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DOE O 225.1B prescribes organizational responsibilities, authorities, and requirements for conducting investigations of certain accidents occurring at DOE sites, facilities, areas, operations, and activities. The purpose of the accident investigation is to understand and identify the causes that contributed to the accident so those deficiencies can be addressed and corrected. This, in turn, is intended to prevent recurrence and promote improved environmental protection and safety and health of DOE employees, contractors, and the public. Moreover, accident investigations are used to promote the values and concepts of a learning organization. The department’s integrated safety management (ISM) feedback and improvement function envisions organizations that are continually monitoring performance; identifying deviations or questionable conditions; self-assessing; and using quality analysis to improve. An essential component of organizational learning is learning from accidents and near misses. This requires, through the application of DOE O 225.1B, that investigators go beyond the surface levels and understand how the underlying sources of operational vulnerability combined to result in failure. The explanation of how the failure was able to emerge in a normally safe and reliable system will
lead to an understanding of where the system and processes can be improved and promote accident prevention.