Incident Investigation - doe-hdbk-1101-20040165

DOE-HDBK-1101-2004

(iii)

Modifications to operating procedures;

(iv)

Necessary time period for the change; and,

(v)

Authorization requirements for the proposed change.

(3)

Employees involved in operating a process and maintenance and contract

employees whose job tasks will be affected by a change in the process shall be

informed of, and trained in, the change prior to start-up of the process or affected

part of the process.

(4)

If a change covered by this paragraph results in a change in the process safety

information required by paragraph (d) of this section, such information shall be

updated accordingly.

(5)

If a change covered by this paragraph results in a change in the operating

procedures or practices required by paragraph (f) of this section, such procedures

or practices shall be updated accordingly.

(m) Incident Investigation.

(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,

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