E
Accident
definition, 1-1, 1-8, A-1
why accidents occur, 1-1
Accident Investigation
activities and schedules, 2-11, 5-2 to 5-4
definition, A-1
process overview, 2-9
scope, 3-2, 6-12
see also Managing the Investigation Process
Accident Investigation Board, 1, 2-3, 3-1 to 3-3, 4-6, 5-1, 5-3, 5-6, 5-7, 5-9, 6-1, 7-1,
7-2, 7-5, 7-6, 7-21, 7-27, 7-28, 8-1 to 8-5
responsibilities, 2-3, 5-1 to 5-3
see also Advisors and Consultants, Board Chairperson, Board Members, Support Staff
Accident Investigation Day Planner: Guide for Accident Investigation Board
Chairpersons, 5-3
Accident Investigation Equipment Checklist, 2-8, 2-15 to 2-19, 5-3
Accident Investigation "Go Kit," 2-20, 2-21, 5-3
Accident Investigation Information Request Form, 5-1, 5-10, 5-22
Accident Investigation Process Overview, 2-9 to 2-11
Accident Investigation Startup Activities List, 5-1, 5-19 to 5-21
Accident Reconstruction, 7-57
Accident Scene, 2-6, 2-8, 2-9, 4-1 to 4-6, 5-6, 5-10
documenting, 4-3, 5-10
securing and preserving, 4-2, 4-3
taking control of, 5-6
Acronyms and Initialisms (report), 9-4, 9-6
Administrative Coordinator, 2-5, C-1
see also Support Staff
Advanced Analytic Methods
see also Analytic Trees, Management Oversight and Risk Tree (MORT) Analysis,
Project Evaluation Tree (PET) Analysis
Advisors and Consultants, 1, 2-5, 3-1, 3-2, 5-1, 5-6, 5-9, 5-12 to 5-14, 6-17, 7-53, 9-18
qualifications, 2-5, 3-1
special knowledge or expertise, 2-5
Analysis, 3-2, 5-12, 7-1, 9-23
definition, A-1
example (report), 9-14 to 9-16
how analysis impacts the investigation, 7-1
reporting, 9-10, 9-12, 9-13
software, 5-12, 7-40, 7-41
see also Analytic Trees, Analyzing Data, Core Analytical Techniques, Management
Oversight Risk Tree (MORT) Analysis, Project Evaluation Tree (PET) Analysis
Analytic Methods and Techniques, 2-1, 2-4, 2-5, 7-1, 7-6, 9-1, 9-10
see also Advanced Analytic Methods, Analytic Trees, Core Analytical Techniques,
Management Oversight and Risk Tree (MORT) Analysis, Other Analytical
Techniques, Project Evaluation Tree (PET) Analysis
Analytic Trees, 7-41
completed analytic tree, 7-47
constructing the analytic tree, 7-41 to 7-46
definition, A-1
initiating the process, 7-41
layout of an analytic tree, 7-46
preparation steps, 7-42, 7-43, 7-45
symbols used, 7-44
Analyzing Data, 7-1
case study, 7-10 to 7-12, 7-16, 7-18, 7-22, 7-23
determining facts, 7-2, 7-59
managing the analyses, 5-12
see also Board Chairperson
Appendices (report), 9-18
Appointing Official, 2-1 to 2-4, 2-10, 2-11, 2-13, 3-1 to 3-3, 5-2, 5-9 to 5-11, 5-13, 5-17,
8-2, 8-3, 9-1, 9-3, 9-4, 9-22
appointment memorandum, 3-1, 3-2
briefing the board, 3-2
definition, A-1
roles and responsibilities, 2-1 to 2-3, 2-13
selecting the accident investigation board, 3-1 to 3-3
statement of report acceptance and example, 9-4
Appointment Letter (report), 9-5, 9-18
Appointment Memorandum, 3-1 to 3-3
Assistant Secretary for Environment, Safety, and Health (EH-1), 2-1, 2-4, 2-12, 2-13, 3-1,
3-2, 5-13, 8-2
report review, 2-13
Barrier, 1-1, 1-8, 7-13
definition, A-1
management barriers, 1-1, 7-14
physical barriers, 1-1, 7-14
see also Barrier Analysis
Barrier Analysis, 7-6, 7-13 to 7-17, 7-24, 7-56, 7-59, 9-10, 9-13, 9-14
analyzing results and example, 7-17, 7-18
basic process, 7-16
case study, 7-16 to 7-18
definition, A-1
guidelines for completing, 7-15
minimum data and sources needed, 7-15
summary chart, 7-18
summary results (report and examples), 9-14
Barrier Analysis Worksheet
example, 7-16
Bloodborne Pathogens, 6-7
universal precautions, 6-8
Board Chairperson, 1, 2-4 to 2-13, 3-1 to 3-3, 4-1, 4-6, 5-1 to 5-3, 6-9, 6-17, 8-5, 9-20
briefings, 3-2, 4-6, 5-6, 5-13, 5-17
communications, internal and external, 2-4, 5-5 to 5-7, 5-9 to 5-11, 5-13, 5-16
costs and schedules, 5-2, 5-3, 5-14
definition, A-1
developing teamwork, 5-7 to 5-9, 5-16
managing information collection, 5-9, 5-10, 6-9
managing onsite closeout activities, 5-13
managing post-investigation activities, 5-14
managing report writing, 5-12, 9-21
managing the investigative process and analysis, 3-2, 5-1, 5-6, 5-12, 5-15, 7-41, 7-53
see also Collecting Data/Evidence
project control, 5-1, 5-6, 5-13, 5-15
project planning, 5-1 to 5-5, 5-16
see also Project Planning
qualifications, 3-1, 3-2
quality (investigation), 2-4, 5-15, 9-1
report review, 9-21
roles and responsibilities, 2-4, 2-13
submitting the report, 9-22
training requirements, 3-2
Board Members, 1, 2-2, 2-4, 2-5, 3-1, 5-1, 5-6, 5-9, 5-10, 5-12, 6-1, 6-9, 6-17, 7-2,
7-21, 7-27, 7-53, 8-2, 8-4, 8-5, 9-19
briefing, 3-2
definition, A-1
qualifications, 3-1, 3-2
report writing, 9-1 to 9-20
roles and responsibilities, 2-4, 2-5, 2-13, 5-8, 5-12
training requirements, 3-2
see also Analyzing Data, Collecting Data/Evidence, Report Writing
Board Signatures (report), 9-18, 9-19
Case Study, 7-3, 7-10 to 7-12, 7-16, 7-18, 7-22, 7-23
Categories and Questions for Completing Root
Cause Analysis Tier Diagram, 7-30 to 7-33
Causal Factors, 5-2, 5-12, 5-13, 5-17, 6-11, 7-2, 7-4 to 7-12, 7-20, 7-24 to 7-29, 7-37,
7-42, 7-43, 8-1 to 8-5, 9-1, 9-13, 9-15, 9-16
definition, A-1
determining causal factors, 7-4
report; example, 9-15, 9-16
see also Contributing Causes, Direct Cause, Root Causes
Cause
definition, A-2
Chain of Custody, 4-4, 6-17, 6-19
definition, A-2
Change, 7-17
definition, A-2
Change Analysis, 7-17, 7-20 to 7-23, 7-59, 9-12
change analysis process, 7-17
conducting change analysis, 7-17
data sources, 7-20
definition, 7-17, A-2
questions to consider, 7-22, 7-23
report; example, 9-15
summary from case study, 7-23
Change Analysis Worksheet, 7-22, 7-62
Classification Review, 9-21
Closeout Activities, 5-13
see also Board Chairperson
Cognizant Secretarial Officer, 2-3, 4-1
Collecting Data/Evidence, 4-3, 4-4, 6-1, 6-2
chain of custody, 4-4, 6-17
collecting physical evidence, 6-7
description, 6-1, 6-18
managing the process, 5-9
preserving and controlling, 6-13, 6-17, 6-18
steps in pursuing evidentiary material, 6-2, 6-18
types of evidence, 6-1, 6-18
Command Center, 4-1, 5-3, 7-13
Common Cause Failure Analysis, 7-54
Communications, 5-5, 5-16
external, 5-9 to 5-11, 5-13, 5-16
internal, 5-7, 5-9 to 5-11, 5-16
see also Board Chairperson, roles and responsibilities
Compliance/Noncompliance, 7-27, 7-38 to 7-40
see also Root Cause Analysis
Conclusions, 2-4, 2-10, 2-11, 3-2, 5-2, 5-13, 6-1, 8-1, 8-2, 8-4, 8-5, 9-1,
9-2, 9-5, 9-8, 9-9, 9-15, 9-17, 9-21
definition, 8-1, A-2
examples, 8-1
procedures for developing, 8-1
report; example, 9-8, 9-17
Conflict of Interest, 3-1, 3-3, 5-3, 5-23
Consultants
see Advisors and Consultants
Contractors (site), 2-6 to 2-8, 5-9, 5-16, 9-21
determine composition of readiness team, 2-6, 2-7
establish readiness to respond to accidents, 2-6 to 2-8
establish site readiness procedures, 2-8
readiness training, 2-8, 2-9
Contributing Causes, 7-4, 7-5, 7-17, 7-49, 7-59, 9-8, 9-15
determining and examples, 7-4, 9-8
see also Causal Factors, Direct Cause, Root Causes
Controlling Information, 5-3, 5-5, 5-9, 5-13, 5-16, 6-17, 6-18
Controls
definition, A-2
Core Analytical Techniques, 7-6, 7-15, 7-26, 7-41, 7-59
see also Barrier Analysis, Change Analysis, Events and Causal Factors
Charting and Analysis, Root Cause Analysis
Core Functions for Integrated Safety Management, 6-14, 6-19, D-1, D-2
Corrective Actions, 2-2, 2-13, 5-13, 5-17, 7-1, 7-27, 8-2
report, 9-22
Cost Control, 5-14
Court Reporters, 2-6
see also Support Staff
Decision Processes, 5-8
Department-Wide Area Qualification Standard—Occupational Safety Qualification
Standard Competencies, B-1
Deputy Assistant Secretary for Oversight (EH-2), i, 2-2, 2-9, 2-12, 5-10, 5-11, 5-16
report review, 2-11, 9-22
Design Criteria Analysis, 7-57
Direct Cause, 7-4, 7-30, 7-59, 9-8, 9-15
determining and examples, 7-59, 9-8
see also Causal Factors, Contributing Causes, Root Causes
Disclaimer
report; example, 9-3
Documentary Evidence, 4-3, 4-6, 6-1, 6-2, 6-11, 6-18, 6-19
examples, 6-11, 6-12, 6-19
see also Collecting Data/Evidence
DOE Accident Investigation Program, 1, 2-1, 2-13
DOE Headquarters, 2-4, 5-5, 5-7, 5-9, 5-10, 5-13, 6-6, 6-12
DOE Office of Enforcement and Investigation (EH-10), 2-4, 5-11
DOE Office of the General Counsel, 2-5
DOE Office of the Inspector General, 2-4, 5-11
DOE Office of Oversight, 2-1, 2-9, 2-11, 9-20
DOE Office of Security Evaluations, 2-1
DOE Operations
definition, A-2
DOE Order 225.1A, Accident Investigations, 1, 2-6, 2-7, 2-9, 2-12, 3-1, 5-11,
5-13, 6-6, 6-12, 7-1, 9-2, 9-4, 9-21, 9-22
Attachment 1, Contractor Requirements Document, 2-6
categorization algorithm, 2-2, 2-6
criteria for selecting board members, 3-1, 3-2
report format and contents requirements, 9-2, 9-3
DOE Order 232.1, Occurrence Reporting and Processing of Operations
Information, 2-6, 2-9
DOE Policy 450.4, Safety Management System Policy, 1-6, 3-3, 6-12
evaluation factors, D-1, D-2
DOE Site
definition, A-2
see also Heads of Field Elements, Site Managers
Emergency Response
see Readiness Teams, Site Readiness
Energy, 7-14
definition, A-2
Energy Flow, 7-14
definition, A-2
Equipment/Design Considerations
see Human Factors
Event
definition, A-3
Events and Causal Factors Charting and Analysis, 7-6 to 7-13, 7-24 to 7-26, 7-37, 7-59
benefits, 7-7
case study, 7-10 to 7-12
conducting the analysis, 7-24
constructing the chart, 7-7, 7-8
definition, A-3
guidelines and symbols, 7-9
methods (manual and computerized), 7-7, 7-8
Evidence, 4-2 to 4-4, 5-6, 6-1
see also Collecting Data/Evidence
Evidence Locations and Orientations, 6-28
Executive Summary
report and example, 9-6 to 9-9
Facts, 2-3, 2-11, 3-2, 6-2, 6-12, 7-1, 7-2, 7-59,8-1 to 8-3, 8-5, 9-1, 9-2, 9-6, 9-11, 9-21, 9-23
case study, 7-3
see also Collecting Data/Evidence
Facts and Analysis (report), 9-5, 9-10, 9-21
accident description and chronology, 9-12
case study, 9-14, 9-15
description and analysis, 9-12 to 9-15
facts vs. analysis, 9-12
Factual Accuracy Review, 9-21, 9-22
see also Report Writing
Failure Modes and Effects Analysis, 7-56
Field Element, 2-2, 2-3, 2-6 to 2-9, 2-13, 3-1, 4-1
definition, A-3
see also Field Office Points of Contact, Heads of Field Elements, Program
Office Points of Contact
Field Office Points of Contact (point of contact), 1, 2-1, 2-3, 2-7, 2-9, 2-13, 4-1, 4-6, 5-1, 6-1
activities with readiness teams, 2-7, 2-9
briefings, 4-6, 6-1
definition, A-3
immediate post-accident actions, 4-1
roles and responsibilities, 2-3, 2-7, 2-9, 2-13
transition and transfer, 4-6
Freedom of Information Act (FOIA), 2-5, 5-3, 5-5, 6-5, 6-6, 6-23
see also Project Planning
General Technical Qualification Standard, B-1
"Go Kit"
see Accident Investigation "Go Kit"
Guiding Principles for Integrated Safety Management, 6-15 to 6-17, 6-19, 7-5, D-3 to D-5
Hazard, 7-13 to 7-16
definition, A-3
Heads of Field Elements, 2-2, 2-6 to 2-9, 2-13, 3-1, 4-1, 5-13, 5-14
establish site readiness, 2-6 to 2-9, 4-1
roles and responsibilities, 2-2, 2-13
Human Capabilities
see Human Factors
Human Evidence, 4-2 to 4-4, 6-1, 6-2, 6-18
conducting interviews, 6-2 to 6-6, 6-18
see also Collecting Data/Evidence
Human Factors, 1-1, 1-8
"activity model," 1-2
equipment/design considerations, 1-4, 1-8
human capabilities, 1-2 to 1-4, 1-8
human-machine interface, 1-2, 1-3, 1-8
organizational work environment, 1-6
physical work environment, 1-5 to 1-7, 1-8
Human Factors Analysis, 7-55
Human-Machine Interface
human-machine activity model, 1-2
Immediate Post-Accident Actions, 4-1, 4-2
see also Site Readiness
Integrated Accident Event Matrix, 7-56
Integrated Safety Management System, 5-6, 6-12, 6-14, 6-18, D-1, D-2
see also Core Functions for Integrated Safety Management, Guiding Principles for
Integrated Safety Management
Interviews, 4-4, 4-5, 5-10, 6-2 to 6-6, 6-18
Accident Investigation Interview Schedule Form, 6-3, 6-21
Accident Investigation Preliminary Interview List, 4-4, 4-9, 6-3
Accident Investigation Witness Statement Form, 4-5, 4-10, 4-11
model opening statement, 5-5, 6-23
see also Collecting Data/Evidence
Introduction (report), 9-10
case study, 9-8, 9-11
example (executive summary), 9-8, 9-11
Investigation
definition, A-3
see also Accident Investigation
Investigation Report
definition, A-3
see also Report Writing
Judgments of Need, 2-1, 2-2 to 2-4, 2-10 to 2-12, 3-2, 3-3, 5-2, 5-12, 5-13, 5-17,
7-2, 8-1 to 8-5, 9-1, 9-2, 9-6, 9-8, 9-9, 9-21
case study examples, 8-4, 9-8, 9-9, 9-17
definition, 8-2, A-3
guidance for writing, 8-2, 8-4, 9-15
Legal Advisor, 2-5, 5-5
Lessons Learned, 2-2, 2-13, 9-1, 9-2
Limited Scope Investigations, 2-12, 3-1, 9-22
Line Management Oversight, 3-2, 5-12, 6-12, 9-6
Management Oversight and Risk Tree (MORT)
analysis, 7-47 to 7-52
benefits, 7-48
completed MORT charts, examples, 7-50 to 7-52
Management Systems, 1-6, 2-3, 2-4, 3-2, 3-3, 5-12, 6-12, 6-19, 7-6, 7-7, 7-38,
7-48, 9-6
Managing the Accident Investigation, 5-1
see also Board Chairperson
Managing the Investigation Process, 5-6
see also Board Chairperson
Mapping and Sketching the Accident Site
see Photography, Physical Evidence
Materials and Structural Analysis, 7-57
Media (press) relations, 4-5, 5-5, 5-10, 5-14, 5-16, 6-3
Medical Advisor, 2-5
Minority Opinions, 8-4, 8-5
Minority Report, 5-13, 9-18
Occupational Safety and Health Administration (OSHA), 1-5
Occurrence
definition, A-3
see also DOE 232.4 Occurrence Reporting and Processing of Operations Information
Occurrence Reporting and Processing System (ORPS), B-1
definition, A-3
Other Analytic Techniques, 7-53
common cause failure, 7-56
design criteria, 7-57
failure modes and effects, 7-56
human factors, 7-55
integrated accident event matrix, 7-56
materials and structural, 7-57
scientific modeling, 7-55, 7-56
sneak circuit, 7-56
software hazards, 7-56
time loss and sample, 7-53, 7-55
Photography, 2-5, 2-6, 2-9, 4-3, 4-4, 6-8 to 6-10, 6-13, 6-18, 6-19, 9-10
Accident Investigation Photographic Log Sheet, 6-9, 6-10, 6-13, 6-29
Accident Investigation Sketch of Photography Locations and Orientations, 6-10, 6-28
Physical Evidence, 4-2, 4-3, 6-1, 6-2, 6-7 to 6-10, 6-18, 6-19
Accident Investigation Physical Evidence Log Form, 6-8, 6-17, 6-24
Accident Investigation Position Mapping Form, 6-9, 6-27
Accident Investigation Site Map, 6-9, 6-26
Accident Investigation Site Sketch, 6-9, 6-25
Accident Investigation Sketch of Physical Evidence Locations and Orientations, 6-9, 6-28
inspecting and preserving, 4-2 to 4-4, 6-7 to 6-11, 6-13
photographing and videotaping, 6-9, 6-10
removing and guidelines, 6-10, 6-11
sketching and mapping, 4-3, 6-8, 6-18, 6-19
see also Site Readiness
Post-Investigation Activities, 5-14
see also Board Chairperson
Price-Anderson Amendment Act of 1988, 2-4, 5-11
Privacy Act, 2-5, 5-3, 5-5, 5-14, 5-16, 6-5, 6-6
Program Manager (DOE Accident Investigation Program Manager), 2-1, 2-13, 3-1, 4-1, 4-6,
5-3, 5-13, 5-14, 9-22
Program Office Points of Contact, 1, 2-3, 2-6, 2-7, 2-9, 2-13, 4-1, 4-6, 5-1, 6-13
see also Field Office Points of Contact
Project Evaluation Tree (PET) Analysis, 7-49, 7-53
benefits, 7-49
branch of PET chart, 7-54
PET analysis worksheet, 7-63
Project Planning, 5-1 to 5-5, 5-16
acquiring resources, 5-3
determining task assignments, 5-1
scheduling, 5-2, 5-3, 5-4
see also Board Chairperson, Managing the Accident Investigation
Prologue (report), 9-6, 9-7, 9-23
Promoting Teamwork, 5-7 to 5-9
see also Board Chairperson
Protocols (information), 5-3, 5-5, 5-10, 5-14, 5-16, 6-13
Quality Assurance, 5-15
Quality Review (report), 9-21
Readiness, 2-6, 2-7
see also Accident Investigation "Go Kit," Site Readiness
Readiness Teams, 2-7 to 2-10, 4-1, 4-7
collecting, preserving, and controlling evidence, 4-2 to 4-4, 4-6
composition, 2-8
definition, A-4
documenting the accident scene, 4-3, 4-7
immediate post-accident activities, 4-1, 4-2, 4-7
see also Collecting Data/Evidence
obtaining initial witness statements, 4-4, 4-5, 4-7
preserving the accident scene, 4-2, 4-7
roles and responsibilities, 2-6, 2-7, 4-2, 4-3, 4-7, 6-2
transferring information to the board, 4-6, 4-7
Report Acceptance, 9-22, 9-23
Report Writing, 5-1, 5-12, 9-1
elements, 9-3
format and contents, 9-2, 9-3, 9-18
managing the report writing, 5-12, 5-13
see also Board Chairperson
quality, 5-15, 9-21, 9-23
reviews and approval, 9-22, 9-23
submitting the report, 9-22, 9-23
table of contents, examples, 9-5
tips, 9-2
Requirements Verification Analysis, 5-15, 8-2, 9-21
definition, A-4
see also Report Writing
Root Cause, 3-2, 7-4, 7-5, 7-24, 7-37, 7-38, 7-40, 7-43, 9-8, 9-15
definition, 7-4, A-4
see also Contributing Causes, Direct Cause, Root Cause Analysis
Root Cause Analysis, 7-6, 7-26, 7-27, 9-10, 9-13
compliance/noncompliance technique, 7-38 to 7-40
definition, 7-26, A-4
initiating an analysis, 7-27
tier diagraming guidelines, steps and sample, 7-28 to 7-38
Safety Management System Policy
see DOE Policy 450.4
Scientific Modeling, 7-57, 7-58
Signatures of Board
report and example, 9-18, 9-19
Site Managers, 2-4, 2-7, 5-10, 5-13, 5-16
Site Readiness, 2-6 to 2-9, 4-1
implementing, 4-1
practice and evaluation, 2-9
readiness training, 2-8, 2-9
resources, 2-8
written procedures, 2-8
see also Readiness
Site Readiness Teams
see Readiness Teams
Sketches
see Photography, Physical Evidence
Sneak Circuit Analysis, 7-56
Software Hazards Analysis, 7-56
Support Staff, 2-5, 5-6, 5-9, 5-13, 5-14, 6-17
administrative coordinator, 2-5, 5-1, 5-10, 5-13, 6-7, 9-2, C-1
court reporters, 2-6, 5-3, 6-3
technical writer/editor, 2-5, 5-13, 9-2
typist/text processor, 2-5
Table of Contents
report and example, 9-4, 9-5
see also Report Writing
Target, 7-13 to 7-18
definition, A-4
see also Barrier Analysis
Team Dynamics, 5-7 to 5-9, 5-16
see also Board Chairperson, Promoting Teamwork
Technical Experts, 2-5
Technical Writer/Editor, 2-5
see also Support Staff
Tier Diagram Worksheet for Root Cause Analysis, 7-29
Tier Diagraming, 7-28 to 7-38
see also Root Cause Analysis
Time Loss Analysis, 7-53, 7-55
Type A Investigation, 2-2, 2-4, 2-6, 2-11 to 2-13, 3-1, 3-2, 5-3, 5-10, 5-13 to 5-16, 9-3, 9-22, 9-23
Type B Investigation, 2-2, 2-6, 2-11 to 2-13, 3-1, 3-2, 5-15, 9-3, 9-22, 9-23
Typist/Text Processor, 2-5
see also Support Staff
Unions, 2-5, 5-16
Unlawful Activity, 2-4, 5-11
Validation
see Requirements Verification Analysis
Videotape, 4-2 to 4-4, 6-8, 6-9
Walkthrough (accident scene), 4-2, 4-3, 7-2
Witnesses, 4-1, 4-3 to 4-5, 4-7, 5-10, 6-1 to 6-3, 6-6, 6-18
see also Interviews
Work Environment
see Human Factors