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DOE-HDBK-1208-2012

January 30, 2013

Accident Investigation and Prevention

This handbook has been organized along a logical sequence of the application of the DOE “core analytical techniques” for conducting a DOE Federal-, or contractor-led Accident Investigation or an OSR in order to prevent accidents. The analysis techniques presented in this Handbook have been developed and informed from academic research and validated through industry application and practice.

The techniques are for performance improvement and learning, thus are applicable to both AI and OSR. This handbook serves two primary purposes:

  • as the training manual for the DOE Accident investigation course, and the Operational Safety and Accident Analysis course, taught through the National Training Center (NTC) and,
  • as the technical basis and guide for persons conducting accident investigations or operational safety analysisi while in the field.

Volume I  - Chapter 1; provides the functional technical basis and understanding of accident prevention and investigation principles and practice. Volume 1 - Chapter 2; provides the practical application of accident investigation techniques as applicable to a DOE Federally-led Accident Investigation under DOE O 225.1B. This includes: the process for organizing an accident investigation, selecting the team, assigning roles, collecting and recording information and evidence; organizing and analyzing the information, forming Conclusions (CON) and Judgments of Need (JON), and writing the final report. This chapter serves as a ready easily available reference for Board Chairpersons and members during an investigation.

Volume II provides the adaptation of the above concepts and processes to an OSR, as an approach to go deeper within the contractor’s organization and prevent accidents by revealing organizational weaknesses before they result in an accident.