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Policy Area

ESH-Environment Safety & Health

Procedure Number

ESH100.4.RPT.9

Procedure Title

Manage the Formal Accident Investigation Process

Procedure Manager

Darrell G. Fong

Status

Active

Subject Matter Expert

Ralph Fevig

 

Applicability, Exceptions, and Consequences

This corporate procedure applies to all Sandia National Laboratories (SNL) organizations, all management elements, all SNL sites, and all Members of the Workforce.

Exceptions to, or deviations from this procedure must be approved through the Executive Policy Sponsor or Policy Area Manager, if delegated. Click here to view Contacts for CPS Policies, Processes, and Procedures. See CG100.1.7, Request an Exception to a Policy, Process, or Procedure, for directions on how to obtain an exception to this procedure.

Granting or permitting exceptions or violations of policy, process, or procedure without authority, regardless of position or title, may be cause for disciplinary action up to and including termination of employment. Violating a policy, process, or procedure may be cause for disciplinary action up to and including termination of employment.

 

IMPORTANT NOTICE: A printed copy of this document may not be the document currently in effect. The official version is located on the Sandia National Laboratories Sandia Restricted Network (SRN).

Procedure Overview

This procedure adds formality and uniformity to accident and near miss investigations that may occur on Sandia-controlled premises or involve Sandia employees or contractors when deemed necessary by both ES&H and Line management.

Procedure Requirements

Requirements

Activity Responsible Individual Required Action
Performing Safety Engineering Accident Investigations Line Director
  • Appoint the accident investigation chairperson and members of the team
  • Approve the final report.
  • Submit the final report to the center ES&H director.
Safety Engineering Department     
  • Establish a pool of accident investigators for any investigations that require use of this process.

Note: In the event that there are ES&H subject matter experts (SMEs) that have completed the accident investigation training, they may be asked to participate as appointed accident investigators if the nature of the accident is directly related to the SMEs’ fields of expertise.

 
Appointed Accident Owning Line Organization
  • Communicate accident investigation specifics to the appointing line organization director and Director of ES&H.
  • Oversee all activities of the team. 
  • Avoid undue influence and conflict of interest in the accident investigation process by implementing the accident investigation team composition process in this document.
Appointed Accident Investigator
  • Ensure that current accident and investigation tools and methodologies are employed and adhered to (see DOE Accident Investigation Program).
Accident Investigation Team Members (see Table 1 below, Accident Investigation Team Composition)
  • Collect and analyze accident information.
  • Derive conclusions regarding causal factors. Identify judgments of need as defined in the DOE Workbook, Conducting Accident Investigations, Section 8, “Developing Conclusions and Judgments of Need.”
  • Develop the accident investigation report content.

 
Advisors and Consultants
  • Provide technically accurate information and guidance to the team for the areas of investigation that require technical interpretation (e.g., physicists or chemists).
Technical Writer
  • Review the draft and final reports to ensure grammatical consistency with current Sandia standards.

Note: The writer may support the accident investigation team in standardizing the content.

 

Table 1.  Accident Investigation (AI) Team Composition

Member

Description
Chairperson A department manager or above who is knowledgeable in the type of process, operations, or facility and work where the accident occurred. The chairperson may not be from the accident owning organization.
Accident Investigator An individual who has been appointed by the Safety Engineering Manager.
Team Members
  • Members of the Workforce who understand the type of process, operations, or facility and work that is involved in the accident.
  • Team members cannot participate in accident investigations that occur in their organization.
  • A supervisor and subordinate may never be part of the same accident investigation team.
  • Two to five team members are recommended, not including the chairperson and trained accident investigator.
Advisors and Consultants Those Members of the Workforce who have the special skills or process knowledge necessary to conduct a complete and thorough accident investigation.
Technical Writer Someone who can review the draft and final reports to ensure grammatical consistency with current Sandia standards and can support the accident investigation team in standardizing the content.

 

Response to Accidents/Injuries or Near Misses

Activity Responsible Individual Required Action
Responding to Accidents, Injuries, or Near Misses Line Management and ES&H Management
  • Determine that an accident/injury or near miss warrants an investigation and make the request for a formal accident investigation to commence.

Note: This is the preliminary investigation phase for an accident/injury or near miss. The formal investigation will begin no later than five days from the formal request to conduct an investigation. It is understood that a preliminary investigation will already be underway that includes safety engineering and the responsible line organization Members of the Workforce.

  • Provide preliminary accident investigation information to the formal accident team within three (3) working days of the formal request.
  • Complete the investigation within 45 days.
  • Issue the report to the accident owning line organization within 10 working days after completion of the investigation.

 

Required Records and Retention Schedule

Accident Investigation Report

Requirement Drivers (Prime Contract Baseline Directives)

DOE O 225.1A DOE M 231.1-2

Additional Drivers

  • DOE G 225.1A-1, Implementation Guide for use with DOE Order 225.1A, Accident Investigations.
  • 10 CFR 851,Worker Safety and Health Program.

 

Related Processes and Procedures

Process

  • ESH100.4, Feedback and Improve.

 

Change Summary

06/22/2010

Administrative

Modified

  • Corrected the links for ESH100.4, Feedback and Improve, and the DOE Workbook.

 
10-27-2009

Added:

This procedure is new and is part of the ESH Corporate Procedure Set.