Section 5.1
INCIDENT REVIEWING AND REPORTING

Contents

Approved by Richard DeBusk
Revised 10/2007


5.1.1 Policy

5.1.1.1 Incident Types
5.1.1.2 Emergency — Immediate Steps to Take
5.1.1.3 Preservation of Other-Than-Minor Incident Scenes
5.1.1.4 Occupational Injuries and Illness Cases
5.1.1.5 Motor Vehicle Accidents
5.1.1.6 Property Damage Incidents
5.1.1.7 Other Cases

5.1.2 Reviewing and Reporting Serious Incidents

5.1.2.1 Procedure for Reviewing OSHA Recordable Injuries
5.1.2.2 Serious Other-Than-OSHA Recordable Injuries

5.1.3 Reviewing and Reporting Minor Incidents
5.1.4 Roles and Responsibilities for Reviewing Minor and Serious Incidents
5.1.5 Standards
5.1.6 Related PUB-3000 Chapters
5.1.7 References

NOTE:
. . . . .	Denotes a new section.
. . . . . . . .	Denotes the beginning of changed text within a section.
. . . . . . . .	Denotes the end of changed text within a section.

_____________________

5.1.1 Policy

All accidents, injuries, and significant mishaps will be investigated, analyzed, and reported in accordance with the requirements of this chapter. This investigation and analysis is intended to determine the underlying causes of such events, to reduce the likelihood of their recurrence, and to satisfy regulatory requirements.

5.1.1.1 Incident Types

EH&S Incidents at Berkeley Lab are grouped into three categories related to their severity.  The three categories are listed below by decreasing severity:

Incidents that require a DOE Type A or B investigation which includes the following:

• A fatality
• Disabling injuries to or illness of five or more persons
• Property damage in excess of $1,000,000
• Radiation exposure that exceeds allowable limits
• Serious environmental release, greater than twice the reporting limits

Serious Incidents: Cases resulting in an OSHA recordable injury and many ORPS reportable events.

Minor Incidents: Cases involving first aid injuries, low level Occurrence Reports, etc.

5.1.1.2 Emergency — Immediate Steps to Take

In case of fire, explosion, gas leak, chemical incident, radiological incident, or any other emergency:

• Evacuate personnel from the immediate area to prevent further injury.


• Get help from professional emergency responders by calling 7911 (onsite) and 9-911 (off site).  Give all information needed to dispatch appropriate aid to the scene. Identify who you are, where you are calling from, the phone number you are calling from, the nature of the emergency, and the extent of the injury or spill. Stay on the phone until released by the dispatcher.

Assign someone to meet the emergency crew and direct it to the incident.

• Do not move injured individuals unless necessary to prevent further injury.


• Apply first aid to stop severe bleeding and/or restore breathing immediately, if you are qualified to do so.


• REFER TO THE EMERGENCY RESPONSE GUIDE FOR DETAILED INSTRUCTIONS. THIS GUIDE IS POSTED THROUGHOUT THE LABORATORY.

5.1.1.3 Preservation of Other-Than-Minor Incident Scenes

Each of these types of incidents will be investigated by an LBNL Incident Review Team or by a DOE Accident Investigation Board.  In case of a serious incident, the scene must be preserved until the review team has released the area.

Consult your EH&S Division Liaison to determine if an incident scene must be preserved for review.

An LBNL Incident Review Team will investigate significant incidents that do not meet the DOE criteria but that are of concern to Berkeley Lab management. This determination will be made on a case-by-case basis, but will typically include the following types of cases:

• OSHA Recordable injuries
• Cases with the potential for severe injury, exposure, damage, or environmental release
• Many incidents that require an ORPS report

Until senior management or designated individuals arrive, the area supervisor or lead employee is in charge of the scene of any incident.  In the event of such an incident, take the following actions:

• Verify that emergency assistance is present, or call ext. 7911 (on site) or 9-911 (off-site) for assistance.
• Preserve the scene: do not permit any equipment or vehicles involved in the incident to be moved.
• Notify EH&S, ext. 5251, immediately.
• Obtain photographs, particularly of transient evidence such as liquid spills or scuff marks.

5.1.1.4 Occupational Injuries and Illness Cases

All occupational injuries and illness cases must be reported to Health Services. Typically, the supervisor will direct the injured employee to report to Health Services for evaluation and treatment. When the injured employee does not or cannot report to Health Services at the time of injury, the supervisor must promptly notify Health Services of the injury.  Health Services will initiate a Supervisor's Accident Analysis Report (SAAR). Health Services will also initiate any required reports for Workers' Compensation purposes.

For off-hour injuries, report to the Fire Department for first aid treatment or for transport to offsite medical care. The Fire Department will notify Health Services to initiate all required reviews and reporting.

For work-related injuries that occur off site or that manifest themselves away from the Laboratory, notify Health Services as soon as possible. Also notify Health Services of injuries to student employees who were treated at the Tang Center.

5.1.1.5 Motor Vehicle Accidents

For on-site motor vehicle accidents, notify Berkeley Lab Security. If a government vehicle is involved, complete the LBNL motor vehicle accident report and submit it to the motor pool at http://iss15501.lbl.gov:591/accident_reports/.

For off-site accidents involving a government vehicle, notify the local police authority, complete an LBNL motor vehicle accident report, and submit it to the motor pool at http://iss15501.lbl.gov:591/accident_reports/.

For motor vehicle accidents involving a rental car or personal vehicle on official business, notify the local police authority, and complete the forms required by the rental company or by the insurance company. Furnish copies of all reports to the LBNL Risk Manager (Laboratory Counsel).

5.1.1.6 Property Damage Incidents

Incidents that result in property damage may require ORPS reporting.  Consult with your Division ES&H Coordinator or with the Office of Contract Assurance for details.

5.1.1.7 Other Cases

Various radiological incidents, chemical exposures, and environmental releases also require reporting and analysis. Consult with your EH&S liaison for appropriate procedures in specific cases.

5.1.2 Reviewing and Reporting Serious Incidents

Review teams will include a designated LBNL Incident Investigator for all incidents that are deemed of sufficient severity or potential significance to require a detailed impartial analysis. This includes all cases resulting in an OSHA recordable injury and many ORPS reportable events.  Other cases may be investigated in this manner at the discretion of the EH&S Division Director. Berkeley Lab Incident Investigators have completed a 5-day training program for incident investigation and root cause analysis and have been formally appointed by the EH&S Division Director.

5.1.2.1 Procedure for Reviewing OSHA Recordable Injuries

The procedure for reviewing OSHA recordable injuries is outlined below:

1. Employee reports injury to his/her supervisor and to Health Services, and injury is classified as OSHA recordable.


2. Health Services sends OHM Report notification to:


• Injured employee’s Supervisor
• Division Safety Coordinator
• EH&S Liaison
• Incident Review Program Manager


3. The Incident Review Program Manager promptly assigns a designated Incident Investigator to the Review Team.


4. To plan and perform the review, the Division Safety Coordinator contacts the:


• Injured employee
• Injured employee’s Supervisor
• EH&S Liaison
• Incident Investigator


5. A complete review is performed including identification of root causes and corrective actions. The SAAR and Investigator’s Report are prepared in parallel.


6. Supervisor submits the SAAR.


7. The Division Safety Coordinator approves and submits the SAAR, and the Investigator’s Report is submitted by the EH&S Liaison within seven calendar days of the employee reporting the injury.


8. The Supervisor (with assistance from the Division Safety Coordinator) enters the corrective actions into CATS within seven calendar days following the submittal of the SAAR and Investigator’s Report (14 days after the employee reported the injury).

5.1.2.2 Serious Other-Than-OSHA Recordable Injuries

The exact procedures and documentation for other serious incidents may be driven by regulatory requirements and will vary.  Absent specific instructions or guidance to the contrary, the Team shall prepare a written report that includes a descriptive narrative of the events, a detailed root cause analysis, and specific recommendations that address the root causes of the incident.

5.1.3 Reviewing and Reporting Minor Incidents

All minor incidents, including cases involving first aid injuries, will be reviewed by a team consisting of at least the injured employee, the respective supervisor, the Division ES&H Coordinator and the EH&S Division Liaison. Other members may be added by the Division as desired.

For minor incidents where no useful information is likely to result from an incident investigation (e.g., bee sting, paper cut) the requirement for an investigation can be waived by the Incident Review Program Manager.

When a case is likely to become an OSHA recordable injury, the team will also include a designated LBNL Incident Investigator.  An LBNL Incident Investigator will be made available for lesser cases whenever requested.  Contact the Incident Review Program Manager to request such.

Division ES&H Coordinators and Liaisons have received training to assist the supervisor in reviewing and reporting minor incidents.  For cases that involve an injury, the results of the incident review will be recorded on the LBNL Supervisor's Accident Analysis Report (SAAR). While the review of such incidents is a team responsibility, completion of the electronic SAAR is the responsibility of the supervisor.  To meet regulatory requirements, the SAAR and the Investigator’s Report must be submitted within 7 calendar days of the time that the Laboratory had notice of the incident.  The report may be modified later if additional information is obtained.  Occasionally forms or reports other than the SAAR will be required. However, the basic steps and the principles remain the same.

5.1.3.1 Procedure for Reviewing First-Aid Injuries

The procedure for reviewing first-aid injuries is outlined below:

1. Employee reports injury to his/her supervisor. An employee at the main LBNL site reports to Health Services and receives first-aid treatment. An employee at other LBNL sites reports to either a neighboring first-aid provider or Health Services for treatment. The supervisor is responsible for reporting the injury to Health Services.


2. Health Services sends OHM Report notification to:


• Injured employee’s Supervisor
• Division Safety Coordinator
• EH&S Liaison
• Incident Review Program Manager


3. To plan and perform the review the Division Safety Coordinator contacts the:


• Injured employee
• Injured employee’s Supervisor
• EH&S Liaison


4. A complete incident review is performed (causal analysis stops at identification of causal factor(s)) and the SAAR is drafted by the Supervisor.


• For minor first aid injuries, the Supervisor or the Division Safety Coordinator can request that the Incident Review Program Manager waive the requirement for a review.
• When a review is waived, a SAAR will still need to be submitted documenting that a review was not required.
• If necessary, the Division Safety Coordinator can contact the Incident Review Program Manager for support.
• If a first aid injury looks like it will become an OSHA recordable injury, contact the Incident Review Program Manager as soon as possible.
• Liaison uses the Investigator’s Report form to enter SAAR codes.


5. The Division Safety Coordinator approves the SAAR which is then submitted within seven calendar days after the employee reports the injury.


6. The Supervisor (with assistance from the Division Safety Coordinator) enters the corrective actions into Corrective Action Tracking System (CATS) within seven calendar days following the submittal of the SAAR (14 days after the employee reports the injury).

5.1.4 Roles and Responsibilities for Reviewing Minor and Serious Incidents

• Injured Employee


• Participates in the incident review


• Supervisor for Injured Employee or incident scene.


• Responsible for completion of an appropriate incident review including, preparation of reports and development of corrective actions within the required time frames.
• Completes and submits the SAAR.
• Works with team to complete the Investigator’s Report.
• Submits corrective actions into the Corrective Action Tracking System (CATS).


• Division Safety Coordinator


• Initiates reviews for first aid and OSHA recordable injuries.
• Supports the Supervisor by applying knowledge of incident reviews.
• Facilitates interviews
• Works with the Supervisor to complete the SAAR and submit corrective actions into CATS.
• Reviews and approves the SAAR after the Supervisor drafts it.
• Works with Team to complete the Investigator’s Report.
• When first aid reviews require more expertise, contacts the Incident Review Program Manager.


• EH&S Liaison


• Participates on incident reviews.
• Submits completed Investigator’s Report for OSHA recordable cases.
• Assists with providing EH&S subject matter experts as required.
• For first aid cases, uses the Investigator’s Report form to enter SAAR codes.


• Incident Investigator


• Participates on OSHA recordable injury reviews and performs root cause analyses.
• Works with Team to complete the Investigator’s Report.
• When requested, also provides support for first aid reviews


• Incident Review Program Manager


• Coordinates support including assigning investigators for OSHA recordable review teams.
• Reviews all Investigator’s Reports.
• Where appropriate, waives the requirement for a review for minor cases where a review is unlikely to add value.

5.1.5 Standards

DOE Order 225.1, Change 1 and 2, Accident Investigation

DOE Order 231.1, Change 1, Environment, Safety & Health Reporting

DOE Manual 231.1-1, Environment, Safety & Health Reporting Manual

5.1.6 Related PUB-3000 Chapters

• Lessons Learned (Chapter 14)

5.1.7 References

• Lawrence Berkeley National Laboratory Master Emergency Plan, LBNL/PUB-533, Lawrence Berkeley National Laboratory, latest revision


• Emergency Preparedness Web Site (access restricted; LDAP user name and password required)

<< Chapter 5 Contents || PUB 3000 Contents || Section 5.2 >>