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, and to perform comprehensive trend analysis in order to avoid recurrence. Jefferson Lab’s ESH&Q Reporting Officer analyzes all event investigations and reports any that qualify to the Department of Energy (DOE).

This event investigation and causal 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 6800 Injuries and Illnesses Requiring First Aid or Emergency Medical Response.

2.0 Scope

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

· 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 to 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 procedure.

· Any type of reduced effectiveness discovery in a safety system.

· Discovery of suspect or counterfeit material.

· Environmental release of hazardous material, of any severity, including that which occurs as a result of off-site 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.

· 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 the ESH&Q Division. Relevant first aid case information is compiled for safety related trend analysis. This information is then presented to various forums and acted upon as appropriate.

This process does not negate DOE Order 225.1 Accident Investigation which allows the TJSO to do an independent investigation of any event at Jefferson Lab. Any such investigation is coordinated through the Associate Director – ESH&Q.

3.0 Responsibilities

NOTE: Management authority may be delegated at the discretion of the responsible manager.

3.1 Witnesses and Involved Persons

· Report any event to your supervisor/SOTR/sponsor or the ESH&Q Reporting Officer (duty phone 876-1750). This includes events that happened off site on job-related business.

Injuries, illnesses, and first aid cases (including off-site job-related injuries) are to be reported to your Supervisor/SOTR/Sponsor or Occupational Medicine as part of the process outlined within ES&H Manual Chapter 6800 Appendix T2 Injuries and Illnesses Requiring First aid or Emergency Medical Response.

3.2 Supervisor/Subcontracting Officer’s Technical Respresentative (SOTR)/Sponsor

· Notify the ESH&Q Reporting Officer, Division Safety Officer, Associate Director/Division Manager of event.

· Ensure the affected area/equipment is preserved pending an investigation. This may include cordoning off the area; and taking preliminary photographs.

3.3 Division Safety Officer (DSO)

· Appoint a Lead Investigator to investigate an event. (Contact the ESH&Q Reporting Officer for a list of trained individuals.)

· 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

· Inform the Laboratory Director and the Chief Operating Officer (COO) of an event as soon as possible.

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

· Ensure that corrective actions are tracked and documented to closure in a timely manner using the Corrective Action Tracking System.

3.5 ESH&Q Reporting Officer

· Ensure event investigation training is provided to specified personnel; and maintain a list of trained investigators.

· Categorize events in accordance with DOE reporting criteria.

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

· Ensure the investigation is documented in accordance with the requirements of ES&H Manual 5200 Appendix T1 Event Investigation and Causal Analysis Procedure using the Notable Event Worksheet.

· Perform initial and follow-up reporting consistent with the event’s significance code.

· Maintain Contact Information for Urgent Events listing.

DOE Reporting (including ORPS, CAIRS and NTS determinations, is the sole responsibility of the ESH&Q Reporting Officer.) After the initial facts of the event are adequately known, the ESH&Q Reporting Officer evaluates DOE reportability and proceeds as appropriate and performs the reporting procedures found in ES&H Manual Chapter 5300 Occurrence Reporting to DOE.

3.6 Lead Investigator

· Form the investigation team. Ensure at least one individual on the team is trained in Event Investigation and Root Cause Analysis (SAF 124) – This person is assigned responsibility for conducting the Causal Analysis.

· Coordinate event investigation activities.

· Document the event investigation and analysis information using ES&H Manual 5200 Appendix T1 Notable Event Worksheet.

4.0 Expectations

4.1 Event Investigation and Causal Analysis

Jefferson Lab assigns a Lead Investigator to each event investigation. This person is responsible for data collection, interviews, documentation, and other activities required to ensure a complete and accurate summary of events. ES&H Manual Chapter 5200 Appendix T1 Event Investigation and Causal Analysis using the Notable Event Worksheet Procedure provides the process steps used to document the investigation activities and record the level of analysis applied to investigation activities.

5.0 Event Investigation and Causal Analysis Flowchart

6.0 References

· ES&H Manual Chapter 6800 Injuries and Illnesses Requiring First Aid or Emergency Medical Response

· ES&H Manual Chapter 5300 Occurrence Reporting – DOE reportable occurrences are subject to special reporting procedures

7.0 Revision Summary

Revision 1.3 – 01/30/12 – Updated ESH&Q Reporting Officer assignment from SSmith to CJohnson per MLogue

Revision 1.2 – 06/24/11 – Update to reflect edits made to associated Appendix T1 Event Investigation and Causal Analysis using the Notable Event Worksheet Procedure.

Revision 1.1 – 04/19/11 – Added “categorization of events” and “initial and follow-up reporting” responsibilities.

ISSUING AUTHORITY	TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	EXPIRATION DATE	REV.
ESH&Q Division	Tina Johnson	10/19/09	10/19/12	1.3

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 9/13/2012.