ES&H Manual



5200 Appendix T1

Event Investigation and Causal Analysis Procedure



1.0             Purpose

Jefferson Lab investigates all notable events, including near misses, and evaluates the Human Performance Improvement (HPI) perspective to gain an understanding of latent organization weaknesses and error precursors. This procedure provides the framework for conducting an adequate investigation to ensure sufficient data is collected, performing an accurate causal analysis, and developing meaningful corrective actions and lessons learned to understand those organizational weaknesses that could leave the Jefferson Lab vulnerable for future events that potentially could result in worse consequences.

2.0             Scope

This procedure is applicable to all notable events and near misses including subcontractor activities.

3.0             Process Steps

3.1              Initial Actions

·         All Employees

o   If event resulted in injury to personnel, tend to injured party immediately and call Occupational Medicine (ext. 7539) or 911 for medical assistance.

·         Involved Persons

o   Place in a safe condition and secure the scene.

o   Notify your Supervisor/SOTR/Sponsor ASAP.

o   Provide witness account statement (template provided), including:

§  Event sequence

§  Description of work and conditions in progress

§  Your role in the event sequence

§  Others that may have been involved

§  Any observations/comments applicable to the event

·         Supervisor/SOTR/Sponsor/Line Manager

o   Ensure the injured person(s) is taken to Occupational Medicine or the Emergency Room.

o   Ensure the scene is cordoned off, take photographs, and perform other activities to preserve evidence.

o   Obtain witness account statements.   

o   Notify ES&H Reporting Officer (after business hours use cell phone 757-876-1750).

o   Determine if a potential release to the environment occurred.

NOTE: Incident scene must be preserved until cleared by ES&H Reporting Officer.

·         ES&H Reporting Officer notifies:

o   Associate Director, ES&H who then notifies:

§  Laboratory Director

§  Chief Operating Officer

§  Appropriate Division Manager(s)

3.2              Event Investigation Process

3.2.1        Conduct Initial Fact Finding Meeting – the purpose of the fact-finding meeting is to document “what happened”, “when it occurred” and “which employees were involved” leading up to the event. The Associate Director/Division Manager of the affected organization appoints a lead investigator.

Step 1:            The ES&H Reporting Officer schedules a meeting within 24 hours of discovery, at the location of the event (if possible).

a.       Required Attendees

§ Lead Investigator, if appointed

§ ES&H Reporting Officer or their designate

§ Supervisor/Line Manager of the directly involved person(s)

§ The involved person(s)[1] and/or those directly impacted by the event

§ Witnesses to the event (only pertinent personnel are required to attend)

b.      Optional Attendees

§ Facility or Equipment Owner

§ TJSO Representative (as an investigation observer)

§ Associate Director/Division Manager

Step 2:            The Lead Investigator leads the fact finding meeting. If an investigator has not been appointed, the ES&H Reporting Officer or their designate will lead. Responsibilities include:

§ Gather written statement(s) prior to the fact finding meeting

§ Appoint Scribe to take notes  

§ Follow the fact finding agenda template

3.2.2        Form Investigation Team

The investigation team provides support to the Lead Investigator. The team should be able to provide a broad experience base. The purpose of the investigation team is to help understand what ‘did not go right’ by analyzing how the work was imagined and evaluating how the work was performed.  

·         Team Lead recommends team members.

·         Team Lead recommends SME support needed.

·         Team Lead seek divisional and cross-divisional team members. Where possible, include peers of those involved in the event to help understand context.

·         Team Lead convenes a meeting of Investigation Team Members as soon as possible (or within 24 hours) of Initial Fact Finding Meeting.

·         Review the initial fact finding notes, witness statements, and discuss the scope of the investigation.

·         Determine what records and documents are required.

·         Delegate responsibilities to team members to ensure that adequate and complete information will be obtained.

·         Associate Director/Division Manager determines if a formal written report is required.

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

Step 1:            Gather Information

§ Team generates a summary of the events

§ Interview witnesses (see Human Performance Interview guidelines)

§ Review Records, Work Control Documents, Pictures, and Other References

NOTE: The Change Method, 5 Whys, and TapRoot are great tools to start your causal analysis.

Step 2:            Perform Analysis

§ Identify barriers and controls in place

§ Analyze change between work as imagined and work completed. Compare the facts to the work planned (change method, etc.).

§ Consider context of individual actions

Step 3:            Conduct Causal Analysis – determine the cause(s) of the event

§ Root Cause – determine the underlying system weaknesses that contributed to the hazardous and/or unsafe behaviors.

§ Contributing Causes – analyze the actions leading up to the event to determine the contributing cause(s).

o   Use facts to determine the root and contributing causes.

o   Identify any latent organizational weaknesses and error precursors.

o   Ensure that the root and contributing cause are factual and reflect the HPI factors.

Step 4:            Extent of Condition – determine if the root or contributing cause(s) exist within other processes, equipment, or human performance.

§ Identify areas where processes, equipment or performances are at similar risk of event recurrence.

§ Determine what immediate actions are needed to address the extent of condition, to ensure a recurrence.

Step 5:            Recommend Judgement of Needs (JON)

§ JONs are managerial controls, safety measures, or human performance improvements necessary to prevent or minimize the probability or severity of a recurrence of an accident.

§ JONS are not prescriptive; they are linked to the causal factors.

§ JONs are supported by causal analysis.

Step 6:            Determine Lessons Learned

§ During the course of an investigation, innovative approaches or devise changes that allow work to be accomplished more efficiently are often discovered. If documented and shared, these positive and negative discoveries can have a significant positive teaching impact on laboratory operations.

§ Record any Lessons Learned during the investigation.

Step 7:            Document Investigation

NOTE: Report, including JON, due 21 days after the date of the event.

§ ES&H Reporting Officer – verifies that all relevant document numbers or codes for information or data, have been generated during the investigation process:

o   Notable Events identification number

o   CATs action number  

o   Lessons Learned lesson number

o   ORPS identification number

o   NTS identification number

o   CAIRS Entry

o   DOE Cause Code

o   ISM Code

§ Lead Investigator

o   Document investigation in Notable Event database.

o   Draft a formal written report when required by the Associate Director/Division Manager.

o   Submit for factual accuracy.

o   Respond to comments received and finalize report.

§ Investigation Team signs report.

§ Associate Director/Division Manager accepts report.

3.3              Corrective Action Determination

NOTE: Corrective/preventive actions are due 21 days after receipt of final report.

·         ES&H Reporting Officer schedules meeting within 7 days of investigation report finalization, with AD/DM, AD ES&H, and Lead Investigator to discuss JONs and corrective actions.

·         Line Organizations determine corrective actions.

·         Lead Investigator concurs on whether corrective actions will address JONs. If they do not, AD ES&H will facilitate discussions.

·         ES&H Reporting Officer will document corrective actions in Notable Event database.

3.4              Post and Distribution  

The ES&H Reporting Officer performs the following process steps:

Step 1:            Post approved Notable Event Report to the Notable Event Website.  

Step 2:            Distribute a copy of the accepted Notable Event worksheet to:

§ Associate Director/Department Manager/Line Manager

§ Division Safety Officers

§ Investigation Team Members

§ ES&H Liaisons

4.0             References

·         Corrective/Preventive Actions:

Division Managers use the Issues Management Procedure to initiate Corrective/Preventive Actions. The Issues Management process encompasses tracking to completion, approval and closure of actions recommended by the line managers impacted by the event.

Longer-term extent of conditions checks may be planned and performed to ensure the event’s corrective/preventive actions eliminate the possibility of recurrence across the entire site, in all applicable areas.

·         Lessons Learned:

The ES&H Reporting Officer shares lessons learned either through posting on the Lessons Learned website and the Notable Event webpage. This information is also encouraged for use during staff safety meeting discussions and special operational notices.

5.0             Revision Summary  

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 ES&H 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









ES&H 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 6/11/2019.

[1] Note: The person(s) directly involved may not be able to attend due to injury or illness. If this is the case, the lead investigator determines if a separate interview or discussion is acceptable.