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ES&H Manual
Chapter 5200 Event Investigation and Causal Analysis Process
Purpose

Jefferson Lab initiates and completes investigations for all notable events, which may include near misses, while analyzing Human Performance Improvements (HPI) in an effort to learn from mistakes and gain perspective from the event. This process encourages the development and sharing of lessons learned and follows the guidelines outlined in DOE Order 232.2A Occurrence Reporting and Processing of Operations Information.

All unwanted events should be reported to the ES&H Reporting Officer for screening to determine if they are “notable” and subject to a formal investigation, including a causal analysis. The event investigation and causal analysis process enables the Lab to capture, develop, and implement corrective actions that reduce the likelihood of reoccurrence; perform trend analyses; and learn from these unintended events.

This may include capturing the data for the investigation and entering it into the following DOE reporting requirements:

  • Occurrence Reporting and Processing System (ORPS)
  • Computerized Accident Incident Reporting and Recordkeeping System (CAIRS)
  • Noncompliance Tracking System (NTS)

NOTE: This process does not negate DOE Order 225.1B Accident Investigation, which allows TJSO to conduct an independent investigation of any event at Jefferson Lab. Any such investigation is coordinated through the Associate Director, ES&H.

Scope

This chapter outlines Jefferson Lab responsibilities to report unwanted events and notify the appropriate personnel.

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 that Jefferson Lab Management directs to be investigated.

2.2  Radiological Events:

All radiological events are screened by the ESamp;&H Reporting Officer in conjunction with the Radiation Control (RadCon) Manager in accordance with DOE Order 232.2A Occurrence Reporting and Processing of Operations Information and 10 CFR 835 Occupational Radiation Protection Program.

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 Incidents:

Other incidents, including first aid cases, are dispositioned for investigation on a graded approach between the Associate Director, ES&H and the affected Division Safety Officer. The information is compiled and used for safety related trend analysis. In some instances, there are corrective actions associated with the incident that are entered into CATS and tracked to completion. This information is then shared at various meetings with lab management.

Any event or trend may be elevated to a Notable Event, or reported through ORPS or NTS as a management concern by the Associate Director, ES&H.

Table 1: Required Training Courses for Lead Investigators

Training Course Lead Investigator
Event Investigation and Root Cause Analysis
SAF124
X
EIP-120DE, Accident Investigation Overview via National Training Center
*Prerequisite to SAF 308
X
Human Performance Improvement
GEN500
X
Event Investigation and Reporting
SAF308
X


Appendices:

Event Investigation and Causal Analysis Process

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 Procedure provides the process steps used to document the investigation activities and record the level of analysis applied to investigation activities.

Event Investigator Process

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References:

Responsibilities:

Note: Management authority may be delegated to a task qualified Jefferson Lab employee at the discretion of the responsible manager.

Witnesses and Involved Persons
  • Report any event to your supervisor/SOTR/sponsor or the ES&H Reporting Officer (876-1750) in a timely manner. This includes events that occurred offsite on job related business.
  • If injured, seek immediate medical attention onsite at the Occupational Medicine office (ext. 7539) or offsite at a designated after hours location. If your injuries are serious or life threatening, immediately contact 911 or have someone drive you to the nearest medical facility.
  • Report any injury, illness, or first aid case(s) (including offsite job related injuries) to your Supervisor/SOTR/Sponsor/Line Manager as part of the process outlined in ES&H Manual Chapter 6800 Appendix T2 Injuries and Illnesses Requiring First Aid or Emergency Medical Response.
  • Share lesson learned with co-workers in efforts to help prevent recurrence.
Supervisor/Subcontracting Officer's Technical Representative (SOTR)/Sponsor
  • Immediately notify the ES&H Reporting Officer (cell-757-876-1750), Division Safety Officer, and Associate Director/Division Manager of the event.
  • Ensure the affected area/equipment is preserved pending an investigation. This may include cordoning off the area and taking preliminary photographs.
  • If the event involves an injury, ensure the injured part is cared for prior to making notifications.
Associate Director & Division Manager
  • Inform the Laboratory Director, Chief Operating Officer (COO), Associate Director or Division Manager of an event as soon as possible.
  • Ensure that event investigations are conducted in a timely and effective manner.
  • Work with the Lead investigator to develop lessons learned, corrective, and preventive actions after reviewing the results of the investigation.
  • Ensure that corrective actions are tracked and documented to closure in a timely manner using the Corrective Action Tracking System (CATS).
ES&H Reporting Officer
  • Categorize events and notify appropriate personnel in accordance with DOE reporting criteria.
  • Notify Thomas Jefferson Site Office representative within the time limits established in DOE Order 232.2A Attachment 4.
  • Ensure event investigation training is provided to specified personnel; and maintain a list of trained investigators.
  • Provide technical expertise during investigations to ensure compliance with DOE requirements.
  • Ensure the investigation focuses on Human Performance Improvement (HPI), while emphasizing a learning environment with solutions for root and contributing causes.
  • 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 Database.
  • Ensure the final Notable Event report is exported into the Jefferson Lab Corrective Action Tracking System (CATS) and the Lessons Learned database.
  • Review the evidence of completion submitted for each corrective action in Corrective Action tracking System 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.
  • Maintain Contact Information for Urgent Events listing.
DOE Reporting (including ORPS, CAIRS and NTS determinations) is the sole responsibility of the ES&H Reporting Officer. After the initial facts of the event are evaluated, the Reporting Officer determines DOE reportability and if applicable, proceeds per ES&H Manual Chapter 5300 Occurrence Reporting to DOE.
Lead Investigator
  • Form the investigation team and include the appropriate subject matter experts, managers, and workers from other non-impacted areas to ensure it is well balanced.
  • Ensure at least one individual on the team is trained in Event Investigation and Root Cause Analysis (SAF 124 or the equivalent) and they are assigned responsibility for conducting a thorough causal analysis using the graded approach.
  • Coordinate event investigation activities.
  • Document the investigation and causal analysis results using facts from the event, the ES&H Manual 5200 Appendix T1 Event Investigation and Causal Analysis Procedure, and the notable event database. There is a worksheet available to help capture all relevant information.
Document Control:
  • ISSUING AUTHORITY:   ES&H Division
    TECHNICAL POINT-OF-CONTACT:  Tina Johnson
    APPROVAL DATE:   05/29/19
    REVIEW DATE:  05/29/22
    REVISION HISTORY
    Revision 2.0 - 05/20/18 - Periodic Review; updated Purpose, training table, causal analysis process to align with HPI concepts and initiatives.
    Periodic Review - 05/20/18 - Extended 1-year per TPOC due to anticipated changes regarding this process.
    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 ES&H Reporting Officer assignment from SSmith to CJohnson per MLogue.
    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.

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