Reporting Adverse ES&H Occurrences in ORPS EHS-802

1. Reporting Adverse ES&H Occurrences in ORPSEHS-802 Michelle Flynn / John Chernowski Office of Contract Assurance ORPS Coordinators ext. 4046 / 7457

2. ORPS Training Outline • Introduction • Roles and Responsibilities • Use of ORPS Flowchart • Processing requirements based on significance • Use of ORPS Report Worksheet • Use of ORPS Short Form Worksheet • Overview of LBNL ORPS Website

3. What is ORPS? Occurrence Reporting and Processing System: • A DOE complex-wide process to report adverse ES&H events resulting from work activities at all DOE facilities. • A central database that captures occurrence information and allows for lessons learned, trending and management actions. • Over 40,000 occurrences in the database since inception in 1988.

4. ORPS Objectives • Inform DOE and Lab senior management promptly of significant occurrences and/or conditions that: • affect the health & safety of workers and the public • seriously impact the purpose of facilities • adversely affect the environment • impact the image of DOE • Use of ORPS information to prevent recurrences

5. Examples of Reportable Occurrences • Occupational injury with inpatient hospitalization of 3 or more personnel • Fire burning longer than 10 minutes or activates fire suppression system • Threshold-based radiation incidents: unplanned exposure, contamination, loss of control • Facility shutdown due to safety reasons • Environmental releases or regulatory violations • Exposures to chemical, biological, or physical agents above OSHA and ACGIH thresholds

6. New ORPS Program • Streamlines the number of reportable events from 175 to 55 events applicable to LBNL. Eliminates past nuisance reports. • A more pronounced graded approach: • instead of only unusual and off-normal categories, now four significance categories. • less processing and review/approval for lower significance category events. • More focus on analysis and trending.

7. Roles and Responsibilities LBNL personnel 1. Work safely 2. If involved in or witness an adverse ES&H occurrence, stabilize as safely feasible and call for assistance. Division ORPS Point of Contact 1. Be the point of contact to gather information on the occurrence and communicate to division management and OCA/EH&S. 2. Assist in the investigation, reporting, and corrective actions. 1. Coordinate with divisions on ORPS investigation, reporting, and corrective actions. 2. Interface with DOE/BSO for notification, investigation, reporting, and closeout. 3. Provide data entry for ORPS database. OCA EH&S 1. Serve as subject matter experts for investigations, analysis, and corrective actions. 2. Develop institutional corrective actions as appropriate. Division Director (Facility Mgr) 1. Have overall responsibility for the investigation, reporting, & corrective actions. 2. Approve final ORPS reports.

8. Basic Steps of ORPS 1. Discovery 2. Initial determination Adverse ES&H Occurrence Division ORPS POC assess significance & reportability 5. Processing Occurrences Notification, investigation, reporting, analysis, corrective actions 3. Institutional Support OCA 4. Categorization Group 2 Group 4 Group 5 Group 6 Group 8 Group 9 Group 10

9. Significance Categories Significant impact on safe facility operations, work or public safety & health, regulatory compliance, or public/business interests. Category 1 Significant Impact Moderate impact on safe facility operations, work or public safety & health, regulatory compliance, or public/business interests. Category 2 Moderate Impact Minor impact on safe facility operations, work or public safety & health, regulatory compliance, or public/business interests. Category 3 Minor Impact Some impact on safe facility operations, work or public safety & health, regulatory compliance, or public/business interests. Category 4 Some Impact

10. Special Categories Requires 15 minute prompt notification to DOE/HQ; then treated like Category 1 occurrences Operational Emergencies Periodic trending analysis by OCA may identify recurring events, which will result in a new occurrence report. Category 2R Recurring Processing OR and 2R occurrences will not directly involve division ORPS POC.

11. Group 1 Operational Emergencies Unplanned, significant events or conditions that require time urgent responses from outside of the immediate affected site or facility (i.e., fire department response). CALL 7-911

12. Group 2 Personnel Safety & Health • Subgroup 2A: Occupational iIlnesses/injuries • 3 or more DART cases from single incident • serious occupational injury • Subgroup 2B: Fire/Explosions • all reportable fires/explosions require prompt notification (*). • Subgroup 2C: Hazardous Energy Control • penetration of underground lines NEW!

13. Group 4 Facility Status • Subgroup 4B: Operations • facility evacuation to an actual event; no reporting for false alarms or precautionary evacuations • deviation or inadequate procedures resulting in an adverse effect on safety • *facility shutdown for safety reasons • facility stand-down (secondary criterion) • Subgroup 4C: Suspect/Counterfeit and Defective Items or Material • Cat 4 mechanism for reporting SCI and defective materials

14. Group 5 Environmental • Subgroup 5A: Releases • Call EHS Environmental Service Group for all releases and reporting to regulatory agencies. • Subgroup 5B: Ecological and Cultural Resources • NA

15. Group 6 Contamination/Radiation Control All unusual radiological incidents must be reported to the EHS Radiation Protection Group regardless of thresholds or significance. Subgroup 6A: Loss of Control of Radioactive Material Subgroup 6B: Spread of Radioactive Contamination Subgroup 6C: Radiation Exposure Subgroup 6D: Personnel Contamination

16. Group 8 Transportation • Transport of hazardous materials whose quantity or nature is different than intended, resulting in the disruption of the receiving organization’s operations or corrective actions by the originating organization. • Packaging and transportation activities resulting in the onsite release of hazardous materials. Call appropriate EHS program to determine any threshold and significance.

17. Group 9 Noncompliance Notifications All notices of noncompliance from regulatory agencies should be coordinated with the appropriate EHS program managers.

18. Group 10 Management Concerns/Issues • Determination by line management of significant occurrences or near misses that do not meet any other reporting criteria. Line management determines significance. • * Occurrences that may garner significant and immediate outside interest.

19. Is this reportable? There is a small chemical explosion in a fume hood at an LBNL lab. • The LBNL Fire Department responds to the incident. There is no fire. • The building occupants are evacuated because the building alarm is activated. • Three lab employees are injured, mainly from cuts and bruises from broken glass. All three receive treatment at a local hospital; two are released after first aid; the third stays at the hospital overnight for observation.

20. Is this reportable? Three subcontract workers are working on a scaffold when it breaks apart. The three workers fall off. • One worker has a broken arm. • The other two workers are apparently unhurt and return to work later that day.

21. Is this reportable? An employee who has a joint appointment at both UCB and LBNL transports in his private vehicle two sealed sources from his UCB lab. • It is determined that the transport is in violation of DOT regulations. • The employee has no radiation authorization to use or store the sealed sources in his LBNL lab, and therefore, he is in violation of LBNL rad procedures. • There is no exposure or contamination; the sources were not used, and after discovery, they were properly packaged and transported back to UCB.

22. Is this reportable? A Lab vehicle is reported missing. The next day, the California Highway Patrol notifies the Lab that the vehicle was involved in a crash on I-80. • A Lab employee was identified as the driver and arrested for drunk driving. • He is injured and hospitalized. • The Lab vehicle is totaled; estimated loss is over $10,000.

23. Prompt Notification Category 1 Significant Impact • Contact OCA as soon as feasible after discovery of the occurrence. • OCA will e-mail and phone appropriate DOE elements NO LATER THAN TWO HOURS AFTER CATEGORIZATION. • DOE/HQ prompt notification for all categories identified with asterisks. Category 2 Moderate Impact Category 3 Minor Impact Cat 1 -4 With asterisks Category 4 Some Impact No prompt notification required.

24. Written Notification Before the close of the next business day from categorization, but not to exceed 80 hours. Category 1 Significant Impact Before the close of the next business day from categorization. Category 2 Moderate Impact Before the close of the second business day from categorization. Category 3 Minor Impact Before the close of the second business day from categorization. Use SHORT FORM REPORT. Category 4 Some Impact

25. ORPS Report Worksheet • Download from ORPS website: www.lbl.gov/ehs/orps • Use with all categories except Significance Category 4. • Use for written notification, update reports and final reports. • E-mail to OCA for review and data entry into the DOE ORPS database.

26. Short Form Worksheet • Download from ORPS website: www.lbl.gov/ehs/orps • Use with only Significance Category 4 occurrences. • No other reporting required. • E-mail to OCA for review and data entry into the DOE ORPS database.

27. Investigation, Analysis, Corrective Actions • On a graded basis, EHS subject matter experts should be involved in investigations, causal analysis, & corrective action development. • Causal analysis must follow DOE Causal Analysis Tree (Appendix E). OCA staff have been trained to the DOE methodology. • OCA will use the TapRoot methodology for root cause analysis. • During investigation and analysis, update reports can be submitted with new significant information. • Corrective actions should be tracked in CATS. Category 1 Significant Impact Category 2 Moderate Impact Category 3 Minor Impact Category 4 Some Impact Complete SHORT FORM REPORT and remedy problem.

28. Final ORPS Report Division Directors must approve all ORPS final reports. Category 1 Significant Impact Submit within 45 calendar days; review and approval by DOE elements. Category 2 Moderate Impact Submit within 45 calendar days; no DOE approval required. Category 3 Minor Impact Category 4 Some Impact Only SHORT FORM REPORT required and due within two business days.

29. Performance Analysis & Identification of Recurring Occurrences • On a quarterly basis, OCA will analyze unusual and adverse ES&H incidents or conditions, including non-reportable ORPS events, to identify trends and recurring occurrences. • If a trend is established, a new occurrence report, under Category 2R, is prepared to report the recurring occurrences.

30. Closeout of ORPS Reports • All ORPS reports now on the DOE ORPS database. • Category 4 Short Form Reports are closed out once on the database. LBNL CATS requires close out of corrective actions. • All other ORPS reports are closed out when corrective actions are completed.

31. Key ORPS Resources • ORPS Website www.lbl.gov/ehs/orps • DOE Order 231.1A and DOE Manual 231.1-2 • Reporting criteria • Recent ORPS reports • ORPS Flowchart • simplified description of reporting process • abbreviated description of each reporting criterion • OCA (Michelle Flynn & John Chernowski) • interface with DOE and ORPS database • assist in identifying appropriate reporting criteria & in processing ORPS reports • conduct causal analysis and investigation as applicable.