Questions - doe-hdbk-1101-20040103

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.