LS-ESH-PRM-1.1.1

The only official copy of this file is the one on-line in the NSLS ESH website. Before using a printed copy, verify that it is the most current version by checking the document issue date on the NSLS ESH website.

Number:	LS-ESH-PRM-1.1.1
Section:	INJURY AND INCIDENT/ACCIDENT INVESTIGATIONS, CRITIQUES AND OCCURRENCE REPORTS
Date:	06/18/2007
Revision:	2
Prepared by:	Nicholas F. Gmür
Reviewed by:	Andrew Ackerman, NSLS ESH/Q Manager
Reviewed by:	W. Robert Casey, NSLS-II ESH Manager
Approved by:	Chi-Chang Kao, NSLS Chairman
Approved by:	Steve Dierker, NSLS-II Project Director

1. Introduction

It is important that all incidents, accidents, injuries, and illnesses be investigated in order to determine if steps can be taken to prevent or reduce the likelihood of a similar event in the future. These investigations will be conducted using a graded approach that takes into account the actual and potential severity and consequences of the incident. Many accidents can be investigated by the worker, supervisor and a member of the Light Sources Directorate ESH staff. Some events may require the appointment of a formal review committee involving the Directorate, BNL and DOE personnel. In either case, prompt and complete investigation of incidents and accidents are keys to identifying the causes and establishing effective corrective actions to prevent recurrence.

2. Scope

The requirements of this PRM apply to work at the Light Sources Directorate (including SDL) by all Directorate staff, users and sub-contractors.

3. Responsibilities

a. The NSLS Chair and NSLS-II Project Director are responsible for the overall implementation of this program.

b. The NSLS ESH/Q Manager and NSLS-II ESH Manager are responsible for day-to-day implementation and interpretation of these requirements.

c. Supervisors are responsible to ensure that incidents and accidents are promptly reported to line management. First priority for all supervisors at an accident scene is to take steps to assure medical support as needed for any injured persons and to secure the area to prevent additional injury and property damage. It is also important to maintain the area as-is until released by the ESH Coordinator or ESH Managers to permit pictures or on-the-scene investigation if needed. See NSLS ESH Highlight #32.

d. Workers are responsible to ensure that incidents and accidents are promptly reported to their supervisor and line management.

4. General Requirements

a. Overview

All staff, users and sub-contractors shall promptly report accidents, injuries, ESH deficiencies, emergencies, and off-normal events to Supervisors and Line Management in order to ensure proper response and follow-up. When an abnormal event or condition of significant magnitude is reported to line management, it must be promptly discussed with a

BNL Occurrence Categorizer (631-433-0443)

who determines if the event or condition meets the criteria for a reportable occurrence. The determination will establish the level of follow-up actions required for internal and external notifications, occurrence investigation and analysis, and occurrence reporting. The Laboratory procedures for evaluating occurrences for reportability are defined in the Occurrence Reporting Subject Area . A member of the appropriate ESH staff should be contacted immediately following an incident to coordinate the occurrence reporting process.

b. Injury and Incident Investigation

BNL requirements for injury and incident investigation are defined in the Investigation of Incidents, Accidents, and Injuries Subject Area. In many cases the investigation of an injury or incident can be addressed by the supervisor, the involved workers and a member of the applicable ESH staff, normally the ESH Coordinator. Reporting of the results of the investigation is defined in the referenced Subject Area.

c. Critiques

In some cases, as deemed necessary by the Light Sources Directorate management or as required by BNL policy, a formal critique and review process for the incident will be initiated. In these cases, the NSLS Chair or NSLS-II Project Director will appoint an independent team of personnel to review the incident and issue a report which establishes the causal factors of the incident and identifies appropriate corrective actions to prevent recurrence. In these reviews it is customary to have participation from other BNL organizations and from the DOE. BNL requirements and implementation guidance for this type of review are provided in the Event/Issues Subject Area. Within the Light Sources Directorate the following additional points will be addressed in all critiques:

·        A Witness Statement Form may be requested from the person(s) involved in or observing the incident as soon as possible after the incident.

·        A fact-finding meeting involving all personnel involved in the incident and the members of the critique team will be convened as soon as practical to establish a written time line for the activities and events leading up to the incident. Supervisors of personnel involved in the incident will also be invited to the fact-finding meeting. A draft of the time line will be circulated for factual accuracy review and comment.

·        A draft of the investigation report and recommendations for corrective actions issued by the critique team will be distributed to all involved personnel for a factual accuracy review and comment prior to the issuance of the final report.

·        Each approved corrective action will be assigned to a responsible person and tracked in the NSLS Assessment Tracking System until closed.

d. Risk Assessments

The Directorate maintains a set of job and facility risk assessments that review and analyze the various hazards and associated controls for work activities. Following investigations of injuries and incidents within the Light Sources Directorate work place, the relevant risk assessments will be reviewed and updated as needed to reflect any additional information or controls that were established following the investigation.

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For information regarding this document contact Nicholas Gmur, gmur@bnl.gov,

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