# Presentation: 046744

## Event/Issues Management Subject AreaORPS Subject Area

**Awareness Training**
**December 6, 2006**
**Presented by E. Sierra and J. Usher**

## BNL’s Objective

- Achieve and maintain excellence in science and operations supported by the creation of a learning organization.
- Move beyond responding to the problems of the day and actually get into a true prevention mode by learning what we can from appropriate issues or events.

## Supporting Achievement of BNL’s Objective

- We must have:
- A systematic process that ensures timely, reliable, consistent collection and evaluation of issues and events
- Methods for reporting and investigating the right level of issues/events that yield high quality, value added results
- Methods for ensuring that what we learned is reliably applied to preventing recurrence

## What are the desirable characteristics of Event/Issues Management?

- Processes must be simple, efficient and consistently applied
- Must address the “right level” of events/issues so we don’t get bogged down in “administrivia.”
- A well documented systematic process that is usable and defensible.
- Capitalize on existing systems (ORPS), not invent new ones.

## Institutional Benefits

- BNL management (at all levels) can define and analyze “lower level” events/issues and take action to prevent and/or mitigate undesirable consequences.
- 	“Lower level” issues and events are now clearly defined  for consistent use across our institution.
- The ability to trend across the site can provide better information to effect improved performance.
- Systematic, formalized trending addresses DOE expectations for ORPS, PAAA, and the Worker Safety and Health rule.

## There are Some Cons

- Categorizer’s work loads will increase.  The increase can be estimated but is largely unknown.
- Requirements for analysis of events/issues will increase the burden on the owner (line organizations) but many existing subject areas already require analysis/response that may not be happening.

## The development of the Event/Issues Management Process  (documented in SBMS) 

- Analyzed findings regarding effectiveness of critiques, issues management, and action management
- Reviewed processes in place at other Labs
- Established Development Team (science and support representation)
- Team drafted subject area based on ORPS, Critiques, Corrective/Preventive Action
- Team drafted Criteria for lower-level reporting (consulted with Categorizers and SMEs)
- Developed Implementation Plan and issued Subject Area

## Implementation Plan

- Subject Area issued and posted on SBMS - Sept. 28
- Compliance with most of Subject Area as of Nov. 1
- Multiple awareness sessions scheduled in October (required for Level 1 and 2 Managers and Qualified Facilitators)
- Facilitator training in Jan.
- Qualified Facilitators available Feb. 1, 2007 (QMO support required in interim per ALD ESH&Q memo)
- Causal Analysis training ongoing (Dec. and beyond)
- Full compliance as of Feb. 1, 2007

## Training Instructional Goals

- Communicate the requirements (highlighting what’s new) in the Event/Issues Management Subject Area
- Communicate the responsibilities (highlighting what’s new) in the Subject Area
- Improve awareness of the ORPS Subject Area

## Event/Issues Management Super Subject Area

**Subject Area Sections**
**1. Initial Response to Event**
- 	Address injuries, secure the scene,
- 	notify your supervisor, and
- 	call the Categorizer
- 	*What about ORPS?*
**2. Scheduling Fact-Finding Meetings**
- 	Contact the SME who assigns a Facilitator, schedule the meeting, invite only necessary participants
**3. Conducting Fact-Finding Meetings**
- 	Gather information/facts, develop a timeline, prepare the Event/Issue Summary Form

## E/I Management Subject Area (continued)

**4. Analyzing Event/Issues**
- 	Select issues to be analyzed, select causal analysis method(s), analyze, ORPS cause codes, extent of condition review
**5. Developing Corrective and Preventive Actions**
- 	Develop actions, prioritize actions, assign/schedule actions working with owners, submit to ATS
**6. Managing Corrective and Preventive Actions**
- 	Status actions, extend due dates, verify closure of actions, validate effectiveness of actions, close the Assessment in ATS

## Insert the flowchart here?

## Section 1. of the Subject AreaInitial Response to the Event 

- Address any injuries, mitigate any safety issues, preserve, and **secure the scene** of the incident.
- If the event is perceived as an **emergency**, activate an appropriate alarm and/or call extension **2222 or 911**.
**Report the event to your supervisor** (if unavailable, to the next higher level of management), as soon as practical, or to the ES&H Coordinator who must notify the Department Chair/Division Manager, as appropriate.

## When do I Call the Event Categorizer? 

- If the abnormal event,
- Endangers the health and safety of staff or the public;
- Has an adverse effect on the environment;
- Impacts the operations and intended purpose of BNL facilities; or
- Has the potential to result in the above impacts;
- contact the **Event Categorizer** via cell phone at **631-433-0443**, **as soon as practical**, but allowing enough time so that a determination of reportability will take place **within two hours of the event discovery.**

## 1. Initial Response to the Event (continued)

- If the Event Categorizer determines that the event meets the criteria for an **ORPS reportable** occurrence, then follow the procedures in the ORPS Subject Area.
- If the Event Categorizer determines that the event is **Significance Category BNL** **(SCBNL),** the Event Owner initiates a Fact-finding Meeting.
- Otherwise line manager’s discretion, dictates path forward.

##                 Purpose of

**“****Primary”**** - Notification System**
- Ensure Prompt Notification of _Significant_ Events to Senior DOE Management
**“****Secondary”**** - Data Collection System**
- Management Tool for Improvement

## Event Significance Categories

_**ORPS:**_
- Operational Emergency
- Significance Category 1 (SC1)
- Recurring (SCR)
- SC2
- SC3
- SC4
_**BNL Internal Reporting:**_
- Significance Category BNL (SCBNL)

## Event Reportability Criteria

**Operational Emergencies**
**Personnel Safety ****(SCBNL added)**
**Nuclear Safety Basis**
**Facility Status ****(SCBNL added)**
**Environmental**
**Cont/Rad Control ****(SCBNL added)**
**Nuclear Explosive Safety**
**Transportation**
**Noncompliance Notifications**
**Management Concerns/Issues**

## SCBNL Criteria 

_**Group 2 - Personnel Safety and Health**_
- A. An occupational injury that
- Requires hospitalization
- Results in simple fractures of fingers, toes, or nose, or a minor chipped tooth
- Causes damage to nerves, muscles, tendons, and/or ligaments as determined by a physician
- Causes third-degree burns
- Causes second degree burns with the exception of burns to extremities
- B. Any fire on the BNL site

## SCBNL Criteria 

_**Group 4 - Facility Status**_
- Any evacuation not due to false alarm or part of drill/exercise
- Any Stop Work issued for confirmed imminent danger
_**Group 6 - Contamination/Radiation Control**_
- Loss of radioactive material which exceeds 50% of the quantities specified in 10 CFR Part 835, Appendix E, or loss of accountability of such material for more than 24 hours.
- Identification of onsite radioactive contamination greater than 5 times the total contamination values in 10 CFR 835 Appendix D
- Identification of onsite legacy radioactive contamination greater than 5 times the total contamination values in 10 CFR 835 Appendix D

## SCBNL Criteria 

_**Group 6 - Contamination/Radiation Control**_
- Any single occupational exposure that exceeds an expected exposure or dosimetry result by: (1) 250 mrem Committed Effective Dose Equivalent (CEDE), or (2) the greater of 5% or 50-mrem effective dose equivalent due to external exposure.
- Determination of an estimated annual dose that exceeds 5 mrem Total Effective Dose Equivalent (TEDE) for offsite exposures to a member of the public from air pathways only.
- Any onsite contamination of personnel or clothing (excluding site-provided protective clothing) that exceeds 5 times the values for total contamination identified in 10 CFR Part 835, Appendix D. The contamination level must be based on direct measurement and not averaged over any area. This criterion does not apply to tritium contamination.

## ORPS Reportable and Nonreportable Cat Entries

## CAT Electronic Entries 4th Qtr FY06Backfit Analysis (SCBNL’s)

**07/18 – RK, Contaminated TMI resin spill at B830**
**07/20 – RK, Pulling cable along floor results in back strain**
**07/31 – KK, A/C mechanic cuts arm at RSB Construction Site**
**07/31 – AL, Trit cont on unposted benchtop in a posted RMA at B490**
**08/09 – KS, Stop Work Order issued due to antennae at edge of B510 roof**
**08/11 – ES, Injury (fracture of 3rd metatarsal)** **after tripping over rug/mat **
**08/21 – MD, Leg laceration while descending ladder at B1005**
**09/29 – SM, A/C mechanic lacerates finger tendon  **

## Insert the flowchart here?

## Section 2. of the Subject AreaScheduling Fact-finding Meetings 

**The Event Owner:**
- contacts the SME (Ed Sierra, ext. 4080) or designee, who appoints a qualified fact-finding meeting Facilitator
- and Facilitator discuss the event and determine the scope and expected outcomes of the fact-finding meeting.
- Schedules (ASAP) the time and place for the fact-finding meeting.
- invites the following staff and limits attendance to only those staff:
- Facilitator;
- A scribe (to record meeting minutes/notes);
- Staff involved in the event or operation;
- Witnesses to the event;
- Supervisors of the staff who were involved in the event or operation;
- Brookhaven Site Office (BHSO) facility representative.
- Requests that relevant items be brought to meeting (checklist)

## What is a Qualified Facilitator? 

- Candidates nominated by Level 1 and 2 Managers
- A person trained in the Event/Issues Management process (**today’s training required**)
- and
- trained to be an “Effective Facilitator” (**training in Jan. 2007**)
- A Qualified Facilitator will support the Event Owner in ensuring that the fact-finding meeting stays on track to develop a timeline of what happened and will prevent the meeting from evolving into fault-finding instead of fact-finding.

## Facilitators in the Interim 

- It is expected that a cadre of **Qualified Facilitators** will be in place before **Feb. 1, 2007.**
- Prior to the establishment of the cadre, the ALD ESH&Q’s memorandum will remain in force: for ORPS or SCBNL (after Nov. 1) events, contact the Quality Management Office so that a member of that Office may facilitate or observe fact-finding meetings.

## Section 3. of the Subject AreaConducting Fact-finding Meetings 

- The Event Owner convenes the meeting and gives an overview of the fact-finding process to the team.
- The Facilitator ensures that the team collates the facts and establishes the chronology of the event.
**Note:** The Facilitator ensures that the team does not attempt to "problem solve" at this stage.
- The Scribe and Event Owner prepare the fact-finding meeting summary using the **Event/Issue Summary Form**** **(web-based demonstration).
**Remember:**** Fact-finding not fault-finding**

## Change Focus  to "What Happened“ (Fact-finding)

**Incident**

**Events**

**Events**

## Slide 30

## Why fill out the E/I Summary Form?

- Prevent More Serious Events from Occurring by Focusing on Review and Analysis of Low Significance (**low-level**) Events

**Radiological Awareness Reports**

**Assessments**

**Tier 1**

**ORPS/ACCIDENTS/PAAA**

**Spills**

**Nonconformances**

**Audits**

**SCBNL**

**Incidents**
**Conditions**

## Insert the flowchart here?

## Section 4. of the Subject AreaAnalyzing Event/Issues 

- Up until now we’ve been dealing with **Events** only.  Now we are bringing in _**Issues**_ such as findings from assessments.
- If the assessment report (from IA&O or DOE, for example) instructs the Issue Owner to conduct **causal analysis** and submit an action plan, Owner should follow those instructions and proceed through E/I Management.
- If the assessment report is published with no instructions as to response, then the Issue Owner decides whether or not to proceed through E/I Management with the findings.

## 4. Analyzing Event/Issues (continued) 

- The **Issue Owner** reviews each finding from the assessment to determine if the finding:
- Endangers the health and safety of staff or the public;
- Has an adverse effect on the environment;
- Impacts the operations and intended purpose of BNL facilities; or
- Has the potential to result in the above impacts.

## 4. Analyzing Event/Issues (continued)

- The Event/Issue Owner reviews _**Causal Analysis Methodology Selection Guidance**_ and determines the appropriate method to use.
- Using the methodology(ies) selected, analyze the event/issue to **determine the cause(s).**
- Help will be provided to map identified cause(s) to the ORPS _**Causal Code Tree**_
- The Event/Issue Owner determines the need for an _**Extent of Condition/Cause (EoC) review**_ and conducts the review if necessary.
- Document the analysis on the (simple) _**Event/Issue Summary Form**_**.**

## Why Do a Causal Analysis?

***“******It’s impossible to solve significant problems using the same level of knowledge that created them!”***

## Causal Analysis Methodologies “Recipes for Effective Corrective Actions”

_**Low Complexity Level**_
- Brainstorming
- Expert Judgment
- What-if Analysis
- Five Whys
_**Moderate Complexity Level**_
- Barrier Analysis
- Change Analysis
- Events & Causal Factors Analysis

_**High Complexity Level**_
- TapRooT®
- Fault Tree Analysis
- Management Oversight and Risk Tree Analysis

## Causal Analysis Support

- Help is available for conducting causal analysis.
- SMEs are available for all the methods listed.
**Contact Ed Sierra x4080** for assistance.
- 50 people recently completed training in Five Whys and Barrier Analysis.
- Training in other methods will also be provided.

## ORPS Cause Code Structure

**ORPS Cause Code Structure**

**Notes:**
Talking  Points

## Extent of Condition/Cause Review

- 1. Does the **same (or very similar) problem/condition** possibly exist elsewhere?
- 2. Do the **same causes** of the problem/condition possibly affect performance elsewhere?
- If yes, then look for:
- the same or similar affected equipment;
- the same problem in other applications, locations or facilities;
- other manifestations of the causes of the problem.
**Help is available to deal with issues that cross organizational boundaries.    **

## Section 5. of the Subject AreaDeveloping Corrective and Preventive Actions

- Develop **corrective and/or preventive action** that addresses the _cause(s)_ of the event/issue of concern.
**Corrective** - actions taken to resolve events or problems (“stop the bleeding”) prior to formal causal analysis.** **
**Preventive** - actions carefully designed to eliminate or reduce the likelihood of recurrence of events or issues. Action results from formal causal analysis.
**Preventive actions address causes while Corrective actions address events/issues.**

## Action Selection Guidance

- Action types (**physical, administrative, management**) are compared using level of effectiveness.
- Examples are provided for each action type.
- Advantages and disadvantages of each type are listed.

## Prioritization of Actions

- Actions are identified as “Corrective” or “Preventive” for entry into ATS.
- Owners may develop other actions intended to improve performance (“Improvement”) that do not address causes.
- A pull-down menu in ATS lists
- 		**Preventive**
**	****	****Corrective**
**	****	****Improvement**** **

## Finalizing the Action Plan

- The Event/Issue Owner identifies and _**works with**_ appropriate Condition/Action Owners to develop actions and schedule due dates.
- Assistance is available to help with the action plan.
- The action plan is tracked to completion in the Institutional ATS.

## Section 6. of the Subject Area Managing Corrective and Preventive Actions 

- The Assessment Owner periodically **statuses** actions to determine if actions are on schedule to be completed as planned.
- If Corrective/Preventive actions cannot be completed by the assigned due date, the Action Owner (**with ALD or Level 1 Manager concurrence**) can extend the due date with justification by using the appropriate update form in ATS.

## Closing Actions 

- As Actions/Conditions are completed, the Owners provide the ATS Administrator with the appropriate closure form.
- For **Preventive** actions, the Action Owner also submits the Action Closure Verification Checklist.

## Verification of Action Closure 

- Basically this is asking the question, “Were the actions implemented as defined in the action plan?”
- Examples are provided for:
- 	**Changing policy or procedure**
**	****Development or conduct of training**
**	****Conducting an assessment**

## Effectiveness of Actions (only for Preventive actions)

- The Subject Area provides a tool that will help, basically asking the question, “Are the actions working as intended to solve the problem and/or prevent recurrence?”
- A list of methods of effectiveness reviews is provided.
- Examples are provided for:
- 	**Changing policy or procedure**
**	****Development or conduct of training**

## Insert the flowchart here?

## Summary Message 

**This initiative is a Lab-wide performance expectation**
- 	Causes of low level events/issues are almost always the causes of significant events/issues
- 	Fixing the causes of low level events/issues clearly reduces the likelihood of future significant events/issues
**Events/issues do not speak for themselves**
-      Analysis is essential
-      Help is available each step of the way
**Organizational response is more significant than the events/issues themselves**
- 	Understanding and using a systematic, well-documented process will help us succeed in this effort
-      Encouraging open, honest reporting is the crucial first step

## Takeaways

- Take this message back to those who aren’t here—report events/issues to your supervisor/others as required.
- Contact the Event Categorizer via cell phone number 631-433-0443 as soon as practical.
- If you need help with any of this or have a question or comment, call:
**	****Ed Sierra x4080****	****	****John Usher x2096**
**	****Jessie Wilke x6135****	****	****Roy Lebel x6392**

## End  of  Training !