Contents
Approved by Otis Wong
Revised 9/02
14.1 Policy
14.2 Scope
14.3 Sources
14.3.1 Overview
14.3.2 ORPS
14.3.3 LBNL Self-Assessment
14.3.4 Accident Investigation Program
14.3.5 Division Lessons Learned Programs
14.3.6 LBNL Staff
14.3.7
DOE Lessons Learned Programs
14.3.8 Other Professional Materials
14.4 Lessons Learned Deliverables
14.5 Procedures
14.5.1 Overview
14.5.2 Obtaining Data
14.5.3 Determining Applicability
14.5.4 Distributing Deliverables
14.5.5 Tracking Deliverables
14.5.6
Lessons Learned Program Effectiveness
14.6 Responsible Parties
14.6.1 EH&S
14.6.2 
Office of Assessment
and Assurance (OAA)
14.6.3 Division Directors
14.6.4 LBNL Staff
14.7 Standards
14.8 Related LBNL/PUB-3000 Chapters
14.9 References
14.10 Appendices
Appendix A
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LBNL practices a policy that enhances the Laboratory’s safety culture and improves
safety performance at all levels. This is accomplished through event analysis,
determination of event causes, development of corrective actions, and distribution
of lessons learned.
The lessons learned process is an integral part of every safety, health,
and environment program at LBNL. In every case, it is the intent of the Laboratory
to correct on as broad a basis as possible any problems found.
Major LBNL safety programs that contain lessons learned elements are
included in the Sources section of this chapter. In addition, LBNL has
developed a Lessons Learned Program. This program formalizes the communication
process and ensures consistent distribution of lessons learned to the
LBNL staff and DOE community.
The Lessons Learned Program ensures that incidents, near misses, and other
events at LBNL are identified and translated into corrective actions that improve
safety performance and prevent recurrence. The Program addresses safe practices
as well as practices leading to events or accidents.
The sources for lessons learned include:
Occurrence Reporting Processing System (ORPS)
LBNL Self-Assessment Program
LBNL Accident Investigations
Division Lessons Learned Program
LBNL Staff
DOE Lessons Learned Programs
Other Professional Materials
The Occurrence Reporting Processing System (ORPS) implements DOE Order 232.1,
Occurrence Reporting, which dictates that divisions analyze occurrence
criteria, as developed by the Order and the LBNL document Occurrence
Reporting, LBID-1694, to determine root causes, corrective actions,
and lessons learned. The division affected has the opportunity to use
lessons learned both for internal and Labwide changes and observations.
Instructions say: “Include any lessons that others might learn from the occurrence
that could be of importance to other facility operators or that should be addressed
in personnel training or facility procedures.”
The Laboratory’s Operating
and Assurance Program (OAP) requires that management and personnel evaluate
their performance to identify, correct, and prevent problems, and to ensure
achievement of performance objectives. The LBNL Self-Assessment
Program implements these requirements through a formalized information-gathering
process of appraisals and assessments. The self-assessment process generates
lessons learned within each division and the Laboratory as a whole. These
lessons are reported, by division, in annual self-assessment reports to the
Office of Assessment and Assurance (OAA). The OAA provides the Lessons Learned
Administrator with these reports annually.
The Laboratory’s Accident Investigation Program has been developed to identify
and eliminate accident causes, thereby preventing similar accidents. Accident
investigation is a major component of LBNL’s safety, health, and environment
programs, which aim to provide employees with a safe and healthy work environment.
The Accident Investigation Program’s primary emphasis is on accident prevention
by engineering safe facilities and equipment, developing sound operational procedures,
and providing adequate training and protective equipment. Lessons learned
from the accident investigation process help to define and improve these efforts.
The Accident Investigation Program is written to conform with the requirements
of DOE Order 225.1, Chapters 1 and 2, and LBNL’s Health and Safety Manual,
LBNL/PUB-3000.
Many LBNL divisions have a Lessons Learned Program as part of self-assessment
or as part of the Division’s Safety Committee Charter. The LBNL
Lessons Learned Program offers the Division a Laboratory-wide communication
network for dissemination of specific safety lessons.
All staff are encouraged to supply lessons learned covering any subject
they believe to be important to the Laboratory and the DOE community. (See the
LBNL Lessons Learned Input Form in Appendix A.)
Lessons learned received from DOE headquarters and facilities (e.g., through
the Society of Effective Lessons Learned Sharing [SELLS], Lessons Learned List
Server, Operating Experience Weekly Summary, Safety Note, Safety Bulletin, or
Occupational Safety Observer) are reviewed for applicability and distributed
to the targeted LBNL audience.
Input from professional journals, papers, and other documents is reviewed for
applicability to the LBNL community.
There are three LBNL-generated lessons learned deliverables: (1) Safety
News Bulletin, (2) Safety Alert, and (3) Lessons Learned Report.
The Safety News Bulletin is an informational announcement, issued on
a need-only basis, that addresses a single subject (e.g., “Relay Socket Design
May Cause Breakage,” No. 302). The Bulletin is distinguished by a colored
header.
The Safety Alert is an announcement, issued on a need-only basis, that
dictates immediate corrective actions and accountability responsibilities. It
is distinguished by a colored header.
The Lessons Learned Report is a blue information sheet covering any
subjects of interest to the Laboratory (e.g., Small Spill Requirements, Construction
Hazard Safety Tips).
The Lessons Learned Administrator (LLA) in the Office
of Assessment and Assurance (OAA) follows these procedures
to implement the Lessons Learned Program:
1. Obtain applicable lessons learned data from LBNL programs and
external sources.
2. Determine the applicability of each lessons learned element
(see Determining Applicability, below).
3. Distribute lessons learned deliverables, including the DOE-printed
lessons learned materials, LBNL Lessons Learned Report, LBNL Safety
News Bulletin, LBNL Safety Alert, and occurrence report summaries, to
the Laboratory, DOE, and DOE facilities.
4. Track Safety News Bulletins and Safety Alerts
for any actions taken (e.g., safety alert requiring removal
of a defective equipment component).
All LBNL organizations are requested to provide prospective lessons learned
items to the LLA for review and inclusion in the Lessons Learned Program deliverables.
The LBNL Lessons Learned Input Form (see Appendix
A) is used for this process. Specific areas and programs (e.g., OAA, Occurrence
Reporting, division safety committees, Facilities) routinely contribute information
for inclusion in the lessons learned deliverables.
DOE-published documents (e.g., Weekly Operating Summary, The Safety
Observer) are distributed to divisions and other interested parties. The
LLA annually reviews the mailing lists provided by the originator to reduce
duplication and to ensure that the publications are distributed to the correct
LBNL audience (e.g., division directors, safety committees, building managers).
The LLA and other technical support personnel, with the LLA as lead, review
potential lessons learned materials and events to determine applicability
based on priority criteria, to evaluate technical accuracy, and to determine
distribution. Priority criteria include, but are not limited to, probability
of recurrence and events posing an obvious and significant hazard to personnel,
the environment, or programs.
All LBNL-oriented deliverables (i.e., Lessons Learned Report, Safety News
Bulletin, Safety Alert) are distributed to targeted
audiences who may benefit from the lessons learned. The audience can be the
entire Laboratory community, division directors, safety
committees, building managers, major program heads, and DOE. Special distribution
lists per the LBNL Regulations and Procedures Manual (RPM), LBNL/PUB-201, can
also be accommodated. The DOE electronic
lessons learned materials are distributed to division directors, safety
committees, public use areas, and special interest groups.
LBNL Lessons Learned Reports,
Safety News Bulletins, and Safety Alerts are numbered for tracking
purposes. Appropriate lessons learned deliverables are provided to EH&S
personnel, who perform training for development or upgrade of training programs,
should it be necessary.
A management review of the Lessons Learned Program is conducted triennially
to assess the effectiveness of the program to communicate ES&H information
and experiences for the purpose of preventing recurrences and improving ES&H
performance.
Division Directors are responsible for completion
of corrective actions when directed by the deliverable.
The Lessons Learned Program is the responsibility of the EH&S Division,
Office of Assessment and Assurance,
division directors, and LBNL staff.
The EH&S Division manages the Lessons Learned Program.
OAA is responsible for the coordination,
analysis, publication, and distribution of the LBNL Lessons Learned Program.
OAA analyzes LBNL events by using occurrence reporting, accident investigations,
self-assessment, and quality assurance findings, as well as other materials
provided by the divisions. This information is the basis for the lessons learned
deliverables. OAA provides EH&S staff
who perform training with LBNL event materials for review and inclusion in formal
training programs, where appropriate.
Division directors and their designees
are responsible for ensuring that lessons learned deliverables are available
and distributed to their staff and that any necessary follow-up actions are
implemented. Division directors are responsible for seeing that lessons learned
in their divisions that have a Laboratory impact are brought to the attention
of OAA, using the LBNL Lessons
Learned Input Form.
All staff are responsible for safety awareness of the issues presented in the
lessons learned deliverables. Staff are encouraged to provide input directly
to OAA for consideration for the Lessons
Learned Program.
DOE Order 232.1, Occurrence Reporting and Processing of Operations Information
Occupational Safety (Chapter 5)
Occurrence Reporting (Chapter 15)
Lawrence
Berkeley National Laboratory Self-Assessment Program (latest
revision on Web), Lawrence Berkeley National Laboratory,
LBNL/PUB-5344
LBNL Operating and
Assurance Program (latest revision on Web),
Lawrence Berkeley Laboratory, LBNL/PUB-3111
Occurrence Reporting
(latest revision on Web), Lawrence
Berkeley Laboratory, LBID-1694
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