Accident: An unwanted transfer of energy or an environmental condition which, due to the absence or failure of barriers or controls, produces injury to persons, damage to property, or reduction in process output.Accident Investigation: The systematic appraisal of unwanted events for the purpose of determining causal factors, subsequent corrective actions, and preventive measures.
Accident or Emergency Response Team: A team or teams of emergency and accident response personnel for a particular site. This team may be composed of a number of teams from the site, such as local police and firefighter units, emergency medical personnel, and hazardous material teams.
Analysis: The use of methods and techniques for arranging data to: (a) assist in determining what additional data are required; (b) establish consistency, validity, and logic; (c) establish necessary and sufficient events for causes; and (d) guide and support inferences and judgments.1
Analytical Tree: Graphical representation of an accident in a deductive approach (general to specific). The structure resembles a tree—that is, narrow at the top with a single event (accident) and then branching out as the tree is developed, and identifying root causes at the bottom branches.
Appointing Official: A designated authority responsible for assigning accident investigation boards for Type A and Type B investigations, with responsibilities as prescribed in DOE Order 225.1A, Paragraph 5.d.
Barrier: Anything used to control, prevent, or impede energy flows. Common types of barriers include equipment, administrative procedures and processes, supervision/management, warning devices, knowledge and skills, and physical objects.
Barrier Analysis: An analytical technique used to identify energy sources and the failed or deficient barriers and controls that contributed to an accident.
Board Chairperson: The leader who manages the accident investigation process, represents DOE in all matters regarding the accident investigation, and reports to the appointing official for purposes of the accident investigation.
Board Members: A group of three to six DOE staff assigned to investigate an accident. This group reports to the board chairperson during the accident investigation.
Causal Factor: An event or condition in the accident sequence necessary and sufficient to produce or contribute to the unwanted result. Causal factors fall into three categories:
- Direct cause
- Contributing cause
- Root cause
Cause: Anything that contributes to an accident or incident. In an investigation, the use of the word "cause" as a singular term should be avoided. It is preferable to use it in the plural sense, such as "causal factors," rather than identifying "the cause."
Chain of Custody: The process of documenting, controlling, securing, and accounting for physical possession of evidence, from initial collection through final disposition.
Change: Stress on a system that was previously in a state of equilibrium, or anything that disturbs the planned or normal functioning of a system.
Change Analysis: An analytical technique used for accident investigations, wherein accident-free reference bases are established, and changes relevant to accident causes and situations are systematically identified. In change analysis, all changes are considered, including those initially considered trivial or obscure.
Conclusions: Significant deductions derived from analytical results. Conclusions are derived from and must be supported by the facts, plus results from testing and analyses conducted. Conclusions are statements that answer two questions the accident investigation addresses: what happened and why did it happen? Conclusions include concise recapitulations of the causal factors (direct, contributing, and root causes) of the accident determined by analysis of facts.
Contributing Cause: An event or condition that collectively with other causes increases the likelihood of an accident but that individually did not cause the accident.
Controls: Those barriers used to control wanted energy flows, such as the insulation on an electrical cord, a stop sign, a procedure, or a safe work permit.
Direct Cause: The immediate events or conditions that caused the accident.
DOE Accident Investigator: An individual who understands DOE accident investigation techniques and has experience in conducting investigations through participation in at least one Type A or Type B investigation. Effective October 1, 1998, DOE accident investigators must have attended an accident investigation course of instruction that is based on current materials developed by the Office of Deputy Assistant Secretary for Oversight.
DOE Operations: Activities funded by DOE for which DOE has authority to enforce environmental protection, safety, and health protection requirements.
DOE Site: A tract either owned by DOE, leased, or otherwise made available to the Federal government under terms that afford DOE rights of access and control substantially equal to those it would possess if it held the fee (or pertinent interest therein) as agent of and on behalf of the government. One or more DOE operations/program activities carried out within the boundaries of the described tract.
Energy: The capacity to do work and overcome resistance. Energy exists in many forms, including acoustic, potential, electrical, kinetic, thermal, biological, chemical, and radiation (both ionizing and non-ionizing).
Energy Flow: The transfer of energy from its source to some other point. There are two types of energy flows: wanted (controlled—able to do work) and unwanted (uncontrolled—able to do harm).
Event: An occurrence; something significant and real-time that happens. An accident involves a sequence of events occurring in the course of work activity and culminating in unintentional injury or damage.
Events and Causal Factors Chart: Graphical depiction of a logical series of events and related conditions that precede the accident.
Eyewitness: A person who directly observed the accident or the conditions immediately preceding or following the accident.
Fatal Injury: Any injury that results in death within 30 calender days of the accident.
Field Element: A general term for all DOE sites (excluding individual duty stations) located outside the Washington, D.C. metropolitan area.
General Witness: A person with knowledge about the activities prior to or immediately after the accident (the previous shift supervisor or work controller, for example).
Hazard: The potential for energy flow(s) to result in an accident or otherwise adverse consequence.
Heads of Field Elements: First-tier field managers of the operations offices, the field offices, and the power marketing administrations (Administrators).
Human Factors: The study of human interactions with products, equipment, facilities, procedures, and environments used in work and everyday living. The emphasis is on human beings and how the design of equipment influences people.
Investigation: A detailed, systematic search to uncover the "who, what, when, where, why, and how" of an occurrence and to determine what corrective actions are needed to prevent a recurrence.
Investigation Report: A clear and concise written account of the investigation results.
Judgments of Need: Managerial controls and safety measures necessary to prevent or minimize the probability or severity of a recurrence of an accident.
Lessons Learned: A "good work practice" or innovative approach that is captured and shared to promote its repeated application. A lesson learned may also be an adverse work practice or experience that is captured and shared to avoid recurrence.
Limited Scope Investigation: An accident investigation chartered by the Assistant Secretary for Environment, Safety and Health that is reduced in scope, duration, and resources from that normally associated with a Type A or Type B investigation.
Occurrence: An event or condition that adversely affects or may adversely affect DOE or contractor personnel, the public, property, the environment, or DOE mission.
Occurrence Reporting and Processing System (ORPS): The reporting system established and maintained for reporting occurrences related to the operation of DOE facilities.
Point of Contact: A DOE staff member who is assigned the role of liaison with the Accident Investigation Program Manager in the Office of Security Evaluations (EH-21), who administers the accident investigation program. In this role, the point of contact ensures that site readiness teams are trained in collecting and maintaining initial accident investigation evidence and that their activities are coordinated with accident and emergency response teams.
Principal Witness: A person who was actually involved in the accident.
Readiness Team: Trained personnel who are available to perform initial investigative response activities immediately following an accident. They are responsible for initiating the accident investigation, maintaining the integrity of evidence before the accident investigation board arrives, and supporting the board after its arrival.
Requirements Verification Analysis: A validation technique that determines whether the logical flow of data from analysis to conclusions and judgments of need is based on facts. This technique is conducted after all the analyses are completed.
Root Cause: The causal factor(s) that, if corrected, would prevent recurrence of the accident.
Root Cause Analysis: Any methodology that identifies the causal factors that, if corrected, would prevent recurrence of the accident.
Target: A person, object, or animal upon which an unwanted energy flow may act to cause damage, injury, or death.
1Ferry, Ted S., Modern Accident Investigation and Analysis, 2nd Edition, John Wiley & Sons, New York, New York, 1988.