Documentation Requirements

DOE-HDBK-1101-96

Documentation Requirements

Incident investigation findings must be documented in a written report that contains the date of the

incident, the date the investigation began, a description of the incident, the factors that contributed to

the incident, and recommendations. The PSM Rule requires that a team be appointed and an

investigation initiated within 48 hours of discovery of the incident. However, current DOE Orders

are more restrictive and should be consulted for additional requirements.

Minimum Implementation Criteria

Investigations must be conducted for all incidents that result in, or could reasonably result in,

catastrophic releases of highly hazardous chemicals. DOE contractors must assemble a team and

initiate an investigation within 48 hours of an incident or sooner, per DOE requirements [Q88].

Therefore, an effective written incident investigation procedure must be in place for establishing an

incident investigation team, including a leader, and preserving relevant information and evidence.

Activities for preserving information include securing/barricading the scene, initiating the collection

of transient information, and interviewing personnel.

The incident investigation team should vary according to the type of incident. A typical team may

include management personnel from the facility where the incident occurred; engineering and/or

maintenance personnel; facility and/or operations personnel; ES&H personnel; and technical and/or

research personnel. Incident investigation teams must include at least one person knowledgeable in

the process involved in the incident. If the incident involved the work of a subcontractor, at least

one subcontractor employee must be included on the investigation team. Other members should

have the appropriate knowledge and experience to support the investigation.

The team chairperson must effectively control the scope of team activities by identifying the lines of

investigation to be pursued; assigning tasks and establishing timetables; and keeping facility

management advised of the progress of the investigation.

Investigations should include a visit to the incident scene; preparation of visual aids, such as photos

and field sketches; eyewitness interviews, conducted privately and individually; observation of any

mechanical equipment involved; review of as-built drawings, operating logs, recorder charts,

previous reports, procedures, equipment manuals, design data, laboratory tests, and other potentially

useful information; and documentation of the sources of information for the incident report.

Incident investigations should analyze for root causes that will lead to recommendations for

corrective actions. Recommendations should include the actions to prevent a recurrence of the

incident, the identification of the person responsible for completing the actions, and the schedule for

completion. Corrective actions should be aimed primarily at preventing or controlling the

underlying causes of an incident rather than the surface manifestations.

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