Contents

Section 8 C DevelopingConclusions and Judgmentsof Need

8.1 Conclusions ......................................................................................................... 8-18.2 Judgments of Need .............................................................................................. 8-28.3 Minority Opinions ............................................................................................... 8-4

Key Points to Remember ........................................................................................... 8-5

List of Tables

Table 8-1. These guidelines are useful for writing judgments of need ................... 8-3Table 8-2. Case Study: Judgments of need .............................................................. 8-4

List of Figures

Figure 8-1. Facts, analyses, and causal factors are needed to support judgmentsof need .................................................................................................... 8-3

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Part II Section 8 — Developing Conclusions and Judgments of Need

8Developing Conclusions and

Judgments of Need

Conclusions and judgments of needare key elements of the investigationthat must be developed by the board.

8.1 Conclusions

Conclusions are significant deductionsderived from the investigation’s analyticalresults. They are derived from and must besupported by the facts plus the results oftesting and the various analyses conducted.

Conclusions may:

n Include concise statements of the causalfactors of the accident determined byanalysis of facts

n Be statements that alleviate potentialconfusion on issues that were originallysuspected causes

n Address significant concerns arising outof the accident that are unsubstantiatedor inconclusive

n Be used to highlight positive aspects ofperformance revealed during the investi-gation, where appropriate.

When developing conclusions, the boardshould:

n Organize conclusions sequentially,preferably in chronological order, or inlogical sets (e.g., hardware, procedures,people, organizations)

n Base conclusions on the facts and thesubsequent analysis of the facts

n Include only substantive conclusionsthat bear directly on the accident, andthat reiterate significant facts andpertinent analytical results leading to theaccident’s causes

n Keep conclusions as short as possibleand, to the extent possible, limit refer-ence citations (if used) to one perconclusion.

EXAMPLE: CONCLUSIONS

# XYZ contractor failed to adequately implement a medical surveillance program, thereby allowingan individual with medical restrictions to work in violation of those restrictions. This was acontributing factor to the accident.

# Welds did not fail during the stam line rupture.

# Blood tests on the injured worker did not conclusively establish his blood alcohol content at thetime of the accident.

# The implementation of comprehensive response procedures prevented the fire from spreadingto areas containing dispersible radioactive materials, averting a significant escalation in theconsequences of the fire.

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Section 8 — Developing Conclusions and Judgments of Need Part II

TIPThe process of determining conclusionsseeks to answer the questions—what hap-pened and why did it happen?

8.2 Judgments ofNeed

Judgments of need are the managerialcontrols and safety measures determinedby the board to be necessary to prevent orminimize the probability or severity of arecurrence. Judgments of need should belinked to causal factors and logically flowfrom the conclusions. They should be:

n Stated in a clear, concise, and directmanner

n Based on the facts/evidence

n Stated so that they can be the basis forcorrective action plans.

Judgments of need:

n Should not be prescriptive correctiveaction plans or recommendations, norshould they suggest punitive actions

n Should not include process issues(e.g., evidence control, preservationof the accident scene, readiness) unlessthese issues have a direct impact on theaccident. These concerns should benoted in a separate memorandum to theappointing official, with a copy to sitemanagement and the Assistant Secretaryfor Environment, Safety and Health.

TIPBoard members should work together toderive judgments of need to assure that themerits and validity of each are openlydiscussed and that each one flows from thefacts and analyses.

An interactive process is the preferredapproach for generating judgments of need.That is, board members should work to-gether to review causal factors and thenbegin generating a list of judgments of need.These judgments should be linked directlyto causal factors, which are derived fromfacts and analyses.

One method for ensuring that all significantfacts and analytical results are addressed inthe judgments of need is to develop displayslinking judgments of need with facts,analyses, and causal factors. Previousboards have found it useful to display theseelements on the walls of the board’s confer-ence room. Figure 8-1 demonstrates howthis information can be arranged to providean ongoing assessment of linkages amongthe four elements. It portrays the concept ofrequirements verification analysis describedin Section 9 of this workbook. Using thisapproach, the board can identify gaps in thedata where a clear, logical flow among thefour elements is missing. The board can usethis information to determine whetherjudgments of need are supported by linkagesconnecting the facts, results from analyses,and causal factors.

TIPIf a judgment of need cannot be clearlylinked to causal factors derived fromanalysis of facts, exclude it from the report.

Once the board has identified the judgmentsof need derived from their investigationactivities, the members can begin writingstatements documenting these judgments.Table 8-1 presents guidance on writing thesestatements.

Table 8-2 provides samples of well-writtenjudgments of need for the case study electri-cal accident. Information in this tabledemonstrates the relationships amongsignificant facts, analysis, causal factors,and judgments of need.

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Part II Section 8 — Developing Conclusions and Judgments of Need

Figure 8-1. Facts, analyses, and causal factors are needed to support judgments of need.

Fact

Fact

Fact

Fact

Fact

Fact

Fact

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Analysis

Analysis

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Analysis

Causal Factor

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Causal Factor

Judgmentof Need

Judgmentof Need

Judgmentof Need

Judgmentof Need

Clearly identify organizations that need to implement actions to prevent recurrence of the accident.Where applicable, specify whether the judgment of need applies to a DOE Headquarters or fieldelement, contractor, subcontractor, or some combination of these.

Avoid generic statements and focus on processes and systems, not individuals.

Focus on causal factors.

Be specific and concise; avoid vague, generalized, broad-brush, sweeping solutions introduced by"should."

Do not tell management how to do something; simply identify the need.

Present judgments of need in a manner that allows a specific organization to translate them intocorrective actions sufficient to prevent recurrence.

Table 8-1. These guidelines are useful for writing judgments of need.

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Section 8 — Developing Conclusions and Judgments of Need Part II

Judgments of need form the basis forcorrective action plans, which are theresponsibility of line management andshould not be directed by the board. Ifthe board finds a need to make specificrecommendations, they should appear in aseparate communication and not in the bodyof the report or in the transmittal letter to theappointing official.

8.3 Minority Opinions

During the process of identifying judgmentsof need, board members may find that theydisagree on the interpretation of facts,analytical results, causal factors, conclu-sions, or judgments of need. This disagree-ment can occur because the board:

n Has too few facts or has conflictinginformation from different sources;when this occurs, additional informationmay be needed to resolve these conflicts

n Needs to evaluate the analyses con-ducted and consider using differentanalytical techniques

Safety training for the accidentvictim as required by WSES&H Manual Procedure 1234was not completed prior to theaccident.

The standing work ordersystem normally used fornonroutine, nonrepetitive taskswas used to authorize thework involved in the accident.

WS management needs toevaluate the effectiveness ofimplementation of the trainingprogram by observing andmeasuring workplace perfor-mance.

XYZ management needs toassure that the standing workorder system is used only onroutine, repetitive, andnoncomplex tasks where nosignificant risks or hazards havebeen identified or could reason-ably be encountered.

Significant Facts Causal Factors Judgments of Need

Training implementation wasinformal and was not based onappropriate structured develop-ment and measurement oflearning. This programmaticdeficiency was a contributingcause to the accident.

Using the standing work orderprocess, normally used forroutine tasks, to accomplishnonroutine, complex modifica-tion and construction work, wasa root cause of the accident.

Table 8-2. Case Study: Judgments of need.

n Disagrees on the linkages among facts,analyses and causal factors.

Even when new facts are collected and newanalyses are conducted, board members maystill strongly disagree on the interpretationof facts, the conclusions, or the judgmentsof need. Board members should make thesedifferences known to the chairperson assoon as they arise.

Every effort should be made to resolve aboard member’s dissenting opinion bycollecting additional facts, if possible, andconducting additional analyses.

When board members still disagree, it isrecommended that the chairperson:

n Obtain a detailed briefing from those notin agreement and consider the facts,analyses, causal factors, and conclusionsthat each used.

n Monitor the differences between thosenot in agreement by holding meetings todiscuss any new information collected

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Part II Section 8 — Developing Conclusions and Judgments of Need

or new analyses conducted; morecommon ground may be found as thisinformation emerges.

n Work with the board to identify areas ofmutual agreement and areas of disagree-ment as the end of the investigationapproaches.

n Openly discuss his or her positionconcerning the causal factors, conclu-sions, and judgments of need with theboard and achieve consensus. At thispoint, board members who disagree withthe consensus should describe their

position and indicate whether there is aneed to present a minority opinion in theaccident investigation report.

Note that the board is not required to reachconsensus, but is encouraged to workdiligently to resolve differences of opinion.However, if one or more board membersdisagree with the interpretation of facts,causal factors, conclusions, or judgments ofneed endorsed by the remainder of theboard, the minority board member ormembers should document their differencesin a minority report. This report is describedin Section 9.

KEY POINTS TO REMEMBER

Conclusions are significant deductions derived from the investigation’s analyti-cal results. They are derived from and supported by the facts plus the results oftesting and various analyses conducted.

# Judgments of need are the managerial controls and safety measures necessary toprevent or minimize the probability or severity of an accident’s recurrence.

# To ensure that a clear and comprehensive list of judgments of need is presented,the board should link each judgment of need with causal factors, analyses, andfacts. If the linkage is weak at any point, the judgment of need should be excludedfrom the list.

# As the board generates the judgments of need, differing opinions may emerge. Ifthese differences cannot be resolved at the end of the investigation, the boardmember(s) whose opinion(s) differs from the majority should prepare a reportdescribing those differences (i.e., the minority report). This circumstance gener-ally arises as a result of: (1) insufficient or conflicting factual information, (2)inconclusive or conflicting analytical results, (3) disagreement as to the interpreta-tion of facts, causal factors, conclusions, or judgments of need, or (4) unclearlinkage among facts, analyses, and causal factors.