RPM

Title:	Occurrence Reporting
Publication date:	2/15/2013
Effective date:	6/30/2011

BRIEF

Policy Summary

Berkeley Lab's Occurrence Reporting policy addresses the reporting of environmental, health, and safety incidents at Berkeley Lab by:

Using the Occurrence Reporting and Processing System (ORPS) when an incident occurs
Outlining a method to rank the significance of an occurrence
Investigating and analyzing occurrences to:
- Determine the cause
- Identify corrective actions
- Identify Lessons Learned
Ensuring that occurrences are reviewed over time to identify trends

Who Should Read This Policy

All Berkeley Lab employees, visitors, affiliates, and subcontractors

To Read the Full Policy, Go To:

The POLICY tab on this wiki page

To Read the EH&S Program Details, Go To:

http://www.lbl.gov/ehs/pub3000/CH15.html

Contact Information

ORPS Program Manager
EH&S Division

Title:	Occurrence Reporting
Publication date:	2/15/2013
Effective date:	6/30/2011

POLICY

A. Purpose

The Occurrence Reporting policy of Lawrence Berkeley National Laboratory (Berkeley Lab) addresses the reporting of environmental, health, and safety incidents at Berkeley Lab by:

Using the Occurrence Reporting and Processing System (ORPS) when an incident occurs
Outlining a method to rank the significance of an occurrence
Investigating and analyzing occurrences to:
1. Determine the cause
2. Identify corrective actions
3. Identify Lessons Learned
Ensuring that occurrences are reviewed over time to identify trends

B. Persons Affected

All persons who work at or visit the Laboratory

C. Exceptions

Work covered under a Memorandum of Understanding involving the Department of Energy (DOE) and Berkeley Lab, such as that governing work in some areas of the University of California (UC) at Berkeley campus, may be excluded from the requirements of this policy.

D. Policy Statement

Berkeley Lab strives to prevent all injuries and illnesses; environmental damage; significant business, facility, and community disruptions; and regulatory noncompliance. If these types of occurrences happen, Berkeley Lab will act as needed to identify causes, implement corrective actions to prevent recurrence, and share Lessons Learned.
Berkeley Lab determines whether any occurrences must be reported to DOE per DOE Order 232.2, Attachment 1, Contractor Requirements Document, and if so, must follow DOE reporting requirements. These requirements include:
1. Reporting the issue to the Environment, Health & Safety (EH&S) Division
2. Collecting facts and determining whether the event or condition meets one or more of DOE's reportable criteria. Divisions make this determination.
3. Categorizing the occurrence per DOE Order 232.2. Divisions make this determination.
4. Notifying the DOE Berkeley Site Office (BSO). EH&S completes this notification.
5. Submitting preliminary details into the DOE Occurrence Reporting database. EH&S completes this action following approval from the divisions.
6. Investigating the occurrence per Berkeley Lab's institutional Issues Management Program.
7. Identifying corrective actions to prevent recurrence; identifying Lessons Learned. Divisions complete these steps.
8. Submitting final reports to DOE. EH&S completes these steps following approval from the divisions.
9. Periodically trending data. EH&S completes this step.

E. Roles and Responsibilities

Role	Responsibility
Employees, Affiliates, and Subcontractors	Report unsafe or abnormal events and conditions (hereafter referred to as "occurrences") in a timely manner, according to Berkeley Lab policy and the applicable division's policies and procedures
Supervisors and Work Leads	Ensure that employees understand workplace health and safety reporting responsibilities. When a supervisor or work lead learns of an occurrence, he or she must ensure appropriate authorities are notified, including the division safety coordinator and the EH&S Division.
Division Directors Note: A division director is sometimes referred to as a facility manager for purposes of the DOE Occurrence Reporting Program.	Meet the requirements of DOE Order 232.2 — including categorization, notification, investigation, and reporting — for occurrences at their facilities or operations Provide appropriate resources to report events in a timely manner, investigate causes, and institute corrective actions to prevent recurrence Decide whether an occurrence is DOE reportable. When occurrence categorization is unclear, or for management concerns, EH&S can assist with this determination. Approve final reports before EH&S submits them to DOE
Division Designees Appropriate candidates for division designees include deputy division directors, division safety managers, or division safety coordinators. These individuals may be listed as points of contact for DOE-reportable occurrences within divisions (see http://www.lbl.gov/ehs/orps/pdf/divisionORPS.pdf for a list of points of contact). If no division designee is chosen, the division director is responsible for implementing these procedures.	Must be familiar with the procedures described in this chapter Assist line managers and staff in meeting occurrence-reporting requirements, including communicating with EH&S to ensure proper DOE notifications are completed Should notify EH&S of an occurrence as soon as possible to get guidance through the occurrence-reporting process.
Environment, Health & Safety Division	Oversees the occurrence-reporting process to ensure it is properly managed Assists divisions as needed to respond to, mitigate, categorize, and investigate occurrences, and to support division directors and their designees with DOE occurrence reporting Completes the required DOE notifications and submits the required DOE reports into the online DOE Occurrence Reporting database Reports any observed occurrence to the appropriate person within the EH&S Division
Office of Contractor Assurance	Provides oversight for the Issues Management Program Maintains the Corrective Action Tracking System (CATS) and reviews Root Cause Analysis reports, Extent of Condition Review reports, Corrective Action Plans, and Effectiveness Review Reports prior to issuance and approval Oversees the Causal Analysis Program. The products of these programs are used, when applicable, in the preparation of Final Reports.

F. Definitions/Acronyms

Term	Definition
Apparent Cause	The most probable/reasonable cause(s) of an incident that management has the control to fix through effective corrective actions. There may be more than one apparent cause for a given incident.
Condition	"Any as-found state, whether or not resulting from an event, that may have adverse safety, health, quality-assurance, operational, or environmental implications. A condition is usually programmatic in nature. Examples of conditions: errors in analysis or calculation, anomalies associated with design or performance, or items indicating a weakness in the management process." (Definition from DOE Order 232.2)
Facility	"Any equipment, structure, system, process, or activity that fulfills a specific purpose. Examples include accelerators, storage areas, fusion research devices, nuclear reactors, production or processing plants, coal-conversion plants, magnetohydrodynamic experiments, windmills, radioactive waste-disposal systems and burial grounds, environmental-restoration activities, testing laboratories, research laboratories, transportation activities, and accommodations for analytical examinations of irradiated and un-irradiated components." (Definition from DOE Order 232.2)
Facility Manager	Division director (Berkeley Lab policy clarification of definition from DOE Order 232.2)
Facility Representative	Berkeley Site Office (Berkeley Lab policy clarification of definition from DOE Order 232.2)
Lessons Learned	A lesson that is derived from an event, incident or implementation and evaluation of a system, process, or program that is used to identify strengths and weaknesses. A lesson learned may be derived from an internal or external source and is used to improve systems, processes, or programs.
Nonreportable Event	"An event that falls within the Occurrence Reporting and Processing System (ORPS) Reporting Groups, does not meet any of the specific ORPS reporting criteria, and that the reporting organization is including in the required ORPS Performance Analysis activity" (Definition from DOE Order 232.2)
Notification Report	"The initial documented report to DOE of an event or condition that meets the reporting criteria defined in DOE Order 232.2" (Definition from DOE Order 232.2)
Occurrence	"One or more events or conditions that adversely affect, or may adversely affect, DOE (including the National Nuclear Safety Administration [NNSA]) or contractor personnel, the public, property, the environment, or the DOE mission. Occurrences are events or conditions meeting the criteria thresholds identified in DOE Order 232.2 or determined to be recurring through performance analysis." (Definition from DOE Order 232.2)
Occurrence Investigation	"An investigation conducted according to site-specific procedures and/or when determined by DOE procedures that an investigation by a federal Accident Investigation Board is required" (Definition from DOE Order 232.2)
Occurrence Report	"A documented evaluation of a reportable occurrence with details sufficient to enable the reader to assess its significance, consequences, or implications and to evaluate the actions being proposed or employed to correct the condition or to avoid recurrence" (Definition from DOE Order 232.2)
Prompt Notification	"Timely reporting of the occurrence to the DOE Field Office and the DOE Headquarters Operations Center, as required by the significance category and the reporting criteria of the occurrence" (Definition from DOE Order 232.2)
Reportable Occurrence	"Occurrence to be reported in accordance with the criteria defined in DOE Order 232.2" (Definition from DOE Order 232.2)
Root Cause	The underlying or basic cause of an adverse condition that can reasonably be identified and that management has the control to fix, and when fixed, will preclude recurrence or significantly reduce the likelihood of recurrence of the same or similar adverse conditions. The root cause is typically one level further in analysis beyond an apparent cause, the fundamental reason for the apparent cause.
Significance Categories	A means to reflect the perceived risk associated with a given occurrence. The significance categories are: Operational Emergencies (OEs). These are defined in DOE Order 151.1C and include major unplanned or abnormal events or conditions that involve or affect DOE facilities and activities by causing, or having the potential to cause, serious health and safety or environmental impacts; require resources from outside the immediate/affected area or local event scene to supplement the initial response; and require time-urgent notifications to initiate response activities at locations beyond the event scene. Significance Category 1. Non-OE events that caused actual harm, posed the potential for immediate harm or mission interruption due to safety system failure and required prompt mitigative action, or constituted an egregious noncompliance with regulatory requirements that created the potential for actual harm or mission interruption Significance Category 2. Circumstances that reflected degraded safety margins, necessitating prompt management attention, along with modified normal operations to prevent an adverse event on safe facility operations; worker or public safety and health, including significant personnel injuries; regulatory compliance; or public/business interest Significance Category 3. Occurrences with localized implications, including personnel injury, environmental releases, equipment damage, or hazardous circumstances that were locally contained and did not immediately suggest broader systemic concerns Significance Category 4. Events or circumstances that were mitigated or contained by normal operating practices, but where reporting provides potential learning opportunities for others Significance Category R. Occurrences identified as recurring, either directly or through periodic analysis of occurrences and other nonreportable events (Definition from DOE Order 232.2)

G. Recordkeeping Requirements

Role	Recordkeeping Requirement
Subject Matter Expert	Occurrence Reports (as of April 2012, stored online at https://www.lbl.gov/ehs/orps/reports/index.shtml)
Office of Contractor Assurance	Root Cause Analysis Reports

H. Implementing Documents

Document Number	PUB-3000 Reference	Title	Type
07.03.001.001	Chapter 15	Occurrence Reporting	Program
07.03.001.002	Chapter 15, Work Process A	Discovery, Reporting, and Preliminary Review	Work Process
07.03.001.003	Chapter 15, Work Process B	Categorization	Work Process
07.03.001.004	Chapter 15, Work Process C	Notification	Work Process
07.03.001.005	Chapter 15, Work Process D	Occurrence Investigation and Causal Analysis	Work Process
07.03.001.006	Chapter 15, Work Process E	Corrective Actions and Lessons Learned	Work Process
07.03.001.007	Chapter 15, Work Process F	Final and Update Reports	Work Process
07.03.001.008	Chapter 15, Work Process G	Performance Trends and Recurring Occurrences	Work Process
07.03.001.009	Chapter 15, Work Process H	Training	Work Process
PUB-5519(1)		Issues Management Program Manual System
PUB-5519(2)		Causal Analysis Program Manual System
PUB-5519(3)		Data Monitoring and Analysis Program Manual System
PUB-5519(4)		Lessons Learned and Best Practices Program Manual System

I. Contact Information