Less obvious but potentially important physical evidence includes fluids (liquids and gases). Many DOE facilities use a multitude of fluids, including chemicals, fuels, hydraulic control or actuating fluids, and lubricants. Analyzing such evidence can reveal much about the operability of equipment and other potentially relevant conditions or causal factors.

Care should be taken if there is the potential for pathogenic contamination of physical evidence (e.g., blood); such material may require autoclaving or other sterilization. Specialized technicians experienced in fluid sampling should be employed to help the board collect and analyze fluid evidence. If required, expert analysts can be requested to perform tests on the fluids and report results to the board.

When handling potential bloodborne pathogens, universal precautions such as those listed in Table 6-6 should be observed to minimize potential exposure. All human blood and body fluids should be treated as if they are infectious. The precautions in Table 6-6 should be implemented for all potential exposures. Exposure is defined as reasonable anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials.

TIP Significant physical evidence is often found in obscure and seemingly insignificant places, such as hinges and supports.

Physical evidence should be systematically collected, protected, preserved, evaluated, and recorded to ultimately determine how and why failures occurred and whether use, abuse, misuse, or nonuse was a causal factor.

Items that have been fractured or otherwise damaged should be packaged carefully to preserve surface detail. Delicate parts should be padded and boxed. Both the part and the outside of the package should be labeled. Greasy or dirty parts can be wrapped in foil and placed in polyethylene bags or other nonabsorbent materials for transport to a testing laboratory, command center, or evidence storage facility. If uncertainties arise, subject matter experts can advise the board regarding effective methods for preserving and packaging evidence and specimens that must be transported for testing.

When preparing to remove physical evidence, these guidelines should be followed:

• Normally, extraction should not start until witnesses have been interviewed, since visual reference to the accident site can stimulate one's memory

• Extraction and removal or movement of parts should not be started until position records (measurements for maps, photographs and videotape) have been made

• Be aware that the accident site may be unsafe due to dangerous materials or weakened structures

• Locations of removed parts can be marked with orange spray paint or wire-staffed marking flags; the marking flags can be annotated to identify the part removed and to allow later measurement

• Care during extraction and preliminary examination is necessary to avoid defacing or distorting impact marks and fracture surfaces

• The board chairperson and investigators should concur when the parts extraction work can begin, in order to assure that board members have completed all observations requiring an intact accident site.

6.3 Collecting Documentary Evidence

Documentary evidence can provide important data and should be preserved and secured as methodically as physical evidence. This information might be in the form of paper, photos, videotape, magnetic tape, or electronic media, either at the site or in files at other locations.

Some work/process/system records are retained only for the workday or the week. Once an accident has occurred, the board must work quickly to collect and preserve these records so they can be examined and considered in the analysis.

Accident investigation preplanning should include procedures for identifying records to be collected, as well as the people responsible for their collection. Because records are usually not located at the scene of the accident, they are often overlooked in the preliminary collection of evidence.

Documents often provide important evidence for identifying causal factors of an accident. This evidence is useful for:

Collectively, this evidence gives important clues to possible underlying causes of errors, malfunctions, and failures that led to the accident.

6.4 Examining Organizational Concerns, Management Systems, and Line Management Oversight

DOE Order 225.1A requires that the investigation board "examine policies, standards, and requirements that are applicable to the accident being investigated, as well as management and safety systems at Headquarters and in the field that could have contributed to or prevented the accident."  Additionally, DOE Order 225.1A, Paragraph 4.c.(2)(b) and (d), requires the board to "evaluate the effectiveness of management systems, as defined by DOE Policy 450.4 (Safety Management System Policy), the adequacy of policy and policy implementation, and the effectiveness of line management oversight as they relate to the accident." Therefore, accident investigations must thoroughly examine organizational concerns, management systems, and line management oversight processes to determine whether deficiencies in these areas contributed to causes of the accident. The investigation board should consider the full range of management systems from the first-line supervisor level, up to and including site and Headquarters, as appropriate. It is important to note that this focus should not be directed toward individuals.

In determining sources and causes of management system inadequacies and the failure to anticipate and prevent the conditions leading to the accident, investigators should use the framework of DOE's integrated safety management system established by the Department in DOE Policy 450.4. This policy lists the objective, guiding principles, core functions, mechanisms, responsibilities, and implementation means of an effective safety management system.

The safety management system elements described in DOE Policy 450.4 should be considered when deciding who to interview, what questions to ask, what documents to collect, and what facts to consider pertinent to the investigation. Even more importantly, these elements should be considered when analyzing the facts to determine their significance to the causal factors of the accident.

In many accidents, deficiencies in implementing the five core safety management functions defined in DOE Policy 450.4 cause or contribute to the accident. The five core functions are: (1) define the scope of work; (2) identify and analyze the hazards associated with the work; (3) develop and implement hazard controls; (4) perform work safely within the controls; and (5) provide feedback on adequacy of the controls and continuous improvement in defining and planning the work. Table 6-7 contains a list of typical questions board members may ask to determine whether any deficiencies in the implementation of the core functions affected the accident sequence.

Table 6-8 contains a list of typical questions board members may ask to determine whether line management deficiencies affected the accident. These questions are based on the seven guiding principles of DOE Policy 450.4.

The questions in Tables 6-7 and 6-8 are provided in Appendix D to facilitate use by the board. These are not intended to be exhaustive. Board members should adapt these questions or develop new ones based on the specific characteristics of the accident. The answers to the questions may be used to determine the facts of the accident, which, along with the analytical tools described in Section 7, will enable the board to determine whether deficiencies found in management systems and line management oversight are causal factors for the accident.

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

Function #1: Define the scope of work.

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? Were expectations regarding the removal or control of hazards clearly defined and communicated to the workers? Were the required safety support activities identified? Were roles, responsibilities, and authorities for the work activity defined and executed appropriately? Were the worker qualifications required to safely perform the work identified? Were the design, operation, and configuration of equipment known and considered in work planning? Were the characteristics of the work environment known and considered in work planning?

Function #2: Identify and analyze the hazards.

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

Function #3: Develop and implement hazard controls.

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

Function #4: Perform work within controls.

Was the readiness to perform the work checked and confirmed prior to starting work? Was appropriate authorization received to start work? 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)? Were the workers empowered to stop work if unanticipated or unsafe conditions arose?

Function #5: Provide feedback and continuous improvement.

Was there a system to collect and use feedback from workers on workplace hazards? Were workers aware of any hazards affecting the work activity that were not addressed in planning for it? Was management aware of the hazard(s) identified by the workers? 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?

 

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.

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

Did line management define and maintain clearly delineated roles and responsibilities for ES&H to effectively integrate safety into sitewide operations? 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? Did line management establish communication systems to inform the organization, other facilities, and the public of potential ES&H impacts of specific work processes? Were managers and workers at all levels aware of their specific responsibilities and accountability for ensuring safe facility operations and work practices? Were individuals held accountable for safety performance through performance objectives, appraisal systems, and visible and meaningful consequences? 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.

Did line managers demonstrate a high degree of technical competence and understanding of programs and facilities? 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? Were mechanisms in place to assure that only qualified and competent personnel were assigned to specific work activities, commensurate with the associated hazards? 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? Did line management establish and implement processes to ensure that ES&H training programs effectively measure and improve performance and identify training needs? 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?

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.

Did line management demonstrate a commitment to ensuring that ES&H programs had sufficient resources and priority within the line organization? Did line management clearly establish that integrated safety management was to be applied to all types of work and address all types of hazards? 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)? 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.

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? Were requirements established commensurate with the hazards, vulnerabilities, and risks encountered in the current life cycle stage of the site and/or facility? Were policies and procedures, consistent with current DOE policy, formally established and approved by appropriate authorities? 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.

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? Were hazard controls established for all stages of work to be performed (e.g., normal operations, surveillance, maintenance, facility modifications, decontamination, and decommissioning)? 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? Were processes established for ensuring that DOE contractors and subcontractors test, implement, manage, maintain, and revise controls as circumstances change? Were personnel qualified and knowledgeable of their responsibilities as they relate to work controls and work performance for each activity?

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

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? Did DOE and contractor line management establish and agree upon conditions and requirements that must be satisfied for operations to be initiated? 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? 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?

6.5 Preserving and Controlling Evidence

Preserving and controlling evidence are essential to the integrity and credibility of the investigation. Security and custody of evidence are necessary to prevent its alteration or loss and to establish the accuracy and validity of all evidence collected.

The point of contact is responsible for assuring that a chain of custody is established for all evidence removed from the accident scene before the board arrives.

The board chairperson is responsible for establishing an evidentiary custody protocol to ensure that all evidence is well documented at the accident scene and carefully controlled when it is removed and stored after the board arrives. Evidence control procedures similar to the following guidelines will help assure that evidence is not adulterated, corrupted, or lost and that subsequent engineering tests, if conducted, and other analytical results are valid.