• 4.1 Immediate Post-Accident Actions
• 4.2 Preserving and Documenting the Accident Scene
  • 4.2.1 Securing and Preserving the Scene
  • 4.2.2 Documenting the Scene
• 4.3 Collecting, Preserving, and Controlling Evidence
• 4.4 Obtaining Initial Witness Statements
• 4.5 Transferring Information to the Board
• Key Points to Remember

List of Tables

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

List of Forms and Tools

• Accident Investigation Preliminary Interview List
• Accident Investigation Witness Statement Form

This section addresses actions to be taken by field element readiness teams immediately following an accident. All of these actions occur before the DOE accident investigation board chairperson arrives on site.

Many immediate post-accident activities are concurrent with emergency actions taken to save lives and limit losses and hazards. Emergency action considerations—particularly lifesaving and life-protecting activities—always take first priority, even if property or evidence is destroyed, distorted, or broken in the process. The adverse effects of tradeoffs that must be made during emergency response can be minimized through advance preparation and planning to ensure proper coordination of emergency actions with initial investigative activities.

It is important, therefore, that the head of the field element ensure that readiness teams and emergency response personnel coordinate their activities for optimal emergency and initial investigative response. Following these initial actions, the field or program office point of contact is responsible for ensuring a smooth transition of initial investigative activities to the accident investigation board chairperson, including transferring evidence and other information relevant to the accident.

Immediately after an accident occurs, the field or program office point of contact is responsible for notifying and providing critical information to the following individuals: the head of the field element; the cognizant secretarial officer or responsible official at the appropriate Headquarters element; the Accident Investigation Program Manager; the board chairperson (after appointment); the emergency operations center; and the emergency response team. The point of contact then:

• Coordinates with the emergency response team to preserve the accident scene
  

• Begins legal negotiations for temporary control of the area if the accident occurs on public property or on property owned by a private party
  

• Establishes an accident investigation "command center" (a large, dedicated conference room to be used exclusively by the accident investigation board)
  

• Initiates collection and control of evidence and documentation of the accident scene and scenario
  

• Manages identification of witnesses and collection of witness statements
  

• Determines which contractor and line organizations are affected by the accident
  

• Provides input into decisions made by line managers regarding mitigation actions and the restoration of operations, as appropriate.

Each site readiness team member has responsibility for supporting some portion of these activities, particularly those described in the sections that follow.

The effectiveness of an accident investigation depends on immediate preservation of the accident scene and the physical, human, and documentary evidence related to the accident. Because the accident investigation board may not arrive until two or three days after the accident, the site readiness team preserves and documents the condition and status of the accident scene. This encompasses assessing the medical condition and fitness-for-duty status of the injured or others involved in the accident (including requesting an autopsy, as appropriate), and preserving and recording the accident scene by means of written documentation, sketches, video, and photographs (including the location of equipment, parts, materials, debris, spills and stains, injured parties and witnesses, and other pertinent items). Procedures to be used by the site readiness team in preserving, collecting, and documenting evidence for the board are discussed below.

The accident scene should be secured immediately following an accident. This can be achieved in several ways, including:

• Removing and excluding all persons from the accident scene except essential emergency responders

• Cordoning the area with rope, tape, or barricades

• Locking doors and gates

• Posting warning signs

• Posting security personnel to control access

• Taking photographs and narrated videotape recordings of the accident scene, especially of any evidence that easily can be destroyed (e.g., tire tracks, fluids on the ground).

To effectively preserve the accident scene, the first member of the site readiness team to arrive is responsible for performing a walkthrough to:

• Characterize the accident scene

• Identify key human, physical, and documentary evidence

• Identify changes made to the scene because of accident mitigation activities

Designated site readiness team members are responsible for recording the accident scene as it exists after the accident. Effective documentation methods include:

• Photographs

• Videotapes

• Initial position maps

• Sketches.

Because a professional photographer or videographer may not be available, it is important that designated site readiness team members be familiar with these techniques so that they can capture the initial state of the accident scene. Site readiness team members need to be aware of what documentary evidence is needed for successful accident investigations. A sufficient number of qualified readiness team members should be available on site to perform these functions at all times. If necessary, initial photographs and videotapes can be supplemented later with professional photographs and videotapes.

Sketches and position maps can be used to note items removed from the scene prior to photographing and videotaping. These sketches and maps should include measured distances and directions from reference objects that will remain at the scene. The original location of evidence should be marked at the accident scene (using paint, tape, chalk, or other appropriate media) before evidence is removed.

Details on documenting the accident scene using photographs, videotapes, position maps, and sketches are provided in Section 6 of this workbook.

There are three types of evidence: physical, human (given through witness statements or interviews), and documentary (including photographic media). Physical evidence at an accident scene may include solids, liquids, and gases. Documentary evidence includes all the documentation developed by the site readiness team, as well as accident-related paper and electronic information, such as logbooks, instrument charts, as-built drawings, engineering analyses, vendor information, correspondence, and computer software.

Most physical evidence can safely be left intact at a protected accident scene to await examination by the investigation board. However, some evidence may be too perishable to remain safely at the scene, and some may have been removed during emergency response or casualty evacuation. Perishable evidence includes artifacts that may provide information about the accident and are located at the scene, but that may be corrupted, moved, or lost if left at the scene. For example, fluids emanating from equipment or vehicles involved in an accident may quickly evaporate or be absorbed by surrounding materials. Therefore, fluid samples should be taken quickly.

Before any evidence is removed from the accident scene, site readiness team members should preserve its integrity by:

• Recording the exact location and orientation of evidence at the scene, using measurements, logs, sketches, photography, and video

• Establishing secure storage locations for evidence

• Establishing and maintaining a strict chain of custody (documentation showing physical custody) for each item of evidence

• Ensuring that access to evidence is limited only to those who are investigating the accident until transfer of the evidence to the accident investigation board.

Tools to use in collecting, preserving, and controlling evidence are discussed in Section 6 of this workbook.

Human evidence (evidence given through witness statements or interviews) also must be immediately preserved by identifying and isolating witnesses. A witness is anyone who either directly observed or was affected by the accident, or who was directly or indirectly involved in the process, equipment, or system affected. Statements from witnesses must be taken as soon as possible, preferably before they leave the accident scene, to ensure that initial observations and impressions are not lost or altered.

Other persons, such as emergency response personnel, persons who arrive at the scene shortly after the accident, and anyone else who might be expected to provide material information about the accident, should be identified, located, and asked to provide statements. Early statements form the basis for documenting the accident sequence and identifying potential interviewees for the more extensive and formal interviews to be conducted later by the accident investigation board. Guidance on gathering witness statements is provided below.

If accident circumstances prevent the site readiness team from taking witness statements at the scene, names and contact information for all witnesses should be recorded. The Accident Investigation Preliminary Interview List (see end of this section) can be used to record this information.  To preserve initial observations,witnesses to the accident should be: (1) informed not to talk about the accident except to accident response and investigative personnel, and (2) isolated to the extent possible before and while giving their initial statements.  Usually, witnesses can be categorized as shown in Table 4-1, with initial statements taken in the order in which the categories are listed.

  Accident Investigation Preliminary Interview List