ES&H Manual



5200 Event Investigation and

Causal Analysis Process



1.0            Purpose


Jefferson Lab investigates events concerning personal injury; significant 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 reports any event that qualifies to the Department of Energy (DOE), as outlined in ES&H Manual 5300 Occurrence Reporting to Department of Energy (DOE). 


Events that meet established criteria are called “Notable Events” and are subject to a formal investigation, including a causal analysis. 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)

·         Noncompliance Tracking System (NTS)


Events involving first aid are reported to Occupational Medicine, ext.7539, in accordance with ES&H Manual Chapter 6800 Injuries and Illnesses Requiring First Aid or Emergency Medical Response. 


2.0            Scope


2.1              Notable Events at Jefferson Lab could include:

·         Fatalities or injuries (other than first aid).

·         Unplanned operational emergencies, shutdowns, or evacuations.

·         All formal 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.

·         Electrical shocks.

·         Failure to follow a prescribed hazardous energy control process.

·         Chemical exposure above Threshold Limit Values (TLV) and/or Permissible Exposure Limits (PEL).

·         Radiation levels exceeding posted criteria, spread of radioactive contamination beyond control boundaries, or loss of control of radioactive materials which exceed applicable DOE limits. 

·         Radiation barrier breach or unauthorized entry.

·         Personnel radiation exposure or contamination which exceeds applicable DOE limits.

·         Significant property damage.

·         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.

·         Discovery of reduced effectiveness in a safety system that poses potential for immediate harm or mission interruption and requires prompt mitigative action. (e.g., Personnel Safety System, Fire Protection System, etc.).

·         Discovery of suspect or counterfeit material.

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

·         Any radiological event or condition determined to be an infraction of any applicable statutory requirement or DOE Order, or exceeds a condition established by permit (see 2.2 below).

·         Any DOE or regulatory body initiated non-compliance notification.

·         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.


2.2              Radiological Events:

All radiological events are screened by the ESH&Q Reporting Officer in conjunction with the Radiation Control (RadCon) Manager in accordance with ES&H Manual Chapter 5300 Appendix T2 Worker Radiation Protection Event Reporting (10CFR835) under Price Anderson Amendments Act (PAAA). 


Radiological incidents that do not exceed any relevant reporting criteria, and are not infractions of 10 CFR 835 or other applicable requirements, may be dispositioned in accordance with RadCon standard operating procedures. These incidents shall be documented as “Radiation Deviation Reports” in the Corrective Actions Tracking System (CATS) where they are available for review and trending. 


2.3              Other Events:

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.  Information is compiled for safety related trend analysis. This information is then presented to various forums and acted upon as appropriate. 


At the discretion of the Associate Director, ESH&Q, any event or trend may be elevated to a Notable Event, or reported through ORPS or NTS as a management concern.


This process does not negate DOE Order 225.1B 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.


Table 1: Required Training Courses for Lead Investigators

Training Course

Lead Investigator

Event Investigation and Root Cause Analysis




3.0            Responsibilities

NOTE:     Management authority may be delegated to a task qualified Jefferson Lab employee 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 Representative (SOTR)/Sponsor

·         Notify the ESH&Q Reporting Officer, Division Safety Officer, and 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 and notify appropriate personnel 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. 

·         Review evidence of completion submitted for each corrective action in order to verify that it supports the closure of the action.

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


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 Process


6.0            References


·         DOE O 232.2, Occurrence Reporting and Processing of Operations Information

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

Revision 1.5 – 05/20/14 – Added Required Safety Training Table

Revision 1.4 – 02/19/14 – Periodic Review; clarified reporting criteria and Reporting Officer responsibilities; added Radiological Events to Scope; updated flowchart

Revision 1.3  01/30/12 Updated ESH&Q Reporting Officer assignment from S.Smith to C.Johnson per M.Logue

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









ESH&Q Division

Tina Johnson





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 6/5/2017.