TITLE:	ES&H Manual
DOCUMENT ID:	5200 Appendix T2 Event Investigation and Causal Analysis Procedure

1.0 Purpose

This procedure provides the process steps for conducting an event investigation and causal analysis. Steps include a preliminary event assembly, initiation of the event investigation, investigation activities, cause analysis to determine root cause, proposing corrective actions, and submittal for concurrence. Corrective actions are resolved using the Issues and Corrective Action Management Process, and the final report is summarized and distributed within the Lessons Learned Program.

2.0 Scope

Jefferson Lab investigates all events initiated by the occurrence reporting process. This procedure is applicable to all notable events and near misses including subcontractor activities.

3.0 Responsibilities

Note: Authority may be delegated to a task qualified Jefferson Lab employee at the discretion of the responsible manager.

3.1 Performance Assurance (PA) Manager

· Lead the Preliminary Event Meeting

· Commence the Event Investigation.

· Assign a Lead Investigator and Core Team members, which are assigned based on SME input needs

· Submit the Event Investigation Report for Factual Accuracy and Concurrence.

3.2 Lead Investigator / Core Team Members

· Perform the Event Investigation.

· Perform Cause Analysis.

· Propose Corrective Actions.

4.0 Process Steps

NOTE: The Event Investigation must be completed within 21 days of event.

4.1 Occurrence Reporting

4.1.1 Initiate Event Investigation Report Form

When an occurrence is reported an Event Investigation Report Form is initiated by the ES&H Reporting Officer (RO) to ensure accurate, consistent and timely data throughout the process.

· The following information is provided:

1. Event Title

2. Response Owner (affected Organization’s Manager)

3. Category

4. Event Location

5. Date of Occurrence

6. Time of Occurrence

7. Short Summary of Event and/or Injuries

8. Immediate Corrective Actions (including any activities used to preserve the scene.)

9. Emergency Notification Made (Subsequent to the Event)

· The initial event report is saved and submitted to the Performance Assurance Manager (Click “Initiate Report.”). This initial report will be used to record the event investigation team’s activities and findings.

4.1.2 Preliminary Event Meeting

The ES&H RO schedules the Preliminary Event Meeting within 24-hours of the event, at or near the event’s location. This meeting is scheduled to ensure those affected are provided accurate, consistent and timely data. Assembly data is recorded on the Preliminary Event Meeting Form. This is then attach to the associated Notable Event Report. (See ES&H Manual Chapter 5200 Appendix T1 Occurrence Reporting Procedure.)

Review the attach Preliminary Event Meeting Minutes (completed form) prior to initiating investigation activities.

Step 1 - Preliminary Event Meeting Agenda

** Preliminary Event Meeting will be led by PA

Pace the meeting to allow for accurate note taking.

1. Introduction – Provide Event Title, Date and Time of Occurrence, and Location.

2. Attendance – Introduce Attendees present. Provide role or reason for attendance.

3. Summary of Event (Similar to the Summary of Event on the Notable Event Report Form.)

4. Event Reconstruction (Review Witness Account Statements)

a. Personnel and organizations involved in the event.

b. Conditions and actions preceding the event.

c. Chronology (timeline) of the event.

d. Immediate actions taken in response to the event.

5. Clarify Information – Subject-Matter Expert (SME) confirms work conditions.

6. Stop Work or Tag Out Required? If “Yes” – establish restart criteria and inform the affected Management chain.

7. Compensatory Actions Required? If “Yes” summarize responsibility and follow-up activities.

8. Investigation Process (introduce the Lead Investigator who will summarize the proposed plan forward, outline any anticipated records or documentation required to confirm, clarify, or complete the investigation i.e., work plans, work control documents, photos, etc).

9. Other Questions or Concerns: Ask attendees if there are any other questions, concerns, or information that they wish to provide.

Step 2 – Conclusion

1. Request TJSO Observer feedback or opportunities for improvement. (Attach to report.)

2. Collect Witness Account Statements and attach to the Preliminary Event Meeting report

4.2 Event Investigation

4.2.1 Commence Event Investigation

· Access the Event Investigation Report form from the link provided by the ES&H Reporting Officer.

· Attach a copy of the Safety Flash Notification (when provided).

· Assign and notify the Core Investigation Team members. Minimally:

§ Lead Investigator

§ Organization’s Representative

§ Subject Matter Expert (designate one (or two) individual(s) outside the affected organization, when possible. Expertise is dependent on the area, injury, and hazard involved.)

4.2.2 Investigation Activities

The Lead Investigator directs team member activities. Members help gather evidence, conduct/attend interviews, and provide insight to understand what ‘did not go right.’

· Establish an estimated timeline for activities. (If Event Investigation activities take longer than 21 days from the Preliminary Event Assembly, contact the Performance Assurance Manager.)

· Schedule location inspections, interviews, as required.

· Assign responsibilities to team members.

· Document activities - Attach records, witness statements, and pictures to the Event Investigation Report, as evidence.

4.2.3 Draft Event Investigation Report

· Upload team member’s data into the event investigation report form.

· Organize data to provide a coherent summary of the events.

· Provide any human performance indicators (HPI) identified, to help answer the question, “Why actions made sense at the time.”

· Collaborate with team members to confirm the investigation accuracy.

4.3 Cause Analysis

4.3.1 Cause Analysis

Base the cause analysis on relevant facts and Human Performance Indicators (HPI) factors. Use DOE-STD-1197-2011 Occurrence Reporting Causal Analysis for reference.

· Identify Contributing Causes

o Use evidence collected to determine the event’s contributing causes.

o Identify any latent organizational weaknesses and error precursors.

· Determine the Root Cause

o Determine the single underlying system weakness that would, if corrected, prevent recurrence.

· 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 performances are at similar risk of event recurrence.

o Determine what immediate actions are needed to address the extent of condition, to prevent recurrence.

4.3.2 Propose Corrective Action

A Corrective Action is an activity that, when completed, restores an issue, (e.g. service, item, component, or process) to a state of compliance with specifications, procedures, or regulatory requirements. The Event Investigation Team may propose corrective actions for consideration by owning supervisors, managers and directors.

4.4 Submit for Factual Accuracy and Concurrence

The Lead Investigator submits the Event Investigation Report to the Performance Assurance Manager. If acceptable, it is then submitted to the effected manager, and others as appropriate, for concurrence and corrective action determination.

5.0 Post/ Distribute

1. Ensure that the identified corrective action items on the notable event report are loaded into Corrective Action Tracking System (CATS)

2. Pdf the notable event report and post on the ES&H Notable Event website *All attachments must be attached in pdf form

3. Email the link to the final report to all of the team members, Reporting Officer, DSOs, and ES&H Liaisons

6.0 References

DOE O 225.1 Accident Investigations

DOE-STD-1197-2011 – Occurrence Reporting Causal Analysis.

Issues Management and Corrective Action Program – used to track corrective actions to completion.

Assessment Program – used to evaluate extent of conditions and determine effectiveness of corrective actions

Lessons Learned Program – used to distribute a summary of the event and corrective actions

7.0 Revision Summary

Revision 3.0 – 10/26/21 – Moved Event Investigation and Reporting to Appendix T2. The Performance Assurance Department is now responsible for the investigation and report submittal process. Responsibilities of the ESH Reporting Officer/Department Managers have been reassigned to Performance Assurance. Process steps streamlined to complete a report within 21 days of an event. Approved chapter was not posted until database was live. Procedure posted on 1/10/22. Approved by S. Hoey and S. Henderson

Revision 2.0 – 05/29/19 – Periodic Review; updated Purpose, Scope, and Process Steps to align with HPI initiatives and concepts

Revision 1.6 – 05/20/17 – Periodic Review; extended 1-year per TPOC due to anticipated changes regarding this process

Revision 1.5 – 10/04/13 – Changed COE to Lessons Learned; updated process for Lessons Learned Coordinator to reflect current laboratory operations

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 Smith to Johnson per Morgue

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 1.0 – 10/19/09 – Updated to reflect current laboratory operations

ISSUING AUTHORITY	TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	REVIEW DATE	REV.
ES&H Manual	Steve Smith	10/26/2021	10/26/2024	3.0

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 1/10/2022.