Notable Event Report

(See ES&H Manual Chapter 5200 Appendix T1 Event Investigation and Causal Analysis for Instructions)

 

Notable Event Report

Title of Event

Event Title:

 

Date and Time of Occurrence:

 

Notable Event Number:

 

Event Location:

 

Date Notable Event Report is Due*:

 

*The Notable Event Report is due to the ESH&Q Reporting Officer with 30 days of the Initial Fact Finding Meeting unless an extension is requested.

Summary of Event and / or Injuries, including Initial Fact Finding Meeting information: determine the chain of events and timeline.  Use attachment as necessary.

 

Causal Analysis: (Use attachment as necessary)

Root Cause: 

 

Contributing Causes:

(List as many as apply.)

 

Extent of Condition Check

JLab CATS Number

Target Date

Action Owner

 

 

Does this event involve failed equipment?

 Y         N

Is there similar equipment in other areas?

Y         N

** If yes, assign extent of condition check to the appropriate DSO(s).

 

Corrective Action(s)

JLab CATS Number

Target Date

Action Owner

 

 

 

 

 

 

Lessons Learned (Confer with Lessons Learned Coordinator)

         (Use attachment as necessary)

Lessons Learned Number

 

Witness Accounts:  (Use attachments as necessary.  Box will expand as necessary)

 

Records, Documents, Pictures, and Other References: (Copy and paste, use attachments or document links as necessary)

 

Emergency Notifications Made (Subsequent to the Event):

Date

Time

Fire, Rescue & Emergency Medical:  (9-911)

Guard Post:  x5822; 269-5822

Occupational Medicine  269-7539

ESH&Q Reporting Officer:  876-1750

Crew Chief  630-7050

Industrial Hygiene:  269-7863:

Other:

 

Confirmation Review Distribution:

Investigation Team Members

Affected Division Managers

ESH&Q Reporting Officer

 

It is asked that you review and provide comments to this document to the Lead Investigator (denoted on Page 1) within ____ days.  Your comments will be reviewed and incorporated as appropriate.  Thank you for your consideration in this matter.

 

Investigation Team Confirmation:

The below signees, confirm to the best of their knowledge, that the information presented in this document is accurate and complete.

Role

 

Print                                                                            Signature

Date

Lead Investigator

 

 

 

 

 

 

 

 

 

 

 

Acceptance/Acknowledgement of Facts

Print                                                    Signature

Date:

Associate Director/ Department Manger

 

 

 

 

 

 

 

 

Upon confirmation submit document to the ES&H Reporting Officer for completion and distribution.

Documentation of Findings:  (To be Completed by ESH&Q Reporting Officer)

Notable Event Number: 

CATS Number:

Lessons Learned Number:

 

ORPS Number:

NTS Number:

CAIRS Entry:

DOE Cause Code:

ISM Code:

Unless otherwise specified the following is to be completed by the Lead Investigator.

 

Step 1 Initial Fact-Finding Meeting (To be held as soon as reasonably possible following event(within 24 hours))

Date:

 

Time:

 

Location:

 

Required Attendees: (Print Name)

Optional Attendees: (Print Name) Present

Lead Investigator:

 

Associate Director:

 

ESH&Q Representative:

 

TJSO Observer:

 

Supervisor of involved persons(s):

 

Subject Matter Expert(s), Facility/Equipment Owner as applicable:

Involved or impacted person(s):

 

Witness(es):

 

 

 

 

Agenda

(Ensure the pace of the meeting allows time for accurate note taking.)

Φ if

Complete

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

2.      Attendance - Are Required Attendees present.

3.      Purpose of Initial Fact-Finding meeting.

4.      Event Reconstruction – Use information to complete Section 3. Summary of Event and/or Injuries below.

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

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

7.      Compensatory Actions Required?  If “Yes” determine responsibility and include confirmation documentation.

8.      Records or documentation required to confirm, clarify, or complete information (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.

10.  Obtain TJSO Observer feedback on conduct of fact finding meeting and potential improvements.

 

 

Step 2  Investigation Team:

Date Convened:

(Within 24 hours of Fact Finding Meeting.)

 

Role

Name

Department/Group

Phone

Lead Investigator

 

 

 

 

 

TJSO Observer

TJSO

 

Environmental Aspects

Type of Material Released:

 

Quantity:

 

Source:

Time Flow was Halted or Controlled:

 

For Investigation Team (Φ All That Apply):

 

Reportable Quantity

Impact Ground/Soil

Storm Water Channel/Drain

Sanitary Sewer

 

Categorization and Reporting

(To be completed by ESH&Q Reporting Officer within two hours – unless essential information is still pending)

 

ORPS Determination:

Date:

 

Time:

 

 

10 CFR 851 Screen:

Date:

 

Time:

 

 

 

 

Final Distribution:

ES&H Reporting Officer (Original)

Associate Director/Department Manager

Division Safety Officer

Investigation Team Members

ESH&Q Liaisons

Form Revision Summary

Revision 1.6 – 02/22/16 – Updated form to reflect extent of condition ensuring it covers failed equipment per MOA

Revision 1.5 – 10/04/13 – Changed COE to Lessons Learned; updated links.

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 S.Smith to C.Johnson per M.Logue

                                                Edited to clarify process steps.

Revision 1.2 – 10/20/11 – Updated ESH&Q Reporting Officer assignment from J.Kelly to S.Smith per M.Logue.

Revision 1.1 – 05/24/11 – Edited to clarify process steps.

Revision 1.0 – 11/23/10 – Updated to reflect current laboratory operations.

 

ISSUING AUTHORITY

FORM TECHNICAL

POINT-OF-CONTACT

APPROVAL DATE

REVIEW DATE

REV.

 

 

ESH&Q Division

Tina Johnson

02/22/16

02/22/19

1.6

 

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 2/22/2016.