|
TITLE: |
||
|
|||
DOCUMENT ID: |
5200
Appendix T2 Event
Investigation and Causal Analysis Procedure |
||
|
|||
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.
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.
Note: Authority may be delegated to a task qualified Jefferson Lab employee
at the discretion of the responsible 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.
·
Perform
the Event
Investigation.
·
Perform
Cause Analysis.
NOTE: The Event Investigation must be completed
within 21 days of event. |
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.
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.)
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
·
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.)
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.
·
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.
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.
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.
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.
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 |
10/26/2021 |
10/26/2024 |
3.0 |
|