Chapter 28: Incident Investigation
This chapter has been rescinded and the program transferred to
Contractor and Quality Assurance. For current information on incident
investigation, please see the Incident Reporting and Investigation Process [pdf] document.
An incident is an event or deviation from normal/expected operations, activities or conditions which has harmed or has the potential to harm SLAC personnel or property, the public, the environment, or SLAC's mission. When an incident occurs at SLAC, the Incident Reporting and Investigation Process must be followed to ensure that the incident is properly reported, and investigated if necessary.
The purpose of investigating an incident is to prevent recurrence of that incident or a similar incident by:
- Identifying the root and contributing causes of the incident;
- Taking actions that effectively address the root and contributing causes;
- Sharing lessons learned from the incident with others.
Not all incidents require the same level of investigation. For some minor incidents, the root and contributing causes may be obvious without the need for a detailed investigation; however, more significant or complicated incidents may require investigation using formal causal analysis techniques to identify the root and contributing causes. The Incident Reporting and Investigation Process provides a graded approach to incident investigation, to ensure that SLAC's resources are used efficiently in this effort.