A department head or the facility safety review committee deems an
investigation is appropriate.
"Near miss" situations often serve as indicators of underlying problems and
should therefore be investigated. The following are some examples of near
An operator action was not performed, or was performed improperly, but
the error was identified and corrected before the process was damaged.
The near miss may indicate a problem in the operator's training or the
A maintenance activity, such as calibration or testing, produced a transient
in an operating system; the system was prevented from upset only by the
response of an attentive operator. The near miss may indicate a problem
in the maintenance procedures or may point to a need for better
coordination of operations and maintenance activities.
All events that require notification to DOE (in accordance with DOE Order
232.1A) or reporting to other agencies (e.g., Environmental Protection
Agency) should be investigated.
Responsibility and Qualification
Responsibility for investigating, reporting on, and identifying corrective actions
for abnormal events rests with management, although specific investigative
tasks may be delegated. When the root cause of the event has been determined
and documented, management should ensure that appropriate corrective action
is initiated to prevent recurrence of this or similar events.
Personnel assigned as investigators should be technically qualified,
knowledgeable of factors affecting human performance, and trained in
investigative methods, such as root cause analysis and interviewing techniques.
They should maintain an unbiased attitude in relation to the event being
investigated and the personnel involved at the time of the occurrence.
The operations manager is responsible for event investigations involving plant
operations. The operations manager may delegate specific investigations or