**OCCURRENCE REPORT FORM**

NAME OF FACILITY:

FACILITY FUNCTION INVOLVED (check only one):

\[ \] Plutonium Processing/Handling \[ \] Tritium Activities

\[ \] Special Nuclear Materials Storage \[ \] Fusion Activities

\[ \] Explosive \[ \] Environmental Restoration Activities

\[ \] Uranium Enrichment \[ \] Category ÒAÓ Reactors

\[ \] Uranium Conversion/Processing/Handling \[ \] Category ÒBÓ Reactors

\[ \] Irradiated Fissile Material Storage \[ \] Solar Activities

\[ \] Reprocessing \[ \] Fossil & Petroleum Reserves

\[ \] Nuclear Waste Operations \[ \] Accelerators \[ \] Balance-of-Plant

NAME OF LABORATORY, SITE OR ORGANIZATION:

**LAWRENCE BERKELEY NATIONAL LABORATORY**

FACILITY MANAGER/DESIGNEE:

Name:

Title: Phone:

ORIGINATOR:

Name:

Title: Phone:

AUTHORIZED CLASSIFIER:

Name:

Date:

1\. OCCURRENCE REPORT NUMBER

2\. REPORT TYPE AND DATE: [Date]{.underline} [Time]{.underline}

\[ \] Notification Report

\[ \] Initial Update

\[ \] Latest Update

\[ \] Final Report

3\. OCCURRENCE CATEGORY: (check only one)

\[ \] Emergency \[ \] Unusual \[ \] Off-Normal \[ \] Cancelled

4\. NUMBER OF OCCURRENCES: (1Ð30) ORIG. OR: (valid OR number)

5\. DIVISION OR PROJECT:

6\. SECRETARIAL OFFICE: (check only one)

\[ \] DP \[ \] EE \[ \] EH \[ \] EI \[ \] EM \[ \] ER

\[ \] FE \[ \] HR \[ \] NE \[ \] NN \[ \] RW

7\. SYSTEM, BUILDING, OR EQUIPMENT: 8. UCNI: 9. PLANT AREA:

Yes \[ \]

No \[ \]

10\. DATE AND TIME DISCOVERED:

11\. DATE AND TIME CATEGORIZED:

12\. DATE AND TIME OF DOE NOTIFICATION:

13\. DATE, TIME AND NAME OF OTHER NOTIFICATIONS:

14 SUBJECT OR TITLE OF OCCURRENCE:

15\. NATURE OF OCCURRENCE: (check up to 3)

1\. \[ \] Facility Condition

> a\. \[ \] Nuclear Criticality Safety
>
> b\. \[ \] Fires/Explosions
>
> c\. \[ \] Safety Status Degradation
>
> d\. \[ \] Loss of Control of Radioactive Material/Spread Contamination
>
> e\. \[ \] Vital System/Component Degradation
>
> f\. \[ \] Violation/Inadequate Procedures
>
> g\. \[ \] Unsatisfactory Surveillance/Inspections
>
> h\. \[ \] Operations

2\. \[ \] Environmental

a\. \[ \] Radionuclide Releases

b\. \[ \] Hazardous Substances/Regulated Pollutants/Oil

c\. \[ \] Hazardous Material Contamination

d\. \[ \] Ecological Resources

e\. \[ \] Agreement/Compliance Activities

3\. \[ \] Personal Safety

a\. \[ \] Occupational Illness/Injuries

b\. \[ \] Vehicular/Transportation Accident

c\. \[ \] Safety Concerns

4\. \[ \] Personnel Radiation Protection

a\. \[ \] Radiation Exposure

b\. \[ \] Personnel Contamination

5\. \[ \] Safeguards/Security

a.  \[ \] Criminal Acts f. \[ \] Unplanned/Unscheduled Outage of Site
    Security System

b\. \[ \] Unaccounted-for Classified Material or g. \[ \]
Demonstrations/Protests

Compromised Information

c\. \[ \] Substance Abuse h. \[ \] Firearms

d\. \[ \] Intelligence Activities i. \[ \] Other Security Concerns

e\. \[ \] Security Computer Equipment/Systems j. \[ \] Material Control
and Accountability

6\. \[ \] Transportation of DOE Materials (freight)

7\. \[ \] Value Basis Reporting

a\. \[ \] Cost Based

b\. \[ \] Defective Item, Material, or Service

8\. \[ \] Facility Status

a\. \[ \] Facility/Process/Activity Terminating/Curtailing Operations

b\. \[ \] Facility/Process/Activity Shutdown Extension

c\. \[ \] New Facility/Process Startup Delay

9\. \[ \] Nuclear Explosive Safety

10\. \[ \] Cross-Category Items

a\. \[ \] Collectively Significant Related Occurrences

b\. \[ \] Near-miss Occurrences

c\. \[ \] Potential Concerns/Issues

16\. DESCRIPTION OF OCCURRENCE:

17\. OPERATING CONDITIONS OF FACILITY AT TIME OF OCCURRENCE:

18\. ACTIVITY CATEGORY: (check only one)

1\. \[ \] Construction 7. \[ \] Training

2\. \[ \] Maintenance 8. \[ \] Transportation

3\. \[ \] Normal Operations 9. \[ \] Emergency Response

4\. \[ \] Startup 10. \[ \] Inspection/Monitoring

5\. \[ \] Shutdown 11. \[ \] Facility Decontamination/Decommissioning

6\. \[ \] Facility/System/Equipment

Testing

19\. IMMEDIATE ACTIONS TAKEN AND RESULTS:

20\. **[DIRECT CAUSE:]{.underline}** Check only **[ONE]{.underline}
DIRECT CAUSE CATEGORY** and only **[ONE]{.underline}**

**SUBCATEGORY** within the selected direct cause category.

> 1\. \[ \] EQUIPMENT/MATERIAL PROBLEM
>
> a\. \[ \] Defective or Failed Part
>
> b\. \[ \] Defective or Failed Material
>
> c\. \[ \] Defective Weld, Braze, or Soldered Joint
>
> d\. \[ \] Error by Manufacturer in Shipping or Marking
>
> e\. \[ \] Electrical or Instrument Noise
>
> f\. \[ \] Contaminant
>
> g\. \[ \] End-of-Life Failure
>
> 2\. \[ \] PROCEDURE PROBLEM
>
> a\. \[ \] Defective or Inadequate Procedure
>
> b\. \[ \] Lack of Procedure
>
> 3\. \[ \] PERSONNEL ERROR
>
> a\. \[ \] Inattention to Detail
>
> b\. \[ \] Procedure not Used or Used Incorrectly
>
> c\. \[ \] Communication Problem
>
> d\. \[ \] Other Human Error
>
> 4\. \[ \] DESIGN PROBLEM
>
> a\. \[ \] Inadequate Work Environment
>
> b\. \[ \] Inadequate or Defective Design
>
> c\. \[ \] Error in Equipment or Material Selection
>
> d\. \[ \] Drawing, Specification, or Data Errors
>
> 5\. \[ \] TRAINING DEFICIENCY
>
> a\. \[ \] No Training Provided
>
> b\. \[ \] Insufficient Practice or Hands-On Experience
>
> c\. \[ \] Inadequate Content
>
> d\. \[ \] Insufficient Refresher Training
>
> e\. \[ \] Inadequate Presentation or Materials
>
> 6\. \[ \] MANAGEMENT PROBLEM
>
> a\. \[ \] Inadequate Administrative Control
>
> b\. \[ \] Work Organization/Planning Deficiency
>
> c\. \[ \] Inadequate Supervision
>
> d\. \[ \] Improper Resource Allocation
>
> e\. \[ \] Policy not Adequately Defined/Disseminated/Enforced
>
> f\. \[ \] Other Management Problem
>
> 7\. \[ \] EXTERNAL PHENOMENA
>
> a\. \[ \] Weather or Ambient Condition
>
> b\. \[ \] Power Failure or Transient
>
> c\. \[ \] External Fire or Explosion
>
> d\. \[ \] Theft, Tampering, Sabotage, Vandalism
>
> 8\. \[ \] RADIOLOGICAL/HAZARDOUS MATERIAL PROBLEM
>
> a\. \[ \] Legacy Contamination
>
> b\. \[ \] Source Unknown

21\. **[CONTRIBUTING CAUSE:]{.underline}** Check UP TO
**[THREE]{.underline} CONTRIBUTING CAUSE**

**CATEGORIES** and only **[ONE]{.underline}** **SUBCATEGORY** within the
EACH selected contributing

cause category.

> 1\. \[ \] EQUIPMENT/MATERIAL PROBLEM
>
> a\. \[ \] Defective or Failed Part
>
> b\. \[ \] Defective or Failed Material
>
> c\. \[ \] Defective Weld, Braze, or Soldered Joint
>
> d\. \[ \] Error by Manufacturer in Shipping or Marking
>
> e\. \[ \] Electrical or Instrument Noise
>
> f\. \[ \] Contaminant
>
> g\. \[ \] End-of-Life Failure
>
> 2\. \[ \] PROCEDURE PROBLEM
>
> a\. \[ \] Defective or Inadequate Procedure
>
> b\. \[ \] Lack of Procedure
>
> 3\. \[ \] PERSONNEL ERROR
>
> a\. \[ \] Inattention to Detail
>
> b\. \[ \] Procedure not Used or Used Incorrectly
>
> c\. \[ \] Communication Problem
>
> d\. \[ \] Other Human Error
>
> 4\. \[ \] DESIGN PROBLEM
>
> a\. \[ \] Inadequate Work Environment
>
> b\. \[ \] Inadequate or Defective Design
>
> c\. \[ \] Error in Equipment or Material Selection
>
> d\. \[ \] Drawing, Specification, or Data Errors
>
> 5\. \[ \] TRAINING DEFICIENCY
>
> a\. \[ \] No Training Provided
>
> b\. \[ \] Insufficient Practice or Hands-On Experience
>
> c\. \[ \] Inadequate Content
>
> d\. \[ \] Insufficient Refresher Training
>
> e\. \[ \] Inadequate Presentation or Materials
>
> 6\. \[ \] MANAGEMENT PROBLEM
>
> a\. \[ \] Inadequate Administrative Control
>
> b\. \[ \] Work Organization/Planning Deficiency
>
> c\. \[ \] Inadequate Supervision
>
> d\. \[ \] Improper Resource Allocation
>
> e\. \[ \] Policy Not Adequately Defined/Disseminated/Enforced
>
> f\. \[ \] Other Management Problem
>
> 7\. \[ \] EXTERNAL PHENOMENA
>
> a\. \[ \] Weather or Ambient Condition
>
> b\. \[ \] Power Failure or Transient
>
> c\. \[ \] External Fire or Explosion
>
> d\. \[ \] Theft, Tampering, Sabotage, Vandalism
>
> 8\. \[ \] RADIOLOGICAL/HAZARDOUS MATERIAL PROBLEM
>
> a\. \[ \] Legacy Contamination
>
> b\. \[ \] Source Unknown

22\. **[ROOT CAUSE:]{.underline}** Check only **[ONE]{.underline}**
**ROOT CAUSE CATEGORY** and only **[ONE]{.underline}**

**SUBCATEGORY** within the selected root cause category.

> 1\. \[ \] EQUIPMENT/MATERIAL PROBLEM
>
> a\. \[ \] Defective or Failed Part
>
> b\. \[ \] Defective or Failed Material
>
> c\. \[ \] Defective Weld, Braze, or Soldered Joint
>
> d\. \[ \] Error by Manufacturer in Shipping or Marking
>
> e\. \[ \] Electrical or Instrument Noise
>
> f\. \[ \] Contaminant
>
> g\. \[ \] End-of-Life Failure
>
> 2\. \[ \] PROCEDURE PROBLEM
>
> a\. \[ \] Defective or Inadequate Procedure
>
> b\. \[ \] Lack of Procedure
>
> 3\. \[ \] PERSONNEL ERROR
>
> a\. \[ \] Inattention to Detail
>
> b\. \[ \] Procedure not Used or Used Incorrectly
>
> c\. \[ \] Communication Problem
>
> d\. \[ \] Other Human Error
>
> 4\. \[ \] DESIGN PROBLEM
>
> a\. \[ \] Inadequate Man-Machine Interface
>
> b\. \[ \] Inadequate or Defective Design
>
> c\. \[ \] Error in Equipment or Material Selection
>
> d\. \[ \] Drawing, Specification, or Data Errors
>
> 5\. \[ \] TRAINING DEFICIENCY
>
> a\. \[ \] No Training Provided
>
> b\. \[ \] Insufficient Practice or Hands-On Experience
>
> c\. \[ \] Inadequate Content
>
> d\. \[ \] Insufficient Refresher Training
>
> e\. \[ \] Inadequate Presentation or Materials
>
> 6\. \[ \] MANAGEMENT PROBLEM
>
> a\. \[ \] Inadequate Administrative Control
>
> b\. \[ \] Work Organization/Planning Deficiency
>
> c\. \[ \] Inadequate Supervision
>
> d\. \[ \] Improper Resource Allocation
>
> e\. \[ \] Policy Not Adequately Defined/Disseminated/Enforced
>
> f\. \[ \] Other Management Problem
>
> 7\. \[ \] EXTERNAL PHENOMENA
>
> a\. \[ \] Weather or Ambient Condition
>
> b\. \[ \] Power Failure or Transient
>
> c\. \[ \] External Fire or Explosion
>
> d\. \[ \] Theft, Tampering, Sabotage, Vandalism
>
> 8\. \[ \] RADIOLOGICAL/HAZARDOUS MATERIAL PROBLEM
>
> a\. \[ \] Legacy Contamination
>
> b\. \[ \] Source Unknown

23\. DESCRIPTION OF CAUSE:

24\. EVALUATION: (By Facility Manager Designee)

25\. IS FURTHER EVALUATION REQUIRED?:
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....Yes \[ \]
No \[ \]

IF YES, BEFORE FURTHER OPERATION:
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....Yes \[
\] No \[ \]

IF YES, BY WHOM?:

BY WHEN?:

26\. CORRECTIVE ACTIONS:

Corrective Target Actual

[Action Completion Date Completion Date]{.underline}

27\. IMPACT ON ENVIRONMENT, SAFETY, AND HEALTH:

28\. PROGRAMMATIC IMPACT:

29\. IMPACT UPON CODES AND STANDARDS:

30\. LESSONS LEARNED:

31\. SIMILAR OCCURRENCE REPORT NUMBERS:

32\. USER FIELD #1 (124 characters maximum):

33\. USER FIELD #2 (124 characters maximum):

34\. DOE FACILITY REPRESENTATIVE INPUT: (Completed by DOE)

Entered by: Date:

35\. PROGRAM MANAGER INPUT: (Completed by DOE)

Entered by: Date:

36\. SIGNATURES:

FACILITY MANAGER/DESIGNEE

Approved by: Date:

Typed Name:

Telephone No:

DOE FACILITY REPRESENTATIVE/DESIGNEE

Approved by: Date:

Typed Name:

Telephone No:

DOE PROGRAM MANAGER/DESIGNEE

Approved by: Date:

Typed Name:

Telephone No: