Purpose of Reporting
Every incident or miscue indicates a need for improvement in some respect. To
promote improvement in operations and maintenance procedures, each incident must
be reviewed and reports prepared. To profit from such experiences, it is necessary to
analyze existing problems and study recommended solutions. Written reports are
intended for this purpose.
Definitions of Employee Incident
It is essential that the definitions of incidents be sufficiently clear to permit meaningful
analysis of problems. The use of standard definitions will promote uniformity and
minimize inequities among regions. Toward that end, the definitions on PO&M-171
have been developed.
Formation of Review Boards
In cases of major incident involving personal injury, loss of life, serious damage to
equipment or major system breakup, a review board shall be appointed by the
Regional Director or higher authority and shall include a member from the Division of
Engineering, D-5200, Denver Office. In all other cases, it is recommended that a
project-appointed review board of one to three members conduct the investigation and
write the reports, including statements covering actions already taken or
recommended that will aid in preventing similar recurrences. In the case of incidents
of a minor nature, it may be more effective if the project-appointed review board
consists of local participants such as the plant superintendent, foremen, and co-
workers of the individual involved in the error. Project safety and personnel staff
members should be used as required in an ad hoc advisory capacity.
Need For Prompt Attention
It is essential that all incidents/miscues receive prompt attention, action, and response
by the review board. The action taken on the incident by the review board should be
made available to all personnel involved as quickly as possible. Swift review promotes
better understanding by the review board members of the circumstances surrounding
the incident and leads more directly to the cause and solution.