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DOE-EM-STD-5505-96
Observe the person responsible for leading the investigation during the investigative process.
Observe the investigation that is in progress. Determine if it is being conducted in accordance
with activity procedures and DOE Directives. Specifically, observe the process used to
conduct the investigation (i.e., reconstruction of the event, event analysis and evaluation, root
cause analysis, corrective action determination).
Once the observation has been completed, compare what was observed to the requirements
contained in activity policies and procedures to identify any apparent deviations from
requirements. Pursue these leads using additional observations, interviews, and document reviews
to confirm or disprove them and determine if programmatic breakdowns or widespread problems
exist.
6.6.4 Interview. The following personnel may be interviewed to assess Investigation of
Abnormal Events:
Selected members of the investigation team
Shift supervisors
Activity managers and operations supervisors
Training department personnel
A line of questioning for a member of the investigation team might proceed as follows:
As a member of the investigation team, what are your responsibilities?
Are these responsibilities delineated in writing?
What training have you had in the area of root cause analysis?
Briefly explain the process employed in performing an investigation.
How are lessons learned from investigations used to help prevent recurrence of similar events?
How does management determine the level of investigation required for a particular event?
Discuss how events are reconstructed.
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