** **

**3030**

**          Rev. 02/2007**

 

 

**NonCompliance Tracking System**

** **

 

**Introduction**

 

The purpose of this article is to describe the reporting requirements
outlined in the Price Anderson Amendments Act (PAAA) Noncompliance
Tracking System program.

The DOE Office of Enforcement and Investigation is responsible for the
enforcement of nuclear safety regulations applicable to the Department
of Energy\'s (DOE) indemnified contractors. They have established the
internet-based Noncompliance Tracking System (NTS). This system is to be
used by the PAAA Coordinator or alternate for the submission and
tracking of potential regulatory non-compliances exceeding thresholds
specified by DOE and to develop effective corrective actions to prevent
their recurrence. Prompt identification, reporting to DOE, and timely
correction of non-compliances may provide DOE with a basis to exercise
discretion to mitigate civil penalties, and suspend the issuance of
Notices of Violation for certain violations.

This chapter describes the identification and reporting of radiation
protection and worker health and safety non-compliances. It also
identifies threshold reporting criteria intended to be consistent with
guidance provided by the DOE.

Reporting criteria is also derived from portions of DOE Order 232.1A,
Occurrence Reporting and Processing of Operations Information, and its
attendant Manual.

Potential non-compliances beneath those thresholds are tracked through
the ESHTRK database (see FESHM 1040.1) and the Significant Events Log.

# Definitions 

** **

**Computerize Accident Incident Recordkeeping and Reporting System
(CAIRS) --** An on-line DOE database utilized to capture issues
pertaining to workplace injuries.

 

**Occurrence Report and Processing System (ORPS) --** An online DOE
database used to report on incidents and events that meet or exceed
criteria listed in DOE M231.1-2, \"Occurrence Reporting and Processing
of Operations Information\", August 2003.

 

**Environment, Safety and Health Tracking System** (**ESHTRK) -**
Fermilab's internal database tracking system to track non-compliance
issues beneath the NTS threshold.

**Noncompliance Tracking System (NTS)** -- An online DOE database used
to report of potential regulatory non-compliances exceeding thresholds
specified by DOE.

**Significant Events Log** -- An on-line record maintained by the PAAA
and Alternate for the purpose of capturing significant events/issues
that may qualify for reporting under CAIRS, ORPS, NTS.

>  

**Responsibilities**

** **

[The Associate Head, ES&H -RP]{.underline} is responsible for

-   Serving as a co-PAAA Coordinator as designated by the ES&H Director
    for radiological matters

-   Employing a number of venues and methods to identify problems in the
    Radiation Protection Program to evaluate them for possible
    compliance issues.

-   Periodically providing orientation on the PAAA reporting system and
    enforcement procedures to senior management staff and Radiological
    Control Organization personnel.

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-   Consulting with the ES&H Director and other ES&H Section staff to
    identify and implement additional reporting of radiological events
    under ORPS (see FESHM Chapter 3010) and to any external agencies
    under applicable requirements and regulations.

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-   Conducting discussions at regular meetings of Laboratory Management,
    ES&H professionals, the Laboratory Safety Committee and its
    subcommittees including the Radiation Safety Subcommittee

-   Reviewing notifications of events and issues as they arise by
    laboratory management, professional ES&H staff lab‑wide, and other
    concerned individuals, including reports received through the
    Laboratory\'s Employee Concerns Program.

-   Responding to observations made by members of the DOE-Fermi Site
    Office (DOE‑FSO) and other DOE officials, and related follow-up
    activities of the line organization and the Radiological Control
    Organization staff.

-   Reviewing occurrences and programmatic issues identified at other
    facilities.

-   Reviewing results of formal assessments and ESHTRK entries.

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-   Determining need for formal investigations, reports and entries to
    the Significant Event Log, and the NTS.

-   Approving final investigation reports that involve potential PAAA
    non-compliances.

-   Reviewing corrective action as reports are submitted to DOE.

-   Designating an alternate PAAA-Coordinator for radiological matters.

** **[The Associate Head ES&H -SEP]{.underline} is responsible for:

-   Serving as a co-PAAA Coordinator for worker safety and health
    matters as designated by the ES&H Director.

-   Consulting with the ES&H Director and other ES&H Section staff to
    identify and implement additional reporting of Worker Safety and
    Health Program under ORPS (see FESHM Chapter 3010) and to any
    external agencies under applicable requirements and regulations.

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-   Conducting discussions at regular meetings of Laboratory Management,
    ES&H professionals, the Laboratory Safety Committee and its
    technical subcommittees, including the Senior Safety Officer
    subcommittee.

-   Reviewing notifications of events and issues as they arise to
    laboratory management, professional ES&H staff lab‑wide, and other
    concerned individuals, including reports received through the
    Laboratory\'s Employee Concerns Program

-   Responding to observations made by members of the DOE-FSO and other
    DOE officials, and related follow-up activities of the line
    organization and the ES&H Section.

-   Reviewing occurrences and programmatic issues identified at other
    facilities.

-   Reviewing results of formal assessments and ESHTRK entries.

-   Determining need for formal investigations, reports and entries to
    the Significant Event Log, and NTS.

-   Approving final investigation reports that involve potential PAAA
    non-compliances.

-   Reviewing corrective action as reports are submitted to DOE.

-   Designating an alternate PAAA-Coordinator for worker safety and
    health matters.

[PAAA- Coordinator or Alternate]{.underline} is responsible for:

-   Entering non-compliances into the NTS.

-   Conducting a quarterly review of reported incidents, inspection
    reports, and program reviews to identify programmatic trends which
    need to be screened for NTS submission, and notifying the PAAA
    Coordinator and/or Alternate.

-   Inputting any audit, review or trending analysis which meets NTS
    reporting requirements.

-   Coordinating through the host division/section for information
    review.

-   Ensuring forms are completed in a timely manner.

-   Tracking corrective actions and closing them out in NTS upon
    receiving report by the d/s.

[Division/Section (D/S) Heads]{.underline} are responsible for

-   Notifying one of the co-PAAA Coordinators or Alternates of any
    incident or program review that may meet the threshold for reporting
    through the NTS.

-   Conducting investigation into the incident, consulting with the one
    of the co-PAAA Coordinators or Alternates providing sufficient
    information within the allotted time for the submission of the base
    report (CAIRS, ORPS or NTS).** **

-   Assuring all corrective actions are placed into ESHTRK and
    coordinating the implementation of all corrective actions.  See
    FESHM 1040.1 for additional information.

-   Assuring the NTS Coordinator is kept apprised of the closing of
    ESHTRK items or changing of tentative completion dates.

-   Providing the NTS Coordinator with citations as to what
    rules/regulations were violated.

 

** **

**Procedure**

On discovery of an event, the Division/Section should utilize the
flowchart in Appendix B to aid in determining the reporting
requirements.

Any CAIRS or ORPS events that meet the reporting criteria identified in
Appendix A will have a NTS report initiated upon the completion of the
CAIRS report or the filing of the final ORPS.

If as a result of audits, assessments, evaluations or data review issues
are identified meeting NTS criteria, then submission will be required
and coordinated between the ES&H Section and the affected d/s.

Findings/issues identified as a result of an audit/assessment, CAIRS or
ORPS will be entered into ESHTRK for tracking. These items will also be
included in the NTS report.

**NTS Filing Process**

 

1\. The co-PAAA Coordinator or Alternate will initiate the NTS filing
process.

2\. Information required for the NTS report will be taken directly from:

> a\. ORPS or CAIRS report;
>
> b\. Issues identified by means of formal audits that are not routine
> monitoring and inspection activities of the Radiological Control
> Organization;
>
> c\. Repetitive issues identified during formal or informal audits and
> reviews, even minor ones, that could possibly be indicative of
> systematic, rather than isolated failure to properly implement the
> Radiation Protection Program;
>
> d\. Minor issues other than those found and corrected during routine
> monitoring and inspections of potential noncompliance that cannot be
> resolved in a short period of time (a radiological posting having
> fallen off of a door is an example);
>
> e\. Issues that may plausibly lead to other, perhaps more significant,
> non-compliances (a missing sign needed to post the entrance to a high
> radiation area might be an example);
>
> f\. Non-compliances that potentially involve more than one division or
> section.

3\. Additional information, citation references and corrective action
will be obtained from the D/S SSO.

4\. A Draft NTS report will be generated the co-PAAA Coordinator or
Alternate, for review by the affected Division/Section SSO, the ES&H
Director, and DOE-FSO.

5\. Initial submission, update and completed NTS reports will be
generated and retained in a PDF format.

6\. PDF copies will be electronically distributed to the PAAA
Coordinator and Division/Section SSO. It will also be posted on the ES&H
website.

**REFERENCES** 

 

Office of Price-Anderson Enforcement (EH-6) U.S. Department of Energy,
Office of Price Andersen Enforcement (EH-6) Noncompliance Tacking System

## 135 Price Anderson Amendments Act (PAAA) Program Implementation

## Procedures and Guidance Maintained by the DOE Office of Price-Anderson Enforcement maintained at: http://www.eh.doe.gov/enforce/index.html

DOE O231.1A, \"Environment, Safety and Health Reporting\", August 2003

DOE G231.1-1, \"Occurrence Reporting and Performance Analysis Guide\",
August 2003

DOE G231.1-2, \"Occurrence Reporting Causal Analysis Guide\", August
2003

DOE M231.1-2, \"Occurrence Reporting and Processing of Operations
Information\",    August 2003

Appendix A

NTS Reporting Criteria

Associated with DOE O 231.1-2

+-----------------------------------+-----------------------------------+
| **Occupational Injuries or        | **Fire Explosions**               |
| Illness**                         |                                   |
|                                   | 1 Unplanned fire or related event |
| 1\. Fatality/terminal illness SC1 | /explosion within primary         |
|                                   | confinement/containment barrier   |
| 2\. Inpatient hosp \>= 3 pers SC1 | SC 1                              |
|                                   |                                   |
| 3\. \>= 3 pers having DART case   | 2\. Unplanned fire/explosion in   |
| SC2                               | nuclear facility that activates   |
|                                   | fire suppression system SC 2.     |
| 4.Pers exp \> limits requiring    |                                   |
| med                               | 3\. Unplanned fire/explosion in   |
|                                   | non-nuclear facility SC 3 that    |
| treatment SC 2                    | activates a fire suppression      |
|                                   | system or takes longer than 10    |
| 5\. Pers Exposure \> limits SC 3  | minutes to extinguish.            |
|                                   |                                   |
| 6\. Serious Occupational injury   |                                   |
| SC 3                              |                                   |
+-----------------------------------+-----------------------------------+
| **Failure of Hazardous Energy     | **Near Miss**                     |
| Controls**                        |                                   |
|                                   | ORPS Group 10 SC 1- 3             |
| 1\. Process failure/resulting in  |                                   |
| burn shock SC 2                   |                                   |
|                                   |                                   |
| 2\. Process failure/discovery of  |                                   |
| uncontrolled energy source SC 3.  |                                   |
+-----------------------------------+-----------------------------------+
| **Other significant conditions**  |                                   |
|                                   |                                   |
| **Conditions meeting the criteria |                                   |
| of Severity Level 1**             |                                   |
|                                   |                                   |
| (Serious) violations \> high      |                                   |
| relative risk. (OSHA)             |                                   |
|                                   |                                   |
| Contractors who receive a notice  |                                   |
| of violation while under contract |                                   |
| with the Department of Energy     |                                   |
| must create and submit an NTS     |                                   |
| report                            |                                   |
+-----------------------------------+-----------------------------------+
| **Management issues: Repetitive   |                                   |
| noncompliance, programmatic       |                                   |
| issues, intentional violation or  |                                   |
| misrepresentation**               |                                   |
|                                   |                                   |
| **FNAL analysis of eshtrk, audits |                                   |
| and surveys**                     |                                   |
|                                   |                                   |
| Identification of trends,         |                                   |
| patterns or may be of value in    |                                   |
| the DOE Complex.                  |                                   |
+-----------------------------------+-----------------------------------+

**Technical Appendix 30xx**

**Reporting Criteria under NTS**

**Extract from DOE O 231.1-2**

+-----------------------------------+-----------------------------------+
| **Group 2 - Personnel Safety and  | **Group 2 - Personnel Safety and  |
| Health Subgroup A**               | Health Subgroup B**               |
|                                   |                                   |
| **Occupational Illnesses          | **Fires/Explosions**              |
| /Injuries**                       |                                   |
+-----------------------------------+-----------------------------------+
| ** # SC Criterion**               | **\# SC Criterion**               |
|                                   |                                   |
| \(1\) \*1 Any occurrence due to   | \(1\) \*1 Any unplanned fire or   |
| DOE operations resulting in a     | explosion within primary          |
| fatality or                       | confinement/containment           |
|                                   | boundaries for nuclear or         |
| Terminal injury/illness. For      | hazardous material within a       |
| fatalities caused by              | facility.                         |
| overexposures, the intent of this |                                   |
| criterion is to report those      | \(2\) \*2 Any unplanned fire or   |
| caused by acute rather than       | explosion in a nuclear facility   |
| chronic effects.                  | that activates                    |
|                                   |                                   |
| \(2\) \*1 Any single occurrence   | a fire suppression system (e.g.,  |
| requiring in-patient              | halon discharge, sprinkler heads  |
| hospitalization of three or more  | activating), is extinguished by a |
| personnel.                        | fire department, or disrupts      |
|                                   | normal facility operations.       |
| \(3\) 2 Any single occurrence     |                                   |
| resulting in three or more        | \(3\) \*3 Any unplanned fire or   |
| personnel having Days Away,       | explosion in a non-nuclear        |
| Restricted or Transferred (DART)  | facility that                     |
| cases per 29 CFR Part 1904.7. DOE |                                   |
| M 231.1-2                         | a\) Activates a fire suppression  |
|                                   | system,                           |
| \(4\) \*2 Personnel exposure to   |                                   |
| chemical, biological or physical  | b\) Takes longer than 10 minutes  |
| hazards above limits established  | to extinguish following the       |
| by the Occupational Safety and    | arrival of fire protection        |
| Health Administration (refer to   | personnel, or                     |
| 29 CFR Part 1910) or American     |                                   |
| Conference of Governmental        | c\) Disrupts normal operations in |
| Industrial Hygienists, whichever  | a high hazard facility.           |
| is lower, and that requires the   |                                   |
| administration of medical         |                                   |
| treatment beyond simple first aid |                                   |
| on the same day as the exposure.  |                                   |
| \[29 CFR 1904.7(b)(5)(i) and (ii) |                                   |
| define "medical treatment" and    |                                   |
| "first aid."\]                    |                                   |
|                                   |                                   |
| \(5\) 3 Personnel exposure to     |                                   |
| chemical, biological or physical  |                                   |
| hazards above limits established  |                                   |
| by the Occupational Safety and    |                                   |
| Health Administration (refer to   |                                   |
| 29 CFR Part 1910) or American     |                                   |
| Conference of Governmental        |                                   |
| Industrial Hygienists.            |                                   |
|                                   |                                   |
| \(6\) 3 Any single occurrence     |                                   |
| resulting in a serious            |                                   |
| occupational injury.              |                                   |
|                                   |                                   |
| A serious occupational injury is  |                                   |
| an occupational injury that:      |                                   |
|                                   |                                   |
| \(a\) Requires hospitalization    |                                   |
| for more than 48 hours,           |                                   |
| commencing within 7 days from the |                                   |
| date the injury was received;     |                                   |
|                                   |                                   |
| \(b\) Results in a fracture of    |                                   |
| any bone (except simple fractures |                                   |
| of fingers, toes, or nose, or a   |                                   |
| minor chipped tooth);             |                                   |
|                                   |                                   |
| \(c\) Causes severe hemorrhages   |                                   |
| or severe damage to nerves,       |                                   |
| muscles, or tendons;              |                                   |
|                                   |                                   |
| \(d\) Damages any internal organ; |                                   |
| or                                |                                   |
|                                   |                                   |
| \(e\) Causes second- or           |                                   |
| third-degree burns, affecting     |                                   |
| more than five percent of the     |                                   |
| body surface                      |                                   |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **Group 2 - Personnel Safety and  | **Group 10**                      |
| Health**                          |                                   |
|                                   | **Management Concerns /Issues**   |
| **Subgroup C Hazardous Energy     |                                   |
| Control**                         |                                   |
+-----------------------------------+-----------------------------------+
| **\# SC Criterion**               | **\# SC Criterion**               |
|                                   |                                   |
| \(1\) 2 Failure to follow a       | \(1\) 2 Any event resulting in    |
| prescribed hazardous energy       | the initiation of a Type A or B   |
| control process (e.g., lockout    | accident investigation as         |
| /tagout) or disturbance of a      | categorized by DOE O 225.1A,      |
| previously unknown or mislocated  | *Accident Investigation*.         |
| hazardous energy source (e.g.,    |                                   |
| live electrical power circuit,    | \[Note: This reporting criterion  |
| steam line, pressurized gas)      | may raise the significance        |
| resulting in a person contacting  | category of an occurrence already |
| (burn, shock, etc.) hazardous     | reported under separate criteria. |
| energy.                           | Multiple reporting criteria       |
|                                   | should be noted when              |
| \(2\) 3 Failure to follow a       | appropriate.\]                    |
| prescribed hazardous energy       |                                   |
| control process (e.g.,            | \(2\) 1-4† An event, condition,   |
| lockout/tagout) or a site         | or series of events that does not |
| condition that results in the     | meet any of the other reporting   |
| unexpected discovery of an        | criteria, but is determined by    |
| uncontrolled hazardous energy     | the Facility Manager or line      |
| source (e.g., live electrical     | management to be of safety        |
| power circuit, steam line,        | significance or of concern to     |
| pressurized gas). This criterion  | other facilities or activities in |
| does not include discoveries made | the DOE complex. One              |
| by zero-energy                    |                                   |
|                                   | of the four significance          |
| checks and other precautionary    | categories should be assigned to  |
| investigations made before work   | the occurrence, based on an       |
| is authorized to begin.           | evaluation of the potential risks |
|                                   | and the corrective actions taken. |
|                                   |                                   |
|                                   | \[† Note: An SC 1 occurrence      |
|                                   | report requires Prompt            |
|                                   | Notification.\]                   |
|                                   |                                   |
|                                   | \(3\) 1-4† A near miss, where no  |
|                                   | barrier or only one barrier       |
|                                   | prevented an event from having a  |
|                                   | reportable consequence. One of    |
|                                   | the four significance categories  |
|                                   | should be assigned to the near    |
|                                   | miss, based on an evaluation of   |
|                                   | the potential risks and the       |
|                                   | corrective actions taken.         |
|                                   |                                   |
|                                   | \[† Note: An SC 1 occurrence      |
|                                   | report requires Prompt            |
|                                   | Notification.\]                   |
|                                   |                                   |
|                                   | \(4\) \*4 Any occurrence that may |
|                                   | result in a significant concern   |
|                                   | by affected state, tribal, or     |
|                                   | local officials, press, or        |
|                                   | general population; that could    |
|                                   | damage the credibility of the     |
|                                   | Department; or that may result in |
|                                   | inquiries to Headquarters.        |
|                                   |                                   |
|                                   | \(5\) \*4 Any occurrence of such  |
|                                   | significant immediate interest to |
|                                   | offsite personnel and             |
|                                   | organizations that it warrants    |
|                                   | prompt notification to the DOE    |
|                                   | Headquarters Operations Center    |
|                                   | (DOE HQ OC), and which is not     |
|                                   | already designated elsewhere in   |
|                                   | this set of reporting criteria to |
|                                   | have prompt notification          |
|                                   | \[denoted by having an asterisk   |
|                                   | (\*) next to the significance     |
|                                   | category\].                       |
+-----------------------------------+-----------------------------------+

**.**Other significant conditions

+-----------------------------------+-----------------------------------+
| **OSHA BASED**                    | **FNAL IN-HOUSE**                 |
+-----------------------------------+-----------------------------------+
| **Conditions meeting the criteria | **FNAL analysis of ESHTRK, audits |
| of Severity Level 1**             | and surveys**                     |
|                                   |                                   |
| (serious) violations \> low       | Identification of trends,         |
| relative risk. (OSHA)             | patterns or which may be of value |
|                                   | in the DOE Complex.               |
| Contractors who receive a notice  |                                   |
| of violation while under contract | **Management issues: Repetitive   |
| with the Department of Energy     | noncompliance, programmatic       |
| must create and submit an NTS     | issues, intentional violation or  |
| report                            | misrepresentation**               |
+-----------------------------------+-----------------------------------+

Appendix B

**DECISION FLOWCHART**

 

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