Investigative Process

DOE-STD-1045-93

portions of investigations to other personnel. For example, the initial review

following a plant transient might be conducted by the on-shift shift manager;

the results of this investigation will establish the need for further review.

4.2.3

Investigative Process

The process of investigation begins with collecting data. Facility guidelines

should identify the types of information that will be needed in an investigation,

and the methods that should be used to collect and preserve the information.

Operations logs, round sheets, and statements from persons present during the

event would typically be required for any investigation. Use of prepared forms

for personal statements can aid in obtaining and documenting relevant

information for the investigation. A sample personal statement form is shown

in Appendix A.

Some events may warrant collection of physical evidence such as: recorder

charts, readouts from monitoring equipment, photographs and/or drawings of

the area, procedures, technical documents, broken or failed components, and

laboratory analyses. In some situations, it may be necessary to quarantine

certain equipment or systems until the investigation is finished. As soon as

possible after an event, personnel should be assigned responsibility to collect

and/or preserve appropriate information and evidence.

A structured review of the abnormal event should be initiated when all data has

been collected. The format of the investigation depends on the significance of

the event. The steps detailed below should be included in each investigation.

Event Reconstruction

The abnormal event should be reconstructed using the collected

information. When applicable, this is best accomplished using the

sequence of events recorder printout as a basis. A chronological list of

events is developed. It is desirable to include the personnel involved in the

event in the reconstruction process.

Event Analysis and Evaluation

Once the facts have been established, the event may be analyzed to

determine the responses of equipment and personnel. During the analysis,

actual and expected responses of facility systems, adequacy of procedures,