Chapter 28 Table of Contents. View the entire chapter in a PDF format. Please use the pdf for printing.

Requirements:
General (5.1)

Notification (5.1.1)

The incident investigation program manager must be notified of all incidents. Additional notification requirements depend on the type of incident, as described in Incident Investigation: Notification Requirements [pdf].

Scene Preservation (5.1.2)

The ORPS deputy facility manager or the incident investigation program manager will determine which incidents require scene preservation. For incidents determined to warrant scene preservation, the SLAC Readiness Emergency Management (REM) team will be deployed. SLAC Safeguard and Security and the REM team may work jointly to secure a scene, controlling personnel access and preventing movement of equipment or vehicles in and around the scene. (See Incident Investigation: Scene Preservation Guidelines [pdf].)

Documentation (5.1.3)

Incidents must be documented as soon as possible, using the following such items: photographs, witness statements, reports, inventories, physical evidence, notes, drawings, medical reports, conversations regarding the incident, and timelines. (See Incident Investigation: Evidence Collection Procedures and related [pdf].)

These items are evidence and may be used in legal proceedings. Strict chain of custody procedures should be observed. When responding to an incident particular attention should be paid to documenting transient evidence.

For non-ORPS events, hard-copy reports, forms, photos, and other evidence will be kept in the Chemical and General Safety Department and secured until the evidence is returned, destroyed, or transferred.

For ORPS events, hard-copy reports, forms, photos, and other evidence will be kept by the ORPS program manager until the evidence is returned, destroyed, or transferred.

Classification (5.1.4)

How an incident is investigated and by whom depends on its type; the classification is complex and overlapping, depending on the severity of harm and its object (persons, property, or the environment).

• For injuries, the Medical Department makes the determination of severity when an employee goes to Medical for treatment and the Fire Department makes the determination when responding to emergencies. For other situations, the REM team and Safeguards and Security may make the initial determination of severity.
• The determination of whether a given injury or incident is ORPS-reportable is the responsibility of the ORPS facility manager and his/her deputies.
• The incident investigation program manager will determine which first aid and other incidents require additional investigation. He/she will also determine, in conjunction with supervisors, managers, and other incident investigators, which corrective actions for non-ORPS incidents will be tracked in CATS. (See Incident Investigation: Classification and Notification Flow Chart [pdf] for information on determining the severity of an incident and what steps need to be taken.)

Investigation (5.1.5)

Information Gathering

To maintain the consistency and quality of investigations, investigators are required to obtain all pertinent information related to each incident. (See Incident Investigation: Report Requirements [pdf])

Time Limits

Non-ORPS related internal investigations will be completed within 15 working days from the date of knowledge of an incident. Other limits are given below by type of incident.

Close Calls and Near Misses

The incident investigation program manager will ask line management to investigate close calls that could have caused serious injury, environmental hazards, or significant property damage, or that have good learning value. CGS will supply investigative resources to the cases that have the greatest potential for learning value (approximately 20 percent of these cases will have 80 percent of the learning value).

• These cases will be selected at the discretion of the CGS department head and the incident investigation program manager.
• The CGS department head and the incident investigation program manager have the authority to compel line management to assist in the investigation of close calls.

First Aid Injuries

All first aid injuries will be investigated by supervisors, managers, or their designees and documented using side B of the SLAC SU-17 form. The incident investigation program manager will determine, based on potential severity of the injury or learning value, whether formal investigation is warranted. Any first aid injury requiring formal investigation must be reviewed and approved by a competent incident investigator. (See Incident Investigation: First Aid Investigation Procedure [pdf].)

Side A of the SU-17 must be completed by the injured employee within 24 hours from reporting to the Medical Department; side B by the employee's manager or supervisor within five business days.

OSHA Recordable Injuries

All OSHA recordable cases will be formally investigated by a competent incident investigator. In addition, the results of the investigation should be reviewed and approved by a second competent incident investigator.

OSHA Reportable Injuries

All OSHA reportable injuries will be investigated following the requirements for OSHA recordable injuries, plus notification to OSHA within eight hours.

ORPS Incidents

ORPS incidents must be investigated and signed by an ORPS incident investigator. All ORPS incidents will be investigated by an ORPS incident investigator and at least one person with technical experience in the relevant discipline(s). ORPS reports must be completed within 45 days from the submittal of the preliminary notification report (PNR).

Additional Investigation

The incident investigation program manager and other ES&H program managers will review and request additional information for certain investigations at their discretion.

Reporting (5.1.6)

In addition to specific reports required as part of individual investigations, other reports will be made to communicate individual incidents and trends to appropriate parties. (For lessons learned, see Section Section 5.1.8, “Lessons Learned”.)

Note: These and all widely disseminated reports will be observant of constraints on use of personal identifiers imposed by privacy laws.

Privacy

All widely disseminated reports will be observant of constraints on the use of personal identifiers imposed by privacy laws.

"Real Time" Injury

The incident investigation program manager will ensure all injuries reported to him/her are available through the "Real Time Injury Reporting" system as soon as possible. For incidents warranting corrective actions, status of these actions will be available continuously through CATS.

Weekly

The incident investigation program manager will report all injuries and incidents, including first aid injuries, informally through a weekly report. The target audience for this report is all supervisors, ES&H coordinators, university technical representatives, the Human Resources Department, and the ES&H Division.

Quarterly Reports

Information on the number of injuries and injury rates will be included in the ES&H quarterly report. In addition, the incident investigation program manager will prepare formal quarterly incident presentations for delivery to the ES&H Coordinating Council.

OSHA Injuries

OSHA recordable injuries will be reported to the DOE periodically through the use of CAIRS. The OSHA 300 log for SLAC will be maintained by Stanford University Risk Management. The SLAC Human Resources Department will apprise the university of all new cases.

ORPS Incidents

ORPS investigative reports will be sent to all ES&H coordinators and SLAC supervisors by the ORPS program manager as soon as possible after final reports are posted.

Tracking and Trending (5.1.7)

General

The incident investigation program manager will track all investigated incidents, including total recordable cases (TRC), days away restricted or transferred (DART), days away from work (DAFW), and other injury statistics. The Basic Incident Information (BII) Database will be used for this purpose. The incident investigation program manager will use this information to identify and analyze trends and develop prevention strategies.

Corrective Actions General Requirements

All corrective actions for ORPS-reportable incidents will be managed to completion. The Corrective Action Tracking System (CATS) will be used for this purpose. Once an investigation report is completed the ORPS program manager will submit corrective actions to CATS.

For non-ORPS incidents, items that warrant tracking will be managed to completion using CATS. Only items that were not corrected immediately after the action and have a corrective action that will happen in the future with a close out date must be tracked for non-ORPS incidents. Once an investigation report is completed, either the investigator, or the ES&H coordinator, or the supervisor/manager with responsibility for the event, will submit any corrective action items to CATS.

Other tracking methods, in addition to BII and CATS, will be used as appropriate. Examples follow.

First Aid and OSHA Recordable Injuries

OSHA recordable and first aid injuries will also be tracked in CompWatch.

ORPS Incidents

ORPS incidents will also be tracked in the Occurrence Report (OR) Log maintained by the Facility Manager's Office. That office also keeps all hard-copy, final, signed ORPS investigative reports on file, in addition to posting them electronically.

Lessons Learned (5.1.8)

A collection of lessons learned will be maintained and made available to the SLAC public. These lessons will be gleaned from SLAC incidents, DOE lessons learned, and/or from the community at large. Lessons will be reviewed by subject matter experts (SMEs) for content, lesson value, and appropriateness. Once a lesson is deemed appropriate for general distribution by the SMEs and ultimately the lessons learned program manager, it will be published. (See Incident Investigation: Lessons Learned Guidelines [pdf] and the "Lessons Learned" web page.)

Personnel (5.1.9)

Designation

ORPS Facility Managers

The laboratory will designate an ORPS facility manager, as required by the DOE. In addition, SLAC will appoint ORPS deputy facility managers and an ORPS program manager. The ORPS deputy facility managers must be on call on a rotating basis for site emergencies.

Investigators

Each directorate will designate at least one competent incident investigator and one ORPS incident investigator to investigate incidents under its jurisdiction.

Competent incident investigators are responsible for investigating OSHA recordable, complicated close call, and other incidents requiring formal investigation. ORPS incident investigators are responsible for investigating ORPS incidents and may be called upon to investigate other incidents as needed.

Qualifications

Competent and ORPS incident investigators must be formally trained (see Section 5.3, “Training”).

Readiness Emergency Management Team

SLAC will maintain a readiness emergency management (REM) team composed of competent and ORPS incident investigators, employees from the Chemical and General Safety Department, the Emergency and Preparedness and Response Group, and trained volunteers.

continue to Requirements, Roles & Responsibilities (5.1.10)