ESH100.4.RPT.3

Policy Area

ESH-Environment Safety & Health

Procedure Number

ESH100.4.RPT.3

Procedure Title

Report Occurrences

Procedure Manager

BENDURE, ALBERT O.

Status

Active

Subject Matter Expert

Robert S. Goetsch (Bob)

Applicability, Exceptions, and Consequences

This procedure applies to Members of the Workforce who identify, report, or own occurrences.

Exceptions to, or deviations from, this procedure must be approved through the Executive Policy Sponsor or Policy Area Manager, if delegated. Click here to view Contacts for Corporate Policies, Processes, and Procedures. See CG100.1.7, Request an Exception to a Policy, Process, or Procedure, for directions on how to obtain an exception to this procedure.

Granting or permitting exceptions or violations of policy, process, or procedure without authority, regardless of position or title, may be cause for disciplinary action up to and including termination of employment. Violating a policy, process, or procedure may be cause for disciplinary action up to and including termination of employment.

IMPORTANT NOTICE: A printed copy of this document may not be the document currently in effect. The official version is located on the Sandia National Laboratories Sandia Restricted Network (SRN).

Procedure Overview

This procedure describes the requirements to identify and report events and implement occurrence management and reporting requirements.

Procedure Requirements

Training

Activity	Responsible Individual	Required Action
Ensure Training Compliance	Managers	Ensure that Members of the Workforce complete the training identified in ESH100.4.RPT.3 prior to performing the indicated work activity or fulfilling the indicated role. Note: See Sandia corporate procedure HR100.2.1, Identify and Complete Sandia Required Training for all Members of the Workforce.

Activity

Responsible Individual

Required Action

Ensure Training Compliance

Managers

Ensure that Members of the Workforce complete the training identified in ESH100.4.RPT.3 prior to performing the indicated work activity or fulfilling the indicated role.

Note: See Sandia corporate procedure HR100.2.1, Identify and Complete Sandia Required Training for all Members of the Workforce.

Ownership of Occurrence Reports

Activity	Responsible Individual	Required Action
Own Occurrences	Vice President	Designates a facility manager/designee (FM/D), if the vice president (VP) does not personally assume that responsibility. Note: A facility manager, with respect to occurrence reporting and related processes, is the VP who is responsible for the division where the occurrence happened. Facility managers may delegate occurrence-reporting responsibilities to a designee who is a center director or below. Delegation should be documented per CG 100.5.4 requirements.
Ensure Quality of Occurrence Reports	Facility Managers/ Designees	Ensure the quality, accuracy, and approval of final occurrence reports. Note: Center directors are responsible for this when they are delegated occurrence reporting responsibilities and when others are delegated occurrence reporting (OR) responsibilities by facility managers.

Activity

Responsible Individual

Required Action

Own Occurrences

Vice President

Designates a facility manager/designee (FM/D), if the vice president (VP) does not personally assume that responsibility.

Note: A facility manager, with respect to occurrence reporting and related processes, is the VP who is responsible for the division where the occurrence happened. Facility managers may delegate occurrence-reporting responsibilities to a designee who is a center director or below. Delegation should be documented per CG 100.5.4 requirements.

Ensure Quality of Occurrence Reports

Facility Managers/
Designees

Ensure the quality, accuracy, and approval of final occurrence reports.

Note: Center directors are responsible for this when they are delegated occurrence reporting responsibilities and when others are delegated occurrence reporting (OR) responsibilities by facility managers.

Handling Events

Activity	Responsible Individual	Required Action
Handle Events	Facility Managers/ Designees	Keep responsibilities for all aspects of the occurrence reporting process for events within your areas. Qualify events within your controlled areas as reportable occurrences according to the Occurrence Management Reporting Criteria. Note: See the Occurrence Management (OM) website for reporting time constraints. Follow events that are classified as reportable occurrences according to the Occurrence Reporting Model (ORM) requirements at the Occurrence Reporting website and take action as follows: Notify the DOE/NNSA Sandia Site Office (SSO) according to the reporting requirements listed on the occurrence reporting ORM model. Note: See the notification process and list of SSO facility contacts, including facility representatives at the OM website. Notify the Sandia Occurrence Management (OM) Representative (i.e., the occurrence reporting staff) immediately. Notify the appropriate ES&H coordinator of the event. Investigate, analyze, and report occurrences properly. Participate in the process to facilitate a thorough investigation, quality reports, and effective follow-up actions through appropriate personnel (e.g., division ES&H team personnel, applicable subject matter experts, etc.). Review reports through a derivative classifier (DC). Write reports for a broad audience and according to the Critique Template. Submit reports to SNL's Occurrence Management representative for transmittal to DOE's Occurrence Reporting Process System (ORPS). Identify lessons learned and generic or programmatic implications and take actions to minimize or prevent recurrence. Identify causes and implement corrective actions (see CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews, and CG100.6.6, Perform Corrective Action). Retain all supporting information pertaining to occurrence reports (e.g., graphs, analyses, and formal investigation reports) in accordance with the Sandia Records Retention and Disposition Schedule. If in electronic format, documentation must be maintained in a location that provides SSO access per H-3 Contractor Assurance System Clause Section A. Keep required record material to include causal analysis documentation, corrective action evidence, and initial fact-finding and investigation (critique) information documents. (See Guidance for Critiques for information on performing critiques.) Review occurrence reports and operations information from other organizations to determine generic implications and improve operations within your own facilities (see ESH100.4.FI.2, Identify and Report Lessons Learned). Review occurrence reports and operations information from other organizations to determine generic implications and improve operations within your own facilities (see ESH100.4.FI.2, Identify and Report Lessons Learned).
Handle Events	Members of the Workforce	Upon becoming aware of an event that may constitute a problem, concern, failure, malfunction, or deficiency in equipment, processes, procedures, or programs, which could possibly result in an adverse effect upon DOE or contractor personnel, the public, property, the environment, or DOE's mission, security, or operations: Report the event either as a Non-Occurrence Trackable Event (NOTE) or to the appropriate emergency or non-emergency phone number. Notes: ESH100.3.1, Prepare for and Manage Emergencies, explains the difference between emergencies and non-emergencies. To report an event at non-SNL-controlled premises, follow the reporting procedures of the host site, as appropriate, and contact the SNL occurrence management representative. Notify the appropriate SNL management. Preserve and document the evidence of accidents to the extent feasible (see Initial Accident Scene Investigation and Example Investigation Hold Tag in the Guidance on Handling Events and the Occurrence Reporting Critique Template). Note: Some events require accident investigation by DOE (see DOE O 225.1A, Accident Investigations, Attachment 2, “Accident Investigation Algorithm”).

Activity

Responsible Individual

Required Action

Handle Events

Facility Managers/
Designees

Keep responsibilities for all aspects of the occurrence reporting process for events within your areas.
Qualify events within your controlled areas as reportable occurrences according to the Occurrence Management Reporting Criteria.

Note: See the Occurrence Management (OM) website for reporting time constraints.
Follow events that are classified as reportable occurrences according to the Occurrence Reporting Model (ORM) requirements at the Occurrence Reporting website and take action as follows:
- Notify the DOE/NNSA Sandia Site Office (SSO) according to the reporting requirements listed on the occurrence reporting ORM model.
  
  Note: See the notification process and list of SSO facility contacts, including facility representatives at the OM website.
- Notify the Sandia Occurrence Management (OM) Representative (i.e., the occurrence reporting staff) immediately.
- Notify the appropriate ES&H coordinator of the event.
- Investigate, analyze, and report occurrences properly.
- Participate in the process to facilitate a thorough investigation, quality reports, and effective follow-up actions through appropriate personnel (e.g., division ES&H team personnel, applicable subject matter experts, etc.).
- Review reports through a derivative classifier (DC).
- Write reports for a broad audience and according to the Critique Template.
- Submit reports to SNL's Occurrence Management representative for transmittal to DOE's Occurrence Reporting Process System (ORPS).
- Identify lessons learned and generic or programmatic implications and take actions to minimize or prevent recurrence.
- Identify causes and implement corrective actions (see CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews, and CG100.6.6, Perform Corrective Action).
Retain all supporting information pertaining to occurrence reports (e.g., graphs, analyses, and formal investigation reports) in accordance with the Sandia Records Retention and Disposition Schedule. If in electronic format, documentation must be maintained in a location that provides SSO access per H-3 Contractor Assurance System Clause Section A.
Keep required record material to include causal analysis documentation, corrective action evidence, and initial fact-finding and investigation (critique) information documents. (See Guidance for Critiques for information on performing critiques.)
Review occurrence reports and operations information from other organizations to determine generic implications and improve operations within your own facilities (see ESH100.4.FI.2, Identify and Report Lessons Learned).
Review occurrence reports and operations information from other organizations to determine generic implications and improve operations within your own facilities (see ESH100.4.FI.2, Identify and Report Lessons Learned).

Handle Events

Members of the Workforce

Upon becoming aware of an event that may constitute a problem, concern, failure, malfunction, or deficiency in equipment, processes, procedures, or programs, which could possibly result in an adverse effect upon DOE or contractor personnel, the public, property, the environment, or DOE's mission, security, or operations:

Report the event either as a Non-Occurrence Trackable Event (NOTE) or to the appropriate emergency or non-emergency phone number. Notes:
- ESH100.3.1, Prepare for and Manage Emergencies, explains the difference between emergencies and non-emergencies.
- To report an event at non-SNL-controlled premises, follow the reporting procedures of the host site, as appropriate, and contact the SNL occurrence management representative.
Notify the appropriate SNL management.
Preserve and document the evidence of accidents to the extent feasible (see Initial Accident Scene Investigation and Example Investigation Hold Tag in the Guidance on Handling Events and the Occurrence Reporting Critique Template).

Note: Some events require accident investigation by DOE (see DOE O 225.1A, Accident Investigations, Attachment 2, “Accident Investigation Algorithm”).

Supporting DOE Investigations

Activity	Responsible Individual	Required Action
Support DOE Investigations	Facility Managers/Designee	Note: Sandia facility managers/designees are not required to perform an identical investigation when DOE is conducting Type A or B investigations of an occurrence. Provide support for DOE Type A and Type B investigations to include the following: Gather information to submit to the DOE Accident Investigation Board. Support DOE during their conduct of Type A or B investigations (see Occurrence Reporting Model.). Establish and maintain readiness to respond to accidents, mitigate the consequences, assist in collecting and preserving evidence, and assist with the conduct of the investigation, including preserving the accident scene (see ESH100.4.RPT.5, Report Vehicle Accidents and Property Damage) through photography and other means. Provide office space and equipment for the DOE Accident Investigation Board and provide general administrative assistance. Prepare, implement, and track completion of approved corrective action plans that satisfy judgments of the need identified by the DOE Accident Investigation Boards.

Activity

Responsible Individual

Required Action

Support DOE Investigations

Facility Managers/Designee

Note: Sandia facility managers/designees are not required to perform an identical investigation when DOE is conducting Type A or B investigations of an occurrence.

Provide support for DOE Type A and Type B investigations to include the following:
- Gather information to submit to the DOE Accident Investigation Board.
- Support DOE during their conduct of Type A or B investigations (see Occurrence Reporting Model.).
- Establish and maintain readiness to respond to accidents, mitigate the consequences, assist in collecting and preserving evidence, and assist with the conduct of the investigation, including preserving the accident scene (see ESH100.4.RPT.5, Report Vehicle Accidents and Property Damage) through photography and other means.
- Provide office space and equipment for the DOE Accident Investigation Board and provide general administrative assistance.
- Prepare, implement, and track completion of approved corrective action plans that satisfy judgments of the need identified by the DOE Accident Investigation Boards.

Non-Occurrence Trackable Event

Note: DOE M 231.1-2, Occurrence Reporting and Processing of Operations Information, establishes a class of events that are below the thresholds for occurrence reporting, but still must be tracked and analyzed for trends. The order calls these “non-reportable events” but does not explicitly define them. For clarity, the Sandia Occurrence Management group has renamed this type of event a Non-Occurrence Trackable Event (NOTE). For further information on the NOTE reporting process, see the Occurrence Management Non-Occurrence Trackable Event (NOTE) website.

Activity

Responsible Individual

Required Action

Determine a Non-Occurrence Trackable Event (NOTE)

Members of the Workforce

Contact the ES&H coordinator or facility manager and/or designee regarding submitting the event to the Occurrence Management staff, when an event is determined to be a NOTE.

Notes:

DOE G 231.1-2, Occurrence Reporting and Processing of Operations Information, establishes a class of events that are below the thresholds for occurrence reporting, but still must be tracked and analyzed for trends. The order calls these “non-reportable events” but does not explicitly define them. For clarity, the Sandia Occurrence Management group has renamed this type of event a Non-Occurrence Trackable Event.
For further information on the NOTE reporting process, see the Occurrence Management Non-Occurrence Trackable Event (NOTE) website.

Implementing Tools

Guidance

Handling Events
Guidance for Critiques

Websites

Emergency or Non-emergency phone number.
Occurrence Management (OM).
Occurrence Management Non-Occurrence Trackable Event (NOTE).
Occurrence Management Reporting Criteria.
Occurrence Reporting contacts.
Occurrence Reporting Critique Template. .
Occurrence Reporting Model (ORM).
Reporting time constraints.
Sandia Records Retention and Disposition Schedule.

Required Records and Retention Schedule

Managers must ensure that the records specified below are managed in accordance with the Sandia Records Retention and Disposition Schedule. The applicable Sandia record series number is SA-150-214-000, Occurrence Reports Records. Records include, but are not limited to the following: occurrence report logs, occurrence reports, drawings of areas, photographs, nature and description of occurrence, action taken, corrective action needed with target completion dates, anomaly report, survey results, report of occupational occurrences, motor vehicle accident report, investigation reports, correspondence, photographs, unusual occurrence reports, accident injury reports, summary reports, preliminary unusual occurrence, newspaper clippings, and lessons learned.

Requirement Drivers (Prime Contract Baseline Directives)

DOE O 225.1A DOE M 231.1-1A Chg 2 DOE M 231.1-2 DOE 5480.19, Chg 2

Additional Drivers

DOE O 231.1A, Environment, Safety, and Health Reporting.
DOE G 231.1-1, Occurrence Reporting and Performance Analysis Guide.
DOE G 231.1-2, Occurrence Reporting Causal Analysis Guide.
DOE-NE-STD-1004-92, Root Cause Analysis Guidance Document.
DOE O 151.1B, Comprehensive Emergency Management System.
36 CFR 1236, "Management of Vital Records"
Methodology for Performance Analysis of Occurrences & Non-occurrence Trackable Events.

Training Requirements

Responsible Individual	Required	Recommended
Facility Manager/Designee (FM/D) website.	FM/D training on Occurrence Management (OM) website.	N/A

Related Processes and Procedures

Processes

ESH100.3, Perform Work.
ESH100.4, Feedback and Improve.

Procedures

CG100.5.4, Implement Conduct of Operations.
CG100.6.6, Perform Corrective Action.
CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews.
ESH100.3.1, Prepare for and Manage Emergencies.
ESH100.4.FI.2, Identify and Report Lessons Learned.
ESH100.4.RPT.5, Report Vehicle Accidents and Property Damage.

Change Summary

Date	Summary
02/28/2012	Administrative Modified Replaced the references and links to "Critique Checklist” and “Critique Worksheet” with the linked reference, “Critique Template” in Requirements & Instructions. Replaced the SAPLE link for the subject matter expert to a direct e-mail link for improved usability. Added Added the parenthetical information “(See Guidance for Critiques for information on performing critiques.)” to “Requirements & Instructions” under “Handling Events.” Added “Guidance for Critiques” to “Guidance” under “Forms, Links & Tools.”
05/05/2011	*Administrative* Modified Replaced Karen Armstrong with Bob Goetsch as subject matter expert.
12/09/2010	*Administrative* Modified Changed the dictionary links to "facility managers/designees" and "reportable occurrences." (Requirements & Instructions) Changed "OM representative" to "Occurrence Management (OM) Representative" and linked to the dictionary. (Requirements & Instructions) Changed the links to "occurrence reporting staff" and "Occurrence Management staff." (Requirements & Instructions) Changed the link to "Handling Events." (Forms, Links & Tools, Guidance) Changed the links to "Emergency" and "Non-emergency" phone number and "Occurrence Reporting contacts." (Forms, Links & Tools, Websites) Changed the link to 36 CFR 1236. (Drivers)
11/17/2010	*Administrative* Modified Updated SAPLE link to subject matter expert for system consistency. Un-merged cells in Requirements & Instructions for display purposes. Updated all dictionary terms to contain term identification numbers for system consistency.
6/17/2010	*Administrative* Modified Updated hyperlink to SME.
5/11/2010	*Administrative* Modified Updated glossary term hyperlinks throughout document. Updated hyperlink to DOE O 151.1B.
11/13/2009	Administrative Modified Updated link to guidance document “Handling Events."
11/09/2009	Administrative Modified Unbolded 'note' text (Requirements & Instructions, Non-Occurrence Trackable Event) Reformatted several 'notes' separating them from the main text (Requirements & Instructions)
11/04/2009	Administrative Modified Corrected nonfunctioning website link to "OM website" in Procedures, Handling Events.