1.1 The Nature of Accidents
1.2 Human Factors Considerations

1.2.1 Human-Machine Interface
1.2.2 Human Capabilities
1.2.3 Equipment/Design Considerations
1.2.4 Physical Work Environment
1.2.5 Organizational Work Environment

Key Points to Remember

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

3.1 Establishing the Accident Investigation Board and Its Authority
3.2 Briefing the Board

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

5.1 Project Planning

5.1.1 Collecting Initial Site Information
5.1.2 Determining Task Assignments
5.1.3 Preparing a Schedule
5.1.4 Acquiring Resources
5.1.5 Addressing Potential Conflicts of Interest
5.1.6 Establishing Information Access and Release Protocols

5.2 Managing the Investigation Process

5.2.1 Taking Control of the Accident Scene
5.2.2 Initial Meeting of the Investigation Board
5.2.3 Promoting Teamwork
5.2.4 Managing Information Collection
5.2.5 Coordinating Internal and External Communication
5.2.6 Managing the Analysis
5.2.7 Managing Report Writing
5.2.8 Managing Onsite Closeout Activities
5.2.9 Managing Post-Investigation Activities

5.3 Controlling the Investigation Process

5.3.1 Monitoring Performance and Providing Feedback
5.3.2 Controlling Cost and Schedule
5.3.3 Assuring Quality

6.1 Collecting Human Evidence

6.1.1    Locating Witnesses
6.1.2    Conducting Interviews

6.2    Collecting Physical Evidence

6.2.1    Documenting Physical Evidence
6.2.2    Inspecting Physical Evidence
6.2.3    Removing Physical Evidence

6.3    Collecting Documentary Evidence
6.4    Examining Organizational Concerns, Management Systems, and Line Management Oversight
6.5    Preserving and Controlling Evidence

Key Points to Remember

7.1 Determining Facts
7.2 Determining Causal Factors

7.2.1    Direct Cause
7.2.2    Contributing Causes
7.2.3    Root Causes
7.2.4    The Importance of Causal Factors

7.3 Using the Core Analytical Techniques

7.3.1    Events and Causal Factors Charting
7.3.2    Barrier Analysis
7.3.3    Change Analysis
7.3.4    Events and Causal Factors Analysis
7.3.5    Root Cause Analysis

7.4 Using Advanced Analytic Methods

7.4.1    Analytic Trees
7.4.2    Management Oversight and Risk Tree Analysis (MORT)
7.4.3    Project Evaluation Tree (PET) Analysis

7.5 Other Analytic Techniques

7.5.1     Time Loss Analysis
7.5.2     Human Factors Analysis
7.5.3     Integrated Accident Event Matrix
7.5.4     Failure Modes and Effects Analysis
7.5.5     Software Hazards Analysis
7.5.6     Common Cause Failure Analysis
7.5.7     Sneak Circuit Analysis
7.5.8     Materials and Structural Analysis
7.5.9     Design Criteria Analysis
7.5.10   Accident Reconstruction
7.5.11   Scientific Modeling

Key Points to Remember

8.1 Conclusions
8.2 Judgments of Need
8.3 Minority Opinions

Key Points to Remember

9.1 Writing the Report
9.2 Report Format and Content

9.3 Performing Quality Review and Validation of Conclusions
9.4 Conducting the Factual Accuracy Review
9.5 Review by the Assistant Secretary for Environment, Safety and Health
9.6 Submitting the Report

Key Points to Remember

Appendix A - Glossary
Appendix B - References
Appendix C - Specific Administrative Needs
Appendix D - Safety Management System
Appendix E - Subject Index

Table 1-1. Human capabilities contribute to work performance
Table 1-2. Equipment design can affect human performance
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
Table 3-1. Board members must meet these criteria
Table 4-1. Several types of witnesses should provide preliminary statements
Table 5-1. These activities should be included on an accident investigation schedule
Table 5-2. The chairperson establishes protocols for controlling information
Table 5-3. The chairperson should use these guidelines in managing information collection activities
Table 5-4. The Price-Anderson Amendments Act of 1988
Table 6-1. These sources are useful for locating witnesses
Table 6-2. It is important to prepare for interviews
Table 6-3. Group and individual interviews have different advantages
Table 6-4. Interviewing do's
Table 6-5. Interviewing don'ts
Table 6-6. Use these universal precautions when handling potential bloodborne pathogens
Table 6-7. These are typical questions for addressing the five core functions of integrated safety management
Table 6-8. These are typical questions for addressing the seven guiding principles of integrated safety management
Table 7-1. Case study introduction
Table 7-2. Benefits of events and causal factors charting
Table 7-3. Guidelines and symbols for preparing an events and causal factors chart
Table 7-4. Sample barrier analysis worksheet
Table 7-5. Sample change analysis worksheet
Table 7-6. Case Study: Change analysis summary
Table 7-7. Tier diagram worksheet for a contractor organization
Table 7-8. Example tier diagram approach
Table 7-9. Compliance/noncompliance root cause model categories
Table 7-10. MORT color coding system
Table 8-1. These guidelines are useful for writing judgments of need
Table 8-2. Case Study: Judgments of need
Table 9-1. Useful strategies for drafting the investigation report
Table 9-2. The accident investigation report should include these items
Table 9-3. Facts differ from analysis

Figure 1-1. Human-machine "activity model"
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
Figure 5-1. A typical schedule of accident investigation activities covers 30 days
Figure 7-1. Simplified events and causal factors chart
Figure 7-2. Sample of an events and causal factors chart (in progress)
Figure 7-3. Barriers are intended to protect personnel and property against hazards
Figure 7-4. Barriers to protect workers from hazards
Figure 7-5. Summary results from a barrier analysis reveal the types of barriers involved
Figure 7-6. Summary results from a barrier analysis can highlight the role of the core functions in an accident
Figure 7-7. The change analysis process is relatively simple
Figure 7-8. Events and causal factors analysis; driving events to causal factors
Figure 7-9. Grouping root causes on the events and causal factor chart
Figure 7-10. Identifying the linkages on the tier diagram
Figure 7-11. The analytic tree process begins with the accident as the top event
Figure 7-12. Analytic trees are constructed using symbols
Figure 7-13. The layout of an analytic tree shows logical relationships
Figure 7-14. A completed analytic tree shows the flow of lower-tier elements to the top event
Figure 7-15. The initial MORT chart uses logic symbols
Figure 7-16. The accident description can be shown on a MORT chart
Figure 7-17. Management system factors can be shown on a MORT chart
Figure 7-18. This branch of the PET chart deals with procedures
Figure 7-19. Time loss analysis can be used when emergency response is in question
Figure 8-1. Facts, analyses, and causal factors are needed to support judgments of need

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Accident Investigation Equipment Checklist
Accident Investigation "Go Kit" Contents
Accident Investigation Preliminary Interview List
Accident Investigation Witness Statement Form
Accident Investigation Startup Activities List
Accident Investigation Information Request Form
Individual Conflict of Interest Certification Form
Accident Investigation Interview Schedule Form
Accident Investigation Interview Form
Model Opening Statement
Accident Investigation Physical Evidence Log Form
Accident Investigation Site Sketch
Accident Investigation Site Map
Accident Investigation Position Mapping Form
Accident Investigation Sketch of Physical Evidence Locations and Orientations
Accident Investigation Photographic Log Sheet
Accident Investigation Sketch of Photography Locations and Orientations
Barrier Analysis Worksheet
Change Analysis Worksheet
PET Analysis Worksheet