Office of Inspector General report on inspection of selected issues regarding the Department of Energy accident investigation program

One method used by the Department of Energy (DOE) to promote worker safety is through the Department`s accident investigation program. The objectives of the program are, among other things, to enhance safety and health of employees, to prevent the recurrence of accidents, and to reduce accident fatality rates and promote a downward trend in the number and severity of accidents. The Assistant Secretary, Office of Environment, Safety and Health (EH), through the EH Office of the Deputy Assistant Secretary for Oversight, is responsible for implementation of the Department`s accident investigation program. As part of the inspection, the authors reviewed an April 1997 EH accident investigation report regarding an accident involving a Lockheed Martin Energy Systems (LMES) welder, who suffered fatal burns when his clothing caught fire while he was using a cutting torch at the Oak Ridge K-25 Site. They also reviewed reports of other accident investigations conducted by EH and DOE field organizations. Based on the review of these reports, the authors identified issues concerning the adequacy of the examination and reporting by accident investigation boards of specific management systems and organizations as a possible accident root cause. The inspection also identified issues concerning worker safety that they determined required immediate management attention, such as whether occurrences were being reported in the appropriate management systems and whether prompt consideration was being given to implementing revisions of national standards when the revisions increased worker safety