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5200
Appendix T1 Event
Investigation and Causal Analysis using the Notable Event Worksheet Procedure |
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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. This appendix provides the process steps used to
document investigation activities and record the level of analysis applied.
The
overarching reason to perform an accurate investigation is to prevent
recurrence of the event. This procedure provides
the process Jefferson Lab uses to ensure participants understand their roles
and responsibilities to ensure appropriate notifications are made; an adequate investigation
is performed; sufficient data is collected to ensure an accurate causal
analysis; and follow-up actions are performed to prevent recurrence.
NOTE: Management authority may be delegated
at the discretion of the responsible manager.
3.1
Witnesses and Involved Persons
·
Report
any event to your Supervisor/SOTR/Sponsor or the ESH&Q
Reporting Officer (duty phone 876-1750). This includes incidents that happened off
site on job-related business.
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Injuries, illnesses, and first aid cases (including off-site job-related injuries) are to be reported to your Supervisor/SOTR/Sponsor or Occupational Medicine as part of the process outlined within ES&H Manual Chapter 6800 Appendix T2 Injuries and Illnesses Requiring First aid or Emergency Medical Response. |
3.2
Supervisor/Subcontracting Officer’s Technical
Representative (SOTR)/Sponsor
·
Immediately notify the ESH&Q
Reporting Officer (cell
876-1750),
Division Safety
Officer, and Associate Director/Division
Manager of an event occurrence including time, location, and observed details.
·
Ensure
the affected area/equipment is preserved pending an investigation. This may include cordoning off the area and
taking preliminary photographs.
3.3
Associate
Director & Division Manager
·
Inform
the Laboratory Director and the Chief Operating Officer of an event as soon as
possible.
·
Ensure
that event investigations are conducted in a timely and effective manner.
·
Ensure
that corrective actions are tracked and documented to
closure in a timely manner using the Corrective Action Tracking System
(CATS).
3.4
Division
Safety Officer
(DSO)
·
Appoint
a Lead Investigator to investigate an event (Contact the ESH&Q Reporting
Officer for a list of trained individuals).
·
Use
the Jefferson Lab CATS to coordinate tracking and documentation of corrective
actions.
·
Ensure that lessons learned, corrective, and future preventive actions
are initiated.
·
Ensure event investigation training is provided to
specified personnel; and maintain a list of trained investigators.
· Categorize
events in accordance with DOE reporting criteria.
· Provide technical expertise
during investigations to ensure compliance with DOE requirements.
·
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
Worksheet.
· Perform
initial and follow-up reporting consistent with the event’s
significance code.
·
Maintain Contact Information for Urgent
Events listing.
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DOE Reporting
(including ORPS, CAIRS and NTS determinations, is the sole responsibility of
the ESH&Q Reporting Officer.) After the initial facts of the event are
adequately known, the ESH&Q Reporting Officer evaluates DOE reportability
and proceeds as appropriate and performs the reporting procedures found in ES&H Manual Chapter 5300 Occurrence Reporting
to DOE. |
3.6
Lead Investigator (click for a listing of trained
individuals)
·
Form the investigation team.
Ensure at least one individual on the team is trained in Event
Investigation and Root Cause Analysis (SAF 124) – This person is assigned
responsibility for conducting the Causal Analysis.
·
Coordinate event investigation activities.
·
Document the event investigation and analysis information using ES&H Manual 5200 Appendix T1 Notable Event
Worksheet.
Responsibilities for each process step are outlined within the procedure.
·
Notifications
o
Involved
Person(s):
Immediately
notify your Supervisor/ SOTR/ Sponsor (voice contact required) – This
will happened as
part of the process outlined within ES&H Manual Chapter 6800 Appendix T2 Injuries
and Illnesses Requiring First Aid or Emergency Medical Response.
RESULTING ACTION:
§ Supervisor/SOTR/Sponsor: Tell Involved Person to cordon off the area, take
photographs, and perform other activities to preserve evidence.
THEN
o Supervisor/SOTR/Sponsor Notifies:
§ ESH&Q Reporting Officer (after
business hours use cell phone 757-876-1750),
then
o ESH&Q
Reporting Officer notifies:
§ Appropriate
Urgent Event Personnel as required.
§ Division
Safety Officer who
then appoints a Lead Investigator.
§ ESH&Q
Associate Director who
then notifies:
§
Appropriate Division Manager
§
Chief
Operating Officer, and
§
Laboratory
Director.
4.2
Categorization
and Reporting
·
ESH&Q
Reporting Officer makes an initial DOE categorization of the event from initial
information provided. This is done
within two (2) hours of notification
unless essential information is still pending.
The Lead Investigator performs the
following process steps using
the Notable Event Worksheet.
Step 1:
Initial
Fact Finding Meeting – Held as soon as possible (or within 24 hours of
discovery), at the location of the event if possible.
Make arrangements to ensure that detailed notes are taken during this
meeting to be used as future reference during the investigation.
·
Required Attendees:
Notify the following individuals. They are required to be in attendance:
o
Lead
Investigator
o ESH&Q Reporting Officer or
other representative
o Supervisor of the involved
person(s)
o The involved person(s)[1] in
and/or those impacted by, the event
o Witnesses to the event
·
Optional Attendees:
Notify the following individuals
(their attendance is optional):
o Associate Director
o
TJSO
Representative – as an investigation observer
o
Subject Matter Experts (SMEs)
o
Facility
or Equipment Owner
·
Agenda
Use
the following format:
1. Introduction: Provide attendees with the Title, Date, Time, and
Location of the Event to be discussed.
2. Attendance: Ensure all “Required Attendees” are present.
3. Purpose of
Initial Fact-Finding Meeting: Provide attendees with a brief
summary of the following:
o
Current
known status of personnel and equipment.
o
What
facts have been determined and what needs to be collected to support the Notable
Event Worksheet.
o
If
additional compensatory measures are required to ensure safety, discuss how
this will affect the investigation.
(This information is separate from the causal analysis and corrective/preventive
actions.)
4. Event
Reconstruction: Confirm the chain of
events leading to the occurrence (include a timeline if possible). Allow brief discussion of the following:
a.
Personnel and organizations involved in the event.
b.
Conditions and actions preceding the event.
c.
Chronology (timeline) of the event; and
d.
Immediate actions taken in response to the event.
5. Clarify information: Does
SME agree that work conditions were acceptable?
6. Stop Work or
the Tag Out Required: If “Yes” – establish the restart criteria and
inform the affected Management chain. (See
ES&H
Manual Chapter 3330 Stop work and Re-Start for Safety Program or 6111 Administrative
Control using Locks and Tags.)
7. Compensatory Actions Required: If “Yes” determine responsibility and include
confirmation documentation in the final Notable Event Report.
8. Records and Documents
Required: Determine what documentation will be required to
confirm, clarify, or complete the report information (i.e., work plans, work
control documents, pictures, etc).
9. Other Questions
or Concerns: Ask attendees if there are any other questions,
concerns, or information that they may wish to provide.
10. If present obtain TJSO Representative feedback on conduct of Initial Fact Finding Meeting and
potential improvements.
Step 2:
Investigation
Team
o
Determine appropriate Investigation Team Members.
o Convene
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.)
o Delegate
responsibilities to team members to ensure that adequate and complete
information will be obtained.
Step 3:
Summary of Event and / or Injuries
o Produce
a Summary of Events and/or Injuries derived from the Initial Fact-Finding
Meeting notes.
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Timeline: Preliminary Activities |
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The Lead Investigator performs
the following process steps:
Step 1:
Emergency Notifications Made (Subsequent to
Event):
Determine which emergency notifications were
made, the date and time.
Step 2:
Witness/ or Others Accounts:
Conduct
one-on-one interviews with witnesses, or others as appropriate, to collect
statements.
o
Schedule
interviews
o
Summarize
discussions
o
Request
confirmation of summary from individual
Step
3:
Environmental Aspects
Was
any material released into the environment that would be considered
harmful? If so document the following:
o
Type
of material released
o
Quantity
o
Source
o
Time
flow was halted or controlled.
Step 4:
Records, Documents, Pictures, and Other
References
Review photographs, digital images, sketches, and
other relevant scene documents. These
could include:
o
Lessons
learned
o
Previous
investigation reports
o
Training
records
o
Medical
records (as allowed)
o
Maintenance
records
o
OSHA 300
Log (past similar injuries)
o
Safety
Committee records
Step 5:
Causal
Analysis
Determine the
cause(s) of the event:
o
Root Cause: Determine the underlying system
weaknesses that contributed to the hazardous conditions and/or unsafe
behaviors.
o
Contributing Causes: Analyze the actions leading up
to the event to determine the contributing cause(s).
Step 6:
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 performance are at similar risk of event
recurrence.
o
Assigned
a responsible individual to rectify the condition.
o
Record
the condition in the Jefferson Lab CATS and the number denoted on the
worksheet.
o
Note
the anticipated target date for correction on the worksheet.
Step 7:
Corrective/Preventive Actions
Recommend
actions to be taken to address situations identified in the Causal Analysis and
Extent of Condition Sections. Actions
are to mitigate the root and contributing causes of the incident to prevent
recurrence. Recommendations are
documented in CATS (denote the number(s) on the worksheet) and include:
o
Engineering
controls (e.g.: install local exhaust ventilation; or use a lift assisting
device.)
o
Work
practice controls (e.g.: perform additional pre-planning work activities; or
remove jewelry and loose fitting clothing before operating machinery.)
o
Administrative
controls (e.g.: include an Operational Safety Procedure; or provide for worker
rotation in the work plan)
o
Personal
protective equipment (e.g.: Provide and ensure use of safety glasses or
respirators.)
Step 8:
Lessons Learned
During the course of an investigation innovative approaches or devise changes are often discovered which allows work to be accomplished more efficiently. If documented and shared these discoveries can have a significant positive impact on laboratory operations.
o Record any Lessons Learned during the investigation.
o Confer with Division/Department Lessons Learned Coordinators. They have received training on how to input data to the lessons learned system and should be the first point of contact for questions.
Step 9:
Confirmation
o Distribute
the draft Notable Event Worksheet to the Investigation Team Members, affected
Division Management, and ESH&Q Reporting Officer for review.
o
Incorporate comments as appropriate.
o
When acceptable, the Investigation Team Members confirm
that the information presented is accurate and complete by signing and dating
the worksheet.
o
Submit the confirmed Report to the ES&H
Reporting Officer for final review and distribution.
The
ESH&Q Reporting Officer performs the following process steps:
Step 1:
Verify that all relevant document numbers or codes,
for information or data, have been generated during the investigation process. These include:
·
Notable Event Number
·
CATS Number
·
JLab COE Number
·
ORPS Number
·
NTS Number
·
CAIRS Entry
·
DOE Cause Code
·
ISM Code
4.6
Review
and Acceptance/Acknowledgement of Facts
The
ESH&Q Reporting Officer performs the following process steps:
Step 1:
DOE Categorization
and Report Update (within time constraints)
Review
the Notable Event Report and confirm
or revise the initial DOE categorization.
Step 2:
Acceptance/Acknowledgement
of Facts
Submit
the final Notable Event Report for signature to the appropriate Associate
Director/ Department Manger for Acceptance/ acknowledgement of facts.
The ESH&Q Reporting Officer performs the following process steps:
Step 1:
Post
Post the approved Notable Event Report
to the Notable Event website.
Step 2:
Distribution
Distribute
a copy of the accepted Notable Event Worksheet to:
·
Associate Director/Department Manager
·
Division Safety Officer
·
Investigation Team Members
·
ESH&Q Liaisons
5.1
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
investigation team.
Longer term extent-of-condition
checks may be planned and performed to ensure that an event’s corrective/preventive
actions eliminate the possibility of recurrence across the entire site, in all
applicable areas.
The ESH&Q Reporting Officer shares lessons learned either through posting on the Jefferson Lab Lessons Learned website, or the Notable Event webpage. This information is also encouraged for use during staff safety meeting discussions and special operational notices.
6.0
Revision Summary
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 SSmith to CJohnson per MLogue
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 – 10/19/09 – Updated to
reflect current laboratory operations.
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ISSUING
AUTHORITY |
TECHNICAL POINT-OF-CONTACT |
APPROVAL
DATE |
EXPIRATION
DATE |
REV. |
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ESH&Q Division |
10/19/09 |
09/05/15 |
1.4 |
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