Responsibility and Qualification

DOE-STD-1045-93

A department head or the facility safety review committee deems an

investigation is appropriate.

"Near miss" situations often serve as indicators of underlying problems and

should therefore be investigated. The following are some examples of near

misses:

An operator action was not performed, or was performed improperly, but

the error was identified and corrected before the process was damaged.

The near miss may indicate a problem in the operator's training or the

operating procedures.

A maintenance activity, such as calibration or testing, produced a transient

in an operating system; the system was prevented from upset only by the

response of an attentive operator. The near miss may indicate a problem

in the maintenance procedures or may point to a need for better

coordination of operations and maintenance activities.

All events that require notification to DOE (in accordance with DOE Order

232.1A) or reporting to other agencies (e.g., Environmental Protection

Agency) should be investigated.

4.2.2

Responsibility and Qualification

Responsibility for investigating, reporting on, and identifying corrective actions

for abnormal events rests with management, although specific investigative

tasks may be delegated. When the root cause of the event has been determined

and documented, management should ensure that appropriate corrective action

is initiated to prevent recurrence of this or similar events.

Personnel assigned as investigators should be technically qualified,

knowledgeable of factors affecting human performance, and trained in

investigative methods, such as root cause analysis and interviewing techniques.

They should maintain an unbiased attitude in relation to the event being

investigated and the personnel involved at the time of the occurrence.

The operations manager is responsible for event investigations involving plant

operations. The operations manager may delegate specific investigations or