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DOE-HDBK-1101-2004
Incident investigation report findings and recommendations must be implemented and
documented promptly. A system should be in place to ensure follow-up, closure, and
documentation of open recommendations from an incident investigation.
Incident investigation reports must be reviewed with all affected personnel, whose jobs relate to
the incident findings, including subcontractor employees, where applicable. Consideration
should be given to sharing lessons learned with similar DOE facilities through the
Accident/Incident Reporting System or the Occurrence Reporting and Processing System.
Incident investigation reports must be retained for at least 5 years. The purpose of maintaining
the reports is to detect incident patterns.
Questions
87. How severe must an incident be before it is investigated? What does or could reasonably
have resulted in mean? Does the same investigation technique have to be applied to all
incidents covered under this element?
DOE contractors must investigate each incident that resulted in or could reasonably have
resulted in a catastrophic release which the PSM Rule defines as "a major, uncontrolled
emission, fire, or explosion, involving one or more HHCs, that presents a serious danger to
employees in the workplace." The PSM Rule provides no further guidance on what or could
reasonably have resulted in means. Existing criteria which mandate the investigation of
occurrences and accidents and incidents provide the basic guidance within DOE. However,
contractors should include relevant process incidents historically referred to as near-misses.
88. If we cannot gain access to the area where an accident occurred within 48 hours due to
the hazards the area may pose to members of the investigation team, are we in violation of
the requirement to begin the investigation within this time period?
Assembling an accident investigation team and preparing to conduct an onsite inspection is
considered the beginning of the investigation. Contractors are not relieved of time requirements
for occurrence reporting.
87


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