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5300 Occurrence
Reporting |
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1.0
Introduction
Jefferson
Lab’s ESH&Q program is designed to prevent unplanned events. However, if such an event—termed an occurrence—takes
place, Jefferson Lab will investigate and analyze the mishap to discover the
cause and prevent similar incidents from recurring. In order to help other research facilities
avoid potential safety problems, Jefferson Lab shares its occurrence reports
with the Department of Energy (DOE). The
information is put into a computerized occurrence reporting and tracking system
shared by all DOE facilities, allowing them to better prevent, control, and
respond to similar situations.
Because of the desire to keep the
Department of Energy informed about current Jefferson Lab safety issues, this
facility sends DOE an occurrence report on any event that has or could:
·
endanger workers
·
affect the public's safety
and health
·
seriously impact the
laboratory
·
adversely affect the
environment
The Jefferson
Lab Occurrence Reporting Program for reportable occurrences is based on the
requirements contained in DOE Order 231.1A, Environment, Safety, and Health
Reporting, and DOE Manual 231.1-2, Occurrence Reporting and Processing of
Operations Information (ORPS). This guidance became effective at Jefferson Lab
on December 1, 2003 and all new occurrences are being reported using the new
reporting criteria.
The new DOE
ORPS guidance establishes a graded approach for reporting and investigation of
occurrences. This approach identifies the required reporting timelines, level
of investigation and causal analysis, approval, corrective action development,
verification, and validation for the various severity categories.
The DOE Order
establishes the following severity categories in addition to Emergency Events
such as Operational Emergencies (OEs) (as defined in applicable DOE emergency
management guidance found in DOE 151.1A). OEs, as defined in this DOE Order,
are not likely to occur at Jefferson Lab or the other two program dedicated
research accelerator facilities (the Fermi National Accelerator Laboratory and
the Stanford Linear Accelerator Center) unless from off-site hazardous material
releases.
Significance Category 1:
Occurrences that have a significant impact on safe facility operations, worker
or public safety and health, regulatory compliance, or public/business
interests.
Significance Category 2:
Occurrences that have a moderate impact on safe facility operations, worker or
public safety and health, regulatory compliance, or public/business interests.
Significance Category 3:
Occurrences that have a minor impact on safe facility operations, worker or
public safety and health, regulatory compliance, or public/business interests.
Significance Category 4:
Occurrences that have some impact on safe facility operations, worker or public
safety and health, regulatory compliance, or public/business interests.
Significance Category R:
Occurrences identified as recurring, as determined from the periodic
performance analysis of occurrences.
The Jefferson
Lab Facility Manager Designee must notify the DOE Site Office Facility
Representative and the DOE Headquarters Operations Center (DOE HQ OC) as
required, of the following reportable occurrences as soon as practical, but no
later than 2 hours after categorization:
1. All Significance Category 1, 2, and R occurrences require a prompt notification to the Facility Representative and DOE HQ OC.
2. All Significance Category 3 and 4 occurrences require a prompt notification to the Facility Representative.
3. Additionally, specific Significance Category 3 and 4 occurrences (identified as requiring prompt notification with an asterisk (*) in the reporting criteria listed in ES&H Manual Chapter 5300 Appendix T1 Occurrence Reporting and Notification Procedures) require prompt notification to the DOE HQ OC
Jefferson Lab events
that may influence performance, reliability, safety or the environment, but do
not fully meet DOE occurrence reporting criteria, are classified as Notable
Events. ES&H
Manual Chapter 5300 Appendix T3
Notable Event and Notification Procedure, describes how other staff
are made aware of notable events so they may take steps to prevent similar
events
Important personnel
and organization phone numbers are provided in Table 1 of ES&H
Manual Chapter 5300 Appendix T1
Occurrence Reporting and Notification Procedures for use in making any
type of notification.
Specifics on time
guidelines for initial notification and categorizing an occurrence are in ES&H
Manual Chapter 5300 Appendix T1
Occurrence Reporting and Notification Procedures. The guidelines in ES&H
Manual Chapter 5300 Appendix T2
Occurrence Documentation and Tracking Procedure are to be followed
for occurrence report preparation and follow-up activities.
Jefferson Lab’s
occurrence reporting system improves communications and facilitates a
meaningful exchange of lessons learned through fact finding, rather than fault
finding, at Jefferson Lab and other facilities in the DOE complex.
Occurrence Reporting
Orientation Briefings
Orientation briefings on occurrence reporting requirements will be
conducted by ESH&Q Reporting staff for management personnel in each
Jefferson Lab Division and Office. All Jefferson Lab staff will be informed of
the occurrence reporting program by the distribution of appropriate
information. Ongoing occurrence reporting awareness information will be
incorporated into annual emergency management information that is provided to
Jefferson Lab staff.
The briefings for management staff include the following areas:
·
occurrence reporting philosophy
·
identification, classification, and notification requirements of
occurrence reporting
·
analysis and closure process
·
use of the ORPS database for appropriate “lessons learned”
2.0
Key
Terms
Jefferson Lab Facility Manager The person with direct line responsibility
for operation of Jefferson Lab, including authority to direct physical changes
to a facility. The Facility Manager and his alternates are listed in Table 1, ES&H
Manual Chapter 5300 Appendix T1
Occurrence Reporting and Notification Procedures
notable event An unplanned or abnormal incident that affects or has the
potential to affect performance, reliability, safety, or the environment but
does not fully meet DOE occurrence reporting criteria.
reportable occurrence Any unusual or unplanned event that has
or could adversely affect public health, the performance, reliability, or
safety of a facility, or the environment, as described in ES&H
Manual Chapter 5300 Appendix T1
Occurrence Reporting and Notification Procedures. Reportable
occurrences are classified by their potential for personal injury,
environmental damage, and/or equipment loss. Additional information on the
occurrence categorization process is available in DOE Manual 231.1-2.
DOE Occurrence Reporting and Processing System of Operations
Information (ORPS) An electronic, internet-based reporting and incident tracking
system. The system lets staff at DOE sites and facilities across the country
share occurrence/incident information and lessons learned.

3.0
Responsibilities
Everyone
At Jefferson Lab - In The Event of an Unplanned Event
·
Initiate evacuation of the area, if warranted, and if safe to do
so, acts to minimize the hazard.
·
Call 911 to request an emergency response team, if needed.
·
Call ext. 4444 to notify Jefferson Lab Security of the nature and
location of the problem.
·
For any potentially reportable incident within the accelerator
complex fence, notify the Machine Control Center crew chief (ext. 7045,
cellular phone # 630-7045).
·
Advise your supervisor of all potentially reportable events, and
the time you became aware of them. If you are unsure whether an event meets
reporting criteria, report the event to your supervisor as soon as possible.
·
Don’t disturb the accident area, except to prevent further injury
or damage.
·
Refer to ES&H
Manual Chapter 3510 Emergency Management Plan and ES&H Manual
Chapter 5200 Incident/Injury Investigation.
·
Crew
Chiefs or Supervisors
·
Upon discovery, notify the Facility Manager Designee at cellular
phone # 876-1750 of a potentially reportable event.
·
Start a written chronology of events.
·
Reportable and potentially reportable events are to be reported
through the line management chain to the Jefferson Lab Director as soon as
possible anyway.
·
Fill out and submit written notification and follow-up reports
within time limits, per ES&H
Manual Chapter 5300 Appendix T1
Occurrence Reporting and Notification Procedures and ES&H
Manual Chapter 5300 Appendix T2
Occurrence Documentation and Tracking Procedure. Assess applicability of ES&H Manual
guidance and work control documents and make recommendations for improvements
to the guidance that could help to avoid a repeat of the occurrence.
·
Implement all necessary corrective actions identified on reports.
Facility
Manager Designee
·
Decide if an event is reportable, and if so, categorize it with Facility
Manager concurrence. See ES&H
Manual Chapter 5300 Appendix T1
Occurrence Reporting and Notification Procedures for guidelines in
categorizing an occurrence.
· Oversee the
notification of DOE personnel as specified in ES&H
Manual Chapter 5300 Appendix T2
Occurrence Documentation and Tracking Procedure.
·
Oversee input of report information into the DOE operational
database
ESH&Q
Reporting Manager
·
Facilitate
the occurrence reporting, documentation, and tracking procedures.
·
Maintain
a log of site incidents that were reported internally but were determined not
to be reportable to the DOE or the National Response Center.
·
Review
the ORPS database at least quarterly for incidents of potential interest to
Jefferson Lab.
·
Distribute
information from such reports to staff through appropriate means, such as
telephone, electronic mail, ESH&Q messages, meeting minutes, and
newsletters.
·
Refer
ESH&Q Manual change recommendations resulting from incident investigations
to the ESH&Q Policies and Manuals Manager.
ESH&Q
Staff
·
Conduct
“lessons learned” briefing or distribute appropriate information for
supervisors in each division, if applicable to the activities of that division.
4.0
Program
Summary
Jefferson Lab’s Occurrence Reporting Procedure, that identifies
the site process for reporting an event or situation, strives to improve
communication and facilitate a meaningful exchange of lessons learned through
fact finding, not fault finding, here and at other facilities in the DOE
complex.
Reportable events include,
but are not limited to:
ES&H
Manual Chapter 5300 Appendix T1
Occurrence Reporting and Notification Procedures covers occurrence
categorization and outlines initial notification procedures. ES&H Manual Chapter 5300 Appendix
T2 Occurrence Documentation and Tracking Procedure. explains follow-up reporting requirements. Notification and
reporting procedures are broken down into specific tasks.
Initial Discovery and
Response
Anyone witnessing an accident or potentially dangerous situation
should initiate basic hazard response activities, such as evacuating a building
or contacting the appropriate disaster response team, fire department, or
ambulance, via phone number 911 and Security, ext. 4444. For incidents within
the accelerator complex fence, the crew chief (ext. 7045, cellular phone # 630-7045)
must be notified immediately.
If you discover a potentially reportable event, advise your
supervisor as soon as possible.
Notifications
The Facility Manager/Designee checks the information for errors
and categorizes the occurrence. If the event is determined to be reportable,
the Facility Manager makes the necessary DOE notifications.
Documentation,
Follow-up and Corrective Action
Supervisors having responsibility for the problem area provide
documentation of events and circumstances, and implement necessary corrective
action. Documentation should include an
assessment of applicable ESH&Q Manual guidance
or work control document provisions which address the circumstances and why
they were not effective in preventing the problem. Recommendations to correct
identified shortcomings should be provided to reduce the likelihood of a repeat
occurrence.
Applicable
Line Management and the Facility Manager approve report information for entry
into the DOE ORPS database. The report shall provide references to
documentation of apparent cause analysis or other causal analysis if
applicable.
Support
The
ESH&Q Reporting Manager oversees the occurrence reporting system, maintains
awareness of reporting requirements, informs other personnel with reporting
responsibilities, and disseminates information of interest to Jefferson Lab
staff.
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