Investigation of Abnormal Events cont'd

DOE-STD-1045-93

investigation is appropriate for all events, conditions, "near misses," or other indications

of situations within or outside the operations organization that, if uncorrected, can

impact safety or reliability. Acts of actual or suspected sabotage represent a special case

for investigation.

The investigative process described in this guide is intended to assist the operating

organization in evaluating and responding to operational abnormalities. These

investigations are not intended to replace the formal Type A, B, or C investigations that

are required for certain occurrences in accordance with DOE Order 5484.1,

Environmental Protection, Safety, and Health Protection Information Reporting

Requirements, although both investigations have similar objectives. Consider again the

situation of a supervisor immediately after a serious operating event. Even though

immediate actions have been taken in accordance with appropriate procedures, the event

may still impact personnel or facility safety. Therefore, it is important that the

operations organization begin the investigative process as soon as possible.

To ensure consistency, facilities should provide written guidelines to address all aspects

of the investigative process. Concise instructions will aid the supervisor in properly

collecting and/or preserving physical evidence that may be needed in the investigation.

Standard forms, or an example format, will aid in documenting statements from the

personnel present during the event. Checklists may be useful for ensuring that all

appropriate operating records (e.g., recorder charts, round sheets, logs) are collected or

copied for use in the investigation. Finally, clear instructions for conducting the

investigation will make effective use of time and will aid personnel in evaluating the

corrective actions taken and the results of those actions. This process will enable

personnel to determine the current safety status of the facility and the capability for

continued operation.