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**LBNL ORPS REPORT WORKSHEET**

**Notes and instructions:**

1.  Fields with asterisks (\*) must be completed, at the minimum, for
    the notification report. All other fields are to be completed as
    information becomes available.

2.  Some fields in the DOE ORPS database are not applicable to LBNL
    operations, thus field numbers in this form are not sequential.

3.  Electronic version of this form is available at the LBNL ORPS web
    site, [www.lbl.gov/ehs/orps](http://www.lbl.gov/ehs/orps). Other
    ORPS references and resources are available at the website or
    contact the Office of Assessment and Assurance (OAA) at 4046 / 7457
    for additional assistance.

**This ORPS report is a**:

  -- ---------------- -- --------------- -- ---------------- -- ---------------
     **Notification      **Initial          **Latest Update     **Final
     Report**            Update Report**    Report**            Report**

  -- ---------------- -- --------------- -- ---------------- -- ---------------

FACILITY / PERSONNEL INFORMATION

  --------------------------- ------------------ -- ---- -- --- -- -- ------------------ ------------- -- -- --------- -- ------------------ ---- -- ----------
  **\*2. Name of Division /                                                                                                                          
  Department:**                                                                                                                                      

  **\*3. Facility Function                                                                                                                           
  Code** (check only one):                                                                                                                           

                              Explosive (03)                          Tritium Activities                                  Fusion Activities          
                                                                      (09)                                                (10)                       

                              Environmental                           Solar Activities                                    Accelerators (16)          
                              Restoration (11)                        (14)                                                                           

                              Laboratory --                           Laboratory -- R &                                   Balance-of-Plant           
                              Analytical (17A)                        D (17B)                                             -- Offices (99A)           

                              Balance-of-Plant                        Balance-of-Plant                                    Balance-of-Plant           
                              -- Machine shops                        -- Site/outside                                     -- Safeguard /             
                              (99B)                                   utilities (99C)                                     security (99D)             

                              Balance-of-Plant                        Balance-of-Plant                                    Balance-of-Plant           
                              -- Storage (99E)                        -- Laundries (99F)                                  -- Infrastructure          
                                                                                                                          (99G)                      

  **\*5. Name of Division                                                                                                                            
  Director/ Division ORPS                                                                                                                            
  Designee:**                                                                                                                                        

  **\*6. DD / Designee Phone                                                             **\*7. Job                                                  
  No.:**                                                                                 Title of ORPS                                               
                                                                                         Designee:**                                                 

  **\*11. Program /                                                                                                                                  
  Project:**                                                                                                                                         

  **\*12. DOE Secretarial                                                                                                                            
  Office** (i.e., sponsoring                                                                                                                         
  DOE program; Office of                                                                                                                             
  Science \[SC\] is LBNL's                                                                                                                           
  default choice):                                                                                                                                   

                              BV                    EE                EH                                     EI           EM                         FE

                              ME                    NA                NE                                     NP           RE                         SC
                                                                                                                                                     (default
                                                                                                                                                     choice)

                              SE                    SO                SW                                     UE           WA                         

  **\*13.                                                                                                                                            
  System/Building/Equipment                                                                                                                          
  involved in occurrence:**                                                                                                                          

  **\*17. Plant Area** (                                                                                                                             
  building & room location of                                                                                                                        
  occurrence)**:**                                                                                                                                   
  --------------------------- ------------------ -- ---- -- --- -- -- ------------------ ------------- -- -- --------- -- ------------------ ---- -- ----------

**DATE AND TIME INFORMATION**

  ------------------------------------------- ----------- -------- ----------- --------
  **\*18. Discovery** (when event or          **Date:**            **Time:**   
  condition was first identified)                                              

  **\*19. Categorization** (when              **Date:**            **Time:**   
  reportability and significance determined)                                   

  **\*26. DOE Notification**                  **Date:**            **Time:**   

  **\*27. Other Notification (person and      **Date:**            **Time:**   
  organization contacted):**                                                   

                                                                               
  ------------------------------------------- ----------- -------- ----------- --------

**OCCURRENCE DESCRIPTION**

  ------------------------------------------------------- -------------- --------------------- -- ------------- -- -- ---------- ----------------------- --------- --- ------------------------- -- --------------- ----------- -- ----------------------- -- --------- -- -------- --
  **\*20. Subject / Title of Occurrence:**                                                                                                                                                                                                                                          

  **21. Reporting Criteria** (Groups & subgroups are only                                                                                                                                                                                                                           
  identified here. Additional details of reportable                                                                                                                                                                                                                                 
  occurrences are available at:                                                                                                                                                                                                                                                     
  [www.lbl.gov/ehs/orps](http://www.lbl.gov/ehs/orps) or                                                                                                                                                                                                                            
  contact OAA \[ext. 4046/7457\] for further                                                                                                                                                                                                                                        
  assistance)**.**                                                                                                                                                                                                                                                                  

                                                                         Group 1 Operational                                                                           5B Ecological & Cultural                                                                                     
                                                                         Emergencies                                                                                   Resources                                                                                                    

                                                                         Group 2 Personnel                                                                             Group 6                                                                                                      
                                                                         Safety                                                                                        Contamination/Radiation                                                                                      
                                                                                                                                                                       Control                                                                                                      

                                                                         2A Occupational                                                                               6A Loss of Control of                                                                                        
                                                                         Illnesses / Injuries                                                                          Radioactive Materials                                                                                        

                                                                         2B Fires/Explosions                                                                           6B Spread of Radioactive                                                                                     
                                                                                                                                                                       Contamination                                                                                                

                                                                         2C Hazardous Energy                                                                           6C Radiation Exposure                                                                                        
                                                                         Control                                                                                                                                                                                                    

                                                                         Group 4 Facility                                                                              6D Personnel                                                                                                 
                                                                         Status                                                                                        Contamination                                                                                                

                                                                         4B Operations                                                                                 Group 8 Transportation                                                                                       

                                                                         4C                                                                                            Group 9 Noncompliance                                                                                        
                                                                         Suspect/Counterfeit &                                                                         Notifications                                                                                                
                                                                         Defective                                                                                                                                                                                                  
                                                                         Items/Material                                                                                                                                                                                             

                                                                         Group 5 Environmental                                                                         Group 10 Management                                                                                          
                                                                                                                                                                       Concerns / Issues                                                                                            

                                                                         5A Releases                                                                                                                                                                                                

  **\*22. Significance Category (**each reportable                                                                                                                                                                                                                                  
  occurrence has a Significance Category. See                                                                                                                                                                                                                                       
  [www.lbl.gov/ehs/orps](http://www.lbl.gov/ehs/orps).)                                                                                                                                                                                                                             

                                                          Cat 1 --                                                    Cat 2 --                                                                                      Cat - 3                                   Cat 4 --              
                                                          significant                                                 moderate                                                                                      minor                                     some                  
                                                          impact                                                      impact                                                                                        impact                                    impact                

                                                          Special                                 Cat OE --                                                                                                         Cat R -                                                         
                                                          categories                              operational                                                                                                       recurring                                                       
                                                                                                  emergencies                                                                                                                                                                       

  **\*25. Description of Occurrence**                                                                                                                                                               **24.                                                     **Yes**      **No**   
                                                                                                                                                                                                    Subcontractor                                                                   
                                                                                                                                                                                                    Involved**                                                                      

                                                                                                                                                                                                                                                                                    

  **\*28. Operating Conditions of                                                                                                                                                                                                                                                   
  System/Building/Equipment:**                                                                                                                                                                                                                                                      

  **29. Activity Category (**check one):                                                                                                                                                                                                                                            

                                                          01                                                                     02 Maintenance                                                                                    03 Normal Operations                             
                                                          Construction                                                                                                                                                                                                              

                                                          04 Start-up                                                            05 Shutdown                                                                                       06                                               
                                                                                                                                                                                                                                   Facility/System/Equip                            
                                                                                                                                                                                                                                   Testing                                          

                                                          07 Training                                                            08A Transportation                                                                                08B Transportation                               
                                                                                                                                 onsite                                                                                            offsite                                          

                                                          09 Emergency                                                           10                                                                                                11 Facility                                      
                                                          response                                                               Inspection/Monitoring                                                                             Decontamination /                                
                                                                                                                                                                                                                                   Decommissioning                                  

                                                          12 Research                                                                                                                                                                                                               

  **30 Immediate Actions Taken:**                                                                                                                                                                                                                                                   
  ------------------------------------------------------- -------------- --------------------- -- ------------- -- -- ---------- ----------------------- --------- --- ------------------------- -- --------------- ----------- -- ----------------------- -- --------- -- -------- --

**CAUSAL INFORMATION**

**Note:** Formal causal analysis must been done by OAA personnel who
have been trained to the DOE Causal Analysis Tree methodology. Below are
apparent causes (Level A & B nodes) for preliminary causal analysis.
More detailed analysis (Level C nodes) is available at
[www.lbl.gov/ehs/orps](http://www.lbl.gov/ehs/orps). Contact OAA for
assistance. LTA = Less than Adequate

  -------------------- ---------------------- -------------------- ------------------------ -------------- ---------------------
  **31. Causal Codes                                                                                       
  (**check all that                                                                                        
  are applicable):                                                                                         

  **A1                                        **A2                                          **A3 Human     
  Design/Engineering                          Equipment/Material                            Performance    
  Problem**                                   Problem**                                     LTA**          

                       B1 Design input LTA                         B1 Calibration for                      B1 Skill based error
                                                                   instruments LTA                         

                       B2 Design output LTA                        B2 Periodic/corrective                  B2 Rule based error
                                                                   maintenance LTA                         

                       B3                                          B3 Inspection/testing                   B3 Knowledge based
                       Design/documentation                        LTA                                     error
                       LTA                                                                                 

                       B4 Design/installation                      B4 Material control LTA                 B4 Work practices LTA
                       verification LTA                                                                    

                       B5 Operability of                           B5 Procurement LTA                      
                       design/ environment                                                                 
                       LTA                                                                                 

                                                                   B6 Defective, failed, or                
                                                                   contaminated                            

  **A4 Management                             **A5 Communication                            **A6 Training  
  Problem**                                   LTA**                                         Deficiency**   

                       B1 Management methods                       B1 Written                              B1 No training
                       LTA                                         communications method of                provided
                                                                   presentation                            

                       B2 Resource management                      B2 Written communication                B2 Training methods
                       LTA                                         content LTA                             LTA

                       B3 Work organization &                      B3 Written communication                B3 Training material
                       planning LTA                                not used                                LTA

                       B4 Supervisory methods                      B4 Verbal communication                 
                       LTA                                         LTA                                     

                       B5 Change management                                                                
                       LTA                                                                                 

  **A7 Other Problem**                                                                                     

                       B1 External Phenomena                       B2                                      
                                                                   Radiological/hazardous                  
                                                                   material problem                        

  **\*32. Description                                                                                      
  of Cause:**                                                                                              
  -------------------- ---------------------- -------------------- ------------------------ -------------- ---------------------

**EVALUATIONS**

  ------------- -------- --------- -- -------- -- --------------- ----------- --------- -- -------- --
  **33.                                                                                             
  Evaluation by                                                                                     
  Responsible                                                                                       
  Manager:**                                                                                        

  **34. Further          **Yes**      **No**      **If yes,                   **Yes**      **No**   
  evaluation                                      before further                                    
  required?**                                     operations?**                                     

  **If yes, by                                    **Done by                                         
  whom?**                                         when?**                                           
  ------------- -------- --------- -- -------- -- --------------- ----------- --------- -- -------- --

**DEFICIENCIES, LESSONS LEARNED, AND CORRECTIVE ACTIONS**

  --------------- ------------ ----- -- ---------- -- ------------- -- ------------ ----------------------- -- ------------ -----------
  **35. ISM                                                                                                                 
  Deficiencies or                                                                                                           
  Weaknesses                                                                                                                
  (**check all                                                                                                              
  that are                                                                                                                  
  applicable):                                                                                                              

                  Scope of              Analyzed                                    Developed/Implemented                   
                  Work LTA              Hazards                                     Controls LTA                            
                                        LTA                                                                                 

                  Performed                           Feedback and                                             ISM not      
                  Work Within                         Improvement                                              applicable   
                  Controls LTA                        LTA                                                                   

  **36. Lessons                                                                                                             
  Learned:**                                                                                                                

  **37. Similar                                                                                                             
  Occurrence                                                                                                                
  Reports:**                                                                                                                

  **38.                                                                                                                     
  Corrective                                                                                                                
  Actions                                                                                                                   
  (**Describe                                                                                                               
  actions to                                                                                                                
  mitigate and                                                                                                              
  prevent                                                                                                                   
  recurrence of                                                                                                             
  problem. Use                                                                                                              
  addition sheets                                                                                                           
  if necessary):                                                                                                            

  **CA #1:**                                                                                                                

  **Responsible                                                        **Target                                             
  person:**                                                            completion                                           
                                                                       date:**                                              

  **CA #2:**                                                                                                                

  **Responsible                                                        **Target                                             
  person:**                                                            completion                                           
                                                                       date:**                                              

  **CA #3:**                                                                                                                

  **Responsible                                                        **Target                                             
  person:**                                                            completion                                           
                                                                       date:**                                              

  **CA #4:**                                                                                                                

  **Responsible                                                        **Target                                             
  person:**                                                            completion                                           
                                                                       date:**                                              

  **CA #5:**                                                                                                                

  **Responsible                                                        **Target                                             
  person:**                                                            completion                                           
                                                                       date:**                                              
  --------------- ------------ ----- -- ---------- -- ------------- -- ------------ ----------------------- -- ------------ -----------