Lawrence Berkeley National Laboratory masthead LBNL Home A-Z Index U.S. Department of Energy logo Phone Book Jobs Search

RPM

REQUIREMENTS AND POLICIES MANUAL

Search the RPM
 
Home

Occurrence Reporting

    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:

    1. Using the Occurrence Reporting and Processing System (ORPS) when an incident occurs
    2. Outlining a method to rank the significance of an occurrence
    3. Investigating and analyzing occurrences to:
      1. Determine the cause
      2. Identify corrective actions
      3. Identify Lessons Learned
    4. 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

    1. 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.
    2. 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

    ORPS Program Manager
    EH&S Division

    J. Revision History

    Date

    Revision

    By whom

    Revision Description

    Section(s) affected

    Change Type

    2/15/2013

    1.1

    L. Young

    Updated SRD list

    Document Information

    Editorial

    5/11/2012

    1

    A.F. Peterson

    Reformat for wiki (policy)

    All

    Minor

    1/2/2012

    0

    A.F. Peterson

    Reformat for wiki (brief)

    All

    Minor

    DOCUMENT INFORMATION

    Title:

    Occurrence Reporting

    Document number

    07.03.001.000

    Revision number

    1.1

    Publication date:

    2/15/2013

    Effective date:

    1/31/2012

    Next review date:

    1/2/2015

    Policy Area:

    Incident Review and Reporting

    RPM Section (home)

    ESH

    RPM Section (cross-reference)

    none

    Functional Division

    EH&S

    Prior reference information (optional)

    PUB-3000 Chapter 15

    Source Requirements Documents

    • DOE Order 232.2, Occurrence Reporting and Processing of Operations Information, Attachment 1, Contractor Requirements Document
    • DOE Order 225.1B, Accident Investigations, Attachment 1, Contractor Requirements Document
    • Issues Management Policy, RPM document number 04.02.003.000

    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

     

    • No labels

    Adaptavist ThemeBuilder EngineAtlassian Confluence