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5200
Appendix T1 Event
Investigation and Causal Analysis Procedure using the Notable Event Worksheet |
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1.0
Purpose
This appendix provides the process steps to be used during an event investigation.
2.0
Scope
This procedure outlines the steps used to perform an event investigation including appropriate notification, investigation, causal analysis, and responsibilities of participants in the process, and describes how investigations relate to other follow-up activities and documentation.
3.0
Responsibilities
NOTE: Responsibilities
for each process step are outlined within the procedure.
3.1
Witnesses and Involved Persons
· Immediately relay all details, including
time, location, and observed status to the Supervisor or ESH&Q Reporting Officer (x7007, cell 876-1750).
· Report any injury, including
first aid cases, in accordance with ES&H Manual Chapter 6830 Medical Management of
Occupational Injuries and Illnesses.
3.2
Supervisor
·
Immediately
relay all details, including time, location, and observed status to the ESH&Q Reporting Officer (x7007, cell 876-1750)
·
Ensure
an event investigation is performed.
3.4
Lead Investigator
· Conducts and documents the event investigation.
4.0
Process Steps
Step 1 – Secure
the area or scene
·
Witnesses
and involved persons assure safety at the scene of the event.
·
Witnesses
and involved persons secure the scene so material evidence is not moved or
removed. If the accident is quite
serious, all material evidence may need to be marked and remain at the scene.
Report to Occupational Medicine, if appropriate
Involved person(s) report to Occupational Medicine
in accordance with ES&H
Manual Chapter 6830 Medical Management of Occupational Injuries and Illness
Step 2 – JSA
notifications (in accordance with responsibilities defined in ES&H Manual Chapter 5200 Event Investigation and Analysis Process within 24-hours of the event.
Involved person(s) immediately notifies supervisor/SOTR/sponsor (makes
voice contact);
Supervisor/SOTR/sponsor notifies:
·
ESH&Q Reporting Officer (x 7007 or cell phone 876-1750,
after business hours),
·
Department Manager,
·
Division Safety Officer, and
·
Associate Director
ESH&Q Reporting
Officer notifies
appropriate Urgent
Event Personnel as required.
Division Safety
Officer assigns
and notifies Lead Investigator
Associate Director notifies:
·
Laboratory
Director, and
·
Chief
Operating Officer (COO).
Step 3 – Initial
DOE Categorization and Reporting, if appropriate
ESH&Q Reporting
Officer gathers initial
information regarding what directly and indirectly contributed to the event and determines a preliminary
categorization.
Step 4 – Event Investigation – The Lead Investigator begins the event investigation as soon as
possible – within 24 hours at the latest.
All substeps are performed by the Lead Investigator unless otherwise
noted.
The Lead Investigator may apply a graded approach
to the investigation, depending upon the situation. Considerations may include remaining hazards
to personnel or equipment, operational status, or facility status.
Substep 4.a – Preliminary
Activities facts are established:
·
List of Eye Witnesses and other relevant individuals is compiled
o
Interviews
are scheduled.
·
Relevant Records reviewed including but not limited to:
o
Training
records
o
Disciplinary
records
o
Medical
records (as allowed)
o
Maintenance
records
o
OSHA 200
Log (past similar injuries)
o
Safety
Committee records
·
Review photographs, videotape, sketches, and other
relevant scene documents.
·
At their
discretion, the Lead Investigator may conduct one-on-one meetings with
witnesses in order to collect statements prior to the Initial Critique
Meeting. This allows for the establishment
of a rough timeline for complex events.
Substep 4.b – Initial
Critique Meeting – Held on the same day (or within 24 hours of
discovery), at the location of the event if possible.
·
Critiques are led by the Lead Investigator who is
responsible for assimilating the appropriate documentation, notifying attendees
in a timely manner, and ensuring an appropriate meeting location is arranged.
·
The
primary purpose:
o
Assess
the status of personnel and equipment. (Determine
if additional compensatory measures are required to ensure safety. (This information is separate from the causal
analysis and corrective actions.))
o
Collect
initial facts to support the ensuing investigation and reportability
determination. This initial information
collection is the first step in a thorough investigation.
·
Critique Guidelines:
o Critiques are
conducted for fact finding only. Causal
analysis and corrective action decisions are not included in the critique scope. As such, the Lead Investigator / Critique
Leader should make this clear from the outset.
o
Meeting focus should remain on the facts and
production of an accurate timeline.
o
Fault or blame assignment is not part of the
critique process.
o
Discussion and questions should be limited to
invited participants.
§ The following people are required
for a critique to be convened[1]:
o Lead Investigator
o ESH&Q Representative
o Supervisor of the involved
person(s)
o The involved person(s)[2] in
and/or those impacted by, the event
o Witnesses to the event
§
The
following people are invited:
o
Associate
Director
o
Subject Matter Experts (SMEs)
o
TJSO
Representative
o
Facility or Equipment Owner
See ES&H Manual 5200
Appendix T2 Notable Event Worksheet for a “Critique Meeting Checklist” and follow-up
actions.
Substep 4.c – Causal
Analysis
Lead
Investigator determines the cause(s) of the event:
·
Analyzes
actions leading up to the event to discover the apparent cause(s).
·
Determines
the root cause(s). Root causes are the
underlying system weaknesses that contributed to the hazardous conditions
and/or unsafe behaviors.
Substep 4.d – Extent
of Condition
The
investigation team determines if an extent of condition review is needed, (i.e.
could factors contributing to the event exist within other processes,
equipment, or human performance?)
·
Extent
of Condition reviews are situationally dependent and can apply to either field
or administrative operations.
Additionally, a graded approach should be used when determining if an
Extent of Condition review is necessary.
Lead
Investigators rely on their team, specifically the Subject Matter Experts
(SME’s), to determine the possibility of recurrence. The overarching factor for each investigation
is prevention of recurrence via elimination of the problem across the site.
·
Results
of Extent of Condition reviews should be evaluated to determine if additional
corrective actions are warranted.
·
Additionally,
Extent of Condition Reviews should be documented as a corrective action.
Substep 4.e – Corrective Actions
Lead Investigator provides recommendations
for corrective actions directly related to root and contributing causes, as
well as lessons learned. Recommendations
could include:
·
Engineering
controls (e.g.: local exhaust ventilation or use of an lift assisting device)
·
Work
practice controls (e.g.: pre-plan work or remove jewelry and loose fitting clothing
before operating machinery)
·
Administrative
controls (e.g.: standard operating procedures or worker rotation)
·
Personal
protective equipment (e.g.: safety glasses or respirators)
·
Corrective
actions include actions to address situations identified in the Extent of Condition
portion of the investigation.
Substep 4.f – Documentation of Events.
The completed ES&H Manual Chapter 5200
Appendix T2 Notable Event Worksheet serves as the basis
for more formal documentation whenever needed, and is submitted to the ESH&Q Reporting Officer.
If an injury or illness required medical care beyond first aid,
the supervisor or the ESH&Q Reporting Officer provides the
required information to Occupational Medicine in order to make preliminary
notification to workers compensation insurance carrier. This is done as soon as possible after the event.
Step 5 – Notable Event
Report Approval
The Lead Investigator distributes the draft Notable
Event Report to the team and affected Division Management for review.
Management reviews and confirms the corrective
actions and implementation plans.
The Lead Investigator then submits the final
Notable Event Report to the relevant Division Safety Officer.
Step 6 – DOE Categorization
and Report Update (within time constraints)
ESH&Q Reporting
Officer reviews Notable Event Report and confirms or re-assigns DOE categorization.
Step 7 – Report posted
ESH&Q Reporting
Officer posts final Notable
Event Report
Step 8 – Corrective
Actions
Lead
Investigator uses the Issues
Management Procedure to initiate the Corrective Actions. The Issues Management process encompasses
tracking to completion, approval and closure of actions recommended by the
investigation team.
4.1
Trend
Analysis Conducted (Quarterly)
ESH&Q Reporting
Officer compiles data from Notable
Event Reports, first aid cases, and lessons learned which occur during the
preceding quarter to produce a quarterly trend analysis that is presented to upper management. Results
of the trend analysis are used in future work planning.
4.2
Lessons
Learned
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.
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ISSUING
AUTHORITY |
APPENDIX
AUTHOR |
APPROVAL
DATE |
EFFECTIVE
DATE |
EXPIRATION
DATE |
REV. |
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ESH&Q Division |
10/19/09 |
10/19/09 |
10/19/12 |
1 |
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