1. Executing the Process for Accident Investigations

Management System: Environment, Safety, and Health

Subject Area: Accident Investigation

Procedure 1. Executing the Process for Accident Investigations

Subject Matter Expert: JENISE MULLINS
Management System Owner: PATRICK SMITH
Secondary Management System Owner: KARL MORO

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Issue Date:  10/31/2012
SCMS Revision:  2.0

1.0 Applicability

This information applies to the Accident Investigation (AI) Points of Contact (POC) in the Office of Science (SC) and other Science employees wanting to understand the administration of the AI program.

2.0 Required Procedure

The head of the Field Element appoints an AI POC and an Alternate to administer the AI Program.

Step 1

When an incident is reported, the AI POC assists management in determining if the incident meets the requirements of an Accident Investigation.

Step 2
  1. After an incident has been categorized (per the algorithm in Appendix A of DOE O 225.1B, Accident Investigations), the Head of the Field Element notifies the U.S. Department of Energy (DOE) Headquarters (HQ) SC Office of the Deputy Director for Field Operations (SC-3).

  2. The AI POC will notify the DOE HQ AI Program Manager.

Step 3

SC-3 will consult with the DOE HQ Office of Health, Safety, and Security (HS‑1) to determine which entity will appoint the Accident Investigation Board (AIB) (i.e., the Appointing Official).

When requested, the AI POC assists in identifying trained employees (AIB Chairperson, trained Accident Investigator, and members) to participate in the investigation.

NOTE:  Per DOE O 225.1B, each AI POC maintains a list of trained employees at their respective site.

Step 4

The Appointing Official appoints the AIB.

NOTE:  It has proven helpful to obtain a Records Coordinator and Technical Editor(s) at initiation of investigation.

Step 5

If requested by HQ or the Head of the Field Element, the AI POC prepares correspondence to the affected contractor informing of the AIB’s scope, AIB members, and requesting a liaison to interface with the AIB and accommodate all of the AIB’s needs (e.g., office space, computers, supplies, organization charts) .

NOTE:  For sample transmittal correspondence information, see Sample Contractor Letter Announcing Accident Investigation. If the incident involves only Federal staff operations, there will be no need for this letter. The only memorandum needed will be the AIB Appointment memorandum.
Step 6 AI POC responds to requests from the AIB for technical assistance and/or special advisors during the conduct of the investigation.
Step 7

If requested by the AIB, the AI POC ensures that court reporters are available to record key witness interviews.

NOTE:   The use of Court Reporters is strongly encouraged to expeditiously and accurately capture witness interviews. This process usually requires a Purchase Order be prepared to obtain the services and is usually charged to the Program Office affected by the investigation.
Step 8 If requested, the AI POC assists in identifying appropriate Federal Line Organization Staff affected by the investigation to review the facts section of the draft report for accuracy.
Step 9 If requested, the AI POC assists the AIB in ensuring that a security/classification review and a Legal/Privacy Act Review are completed (by the local Subject Matter Experts) on the draft report before it is sent out for comment.
Step 10

If requested, the AI POC coordinates and participates in a peer review of the draft report for all Accident investigations. SC‑3 and the HQ AI Program Manager receive a draft copy for review also.

NOTE:  The AI POC identifies the employees performing the peer review based on their AI experience and subject matter expertise.
Step 11

After the final draft report is provided to the Appointing Official and accepted, the AI POC attends the AIB briefings with local management and contractor.

Step 12

If requested, the AI POC prepares correspondence to the appropriate contractor from to transmit the AIB’s report with a request for a corrective action plan (CAP) to address the report’s Judgments of Need within 30 calendar days of the date of the letter. See (1) Transmit Report and Contractor Corrective Action Plan Request Letter (Example) and (2) Local Corrective Action Plan Request Memorandum (Example).

Step 13

The AI POC develops lessons learned, as appropriate, from the AI process and provides it to the HQ AI Program Manager to aid in process improvement.

Step 14

If requested, the AI POC assists the AIB Chairperson and local management in identifying lessons learned from the findings of the investigation and provides those lessons to SC‑3 and the AI Program Manager for DOE‑wide dissemination.

Step 15

If requested, the AI POC assists local Line Management in reviewing the contractor’s CAP.

NOTE:  If applicable, the AI POC reviews the Federal Line Management’s CAP for adequacy. Comments, if any, are resolved.

Step 16

The AI POC prepares correspondence from the Head of the Field Element to DOE HQ Director, Office of Science, (SC‑1), to transmit the CAPs (contractor and Federal, if applicable). See Transmit Corrective Action Plan to Headquarters Memorandum (Example).

NOTE:  All appropriate HQ Program Offices and HS‑1 receive copies.

Step 17

Federal Line Management will track and verify closure of contractor and Federal corrective actions.

Step 18

The AI POC prepares correspondence to SC‑1 from the Head of the Field Element to transmit status reports of corrective actions (contractor and Federal, if applicable) when received from Line Management.

NOTE:  All appropriate HQ Program Offices and HS‑1 receive copies.

Step 19

The AI POC prepares correspondence to SC‑1 from the Head of the Field Element recommending that the AI be closed when notified that all actions have been completed and verified.

NOTE:  All appropriate HQ Program Offices and HS‑1 receive copies.

Step 20 If requested, the AI POC will assist the AIB Chair in ensuring AIB files from the investigation are appropriately dispositioned.

3.0 References


This is the online OFFICIAL SCMS COPY of this file. Before using a printed copy, verify that it is the most current version by checking the Last Major Revision and Last Minor Revision dates (at the bottom of each document) on the SCMS Web site.


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