10.14.6 Incident Investigation
Suspected and confirmed overexposures should be investigated. RF control failures, alarms, unauthorized access, and near misses should also be reviewed to a depth proportionate to their potential consequences and learning value.
The investigation should consider:
- the planned and actual task, people, source states, and event timeline;
- the exposure assessment, reconstruction, uncertainty, and compliance conclusion;
- the design, adequacy, verification, maintenance, and failure modes of engineering controls;
- the procedures, authorization, access controls, signs, and other administrative controls;
- source ownership, shared-site coordination, communications, and change control;
- equipment performance, software, alarms, logs, and maintenance history;
- training, competence, supervision, workload, and human factors;
- emergency response, first aid, medical assessment, and reporting;
- previous similar events, audit findings, or known weaknesses; and
- immediate, contributing, systemic, and root causes.
The investigation should seek learning and prevention rather than stop at individual error or use the absence of injury as evidence that the controls were adequate.
10.14.7 Corrective And Preventive Actions
Corrective and preventive action may include:
- revising the applicable Plan, assessment, permit, or safe work procedure;
- eliminating the exposure scenario or improving engineering controls;
- changing boundaries, source states, access conditions, or exclusion zones;
- upgrading signs, markings, alarms, interlocks, or status information;
- improving isolation, authorization, verification, communications, or handback;
- providing training, competency reassessment, supervision, or contractor controls;
- changing inspection, testing, calibration, or maintenance arrangements;
- addressing source ownership, management-of-change, or program weaknesses; or
- modifying equipment, layout, shielding, antenna configuration, or operating modes.
Each action should have an owner, priority, due date, completion evidence, and effectiveness review. Interim controls should be defined where the final action cannot be completed immediately.