safety management?
Guiding Principle #2: Clear lines of authority and responsibility for ensuring safety shall be
established and maintained at all organizational levels within the Department and its
contractors.

n Did line management define and maintain clearly delineated roles and responsibilities for
ES&H to effectively integrate safety into sitewide operations?
n Was a process established to ensure that safety responsibilities were assigned to each
person (employees, subcontractors, temporary employees, visiting researchers, vendor
representatives, lessees, etc.) performing work?
n Did line management establish communication systems to inform the organization, other
facilities, and the public of potential ES&H impacts of specific work processes?
n Were managers and workers at all levels aware of their specific responsibilities and account
ability for ensuring safe facility operations and work practices?
n Were individuals held accountable for safety performance through performance objectives,
appraisal systems, and visible and meaningful consequences?
n Did DOE line management and oversight hold contractors and subcontractors accountable
for ES&H through appropriate contractual and appraisal mechanisms?
Guiding Principle #3: Personnel shall possess the experience, knowledge, skills, and
abilities that are necessary to discharge their responsibilities.

n Did line managers demonstrate a high degree of technical competence and a good
understanding of programs and facilities?
n Did line management have a documented process for assuring that DOE personnel,
contractors, and subcontractors are adequately trained and qualified on job tasks, hazards,
risks, and Departmental and contractor policies and requirements?
n Were mechanisms in place to assure that only qualified and competent personnel were
assigned to specific work activities, commensurate with the associated hazards?
n Were mechanisms in place to assure understanding, awareness, and competence in
response to significant changes in procedures, hazards, system design, facility mission, or
life cycle status?
n Did line management establish and implement processes to ensure that ES&H training
programs effectively measure and improve performance and identify training needs?
n Was a process established to ensure that (1) training program elements are kept current and
relevant to program needs, and (2) job proficiency is maintained?

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Appendix D — Safety Management Program

Table D-2. These are typical questions for addressing the seven guiding principles
of integrated safety management. (Continued)

Guiding Principle #4: Resources shall be effectively allocated to address safety, program-
matic, and operational considerations. Protecting the public, the workers, and the
environment shall be a priority whenever activities are planned and performed.

n Did line management demonstrate a commitment to ensuring that ES&H programs had
sufficient resources and priority within the line organization?
n Did line management clearly establish that integrated safety management will be applied to
all types of work and address all types of hazards?
n Did line management institute a safety management system that provided for integration of
ES&H management processes, procedures, and/or programs into site, facility, and work
activities in accordance with the Department of Energy Acquisition Regulation (DEAR)
ES&H clause (48 CFR 970.5204-2)?
n Were prioritization processes effective in balancing and reasonably limiting the negative
impact of resource reductions and unanticipated events on ES&H funding?

Guiding Principle #5: Before work is performed, the associated hazards shall be evaluated
and an agreed-upon set of safety standards shall be established that, if properly imple-
mented, will provide adequate assurance that the public, the workers, and the environ-
ment are protected from adverse consequences.

n Was there a process for managing requirements, including the translation of standards and
requirements into policies, programs, and procedures, and the development of processes to
tailor requirements to specific work activities?
n Were requirements established commensurate with the hazards, vulnerabilities, and risks
encountered in the current life cycle stage of the site and/or facility?
n Were policies and procedures, consistent with current DOE policy, formally established and
approved by appropriate authorities?
n Did communication systems assure that managers and staff were cognizant of all standards
and requirements applicable to their positions, work, and associated hazards?

Guiding Principle #6: Administrative and engineering controls to prevent and mitigate
hazards shall be tailored to the work performed and associated hazards.

n Were the hazards associated with the work activity identified, analyzed, and categorized so
that appropriate administrative and engineering controls could be put in place to prevent or
mitigate the hazards?
n Were hazard controls established for all stages of work to be performed (e.g., normal
operations, surveillance, maintenance, facility modifications, decontamination, and
decommissioning)?
n Were hazard controls established that were adequately protective and tailored to the type
and magnitude of the work and hazards and related factors that impact the work environ-
ment?
n Were processes established for ensuring that DOE contractors and subcontractors test,
implement, manage, maintain, and revise controls as circumstances change?
n Were personnel qualified and knowledgeable of their responsibilities as they relate to work
controls and work performance for each activity?

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 Appendix D — Safety Management System

Table D-2. These are typical questions for addressing the seven guiding principles
of integrated safety management. (Continued)

Guiding Principle #7: The conditions and requirements to be satisfied for operations to be
initiated and conducted shall be clearly established and agreed upon.

n Were processes in place to assure the availability of safety systems and equipment neces-
sary to respond to hazards, vulnerabilities, and risks present in the work environment?
n Did DOE and contractor line management establish and agree upon conditions and require-
ments that must be satisfied for operations to be initiated?
n Was a management process established to confirm that the scope and authorization docu-
mentation is adequately defined and directly corresponds to the scope and complexity of the
operations being authorized?
n Was a change control process established to assess, approve, and reauthorize any
changes to operations scope ongoing at the time of the accident?

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 Appendix E

Subject Index
 Appendix E — Subject Index

E
Subject Index
Accident Analysis, 3-2, 5-12, 7-1, 9-23
definition, 1-1, 1-8, A-1 definition, A-1
why accidents occur, 1-1 example (report), 9-14 to 9-16
Accident Investigation how analysis impacts the investigation, 7-1
activities and schedules, 2-11, 5-2 to 5-4 reporting, 9-10, 9-12, 9-13
definition, A-1 software, 5-12, 7-40, 7-41
process overview, 2-9 see also Analytic Trees, Analyzing Data,
scope, 3-2, 6-12 Core Analytical Techniques,
see also Managing the Investigation Management Oversight Risk Tree
Process (MORT) Analysis, Project Evaluation
Accident Investigation Board, 1, 2-3, 3-1 to 3-3, Tree (PET) Analysis
4-6, 5-1, 5-3, 5-6, 5-7, 5-9, 6-1, 7-1, 7-2, Analytic Trees, 7-41
7-5, 7-6, 7-21, 7-27, 7-28, 8-1 to 8-5 completed analytic tree, 7-47
responsibilities, 2-3, 5-1 to 5-3 constructing the analytic tree, 7-41 to 7-46
see also Advisors and Consultants, definition, A-1
Board Chairperson, Board Members, initiating the process, 7-41
Support Staff layout of an analytic tree, 7-46
Accident Investigation Day Planner: Guide for preparation steps, 7-42, 7-43, 7-45
Accident Investigation Board Chairpersons, symbols used, 7-44
5-3 Analyzing Data, 7-1
Accident Investigation Equipment Checklist, case study, 7-10 to 7-12, 7-16, 7-18, 7-22,
2-8, 2-15 to 2-19, 5-3 7-23
Accident Investigation “Go Kit,” 2-20, 2-21, 5-3 determining facts, 7-2, 7-59
Accident Investigation Information managing the analyses, 5-12
Request Form, 5-1, 5-10, 5-22 see also Board Chairperson
Accident Investigation Process Overview, Appendices (report), 9-18
2-9 to 2-11 Appointing Official, 2-1 to 2-4, 2-10, 2-11,
Accident Investigation Startup Activities List, 2-13, 3-1 to 3-3, 5-2, 5-9 to 5-11, 5-13,
5-1, 5-19 to 5-21 5-17, 8-2, 8-3, 9-1, 9-3, 9-4, 9-22
Accident Reconstruction, 7-57 5-9, 5-10, 6-9
Accident Scene, 2-6, 2-8, 2-9, 4-1 to 4-6, 5-6, appointment memorandum, 3-1, 3-2
5-10 briefing the board, 3-2
documenting, 4-3, 5-10 definition, A-1
securing and preserving, 4-2, 4-3 roles and responsibilities, 2-1 to 2-3, 2-13
taking control of, 5-6 selecting the accident investigation board,
Acronyms and Initialisms (report), 9-4, 9-6 3-1 to 3-3
Administrative Coordinator, 2-5, C-1 statement of report acceptance and example,
see also Support Staff 9-4
Advanced Analytic Methods Appointment Letter (report), 9-5, 9-18
see also Analytic Trees, Management Appointment Memorandum, 3-1 to 3-3
Oversight and Risk Tree (MORT) Analysis, Assistant Secretary for Environment, Safety, and
Project Evaluation Tree (PET) Analysis Health (EH-1), 2-1, 2-4, 2-12, 2-13, 3-1,
Advisors and Consultants, 1, 2-5, 3-1, 3-2, 5-1, 3-2, 5-13, 8-2
5-6, 5-9, 5-12 to 5-14, 6-17, 7-53, 9-18 report review, 2-13
qualifications, 2-5, 3-1 Barrier, 1-1, 1-8, 7-13
special knowledge or expertise, 2-5 definition, A-1

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Appendix E — Subject Index

management barriers, 1-1, 7-14 Board Signatures (report), 9-18, 9-19

physical barriers, 1-1, 7-14 Case Study, 7-3, 7-10 to 7-12, 7-16, 7-18, 7-22,
see also Barrier Analysis 7-23
Barrier Analysis, 7-6, 7-13 to 7-17, 7-24, 7-56, Categories and Questions for Completing Root
7-59, 9-10, 9-13, 9-14 Cause Analysis Tier Diagram, 7-30 to 7-33
analyzing results and example, 7-17, 7-18 Causal Factors, 5-2, 5-12, 5-13, 5-17, 6-11,
basic process, 7-16 7-2, 7-4 to 7-12, 7-20, 7-24 to 7-29, 7-37,
case study, 7-16 to 7-18 7-42, 7-43, 8-1 to 8-5, 9-1, 9-13, 9-15, 9-16
definition, A-1 definition, A-1
guidelines for completing, 7-15 determining causal factors, 7-4
minimum data and sources needed, 7-15 report; example, 9-15, 9-16
summary chart, 7-18 see also Contributing Causes, Direct
summary results (report and examples), 9-14 Cause, Root Causes
Barrier Analysis Worksheet Cause
example, 7-16 definition, A-2
Bloodborne Pathogens, 6-7 Chain of Custody, 4-4, 6-17, 6-19
universal precautions, 6-8 definition, A-2
Board Chairperson, 1, 2-4 to 2-13, 3-1 to 3-3, Change, 7-17
4-1, 4-6, 5-1 to 5-3, 6-9, 6-17, 8-5, 9-20 definition, A-2
briefings, 3-2, 4-6, 5-6, 5-13, 5-17 Change Analysis, 7-17, 7-20 to 7-23, 7-59,
communications, internal and 9-12
external, 2-4, 5-5 to 5-7, 5-9 to 5-13 change analysis process, 7-17
costs and schedules, 5-2, 5-3, 5-14 conducting change analysis, 7-17
definition, A-1 data sources, 7-20
developing teamwork, 5-7 to 5-9, 5-16 definition, 7-17, A-2
managing information collection, 5-9, 5-10, questions to consider, 7-22, 7-23
6-9 report; example, 9-15
managing onsite closeout activities, 5-13 summary from case study, 7-23
managing post-investigation activities, 5-14 Change Analysis Worksheet, 7-22, 7-62
managing report writing, 5-12, 9-21 Classification Review, 9-21
managing the investigative process and Closeout Activities, 5-13
analysis, 3-2, 5-1, 5-6, 5-12, 5-15, 7-41, 7- see also Board Chairperson
53 Cognizant Secretarial Officer, 2-3, 4-1
see also Collecting Data/Evidence Collecting Data/Evidence, 4-3, 4-4, 6-1, 6-2
project control, 5-1, 5-6, 5-13, 5-15 chain of custody, 4-4, 6-17
project planning, 5-1 to 5-5, 5-16 collecting physical evidence, 6-7
see also Project Planning description, 6-1, 6-18
qualifications, 3-1, 3-2 managing the process, 5-9
quality (investigation), 2-4, 5-15, 9-1 preserving and controlling, 6-13, 6-17, 6-18
report review, 9-21 steps in pursuing evidentiary material, 6-2,
roles and responsibilities, 2-4, 2-13 6-18
submitting the report, 9-22 types of evidence, 6-1, 6-18
training requirements, 3-2 Command Center, 4-1, 5-3, 7-13
Board Members, 1, 2-2, 2-4, 2-5, 3-1, 5-1, 5-6, Common Cause Failure Analysis, 7-54
5-9, 5-10, 5-12, 6-1, 6-9, 6-17, 7-2, 7-21, Communications, 5-5, 5-16
7-27, 7-53, 8-2, 8-4, 8-5, 9-19 external, 5-9 to 5-11, 5-13, 5-16
briefing, 3-2 internal, 5-7, 5-9 to 5-11, 5-16
definition, A-1 see also Board Chairperson, roles and
qualifications, 3-1, 3-2 responsibilities
report writing, 9-1 to 9-20 Compliance/Noncompliance, 7-27, 7-38 to
roles and responsibilities, 2-4, 2-5, 2-13, 7-40
5-8, 5-12 see also Root Cause Analysis
training requirements, 3-2 Conclusions, 2-4, 2-10, 2-11, 3-2, 5-2, 5-13,
see also Analyzing Data, Collecting 6-1, 8-1, 8-2, 8-4, 8-5, 9-1, 9-2, 9-5, 9-8,
Data/Evidence, Report Writing 9-9, 9-15, 9-17, 9-21

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 Appendix E — Subject Index

definition, 8-1, A-2 DOE Accident Investigation Program, 1, 2-1,

examples, 8-1 2-13,
procedures for developing, 8-1 DOE Headquarters, 2-4, 5-5, 5-7, 5-9, 5-10,
report; example, 9-8, 9-17 5-13, 6-6, 6-12
Conflict of Interest, 3-1, 3-3, 5-3, 5-23 DOE Office of Enforcement and Investigation
Consultants (EH-10), 2-4, 5-11
see Advisors and Consultants DOE Office of the General Counsel, 2-5
Contractors (site), 2-6 to 2-8, 5-9, 5-16, 9-21 DOE Office of the Inspector General, 2-4, 5-11
determine composition of readiness team, DOE Office of Oversight, 2-1, 2-9, 2-11, 9-20
2-6, 2-7 DOE Office of Security Evaluations, 2-1
establish readiness to respond to accidents, DOE Operations
2-6 to 2-8 definition, A-2
establish site readiness procedures, 2-8 DOE Order 225.1A, Accident Investigations,
readiness training, 2-8, 2-9 1, 2-6,2-7, 2-9, 2-12, 3-1, 5-11, 5-13, 6-6,
Contributing Causes, 7-4, 7-5, 7-17, 7-49, 6-12, 7-1, 9-2, 9-4, 9-21, 9-22
7-59, 9-8, 9-15 Attachment 1, Contractor Requirements
determining and examples, 7-4, 9-8 Document, 2-6
see also Causal Factors, Direct Cause, categorization algorithm, 2-2, 2-6
Root Causes criteria for selecting board members, 3-1,
Controlling Information, 5-3, 5-5, 5-9, 5-13, 3-2
5-16, 6-17, 6-18 report format and contents requirements,
Controls 9-2, 9-3
definition, A-2 DOE Order 232.1, Occurrence Reporting and
Core Analytical Techniques, 7-6, 7-15, 7-26, Processing of Operations Information, 2-6,
7-41, 7-59 2-9
see also Barrier Analysis, Change DOE Policy 450.4, Safety Management System
Analysis, Events and Causal Factors Policy, 1-6, 3-3, 6-12
Charting and Analysis, Root Cause evaluation factors, D-1, D-2
Analysis DOE Site
Core Functions for Integrated Safety definition, A-2
Management, 6-14, 6-19, D-1, D-2 see also Heads of Field Elements, Site
Corrective Actions, 2-2, 2-13, 5-13, 5-17, 7-1, Managers
7-27, 8-2 Emergency Response
report, 9-22 see Readiness Teams, Site Readiness
Cost Control, 5-14 Energy, 7-14
Court Reporters, 2-6 definition, A-2
see also Support Staff Energy Flow, 7-14
Decision Processes, 5-8 definition, A-2
Department-Wide Area Qualification Equipment/Design Considerations
Standard—Occupational Safety Qualifica- see Human Factors
tion Standard Competencies, B-1 Event
Deputy Assistant Secretary for Oversight definition, A-3
(EH-2), i, 2-2, 2-9, 2-12, 5-10, 5-11, 5-16 Events and Causal Factors Charting and
report review, 2-11, 9-22 Analysis, 7-6 to 7-13, 7-24 to 7-26, 7-37,
Design Criteria Analysis, 7-57 7-59
Direct Cause, 7-4, 7-30, 7-59, 9-8, 9-15 benefits, 7-7
determining and examples, 7-59, 9-8 case study, 7-10 to 7-12
see also Causal Factors, Contributing conducting the analysis, 7-24
Causes, Root Causes constructing the chart, 7-7, 7-8
Disclaimer definition, A-3
report; example, 9-3 guidelines and symbols, 7-9
Documentary Evidence, 4-3, 4-6, 6-1, 6-2, 6-11, methods (manual and computerized), 7-7,
6-18, 6-19 7-8
examples, 6-11, 6-12, 6-19 Evidence, 4-2 to 4-4, 5-6, 6-1
see also Collecting Data/Evidence see also Collecting Data/Evidence

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Appendix E — Subject Index

Evidence Locations and Orientations, 6-28 human-machine interface, 1-2, 1-3, 1-8
Executive Summary organizational work environment, 1-6
report and example, 9-6 to 9-9 physical work environment, 1-5 to 1-7, 1-8
Facts, 2-3, 2-11, 3-2, 6-2, 6-12, 7-1, 7-2, 7-59, Human Factors Analysis, 7-55
8-1 to 8-3, 8-5, 9-1, 9-2, 9-6, 9-11, 9-21, Human-Machine Interface
9-23 human-machine activity model, 1-2
case study, 7-3 Immediate Post-Accident Actions, 4-1, 4-2
see also Collecting Data/Evidence see also Site Readiness
Facts and Analysis (report), 9-5, 9-10, 9-21 Integrated Accident Event Matrix, 7-56
accident description and chronology, 9-12 Integrated Safety Management System, 5-6,
case study, 9-14, 9-15 6-12, 6-14, 6-18, D-1, D-2
description and analysis, 9-12 to 9-15 see also Core Functions for Integrated
facts vs. analysis, 9-12 Safety Management, Guiding Principles
Factual Accuracy Review, 9-21, 9-22 for Integrated Safety Management
see also Report Writing Interviews, 4-4, 4-5, 5-10, 6-2 to 6-6, 6-18
Failure Modes and Effects Analysis, 7-56 Accident Investigation Interview Schedule
Field Element, 2-2, 2-3, 2-6 to 2-9, 2-13, Form, 6-3, 6-21
3-1, 4-1 Accident Investigation Preliminary
definition, A-3 Interview List, 4-4, 4-9, 6-3
see also Field Office Points of Contact, Accident Investigation Witness Statement
Heads of Field Elements, Program Office Form, 4-5, 4-10, 4-11
Points of Contact model opening statement, 5-5, 6-23
Field Office Points of Contact (point of see also Collecting Data/Evidence
contact), 1, 2-1, 2-3, 2-7, 2-9, 2-13, 4-1, Introduction (report), 9-10
4-6, 5-1, 6-1 case study, 9-8, 9-11
activities with readiness teams, 2-7, 2-9 example (executive summary), 9-8, 9-11
briefings, 4-6, 6-1 Investigation
definition, A-3 definition, A-3
immediate post-accident actions, 4-1 see also Accident Investigation
roles and responsibilities, 2-3, 2-7, 2-9, 2-13 Investigation Report
transition and transfer, 4-6 definition, A-3
Freedom of Information Act (FOIA), 2-5, 5-3, see also Report Writing
5-5, 6-5, 6-6, 6-23 Judgments of Need, 2-1, 2-2 to 2-4, 2-10
see also Project Planning to 2-12, 3-2, 3-3, 5-2, 5-12, 5-13, 5-17, 7-2,
General Technical Qualification Standard, B-1 8-1 to 8-5, 9-1, 9-2, 9-6, 9-8, 9-9, 9-21
“Go Kit” case study examples, 8-4, 9-8, 9-9, 9-17
see Accident Investigation “Go Kit” definition, 8-2, A-3
Guiding Principles for Integrated Safety guidance for writing, 8-2, 8-4, 9-15
Management, 6-15 to 6-17, 6-19, 7-5, Legal Advisor, 2-5, 5-5
D-3 to D-5 Lessons Learned, 2-2, 2-13, 9-1, 9-2
Hazard, 7-13 to 7-16 Limited Scope Investigations, 2-12, 3-1, 9-22
definition, A-3 Line Management Oversight, 3-2, 5-12, 6-12,
Heads of Field Elements, 2-2, 2-6 to 2-9, 2-13, 9-6
3-1, 4-1, 5-13, 5-14 Management Oversight and Risk Tree (MORT)
establish site readiness, 2-6 to 2-9, 4-1 analysis, 7-47 to 7-52
roles and responsibilities, 2-2, 2-13 benefits, 7-48
Human Capabilities completed MORT charts, examples, 7-50 to
see Human Factors 7-52
Human Evidence, 4-2 to 4-4, 6-1, 6-2, 6-18 Management Systems, 1-6, 2-3, 2-4, 3-2, 3-3,
conducting interviews, 6-2 to 6-6, 6-18 5-12, 6-12, 6-19, 7-6, 7-7, 7-38, 7-48, 9-6
see also Collecting Data/Evidence Managing the Accident Investigation, 5-1
Human Factors, 1-1, 1-8 see also Board Chairperson
“activity model,” 1-2 Managing the Investigation Process, 5-6
equipment/design considerations, 1-4, 1-8 see also Board Chairperson
human capabilities, 1-2 to 1-4, 1-8 Mapping and Sketching the Accident Site
see Photography, Physical Evidence
Accident Investigation Workbook/Rev 2
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 Appendix E — Subject Index

Materials and Structural Analysis, 7-57 Price-Anderson Amendment Act of 1988, 2-4,
Media (press) relations, 4-5, 5-5, 5-10, 5-14, 5-11
5-16, 6-3 Privacy Act, 2-5, 5-3, 5-5, 5-14, 5-16, 6-5, 6-6
Medical Advisor, 2-5 Program Manager (DOE Accident Investigation
Minority Opinions, 8-4, 8-5 Program Manager), 2-1, 2-13, 3-1, 4-1, 4-6,
Minority Report, 5-13, 9-18 5-3, 5-13, 5-14, 9-22
Occupational Safety and Health Administration Program Office Points of Contact, 1, 2-3, 2-6,
(OSHA), 1-5 2-7, 2-9, 2-13, 4-1, 4-6, 5-1, 6-13
Occurrence see also Field Office Points of Contact
definition, A-3 Project Evaluation Tree (PET) Analysis, 7-49,
see also DOE 232.4 Occurrence 7-53
Reporting and Processing of Operations benefits, 7-49
Information branch of PET chart, 7-54
Occurrence Reporting and Processing System PET analysis worksheet, 7-63
(ORPS), B-1 Project Planning, 5-1 to 5-5, 5-16
definition, A-3 acquiring resources, 5-3
Other Analytic Techniques, 7-53 determining task assignments, 5-1
common cause failure, 7-56 scheduling, 5-2, 5-3, 5-4
design criteria, 7-57 see also Board Chairperson, Managing
failure modes and effects, 7-56 the Accident Investigation
human factors, 7-55 Prologue (report), 9-6, 9-7, 9-23
integrated accident event matrix, 7-56 Promoting Teamwork, 5-7 to 5-9
materials and structural, 7-57 see also Board Chairperson
scientific modeling, 7-55, 7-56 Protocols (information), 5-3, 5-5, 5-10, 5-14,
sneak circuit, 7-56 5-16, 6-13
software hazards, 7-56 Quality Assurance, 5-15
time loss and sample, 7-53, 7-55 Quality Review (report), 9-21
Photography, 2-5, 2-6, 2-9, 4-3, 4-4, Readiness, 2-6, 2-7
6-8 to 6-10, 6-13, 6-18, 6-19, 9-10 see also Accident Investigation “Go Kit,”
Accident Investigation Photographic Log Site Readiness
Sheet, 6-9, 6-10, 6-13, 6-29 Readiness Teams, 2-7 to 2-10, 4-1, 4-7
Accident Investigation Sketch of collecting, preserving, and controlling
Photography Locations and Orientations, evidence, 4-2 to 4-4, 4-6
6-10, 6-28 composition, 2-8
Physical Evidence, 4-2, 4-3, 6-1, 6-2, definition, A-4
6-7 to 6-10, 6-18, 6-19 documenting the accident scene, 4-3, 4-7
Accident Investigation Physical Evidence immediate post-accident activities, 4-1, 4-2,
Log Form, 6-8, 6-17, 6-24 4-7
Accident Investigation Position Mapping see also Collecting Data/Evidence
Form, 6-9, 6-27 obtaining initial witness statements, 4-4, 4-5,
Accident Investigation Site Map, 6-9, 6-26 4-7
Accident Investigation Site Sketch, 6-9, preserving the accident scene, 4-2, 4-7
6-25 roles and responsibilities, 2-6, 2-7, 4-2, 4-3,
Accident Investigation Sketch of Physical 4-7, 6-2
Evidence Locations and Orientations, transferring information to the board, 4-6,
6-9, 6-28 4-7
inspecting and preserving, 4-2 to 4-4, Report Acceptance, 9-22, 9-23
6-7 to 6-11, 6-13 Report Writing, 5-1, 5-12, 9-1
photographing and videotaping, 6-9, 6-10 elements, 9-3
removing and guidelines, 6-10, 6-11 format and contents, 9-2, 9-3, 9-18
sketching and mapping, 4-3, 6-8, 6-18, 6-19 managing the report writing, 5-12, 5-13
see also Site Readiness see also Board Chairperson
Post-Investigation Activities, 5-14 quality, 5-15, 9-21, 9-23
see also Board Chairperson reviews and approval, 9-22, 9-23

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Appendix E — Subject Index

submitting the report, 9-22, 9-23 administrative coordinator, 2-5, 5-1, 5-10,
table of contents, examples, 9-5 5-13, 6-7, 9-2, C-1
tips, 9-2 court reporters, 2-6, 5-3, 6-3
Requirements Verification Analysis, 5-15, 8-2, technical writer/editor, 2-5, 5-13, 9-2
9-21 typist/text processor, 2-5
definition, A-4 Table of Contents
see also Report Writing report and example, 9-4, 9-5
Root Cause, 3-2, 7-4, 7-5, 7-24, 7-37, 7-38, see also Report Writing
7-40, 7-43, 9-8, 9-15 Target, 7-13 to 7-18
definition, 7-4, A-4 definition, A-4
see also Contributing Causes, Direct see also Barrier Analysis
Cause, Root Cause Analysis Team Dynamics, 5-7 to 5-9, 5-16
Root Cause Analysis, 7-6, 7-26, 7-27, 9-10, see also Board Chairperson, Promoting
9-13 Teamwork
compliance/noncompliance technique, Technical Experts, 2-5
7-38 to 7-40 Technical Writer/Editor, 2-5
definition, 7-26, A-4 see also Support Staff
initiating an analysis, 7-27 Tier Diagram Worksheet for Root Cause
tier diagraming guidelines, steps and sample, Analysis, 7-29
7-28 to 7-38 Tier Diagraming, 7-28 to 7-38
Safety Management System Policy see also Root Cause Analysis
see DOE Policy 450.4 Time Loss Analysis, 7-53, 7-55
Scientific Modeling, 7-57, 7-58 Type A Investigation, 2-2, 2-4, 2-6,
Signatures of Board 2-11 to 2-13, 3-1, 3-2, 5-3, 5-10,
report and example, 9-18, 9-19 5-13 to 5-16, 9-3, 9-22, 9-23
Site Managers, 2-4, 2-7, 5-10, 5-13, 5-16 Type B Investigation, 2-2, 2-6, 2-11 to 2-13,
Site Readiness, 2-6 to 2-9, 4-1 3-1, 3-2, 5-15, 9-3, 9-22, 9-23
implementing, 4-1 Typist/Text Processor, 2-5
practice and evaluation, 2-9 see also Support Staff
readiness training, 2-8, 2-9 Unions, 2-5, 5-16
resources, 2-8 Unlawful Activity, 2-4, 5-11
written procedures, 2-8 Validation
see also Readiness see Requirements Verification Analysis
Site Readiness Teams Videotape, 4-2 to 4-4, 6-8, 6-9
see Readiness Teams Walk-through (accident scene), 4-2, 4-3, 7-2
Sketches Witnesses, 4-1, 4-3 to 4-5, 4-7, 5-10,
see Photography, Physical Evidence 6-1 to 6-3, 6-6, 6-18
Sneak Circuit Analysis, 7-56 see also Interviews
Software Hazards Analysis, 7-56 Work Environment
Support Staff, 2-5, 5-6, 5-9, 5-13, 5-14, 6-17 see Human Factors

Accident Investigation Workbook/Rev 2

E-6