Conducting Accident Investigations

1.1  The Nature of Accidents........................................................................................................1-1 1.2  Human Factors Considerations..............................................................................................1-1
       1.2.1 Human-Machine Interface..........................................................................................1-2
       1.2.2 Human Capabilities ....................................................................................................1-3
       1.2.3 Equipment/Design Considerations .............................................................................1-4
       1.2.4 Physical Work Environment.......................................................................................1-4
       1.2.5 Organizational Work Environment.............................................................................1-6 Key Points to Remember..............................................................................................................1-8

Section 2: DOE's Acident Investigation

2.1  Overall Management of the Program.....................................................................................2-1 2.2  Roles and Responsibilities of Key Participants.....................................................................2-1
       2.2.1 Appointing Officials and Line Management Participants..........................................2-2
       2.2.2 The Accident Investigation Board..............................................................................2-3 2.3  Site Readiness........................................................................................................................2-6
       2.3.1 Readiness C What Is It? .............................................................................................2-6
       2.3.2 Establishing Written Procedures and Responsibilities...............................................2-8
       2.3.3 Maintaining Resources to Support Accident Investigations ......................................2-8
       2.3.4 Training for Site Readiness ........................................................................................2-8
       2.3.5 Conducting Periodic Practices and Evaluations.........................................................2-9 2.4  Accident Investigation Process Overview .............................................................................2-9
2.5 Waivers................................................................................................................................ 2-11 2.6 Limited Scope Accident Investigations...............................................................................2-12 Key Points to Remember............................................................................................................2-13

Section 3: Appointing the Investigation

3.1 Establishing the Accident Investigation Board and Its Authority.........................................3-1 3.2 Briefing the Board..................................................................................................................3-2 Key Points to Remember..............................................................................................................3-3

Section 4: Implementin Site Readiness

4.1  Immediate Post-Accident Actions  .........................................................................................4-1
4.2  Preserving and Documenting the Accident Scene.................................................................4-2
       4.2.1 Securing and Preserving the Scene.............................................................................4-2
       4.2.2 Documenting the Scene..............................................................................................4-3
4.3  Collecting, Preserving, and Controlling Evidence.................................................................4-3
4.4  Obtaining Initial Witness Statements.....................................................................................4-4
4.5  Transferring Information to the Board...................................................................................4-5
Key Points to Remember..............................................................................................................4-7

Section 5: Managing the Accident Investigation

5.1  Project Planning.....................................................................................................................5-1
       5.1.1 Collecting Initial Site Information..............................................................................5-1
       5.1.2 Determining Task Assignments..................................................................................5-1
       5.1.3 Preparing a Schedule..................................................................................................5-2
       5.1.4 Acquiring Resources  ..................................................................................................5-3
       5.1.5 Addressing Potential Conflicts of Interest..................................................................5-3
       5.1.6 Establishing Information Access and Release Protocols  ...........................................5-3 5.2  Managing the Investigation Process  ......................................................................................5-6
       5.2.1 Taking Control of the Accident Scene........................................................................5-6
       5.2.2 Initial Meeting of the Investigation Board  .................................................................5-6
       5.2.3 Promoting Teamwork  .................................................................................................5-7
       5.2.4 Managing Information Collection ..............................................................................5-9
       5.2.5 Coordinating Internal and External Communication  .................................................5-9
       5.2.6 Managing the Analysis............................................................................................. 5-11
       5.2.7 Managing Report Writing.........................................................................................5-12
       5.2.8 Managing Onsite Closeout Activities.......................................................................5-13
       5.2.9 Managing Post-Investigation Activities  ...................................................................5-13 5.3  Controlling the Investigation Process..................................................................................5-14
       5.3.1 Monitoring Performance and Providing Feedback...................................................5-14
       5.3.2 Controlling Cost and Schedule.................................................................................5-14
       5.3.3 Assuring Quality.......................................................................................................5-15 Key Points to Remember............................................................................................................5-16

Section 6: Collecting Data

6.1  Collecting Human Evidence  ..................................................................................................6-2
       6.1.1 Locating Witnesses.....................................................................................................6-2
       6.1.2 Conducting Interviews................................................................................................6-2 6.2  Collecting Physical Evidence  ................................................................................................ 6-6
       6.2.1 Documenting Physical Evidence................................................................................6-7
       6.2.2 Inspecting Physical Evidence.....................................................................................6-9
       6.2.3 Removing Physical Evidence ...................................................................................6-10 6.3  Collecting Documentary Evidence  ......................................................................................6-10 6.4  Examining Organizational Concerns, Management Systems, and Line Management       Oversight  .............................................................................................................................6-11 6.5  Preserving and Controlling Evidence  ..................................................................................6-12 Key Points to Remember............................................................................................................6-17

Section 7: Analyzing Data

7.1  Determining Facts..................................................................................................................7-1
7.2  Determining Causal Factors...................................................................................................7-2
       7.2.1 Direct Cause  ...............................................................................................................7-2
       7.2.2 Contributing Causes  ...................................................................................................7-3
       7.2.3 Root Causes................................................................................................................7-4
       7.2.4 The Importance of Causal Factors..............................................................................7-5
7.3  Using the Core Analytical Techniques  ..................................................................................7-5
       7.3.1 Events and Causal Factors Charting...........................................................................7-5
       7.3.2 Barrier Analysis.......................................................................................................... 7-8
       7.3.3 Change Analysis.......................................................................................................7-15
       7.3.4 Events and Causal Factors Analysis.........................................................................7-21
       7.3.5 Root Cause Analysis.................................................................................................7-25
7.4  Using Advanced Analytic Methods.....................................................................................7-39
        7.4.1 Analytic Trees...........................................................................................................7-40
        7.4.2 Management Oversight and Risk Tree Analysis (MORT) .......................................7-44
        7.4.3 Project Evaluation Tree (PET) Analysis  ..................................................................7-47
7.5  Other Analytic Techniques  ..................................................................................................7-52
        7.5.1 Time Loss Analysis  ..................................................................................................7-52
        7.5.2 Human Factors Analysis...........................................................................................7-52
        7.5.3 Integrated Accident Event Matrix ............................................................................7-53
        7.5.4 Failure Modes and Effects Analysis.........................................................................7-53
        7.5.5 Software Hazards Analysis.......................................................................................7-54
        7.5.6 Common Cause Failure Analysis .............................................................................7-54
        7.5.7 Sneak Circuit Analysis .............................................................................................7-54
        7.5.8 Materials and Structural Analysis  ............................................................................7-54
        7.5.9 Design Criteria Analysis...........................................................................................7-54
        7.5.10  Accident Reconstruction  ..........................................................................................7-54
        7.5.11  Scientific Modeling ..................................................................................................7-54
Key Points to Remember............................................................................................................7-56

Section 8: Developing Conclusions and Judgments of Needs

8.1 Conclusions............................................................................................................................8-1 8.2 Judgments of Need.................................................................................................................8-2 8.3 Minority Opinions..................................................................................................................8-4 Key Points to Remember..............................................................................................................8-5

Section 9: Reporting the Results

9.1  Writing the Report  .................................................................................................................9-1 9.2  Report Format and Content....................................................................................................9-1
       9.2.1 Disclaimer...................................................................................................................9-3
       9.2.2 Appointing Official=s Statement of Report Acceptance.............................................9-3
       9.2.3 Table of Contents........................................................................................................9-4
       9.2.4 Acronyms and Initialisms...........................................................................................9-4
      9.2.5 PrologueCInterpretation of Significance  ...................................................................9-5
       9.2.6 Executive Summary....................................................................................................9-5
       9.2.7 Introduction  ................................................................................................................9-6
       9.2.8 Facts and Analysis......................................................................................................9-6
       9.2.9 Conclusions and Judgments of Need........................................................................9-12
       9.2.10  Minority Report........................................................................................................9-13
       9.2.11  Board Signatures  ......................................................................................................9-13
       9.2.12  Board Members, Advisors, Consultants, and Staff ..................................................9-13
       9.2.13  Appendices ............................................................................................................... 9-13 9.3  Performing Quality Review and Validation of Conclusions................................................9-13 9.4  Conducting the Factual Accuracy Review...........................................................................9-16 9.5  Review by the Assistant Secretary for Environment, Safety and Health  ............................9-16 9.6  Submitting the Report..........................................................................................................9-17 Key Points to Remember............................................................................................................9-18

Appendices