Section 5.1
INCIDENT REVIEWING AND REPORTING

Contents

Approved by Richard DeBusk
Revised 9/2010

 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 Work-Related Injuries and Illnesses

5.1.2.1 Procedure for Reviewing Work-Related Injuries and Illnesses

5.1.2.1.1 Notifications
5.1.2.1.2 Investigations
5.1.2.1.3 Analysis and Corrective Action Development
5.1.2.1.4 Investigation Report
5.1.2.1.5 Other Institutional Reporting Systems
5.1.2.1.6 Issues Management: Preventing Recurrence
5.1.2.1.7 Assessment and Improvement

5.1.3 Roles and Responsibilities for Reviewing Work-Related Injuries and Illnesses
5.1.4 Standards
5.1.5 Related PUB-3000 Chapters
5.1.6 References

NOTE:
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5.1.1 Policy

All accidents, injuries, and significant mishaps will be investigated, analyzed, and reported in accordance with the requirements of this chapter, 10 CFR 851, 29 CFR 1904, DOE M 231.1-1A, DOE O 414.1C, and DOE O 226.1A. This investigation and analysis are intended to:

5.1.1.1 Incident Types

Environment, Health, & Safety (EH&S) incidents at Berkeley Lab are grouped into three categories related to their severity. The three categories are listed below by decreasing severity:

1.  Incidents that require a DOE Type A or B investigation, which include the following:

2.  Serious Incidents: Injury cases requiring medical treatment and many Occurrence Reporting Processing System (ORPS) reportable events

3.  Minor Incidents: Injury cases involving first-aid treatment, 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, environmental incident, or any other emergency or accident:

Assign someone to meet the emergency crew and provide directions to the incident.

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 Occupational Safety Group representative, your Division Safety Coordinator, or 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 are of concern to Berkeley Lab management. This determination will be made on a case-by-case basis, and will typically include the following types of cases:

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:

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 the Incident Review process by notifying the supervisor, Division Safety Coordinator, and Occupational Safety Group. 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 off-site 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 away from the Laboratory, the injured employee or supervisor must notify Health Services as soon as possible. Also notify Health Services of injuries to student employees who were treated at the UC Berkeley 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://isswprod.lbl.gov/AccidentReport/.

For off-site accidents involving a government vehicle, notify the local police, complete an LBNL Motor Vehicle Accident Report, and submit it to the motor pool at http://isswprod.lbl.gov/AccidentReport/.

For motor-vehicle accidents involving a rental car or personal vehicle on official business, notify the local police, and complete the forms required by the rental company or by the insurance company. Send 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 Safety Coordinator or with the EH&S Division Office 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 Division Liaison for appropriate procedures in specific cases.

5.1.2 Reviewing Work-Related Injuries and Illnesses

LBNL will review all work-related injuries and illnesses to understand what caused them, and to develop controls to prevent them from recurring. Reviews of work-related injuries and illnesses are owned by cognizant line management. The EH&S Division Occupational Safety Group Incident Review Program assigns a trained investigator to support and facilitate the investigation and data collection, causal analysis, development of recommended controls to prevent recurrence, and to prepare a report for each review. The trained investigator will apply the review process with a graded approach. Once recurrence controls have been recommended, line management is responsible for management of these issues through the LBNL Corrective Action Tracking System (CATS).

5.1.2.1 Procedure for Reviewing Work-Related Injuries and Illnesses

The procedure for reviewing work-related injuries and illnesses[1] is outlined below:

5.1.2.1.1 Notifications
  1. Employee reports injury to his/her supervisor and to Health Services.
  2. Health Services sends the Occupational Health and Medicine (OHM) Report notification to the:
5.1.2.1.2 Investigations

Definitions

Division Ownership means that the injured employee’s division bears responsibility and accountability for controlling factors related to causing an incident and can institute controls to prevent recurrence.

Division line management means the injured employee’s supervisor or other line management representatives as defined in that division’s Integrated Safety Management (ISM) plan (such as the Division Safety Coordinator, a work lead, or another individual with delegated authority and accountability).

Institutional Ownership means that the injured employee’s division bears no or insignificant responsibility or accountability for factors related to the causes of an incident, and that any controls identified to prevent the recurrence of an incident are likely to have an institutional foundation (e.g., controls developed by the Facilities Division, the EH&S Division, or another LBNL organization).

Upon notification of an injury:

  1. The Incident Review Program Manager promptly determines whether the injury may have originated from (or is more related to) the employee’s division oversight or an institutional and infrastructure oversight.
  2. The default classification is Division Ownership and the procedure for Division Ownership cases (immediately below) will be followed unless the injured employee’s line management is notified by the Incident Review Program Manager of a reclassification to Institutional Ownership.

Division Ownership Cases

  1. If the case appears to relate to the injured employee’s division affiliation, the injured employee’s division line management is responsible for initiating an investigation, ensuring that it is promptly completed, and developing and implementing controls to prevent recurrence of injury.
  2. Upon notification of an employee injury, the employee’s division line management initiates an investigation into the causes of the injury in accordance with the internal division protocol and the division’s ISM plan.
  3. To plan and perform the review, the Incident Review Program Investigator contacts:
  4. The Incident Review Program Investigator:

Institutional Ownership Cases

  1. If it appears that the case is not related to the injured employee’s division affiliation, the Incident Review Program Manager initiates and conducts the investigation.
  2. To plan and perform the review, the Incident Review Program Investigator contacts:
  3. The Incident Review Program Investigator:
5.1.2.1.3 Analysis and Corrective Action Development

The Incident Review Program Investigator will ensure that appropriate causal analysis is conducted to determine direct, contributing, and root causes of the incident in accordance with the Causal Analysis Program Manual (PUB-5519[2]). A graded approach in the application of causal-analysis methods will be applied. For example, for minor incidents where no useful information is likely to result from an incident investigation (typically an injury that did not occur due to some ISM deficiency) the requirement for an investigation can be waived by the Incident Review Program Manager.

  1. The Incident Review Program Investigator will use the causal-analysis technique most appropriate for the incident.
  2. The Incident Review Program Investigator will use the selected causal ISM analysis tools to develop recommended corrective actions.
  3. The Incident Review Program Investigator will review the causal-analysis results and recommended recurrence prevention controls with the line management responsible for the investigation.
5.1.2.1.4 Investigation Report

The assigned Incident Review Program Investigator will prepare the injury investigation report.

  1. The report will:
  2. Line-management ownership of the investigation will be demonstrated by signatory concurrence on the report.
  3. Quality review of the report will be performed by a panel (person or persons) appointed by the EH&S Division Director.
5.1.2.1.5 Other Institutional Reporting Systems

When an injury review is performed in response to an incident that triggers other institutional reporting systems (ORPS, Non-Compliance Tracking System [NTS], Vehicle Incident Report), the Incident Review Program Investigator will assist in integrating the injury investigation and reporting with other reporting systems.

5.1.2.1.6 Issues Management: Preventing Recurrence

Once causes have been determined and recurrence controls identified and recommended, division line management follows the process described in the Issues Management Program Manual (PUB 5519[1]).

  1. Line management develops corrective actions to effectively implement the recommended recurrence controls.
  2. The Incident Review Program Investigator can help division line management construct corrective actions that address the causal factors and identified recurrence controls.
  3. The Incident Review Program Investigator can provide guidance on the CATS new issue entry coding and classification (issue type, assessment type, risk level, trend code, and external reporting/significant adverse condition check box).
  4. Quality review of the corrective actions entered and their effectiveness when completed will be in accordance with the protocol in PUB-5519(1).
5.1.2.1.7 Assessment and Improvement

Institutional assurance systems will be used in the following way:

  1. The Incident Review Program Manager will provide suggested self-assessment lines of inquiry to the Office of Contract Assurance designed to aid divisions in the monitoring and improvement of their follow-up to injuries and their use of the LBNL Issues Management Program and CATS.
  2. The Incident Review Program Manager will use the Technical Assurance Program (TAP) process to monitor and measure program effectiveness.

5.1.3 Roles and Responsibilities for Reviewing Work-Related Injuries and Illnesses

Injured employee:

Division line management:

5.1.4 Standards

5.1.5 Related PUB-3000 Chapters

5.1.6 References

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Notes

1. For purposes of brevity, the term” injury” throughout the rest of this procedure encompasses both work-related injuries and illnesses.

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