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Incident Investigation - doe-hdbk-1101-20040101
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DOE-HDBK-1101-2004
Documentation Requirements
Incident investigation findings must be documented in a written report that contains the date of
the incident, the date the investigation began, a description of the incident, the factors that
contributed to the incident, and recommendations. The PSM Rule requires that a team be
appointed and an investigation initiated within 48 hours of discovery of the incident. However,
current DOE Orders are more restrictive and should be consulted for additional requirements.
Minimum Implementation Criteria
Investigations must be conducted for all incidents that result in, or could reasonably result in,
catastrophic releases of highly hazardous chemicals. DOE contractors must assemble a team and
initiate an investigation within 48 hours of an incident or sooner, per DOE requirements [Q88].
Therefore, an effective written incident investigation procedure must be in place for establishing
an incident investigation team, including a leader, and preserving relevant information and
evidence. Activities for preserving information include securing/barricading the scene, initiating
the collection of transient information, and interviewing personnel.
The incident investigation team should vary according to the type of incident. A typical team
may include management personnel from the facility where the incident occurred; engineering
and/or maintenance personnel; facility and/or operations personnel; ES&H personnel; and
technical and/or research personnel. Incident investigation teams must include at least one
person knowledgeable in the process involved in the incident. If the incident involved the work
of a subcontractor, at least one subcontractor employee must be included on the investigation
team. Other members should have the appropriate knowledge and experience to support the
investigation.
The team chairperson must effectively control the scope of team activities by identifying the
lines of investigation to be pursued; assigning tasks and establishing timetables; and keeping
facility management advised of the progress of the investigation.
Investigations should include a visit to the incident scene; preparation of visual aids, such as
photos and field sketches; eyewitness interviews, conducted privately and individually;
observation of any mechanical equipment involved; review of as-built drawings, operating logs,
recorder charts, previous reports, procedures, equipment manuals, design data, laboratory tests,
and other potentially useful information; and documentation of the sources of information for the
incident report.
Incident investigations should analyze for root causes that will lead to recommendations for
corrective actions. Recommendations should include the actions to prevent a recurrence of the
incident, the identification of the person responsible for completing the actions, and the schedule
for completion. Corrective actions should be aimed primarily at preventing or controlling the
underlying causes of an incident rather than the surface manifestations.
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