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ESH Web  Manual 
28: Incident Investigation
Overview Requirements Standards Definitions    


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

Requirements:
Roles and Responsibilities (5.1.10)

Incident Investigation Program Manager

Incident investigation program manager will

  • Notify the ORPS deputy facility manager or program manager of any potential ORPS-reportable events
  • Ensure all reported incidents are recorded
  • Assign accident investigators to non-ORPS events as needed
  • Determine which incidents require scene preservation
  • Act as investigator as needed
  • Manage and track completed investigation forms
  • Track, trend, and analyze incidents
  • Develop prevention strategies based on tracking and trending analysis
  • Make periodic reports as required (real time, weekly, quarterly presentation to the ES&H Coordinating Council)
  • Maintain the lessons learned system

ORPS Facility Manager and/or Deputy Facility Managers

The ORPS facility manager and/or deputy facility managers will

  • Determine which incidents require scene preservation
  • Notify the DOE Stanford Site Office (SSO) of significant events that occur at SLAC
  • Be on call for site emergencies on a rotating basis
  • Review preliminary notification reports (PNRs) and determine from these if an incident will be placed into ORPS
  • Approve notification reports (NRs)
  • Approve final reports

ORPS Program Manager

The ORPS program manager will

  • Coordinate the preliminary notification report (PNR) process with line management
  • Create a notification report (NR) from information contained in the PNR and submit it to the facility manager for approval and signature
  • Transfer information on NRs which are categorized as non-reportable to incident investigation program manager for assignment of accident investigator as needed
  • Assign ORPS incident investigators to ORPS incidents as needed or ensure investigations are already under way
  • Maintain ORPS-related records
  • Ensure that corrective actions arising from ORPS-reportable incidents are submitted to CATS

ORPS Administrator

The ORPS administrator will

  • Enter PNRs and ORPS reports into ORPS
  • Close corrective actions in ORPS as directed by Facility Manager's Office

CAIRS Administrator

The CAIRS administrator will upload OSHA recordable injury data into CAIRS.

Competent Incident Investigators

Competent incident investigators will

  • Investigate OSHA recordable, complicated close call, and other incidents requiring formal investigation
  • Review and approve OSHA recordable injury reports, first aid injuries that are formally investigated, and complicated close call events
  • Be trained in incident investigation

ORPS Incident Investigators

ORPS incident investigators will

  • Investigate ORPS incidents
  • Investigate other incidents as needed
  • Be trained in both causal analysis and incident investigation

ES&H Program Managers and Coordinators

Managers of other ES&H programs and ES&H coordinators will collaborate with the incident investigation program manager to analyze incidents, identify trends, and communicate with the SLAC community. The following have the authority to initiate ORPS preliminary notification reports:

  • Main Control Center (MCC) engineering operator-in-charge (EOIC) , and the accelerator department safety officer (ADSO)
  • Linac Coherent Light Source ES&H coordinator
  • Particle and Particle Astrophysics ES&H coordinator
  • Photon Science ES&H coordinator
  • ES&H Division ES&H coordinator, Chemical and General Safety (CGS) department head, and ES&H program managers

Directors

Directors will designate at least one competent incident investigator and one ORPS incident investigator to investigate injuries under their jurisdiction.

Managers and Supervisors

Managers and supervisors will

  • Have injured employees report to the SLAC Medical Department and ensure that the injured employee fills out side A of the SLAC SU-17 form within 24 hours of the injury
  • Fill out side B of the SLAC SU-17 form within five business days from date of knowledge for all injuries. In most cases this form will serve as the incident report for first aid injuries. More significant first aid injuries or minor injuries that could have been more serious if conditions were slightly different will be formally investigated.
  • Notify the incident investigation program manager of incidents, ensure that incidents requiring treatment beyond first aid are formally investigated, a report compiled, and that the report is signed and a copy sent to incident investigation program manager
  • For their areas of responsibility, managers and supervisors will initiate lesson learned write-ups for the incident if it is of particular interest or value to SLAC and send those to the incident investigation program manager
  • Managers and supervisors will discuss recordable injuries, other significant injuries and close calls with the employees involved as well as with their management chain up to and including the department head and others as necessary
  • Ensure corrective actions arising from non-ORPS incidents that require tracking are submitted to CATS

University Technical Representatives

University technical representatives will

  • Report all subcontractor incidents to the project manager and the incident investigation program manager as soon as reasonably possible
  • Ensure that an investigation is completed and a report is sent to the project manager and the incident investigation program manager

Medical Department

The Medical Department will

  • Respond to serious medical injuries and illnesses
  • Provide medical attention or refer injured employees to other physicians for medical attention
  • Provide injured employees and their supervisors with SLAC SU-17 forms
  • Provide employees with workers' compensation forms when warranted
  • Notify the incident investigation program manager and Safeguards and Security of all injuries and illnesses

Environmental Protection Department

The Environmental Protection (EP) Department will

  • Notify the incident investigation program manager of any serious environmental incident
  • Evaluate and investigate spills, write a spill report, and enter it into BII. (See Chapter 16, "Spills".)

Safeguards and Security

Safeguards and Security will

  • Respond to incidents and start the appropriate levels of response, including
    • Securing the scene and ensuring emergency services have been called (if appropriate)
    • Controlling personnel access and prevent movement of equipment or vehicles in and around the scene
    • Documenting the scene as appropriate, focusing on transient evidence such as liquids or scuff marks
    • Notifying the incident investigation program manager of any incident

Readiness Emergency Management Team

The SLAC Readiness Emergency Management (REM) team will respond to incidents and assist in preserving the scene. Both Safeguards and Security and the REM team may work jointly to secure a scene.

Human Resources

The Human Resources Department will

  • Process any workers' compensation claim
  • Enter injury data into CAIRS
  • Notify Stanford University Risk Management of any recordable injuries

Stanford University Risk Management

Stanford University Risk Management will maintain the OSHA 300 log.

Responder Roles

Please see the following for additional information on specific responder roles to incidents and emergencies:

 

 

continue to Procedures and Specific Requirements (5.2)


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