CATS Reference Manual

Document Number:		Review Date:	12/19/2022
Revision Number:	Rev 1.3	Next Periodic Review Date	12/19/2025
Document Custodian:	Mary Jo Bailey

TABLE OF CONTENTS	INTRODUCTION
GETTING INTO THE SYSTEM EVENTS  Event Types:  Assessment/Audit/Management  Inspection  Occurrence (i.e. Notable Event, Accident, Incident)  Radiation Deviation Report ISSUE  ADD an Issue  Describe the Issue.  CLOSE/APPROVE Issues CORRECTIVE ACTIONS  ADD Corrective Action(s)  COMPLETE Corrective Action STATUS UPDATES  Progress  Request an Extension VERIFICATION APPROVAL AUTHORITIES SEARCH  Quick Search  Advanced Search Options CREATING REPORTS KEY POSITIONS TRAINING CERTIFICATION REVISION SUMMARY		Jefferson Lab’s Corrective Action Tracking System (CATS) is used to monitor the progress to completion of Issues and related Corrective Actions identified by Events. This reference manual provides instructions for navigating the CATS database and its functions. The Issues and Corrective Actions Management Program defines the process by which Jefferson Lab identifies Events.
If you have any comments or concerns, please contact the CATS Administrator – Mary Jo Bailey, mbailey@jlab.org (ext 7277) for assistance.

GETTING INTO THE SYSTEM

Go to www.jlab.org Click on the “Search” tab. Click on the C Scroll down and Click “ · Corrective Actions Tracking System (CATS)” Input your User Name and Password, you will get the following screen:

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EVENTS

When an activity identifies a non-conformance with a contract requirement or regulation, it is considered an Event.

Click “Add Event” to initiate a CATS record. è Use the Pull-Down menu to select the “Event Type.” (If you do not see an appropriate category, use “Inspection.”)

v Event Types: · Assessement/Audit/Management includes: · Audits (JSA, Vendor, DOE) · Emergency After Action Reports · Environmental Management System Occurrences · Independent Assessments · Reviews (Readiness, Safety Teams, External) · Other Management · Inspection includes: o Observations (Internal or External) o Management Observations o Safety Observations · Occurrence (Notable Event, Accident or Injury) o Environmental o Facility Status o Management Concern o Noncompliance Notification o Operational Emergency o Packaging & Transportation o Personnel Safety & Health o Radiation Control · Radiation Deviation Report

OR

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· Assessment/Audit/Management

When an Assessment, Audit or other Management resource identifies a non-conformance with requirements it is considered an Event.

Describe the Event. Items denoted with a red â must be completed.
â Report Date: Date Report was completed, or otherwise denoted on the report. â Response Owner: Person responsible for the Report. â Assessment Type: Select the appropriate designation from the pull-down list (See Event Type – Assessment/Audit/Management above). â Title: Title of the Report, or other summary designation. â Report Hyperlink: If it is on the Web copy and paste the report’s URL location. â Business Sensitive: If “Yes” this will restrict the content. è Save Event: Saves the Event. è Add Issues: This will allow you to continue to the next phase (see ADD Issue below).
NOTE: Jefferson Lab utilizes an electronic Assessment Planning and Report System (APRS) to document its formal Assessment/Audit activities. When the APRS provides an electronic solution for adding assessment Events into a CATS Record it automatically pre-populates the information into the CATS.

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· Inspection

When an Inspection identifies a non-conformance with requirements it is considered an Event.

Describe the Event. Items denoted with a red â must be completed.

â Inspection Date: Date inspection was performed. â Response Owner: Person responsible for the Inspection. â Inspection Type: Select the appropriate designation from the pull-down list. (See Inspections above.) â Location: Use the scroll list to designate the inspection area. â Safety Warden: Use the pull-down list to designate the individual. (Click HERE for a listing of Safety Wardens) â Accompanied By: Use the scroll bar to designate any additional individuals. â Business Sensitive: If “Yes” this will restrict the content. è Save Event: Saves the Event. è Add Issues: You may continue to input data (see ADD Issue below).

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· Occurrence (i.e. Notable Event, Accident, Incident)

Notable Events are, by default, Events. They require follow-up Corrective Actions to prevent recurrence. Notable Events are added as a CATS Record as part of the investigation process.

Describe the Event. Items denoted with a red â must be completed.

â Event Date: Date of Occurrence. â Response Owner: Person responsible for the Notable Event Investigation. â Title: Title of the Notable Event, or other summary designation. â Category: Use the scroll down arrow and select the most appropriate. (See Occurrence above.) â Location: Use the scroll list to designate the affected area. · Safety Warden: Use the pull-down list to designate the individual. (Click HERE for a listing of Safety Wardens) â Event Description: Summarize the Notable Event. è Save Event: Saves the Event. è Add Issues: Continue to next section input Issue data. (see ADD Issue below).

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· Radiation Deviation Report

When an activity finds a situation that is not in compliance with requirements outlined within the Radiation Control Manual it is considered a radiation deviation.

Notify Radiation Control (757-1743) immediately; they will determine appropriate actions.

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ISSUE

An Issue is a process, regulation, procedure, material or equipment, found to be deficiency, non-compliant, inadequacy, or defective. The Issue Owner is the person responsible for the regulation, process, procedure, material or equipment that requires correction. This person has the authority and budget to determine and assign Corrective Actions that will result in the acceptable resolution of the issue. Corrective actions are discussed with the action owner prior to assignment to ensure appropriate delegation and timely completion.

v ADD an Issue

Once all Event information is complete click the “Add an Issue” button near the bottom of the Event page.

The following screen will open.

v Describe the Issue.
Items denoted with a red â must be completed. â Issue Owner: The person responsible for determining what subsequent Corrective Action will result in the acceptable resolution of the issue. â Risk Code: The significance of an Issue is dependent on the risk of an unacceptable outcome. Jefferson Lab has established and categorized five Risk Codes applicable to its work activities. Risk Codes are based on the likelihood of an accident occurring (i.e. Probability) coupled with the severity of the outcome (i.e. Consequence). Use the process outlined in ES&H Manual Chapter 3210 Appendix T3 Risk Code Assignment to determine the appropriate Risk Code designation. â Issue Description: Provide a summary of the condition causing the noncompliance. â Primary/Secondary Cause: Use the pulldown menu to select the most applicable. è Extent of Condition required?: Click this when it is determined that the issue may not be isolated to a single Event, or when there is concern that the same or similar event could occur elsewhere. An “extent of condition” review will then be assigned as an additional corrective action. è Add Another Issue: This will provide you with an additional screen. You may add as many Issues as required. (See NOTE:) è Add Actions: See Add Corrective Actions below. è Finish: This will save your work. -Advanced- these are ES&H and Administrators functions.
NOTE: There may be many reasons (i.e. “Issues”) why an activity turned into an Event. Each reason is considered a separate Issue. List each Issue separately using the “Add Another Issue” button.

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v CLOSE/APPROVE Issues

Once all Corrective Actions associated with an Issue are complete the Issue is submitted (via e-mail) to appropriate Approvers for closure. The higher the Risk Code the more Approvals required. (See Approval Authorities below)

Designated Approvers: Click on the link provided in the e-mail. The following screen will open: Review the associated Issue and Corrective Actions as appropriate
IF	è Acceptable	THEN		Click “Approve Issue” button.
	è You do not feel qualified to approve this Issue			Click “Remove Approval” button.
	è Disapprove			Contact the Issue Owner to discuss the concerns. Click “Approve Issue” button.

The following screen will open.

Complete the requested information. Items denoted with a red â must be completed.
IF	Approveâ	THEN		Click Approve? “Yes” radio button
	Disapproveâ			Click Approve? “No” radio button
â Required status update: Provide a summary of the reason for your approval or disapproval. Click Approve/Disapprove Issue button to save your determination.

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CORRECTIVE ACTIONS

Corrective Actions are tasks anticipated to achieve requirement compliance or process improvement to satisfy an Issue. Each Issue must have at least one Corrective Action, but often more than one is required. It is the responsibility of the Issue Owner to assign an individual who has the authority and capacity to complete them.

(Corrective actions that do not facilitate deviations from requirements may be included based on management discretion.)

v ADD Corrective Action(s)

In the space provided, include information detailing a Corrective Action. Items denoted with a red â must be completed:
è Action Assigned To: This person has the authority and capacity to complete the Corrective Action. The Issue Owner is to discuss the action with the proposed owner, prior to assignment. è Corrective Action: Summarize a single activity to be performed. è Priority: This is an optional space for entering a priority to each action. Priority values range from zero, being the lowest, to four being the highest. è Closure Evidence Required: Closure evidence is anything that quickly demonstrates the satisfactory completion of the corrective action (e.g. photo, URL, list of participants, actual final document). è Estimated Completion Date: This is the date the Corrective Action is anticipated to be completed. Estimated Completion Dates are generated with consideration that one Corrective Action may require completion before another can commence. è Requires Verification: Verification can be assigned to any Corrective Action for any reason. All Corrective Actions resulting from Notable Events require Verification by the Jefferson Lab’s ESH&Q Reporting Officer. è Contact Confirmation: To ensure an action is assigned appropriately and completed on time it is discussed with the action owner prior to assignment. è Add Another Action button - Click to add another Corrective Action activity. è Finish button – Click when all corrective actions have been entered. â Contact Confirmation: To ensure an action is assigned appropriately and completed on time confirm that it was discussed with the action owner prior to assignment.
NOTE: Often Issues require several Corrective Actions in order to achieve compliance. Denote each corrective action activity as a separate Corrective Action. Keep in mind that one Corrective Action may need to be completed before another can commence.

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v COMPLETE Corrective Action

A Corrective Action is complete when the Action Owner has satisfactorily completed the assignment, an alternative solution has been established, or the Action Owner does not have the authority or capacity to complete the assignment.
IF	Action is Complete or Alternative Solution is in place:	THEN		Click “Complete Action” button*. & Then Click “Attachments” button. Add additional documents as Evidence of Closure as necessary.
	You do not have the authority or capacity to complete the Corrective Action.			Click “Complete Action” button.
*You will get a screen that looks like this: In the space provided include the following information. (Items denoted with a red â must be completed)
â Completion Date: Denote the date the action was completed. â Required Status Update: Provide a summary of the completed action or the reason it cannot be completed. â Required Documentation: “Evidence of Completion” is required, attach the file, or URL. è Click the “Complete Action” Button.

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v VERIFICATION

Corrective Actions resulting from an Issue having a Risk Code 3 or 4; resulting from a Notable Event; resulting from an Independent Assessment and External Reviews, or a TJSO identified Priority 1 or 2, are verified to ensure effectiveness. Verification is performed after the action is closed to ensure effectiveness. On a case by case basis, management may require a formal effectiveness review to validate the effectiveness of the Corrective Actions for lower Risk Code Issues. Verifications are conducted by personnel designated by the Associate Director / Division Manager or Performance Assurance Manager as appropriate. Independent Assessments and External Review are typically verified the Lead Assessor and Notable Events are typically verified by the Lead Investigator.

When the Corrective Action is designated as “Complete” the Verifier receives a notification e-mail and a link to the action. The Verifier typically has 30 days to perform the verification. 

The Verifier reviews all evidence and status update discussions.

If the evidence is considered inadequate, the Action Owner is contacted to discuss how to rectify the situation.  Typically, the Verifier will request additional evidence or open another corrective action.  In either case a status update is added summarizing the determination of the discussion.

If the evidence is considered adequate, the Verifier provides a brief status update confirming the review and then clicks the button next to the appropriate name.

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STATUS UPDATES

Status Updates are used to document Corrective Action progress. Anyone may enter a Status Update. Typical updates include:

v Progress

Record progress of the assignment (e.g.: “Submitted document for review…;” “Item ordered, awaiting delivery…;” “Awaiting clarification from vendor…” etc.)

v Request an Extension

Most extension requests need approval minimally from the Issue Owner, but, depending on the Priority or Risk Code of the associated Issue approval may be required by the Laboratory Director. (See Approval Authorities below)

Go to the Corrective Action for which you would like to add a status update.	(To close a Corrective Action see “Complete Corrective Action” above)
è Click Add a Status Update button
You will get a screen that looks like this:
è Provide a summary of the activity’s progress, or reason for a request for extension. è Extension Requested: Provide a reasonable date in which the action can be completed. · Choose any additional individuals you would like to receive this update. (The Issue Owner will automatically receive a notification.) è Click Add Update button to save your work.
NOTE: You may add as many status updates as desired to demonstrate effort.

APPROVAL AUTHORITIES

Issues and Corrective Action Authority
	Risk Code 0/Priority 5	Risk Code 1/Priority 4	Risk Code 2/Priority 3	Risk Code 3/Priority 2	Risk Code 4/Priority 1
Assign Issue Owner	Event Owner	Event Owner	Event Owner	Event Owner	Event Owner
Assign Corrective Actions	Issue Owner	Issue Owner	Issue Owner	Issue Owner	Issue Owner
Assign Risk Code	Event Owner	Event Owner	Event Owner	Division AD/Manager	Division AD/Manager
Assign Estimated Completion Date	Issue Owner	Issue Owner	Issue Owner	Issue Owner	Issue Owner
Extension Request Approval*	Issue Owner & Relevant AD/Manager	Issue Owner & Relevant AD/Manager	Issue Owner & Event Owner & Relevant AD/Manager	Issue Owner & Event Owner & Relevant AD/Manager & PerfAssur Manager	Laboratory Director & IF Notable Event: Relevant AD/Manager & ES&H Director
Verification Required	IF Notable Event or Independent Assmt: PerfAssur Manager	IF Notable Event or Independent Assmt: PerfAssur Manager	IF Notable Event or Independent Assmt: PerfAssur Manager	IF Notable Event or Independent Assmt: PerfAssur Manager	Issue Owner & Event Owner & Relevant AD/Manager & PerfAssur Manager & ES&H Director
Completion of Corrective Action(s)	Action Owner	Action Owner	Action Owner	Action Owner	Action Owner
Closure of Issue: Approval* Or	Issue Owner	Issue Owner	Issue Owner & Event Owner	Issue Owner & Event Owner & Relevant AD/Manager & PerfAssur Manager	Issue Owner & Event Owner & Relevant AD/Manager & PerfAssur Manager & ES&H Director & Laboratory Director
Rejection	“Approver” is required to provide a Status Update stating: Reason(s) for rejection and clear means of resolution
*Extension Requests or Approval for Closure for TJSO identified Priority 1 or 2 issues, require concurrence by the TJSO Reporting Officer. (Priority 3, 4, and 5 are exempt from this requirement.) If no concurrence is given within 14 days, the request for closure is considered acceptable by TJSO.

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SEARCH

v Quick Search

NOTE: The quickest way to get to an Event, Issue, or Corrective Action is to use the link within the provided e-mail.
From the CATS homepage, in the “Quick Search” box, input the Event ID (or any part you know) then Click the Quick Search button:
USE (any or all): Letters: AUD - Audits (JSA, Vendor, DOE) ED - Emergency After Action Reports EMS - Environmental Management System Occurrences IA - Independent Assessments STR - Reviews (Readiness, Safety Teams, External) STR - Other Management INSP - Inspections NE - Notable Event, Accident or Injury RDR - Radiation Deviation Report AND: Numbers:
Year – #Event – #Issue – #Corrective Action
You will get a screen that looks like this: Scroll down to find the appropriate item.

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v Advanced Search Options

From the CATS Home page è Click on Search Page
You will get a screen that looks like this: Items denoted with a red â must be completed. â Records to Return: What Items do you want to see? Click the appropriate radio button. â Search by Event: Select the major category. (See Event Types for a detailed list.) · Search for Keyword(s): Input any word that appears in the entry the more unique the better. You may include: o Proper Names o Locations o Departments · Search by Date: You must: o Click an appropriate radio button AND o Enter a range OR a specific date. · Search by Author: Use the pull down menu. Highlight the person who entered the data. · Search by Response Owner: Use the pull down menu. Highlight the person who is responsible for the Event. · Search by Issue Owner: Use the pull down menu. Highlight the person who is responsible for the Issue. · Search by Action Assignee: Use the pull down menu. Highlight the person who is responsible for the Corrective Action.
NOTE: You can use multiple combinations of the search options to narrow your search parameters, or otherwise refine your search criteria.

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CREATING REPORTS

From the CATS Home page Click on Report Page
Select a category to search.
è At the top and bottom of the page, you will see the box check to generate a report. Select the items you would like to have in your report. è Click “Search”
A Pop-Up Box will appear which will display the items available for your report. Check the items you would like to chart. Click “Submit” Depending on how savvy you are at Excel, you can provide graphs, charts or manipulate your data just like any spreadsheet data in Excel.

KEY POSITIONS

Administrator – A person who has authority to delete or otherwise edit CATS entries. An administrator can grant higher levels of access privileges to individuals accorded by training and management authorization. The "Update Org Data For This Person" button changes the org on every CATS item associated with that person.  Useful if someone moves to another org but the CATS item is still in their name. Example:  if I have a corrective action assigned to me, upon entry that corrective action shows up as an MIS (IT Division) action.  If I then move to Accelerator, the corrective action stays as an MIS action, even though I'm now in Accelerator.  If you want to change the action to Accelerator, you can use that function to do so.

Corrective Action Owner – The person responsible for completing a corrective action, providing evidence of closure, and closing the action.

Event/Response Owner – The person responsible for ensuring satisfactory resolution of Issues resulting from an Event.

General Access – The ability to view events, issues, corrective actions, and make status updates. Anyone with a Jefferson Lab username and password is allowed general access.

General User – A person authorized to make CATS entries, including: events, issues, or corrective actions.

Issue Owner – The person who assigns corrective actions, monitors them to completion, and verifies their satisfactory completion.

Verifier – The persons assigned to confirm adequate closure of corrective actions.

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TRAINING CERTIFICATION

Click to Certify

REVISION SUMMARY

Revision	Description	Date
2.0	1. Current Laboratory operations now requires Evidence of Closure to complete a Corrective Action. 2. To align with the new management approach to safety, AD/Managers are now required to approve extensions requested for all levels of corrective actions, DSOs and EHS Director are no longer solely assigned this responsibility. 3. Performance Assurance is no longer required to verify assigned Issue Owners, this is built into the Assessment Corrective Action Plan Process, the Notable Event Process, and the Pressure Vessel Inspection Process.  When events come from an established program the verification of Issue Owners is included within that program’s review/approval process.	01/05/2024
1.3	The Performance Assurance Manager has determined verification responsibilities be assigned to the Lead Assessor and Lead Investigator as appropriate.	12/19/2022
1.2	Removed reference to “Opportunity for Improvement” to reflect current laboratory operations. Added direction for when an “Extent of Condition” review is required. Added “Approval Authorities” table from Issues Management Procedure.	03/15/2022
1.1	Updated “Complete a Corrective Action” to include attachment of files as evidence of closure.	10/15/2020
Periodic Review	Added definition for evidence of closure (see Add Corrective Action)	08/23/2019
Periodic Review	Updates format for better visibility	09/11/2018
1	Updates to reflect current laboratory operations	03/01/2017
Initial	New Content to reflect current laboratory operations	06/04/2013

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