Chapter 15
OCCURRENCE REPORTING

Contents

Approved by Andrew Peterson
Revised 10/12

• 15.1 Policy
• 15.2 Scope
• 15.3 Applicability
• 15.4 Roles and Responsibilities
  • 15.4.1 Employees, Affiliates, and Subcontractors
  • 15.4.2 Supervisors and Work Leads
  • 15.4.3 Division Directors
  • 15.4.4 Division Designees
  • 15.4.5 Environment, Health, Safety, and Security (EHSS) Division
  • 15.4.6 Office of Contractor Assurance
• 15.5 Process Overview
• 15.6 Required Work Processes
  • Work Process A. Discovery, Reporting, and Preliminary Review
  • Work Process B. Categorization
  • Work Process C. Notification
  • Work Process D. Occurrence Investigation and Causal Analysis
  • Work Process E. Corrective Actions and Lessons Learned
  • Work Process F. Final and Update Reports
  • Work Process G. Performance Trends and Recurring Occurrences
  • Work Process H. Training
• Appendices
  • Appendix A. Definitions
  • Appendix B. DOE Reporting Criteria
  • Appendix C. Notification and Reporting Matrix
  • Appendix D. Causal Analysis Tree

NOTE:
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15.1 Policy

Lawrence Berkeley National Laboratory (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.

As part of this process, Berkeley Lab will determine if any occurrences must be reported to the Department of Energy (DOE) per DOE O 232.2, Occurrence Reporting and Processing of Operations Information,and if so, will follow DOE reporting requirements.

15.2 Scope

Chapter 15 documents Berkeley Lab’s program for compliance with DOE O 232.2. The scope of this chapter is limited to occurrences meeting any criteria in DOE O 232.2.

Appendix A provides definitions used in this chapter, including:

• 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. The following are examples of conditions: errors in analysis or calculation, anomalies associated with design or performance, or items indicating a weakness in the management process.
• Event: A significant incident that takes place in real time (e.g., a pipe break, valve failure, loss of power, environmental spill, earthquake, tornado, flood, injury)
• Occurrence: One or more events or conditions that adversely affect, or may adversely affect DOE or contractor personnel, the public, property, the environment, or the DOE mission. Occurrences are events or conditions meeting the criteria thresholds identified in DOE O 232.2 or determined to be recurring through performance analysis.

15.3 Applicability

All Berkeley Lab divisions and departments, including affiliates and subcontractors performing work for the Laboratory, are subject to the requirements of this chapter. Work covered under a Memorandum of Understanding involving DOE and Berkeley Lab, such as that governing work in some areas of the University of California at Berkeley campus, may be excluded from the requirements of this chapter. 

15.4 Roles and Responsibilities

15.4.1 Employees, Affiliates, and Subcontractors

Employees, affiliates, and subcontractors must 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.

Occurrences that cannot be adequately managed internally following existing Laboratory policies and procedures (e.g., the Berkeley Lab Emergency Response Guide) must be reported.

15.4.2 Supervisors and Work Leads

Supervisors and work leads should 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 Environment, Health & Safety (EHSS) Division.

15.4.3 Division Directors

Division directors are ultimately responsible for meeting the requirements of DOE O 232.2 – including categorization, notification, investigation, and reporting – for occurrences at their facilities or operations. They must provide appropriate resources to report events in a timely manner, investigate causes, and institute corrective actions to prevent recurrence.

Where occurrence categorization is not clear, or for management concerns and issues, the division director must decide or agree that the occurrence is DOE reportable. EHSS can assist with this determination. Division directors must approve Final Reports before EHSS submits them to DOE.

Note: A division director is sometimes referred to as a facility manager for purposes of the DOE Occurrence Reporting Program.

15.4.4 Division Designees

Division directors may assign designees from their organizations to help implement these procedures. Division designees assist line managers and staff in meeting occurrence-reporting requirements, including communicating with EHSS to ensure proper DOE notifications are completed. Division designees must be familiar with the procedures described in this chapter.

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.

15.4.5 Environment, Health, Safety, and Security (EHSS) Division

EHSS oversees the occurrence-reporting process to ensure it is properly managed. EHSS assists divisions as needed to respond to, mitigate, categorize, and investigate occurrences, and to support division directors and their designees with DOE occurrence reporting. EHSS completes the required DOE notifications and submits the required DOE reports into the online DOE Occurrence Reporting database.

For events that are ORPS Significance Category 2 and 3 Reportable, EHSS will complete a quality-assurance review of the causal analysis, including the corrective actions, as part of the occurrence-reporting process.

Any EHSS staff member who learns of an occurrence must report this to the appropriate person within the EHSS Division.

Note: Divisions should notify EHSS of an occurrence as soon as possible to get guidance through the occurrence-reporting process.

15.4.6 Office of Contractor Assurance

The Office of Contractor Assurance (OCA) 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 (CAPs), and Effectiveness Review Reports for high-risk issues prior to issuance and approval. OCA also oversees the Causal Analysis Program. The products of these programs are used, when applicable, in the preparation of Final Reports.

15.5 Process Overview

The flowchart below gives a general overview of the DOE occurrence-reporting process. Detailed explanations of each process step are provided in Section 15.6, Required Work Processes. Additional information is available at the EHSS Occurrence Reporting Web site.

15.6 Required Work Processes

Work Process A. Discovery, Reporting, and Preliminary Review

Occurrences — both actual and near-miss events — are discovered in a variety of ways, such as observations by workers, notifications from external agencies, internal assessments, etc. A worker must promptly report unsafe or abnormal events and conditions according to division policies and procedures. Occurrences that cannot be adequately managed within the division following existing Laboratory policies and procedures (e.g., following the Berkeley Lab Emergency Response Guide) must be reported, either directly or indirectly, to the EHSS Division.

If a division has no internal reporting policies or procedures, a worker must report occurrences to the appropriate supervisor/work lead and division safety coordinator. Supervisors/work leads report the occurrence to the EHSS Division or to the division’s safety coordinator, who reports occurrences to EHSS.

A worker at any level and at any time may directly report an occurrence to the EHSS Division. When EHSS receives a report, it contacts appropriate personnel within a division to ensure each occurrence is reviewed for DOE reportability.

Regardless of how an occurrence is reported to EHSS, it must be reviewed to determine if it meets a DOE reporting criterion. Divisions may work collaboratively with EHSS to make this determination (as described in Work Process B), or they can make an initial assessment of reportability. In the latter case, EHSS will either validate this assessment or discuss the assessment with the division until consensus is reached.

Work Process B. Categorization

To categorize an occurrence, compare it against the criteria established in DOE O 232.2 (documented in Appendix B). If the occurrence meets any of the criteria, it is reportable to DOE.

DOE criteria are primarily thresholds organized in one of 10 groups (and possibly a subgroup). Significance categories associated with the criteria determine notification, analysis, and reporting requirements (see Appendix C). In most cases, the significance category is pre-assigned by DOE to the specific criterion.

Most DOE criteria are triggered by exceeding a specific threshold documented in a criterion that has a set significance category, making categorization straightforward. Group 10, Management Concerns and Issues, is more subjective, particularly Criterion 2 for Management Concern, which historically accounts for approximately 30% of Berkeley Lab’s reportable occurrences. In addition, Group 10, Criterion 2 (Management Concern) and Group 10, Criterion 3 (Near Misses) do not have pre-assigned significance categories.

In instances where the criterion is questionable or the significance category is variable, division directors or their designees must make the final decision on categorization, although EHSS may provide input into the decision-making process. EHSS staff — which has knowledge of hazards, awareness of DOE criterion thresholds, and response roles — may initially categorize occurrences in the absence of division directors or designees, and later confirm the categorization with division management.

If an occurrence meets more than one reporting criterion, the criterion with the highest significance category determines the notification, analysis, and reporting requirements. As new information becomes available, the occurrence must be re-evaluated and the occurrence criterion and significance category changed if needed.

If the event or condition is not reportable to DOE, it is considered a “site-reportable” event or condition and will be recorded as appropriate by EHSS for tracking and trending purposes.
Given the subjective nature of some occurrences, EHSS should be contacted to assist with categorization.

Categorization Time Frame

DOE has established time frames for categorization.

• Operational Emergencies. Berkeley Lab must categorize these as soon as possible, as documented in PUB-533, Master Emergency Program Plan (MEPP).
• Occurrences that are not Operational Emergencies. Berkeley Lab must categorize the occurrence within two hours of discovery or as soon thereafter as reasonably possible.

Work Process C. Notification

After an occurrence has been discovered, found to be DOE reportable, and properly categorized, the EHSS Division must notify DOE. For this to happen, divisions must provide EHSS with preliminary details of the occurrence.

Prompt Notification

The first notification to DOE, providing initial details on the occurrence, is called Prompt Notification, and can be completed by a phone call and/or e-mail to the DOE Berkeley Site Office (BSO). This notification includes a brief summary of the occurrence and the reporting group, subgroup (when applicable), criterion number, and significance category.

• Operational Emergencies. Berkeley Lab must notify DOE within 15 minutes if the occurrence is classified per the requirements in PUB-533; otherwise, within 30 minutes.
• Occurrences that are not Operational Emergencies. Berkeley Lab must notify DOE within two hours of categorization.
• Recurring occurrences. These do not require Prompt Notification.

Occurrences meeting specific DOE criteria (noted by the Appendix B criteria marked with an asterisk) must also be reported to DOE Headquarters Operations Center (HQ OC) via e-mail, and receipt must be confirmed. For occurrences that require Prompt Notification of DOE HQ OC, the following details must also be included:

• Occurrence significance category
• All of the reporting criteria (i.e., the group, subgroup, and sequence numbers/criteria) associated with the occurrence
• Location and description of the occurrence
• Date and time of discovery
• Damage and casualties
• Impact of event on other activities and operations
• Protective actions taken or recommended
• Weather conditions at the scene
• Level of media interest at the scene/facility/site
• Other notifications made

If the occurrence is re-categorized based on new or changing information, it must be reconsidered for Prompt Notification and, as appropriate, the same Prompt Notification process must be followed.
Follow-up notification is required if there is further degradation in the level of safety or impact on the environment, health, or operations of the facility, or other worsening conditions subsequent to the initial notification.

Notification Report

Following initial Prompt Notification, EHSS must submit a written report (the Notification Report) into the online DOE Occurrence Reporting database. The Notification Report contains all relevant detail known at the time and must be submitted within the timeline provide in Appendix C or as soon as reasonably possible.

Work Process D. Occurrence Investigation and Causal Analysis

DOE-reportable occurrences require some degree of investigation and analysis to ensure the cause is understood so that effective corrective actions can be identified and implemented. Guidance and training requirements for conducting causal analysis is provided in PUB-5519(1), Issues Management Program Manual; and PUB-5519(2), Causal Analysis Program Manual.

The rigor and scope of the investigation and analysis are based on the significance category of the event, as summarized in Appendix C (for which PUB-5519 is the “locally approved procedure”). Certain events may result in a federal Accident Investigation Board review. Berkeley Lab is not required to conduct an identical investigation under this circumstance.

All causes, once identified, are classified by specific cause codes described in the DOE O 232.2 Causal Analysis Tree (provided as a link in Appendix D). EHSS, with the assistance of the affected division, determines the appropriate cause codes.

Work Process E. Corrective Actions and Lessons Learned

After a causal analysis is completed, corrective actions to prevent recurrence must be identified. Requirements for developing and managing corrective actions are documented in PUB-5519(1), Issues Management Program Manual;andPUB-5519(2), Causal Analysis Program Manual.

The Berkeley Lab Corrective Action Tracking System (CATS) must be used to document and track corrective actions identified for each DOE-reportable occurrence in accordance with OIA-OCA-0001, CATS Database User Manual. With the exception of Significance Category 4 occurrences, corrective actions must also be entered into the DOE Occurrence Reporting database, with reference to the respective CATS identification numbers.

Divisions must ensure all Significance Category 1 and R Corrective Action Plans (CAPs) are reviewed by the Office of Contractor Assurance (OCA) before final submission, which includes CAPs documented via ORPS and/or Price Anderson Amendment Act Non-compliance Tracking System (PAAA-NTS) Reports. EHSS will review all Significance Category 2 and 3 corrective actions before final submission. In addition, any text changes to corrective actions in CATS must be transmitted to EHSS for updating in the DOE Occurrence Reporting database and for possible review and approval by BSO.

Lessons Learned must be considered in accordance with PUB-5519(4), Lessons Learned and Best Practices Program Manual. Any lessons learned that result from the event must be entered into the Lessons Learned field of the DOE Occurrence Reporting database.

Depending on the significance category, Berkeley Lab or BSO may conduct independent verification, sampling, and effectiveness evaluation of the corrective actions.

Work Process F. Final and Update Reports

A written Final Report is required for all Operational Emergencies and Significance Category 1, 2, 3, and R occurrences. The Final Report is due 45 calendar days from the date of occurrence categorization (for Significance Category 4, the Notification Report is the Final Report). The Final Report must contain the following:

• Significance, nature, and extent of the event or condition
• Causes of the occurrence as documented in Causal Analysis Reports (including the root cause, as required) using the codes provided in the Causal Analysis Tree (Appendix D)
• Immediate actions taken, corrective actions to be taken, and any Lessons Learned resulting from the event, as required by this chapter
• For reports on suspect/counterfeit and defective items or material:
• Manufacturer/supplier/vendor (including a contact, phone number, and Web site)
• Model and part numbers
• Quantity involved
• Why the item/material is suspect/counterfeit or defective, and how the item/material is being used
• Method of detection (e.g., receipt inspection, craft inspection prior to installation, in-service inspection, or failure)
• Resulting consequences, along with any photos via hyperlink, as appropriate
• Level of contamination, dose, exposure, release, and damage (e.g., estimate the acres of wildland burned) when possible, rather than merely stating that a reportable limit was exceeded
• If the event triggered a federal Accident Investigation Board review, all causes (direct, contributing, and root) identified in the accident investigation report, as well as corrective actions developed in response to the judgment of need

Additional information may be included in the Final Report as appropriate. Examples include:

• Discussion of Berkeley Lab’s implementation of the Integrated Safety Management (ISM) program relative to the occurrence
• Generic implications, such as the need for Extent of Condition Reviews

If the Final Report will not be completed within 45 days, divisions must communicate this to EHSS, which will request a DOE extension in an Update Report filed within the original 45 days. The Update Report must include a detailed explanation of the delay in the Facility Manager’s Evaluation field and provide an estimated completion date.

Update Reports are also required in other circumstances:

• Change in significance criteria. Any changes to the significance criteria of the event, either lower or higher, must be documented in an Update Report and submitted within the time frame required for the Notification Report under the new significance category. The Update Report must include a discussion of the category change at the end of the Description of Occurrence field.
• Significant new information. Any significant and new information about the event (excluding Significance Category 4 events) requires an Update Report, which should include the status of occurrence inquiries, recurring consequences, and the identification of additional component defects.
• Final Report revision deadline to be missed. If a rejected Final Report that requires revision will not be completed within the 21-day limit as described below under Report Closure, an Update Report is required.

The Update Report eventually becomes the Final Report when all pertinent information on the investigation and analysis — including significance, nature, and extent of the occurrence; causes; corrective actions; and lessons learned — is entered into the DOE Occurrence Reporting database and required approvals have been obtained as described below.

Report Approval

Regardless of the significance category of the occurrence, the responsible division director must approve the Final Report (which includes an OCA quality-assurance [QA] review of the Corrective Action Plan for Significance Category 1 or R events) prior to submission to external organizations such as BSO or DOE HQ. Additional DOE approval is required for Operational Emergency Significance Category 1, 2, and R occurrence reports, as documented in Appendix C.

Report Closure

For Operational Emergency and Significance Category 1, 2, and R Final Reports, BSO must review, approve or reject, and add any comments within 14 calendar days of receipt of the report. If approved by BSO, Operational Emergency and Significance Category 1 Final Reports must be submitted to the DOE HQ Program Office, which has 14 days to review, approve or reject, and add comments.

If the Final Report is not approved by BSO or DOE HQ, the DOE employee who rejected the report must provide the reason for disapproval in the report’s DOE comment section. The Berkeley Lab division, with assistance from EHSS, must prepare a revised Final Report and resubmit it to BSO within 21 calendar days of the disapproval. If the revised Final Report cannot be resubmitted within this time, an Update Report must be submitted within 21 calendar days, explaining the delay and estimating a resubmission date. This information must be reported in the Field Manager’s Evaluation field of the DOE Occurrence Reporting database.

Work Process G. Performance Trends and Recurring Occurrences

Berkeley Lab periodically reviews reportable and non-DOE reportable (also known as site-reportable) occurrences and events to look for trends, determine if events are recurring, determine if recurring events meet the criteria for ORPS or PAAA-NTS reporting, and evaluate mitigation strategies. Formal reviews are performed quarterly and include data from the previous 12 months at a minimum.

EHSS analyzes non-DOE reportable events to identify trends. EHSS uses the following data sources in this analysis:

1. Safety Concerns/Suggestion Log
2. Operations Incident Log
3. DBO2 Database
4. CATS Database
5. Injury and Illness Database (CAIRS)
6. Lessons Learned/Best Practices Database
7. Laboratory-wide One Call (beginning second quarter, FY 2013)

Input into these databases happens through various mechanisms as briefly summarized below:

1. Safety Concerns/Suggestion Log: Employees are able to submit both safety concerns and safety suggestions to EHSS through the online database.Submissions are entered into a running log of issues, assigned to appropriate EHSS personnel, and tracked.
2. Operations Incident Log: Facilities personnel enter events and conditions that have been reviewed but do not meet DOE reporting criteria. EHSS SMEs may also enter events and conditions into this log. 
3. DBO2 Database: Facilities and EHSS personnel conduct construction site and shop walk-throughs, observe behaviors, and enter observations into the DBO2 database.
4. CATS Database: Employees can enter findings, issues, and associated corrective actions in the CATS Database.
5. Injury and Illness Database (CAIRS): EHSS enters first aid and OSHA-recordable injuries and illnesses into the Injury and Illness Database (CAIRS). 
6. Lessons Learned/Best Practices Database: Employees can enter Lessons Learned from specific events and conditions into the database to share information 
7. Laboratory-wide One Call: Beginning second quarter, FY 2013, calls to ext. 6999 (Laboratory-wide One Call) will be logged by the dispatcher. 

This analysis may also include data from other sources, including issues discovered during assurance assessments (both independent assessment and program self-assessments) and division self-assessments; data collected informally, such as feedback from subject matter experts, division safety coordinators, and Associate Lab Director (ALD) liaisons; and issues identified during stand-downs. An ongoing effort will be made to standardize the trending code of events so that EHSS can effectively trend across multiple data sources. A quarterly report will be generated by EHSS and submitted to the Office of Contractor Assurance (OCA).
OCA analyzes DOE-reported events (i.e., ORPS and PAAA-NTS) to determine if recurring issues exist. Any issue that warrants reporting in ORPS and/or NTS as determined by an EHSS analysis of lower-level events is included in an OCA analysis to determine if a recurring issue exists (refer to PUB-5519[3], Data Monitoring and Analysis Program Manual). Results of this analysis are documented in a written report and provided to BSO and line management.

Recurring Occurrences

Trends will be reviewed to determine if they meet the criteria of ORPS and PAAA-NTS reporting. If so, the trend will be reported as a recurring occurrence (Significance Category R) if deemed appropriate to resolve the trend.  In this case, previous individual occurrence report numbers associated with the recurring issue (if applicable) will be provided in the “similar occurrence report numbers” field. The new occurrence report must  meet all reporting and processing requirements for Significance Category R.

Occurrences meeting NTS requirements will be managed per institutional policy for PAAA-NTS issues.

Work Process H. Training

As part of their Berkeley Lab orientation, employees, supervisors, affiliates, and subcontractors receive basic instructions for reporting unsafe conditions and abnormal events. Division directors and deputy directors receive a brief orientation to the DOE Occurrence Reporting process (via EHS 804). Division designees and others likely to be involved in the occurrence-reporting process will receive more detailed training (via EHS 802).

Appendix A. Definitions

1. APPARENT CAUSE. The most probable cause(s) that explains why the event happened, that can reasonably be identified, that local or facility management has the control to fix, and for which effective recommendations for corrective action can be generated, if necessary

2. BUSINESS DAY. The normal administrative day of the reporting organization (e.g., Monday through Friday, 0800 to 1700 local time) during which normal work activities are conducted. It is not meant to encompass the 24 hours in a day, even if the facility is operated or maintained on a 24-hour basis.

3. 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. The following are examples of conditions: errors in analysis or calculation, anomalies associated with design or performance, or items indicating a weakness in the management process.

4. DEFECTIVE ITEM. Any item or material that does not meet the commercial standard or procurement requirements as defined by catalogs, proposals, procurement specifications, design specifications, testing requirements, contracts, or the like. This does not include parts or services found to be inadequate because of random failures or errors within the accepted reliability level.

5. DISCHARGE. Includes, but is not limited to, any spilling, leaking, pumping, pouring, emitting, emptying, or dumping of oil, but excludes discharges in compliance with a permit under Chapter 402 of the Clean Water Act (CWA); discharges resulting from circumstances identified and reviewed and made a part of the public record with respect to a permit issued or modified under Chapter 402 of the CWA and subject to a condition in such permit; or continuous or anticipated intermittent discharges from a point source, identified in a permit or permit application under Chapter 402 of the CWA, that are caused by events occurring within the scope of relevant operating or treatment systems

6. DISCOVERY DATE AND TIME. The point at which facility staff discovered or became aware of the event or condition. Discovery date is NOT the date and time the event or condition is determined to be reportable. Facility staff are those personnel assigned to the facility and cognizant of the area in which the event or condition is identified.

7. ELECRICALLY SAFE WORK CONDITION. A state in which the conductor or circuit part to be worked on or near has been disconnected from energized parts; locked/tagged in accordance with established standards; tested to ensure the absence of voltage; and grounded, if determined necessary

8. EQUIVALENT DOSE

1. Committed Effective Dose (E50). Refer to 10 CFR 835.2 or to DOE O 458.1 Chg 2, Radiation Protection of the Public and the Environment, dated 6-6-11, Attachment 2 (Definitions)
2. Committed Equivalent Dose (HT,50). Refer to 10 CFR 835.2 or to DOE O 458.1 Chg 2, Radiation Protection of the Public and the Environment, dated 6-6-11, Attachment 2 (Definitions)
3. Effective Dose (E). Refer to 10 CFR 835.2 or to DOE O 458.1 Chg 2, Radiation Protection of the Public and the Environment, dated 6-6-11, Attachment 2 (Definitions)
4. Total Effective Dose (TED). Refer to 10 CFR 835.2 or to DOE O 458.1 Chg 2, Radiation Protection of the Public and the Environment, dated 6-6-11, Attachment 2 (Definitions)

9. EVENT. A significant incident that takes place in real time (e.g., pipe break, valve failure, loss of power, environmental spill, earthquake, tornado, flood, injury)

10. 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.

11. FACILITY MANAGER. Division director

12. FACILITY REPRESENTATIVE. Berkeley Site Office

13. HAZARDOUUS ELECTRICAL ENERGY EXPOSURE. Within the limited approach boundary (LAB) of an energized part not suitably guarded, isolated, or insulated. This includes de-energized parts for which a safe work condition has not been established, e.g., lockout/tagout.

14. HAZARDOUS SUBSTANCE OR MATERIAL

1. Department of Energy - Hazardous Material. Any solid, liquid, or gaseous material that is chemically toxic, flammable, radioactive, or unstable upon prolonged storage and that exists in quantities that could pose a threat to life, property, or the environment
2. Department of Transportation - Hazardous Materials (see 49 CFR 171.8 and 172.101). A substance or material, including a hazardous substance, that has been determined by the Secretary of Transportation to be capable of posing an unreasonable risk to health, safety, and property when transported in commerce and that has been so designated
3. Comprehensive Environmental Response, Compensation, and Liability Act Hazardous Substances (see 40 CFR Part 302)
4. Occupational Safety and Health Administration (OSHA) Hazardous Chemical (see 29 CFR 1910.1000 and 29 CFR 1910.1200). Any chemical that is a physical or health hazard
5. Superfund Amendments and Reauthorization Act Title 3, Extremely Hazardous Substances (see 40 CFR 355). These are not defined but appear on lists in Appendix A and Appendix B of 40 CFR 355.

15. IN-PATIENT HOSPITALIZATION. Admission to a hospital requiring at least one overnight stay. This would include admission for purposes of observation only.

16. ITEM

1. An all-inclusive term used to denote the following: appurtenance, sample, assembly, component, equipment, material, module, part, structure, subassembly, subsystem, system, unit, support systems, documented concepts, or data
2. When used in reference to nuclear material, a visible, single piece or container of nuclear material with a unique identification and known nuclear material mass

17. LESSONS LEARNED. A good work practice or innovative approach that is identified and shared, or an adverse work practice or experience that is captured and shared to prevent recurrence

18. 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 has determined to include in the required ORPS Performance Analysis activity

19. NOTIFICATION REPORT. The initial documented report to DOE of an event or condition that meets the reporting criteria defined in DOE O 232.2

20. NUCLEAR FACILITY. A reactor or nonreactor nuclear facility in which an activity is conducted for or on behalf of DOE and that includes any related area, structure, facility, or activity to the extent necessary to ensure proper implementation of the requirements of 10 CFR 830

21. 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 O 232.2 or determined to be recurring through performance analysis.

22. 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

23. OCCURRENCE REPORT. A documented evaluation of a reportable occurrence that is prepared in sufficient detail 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

24. OFF SITE. Property or location that is not DOE/NNSA or DOE/NNSA contractor owned, leased, or directly controlled

25. OFF-SITE TRANSPORTATION EVENT. Involves movement of materials considered to be in commerce, thus requiring compliance with Department of Transportation Hazardous Materials Regulations (49 CFR Sections 171 – 180)

Transportation events with injuries or fatalities may also require reporting in accordance with Group 2 criteria.

26. OIL. Oil of any kind or in any form, including but not limited to petroleum, fuel oil, sludge, oil refuse, and oil mixed with wastes other than dredged spoil

27. ON SITE. Property or location that is DOE/NNSA or DOE/NNSA contractor owned, leased, or directly controlled

28. ON-SITE TRANSFER EVENT. Involves movement of material not in commerce and subject to regulations in 10 CFR Section 830 or DOE on-site procedures and safety requirements. On-site transfer events with injuries or fatalities may also require reporting in accordance with Group 2 criteria.

29. OPERATIONS. The act, process, or method of operating. This can apply to facilities regardless of mode (shutdown, standby, operational) or state (construction, operational, deactivated, decommissioning).

30. PACKAGING AND TRANSPORTATION. Packaging and Transportation activities/functions include: (1) Packaging - activities related to the design, manufacture, and qualification of packaging represented as qualified for use in the transportation of hazardous materials; (2) pre-transportation functions; (3) transportation functions - movement of hazardous materials and loading, unloading, and storage incidental to the movement; and (4) shipping in accordance with applicable international, federal, state, local, and tribal laws, rules, and regulations governing materials transportation that are consistent with federal regulations (e.g., 10 CFR and 49 CFR) and DOE Packaging and Transportation Directives (e.g., DOE Order 460.1C, DOE Order 460.2A, DOE Manual 460.2-1A, DOE Order 461.1B, and 10 CFR Section 830, Nuclear Safety Management)

31. PERFORMANCE DEGRADATION. Failure or degradation of a facility, process, system, or component that reduces the reliability of critical components of the facility and prevents the system from performing its intended function. Performance degradation does not include: (1) a burned-out power indicator light on a piece of radiation-monitoring equipment that does not prevent the equipment from detecting elevated radiation levels and alarming as designed; (2) a piece of equipment determined to be out of calibration on the conservative side (such as a low-level alarm that is triggered at a higher value than it should); or (3) the temporary loss of a component where redundant components are maintained operable or in operation and the authorization basis is not compromised.

32. PERSONNEL EXPOSURE. An incident of contact or encounter with a hazardous chemical or radiological, physical, biological, or energetic agent at one of the exchange boundaries of the organism (e.g., skin, respiratory system, eyes, ears, or digestive system). Exposure does not refer to a situation where personnel, protected by appropriate personal protective equipment, are subjected to an environment whose ambient conditions present a harmful level of any one, or combination of, the hazards.

33. POLLUTANT. Any material requiring a permit for release into the environment

34. PRE-TRANSPORTATION FUNCTION. A function specified in the Hazardous Materials Regulations (HMR) that is required to assure the safe transportation of a hazardous material in commerce, including: materials classification, packaging, marking, labeling, shipping paper preparation, loading, blocking, bracing, segregating, securing, and placarding (49 CFR 171.8)

35. PRIMARY CONFINEMENT. Provides confinement of hazardous material to the vicinity of its processing. This confinement is typically provided by piping, tanks, glove boxes, encapsulating material, and the like, along with any off-gas systems that control effluent from within the primary confinement.

36. PROGRAM MANAGER. Berkeley Site Office or DOE representative

37. 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

38. RELEASE. Any spilling, leaking, pumping, pouring, emitting, emptying, discharging, injecting, escaping, leaching, dumping, or otherwise disposing of substances into the environment. This includes abandoning/discarding any type of receptacle containing substances in an unenclosed containment structure, but does not include permitted containment structures.

39. REPORTABLE OCCURRENCE. Occurrence to be reported in accordance with the criteria defined in DOE O 232.2.

40. ROOT CAUSE. The causal factor that, if corrected, would prevent recurrence of the occurrence. It is the most basic cause that explains why the event happened; that can reasonably be identified; that senior management has the control to fix; and for which effective recommendations for corrective actions to remedy the problem, prevent specific recurrence of the problem, and preclude occurrence of similar problems can be generated, if necessary. This is typically one level further in analysis beyond the apparent cause(s).

41. SAFETY CLASS STRUCTURES, SYSTEMS, OR COMPONENTS (SAFETY CLASS SSCs). The structures, systems, or components, including portions of process systems, whose preventive or mitigative function is necessary to limit radioactive hazardous material exposure to the public, as determined from safety analyses (10 CFR 830.3)

42. SAFETY SIGNIFICANT STRUCTURES, SYSTEMS, OR COMPONENTS (SAFETY SIGNIFICANT SSCs). The structures, systems, or components that are not designated as safety class structures, systems, or components, but whose preventive or mitigative function is a major contributor to defense in depth and/or worker safety as determined from safety analyses (10 CFR 830.3)

43. SECRETARIAL OFFICER. The Secretary, Deputy Secretary, undersecretaries, and the assistant secretaries and staff office directors reporting to the Secretary either directly or through the Deputy Secretary or undersecretary. The following designations are also used to identify secretarial officers with specific responsibilities in various areas: (1) A program secretarial officer (PSO) is an assistant secretary, office director, or NNSA deputy administrator. In the context of field operations, a PSO funds work at a particular site, facility, or laboratory and is a customer of the field office. (2) A lead program secretarial officer (LPSO) is a PSO to whom designated field offices directly report and who has overall landlord responsibilities for the assigned direct-reporting elements. (3) A cognizant secretarial officer (CSO) is a term used in the context of field operations to designate a PSO, not the LPSO, who is responsible for a laboratory or bounded set of facilities within a field office's jurisdiction.

44. SIGNIFICANCE CATEGORIES. Significance categories provide a means to reflect the perceived risk associated with a given occurrence. The significance categories are:

Operational Emergencies (OE): These are defined in DOE O 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

45. SUSPECT/COUNTERFEIT ITEMS (S/CIs). An item that is suspect when inspection or testing indicates that it may not conform to established government or industry-accepted specifications or national consensus standards or whose documentation, appearance, performance, material, or other characteristics may have been misrepresented by the vendor, supplier, distributor, or manufacturer. A counterfeit item is one that has been copied or substituted without legal right or authority or whose material, performance, or characteristics have been misrepresented by the vendor, supplier, distributor, or manufacturer. Items that do not conform to established requirements are not normally considered S/CIs if nonconformity results from one or more of the following conditions (which must be controlled by site procedures as nonconforming items):

1. Defects resulting from inadequate design or production quality control
2. Damage during shipping, handling, or storage
3. Improper installation
4. Deterioration during service
5. Degradation during removal
6. Failure resulting from aging or misapplication
7. Other controllable causes (IAEA-TECDOC-1169)

Appendix B. DOE Reporting Criteria

Group 1 — Operational Emergencies

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Group 2 — Personnel Safety and Health

Subgroup 2A — Occupational Injuries

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Subgroup 2B — Occupational Exposure

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Subgroup 2C — Fires

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Subgroup 2D — Explosions

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Subgroup 2E — Hazardous Electrical Energy Control

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Subgroup 2F — Hazardous Energy Control (Other than electrical)

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Group 3 — Nuclear Safety Basis

Group 4 — Facility Status

Subgroup 4A — Safety Structure/System/Component Degradation (Nuclear Facilities)

Subgroup 4B — Operations

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Subgroup 4C — Suspect/Counterfeit and Defective Items or Material

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Group 5 — Environmental

Subgroup 5A — Releases

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Subgroup 5B — Ecological and Cultural Resources

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Group 6 — Contamination/Radiation Control

Subgroup 6A — Loss of Control of Radioactive Materials

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

6B — Spread of Radioactive Contamination

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Subgroup 6C — Radiation Exposure

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Subgroup 6D — Personnel Contamination

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

 Group 7 — Nuclear Explosive Safety

 Group 8 — Packaging and Transportation

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Group 9 — Noncompliance Notifications

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Group 10 — Management Concerns and Issues

# = Criterion Number
SC = Significance Category
* = Prompt notification to DOE Headquarters required

Appendix C. Notification and Reporting Matrix

1. Categorization Time is from Discovery Date and Time. Prompt Notification is from Categorization Date and Time. Written Notification is from Categorization Date and Time.
2. Specific Significance Category 2, 3 and 4 occurrences (identified with an asterisk in Appendix B) also require prompt notification to DOE HQ OC.

Appendix D. Causal Analysis Tree

Go here to download an electronic copy of the Causal Analysis Tree.

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