5200 Appendix T1
Event Investigation and Causal Analysis using the Notable Event Worksheet Procedure
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. This appendix provides the process steps used to document investigation activities and record the level of analysis applied.
The overarching reason to perform an accurate investigation is to prevent recurrence of the event. This procedure provides the process Jefferson Lab uses to ensure participants understand their roles and responsibilities to ensure appropriate notifications are made; an adequate investigation is performed; sufficient data is collected to ensure an accurate causal analysis; and follow-up actions are performed to prevent recurrence.
NOTE: Management authority may be delegated at the discretion of the responsible manager.
· Report any event to your Supervisor/SOTR/Sponsor or the ESH&Q Reporting Officer (duty phone 876-1750). This includes incidents 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.
· Immediately notify the ESH&Q Reporting Officer (cell 876-1750), Division Safety Officer, and Associate Director/Division Manager of an event occurrence including time, location, and observed details.
· Ensure the affected area/equipment is preserved pending an investigation. This may include cordoning off the area and taking preliminary photographs.
· Inform the Laboratory Director and the Chief Operating Officer of an event as soon as possible.
· Ensure that event investigations are conducted in a timely and effective manner.
· Appoint a Lead Investigator to investigate an event (Contact the ESH&Q Reporting Officer for a list of trained individuals).
· Use the Jefferson Lab CATS to coordinate tracking and documentation of corrective actions.
· Ensure that lessons learned, corrective, and future preventive actions are initiated.
· 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.
· 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.
Responsibilities for each process step are outlined within the procedure.
o Involved Person(s):
Immediately notify your Supervisor/ SOTR/ Sponsor (voice contact required) – This will happened as part of the process outlined within ES&H Manual Chapter 6800 Appendix T2 Injuries and Illnesses Requiring First Aid or Emergency Medical Response.
§ Supervisor/SOTR/Sponsor: Tell Involved Person to cordon off the area, take photographs, and perform other activities to preserve evidence.
o Supervisor/SOTR/Sponsor Notifies:
§ ESH&Q Reporting Officer (after business hours use cell phone 757-876-1750),
o ESH&Q Reporting Officer notifies:
§ Appropriate Urgent Event Personnel as required.
§ Division Safety Officer who then appoints a Lead Investigator.
§ ESH&Q Associate Director who then notifies:
§ Appropriate Division Manager
§ Chief Operating Officer, and
§ Laboratory Director.
· ESH&Q Reporting Officer makes an initial DOE categorization of the event from initial information provided. This is done within two (2) hours of notification unless essential information is still pending.
The Lead Investigator performs the following process steps using the Notable Event Worksheet.
Step 1: Initial Fact Finding Meeting – Held as soon as possible (or within 24 hours of discovery), at the location of the event if possible. Make arrangements to ensure that detailed notes are taken during this meeting to be used as future reference during the investigation.
· Required Attendees:
Notify the following individuals. They are required to be in attendance:
o Lead Investigator
o ESH&Q Reporting Officer or other representative
o Supervisor of the involved person(s)
o The involved person(s) in and/or those impacted by, the event
o Witnesses to the event
· Optional Attendees:
Notify the following individuals (their attendance is optional):
o Associate Director
o TJSO Representative – as an investigation observer
o Subject Matter Experts (SMEs)
o Facility or Equipment Owner
Use the following format:
1. Introduction: Provide attendees with the Title, Date, Time, and Location of the Event to be discussed.
2. Attendance: Ensure all “Required Attendees” are present.
3. Purpose of Initial Fact-Finding Meeting: Provide attendees with a brief summary of the following:
o Current known status of personnel and equipment.
o What facts have been determined and what needs to be collected to support the Notable Event Worksheet.
o If additional compensatory measures are required to ensure safety, discuss how this will affect the investigation. (This information is separate from the causal analysis and corrective/preventive actions.)
4. Event Reconstruction: Confirm the chain of events leading to the occurrence (include a timeline if possible). Allow brief discussion of the following:
a. Personnel and organizations involved in the event.
b. Conditions and actions preceding the event.
c. Chronology (timeline) of the event; and
d. Immediate actions taken in response to the event.
5. Clarify information: Does SME agree that work conditions were acceptable?
6. Stop Work or the Tag Out Required: If “Yes” – establish the restart criteria and inform the affected Management chain. (See ES&H Manual Chapter 3330 Stop work and Re-Start for Safety Program or 6111 Administrative Control using Locks and Tags.)
7. Compensatory Actions Required: If “Yes” determine responsibility and include confirmation documentation in the final Notable Event Report.
8. Records and Documents Required: Determine what documentation will be required to confirm, clarify, or complete the report information (i.e., work plans, work control documents, pictures, etc).
9. Other Questions or Concerns: Ask attendees if there are any other questions, concerns, or information that they may wish to provide.
10. If present obtain TJSO Representative feedback on conduct of Initial Fact Finding Meeting and potential improvements.
Step 2: Investigation Team
o Determine appropriate Investigation Team Members.
o Convene a meeting of Investigation Team Members as soon as possible (or within 24 hours) of Initial Fact Finding Meeting. (Review the Initial Fact Finding Notes.)
o Delegate responsibilities to team members to ensure that adequate and complete information will be obtained.
Step 3: Summary of Event and / or Injuries
o Produce a Summary of Events and/or Injuries derived from the Initial Fact-Finding Meeting notes.
Timeline: Preliminary Activities
The Lead Investigator performs the following process steps:
Step 1: Emergency Notifications Made (Subsequent to Event):
Determine which emergency notifications were made, the date and time.
Step 2: Witness/ or Others Accounts:
Conduct one-on-one interviews with witnesses, or others as appropriate, to collect statements.
o Schedule interviews
o Summarize discussions
o Request confirmation of summary from individual
Step 3: Environmental Aspects
Was any material released into the environment that would be considered harmful? If so document the following:
o Type of material released
o Time flow was halted or controlled.
Step 4: Records, Documents, Pictures, and Other References
Review photographs, digital images, sketches, and other relevant scene documents. These could include:
o Lessons learned
o Previous investigation reports
o Training records
o Medical records (as allowed)
o Maintenance records
o OSHA 300 Log (past similar injuries)
o Safety Committee records
Step 5: Causal Analysis
Determine the cause(s) of the event:
o Root Cause: Determine the underlying system weaknesses that contributed to the hazardous conditions and/or unsafe behaviors.
o Contributing Causes: Analyze the actions leading up to the event to determine the contributing cause(s).
Step 6: Extent of Condition
Determine if the root or contributing cause(s) exist within other processes, equipment, or human performance.
o Identify areas where processes, equipment or performance are at similar risk of event recurrence.
o Assigned a responsible individual to rectify the condition.
o Record the condition in the Jefferson Lab CATS and the number denoted on the worksheet.
o Note the anticipated target date for correction on the worksheet.
Step 7: Corrective/Preventive Actions
Recommend actions to be taken to address situations identified in the Causal Analysis and Extent of Condition Sections. Actions are to mitigate the root and contributing causes of the incident to prevent recurrence. Recommendations are documented in CATS (denote the number(s) on the worksheet) and include:
o Engineering controls (e.g.: install local exhaust ventilation; or use a lift assisting device.)
o Work practice controls (e.g.: perform additional pre-planning work activities; or remove jewelry and loose fitting clothing before operating machinery.)
o Administrative controls (e.g.: include an Operational Safety Procedure; or provide for worker rotation in the work plan)
o Personal protective equipment (e.g.: Provide and ensure use of safety glasses or respirators.)
Step 8: Lessons Learned
During the course of an investigation innovative approaches or devise changes are often discovered which allows work to be accomplished more efficiently. If documented and shared these discoveries can have a significant positive impact on laboratory operations.
o Record any Lessons Learned during the investigation.
o Confer with Division/Department Lessons Learned Coordinators. They have received training on how to input data to the lessons learned system and should be the first point of contact for questions.
Step 9: Confirmation
o Distribute the draft Notable Event Worksheet to the Investigation Team Members, affected Division Management, and ESH&Q Reporting Officer for review.
o Incorporate comments as appropriate.
o When acceptable, the Investigation Team Members confirm that the information presented is accurate and complete by signing and dating the worksheet.
o Submit the confirmed Report to the ES&H Reporting Officer for final review and distribution.
The ESH&Q Reporting Officer performs the following process steps:
Step 1: Verify that all relevant document numbers or codes, for information or data, have been generated during the investigation process. These include:
· Notable Event Number
· CATS Number
· JLab COE Number
· ORPS Number
· NTS Number
· CAIRS Entry
· DOE Cause Code
· ISM Code
The ESH&Q Reporting Officer performs the following process steps:
Step 1: DOE Categorization and Report Update (within time constraints)
Review the Notable Event Report and confirm or revise the initial DOE categorization.
Step 2: Acceptance/Acknowledgement of Facts
Submit the final Notable Event Report for signature to the appropriate Associate Director/ Department Manger for Acceptance/ acknowledgement of facts.
The ESH&Q Reporting Officer performs the following process steps:
Step 1: Post
Post the approved Notable Event Report to the Notable Event website.
Step 2: Distribution
Distribute a copy of the accepted Notable Event Worksheet to:
· Associate Director/Department Manager
· Division Safety Officer
· Investigation Team Members
· ESH&Q Liaisons
Division Managers use the Issues Management Procedure to initiate Corrective/Preventive Actions. The Issues Management process encompasses tracking to completion, approval and closure of actions recommended by the investigation team.
Longer term extent-of-condition checks may be planned and performed to ensure that an event’s corrective/preventive actions eliminate the possibility of recurrence across the entire site, in all applicable areas.
The ESH&Q Reporting Officer shares lessons learned either through posting on the Jefferson Lab Lessons Learned website, or the Notable Event webpage. This information is also encouraged for use during staff safety meeting discussions and special operational notices.
6.0 Revision Summary
Revision 1.4 – 09/06/12 - Qualifying periodic review. Clarification of content only.
Revision 1.3 – 01/31/12 - Updated ESH&Q Reporting Officer assignment from SSmith to CJohnson per MLogue
Revision 1.2 – 08/12/11 – Recognized that recommendations for corrective/preventive actions are to be documented in CATS.
Revision 1.1 – 06/24/11 – Edited to clarify process steps.
Revision 1 – 10/19/09 – Updated to reflect current laboratory operations.
 Note: The person(s) involved may not be able to attend due to injury or illness. If this is the case, the lead investigator determines if a separate interview or discussion is acceptable.