TITLE:	ES&H Manual
DOCUMENT ID:	5200 Event Investigation and Causal Analysis Process

1.0 Purpose

Jefferson Lab investigates all events concerning personal injury; property or equipment damage; and environmental impact. These investigations allow Jefferson Lab to implement corrective and preventive actions across the site to avoid recurrence. Jefferson Lab’s ESH&Q Reporting Officer analyzes all event investigations to determine whether the event qualifies to be reported to the Department of Energy (DOE).

This event investigation analysis process enables Jefferson Lab to comply with the following DOE reporting requirements:

• Occurrence Reporting and Processing System (ORPS),
• Computerized Accident Incident Reporting and Recordkeeping System (CAIRS), and
• Noncompliance Tracking System (NTS)

Events involving first aid are reported to Occupational Medicine, x7539, in accordance with ES&H Manual Chapter 6830 Medical Management of Occupational Injuries and Illnesses. Jefferson Lab collects this data in order to recognize trends and implement corrective actions before a more serious event occurs.

2.0 Scope

Jefferson Lab personnel use the appropriate procedure, outlined within ES&H Manual Chapter 5200 Appendix T1 Event Investigation and Causal Analysis Procedure using the Notable Event Worksheet, to provide the required level of rigor to an investigation. Information is then provided to appropriate management for corrective action implementation and the ESH&Q Reporting Officer (x7007, cell 876-1750) for further analysis.

The following items are considered events and are investigated by Jefferson Lab:

• Fatalities or injuries (other than first aid) regardless of the circumstances,
• Unplanned Operational Emergencies, Shutdowns, or Evacuations, for any reason,
• All Stop Work Orders, whether Jefferson Lab, subcontractor or Thomas Jefferson Site Office (TJSO) initiated,
• Unplanned activation of a Safety System, whether personnel or equipment related,
• Fires or explosions of any type or severity,
• Electrical shocks of any severity, regardless of circumstances,
• Any type of Lock-Out / Tag-Out violation,
• Abnormal radiation release or loss of control of radioactive materials,
• Any type of radiation barrier breach or unauthorized entry,
• Property damage, including unexpected discovery or damage of any type of utility, regardless of energy status,
• Unexpected discovery of hazardous energy, including pressurized or electrical systems,
• Discovery of an Unreviewed Safety Issue (USI) or potential inadequacy of a documented safety analysis,
• Any type of reduced effectiveness discovery in a safety system,
• Discovery of suspect or counterfeit material,
• Environmental damage or releases of any severity, including those events that occur as a result of offsite transportation,
• Any DOE or regulatory body initiated non-compliance notification,
• Any near miss, where only one or no barriers preventing an above listed event from occurring, or
• Any management concern item where the information is deemed valuable for others, either at Jefferson Lab or the DOE complex.
• Any item or activity which Jefferson Lab Management directs to be investigated.

Other events, including first aid cases, are dispositioned for investigation on a case-by-case basis; between the affected Division Safety Officer and ESH&Q. Relevant first aid case information is compiled and evaluated for safety related trending data. This information is then presented to various forums and acted upon as appropriate.

Any incident involving only first aid is reported to Occupational Medicine (x7539) and the affected management chain. These types of events are not necessarily DOE reportable, but important for Jefferson Lab to collect, trend, and act on safety data.

• Typical first aid incidents can include superficial lacerations, scrapes or minor cuts, insect stings, bruises, and they occur at the workplace or offsite during laboratory related business.

3.0 Responsibilities

3.1 Witnesses and Involved Persons

· Report any injury, including first aid cases, in accordance with ES&H Manual Chapter 6830 Medical Management of Occupational Injuries and Illnesses. This would include off-site, job-related business injuries. If the injury is severe enough to require off-site medical treatment contact your supervisor/SOTR/sponsor or the ESH&Q Reporting Officer (duty phone 876-1750).

· Report any accident to your supervisor, SOTR or Jefferson Lab sponsor. This would include accidents that happened off site on job-related business.

3.2 Supervisors/SOTRs/Sponsors

· Notify the Department Manager, Division Safety Officer (DSO), Associate Director or Division Manager and ESH&Q Reporting Officer of reported events.

· Ensure that work operations that caused an accident are not resumed until appropriate controls are in place.

· Implement temporary hazard-control measures as necessary.

3.3 Division Safety Officer

· Assign a lead investigator to conduct the preliminary fact finding and causal analysis. (Typically this will be the same person.) Each Jefferson Lab division has one or more trained individuals; contact the ESH&Q Reporting Officer (x7007) for your representative.

· Ensure that investigation documentation is completed, to include a preliminary fact finding meeting, or critique, as well as information from interviews and the appropriate causal analysis. The incident’s preliminary information and circumstances should be documented using ES&H Manual 5200 Appendix T1 Event Investigation and Causal Analysis Procedure using the Notable Event Worksheet. Ensure that important investigation information is transmitted promptly to senior management.

· Use the Jefferson Lab Corrective Action Tracking System (CATS) to coordinate tracking and documentation of corrective actions.

· Ensure that lessons learned, corrective, and future preventive actions are initiated.

3.4 Associate Director & Division Manager

· Informs the Laboratory Director and the Chief Operating Officer (COO) of events as soon as possible.

· Ensures that event investigations are conducted in a timely and effective manner.

· Ensures that corrective actions flowing from event investigations are tracked and documented to closure in a timely manner using the CATS.

3.5 ESH&Q Reporting Officer

· Ensures event investigation training is provided to specified personnel.

· Maintains a list of trained investigators.

· Provides technical expertise during investigations to ensure compliance with DOE requirements.

· Determines an adequate amount of time for the investigation. If longer than five business days briefs laboratory senior management regarding any significant developments.

· Ensures lessons learned and other investigation information is communicated using established processes.

· Provides quarterly tracking and trending results from event reports to management.

· Maintains Contact Information for Urgent Events listing.

3.6 Lead Investigator

· Forms the investigation team and coordinates the investigation.

· Documents event investigation and analysis information using ES&H Manual 5200 Appendix T2 Notable Event Worksheet.

Qualifications:

· Jefferson Lab approved training in Root Cause Analysis techniques, including SAF124, Accident Investigation and Root Cause Analysis, TapRooT, or other methods considered acceptable by the Jefferson Lab Training Department.

· Previously served as Lead Investigator

4.0 Expectations

Jefferson Lab’s event investigations are conducted in accordance with ES&H Manual Chapter 5200 Appendix T1 Event Investigation and Causal Analysis Procedure using the Notable Event Worksheet. It includes a preliminary critique session and a causal analysis. The causal analysis is commensurate with the event’s hazard(s) and uses a graded approach to determine the significance of contributing factors. When technical complexities and/or injuries cause delays in a final report, a preliminary draft report is generated within five business days, to be followed by the final report the date of which is determined by the ESH&Q Reporting Officer.

Every event is different; however, the overarching goal for each investigation is prevention of recurrence by total elimination of the problem across the site.

5.0 Event Investigation and Causal Analysis Flowchart

6.0 References

ES&H Manual Chapter 6810 Medical Emergencies

ES&H Manual Chapter 6830 Medical Management of Occupational Injuries and Illness

ES&H Manual Chapter 5300 Occurrence Reporting to Department of Energy (DOE) – DOE reportable occurrences are subject to special reporting procedures

ISSUING AUTHORITY	CHAPTER AUTHOR	APPROVAL DATE	EFFECTIVE DATE	EXPIRATION DATE	REV.	Page 7 of 7
ESH&Q Division	Stephen Smith	10/19/09	10/19/09	10/19/12	1

This document is controlled as an on line file. It may be printed but the print copy is not a controlled document. It is the user’s responsibility to ensure that the document is the same revision as the current on line file. This copy was printed on 10/27/2009.