May 7, 1997
 
MEMORANDUM FOR THE SECRETARY
 
FROM:                John C. Layton
                     Inspector General
                              
SUBJECT:             INFORMATION:  Report on "Audit of
                     Department of Energy Contractor Occupational 
                     Injury and Illness Reporting Practices"
                      
                      
BACKGROUND:
 
The Department and its contractors are responsible for
ensuring that a safe and healthy work environment is
provided to Department and contractor employees at its
operating facilities.  Contractors are responsible for
establishing a comprehensive occupational safety and health
program, which includes reporting of significant work-
related employee injuries.  The Department is responsible
for monitoring the implementation of the contractor's
programs.  Two performance indicators used by the Department
to measure a contractor's safety performance are the number
and severity of work related employee injuries and of lost
workdays rates.  The objective of the audit was to determine
whether Department of Energy contractors accurately reported
occupational injuries and illnesses in accordance with
Departmental requirements.
 
DISCUSSION:
 
Management and operating contractors were not reporting all
significant work-related injuries/illnesses as required by
Departmental and Occupational Safety and Health
Administration (OSHA) guidelines.  The audit identified 111
of 237 judgmentally selected calendar year 1995 cases at the
Savannah River and Lawrence Livermore sites that were
incorrectly categorized as minor.  These cases should have
been reported to the Department as significant injuries or
illnesses.  This underreporting occurred because contractor
personnel did not obtain sufficient medical, restricted work
activity, or lost worktime information relating to the
injury or illness, or they did not properly interpret OSHA
reporting requirements.  In addition, the Department did not
have a systematic process for periodically validating the
completeness and accuracy of contractor generated injury and
illness data.
 
Underreporting of injuries and illnesses has been a
recurring problem at Department of Energy contract
facilities.  In December 1990, OSHA found reporting problems
at about half of the facilities covered in its review,
including underreporting of employee lost workdays and
improper application of work restrictions.  In 1992,
Departmental reviews at the Nevada and Richland Operations 
Offices found instances of recordable work restricted duty 
and medical treatment injury cases that were improperly 
classified as non-recordable or non-occupational cases.  
Similar recordkeeping problems were identified in 1992 and
1994 Departmental reviews at Oak Ridge.  Further, an
October 1996 Departmental review of injury and illness
reporting at the Idaho National Engineering Laboratory
found significant underreporting by subcontractors and
concluded that the subcontractor injury/illness
information reported to the Department was unreliable.
 
Without accurate health and safety information, the
Department cannot adequately manage its occupational
safety and health programs, measure contractor
performance, and ensure that its facilities provide a
safe and healthy work environment.  In addition,
incorrect reporting also could potentially have an
impact on contractor fees.  The Department is
presently developing benchmarks and performance
measures to ensure that its facilities follow "best in
class" policies and practices.  However, without
accurate and complete information provided by
Departmental contractors, this program may not achieve
its intended results.
       
To strengthen the Department's occupational safety and
health program, we recommended that the Managers of
the Savannah River and Oakland Operations Offices
ensure that their contractors take action to correct
the occupational injury and illness recordkeeping
problems identified in the report. We also recommended
that the Department examine all contractor programs
and issue additional guidance delineating OSHA
reporting requirements.  Management generally
concurred with the audit finding and recommendations.
       
Attachment
 
cc:  Deputy Secretary
     Under Secretary
                 
                 
                 U.S. DEPARTMENT OF ENERGY
                OFFICE OF INSPECTOR GENERAL
 
 
 
               AUDIT OF DEPARTMENT OF ENERGY
              CONTRACTOR OCCUPATIONAL INJURY
              AND ILLNESS REPORTING PRACTICES
              
              
              
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 distribution of its reports as customer friendly and cost
  effective as possible.  Therefore, this report will be
available electronically through the Internet five to seven
    days after publication at the following alternative
                        addresses:
                        
         Department of Energy Headquarters Gopher
                     gopher.hr.doe.gov
                     
      Department of Energy Headquarters Anonymous FTP
                    vm1.hqadmin.doe.gov
                    
 Department of Energy Human Resources Administration Home
                           Page
                  http://www.hr.doe.gov/ig
                              
 Your comments would be appreciated and can be provided on
                            the
       Customer Response Form attached to the report.
            This report can be obtained from the U.S.
                  Department of Energy
       Office of Scientific and Technical Information
                         P.O. Box 62
                 Oak Ridge, Tennessee  37831
                              
                              
                              
                              
                              
                              
Report No.:  DOE/IG-0404             Capital Regional Audit Office
Date of Issue:  May 7, 1997          Germantown, Maryland  20874
 
 
 
                AUDIT OF DEPARTMENT OF ENERGY
               CONTRACTOR OCCUPATIONAL INJURY
               AND ILLNESS REPORTING PRACTICES
                              
                              
                      TABLE OF CONTENTS
                              
                              
                                                    Page
         
         SUMMARY . . . . . . . . . . . . . . . . . . 1
 
PART I - APPROACH AND OVERVIEW . . . . . . . . . . . 3 
 
Introduction . . . . . . . . . . . . . . . . . . .   3
 
         Scope and Methodology . . . . . . . . . .   3
 
         Background . . . . . . . . . . . . . . . .  4
 
         Observations and Conclusions . . . . .  .   5
 
PART II -   FINDING AND RECOMMENDATIONS . . . . . .  7
 
         Contractor Occupational Injury and Illness
            Reporting Practices . . . . . . . . . .  7
 
PART III -  MANAGEMENT AND AUDITOR COMMENTS . . . . 16 
 
PART IV  -  OTHER MATTERS . . . . . . . . . . . . . 18
 
PART V - Appendix . . . . . . . . . . . . . . . . . 19
 
         Environment, Safety and Health Management Comments
            on the Draft Report . . . . . . . . . . 19
                  
                  U.S. DEPARTMENT OF ENERGY
                 OFFICE OF INSPECTOR GENERAL
                  OFFICE OF AUDIT SERVICES
                  
                AUDIT OF DEPARTMENT OF ENERGY
               CONTRACTOR OCCUPATIONAL INJURY
               AND ILLNESS REPORTING PRACTICES
 
Audit Report Number: DOE/IG-0404
 
                           
                           SUMMARY
    
    The Department of Energy and its management and operating
contractors share responsibility for ensuring that a safe and
healthy work environment is provided to Department and contractor
employees at its operating facilities. Contractors are
responsible for establishing a comprehensive occupational safety
and health program at each facility, which includes reporting
significant work-related injuries. The Department is responsible
for monitoring the implementation of the contractors' programs.
The objective of the audit was to determine whether Department of
Energy contractors accurately reported occupational injuries or
illnesses in accordance with Departmental requirements.
 
   Management and operating contractors were not reporting all
significant work-related injuries or illnesses as required by
Departmental and Occupational Safety and Health Administration
(OSHA) guidelines.  Through an analysis of judgmentally selected
medical and workers compensation data for three contractors at
the Savannah River and Lawrence Livermore sites, the audit
identified 111 of 237 calendar year 1995 cases that were
incorrectly categorized as minor. These cases should have been
reported to the Department as significant injuries or illnesses.
This underreporting occurred because contractor personnel did not
obtain sufficient medical, restricted work activity, or lost
worktime information relating to the injury or illness, or they
did not properly interpret OSHA reporting requirements. In
addition, the Department did not have a systematic process for
periodically validating the completeness and accuracy of
contractor generated injury and illness data.
 
   Underreporting of injuries or illnesses has been a recurring
problem at Department of Energy contract facilities.  In December
1990, OSHA found reporting problems at about half of the
facilities covered in its review, including underreporting of
employee lost workdays and improper application of work
restrictions.  In 1992, Departmental reviews at the Nevada and
Richland Operations Offices found instances of recordable work
restricted duty and medical treatment injury cases that were
improperly classified as non-recordable or non-occupational
cases. Similar recordkeeping problems were identified in 1992 and
1994 Departmental reviews at Oak Ridge.  Further, an October 1996
Departmental review of injury and illness reporting at the Idaho
National Engineering Laboratory found significant underreporting
by subcontractors and concluded that the subcontractor
injury/illness information reported to the Department was
unreliable.
 
       Without accurate health and safety information, the
Department cannot adequately manage its occupational safety and
health programs, measure contractor performance, and ensure that
its facilities provide a safe and healthy work environment.  In
addition, incorrect reporting also could potentially have an
impact on contractor fees.  The Department is presently
developing benchmarks and performance measures to ensure that its
facilities follow "best in class" policies and practices.
However, without accurate and complete information provided by
Departmental contractors, this program may not achieve its
intended results.
     
     To strengthen the Department's occupational safety and
health program, we recommended that the Managers of the Savannah
River and Oakland Operations Offices ensure that their
contractors take action to correct the occupational injury and
illness recordkeeping problems identified in the report.  We also
recommended that the Department examine all contractor programs
and issue additional guidance delineating OSHA recording
requirements.
 
   Management generally concurred with the finding and
recommendations noting that corrective actions have been
initiated to improve the occupational injury and illness
recordkeeping and reporting process.
                                 ________(Signed)______ 
                                 Office ofInspector General
                             
                             
                             PART I
                                
                      APPROACH AND OVERVIEW
                                
INTRODUCTION
 
    The Department of Energy is responsible for ensuring that
a safe and healthy work environment is provided to Department and
contractor employees at its operating facilities.  Two
performance indicators used by the Department to measure a
contractor's safety performance are the total recordable and lost
workday case rates.  These two indicators are also factors in
contractor performance ratings and award and incentive fee
determinations.
 
   This audit evaluated the processes used by three management
and operating contractors to record and report significant
(recordable and reportable) work-related injuries or illnesses to
the Department.  The objective of the audit was to determine
whether Department of Energy contractors accurately reported
occupational injuries or illnesses in accordance with
Departmental requirements.
 
SCOPE AND METHODOLOGY
 
    Audit fieldwork was performed from March through November
1996 at three of the Department's contractors--the University of
California (Lawrence Livermore National Laboratory), Westinghouse
Savannah River Company, and Wackenhut Services, Inc. (Savannah
River).  Contractor selection was based on injury and illness
data reported in the Department's Office of Environment, Safety
and Health publication entitled "Occupational Injury and Property
Damage Summary, January-September 1995." In addition, fieldwork
was performed at Departmental Headquarters and the Savannah River
and Oakland Operations Offices.  We did not, as part of this
audit effort, evaluate reporting of injuries
and illnesses sustained by Departmental employees.
 
     A review of applicable laws and Departmental orders was
conducted to identify reporting requirements for workrelated
employee injuries and illnesses.  In this regard, it was
determined that the Department utilizes the recording
requirements established under the Occupational Safety and Health
Act and Part 1904 of the OSHA's implementing regulations and
guidelines.  In addition, interviews with OSHA recordkeeping
officials were conducted to obtain their views and
interpretations covering various aspects of its regulations and
guidelines.
 
   In total, 237 judgmentally selected cases involving injuries
or illnesses were examined at two field locations. For each case,
contractor medical or workers' compensation information was
obtained to determine if the employee's injury was severe enough
to warrant medical treatment, work restrictions, or lost
worktime.  OSHA recordkeeping officials were asked to provide
their views on selected cases.  Discussions were also held with
contractor personnel at Savannah River and Lawrence Livermore to
obtain information on selected cases and to gather information on
contractor reporting practices.
 
   For selected contractors, OSHA logs were compared to data in
the Department's Computerized Accident/Incident Reporting System
(CAIRS) and to contractor workers' compensation reports.  These
comparisons were also made to determine if analytical procedures
could be used to identify potential underreporting of significant
injuries and illnesses.  Since the analysis was based on a
judgmental sample, the audit results were not projectable to the
total universe of all calendar year 1995 employee injuries or
illnesses at the two sites.
 
    The audit was made in accordance with generally accepted
Government auditing standards for performance audits and included
tests of internal controls and compliance with laws and
regulations to the extent necessary to satisfy the audit
objective.  Accordingly, we assessed internal controls relating
to contractor compliance with Departmental reporting requirements
for contractor employee injuries and illnesses occurring at
Departmental facilities.  The audit did not significantly rely on
computer-processed data in CAIRS.  Limited testing of the data
disclosed only minor differences between contractor OSHA records
and computerprocessed information.  Because our review of
internal controls was limited, it would not necessarily have
disclosed all internal control and compliance deficiencies that
may have existed.
 
   We discussed our finding with responsible Departmental
Headquarters and field office officials during the course of the
audit.  An exit conference was held with the Savannah River and
Oakland Operations Offices on April 3, 1997.  The Assistant
Secretary for Environment, Safety and Health, however, waived the
exit conference.
 
BACKGROUND
 
   The Secretary's Fiscal Year 1995 and 1996 Performance
Agreements with the President identified environment, safety and
health as one of four factors critical to successfully realizing
the Department's mission.  In accordance with these agreements,
the Department emphasizes prevention and excellence in worker 
protection, public safety and health, and achieving environmental 
standards.  In addition, the Secretary established lost workday 
case rates as a critical safety performance measure for the 
Department.
 
   The Department and its management and operating contractors
share responsibility for ensuring that a safe work environment is
provided to the 155,000 contractor employees that work at
Departmental facilities.  Contractors are responsible for
establishing a comprehensive occupational safety and health
program at each facility, which includes reporting of significant
work-related injuries and illnesses.  The Department is
responsible for monitoring the implementation of the contractors'
programs.
 
   Work-related injury and illness reporting involves several
major steps.  Significant incidents are initially recorded on
contractor maintained OSHA logs.  Information contained in these
logs include:  when the incident occurred, the nature of the
injury or illness, and whether there were any lost or restricted
workdays.  Contractor information provided to the Department for
input into CAIRS describes how the injury or illness occurred,
the nature of the injury, the accident causes, and corrective
actions taken.  Contractors, for calendar year 1995, reported
5,243 significant employee injuries or illnesses to the
Department.
 
   CAIRS is a Department centralized system that accounts for
significant work related injuries and illnesses reported by the
Department's contractors.  Information compiled in CAIRS, such as
rates of recordable injuries and illnesses and lost work days is
used by the Department to develop site specific safety
indicators.  CAIRS data is also used to identify trends in injury
and illness data in an attempt to reduce future work-related
accidents.
 
OBSERVATIONS AND CONCLUSIONS
 
   Management and operating contractors were not reporting all
significant work-related injuries or illnesses as required by
Departmental and OSHA guidelines.  Through an analysis of medical
and workers' compensation data at two sites, the audit identified
111 out of 237 calendar year 1995 cases that were incorrectly
categorized as minor (not recordable or reportable).  These cases
should have been reported to the Department as significant
injuries or illnesses.  The underreporting occurred because
contractor personnel did not obtain sufficient medical,
restricted work activity, or lost worktime information relating
to the injury or illness, or they did not properly interpret OSHA
reporting requirements.
 
   Underreporting of injuries and illnesses has been a recurring
problem at Department of Energy contract facilities.  In December
1990, OSHA found reporting problems at about half of the
facilities covered in its review, including underreporting of
employee lost workdays and improper application of work
restrictions.  In 1992, Departmental reviews at the Nevada and
Richland Operations Offices found instances of recordable work
restricted duty and medical treatment injury cases that were
improperly classified as non-recordable or non-occupational
cases. Similar recordkeeping problems were identified in 1992 and
1994 Departmental reviews at Oak Ridge.  Further, an October 1996
Departmental review of injury/illness reporting at the
Idaho National Engineering Laboratory found significant
underreporting by subcontractors and concluded that the
subcontractor injury/illness information reported to the
Department was unreliable.
   
   Without accurate health and safety information, the Department
cannot adequately manage its occupational safety and health
programs, measure contractor performance, and ensure that its
facilities provide a safe and healthy work environment.  The
Department is presently developing benchmarks and performance
measures to ensure that its facilities follow "best in class"
policies and practices. However, without accurate and complete
information provided by Departmental contractors, this program
may not achieve its intended results.
     
     To strengthen the Department's occupational safety and
health program, we recommended that the Managers of the Savannah
River and Oakland Operations Offices ensure that their
contractors take action to correct the occupational injury and
illness recordkeeping problems identified in the report.  We also
recommended that the Department examine all contractor programs
and issue additional guidance delineating OSHA reporting
requirements.  Until these actions are taken, contractor
underreporting of work-related injuries and illnesses should be
considered a material weakness and reported by the Department in
preparing its yearend assurance memorandum on internal controls.
 
   Management generally concurred with the finding and
recommendations noting that corrective actions have been
initiated to improve the occupational injury and illness
recordkeeping and reporting process.
 
                             
                             PART II
                             
                   FINDING AND RECOMMENDATIONS
                                
    Contractor Occupational Injury and Illness Reporting
                          Practices
                          
                          
FINDING
 
   The Department of Energy requires its contractors to record
all significant work-related injuries and illnesses in accordance
with the Department of Labor's OSHA recordkeeping regulations and
guidelines and report them to the Department.  However, three of
the Department's contractors--the University of California
(Lawrence Livermore National Laboratory), Westinghouse Savannah
River Company, and Wackenhut Services (Savannah River)--did not
report all significant work-related calendar year 1995 injuries
or illnesses as required.  Forty-seven percent of the cases
reviewed represented significant work-related injuries or
illnesses that were not reported to the Department.  Similar
problems were previously reported at several sites by OSHA and
the Department.  The underreporting occurred because of weak
internal controls, system deficiencies, and implementation
problems.  Without complete and accurate injury and illness data,
the Department could not ensure that contractors provided a safe
and healthy work environment for employees working at Department
of Energy facilities.  In addition, the Department could not
measure the contractors' safety performance.  Therefore, award or
incentive fee determinations based on injury or illness reporting as a
performance measure were questionable.
 
RECOMMENDATIONS
   
1.  We recommend that the Assistant Secretary for Environment,
Safety and Health strengthen the Department's occupational 
injury and illness recordkeeping and reporting by
taking the necessary actions to ensure that field element
managers:
 
      Conduct for cause reviews to verify that (1) contractor
      reporting processes are effective, and (2) contractors are
      reporting work-related injuries and illnesses in accordance 
      with Departmental reporting requirements.
 
      Establish quality assurance indicators that would identify
      potential underreporting of significant contractor employee
      injuries and illnesses.
     
2.   We also recommend that the Assistant Secretary for
Environment, Safety and Health issue supplemental guidance to 
all field elements that clearly delineates OSHA's criteria for 
recording work-related injuries and work restrictions.
 
3.   We recommend that the Managers of the Savannah River
and Oakland Operations Offices ensure that their contractors 
incorporate all medically-related information in their injury 
and illness reporting process.
 
MANAGEMENT REACTION
 
   The Assistant Secretary for Environment, Safety and
Health and the Managers of the Savannah River and Oakland
Operations Offices generally concurred with the audit finding
and recommendations and stated that corrective actions have
or will be taken to improve the occupational injury and
illness reporting process.  Also, management's responses
contained suggested changes that have been addressed, where
appropriate, in the report.
 
                     DETAILS OF FINDING
                              
                              
RECORDKEEPING AND REPORTING REQUIREMENTS
 
  The Department's management and operating contractors are
required to record and report all significant work-related
employee injuries and illnesses.  The Department of Energy
Environment, Safety and Health Reporting Manual requires
contractors to record "occupational fatalities, injuries, and
illnesses occurring among their employees while performing
work at DOE-owned or-leased facilities." Furthermore,
contractors are required to report all significant work-
related injuries and illnesses to the Department through
CAIRS.  The reporting criteria used by the Department defines
a significant reportable work-related incident as one that
results in (1) loss of consciousness, illness, or death; (2)
medical treatment (other than first aid); (3) restriction of
work or motion; and (4) transfer to another position.
 
CONTRACTOR RECORDKEEPING AND REPORTING
 
   Management and operating contractors did not report all
significant injuries or illnesses to the Department.  An
analysis of medical and workers' compensation information
disclosed underreporting at two Departmental facilities.
Prior reviews at other sites disclosed similar problems.
Contractor Underreporting
     
     The contractors at the Lawrence Livermore National
Laboratory and the Savannah River Plant incorrectly
designated significant work-related injuries or illnesses as
either minor or non-work-related and did not report these
injuries or illnesses to the Department.  Specifically, the
contractors failed to report significant work-related and
reportable injuries in 47 percent of the judgmentally
selected cases examined.  These incidents included work
related injuries requiring medical treatment, workers'
compensation benefits to cover employee medical bills and/or
lost worktime, or employees being assigned to less strenuous
position.  Detailed information describing the types of
significant injuries classified as minor incidents at each of
the individual contractors is presented below.
 
   Lawrence Livermore National Laboratory
 
   The Lawrence Livermore National Laboratory incorrectly
designated 85 out of a sample of 144 injuries or illnesses
(59 percent) as non-reportable first aid cases.  Thirty-nine
of these 85 cases were disclosed through a review of medical
records and the other 46 were identified through a review of
workers' compensation claim information.  In all 85
instances, injured or ill employees received medical
treatment, lost work time, and/or were placed on work
restrictions applicable to the employees normal work duties
by medical personnel.  Examples of unreported medical
treatment injuries with lost or restricted workdays included:
 
   o An employee injured his right forearm while moving pine
     trees at work.  The injury required surgery to decompress a
     nerve in his forearm.  The employee's surgery, physical
     therapy, and medications cost the contractor over $8,500. In
     addition, the employee received over $1,100 in temporary
     disability for 102 days.
     
   o An employee tore a ligament in his right knee jumping
     down from a truck bed to stop a moving forklift.  The injury
     required surgery to repair the knee.  The contractor paid
     over $25,000 in medical and disability payments for surgery,
     physical therapy, and medication.  The employee was on
     temporary disability for 110 days.
     
The second incident, however, was not reported to the Department
until a subsequent contractor review was performed.  These and 
other similar cases were improperly treated as first aid cases by 
the contractor and were not recorded in accordance with OSHA 
requirements or reported to the Department.
 
   Savannah River Plant
 
   Similar incorrect designations and reporting problems were
identified at two Savannah River contractors.  An analysis of
93 judgmentally selected calendar year 1995 employee injuries
or illnesses disclosed that the contractors incorrectly
recorded 26 of these cases (28 percent) as minor or non-work 
related events.
  
  In these 26 instances, information obtained from medical
records or workers' compensation claim files indicated that
the employees received treatment beyond what OSHA regulations
and guidelines consider to be first aid treatment.  The
injured employees received multiple doses of prescription
medication, underwent a medical procedure, or were restricted
from performing work activities they would normally perform.
 
   The following examples illustrate instances where the
contractor improperly designated an employee's injury as
minor first aid treatment or non-work-related.  In each
instance, information obtained from medical records and
workers' compensation claim files indicated that the injuries
resulted from a work activity and that the employee either
received medical care, was placed on work restricted duty
applicable to their job by medical personnel, or was assigned
to less strenuous job duties.
  
  o  A security officer was performing a one-half mile fitness
     evaluation run at work, which was required as a condition of
     his employment as an armed guard, when he encountered chest
     pains.  The employee was transported by ambulance from the
     job site to a local hospital for observation and treatment.
     The employee was treated at the hospital with prescription
     medication and a medical procedure (angioplasty) was
     subsequently performed to clear a blocked vessel.  The
     employee was off work for over 2 weeks and received
     disability pay.  When he returned to work, the employee was
     temporarily assigned to unarmed guard duties for several
     months prior to returning to his normal job duties.  The
     contractor designated this injury as non-work-related on the
     basis that the problem was not caused by any job related
     incident but rather because of poor eating habits and
     exercise.
  
  o  A welder was walking at work and slipped on a wet step
     injuring his lower back.  On his initial visit to the onsite
     medical department, the employee was given a single dose of
     prescription medication.  The treating physician restricted
     the employee to no heavy lifting and instructed him to avoid
     excessive bending.  The employee returned to the medical
     department the next day and was given prescription medication
     to be taken twice daily for his injury.
     
     We discussed the injury/illness recordkeeping issue with
Savannah River Operations Office safety and health
officials.  These officials conducted a subsequent detailed
assessment of Westinghouse's calendar year 1995
injury/illness recordkeeping.  Their review identified
reporting problems similar to those disclosed by this audit.
Savannah River officials selected and reviewed a "smart
sample" of 22 calendar year 1995 first aid log cases and
found 8 instances where the injury was not reported in
accordance with OSHA and Departmental criteria.  Two cases
involved employees who received multiple doses of
prescription medication and another six cases involved
employees who were placed on restricted work activities
applicable to their jobs.
 
Prior Site Reviews
 
   Underreporting of occupational injuries or illnesses was
not confined to the Savannah River Plant and the Lawrence
Livermore National Laboratory.  Reviews of contractor
occupational injury and illness recordkeeping and reporting
at other Departmental field activities found that
underreporting had been a continuing problem.  For example,
in December 1990 OSHA reported serious job related injury and
illness recordkeeping problems at about half of the
Department of Energy facilities covered in its recordkeeping
reviews.  These problems included underreporting of lost
workdays and use of work restrictions to avoid lost worktime
injury reporting.  Specifically:
 
   o At one facility, the actual Lost Workday Incident (LWDI)
     rate was three times higher than the facility reported.
     Based on OSHA's review of the injury and illness records,
     the recorded LWDI rate of .086 for a 2-year period should
     have been 2.57.
     
   o At a multi-employer facility, 3 different contractors
     failed to record 120 cases over a 6-month period.
                               
   o At another facility, 72 cases were either not recorded or
     were misrecorded for the 6-month period.  OSHA, as a result 
     of this review of Departmental operations, observed that:
     
     Accurate accident reporting is particularly
     important because contractor performance award fee ratings
     in safety and health are often tied to injury and illness
     statistics (recordable cases and/or the lost workday
     incidence rate).  Several contractors provide performance
     awards to managers or supervisors based on the numbers of
     recordable cases.  Many problems stem from the adoption of
     injury and illness rates as safety and health program goals
     and objectives.
     
   In 1992, as a followup to the OSHA review, Departmental
Headquarters (the Office of Environment, Safety and Health)
conducted assessments of contractor occupational injury and
illness recordkeeping and reporting at the Oak Ridge, Nevada,
and Richland Operations Offices and found instances of
contractor underreporting of occupational injuries and
illnesses.  For example, an Oak Ridge contractor employee
suffered a heart attack on the job, which was not reported as
required.
 
     More recent Departmental reviews found that contractors
were continuing to underreport occupational injuries and
illnesses.  A 1994 assessment by the Oak Ridge Operations Office
found that many recordable cases were improperly classified as
non-recordable (first aid or non-occupational) cases.  The
assessment also identified several lost workday cases that were
not properly recorded.  An October 1996 review of injury and
illness reporting at the Idaho National Engineering Laboratory
was conducted by the Office of Environment, Safety and Health's
Office of Oversight.  The management and operating contractor's
recordkeeping and reporting of occupational injuries and
illnesses were found to be acceptable.  However, construction
subcontractors incorrectly classified 4 of the 14 first aid
cases examined. The Headquarters review concluded that
subcontractor underreporting was a significant problem because
the data on the OSHA 200 log and in the Department's CAIRS
system, for those subcontractors, was unreliable.
 
   The extent of potential underreporting was also highlighted
by a comparison of OSHA logs to workers' compensation claims for
calendar year 1995.  The comparison showed significant
differences in the data for two of the Department's largest
contractors.  For instance, Lawrence Livermore National
Laboratory's contractor, the University of California, reported
only 393 injuries and illnesses despite having 704 workers'
compensation claims.  An Oak Ridge contractor (Lockheed Martin
Energy Systems) recorded 578 injuries and illnesses on its OSHA
log although there were 663 workers' compensation claims filed--
a difference of 85 cases.
 
QUALITY ASSURANCE PROCESS NEEDS STRENGTHENING
   
   Departmental contractors underreported calendar year 1995
work-related injuries or illnesses because of weak internal
controls, system deficiencies, and implementation problems.
Specifically, its quality assurance decision-making process did
not ensure that (1) all pertinent medical record and workers'
compensation information relating to an employee's injury or
illness was collected and considered prior to making their
recordkeeping decision, and (2) OSHA requirements for recording
significant injuries or illnesses were properly interpreted.  In
addition, the Department did not have a quality assurance
mechanism that validated the accuracy or completeness of
contractor employee injury and illness data.
 
Injury Reporting Processes
   
   Contractor injury/illness reporting processes at the
University of California, Westinghouse, and Wackenhut did not
ensure that medical treatment and lost/restricted worktime
information were obtained from onsite medical departments.
Medical department personnel were required to notify injury
recordkeeping and reporting officials of initial and follow-up
medical care and whether work restrictions were placed on or
lost worktime was incurred by the injured employee.  However,
onsite medical departments frequently did not provide injury
recordkeeping officials with all relevant medical treatment and
lost/restricted worktime information.
     
     A review of workers' compensation cases, designated as
minor injuries by the University of California, disclosed that
46 of these claims represented injuries where the employee
received workers' compensation benefits for multiple
prescriptions, physical therapy sessions, and/or surgery.  Any
of these medical treatments made the injury a reportable
incident under OSHA and Departmental reporting requirements.  In
another 12 instances, injury recordkeeping and reporting
officials were not informed by medical personnel that the
employees were placed on work-restricted duty or lost work time
due to a work-related injury.
 
   Lawrence Livermore officials agreed that there was a lack of
communication between the medical department and the safety and
health office relating to employee injuries and illnesses.  In a
November 1996 letter to the Office of Inspector General,
Lawrence Livermore advised that to correct this problem
reporting officials now have on-line access to the medical
services data base system and to bimonthly updates of workers'
compensation claims data.  They said that this will ensure
accurate injury/illness reporting by enabling reporting
officials to have full knowledge of data in those two records.  
Contractor reporting officials also indicated that as part of 
their efforts to improve reporting of 1996 injury data, they 
reviewed approximately 600 employee injuries or illnesses that 
occurred in the first 10 months of 1996.  This effort resulted 
in the reclassification of 67 non-reportable (minor) cases as 
reportable (significant) injuries or illnesses.
 
    Like the University of California, Savannah River medical
department personnel also did not always notify recordkeeping
officials of medical treatment provided to injured Westinghouse
and Wackenhut employees.  Westinghouse reported to the Savannah
River Operations Office that it recognizes the importance of
maintaining timely communication between the medical and safety
(recordkeeping) departments, and it was pursuing ways to improve
communications such as the use of checklists and follow-up
reports.
 
Misinterpretations of OSHA Guidance
 
   Underreporting of injuries or illnesses also occurred because
two of the three contractors reviewed misinterpreted OSHA
guidance.  According to OSHA recordkeeping guidelines, injuries
and illnesses that happen on the employer's premises are
"presumed to be work-related" unless proven otherwise.  OSHA
recordkeeping officials stated that not establishing a work
relationship was not in itself sufficient justification for
classifying an injury as nonwork-related if a workplace event or
exposure could have caused or contributed to the injury or
illness.  Savannah River's contractors, however, did not follow
this guidance. Throughout discussions on individual
injury/illness cases, Westinghouse and Wackenhut officials
indicated that if a work relationship could not be established,
the injury/illness was not reportable.
 
   The discussion of the following case illustrates the
difference in reporting approaches.  A laborer, in this
instance, reported to the onsite medical department on a Monday
complaining of lower back pain that he said was caused by
lifting water barrels at work the prior week. Westinghouse
classified the event as non-occupational on the basis that the
employee over the weekend was lifting newspaper bundles, which
may have caused the back pain.  In a signed statement, however,
the employee declared that the injury had not occurred at home.
After reviewing the facts, OSHA officials told us that this case
was reportable because work relationship was presumed unless the
contractor could prove otherwise.
 
Department Quality Assurance Review Process
 
   In addition to the above factors that contributed to
underreporting, the Department did not have a systematic process
for periodically validating the completeness and accuracy of
contractor generated injury/illness data. Further, the
Department did not fully utilize analytical procedures to
identify potential underreporting.
 
   Savannah River and Oakland Operations Office officials
advised us that they did not, as a matter of practice,
periodically review medical and workers' compensation records to
determine if contractors reported all significant injuries and
illnesses.  Savannah River personnel stated that they had
reviewed contractor recordkeeping systems in the past, but they 
did not generally review employee medical or workers' compensation 
records.  An Oakland Operations Office official told us that the 
Department relies heavily on CAIRS for information on work-related 
injuries and illnesses and stated that if one or two contractors 
are not fully reporting injuries and illnesses, the information 
is not very useful to the Department because of the reporting 
inconsistencies.  This official also indicated that to his 
knowledge the Oakland Operations Office had not conducted any 
reviews of the  University of California's injury/illness 
reporting practices.
   
   Further, the Department did not always utilize analytical
procedures to identify potential contractor injury/illness
underreporting.  For instance, the Oakland Operations Office did
not compare total injuries and illnesses on contractor
maintained OSHA logs to CAIRS and workers' compensation claims
filed.  As discussed previously, such comparisons would have
highlighted situations where injury/illness underreporting may
have occurred.
 
IMPACT ON DEPARTMENTAL ADMINISTRATION
    
    Without complete and accurate information, the Department
could not adequately manage its occupational safety and health
program and ensure that its contractors provided a safe and
healthy work environment.  In addition, the Department could not
measure its contractor safety performance since the number and
severity of work-related employee injuries and lost workdays
were incorrect. According to a Departmental safety office
director, accurate injury/illness reporting was extremely
important to the entire safety and health program.  The safety
official stated that the Department used this data to develop
performance indicators and to gauge the safety and health
performance of individual contractors.  However, incomplete and
inaccurate injury and illness data limited the Department's
ability to effectively monitor contractor occupational safety
and health programs.  In essence, the ability of the Department
to measure contractor performance was no better than the data
upon which such assessments were based.
 
   Incorrect reporting could also have a potential impact on
contractor fees.  For example, on October 1, 1996, the
Department awarded Westinghouse a new performance-based contract
for the Savannah River Site.  The performance-based evaluation
plan for this new contract stated in part that ". . .the
contractors general management incentive fee is significantly
dependent on planning and implementing activities, programs, and
changes thereto so that the environment and health of the public
and employees are protected and operational requirements are
met."  An Office of Inspector General audit report issued in
October 1993, further underscored the potential impact of
incorrect reporting on contractor fees.  The report, WR-B-94-01,
"Audit of Kaiser Engineers Hanford Company's Award Fee,"
disclosed that the Department overpaid the contractor up to
$300,000 in award fees because the field office relied on
occupational injury and illness data reported by the contractor
that significantly understated the extent of these injuries and
illnesses.  Underreporting of injuries and illnesses, at other
sites, could similarly effect contractor award and incentive fee
determinations.
                            
                            PART III
                                
                 
                 MANAGEMENT AND AUDITOR COMMENTS
   
   The Assistant Secretary for Environment, Safety and Health
and the Managers of the Savannah River and Oakland Operations
Offices generally agreed with the finding and recommendations.
Management at Departmental Headquarters and the two operations
offices cited specific corrective actions that have or will be
taken to resolve the occupational injury and illness reporting
problems identified in this report.  Also, management's
responses contained suggested changes that have been addressed,
where appropriate, in the report.  A summary of management's
comments and our responses follows.  The Appendix contains the
Assistant Secretary's verbatim comments on the report.
   
   Recommendation 1.  The Assistant Secretary for Environment,
Safety and Health strengthen the Department's occupational
injury and illness recordkeeping and reporting by taking the
necessary actions to ensure that field element managers:
     
     Conduct for cause reviews to verify that (1) contractor
     reporting processes are effective, and (2) contractors are
     reporting work-related injuries and illnesses in accordance 
     with Departmental reporting requirements.
 
     Establish quality assurance indicators that would identify
     potential underreporting of significant contractor employee
     injuries and illnesses.
    
   Management Comments.  The Assistant Secretary for
Environment, Safety and Health plans to carry out recommendation
1 by sending a memorandum to field element office managers
requesting that they (1) review and validate occupational
reporting and recordkeeping processes to verify compliance with
Departmental requirements, and (2) establish quality assurance
systems to identify potential injury/illness underreporting and
identify areas for improvement, and (3) establish an advisory
group to work with field offices to improve injury and illness
recordkeeping and reporting.  The Assistant Secretary will
discuss the report finding and proposed actions to resolve
the reporting problems with the Secretary.
 
   Auditor Comments.  Management's comments are responsive
to the recommendation.
 
   Recommendation 2.  The Assistant Secretary for
Environment, Safety and Health issue supplemental guidance to
all field elements that clearly delineates OSHA's criteria
for recording work-related injuries and work restrictions.
 
   Management Comments.  The Assistant Secretary for
Environment, Safety and Health intends to issue OSHA criteria
for reporting work related injuries/illnesses and work
restrictions.
 
   Auditor Comments.  Management's comments are responsive
to the recommendation.
 
   Recommendation 3.  The Managers of the Savannah River and
Oakland Operations Offices ensure that their contractors
incorporate all medically related information in their injury
and illness reporting process.
 
   Management Comments.  The Savannah River and Oakland
Operations Offices stated that their offices are taking
corrective actions to strengthen the recordkeeping and
reporting process.  Both offices plan to conduct periodic
assessments of contractor recordkeeping and reporting
processes to ensure accurate occupational injury and illness
reporting.  The Oakland Operations Office stated that it will
quarterly reconcile contractor medical and workers'
compensation information with data provided by Lawrence
Livermore to the Department.  This office also will work with
Lawrence Livermore to ensure that the contractor spends the
time and resources necessary to improve the quality of data
gathering and decision making.  Oakland also noted that
Lawrence Livermore has taken actions since this review to
improve their recordkeeping and reporting process such as
weekly meetings and exchange of information between medical,
workers' compensation, and recordkeeping personnel, and
additional training on CAIRS reporting.  Savannah River noted
that contractor medical and recordkeeping personnel now
conduct periodic meetings to ensure that all medically
related information is incorporated into the injury/illness
reporting process.  Savannah River also noted that the
medical department's internal procedure is also being revised
to provide better occupational injury and illness medical
treatment data to recordkeeping personnel.  In addition,
Savannah River's medical department is implementing a
computerized system to track all medical records that will
provide recordkeeping personnel with online access to medical
treatment information and improve communications between
medical and recordkeeping staff.
   
   Auditor Comments.  Management's comments are responsive
to the recommendation.
                           PART IV
                              
                        OTHER MATTERS
                              
         Access to University of California Records
                              
   During the audit, an access to records problem surfaced
relating to the Department's authority to obtain and review
University of California medical and injury/illness records
at the Lawrence Livermore National Laboratory.  These
records, owned by the University, were needed by the auditors
to verify injury/illness information.  Since the University
is a California state institution, these particular records
fall under the disclosure provisions specified in State of
California privacy laws.
 
   This matter was resolved, through a specific agreement
relating to this audit, between Department, University of
California, and Office of Inspector General officials.
However, this one-time resolution may not provide a workable
solution for future situations.
 
   The Department is currently renegotiating its contracts
with the University of California.  In a September 1996,
memorandum to Departmental officials, the Deputy Inspector
General for Audit Services noted that the renegotiation
process provides the Department with an opportunity to
clarify this matter.  He recommended incorporating language
contained in the proposed Department Acquisition Rulemaking
that modifies 48 Code of Federal Regulations parts 917, 950,
952, and 970.  The Office of Inspector General believes this
change would ensure full access to records pertinent to
Departmental operations, even those owned by the contractor.
                                                    
                                                    Appendix
March 28, 1997
 
 
Occupational Safety and Health Policy:Macon:3-6096
 
COMMENTS REGARDING DRAFT REPORT ON "AUDIT OF DEPARTMENT OF
ENERGY (DOE) CONTRACTOR INJURY AND ILLNESS REPORTING
PRACTICES"
 
Gregory H. Friedman
Deputy Inspector General for Audit Services, IG-30
 
We have reviewed the initial draft report on the subject
audit, and generally agree with your finding and
recommendations.  As noted in your report, accurate
occupational injury and illness reporting and recordkeeping
is vital to the Department.
 
The first sentence under "Recommendations" on page five
should be reworded as follows:  "We recommend that the
Assistant Secretary for Environment, Safety and Health take
action to strengthen the Department's occupational injury and
illness reporting and recordkeeping, and that all field
element managers:"
 
We plan to take the following actions in response your
recommendations:
 
o Within 45 days, my office will distribute a memorandum to
  the field element managers asking them, within 6 months, to
  (1) review occupational injury and illness reporting and
  recordkeeping processes to validate that they are in
  compliance with Department of Energy requirements; and (2)
  establish quality assurance systems to identify potential
  underreporting of occupational injury and illnesses and
  identify areas for improvement.  I will request that the
  results be reported to me.
  
o My office will also distribute within 45 days the
  Occupational Safety and Health Administration's criteria
  for reporting work related injuries and illnesses and
  restrictions.
  
o We will establish an occupational injury and illness
  recordkeeping and reporting advisory group in my Office of
  Worker Health and Safety.  This group will work with the
  field elements to improve injury and illness recordkeeping
  and reporting.
  
o We will discuss the results of your findings with the
  Secretary, including the actions my office is taking to
  resolve the deficiencies.
  
o My office will pass your suggestion regarding the
  current contract renewal negotiations to the Office of
  Defense Programs and the Oakland Operations Office.
  
We appreciate the information provided in your report and
will utilize it to help strengthen  the injury and illness
recordkeeeping program.  If you have any questions regarding
these comments, please contact Marty Mathamel in the Office
of Worker Health and Safety.  Mr. Mathamel can be reached at
(301) 903-4343.
 
                              /s/ Peter N. Brush
                              Tara O'Toole, M.D., M.P.H.
                              Assistant Secretary
                              Environment, Safety and Health
                            
                            
                            IG Report No.______________
 
 
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