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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

ACCIDENT INVESTIGATIONS

Dean Decker

U.S. Department of Energy

July 2008

overview
Overview
  • Timetable
  • Activities
  • Examples of analysis charts
timetable and activities
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)
timetable and activities4
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)
timetable and activities6
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
timetable and activities9
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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