Mischance Examinations - PowerPoint PPT Presentation

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Mischance Examinations

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  1. ACCIDENT INVESTIGATIONS Dean Decker U.S. Department of Energy July 2008

  2. Overview • Timetable • Activities • Examples of analysis charts

  3. 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)

  4. 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)

  5. Event & Causal Factors Chart

  6. 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

  7. Barrier Analysis

  8. Change Analysis

  9. 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)

  10. Event and Causal Factors Chart

  11. Tier Responsibility Chart