Part II �The Accident Investigation Process

Section 3 � Appointing the Investigation Board

Section 4 � Implementing Site Readiness

Section 5 � Managing the Accident Investigation

Section 6 � Collecting Data

Section 7 � Analyzing Data

Section 8 � Developing Conclusions andJudgments of Need

Section 9 � Reporting Results

Contents

Section 3 C Appointingthe Investigation Board

3.1 Establishing the Accident Investigation Board and Its Authority ....................... 3-13.2 Briefing the Board ............................................................................................... 3-2

Key Points to Remember ........................................................................................... 3-3

List of Tables

Table 3-1.Board members must meet these criteria ................................................... 3-2

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Part II Section 3 — Appointing the Investigation Board

Before an accident investigation canactually begin, the appointingofficial must conduct a number of

activities, including selecting and briefingthe investigation board. These activities arediscussed below.

3.1 Establishingthe AccidentInvestigation Boardand Its Authority

Upon notification of an accident requiringa Type A or Type B investigation, theappointing official selects the accidentinvestigation board chairperson and three tosix other board members, one of whom mustbe a DOE accident investigator. Theappointing official for a Type A accidentinvestigation is the Assistant Secretary forEnvironment, Safety and Health (EH-1),unless this responsibility is delegated to thehead of the field element. The appointingofficial for Type B accident investigations isthe head of the field element. Limited scopeinvestigations are chartered by the AssistantSecretary for Environment, Safety andHealth. A list of prospective chairpersonswho meet minimum qualifications isavailable from the Program Manager. TheProgram Manager also maintains a list ofqualified board members, consultants,advisors, and support staff, includingparticular areas of expertise for potentialboard members or consultants/advisors.The selected chairperson can help identifyand select board members and othersneeded to conduct the investigation. In

selecting these individuals, the appointingofficial follows the criteria defined in DOEOrder 225.1A, which are shown inTable 3-1.

DOE Order 225.1A establishes someadditional restrictions concerning theselection of board members and chairper-sons. No member shall have:

# A supervisor-subordinate relationshipwith another board member

# Any conflict of interest or direct or linemanagement responsibility for day-to-day operation or management of thefacility, area, or activity involved in theaccident.

Consultants, advisors, and support staff canbe assigned to assist the board wherenecessary, particularly when DOE employ-ees with necessary skills are not available.For example, advisory staff may be neces-sary to provide knowledge of managementsystems or organizational concerns orexpertise on specific DOE policies. Adedicated and experienced administrativecoordinator (see Appendix C) is recom-mended. The Program Manager can helpidentify appropriate personnel to supportaccident investigation boards.

The appointing official must appoint theaccident investigation board within threecalendar days after the accident is catego-rized by issuing an appointment memoran-dum. If the board appointment is delayedbeyond three calendar days, the rationale forthe delay must be provided to the Assistant

3Appointing the

Investigation Board

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Section 3 — Appointing the Investigation Board Part II

Secretary for Environment, Safety andHealth (EH-1).

The appointment memorandum establishesthe board=s authority and includes the scopeof the investigation, the names of theindividuals being appointed to the board, aspecified completion date for the final report(nominally 30 calendar days), and anyspecial provisions deemed appropriate.

The scope of the investigation includes:

# Gathering facts

# Analyzing facts and evidence

# Developing conclusions

# Identifying judgments of need related toDOE and contractor organizations andmanagement systems that could orshould have prevented the accident

# Reviewing all levels of the organizationup to and beyond the level of theappointing official.

3.2 Briefingthe Board

The appointing official is responsible forbriefing all board members as soon aspossible (within three days) after theirappointment to ensure that they clearlyunderstand their roles and responsibilities.This briefing may be given via videoconfer-ence or teleconference. If it is impractical tobrief the entire board, at least the boardchairperson should receive the briefing andthen convey the contents of the briefing tothe other board members before starting theinvestigation. The briefing emphasizes:

# The scope of the investigation

# The board=s authority to examineDOE and contractor organizations andmanagement systems, including linemanagement oversight, as possible rootcauses of an accident, up to and beyondthe level of the appointing official

Table 3-1. Board members must meet these criteria.

Role

Chairperson

BoardMembers

Board Memberor Advisor/Consultant

Qualifications

n Senior DOE managern Preferably a member of the Senior Executive Service or at a senior

general service grade level deemed appropriate by the appointingofficial

n Demonstrated managerial competencen Knowledgeable of DOE accident investigation techniquesn Experienced in conducting accident investigations through participation

in at least one Type A or Type B investigation, or equivalent experiencen Effective October 1, 1998, has participated in an accident investigation

course sponsored by the Deputy Assistant Secretary for Oversight

n DOE employeen Subject matter expertise in areas related to the accident, including

knowledge of the Department’s safety management system policy andintegrated safety management system

n At least one board member must be a DOE accident investigator, havingparticipated in at least one Type A or Type B accident investigation

n Knowledgeable in evaluating management systems, the adequacy ofpolicy and its implementation, and the execution of line managementoversight

n Industry working knowledge in the analytical techniques used todetermine accident causal factors

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Part II Section 3 — Appointing the Investigation Board

# The necessity for avoiding conflicts ofinterest

# Evaluation of the effectiveness ofmanagement systems, as defined byDOE Policy 450.4 (Safety ManagementSystem Policy)

# Pertinent accident information andspecial concerns of the appointingofficial based on site accident patternsor other considerations.

KEY POINTS TO REMEMBER

# Upon notification of an accident requiring an investigation, the appointing officialselects the board chairperson and board members and briefs them before theybegin the investigation.

# Board chairpersons and members must meet the experience and qualificationcriteria defined in DOE Order 225.1A.

# The appointing official establishes the board=s authority in a written appointmentmemorandum.

# The scope of the investigation includes identifying causal factors and developingconclusions and judgments of need related to DOE and contractor organizationsand management systems, including line management oversight, up to and beyondthe level of the appointing official.