Contents

Section 2 - DOE's Accident Investigation Program

• 2.1 Overall Management of the Program
• 2.2 Roles and Responsibilities of Key Participants
• 2.2.1 Appointing Officials and Line Management Participants
• 2.2.2 The Accident Investigation Board
• 2.3 Site Readiness
• 2.3.1 Readiness — What Is It?
• 2.3.2 Establishing Written Procedures and Responsibilities
• 2.3.3 Maintaining Resources to Support Accident Investigations
• 2.3.4 Training for Site Readiness
• 2.3.5 Conducting Periodic Practices and Evaluations
• 2.4 Accident Investigation Process Overview
• 2.5 Waivers
• 2.6 Limited Scope Accident Investigations
• Key Points to Remember

List of Tables

• Table 2-1. Appointing officials and line management participants in accident investigations have clearly defined responsibilities
• Table 2-2. The accident investigation board has these major responsibilities
• Table 2-3. The timeline for a Type A or Type B accident investigation requires conducting multiple simultaneous tasks

List of Figures

• Figure 2-1. The process used to conduct an accident investigation involves many activities
• Figure 2-2. The three primary activity phases in an accident investigation overlap significantly

List of Forms and Tools

• Accident Investigation Equipment Checklist
• Accident Investigation "Go Kit" Contents
  

2

DOE's Accident Investigation Program

A primary mission of DOE is to operate its programs and facilities with a high level of safety. The accident investigation process has been designed to evaluate management systems and determine causal factors to prevent accident recurrence.

Specifically, the objectives of DOE's accident investigation program are to prescribe requirements for conducting investigations that will:

• Contribute to improved environmental protection and enhanced safety and health of DOE employees, contractors, and the public

• Prevent the recurrence of accidents

• Reduce accident fatality rates and promote a downward trend in the number and severity of accidents.

To accomplish these objectives, the accident investigation process must respond with speed, accuracy, focus, and brevity. The results of accident investigations can help managers eliminate underlying causes, prevent similar accidents, and enhance safety across the DOE complex. To achieve maximum benefit, accident investigations need to be convened rapidly, staffed and supported adequately, focused on pertinent and essential facts and causation, conducted accurately and thoroughly, concluded quickly, and reported clearly and concisely. Analytical techniques used to draw conclusions and to establish causes must be valid, appropriate, and easy to use. Finally, sound judgments of need promote better safety practices, address systemic problems, and when implemented, help prevent future occurrences without determining individual fault or proposing punitive measures.

2.1 Overall Management of the Program

The DOE Accident Investigation Program Manager (referred to throughout the workbook as the "Program Manager") in the Office of Oversight administers the program on behalf of the Assistant Secretary for Environment, Safety and Health (EH-1). The Program Manager is the central focal point for field and program office points of contact for program administration and training coordination.

2.2 Roles and Responsibilities of Key Participants

A number of groups and individuals play important roles in DOE's accident investigation program. These persons include appointing officials, line management, the accident investigation board, advisors and consultants to the board, and administrative support staff.

2.2.1 Appointing Officials and Line Management Participants

Table 2-1 lists the primary responsibilities of the appointing official for an accident investigation, heads of field elements, and for field and program office points of contact.

Table 2-1. Appointing officials and line management participants
in accident investigations have clearly defined responsibilities.

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.

 

Table 2-1. Appointing officials and line management participants in accident
investigations have clearly defined responsibilities. (Continued)

2.2.2 The Accident Investigation Board

When an accident occurs, the board must be rapidly assembled to collect the facts, conduct the investigation, reach conclusions, and prepare a report. The board's overall responsibilities are listed in Table 2-2. Responsibilities for those individuals who comprise the investigation board are described below.

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

2.2.2.1. Board Chairperson

The board chairperson manages the investigation by coordinating the efforts of the board members, advisors/consultants, and support staff. The board chairperson is responsible to the appointing official for all aspects of the investigation. The chairperson maintains control of the accident scene until it is no longer needed for the investigation. The chairperson does not normally conduct investigative activities, but rather directs the overall effort, keeping it focused and on schedule.

If unlawful activity is revealed during the investigation, the chairperson notifies DOE and appropriate Federal, state, or local authorities, or in the case of fraud, waste, or abuse, the DOE Office of the Inspector General. If any potential Price-Anderson enforcement concerns are revealed, the chairperson notifies the Director, Office of Enforcement and Investigation (EH-10), the DOE Site Manager, and the contractor as soon as practical.

The chairperson's specific roles and responsibilities include:

• Taking control of the investigation from the site readiness team

• Providing leadership and managing board activities by:

• Establishing and communicating the roles and responsibilities of board members, advisors, consultants, and support staff

• Building effective team relationships with and among board members

• Planning, scheduling, and coordinating activities

• Establishing and meeting deadlines

• Remaining continuously informed of the investigation's progress and status

• Ensuring that the board is supported by appropriate advisors and consultants with specialized expertise, as needed

• Resolving potential conflicts of interest for board members, advisors, and consultants

• Serving as the point of contact with the appointing official and DOE management at the site, facility, or area where the accident occurred, and representing DOE in all matters pertaining to the investigation

• Coordinating with, and communicating board activities to, interested managers and organizations who are stakeholders with a legitimate interest in the accident

• Ensuring an effective and efficient investigation that thoroughly examines all potential causal factors, including management systems, within the allotted time frame

• Generating a quality report of the investigation

• Following report acceptance by the appointing official, conducting a briefing, together with the head of the field element, to Headquarters and field line management, as well as to the Assistant Secretary for Environment, Safety and Health (for Type A investigations), on the outcome of the investigation.

2.2.2.2 Board Members

Board members are primarily responsible for collecting and analyzing information, reaching conclusions regarding causal factors, identifying judgments of need, and writing the report. Board members apply investigative and analytical techniques to make these determinations.

2.2.2.3 Advisors and Consultants

Advisors and consultants are used at the discretion of the chairperson whenever the circumstances of an accident require specialized expertise or special knowledge of the accident itself is required. These individuals may include:

• Legal advisor—helpful in dealing with legal issues that may arise, including liability issues and concerns related to the Freedom of Information and Privacy Acts. DOE counsel from the operations or field office having cognizance over the site, area, or facility involved generally fulfills this role. If this is not feasible, an attorney from the Office of General Counsel can assist the board.

• Medical advisor—a key person in any investigation involving an injury, illness, or fatality. The board may obtain advice from a physician to clarify medical issues early in the investigation.

• Technical experts—provide valuable expertise during investigations involving technical information about operations, policy, hazards, failure modes, component testing, and systems.

• Professional/technical photographer—critical for providing an accurate photographic record of evidence and the accident scene, using techniques not commonly known to investigators.

• Site personnel—may contribute specific knowledge of processes or activities in areas such as metallurgy, chemistry, electrical operations, or conduct of operations.

• Union advisor—can provide information on work practices, facilitate interviews with union members, and convey to workers the board's desire to assure that the accident is thoroughly investigated.

2.2.2.4 Support Staff Roles

The investigation board uses support staff to handle administrative functions or to provide expertise not available from members, consultants, and advisors. The following support positions are recommended:

• Administrative coordinator. This individual should be familiar with the administrative and logistical needs and processes of an accident investigation and be able to provide daily coordination of these matters. Other functions include tracking and controlling documentation, tracking appointments, assigning administrative tasks and priorities, and coordinating report production (a detailed list of responsibilities is included in Appendix C).

• Analyst. An individual trained in and knowledgeable of the various analytical techniques that can be used to support the accident investigation process (see Section 7 of this workbook). Board members have the responsibility for collecting and analyzing information; however, a dedicated analyst can recommend the proper analytical tools based on the type and complexity of the accident and process the information using the tools selected, allowing the board members to concentrate on the results of the analysis.

• Technical writer/editor. This person can facilitate the report writing process. While board members have primary writing responsibilities, use of a dedicated writer focuses responsibility for assembling the report, facilitates report preparation, and results in a more cohesive and readable report.

• Typist/text processor. A board usually needs at least one typist to perform general secretarial and administrative tasks, such as filing, word processing, and answering telephones. These personnel can often be provided by the facility where the investigation is being conducted.

• Court reporters. Using a court reporting service increases the timeliness and accuracy of interview transcripts. The use of court reporters gives all members of the board the opportunity to review interviews in which they did not participate and provides a transcript for reconstructing or developing the chronology of events preceding the accident. When an investigation requires numerous interviews, use of court reporters is essential and can help prevent the investigation from getting behind schedule in its early stages, when most of the interviewing takes place and when the information from interviews is needed. This service is available commercially in most areas.

2.3 Site Readiness

DOE Order 225.1A and its Attachment 1, Contractor Requirements Document, establish requirements and responsibilities for heads of field elements and contractors to:

• Support Type A, Type B, and limited scope accident investigations

• Establish and maintain readiness to respond to accidents.

Site readiness is an important, ongoing part of DOE's accident investigation program. This section addresses responsibilities of points of contact and heads of field elements, as well as activities needed to implement those responsibilities, in meeting site readiness requirements.

2.3.1 Readiness - What Is It?

Readiness to conduct accident investigations means preparing in advance to:

• Respond to and mitigate the consequences of an accident

• Preserve the accident scene and collect and control critical initial evidence—physical, human (given through witness statements or interviews), and documentary (including photographic media)

• Assist the accident investigation board with investigations.

To implement these requirements, the site's point of contact and designated readiness teams normally:

• Assist the head of the field element in categorizing accident severity by using the accident categorization algorithm in Attachment 2 to DOE Order 225.1A and Table 1 of the Implementation Guide for Use with DOE Order 225.1A

• Assist in reporting events (in accordance with DOE Order 225.1A and DOE Order 232.1, Occurrence Reporting and Processing of Operations Information)

• Assist in restoring operations, if requested

• Document the accident scene through photography or other means

• Provide facilities, equipment, supplies, tools, and general administrative and logistical support for accident investigations

• Conduct initial investigative activities

• Provide sufficient numbers of DOE board chairpersons and accident investigators and, if requested, provide them to other DOE sites

• Transfer control and custody for the accident scene and evidence to the board chairperson when he/she arrives at the site.

Readiness teams coordinate their actions with or are integrated with emergency management personnel. The team's composition, location, equipment, and other characteristics are determined by field elements and their contractors. The operation of equipment for the team should be documented in procedures and its performance should be periodically tested.

A well trained readiness team that participates in the initial response to an accident can provide valuable assistance to the accident investigation board when it assembles on site. DOE and contractor managers should ensure that accident responders and readiness teams can complete the immediate and near-term steps that will facilitate the investigation. When an accident occurs, immediate actions include taking charge of the accident scene quickly, initiating any required emergency response, assisting injured parties, ameliorating the accident conditions, and preserving and protecting evidence and the accident scene for later investigation. Each field element is responsible for maintaining a readiness capability to respond to accidents in this manner.

To ensure the capability for the necessary rapid response, heads of field elements and designated points of contact should ensure that:

• Sufficient numbers of readiness team personnel and prospective accident investigation board personnel are trained and available

• Adequate procedures for initial response have been established

• Equipment is available and functional

• The necessary infrastructure can be quickly assembled to respond to the accident and support the accident investigation.

Managers, through points of contact, evaluate the need for site- or organization-specific training to ensure that sufficient numbers of staff are available to perform these functions.

In determining the number and qualifications of potential accident investigation board members, consideration should be given to the need for supporting other Departmental elements by providing chairpersons and board members. Contracts that address accident readiness by contractors should be modified to include these provisions under DOE Order 225.1A, if they are not adequately addressed in existing contracts. The benefits of incorporating initial investigative or investigative support actions into emergency preparedness plans and drills should also be considered. It is important to ensure coordination between readiness teams and emergency management personnel to facilitate an orderly transition of responsibilities for the accident scene.

An important element in establishing site readiness is to ensure that both the DOE field element and contractors work together to ensure that the site has a well coordinated and effective capability for responding to accidents. This capability includes:

• Clearly documented and coordinated procedures, roles, responsibilities, authorities, and accountabilities

• Adequate resources to support investigations

• Focused training for the field or program office points of contact and the site readiness team

• Periodic practice and evaluation.

2.3.2 Establishing Written Procedures and Responsibilities

DOE field elements should have clearly documented and integrated procedures, roles, responsibilities, authorities, and accountabilities in their implementation directives for establishing and maintaining site readiness. In addition, their contractors establish and document their own procedures to identify their organizations' operations in response to an accident or incident. Both field- and organization-specific site readiness programs should:

• Contain appropriate detail regarding the specific responsibilities and activities that make up the accident response approach

• Provide clearly formulated guidelines that address decisions involving tradeoffs between accident mitigation/restoration of operations and accident scene/evidence preservation

• Be consistent with DOE orders

• Be coordinated with the emergency response program

• Be adequately communicated to the people responsible for taking or directing action in response to accidents.

Site readiness procedures should cover the activities indicated in Section 2.3.1.

2.3.3 Maintaining Resources to Support Accident Investigations

Sufficient resources to support an onsite accident investigation should be in place or readily available.

The specific composition of the site readiness team is determined by the field elements and their contractors. Ideally, the team should include individuals currently involved in the emergency response function. Field elements are also responsible for assuring that DOE and contractor organizations have mechanisms in place to provide enough qualified personnel to serve as accident investigation board chairpersons and members to support DOE accident investigations at other sites.

They also assure that other resources are readily accessible. These resources include reference documents, site references, office equipment, tools, measurement devices, office supplies, and protective gear. The Accident Investigation Equipment Checklist (provided at the end of this section) is a tool that field elements can use to assure that adequate resources to support accident investigations are readily available at the site.

TIP To determine the necessary number of trained site readiness personnel, consider both the site's readiness needs and the site's obligation to supply accident investigators and accident investigation chairpersons to other DOE sites.

2.3.4 Training for Site Readiness

Site readiness requires formal training for the points of contact and site readiness team members. In addition, training for emergency response teams should ensure that when they respond to an accident, they consider the need to preserve the accident scene and evidence. Line managers and supervisors also need instruction in accident response; if they are present at an accident scene, these persons can be very useful in providing background about the event (e.g., people involved, witnesses present, equipment involved, material involved, and environmental factors).

The field element is responsible for identifying the minimum site- and organization-specific training requirements to support the site readiness capability.

Managers within affected organizations then develop appropriate training based on these requirements and site-specific needs.

Field elements or program offices are responsible for coordinating with the Program Manager to assure that DOE and contractor staff are trained in accident investigation techniques and readiness. In particular, the field or program office point of contact verifies that site readiness personnel responding immediately following an accident have been trained in:

• Initial reporting and categorization of events (in accordance with DOE Order 225.1A and DOE Order 232.1)

• Photographing and videotaping the accident scene

• Identifying, collecting, controlling, and preserving evidence and information

• Performing other initial investigative functions, such as taking witness statements and determining the fitness-for-duty status of all individuals injured in the accident

• Transferring responsibility for the accident scene, evidence, and documentation to the accident investigation board.

In addition to needing to know how, when, where, and to whom to report an accident and how to summon emergency help, those responding to an accident must know what actions they can take, and what actions require skilled and qualified emergency response professionals. Emergency personnel who direct and coordinate emergency response and rescue operations need to know what equipment, materials, and protective gear are required; how and where they are obtained; and what training or qualifications are required for their use. They also need to know the risks, hazards, or peculiarities of the operation, process, or facility involved, as well as what specialized knowledge, skills, procedures, and equipment are needed to handle them safely. They must know what means are needed and available to control and limit injuries and losses and to prevent emergency teams, rescuers, and investigative readiness teams from causing additional injury or loss or becoming casualties themselves.

Site readiness personnel who are prospective DOE accident investigators and chairpersons, as well as the field or program office point of contact, should attend an accident investigation course of instruction that is based on current materials developed by the Office of the Deputy Assistant Secretary for Oversight and must have the appropriate qualifications through experience in conducting comparable investigations.

2.3.5 Conducting Periodic Practices and Evaluations

To be effective, site readiness plans and procedures should be practiced and evaluated periodically. Because of the need for coordinated efforts, the benefits of incorporating the site readiness actions into emergency preparedness plans/procedures, as well as combining drills for site readiness and emergency preparedness, should be considered. Readiness teams can be evaluated during drills by having appropriate team members demonstrate tasks and functions such as:

• Collecting and storing evidence

• Identifying witnesses and taking statements

• Preparing an information transition plan for a board chairperson.

2.4 Accident Investigation Process Overview

The major activities between the accident and the end of the accident investigation are shown in Figure 2-1. They are discussed in detail in Part II of this workbook.

 

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

A nominal 30-calendar-day timeframe, beginning with the date of the board appointment and ending with submission of the accident report, has been established by DOE as a target for completing Type A and Type B accident investigations. The timeline and schedule of activities, illustrated in Table 2-3, is flexible and depends on specific accident circumstances, such as the accident's severity and complexity. The appointing official should attempt to identify any circumstances that may prolong this 30-day timeline and make appropriate adjustments to the completion date. The board chairperson should be aware of potential delays and make adjustments as early as possible. Figure 2-2 demonstrates how the three primary activity phases of an accident investigation overlap during the accident investigation cycle.

2.5 Waivers

In some instances when an accident meets the criteria for a Type A or Type B investigation, it nevertheless may be desirable not to conduct a Type A or Type B investigation if the head of the field element determines that the investigation would lead to no significant lessons learned. In such a case, the head of the field element submits a request for waiver, within five calendar days after the accident is categorized, to the Office of the Deputy Assistant Secretary for Oversight.

* Limited scope investigations are permitted, if no substantial lessons learned would be expected from conducting a full scope investigation. For limited scope investigations, these activities are expected to be completed within 10-14 days, as discussed in Section 2.6 of this workbook.

 

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

The Office of the Deputy Assistant Secretary for Oversight will review waiver requests and either recommend approval or disapproval of the requests in writing to the Assistant Secretary for Environment, Safety and Health, who will make the final determination in writing.

2.6 Limited Scope Accident Investigations

Limited scope investigations may be conducted when chartered by the Assistant Secretary of Environment, Safety and Health, as prescribed in DOE Order 225.1A, when it is determined that a formal but less resource-intensive investigation is warranted.

Limited scope investigation boards consist of a board chairperson and one to three board members. The requirements for selecting board chairpersons and board members are identical to those for Type A and Type B accident investigation boards. Limited scope investigations are expected to be completed within 10 to 14 days of board appointment.

The process for conducting limited scope investigations uses the same principles as those described previously for Type A and Type B accident investigations. The limited scope investigation may have an abbreviated scope, as determined by the charter. Facts are collected and analyzed using the analytical techniques described in Section 7 of this workbook (although the processes for using them are abbreviated); causal factors are identified; judgments of need are developed; and a report is written and submitted to the appointing official.

 

Accident Investigation Equipment Checklist (page 1 of 5)

Accident Investigation Equipment Checklist (page 2 of 5)

Accident Investigation Equipment Checklist (page 3 of 5)

Accident Investigation Equipment Checklist (page 4 of 5)

Accident Investigation Equipment Checklist (page 5 of 5)

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

 

Accident Investigation "Go Kit" Contents (page 1 of 2)

Accident Investigation "Go Kit" Contents (page 2 of 2)