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5200 Notable Event Process |
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1.0 Purpose
Jefferson Lab initiates and completes investigations for all notable events, including near misses, and analyzes for Human Performance Improvements (HPI) indicators in an effort to learn from mistakes and gain perspective from the event. This process encourages the development and sharing of lessons learned, corrective actions, and follows the guidelines outlined in DOE Order 232.2A Occurrence Reporting and Processing of Operations Information.
All unwanted events reported to the ES&H Reporting Officer are screened to determine if they are “notable,” thus subject to a formal investigation, including a causal analysis. This event investigation and causal analysis process enables the Lab to capture, develop, and implement corrective actions to reduce the likelihood of reoccurrence; perform trend analyses; and learn from these unintended events.
When deemed necessary, events are reported to DOE in accordance with the following requirements:
· Occurrence Reporting and Processing System (ORPS)
· Computerized Accident Incident Reporting and Recordkeeping System (CAIRS)
· Noncompliance Tracking System (NTS)
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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 ES&H Director. |
2.0 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.
Note: Notable Event decision should be joint between the Reporting Officer and Performance Assurance with regards to Management Concerns.
2.2 Radiological Events:
All radiological events are screened by the ES&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 are documented as “Radiation Deviation Reports.” Any corrective actions are tracked to completion 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 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 ES&H Director.
Table 1: Required Training Courses for Lead Investigators
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Training Course |
Lead Investigator |
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Event Investigation and Root Cause Analysis SAF124 or equivalent |
X |
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EIP-120DE, Accident Investigation Overview via National Training Center |
X |
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Human Performance Improvement GEN500 |
X |
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 Everyone at Jefferson Lab
· When an event resulted in injury to personnel, follow the process steps outlined in ES&H Manual 6800 Appendix T2 Injuries and Illnesses Requiring First Aid or Emergency Medical Response.
3.2 Involved Persons
· Place the area in a safe condition and secure the scene.
· Report any event to your supervisor/Technical Representative/sponsor and security as soon as possible. This includes events that occurred offsite on job related business.
3.3 Supervisor/Technical Representative/Sponsor, Occupational Medicine
· Secure affected area/equipment (this may include cordoning off the area and taking preliminary photographs). Ensure the scene is preserved pending the investigation.
· Notify the ES&H Reporting Officer (cell-757-876-1750), Division Safety Officer, and Director/Associate Director/Division Manager.
3.4 ES&H Reporting Officer or designee
· Notify the ES&H Director, Division Safety Officer, and Appropriate Division Manager(s)
· Perform Occurrence Reporting Activities
· Initiate an Notable Event Report Form via the online database
· Arrange and attend the Preliminary Event meeting
3.5 ES&H Director
· Notify Laboratory Director, Chief Operating Officer, Appropriate Division Manager(s)
· Review and approve Safety Flash and both the initial and final ORPS report
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NOTE: DOE Reporting, including ORPS, CAIRS and NTS determinations, is the sole responsibility of the ES&H Reporting Officer. After the initial facts are evaluated, the Reporting Officer determines DOE reportability and if applicable, proceeds per DOE Order 232.2A Occurrence Reporting and Processing of Operations Information. |
3.6 Performance Assurance Manager
· Lead the Preliminary Event meeting
· Commence the Event Investigation if Preliminary Event Meeting indicates that one is warranted
· Assign a Lead Investigator and Core Team members.
· Submit the Event Investigation Report for Factual Accuracy and Concurrence.
· Develop and enter the lessons learned into the database
3.7 Lead Investigator / Core Team Members
· Perform the Event Investigation.
· Perform Causal Analysis
Notable Event Process
3.8 Occurrence Reporting
The Occurrence Reporting Procedure outlines process for notifying the Department of Energy (DOE) - Thomas Jefferson Site Office (TJSO) of any occurrence that could adversely affect the health and safety of the public, its workers, and the environment. Occurrence reporting promotes organizational learning consistent with DOE’s Integrated Safety Management System goal of enhancing mission safety and sharing effective practices to support continuous improvement and adaptation to change.
3.9 Event Investigation and Causal Analysis Procedure
The Event Investigation and Causal Analysis Procedure provides the process steps for conducting an event investigation and causal analysis. Steps include a Preliminary Event Meeting, 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. The final report is summarized and distributed within the Lessons Learned Program.
