Incident Investigation - doe-hdbk-1101-20040101

DOE-HDBK-1101-2004

2.11 Incident Investigation

29 CFR 1910.119 (m)

(1)

The employer shall investigate each incident which resulted in, or could reasonably have resulted in a

catastrophic release of highly hazardous chemical in the workplace.

(2)

An incident investigation shall be initiated as promptly as possible, but not later than 48 hours following

the incident.

(3)

An incident investigation team shall be established and consist of at least one person knowledgeable in

the process involved, including a contract employee if the incident involved work of the contractor, and

other persons with appropriate knowledge and experience to thoroughly investigate and analyze the

incident.

(4)

A report shall be prepared at the conclusion of the investigation which includes at a minimum:

(i)

Date of incident;

(ii)

Date investigation began;

(iii)

A description of the incident;

(iv)

The factors that contributed to the incident; and,

(v)

Any recommendations resulting from the investigation.

(5)

The employer shall establish a system to promptly address and resolve the incident report findings and

recommendations. Resolutions and corrective actions shall be documented.

(6)

The report shall be reviewed with all affected personnel whose job task

are relevant to the incident findings including contract employees where applicable.

(7)

Incident investigation reports shall be retained for five years.

Intent

The purpose of incident investigation is to prevent recurrence of incidents having the same

nature or the root cause. Every incident that results in or could reasonably result in a catastrophic

chemical release must be investigated. The PSM Rule defines catastrophic as "a major,

uncontrolled emission, fire, or explosion, involving one or more HHCs, that present a serious

danger to employees in the workplace" [Q87].

The incident investigation team's recommendations are to be implemented unless it can be

documented that an alternative will address the concerns at least as effectively and efficiently.

Management may reject recommendations that are erroneous, infeasible, or more costly or

complex than a equally protective measure.

Corresponding DOE Programs and Requirements

DOE incident investigations are addressed in DOE O 225.1A, ACCIDENT INVESTIGATION

and DOE M 231.1-2, OCCURRENCE REPORTING AND PROCESSING OF OPERATIONS

INFORMATION. The Accident/Incident Reporting System and the Occurrence Reporting and

Processing System within DOE meet the intent of the incident investigation element of the PSM

Rule. Additional DOE guidance is provided in DOE G 231.1-1, OCCURRENCE REPORTING

AND PERFORMANCE ANALYSIS GUIDE and DOE G 231.1-2, OCCURRENCE

REPORTING CAUSAL ANALYSIS GUIDE.