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ACCIDENT INVESTIGATIONS. Dean Decker U.S. Department of Energy July 2008. Overview. Timetable Activities Examples of analysis charts. Timetable and Activities. Week 1 and 2 Inbrief Initial brief from site on known facts Generic report format; special sections

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ACCIDENT INVESTIGATIONS

Dean Decker

U.S. Department of Energy

July 2008


Overview l.jpg
Overview

  • Timetable

  • Activities

  • Examples of analysis charts


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Timetable and Activities

  • Week 1 and 2

    • Inbrief

    • Initial brief from site on known facts

    • Generic report format; special sections

    • Daily meeting with site representative to request documents

    • Review documents

    • Evidence File (index, numbered folders)


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Timetable and Activities

  • Week 1 and 2 continued

    • Event & Causal Factors Chart

    • Interviews

    • Write down Facts, Requirements, & Findings

    • Develop organization chart (from injured employee up the chain of responsibility)



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Timetable and Activities

  • Week 3

    • Start writing report (put Facts, Requirements, & Findings into report format)

    • Barrier Analysis

    • Change Analysis

    • Add Barriers and Changes to Event Chart




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Timetable and Activities

  • Week 4

    • Bin Barriers and Changes to develop Causal Factors

    • Tier Responsibility Chart

    • Develop Judgments of Need

    • Remove non-significant events from Event Chart

    • Outbriefs

    • Minority Report (if applicable)




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