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U.S. Department of Energy ORDER
Washington, D.C. DOE O 210.2
Approved: 6-12-06
SUBJECT: DOE CORPORATE OPERATING EXPERIENCE PROGRAM
1. OBJECTIVES.
a. To institute a Department of Energy (DOE) wide program for
the management of operating experience to prevent adverse
operating incidents and to expand the sharing of good work
practices among DOE sites.
b. To provide the systematic review, identification,
collection, screening, evaluation, and dissemination of operating
experience from U.S. and foreign government agencies and
industry, professional societies, trade associations, national
academies, universities, and DOE and its contractors.
c. To reinforce the core functions and guiding principles of
DOE’s Integrated Safety Management System (ISMS) to enhance
mission safety and reliability.
d. To provide mutual integration with the lessons learned
requirements in other DOE directives.
2. CANCELLATION. NONE.
3. APPLICABILITY.
a. Departmental Elements. Except for exclusions in paragraph
3c, this Order applies to all Departmental elements (Attachment 1
or online at www.directives.doe.gov) and automatically applies to
Departmental elements created after it is issued.
The National Nuclear Security Administration (NNSA)
Administrator will assure that NNSA employees and
contractors comply with their respective
responsibilities under this Order.
b. DOE Contractors.
(1) Except for the exclusions in paragraph 3c, the Contractor
Requirements Document (CRD), Attachment 2, sets forth
requirements of this order that will apply to contracts that
include the CRD.
(2) The CRD must be included in contracts for management or
operation of a DOE site or facility with activities that should
be covered by DOE’s operating experience program.
The office identified in the Responsibilities
paragraph is responsible for notifying the
contracting officer of which contracts are
affected. Once notified, the contracting officer
is responsible for incorporating the CRD into each
affected contract.
c. Exclusions.
(1) This Order does not apply to activities conducted under the
authority of the Director, Naval Nuclear Propulsion Program, as
assigned by Executive Order 12344.
(2) Consistent with Secretarial Delegation Order Number 00-
033.00A to the Administrator and Chief Executive Officer,
Bonneville Power Administration, (BPA) this Order does not apply
to BPA.
(3) This Order does not apply to the following Secretarial
Offices:
(a) Departmental Representative to the Defense Nuclear
Facilities Safety Board,
(b) Energy Information Administration,
(c) Office of the Chief Financial Officer,
(d) Office of the Chief Information Officer,
(e) Office of Congressional and Intergovernmental Affairs,
(f) Office of Economic Impact and Diversity,
(g) Office of Electricity Delivery and Energy Reliability,
(h) Office of General Counsel,
(i) Office of Hearings and Appeals,
(j) Office of Human Capital Management,
(k) Office of the Inspector General,
(l) Office of Intelligence and Counterintelligence,
(m) Office of Management,
(n) Office of Policy and International Affairs, and
(o) Office of Public Affairs.
4. REQUIREMENTS.
DOE managers and employees are expected to learn from
experience (internal and external) in order to prevent
adverse operating incidents and to expand the sharing of
good work practices. A generalized approach to
accomplishing this objective is depicted in Attachment 3.
a. The DOE Corporate Operating Experience Program has the
following requirements.
(1) A formal process must be established to evaluate operating
experience from DOE and related government or industry programs,
technologies and facilities.
(2) Sources of internal and external operating experience must
be used to assess trends and safety issues that may have a
bearing on the safety and success of DOE missions. Sources
include—
(a) DOE contractors;
(b) DOE programs and site offices, including the Naval Reactors
Program;
(c) U.S. industry, professional societies, trade associations,
national academies, and universities;
(d) other Federal agencies [e.g., the Chemical Safety and Hazard
Investigation Board (CSB), National Transportation Safety Board
(NTSB), National Aeronautics and Space Administration (NASA);
Nuclear Regulatory Commission (NRC), Environmental Protection
Agency (EPA), etc.];
(e) foreign government and foreign industry experience; and
(f) international agencies involved with energy issues [e.g.,
the International Energy Agency (IEA) and the International
Atomic Energy Agency (IAEA)].
(3) Operating experience must be collected, stored, and
retrieved through a central clearinghouse that allows ready
access to and communication about collected information on a
timely, unimpeded basis by all DOE elements. The Corporate
Operating Experience Program Lead Office, who is responsible for
operating the clearinghouse, must—
(a) ensure that operating experience data are sufficiently
comprehensive and of sufficient quality to meet DOE needs and
(b) develop, promulgate, and maintain support systems needed to
implement and sustain an effective operating experience program,
including—
1 the computerized data systems for environment, safety and
health reporting required by DOE O 231.1A, Environment, Safety
and Health Reporting, dated 6-3-04,
2 operating experience web pages, and
3 operating experience analytic tools.
(4) Operating experience must be screened daily by each
organization’s operating experience program, in particular the
designated Corporate Operating Experience Program Lead Office,
for safety significance, generic technical implications or
management considerations. When data suggests a significant near-
term safety risk or vulnerability, those issues must be
prioritized, communicated, and resolved.
(a) Screening results and insights from operating experience
will be communicated first by the DOE site of concern to the DOE
Field Element then elevated to NNSA Deputy Administrators or
Program Secretarial Officers (PSOs) for further dissemination
program-wide. NNSA Deputy Administrators/PSOs will further
evaluate the operating experience to determine any significant
and emerging programmatic (mission related) issues.
(b) Further screening will be used by the designated Corporate
Operating Experience Program Lead Office to determine DOE-wide
applicability.
(c) Analyses and evaluations will be conducted by the designated
Corporate Operating Experience Program Lead Office to provide DOE
management and programs with clear and timely information
regarding significant and emerging safety issues with DOE-wide
applicability.
(5) The following elements must be incorporated into the
operating experience program:
(a) performance indicators and trends,
(b) site-specific issues,
(c) generic technical issues, and
(d) management or institutional issues.
(6) Designated Corporate Operating Experience Program Lead
Office feedback communications on identified environment, safety
and health operating experience issues with DOE Headquarters and
field organizations, contractors, industry and other Federal
agencies and the public must be conducted through actionable or
informative operating experience documents (listed in order of
importance)—
(a) Special Operations Reports (SORs) are issued by the Deputy
Secretary of Energy and disseminated through formal
correspondence to NNSA and the DOE Under Secretaries for action
and further dissemination to the DOE NNSA Deputy Administrators
and PSOs, field elements, and contractors. SORs are also
posted/pushed to users of the DOE Corporate Lessons Learned
Database (URL: http://www.eh.doe.gov/DOEll/index.asp) and posted
on the DOE lessons learned web page hosted by EH (URL:
http://www.eh.doe.gov/paa/specialops_reports.html) to facilitate
communications. SORs are produced to inform the DOE complex of
the most significant events or trends of concern to management.
The following requirements must be met in developing an SOR.
1 Senior management must verify that performance expectations
delineated in the SOR are met.
2 Working groups formed to develop SORs are led by the
Corporate Operating Experience Program Office and include subject
matter experts drawn from representatives of Program Secretarial
Offices (PSOs), NNSA Deputy Administrators (DAs), DOE field
elements, and contractors.
3 SORs must be coordinated by the Corporate Operating
Experience Program lead office through the Under
Secretaries/central technical authorities for concurrence before
being forwarded to the Deputy Secretary for promulgation.
4 SORs can be prepared on the basis of one event (e.g., as a
followup to a Type A or Type B accident investigation as defined
by DOE O 225.1A, Accident Investigations, dated 11-26-97, a
significant external event) or upon a collection of like events
or trends. Criteria for preparing an SOR are as follows.
a The events being reported had a significant impact on safe
facility operations, worker or public safety and health or
regulatory compliance.
b To prevent recurrence or to ensure that potential for a
similar event is acceptably low, management will determine
vulnerabilities and initiate action at the site or at sites that
perform similar work.
c The conditions or symptoms can be identified to illustrate
what to look for and what actions are expected by management at
other sites.
d Trend analysis indicates it is prudent to require management
action to reverse an adverse trend.
5 In response to an SOR, DOE field elements,
Government–owned/Government-operated (GOGO) Sites, and contractor
senior management must submit to their NNSA Deputy Administrator
or PSO formal documentation of the results of their assessments,
including a decision of applicability or non-applicability,
actions taken or planned with completion dates, and a
verification of the close-out of actions.
6 DOE PSOs and NNSA Deputy Administrators, through their Under
Secretary, must provide to the Deputy Secretary (with an
information copy to the Corporate Operating Experience Program
Lead Office) a consolidated report of actions taken and
affirmation that the expectations outlined in the SOR have been
met or will be met by the required date.
(b) Environment, Safety and Health Alerts (SAs), prepared by the
Corporate Operating Experience Program lead office, are issued by
the Assistant Secretary for Environment, Safety and Health and
disseminated by formal correspondence to NNSA Deputy
Administrators and the PSOs requesting their action and further
dissemination to DOE field elements and contractors. SAs are
also posted/pushed to users of the DOE Corporate Lessons Learned
Database (URL: http://www.eh.doe.gov/DOEll/index.asp) and posted
on the DOE lessons learned web page hosted by EH (URL:
http://www.eh.doe.gov/paa/alerts.html) to facilitate
communications. SAs are issued to inform the DOE complex (or
affected sites) of potentially significant safety issues (e.g.,
an immediate conduct of operations problem, suspect/counterfeit
parts, or defective items that require immediate action). The
following requirements apply.
1 SAs are developed by the Corporate Operating Experience
Program lead office. A working group of subject matter experts
drawn from PSOs, DOE field elements and contractor staffs will
assist as necessary.
2 An SA must include—
a a statement of actions the recipient must take, or, as it
pertains to NNSA, that are recommended and
b a method for providing feedback by formal response to the
PSO or NNSA Deputy Administrator.
3 The PSO must provide a consolidated report of actions taken
or of non-applicability to EH.
4 SA recipients must review conduct of operations for similar
problems or potential for purchase or use of reported suspect,
counterfeit or defective items and take appropriate action to
prevent adverse consequences.
(c) Environment, Safety and Health Bulletins (SBs) are issued by
the Assistant Secretary for Environment, Safety and Health and
disseminated by formal correspondence to NNSA Deputy
Administrators and the PSOs recommending their action and further
dissemination to DOE field elements and contractors. SBs are
also posted/pushed to users of the DOE Corporate Lessons Learned
Database (URL: http://www.eh.doe.gov/DOEll/index.asp) and posted
on the DOE lessons learned web page hosted by EH (URL:
http://www.eh.doe.gov/paa/bulletins.html) to facilitate
communications. SBs are prepared on an as-needed basis by the
Corporate Operating Experience Program lead office when operating
experience data shows a trend that warrants senior Headquarters
and field management attention.
1 SBs are the communication vehicle when events or operating
experience data analysis shows trends that warrant attention but
are not of the safety significance level that warrants an SOR or
SA.
2 SBs must recommend specific corrective or preventative
actions to senior management who will ensure that actions are
taken.
3 An SB must request formal response to EH or preparation of
an occurrence report for submission to the Occurrence Reporting
and Processing System (ORPS).
(d) Environment, Safety and Health Advisories (SAds) are issued
by the Corporate Operating Experience Program lead office on an
as-needed basis when analysis of operating experience data shows
an event(s) or a trend(s) that warrants senior Headquarters and
field manager awareness but whose safety significance does not
warrant an SOR, SA, or SB. SAds are disseminated by being
posted/pushed to users of the DOE Corporate Lessons Learned
Database (URL: http://www.eh.doe.gov/DOEll/index.asp) and by
posting on the DOE lessons learned web page hosted by EH. (URL:
http://www.eh.doe.gov/paa/safety_advisory.html).
1 A SAd highlights important environment, safety and health
issues for senior management attention and potential action.
2 No response to a SAd is required.
(e) Operating Experience Summaries (OESs) are issued by the
Corporate Operating Experience Program lead office for a target
audience of first-tier supervisors, work planners, and craft
personnel as a compilation of DOE-wide occurrence information and
lessons learned from which sites could benefit. OESs must be
disseminated by posting on the DOE lessons learned web page
hosted by EH. (URL:
http://www.eh.doe.gov/paa/oesummary/index.html). A limited
number of OESs will also be mailed to senior DOE headquarters and
field managers.
1 These reports include—
a substantive analysis of reported events,
b causes and contributing factors,
c similar events and corrective actions that describe
significant events, or
d important individual DOE activities that provide corporate
lessons learned.
2 Recipients are encouraged to evaluate the occurrences with
an eye toward taking action to ensure that—
a similar events do not occur, or
b existing program elements reflect best practices.
(f) Just-In-Time Operating Experience Reports (JITs) are issued
by the Corporate Operating Experience Program lead office to
inform work planners and workers about a specific safety issue
related to work they perform. JITs must be disseminated by being
posted/pushed to users of the DOE Corporate Lessons Learned
Database (URL: http://www.eh.doe.gov/DOEll/index.asp) and by
posting on the DOE lessons learned web page hosted by EH (URL:
http://www.eh.doe.gov/paa/jit.html).
1 JITs present—
a brief examples of problems and mistakes encountered in
actual cases, and
b points to consider for avoiding pitfalls.
2 Content, which is generated from review of common (i.e.,
frequently performed) tasks, provides practical lessons for—
a program managers,
b field representatives,
c work planners,
d first line supervisors, and
e workers.
3 Over time, JITs will become a library of living documents
for update when new lessons are learned and practices are added.
(g) Suspect/Counterfeit or Defective Items Data Collection Sheet
(DCS) issued by the Corporate Operating Experience Program lead
office provide information on defective or suspect/ counterfeit
items (S/CIs) with potential impact to DOE operations. DCSs must
be disseminated by posting on the DOE Suspect/Counterfeit Items
and Defective Items web pages hosted by EH. (URL:
http://www.eh.doe.gov/sci). A limited number of DCSs may also be
disseminated by Push Mail to a registered users list. .DCSs are
developed from review of—
1 occurrence reports,
2 the Government Industry Data Exchange Program (GIDEP),
3 the Institute of Nuclear Power Operations (INPO), and
4 other databases.
(7) NNSA Deputy Administrators/PSOs also develop DOE Lessons
Learned to provide feedback communications on identified
program/mission-specific operating experience lessons learned
with field organizations and contractors. NNSA Deputy
Administrator/PSO developed DOE Lessons Learned must contain the
basic elements of the DOE Operating Experience Lessons Learned
Template provided in Attachment 5, (i.e., title, number,
statement of the lessons learned, discussion, analysis, and
recommended actions). NNSA Deputy Administrator/PSO issued
lessons learned may emulate the format of the Corporate Operating
Experience Documents (i.e., SOR, SA, SB, SAd, etc.) described in
section 4a(6).
(8) Operating experience records must be maintained according to
National Archives and Records Administration (NARA)-approved DOE
Record Disposition Schedules.
(9) Lessons learned must be incorporated into—
(a) training,
(b) maintenance and work planning,
(c) operations, and
(d) design and construction.
b. A DOE Corporate Operating Experience Program lead office is
designated in this Order and assigned responsibility for program
development and oversight, and clearinghouse development and
maintenance as shown in Attachment 4.
c. Guidance materials must be developed and maintained, and the
Corporate Operating Experience Program lead office will assist
DOE elements with the implementation of this Order.
d. DOE operating experience information must be collected and
analyzed continuously by each organization’s operating experience
program, in particular the designated Corporate Operating
Experience Program lead office, to identify significant
crosscutting issues and trends and detect weak signals across the
Department, and to take action to correct the identified
weaknesses.
e. External operating experience data must be collected and
analyzed by each organization’s operating experience program, in
particular the designated Corporate Operating Experience Program
lead office, to identify significant issues and lessons learned
to make available to the DOE complex.
f. DOE federal and contractor organizations must share
operating experience lessons learned with the DOE complex through
the DOE Corporate Lessons Learned Database (URL:
http://www.eh.doe.gov/DOEll/index.asp), using the standard format
described in Attachment 5.
g. DOE federal and contractor organizations must apply the
following criteria when assessing whether to share a lesson
learned with other DOE organizations.
(1) Lessons learned developed for any Type A or Type B
accidents, as defined by DOE O 225.1A, Accident Investigations,
dated 11-26-97 must be shared.
(2) Lessons learned must be developed for Significance Category
1 or recurring events, as defined in Section 5.2 of DOE M 231.1-
2, Occurrence Reporting and Processing of Operations Information,
dated 8-19-03, and must be shared.
(3) Other operating experience derived from other operating
events, e.g., classifiable operational emergencies (i.e., General
Emergencies, Site Area Emergencies, or Alert) as defined by DOE O
151.1C, Comprehensive Emergency Management System, dated 11-2-05,
Significance Category 2, 3 or 4 occurrences, as defined in
Section 5.2 of DOE M 231.1-2, Occurrence Reporting and Processing
of Operations Information, dated 8-19-03, Price-Anderson
Amendments Act (PAAA) events reported in the Non-Compliance
Tracking System (NTS), injuries or illness reported in the
Computerized Accident/Illness Reporting System (CAIRS),
assessment findings, etc., may provide lessons learned to be
shared when the following criteria are met.
(a) The lesson will provide significant, new information.
(b) The experience has direct relevance to other facilities,
sites, or programs under the cognizance of a PSO/NNSA Deputy
Administrator and is directly relevant to other PSO/NNSA Deputy
Administrator’s programs.
(c) The information has the potential to be the basis for
significant improvements or cost savings.
h. To improve operational safety awareness, information will be
gathered by the Corporate Operating Experience Program lead
office from daily occurrence summaries, emergency operation
center reports, weekly reports, periodic safety management
meeting materials, and occurrence trend reports to assess program
performance trends and the data will be disseminated DOE-wide.
i. Operating experience data must be shared between DOE sites
with similar programs or missions.
j. The DOE Corporate Operating Experience Program must
be integrated with—
(1) ISMS (see DOE P 450.4, Safety Management System Policy,
dated 10-15-96, and 48 CFR 970.5215-3, Integration of
Environment, Safety and Health into Work Planning and Execution);
(2) occurrence reporting requirements as defined in DOE
O 231.1A, Environment, Safety and Health Reporting, dated 6-3-04
and DOE M 231.1-2, Occurrence Reporting and Processing of
Operations Information, dated 8-19-03;
(3) the Quality Assurance Program as defined in 10 CFR Part 830,
Subpart A;
(4) the contract performance clause defined in
48 CFR 970.5204-86, Conditional Payment of Fee, Profit and Other
Incentives; and
(5) lessons learned requirements defined in DOE O 151.1C,
Comprehensive Emergency Management, dated 11-02-05, DOE O 225.1A,
Accident Investigations, dated 11-26-97, DOE O 226.1,
Implementation of Department of Energy Oversight Policy, dated
9-15-05, and DOE O 414.1C, Quality Assurance, dated 6-17-05.
5. RESPONSIBILITIES.
a. Deputy Secretary. Promulgates SORs and requires PSOs and
NNSA Deputy Administrators (DAs) to conduct formal monitoring of
Headquarters and field element implementation.
b. NNSA Administrator, Central Technical Authority (CTA) for
the NNSA, Under Secretary for Energy, Science and Environment
(ESE), Central Technical Authority for ESE, and Under Secretary
for Science.
(1) Periodically discuss DOE- or program-wide and site specific
performance and trends related to operational events and
performance indicators with their PSOs, NNSA Deputy
Administrators, and heads of field elements.
(2) The designated CTAs through the respective Chief of Nuclear
Safety/Chief of Defense Nuclear Safety will give particular
attention to performance and trends that impact nuclear safety,
and track resolution of such trends.
c. Office of the Assistant Secretary for Environment, Safety
and Health.
(1) Is designated as the DOE Corporate Operating Experience
Program lead office and is responsible for developing and
maintaining the central clearinghouse function.
(2) Incorporates implementation of the operating experience
program into Office of Environment, Safety and Health
organizational responsibilities.
(3) Develops, promulgates and maintains program guidance
materials.
(4) Assists DOE elements with the implementation of this Order.
(5) In coordination with the Secretarial Offices and NNSA,
interprets requirements of this Order.
(6) Collects and analyzes operating experience information from
occurrence reports, accident investigations, and site specific
input to identify significant crosscutting issues and trends and
detect weak signals across the Department, and brings this
information to the attention of senior line management.
(7) Collects and analyzes external operating experience
information from other Government agencies, industry
organizations or professional groups to identify significant
issues and lessons learned applicable to DOE. Establishes formal
operating experience exchange mechanisms with external
organizations, (e.g., Government Industry Data Exchange Program
(GIDEP), NRC, INPO, CSB, etc.) as necessary.
(8) Identifies operating experience and DOE-wide safety issues
and determines level of importance and recommends related
actions.
(9) To improve corporate operational safety awareness, develops
documents for disseminating performance trending and analysis
information from daily occurrence summaries, weekly reports,
periodic safety management meeting materials, and occurrence
trend reports.
(10) Develops the following lessons learned documents:
(a) SORs,
(b) SAs,
(c) SBs,
(d) SAds,
(e) OESs,
(f) lessons learned using the standard DOE lessons learned
format, (Attachment 5),
(g) JITs, and
(h) DCSs.
(11) In conjunction with the Chief Information Officer, operates
and maintains computer data support systems (e.g., the DOE
Corporate Lessons Learned Database) required for the central
clearinghouse function.
(12) Ensures that lessons learned from the DOE Corporate
Operating Experience Program are incorporated into directives and
standards development.
(13) Work with the Procurement Executive to ensure the
requirements of this Order relevant to contractors (M&O and/or
non-M&O) are established as a contract clause through rulemaking
action.
d. NNSA Deputy Administrators, Cognizant Secretarial Officers,
Program Secretarial Officers.
(1) Ensure that program office processes include incorporation
of lessons learned into training, maintenance and work planning,
work processes, operations, directives and standards development,
and design and construction.
(2) Designate operating experience program coordinators to
execute responsibilities of this Order.
(3) Review quarterly analyses of reportable and non-reportable
events submitted by contractors and program field elements in
accordance with Section 5.8 of DOE M 231.1-2, Occurrence
Reporting and Processing of Operations Information, dated 8-19-03
to identify operating experience trends and lessons learned.
(4) Provide management and technical/subject matter experts to
participate in the development of SORs, SAs or SBs for issues
applicable DOE-wide and require monitored implementation.
(5) Review, submit comments and provide concurrence on SORs
applicable to PSO/NNSA Deputy Administrator programs back to the
DOE Corporate Operating Experience Program lead office before
submission to the Deputy Secretary for approval.
(6) Verify implementation for all levels of operating experience
reports through line management oversight.
(7) As a part of self-assessments conducted to evaluate
organizational performance in Integrated Safety Management (ISM),
includes an assessment of the effectiveness of the organization’s
operating experience program.
(8) Monitor site- and program-specific performance and discuss
periodically with Departmental senior management.
(9) Screen and share lessons learned from field elements to
ensure that experience gained at one site is shared with other
sites with comparable programs or missions.
(10) Develop and promulgate DOE Lessons Learned unique to their
programmatic areas of responsibility.
(11) Ensure that lessons learned are developed and disseminated
following completion of major program missions (e.g., contractor
closeout of a major cleanup site, major decontamination and
decommissioning projects, construction).
(12) Recommend issues to be addressed by SORs or SAs.
(13) Participate in the development of and concur in SORs and SAs
as requested.
(14) Review formal responses of field elements, GOGOs, and
contractors submitted for corporate operating experience
documents (i.e., SORs and SAs).
(15) Provide consolidated, formal response to corporate operating
experience documents on whether the expectations of the SOR or SA
have been met or will be met by the required date.
e. Heads of Field Elements and Contracting Activities.
(1) Ensure that field element processes incorporate lessons
learned into training, maintenance and work planning, work
processes, operations, and design and construction.
(2) Designate operating experience program coordinators to
fulfill the responsibilities assigned by this Order.
(3) Ensure that quarterly analyses of reportable and
non-reportable events submitted by contractors and program field
elements in accordance with Section 5.8 of DOE M 231.1-2,
Occurrence Reporting and Processing of Operations Information,
dated 8-19-03, are reviewed to identify operating experience
trends and lessons learned.
(4) Ensure that operating experience reports are implemented by
the field element and contractor organizations through line
management oversight.
(5) As a part of self-assessments conducted to evaluate
organizational performance in Integrated Safety Management (ISM),
includes an assessment of the effectiveness of the organization’s
operating experience program.
(6) Review contractor implementation of local operating
experience programs.
(7) Screen contractor-developed operating experience information
to ensure operational awareness.
(8) Monitor contractor performance and sharing of lessons
learned.
(9) Share contractor performance information with the PSOs/NNSA
Deputy Administrators.
(10) Recommend locally developed lessons learned for inclusion in
the DOE Corporate Lessons Learned Database (URL:
http://www.eh.doe.gov/DOEll/index.asp ).
(11) orward lessons learned applicable to specific missions or
programs to the appropriate PSO/NNSA Deputy Administrator for
consideration.
(12) nsure that senior contractor management is held accountable
for recurrence of significant adverse events.
(13) nsure that operating experiences and lessons learned from
departing contractors are shared with new contractors following
awarding of major contracts.
(14) Share operating experience lessons learned with the DOE
complex through the DOE Corporate Lessons Learned Database (URL:
http://www.eh.doe.gov/DOEll/index.asp ).
(15) Provide to the appropriate PSO or NNSA Deputy Administrator
feedback concerning reviews conducted and actions taken for SOR
and SA operating experience documents.
f. Heads of Government–Owned/Government-Operated (GOGO) Sites.
(1) Distribute DOE Corporate and external operating experience
to GOGO personnel for review, analysis and routine use.
(2) Provide to the appropriate PSO or NNSA Deputy Administrator
implementation feedback concerning reviews conducted and lessons
learned for SOR and SA operating experience documents.
(3) Track trends in operating events to identify recurring
issues.
(4) Investigate and identify causes of operating events.
(5) Develop, implement, and track actions to correct problems
identified by causal analysis and develop lessons learned on the
effectiveness of these actions.
(6) Evaluate program performance and the effectiveness of
actions implemented from lessons learned.
(7) Share operating experience lessons learned with the DOE
complex through the DOE Corporate Lessons Learned Database (URL:
http://www.eh.doe.gov/DOEll/index.asp).
(8) Assign roles and responsibilities for the operating
experience program and identify appropriate operating
experience–related training and qualification requirements.
(9) Ensure that local GOGO processes include the incorporation
of lessons learned from the DOE Corporate Operating Experience
Program and those developed locally into training, maintenance
and work planning, work processes, operations, and design and
construction.
(10) Designate operating experience program coordinators to
fulfill the requirements of this Order.
(11) Ensure that quarterly analyses of reportable and
non-reportable events required by paragraph 5.8 of DOE M 231.1-2,
Occurrence Reporting and Processing of Operations Information,
dated 8-19-03, is reviewed to identify operating experience
trends and lessons learned and is forwarded to the appropriate
PSO or NNSA Deputy Administrator.
(12) As a part of self-assessments conducted to evaluate
organizational performance in Integrated Safety Management (ISM),
includes an assessment of the effectiveness of the organization’s
operating experience program.
g. Sites Not Under the Cognizance of a DOE Field Element.
Execute the responsibilities of the Heads of Field
Elements and Contracting Activities (paragraph 5.e) and
Heads of Government–owned/Government operated (GOGO)
sites (paragraph 5f).
h. Operating Experience Program Coordinator.
(1) Develops and manages organization participation in the DOE
Corporate Operating Experience Program.
(2) Develop processes, procedures, communication methods, and
documentation to implement this participation as needed.
(3) Elevate to the appropriate DOE manager for resolution and
direction unresolved issues arising from actions or
determinations on operating experience and lessons learned.
(4) Maintain oversight of contractor operating experience
program activities (field element operating experience program
coordinators ONLY).
(5) With the assistance of line management, ensure that site
lessons learned from operating experience applicable to other DOE
sites are submitted to the DOE Corporate Operating Experience
Program clearinghouse.
(6) Interact with facility personnel and field element
management and oversight organizations as necessary and provide
information and advice on findings to management.
(7) Follow up on significant actions or events to derive lessons
learned.
(8) With the help of subject matter experts, determine
applicability and significance of internal and external operating
experience identified as possible lessons learned.
(9) Distribute applicable corporate and external operating
experience documents to the DOE PSO and field element or GOGO
personnel for review, analysis, and routine use.
(10) Participate in screening, dissemination, analysis, and
development of lessons learned.
(11) Serve as point-of-contact for the DOE Corporate Operating
Experience Program.
(12) Collect information to evaluate program effectiveness and
report to management.
(13) Evaluate implementation of the operating experience
reporting and lessons learned development processes to ensure
compatibility and compliance with requirements of this Order.
i. DOE and NNSA Procurement Executives. Work with the
Office of Assistant Secretary for Environment, Safety
and Health to ensure the incorporation of the CRD of
this Order in the Department of Energy Acquisition
Regulation clauses of affected contracts.
j. Contracting Officers. Once notified, ensure the
incorporation of the CRD without modification into
affected contracts as soon as practicable but no later
than 6 months after the effective date of this Order.
6. DEFINITIONS.
a. Actions. Responses to lessons learned. Examples are—
(1) corrective actions in response to occurrence analysis,
(2) preventive actions to limit recurrence of a negative event,
or
(3) improvement actions based on good work practices or
innovative approaches.
b. Causal Analysis. An evaluation process to determine
behaviors, conditions, that adversely impact the likelihood or
severity of an adverse consequence or event, factors contributing
to and symptoms associated with a negative safety event; or a
review to identify root causes and less-than-adequate systemic
factors following a safety occurrence or event.
c. Clearinghouse. The central program unit dedicated to
development of a cohesive process for coordinating screening
management of operating experience information sources and
communications.
d. Corporate Operating Experience Documents. The following
publications for communicating lessons learned (accessible
through the following URL:
http://www.eh.doe.gov/ll/oellproducts.html):
(1) Special Operations Report (SOR) issued by the Deputy
Secretary to inform the DOE complex of the most significant
events or trends of concern to management.
(2) Environment, Safety and Health Alert (SA) issued by the
Assistant Secretary for Environment, Safety and Health (EH) to
inform the DOE complex or affected sites of a potentially
significant safety issue that can adversely affect operations
(e.g., an immediate conduct of operations problem,
suspect/counterfeit parts or defective items that require
immediate action.
(3) Environment, Safety and Health Bulletin (SB) issued by the
Assistant Secretary for Environment, Safety and Health (EH) when
analysis of operating experience data shows a trend that warrants
senior Headquarters and field manager attention.
(4) Environment, Safety and Health Advisory (SAd) issued by the
Assistant Secretary for Environment, Safety and Health (EH) on an
as-needed basis when analysis of operating experience data shows
a trend that warrants senior Headquarters and field manager
attention but is of less significance than would merit producing
an SOR, SA or SB.
(5) Operating Experience Summary (OES) issued by the Assistant
Secretary for Environment, Safety and Health (EH) to a target
audience of first-tier supervisors, work planners and craft
personnel for distribution of DOE-wide occurrence information and
lessons learned from which sites can benefit.
(6) Just-In-Time (JITs) Operating Experience Report issued by
the Assistant Secretary for Environment, Safety and Health (EH)
to communicate brief examples of problems and mistakes
encountered in actual cases and to present points to consider for
avoiding similar occurrences; a compilation of lessons learned
from review of common (i.e., frequently performed) work
activities for an audience that includes program managers, field
representatives, work planners, first line supervisors, and
workers.
(7) Suspect/Counterfeit or Defective Items Data Collection Sheet
(DCS), issued by the Assistant Secretary for Environment, Safety
and Health (EH) to provide information on suspect/counterfeit
items (S/CIs) and defective items with potential impact to DOE
operations. DCSs are developed from a review of occurrence
reports, the Government Industry Data Exchange Program (GIDEP),
the Institute for Nuclear Power Operations (INPO) and other
databases.
e. DOE Corporate Operating Experience Program. A structured
process for DOE/contractor line management and operating
experience staffs to review, analyze, and identify trends and be
held accountable for implementing and, evaluating the
effectiveness of lessons learned from operating experience in an
effort to prevent recurrence of significant adverse operational
events and trends and to improve performance.
f. Generic Technical Issue. A safety concern involving design,
construction, operation or analysis of a mechanical, structural,
electrical, chemical or electronic system component or structure
not unique to any one facility or site but relevant to more than
one application within the DOE complex. Resolution requires
senior DOE involvement to ensure integrated, balanced
consideration safety risks and mission needs of DOE programs and
missions.
g. Good Work Practice or Best Practice. A positive example of
work processes with potential to be the basis of significant
operational improvements or cost savings.
h. Lesson Learned. A good work practice, innovative approach,
or negative experience shared to promote positive information or
prevent recurrence of negative events.
i. Management/Institutional Issue. A safety issue associated
with DOE or contractor policies, procedures or practices related
to management of hazardous activities or human performance and
organizational interaction. Resolution requires senior DOE
involvement and direction to ensure an integrated, balanced
approach reflected in DOE regulations, policies, directives, and
implementation guidance.
j. Operating Experience. Information that relates to the
methods in which work is planned and conducted and an
organization’s missions are performed. Operating experience
provides the basis for knowledge and understanding that
fosters development of lessons learned and improvement of
operational performance.
k. Records. All books, papers, maps, photographs, machine-
readable materials, or other documentary materials, regardless of
physical form or characteristics, made or received by an Agency
of the United States Government under Federal law or in
connection with the transaction of public business and preserved
or appropriate for preservation by that Agency or its legitimate
successor as evidence of the organization, functions, policies,
decisions, procedures, operations, or other activities of the
Government or because of the informational value of the data in
them (44 U.S.C. 3301).
l. Subject Matter Expert (SME). An individual with
qualifications and experience in a particular field or work
process; an individual who by education, training, and/or
experience is a recognized expert on a particular subject, topic,
or system.
7. REFERENCES. (NOTE: DOE DIRECTIVES ARE AVAILABLE ONLINE AT
WWW.DIRECTIVES.DOE.GOV/DIRECTIVES/CURRENT.HTML.)
a. DOE O 151.1C, Comprehensive Emergency Management, dated 11-
02-05.
b. DOE O 200.1, Information Management Program, dated 9-30-96.
c. DOE G 225.1A-1, Implementation Guide for use with DOE
O 225.1 Accident Investigations, dated 11-26-97.
d. DOE O 225.1A, Accident Investigations, dated 11-26-97.
e. DOE O 226.1, Implementation of Department of Energy
Oversight Policy, dated 9-15-05.
f. DOE G 231.1-1, Occurrence Reporting and Performance Analysis
Guide, dated 8-20-03.
g. DOE G 231.1-2, Occurrence Reporting Causal Analysis Guide,
dated 8-20-03.
h. DOE M 231.1-2, Occurrence Reporting and Processing of
Operations Information, dated 8-19-03.
i. DOE O 231.1A, Environment, Safety and Health Reporting,
dated 6-3-04.
j. DOE O 243.1, Records Management Program, dated 2-3-06.
k. DOE O 414.1C, Quality Assurance, dated 6-17-05.
l. DOE G 414.1-3, Suspect/Counterfeit Items Guide for Use with
10 CFR 830, Subpart A, Quality Assurance Requirements and DOE
O 414.1B, Quality Assurance, dated 11-03-04.
m. DOE P 450.4, Safety Management System Policy, dated
10-15-96.
n. Institute for Nuclear Power Operations (INPO) INPO 94-001,
Significant Event Evaluation and Information Network (SEE-IN)
Program Description.
o. Institute for Nuclear Power Operations (INPO) INPO 97-001,
Guidelines for the Use of Operating Experience.
p. Nuclear Regulatory Commission (NRC) NUREG-0737,
“Clarification of TMI Action Plan Requirements,” Item I.C.5,
“Procedures for Feedback of Operating Experience to Plant Staff.”
q. Nuclear Regulatory Commission (NRC) NUREG-0933, “A
Prioritization of Generic Safety Issues,” Task I.E, “Analysis and
Dissemination of Operating Experience (Rev. 3).”
r. Defense Nuclear Facilities Safety Board (DNFSB)
Recommendation 2004-1, Oversight of Complex, High-Hazard Nuclear
Operations, dated 05-21-04.
s. U.S. Department of Energy Implementation Plan to Improve
Oversight of Nuclear Operations, Revision 1, dated June 2005.
8. CONTACT. Questions concerning this Order should be addressed to the office of Corporate
Performance assessment, Office of Environment, Safety and Health at 301-903-9878.
BY ORDER OF THE SECRETARY OF ENERGY:
CLAY SELL
Deputy Secretary
DOE ELEMENTS TO WHICH
DOE O 210.2 IS APPLICABLE
Office of the Secretary
National Nuclear Security Administration
Office of Civilian Radioactive Waste Management
Office of Energy Efficiency and Renewable Energy
Office of Environment, Safety and Health
Office of Environmental Management
Office of Fossil Energy
Office of Legacy Management
Office of Nuclear Energy, Science and Technology
Office of Science
Office of Security and Safety Performance Assurance
Southeastern Power Administration
Southwestern Power Administration
Western Area Power Administration
CONTRACTOR REQUIREMENTS DOCUMENT
DOE O 210.2, DOE CORPORATE OPERATING EXPERIENCE PROGRAM
Regardless of the performer of the work, the contractor is
responsible for complying with the requirements of this
Contractor Requirements Document (CRD) and flowing down CRD
requirements to subcontractors at any tier using a graded
approach based on risk and severity to the extent necessary to
ensure contractor compliance.
As directed by the contracting officer, the contractor must meet
the following requirements.
1. GENERAL REQUIREMENTS.
a. A DOE contractor must establish an operating experience
function that develops and evaluates site-specific lessons
learned which focus on preventing recurrence of safety or
reliability events, and to share good work practices among DOE
sites. The contractor must—
(1) share lessons learned with the DOE complex through the DOE
Corporate Lessons Learned Database (URL:
http://www.eh.doe.gov/DOEll/index.asp) (see standard format in
Appendix A).
b. The contractor must apply the following criteria when
assessing lessons learned for submission to the DOE Corporate
Lessons Learned Database (URL:
http://www.eh.doe.gov/DOEll/index.asp).
(1) Lessons learned developed for Type A or Type B accidents
(see DOE O 225.1A, Accident Investigations, dated 11-26-97) must
be submitted.
(2) Lessons learned must be developed and submitted for any
significance category 1 or recurring events (See Section 5.2 of
DOE M 231.1-2, Occurrence Reporting and Processing of Operations
Information, dated 8-19-03).
(3) Contractor-specific operating experience derived from other
operating events, e.g., classifiable operational emergencies
(i.e., General Emergencies, Site Area Emergencies, or Alert) (see
DOE O 151.1C, Comprehensive Emergency Management System, dated
11-2-05), significance category 2, 3 or 4 occurrences (See Section
5.2 of DOE M 231.1-2, Occurrence Reporting and Processing
of Operations Information, dated 8-19-03), Price-Anderson
Amendments Act (PAAA) events reported in the Non-Compliance
Tracking System (NTS), injuries or illness reported in the
Computerized Accident/Illness Reporting System (CAIRS),
assessment findings, etc., also may provide lessons learned to be
submitted when the following criteria are met.
(a) The experience provides significant new information.
(b) The experience has direct relevance to other facilities,
sites or programs.
(c) The information has potential to be the basis for
significant improvements or cost savings.
c. The contractor must –
(1) Screen all DOE Corporate Operating Experience Documents and
DOE Lessons Learned (see Appendix B). Also, screen external
organization operating experience documents from U.S. and foreign
government agencies and industry, professional societies, trade
associations, national academies, and universities, as deemed
significant and relevant by contractor management, for
applicability to contractor operations.
(2) Distribute the applicable corporate and external operating
experience documents to personnel for review, analysis,
implementation of corrective actions, and routine use.
(3) Provide feedback through the DOE field element to the
issuing authority for DOE Corporate Operating Experience
Documents (i.e., SORs, SAs, and SBs) when specific implementation
of lessons learned or corrective actions and a formal response
are required.
(4) Assess contractor operating event trends to identify
recurring issues and evaluate the root causes of the recurring
issues.
(5) Investigate and identify contractor operating event causes.
(6) Develop, implement, and track actions to correct problems
identified in causal analysis of contractor operating experience
and develop lessons learned on the successes.
(7) Establish metrics to measure program performance and
evaluate the effectiveness of actions implemented from lessons
learned.
d. The contractor must maintain operating experience records
according to National Archives and Records Administration (NARA)-
approved DOE Record Disposition Schedules.
2. SPECIFIC REQUIREMENTS.
a. Provide resources for developing, implementing, and
maintaining an operating experience program that is coordinated
with the Headquarters Corporate Operating Experience Review
Program Office.
b. Assign roles and responsibilities for the operating
experience program.
c. Incorporate responsibility for implementation and support of
the operating experience program into contractor Roles,
Responsibilities, Accountabilities, and Authorities.
d. Include in management control systems (policies and
procedures) identification of lessons learned and implemented by
organizations involved in identifying and correcting problems,
diagnosing issues, or implementing corrective actions.
e. Integrate lessons learned procedures and processes with
existing programs such as quality assurance, Integrated Safety
Management System (ISMS), and occurrence reporting. Modify
onsite control systems as appropriate.
f. Incorporate DOE and contractor lessons learned into
operations, training, maintenance and work planning, work
processes, and design and construction.
g. As a part of self-assessments conducted to evaluate the
contractor’s ISMS performance, include an assessment of the
effectiveness of the contractor organization’s operating
experience program. Report the results of this effectiveness
review to the DOE Contracting Officer and the DOE Corporate
Operating Experience Program lead office.
h. Designate an operating experience program coordinator who
can raise operating experience issues to senior management. The
coordinator will be responsible for implementing requirements of
this CRD and executing the following tasks.
(1) Manage the operating experience program and its
participation in the DOE program and develop processes,
procedures, communication methods and documentation to implement
the program.
(2) Elevate to management for resolution unresolved issues
associated with operating experience and lessons learned actions
or decision.
(3) Maintain program oversight.
(4) Submit to the DOE Corporate Operating Experience Program
lessons learned that are applicable to other DOE sites.
(5) With assistance from subject matter experts, assess the
applicability and significance of internal and external operating
experiences identified as potential lessons learned.
(6) Distribute internal, DOE and external operating experience
data to personnel for review, analysis, and routine use.
(7) Participate in the screening, dissemination, analysis, and
development of lessons learned.
(8) Serve as contractor point-of-contact for the DOE Corporate
Operating Experience Program.
(9) Collect and report to management information on program
effectiveness.
(10) Evaluate implementation of the operating experience
reporting and lessons learned development processes according to
requirements of this CRD.
APPENDIX A TO THE CONTRACTOR REQUIREMENTS DOCUMENT
DOE OPERATING EXPERIENCE PROGRAM LESSONS LEARNED TEMPLATE
Title:
Identifier:
Originator:
Date:
Contact:
Authorized Derivative Classifier:
Reviewing Official:
Statement of the Lesson Learned from Operating Experience:
Discussion of Activities:
Analysis (may be incorporated into the discussion):
Recommended Actions:
Estimated Savings/Cost Avoidance (if applicable):
Priority Descriptor:
Work/Functions:
User-Defined Category:
Hazards:
ISM Core Functions:
Keywords:
References:
LESSONS LEARNED TEMPLATE—FIELD DESCRIPTIONS
Title: Title of the operating experience document.
Identifier: Unique identification number to assist in referencing a lesson learned that includes calendar year, operations office identifier, organization or field/area office/contractor identifier, and a sequential number (e.g., 1995?CH?BNL?0019; 1995?ID?LITCO?0118)
Originator: Name of the originating organization or contractor.
Date: Date the operating experience document was issued.
Contact: Name and phone number of individual to contact for additional information.
Derivative Classifier: Name of individual who determined that the lesson learned does not contain classified information. (Not required for lessons submitted by unclassified facilities.)
Name of Reviewing Official: Name of reviewing official who determined that the lesson learned did not contain unclassified controlled nuclear information (UCNI). (Not required for facilities that have no UCNI.)
Statement of the Lessons Learned from the Operating Experience: Lessons learned statements are executive summaries that focus on the knowledge gained from the operational experience. Sufficient detail should be provided to allow a reader to understand what the problem is, how it was identified, and what steps have been or will be taken to correct the problem and prevent a recurrence. Information regarding the consequences, actual or worst case, associated with the event should also be provided to allow recipients to take a graded approach to applying the lessons learned.
Discussion of Activities: This section should be as brief as possible and focused on the facts that resulted in the initiation of the operating experience evaluation. Provide situation-specific details that establish the context of the event. Avoid organizational, personnel, and facility description details that merely locate the event in time and space.
Analysis: Results of any analysis that was performed, if available.
Recommended Actions : Includes a description of management approved actions that were taken or will be taken to promote implementation of work enhancements or to prevent the recurrence of undesirable events. This field should focus on actionable recommendations (i.e., the change resulting from the lesson) rather than reminders. Additionally, this field can include a description of activities the event/lessons learned may impact other than the event during which it was identified.
Estimated Savings/Cost Avoidance: If the lesson learned is implemented, an estimate of the savings from the application of a good work practice or the costs avoided from the prevention of a similar event
Priority Descriptor: A descriptive code that assigns a level of significance to the lesson. Options include Red/Urgent, Yellow/Caution, Blue/Information, and Green/Good Work Practice.
Work/Functions: The work or functions to which the lesson applies. Enter all that apply. See listing.
User-Defined Category: Space for organizations to include categories for internal use.
Hazards: Hazards this lesson applies to or that were present in the original situation. See listing.
ISM Core Functions: Identifies the core function or functions in which a failure occurred that contributed to the event and/or the core functions impacted by the recommended actions. See listing.
CATEGORIES OF LESSONS LEARNED FROM OPERATING EXPERIENCE
These bin categories are intended to help lesson authors assign
specific searchable subjects to their lessons so users can find
information focused on their needs. The three sets of bins
(Work/Function, Hazard, and ISM Core Function) provide several
avenues for zeroing in on applicable lessons. Some of these bins
are narrow (Hoisting and Rigging, Mechanical Injury) and some are
broader conceptual areas (Authorization Basis, Energy
Conservation, Environmental Release). This division is meant to
help work planners looking for specific items, to help foremen
looking for training anecdotes, and to help managers looking for
big-picture lessons. The Work/Function and Hazard bins are open
for further improvement and extension.
Lessons Learned Hazards
Confined Space
Electrical/NEC
Elevated Work/Falling Objects
Environmental Release
Ergonomics/Lifting
Excavation and Trenching
Fire/Smoke/NFPA
Firearms and Explosives
Lasers
Natural Phenomena
Other Personal Injury/ExposureAirborne Materials
Ambient Temperature Extremes
Asbestos
Beryllium
Hazardous Material (General)
Infectious Agents
Mechanical Injury (Striking/Crushing)
Noise
Other Personal Injury/Exposure (cont’d)
Radiation/Contamination
Slips and Tripping
Toxic Material
Plants/Animals/Insects
Power Tools
Pressurized Systems
Radiological Release
Suspect/Counterfeit or Defective Items
Traffic
Weather Related
Not Identified
ISM Core Functions
Define Work
Analyze Hazards and Risks Develop/Implement Controls
Perform Work Feedback and Improvement
Work/Function
Alternate Fuels
Authorization Basis
Business and Support Services
Chemical Management
Conduct of Operations
General
Configuration Management
Lockout/Tagout
Procedure Development
Procedure Adherence
Work Planning
Work Control Construction
Contract Administration
Criticality
Decontamination and Decommissioning
Demolition
Driving
Emergency Management
Energy Conservation
Engineering and Design
Nuclear
Non-Nuclear Environmental Protection
General
Environmental Sampling
Releases
RCRA Management
Underground Storage Tanks
NEPA Management
TSCA Management
Environmental Restoration
Excavation
Work/Function (continued)
Excess Property and Equipment Management
Fire Protection
Hoisting and Rigging
Human Factors
Human Resources
Information Technology
Inspection and Testing
Laboratory Experimentation
Maintenance
Electrical
Facility
HVAC
Instrumentation and Control
Mechanical
Other Power Distribution and Utilities
Roads and Grounds
Structural
Safety Systems
Heavy Equipment
Vehicle
Machining and Fabrication
Management
Material
Handling
Storage
Nuclear Safety
Occupational Safety and Health
General
Personnel Protective Equipment Operations
Facility
Heavy Equipment
Other
Packaging and Transportation
Procurement
Protective Force Related
Quality
Radiation Protection
Research and Development
Safeguards and Security
Safety Design
Training and Qualifications
Waste Management
Waste Remediation
Welding, Burning, Hot work
Well Drilling
Not Identified
Priority Descriptors
These priority descriptors were developed by the Lessons Learned Process Improvement Team. The examples are intended to help lessons learned authors assign significance codes to their operating experience lessons. Authors should use their judgment and extend these examples to situations as they arise.
Red/Urgent: A lesson from an actual event with significant adverse outcome
Yellow/Caution: A lesson from an event or condition with potentially adverse outcome
Blue/Information: A fact or discovery of benefit to others
Green/Good Work
Practice: A success story; a practice that results in a positive outcome;
Table 1. Priority Descriptors
GENERAL SUBJECT AREA RED/
URGENT YELLOW/
CAUTION BLUE/
INFORMATION GREEN/
GOOD WORK PRACTICE
Public Safety Event related to site operation that has affected public safety and health or threatened public safety and health Potential event related to site operation which may have affected public safety and health Information to protect public safety and health including, but not limited to, cumulative findings from trending Action, activity, or practice which improves public safety and health
Worker Safety Fatality, near fatality, serious injury, or permanent/ total disability Conditions which resulted in—
§ injury
§ temporary/partial disability or
§ significant loss of work time or productivity Information to protect worker health and safety including, but not limited to, cumulative findings from trending Action, activity, or practice which promotes: safe work practices or healthful work practices
Environmental Protection Unconfined hazardous release beyond the site boundary. Significant unconfined on-site hazardous release requiring cleanup Condition which may have resulted in an uncontrolled release to the environment or a moderate on-site hazardous release Information to protect the environment including: measurable, but minor, hazardous releases or cumulative findings from trending Action, activity, or practice which: prevents on or off-site environmental degradation or- will limit or reduce on or off-site releases to the environment
Compliance Violations of Federal or State law with significant penalties Violations of Federal or State law with minor penalties. Significant non-compliance with the technical requirements of DOE Orders or regulations Information which may improve compliance performance Action, activity, or practice which improves the compliance performance of the site
Management/ Administration Significant management violations including fraud, abuse, and discrimination Identified actions reflecting failure to operate within DOE management imperatives Information which may improve DOE management performance Action, activity, or practice which improves DOE management performance
Investment and Investment Protection Significant loss or damage of major equipment, property or facility Potential for major equipment, property or facility to become—
§ lost or damaged
§ degraded
§ unreliable Information which may improve—
§ value
§ efficiency
§ cost Action, activity, or practice which improves—
§ specifications
§ reliability
§ efficiency
§ credibility
Public Interest On-site event that is perceived by the public—
§ to have an effect on public safety and health or
§ to threaten public safety and health. A potential site operations event which may have affected the public, excluding safety and health, had the event occurred Information beneficial to public relations Action, activity, or practice that promotes benefits to the public
APPENDIX B TO THE CONTRACTORS REQUIREMENTS DOCUMENT
CORPORATE OPERATING EXPERIENCE DOCUMENTS AND DOE LESSONS LEARNED
1. Corporate Operating Experience Documents include the
following publications for communicating lessons learned
(accessible through the following URL:
http://www.eh.doe.gov/ll/oellproducts.html):
a. Special Operations Report (SOR) issued by the Deputy
Secretary of Energy to inform the DOE complex of the most
significant events or trends of concern to management. SORs are
disseminated through formal correspondence to NNSA and the PSOs
for action and further dissemination to DOE field elements and
formal submittal to contractors for action. SORs are also
posted/pushed to users of the DOE Corporate Lessons Learned
Database (URL: http://www.eh.doe.gov/DOEll/index.asp) and posted
on the DOE lessons learned web page hosted by EH (URL:
http://www.eh.doe.gov/paa/specialops_reports.html) to facilitate
communications.
b. Environment, Safety and Health Alert (SA) issued by the
Assistant Secretary for Environment, Safety and Health
(EH) to inform the DOE complex or affected sites of a
potentially significant safety issue that can adversely
affect operations (e.g., an immediate conduct of
operations problem, suspect/counterfeit parts or
defective items that require immediate action). SAs
are disseminated by formal correspondence from EH to
NNSA Deputy Administrators and the PSOs requesting
their action and further dissemination to DOE field
elements and formal submittal to contractors for
action. SAs are also posted/pushed to users of the DOE
Corporate Lessons Learned Database (URL:
http://www.eh.doe.gov/DOEll/index.asp) and posted on
the DOE lessons learned web page hosted by EH (URL:
http://www.eh.doe.gov/paa/alerts.html) to facilitate
communications.
c. Environment, Safety and Health Bulletin (SB) issued by
the Assistant Secretary for Environment, Safety and
Health (EH) when analysis of operating experience data
shows a trend that warrants senior Headquarters, field
manager, and contractor attention. SBs are
disseminated by formal correspondence to NNSA Deputy
Administrators and the PSOs recommending their action
and further dissemination to DOE field elements and
formal submittal to contractors for action. SBs are
also posted/pushed to users of the DOE Corporate
Lessons Learned Database (URL:
http://www.eh.doe.gov/DOEll/index.asp) and posted on
the DOE lessons learned web page hosted by EH (URL:
http://www.eh.doe.gov/paa/bulletins.html) to facilitate
communications.
d. Environment, Safety and Health Advisory (SAd) issued by
the Assistant Secretary for Environment, Safety and
Health (EH) on an as-needed basis when analysis of
operating experience data shows a trend that warrants
senior Headquarters, field manager, and contractor
attention but is of less significance than would merit
producing an SOR, SA or SB. SAds are disseminated by
being posted/pushed to users of the DOE Corporate
Lessons Learned Database (URL:
http://www.eh.doe.gov/DOEll/index.asp) and by posting
on the DOE lessons learned web page hosted by EH. (URL:
http://www.eh.doe.gov/paa/safety_advisory.html).
e. Operating Experience Summary (OES) issued biweekly
(every 2 weeks) by the Assistant Secretary for
Environment, Safety and Health (EH) to a target
audience of first-tier supervisors, work planners and
craft personnel for distribution of DOE-wide occurrence
information and lessons learned from which sites can
benefit. OESs are disseminated by posting on the DOE
lessons learned web page hosted by EH. (URL:
http://www.eh.doe.gov/paa/oesummary/index.html).
f. Just-In-Time (JITs) Operating Experience Report issued
by the Assistant Secretary for Environment, Safety and
Health (EH) to communicate brief examples of problems
and mistakes encountered in actual cases and to present
points to consider for avoiding similar occurrences; a
compilation of lessons learned from review of common
(i.e., frequently performed) work activities for an
audience that includes program managers, field
representatives, work planners, first line supervisors,
and workers. JITs are disseminated by being
posted/pushed to users of the DOE Corporate Lessons
Learned Database (URL:
http://www.eh.doe.gov/DOEll/index.asp) and by posting
on the DOE lessons learned web page hosted by EH (URL:
http://www.eh.doe.gov/paa/jit.html).
g. Suspect/Counterfeit or Defective Items Data Collection
Sheet (DCS), issued by the Assistant Secretary for
Environment, Safety and Health (EH) to provide
information on suspect/counterfeit items (S/CIs) and
defective items with potential impact to DOE
operations. DCSs are developed from a review of
occurrence reports, the Government Industry Data
Exchange Program (GIDEP), the Institute for Nuclear
Power Operations (INPO) and other databases. DCSs are
disseminated by posting on the DOE Suspect/Counterfeit
Items and Defective Items web pages hosted by EH. (URL:
http://www.eh.doe.gov/sci). A limited number of DCSs
may also disseminated by Push Mail to a registered
users list.
2. DOE Lessons Learned consist of lessons learned originating from other DOE
and contractor organizations posted to the DOE Corporate Lessons Learned
Database. (URL: http://www.eh.doe.gov/DOEll/index.asp).
3. NNSA/PSO Originated DOE Lessons Learned include NNSA/PSO feedback
communications on identified program/mission-specific operating experience
lessons learned with field organizations and contractors that contain the basic
elements of the DOE Operating Experience Lessons Learned Template provided
in Appendix A, (i.e., title, number, statement of the lessons learned, discussion,
analysis, and recommended actions). NNSA/PSO issued lessons learned may
emulate the format of the SOR, SA, SB, SAd, etc. described above.
DOE OPERATING EXPERIENCE PROGRAM LESSONS LEARNED TEMPLATE
Title:
Identifier:
Originator:
Date:
Contact:
Authorized Derivative Classifier:
Reviewing Official:
Statement of the Lesson Learned from Operating Experience:
Discussion of Activities:
Analysis (may be incorporated into the discussion):
Recommended Actions:
Estimated Savings/Cost Avoidance (if applicable):
Priority Descriptor:
Work/Functions:
User-Defined Category:
Hazards:
ISM Core Functions:
Keywords:
References:
LESSONS LEARNED TEMPLATE—FIELD DESCRIPTIONS
Title: Title of the operating experience document.
Identifier: Unique identification number to assist in referencing a lesson learned that includes calendar year, operations office identifier, organization or field/area office/contractor identifier, and a sequential number (e.g., 1995?CH?BNL?0019; 1995?ID?LITCO?0118)
Originator: Name of the originating organization or contractor.
Date: Date the operating experience document was issued.
Contact: Name and phone number of individual to contact for additional information.
Derivative Classifier: Name of individual who determined that the lesson learned does not contain classified information. (Not required for lessons submitted by unclassified facilities.)
Name of Reviewing Official: Name of reviewing official who determined that the lesson learned did not contain unclassified controlled nuclear information (UCNI). (Not required for facilities that have no UCNI.)
Statement of the Lessons Learned from the Operating Experience: Lessons learned statements are executive summaries that focus on the knowledge gained from the operational experience. Sufficient detail should be provided to allow a reader to understand what the problem is, how it was identified, and what steps have been or will be taken to correct the problem and prevent a recurrence. Information regarding the consequences, actual or worst case, associated with the event should also be provided to allow recipients to take a graded approach to applying the lessons learned.
Discussion of Activities: This section should be as brief as possible and focused on the facts that resulted in the initiation of the operating experience evaluation. Provide situation-specific details that establish the context of the event. Avoid organizational, personnel, and facility description details that merely locate the event in time and space.
Analysis: Results of any analysis that was performed, if available.
Recommended Actions : Includes a description of management approved actions that were taken or will be taken to promote implementation of work enhancements or to prevent the recurrence of undesirable events. This field should focus on actionable recommendations (i.e., the change resulting from the lesson) rather than reminders. Additionally, this field can include a description of activities the event/lessons learned may impact other than the event during which it was identified.
Estimated Savings/Cost Avoidance: If the lesson learned is implemented, an estimate of the savings from the application of a good work practice or the costs avoided from the prevention of a similar event.
Priority Descriptor: A descriptive code that assigns a level of significance to the lesson. Options include Red/Urgent, Yellow/Caution, Blue/Information, Green/Good Work Practice.
Work/Functions: The work or functions to which the lesson applies. Enter all that apply. See listing.
User-Defined Category: Space for organizations to include categories for internal use.
Hazards: Hazards this lesson applies to or that were present in the original situation. See listing.
ISM Core Functions: Identifies the core function or functions in which a failure occurred that contributed to the event and/or the core functions impacted by the recommended actions. See listing.
CATEGORIES OF LESSONS LEARNED FROM OPERATING EXPERIENCE
These bin categories are intended to help lesson authors assign specific searchable subjects to their lessons so users can find information focused on their needs. The three sets of bins (Work/Function, Hazard, and ISM Core Function) provide several avenues for zeroing in on applicable lessons. Some of these bins are narrow (Hoisting and Rigging, Mechanical Injury) and some are broader conceptual areas (Authorization Basis, Energy Conservation, Environmental Release). This division is meant to help work planners looking for specific items, to help foremen looking for training anecdotes, and to help managers looking for big-picture lessons. The Work/Function and Hazard bins are open for further improvement and extension.
Lessons Learned Hazards
Confined Space
Electrical/NEC
Elevated Work/Falling Objects
Environmental Release
Ergonomics/Lifting
Excavation and Trenching
Fire/Smoke/NFPA
Firearms and Explosives
Lasers
Natural Phenomena
Other Personal Injury/Exposure
Airborne Materials
Ambient Temperature Extremes
Asbestos
Beryllium
Hazardous Material (General)
Infectious Agents
Mechanical Injury (Striking/Crushing)
Noise
Other Personal Injury/Exposure (cont’d)
Radiation/Contamination
Slips and Tripping
Toxic Material
Plants/Animals/Insects
Power Tools
Pressurized Systems
Radiological Release
Suspect/Counterfeit or Defective Items
Traffic
Weather Related
Not Identified
ISM Core Functions
Define Work
Analyze Hazards and Risks Develop/Implement Controls
Perform Work Feedback and Improvement
Work/Function
Alternate Fuels
Authorization Basis
Business and Support Services
Chemical Management
Conduct of Operations
General
Configuration Management
Lockout/Tagout
Procedure Development
Procedure Adherence
Work Planning
Work Control Construction
Contract Administration
Criticality
Decontamination and Decommissioning
Demolition
Driving
Emergency Management
Energy Conservation
Engineering and Design
Nuclear
Non-Nuclear Environmental Protection
General
Environmental Sampling
Releases
RCRA Management
Underground Storage Tanks
NEPA Management
TSCA Management
Environmental Restoration
Excavation
Work/Function (continued)
Excess Property and Equipment Management
Fire Protection
Hoisting and Rigging
Human Factors
Human Resources
Information Technology
Inspection and Testing
Laboratory Experimentation
Maintenance
Electrical
Facility
HVAC
Instrumentation and Control
Mechanical
Other Power Distribution and Utilities
Roads and Grounds
Structural
Safety Systems
Heavy Equipment
Vehicle
Machining and Fabrication
Management
Material
Handling
Storage
Nuclear Safety
Occupational Safety and Health
General
Personnel Protective Equipment Operations
Facility
Heavy Equipment
Other
Packaging and Transportation
Procurement
Protective Force Related
Quality
Radiation Protection
Research and Development
Safeguards and Security
Safety Design
Training and Qualifications
Waste Management
Waste Remediation
Welding, Burning, Hot work
Well Drilling
Not Identified
Priority Descriptors
These priority descriptors were developed by the Lessons Learned Process Improvement Team. The examples are intended to help lessons learned authors assign significance codes to their operating experience lessons. Authors should use their judgment and extend these examples to situations as they arise.
Red/Urgent: A lesson from an actual event with significant adverse outcome
Yellow/Caution: A lesson from an event or condition with potentially adverse outcome
Blue/Information: A fact or discovery of benefit to others
Green/Good Work
Practice: A success story; a practice that results in a positive outcome
Table 1. Priority Descriptors
GENERAL SUBJECT AREA RED/
URGENT YELLOW/
CAUTION BLUE/
INFORMATION GREEN/
GOOD WORK PRACTICE
Public Safety Event related to site operation that has affected public safety and health or threatened public safety and health Potential event related to site operation which may have affected public safety and health Information to protect public safety and health including, but not limited to, cumulative findings from trending Action, activity, or practice which improves public safety and health
Worker Safety Fatality, near fatality, serious injury, or permanent/ total disability Conditions which resulted in
§ injury
§ temporary/ partial disability or
§ significant loss of work time or productivity Information to protect worker health and safety including, but not limited to, cumulative findings from trending Action, activity, or practice which promotes: safe work practices or healthful work practices
Environmental Protection Unconfined hazardous release beyond the site boundary. Significant unconfined on-site hazardous release requiring cleanup Condition which may have resulted in an uncontrolled release to the environment or a moderate on-site hazardous release Information to protect the environment including: measurable, but minor, hazardous releases or cumulative findings from trending Action, activity, or practice which: prevents on or off-site environmental degradation or will limit or reduce on or off-site releases to the environment
Compliance Violations of Federal or State law with significant penalties Violations of Federal or State law with minor penalties. Significant non-compliance with the technical requirements of DOE Orders or regulations Information which may improve compliance performance Action, activity, or practice which improves the compliance performance of the site
Management/
Administration Significant management violations including fraud, abuse, and discrimination Identified actions reflecting failure to operate within DOE management imperatives Information which may improve DOE management performance Action, activity, or practice which improves DOE management performance
Investment and Investment Protection Significant loss or damage of major equipment, property or facility Potential for major equipment, property or facility to become—
§ lost or damaged
§ degraded
§ unreliable Information which may improve—
§ value
§ efficiency
§ cost Action, activity, or practice which improves—
§ specifications, reliability
§ efficiency
§ credibility
Public Interest On-site event that is perceived by the public to—
§ have an effect on public safety and health or
§ threaten public safety and health. A potential site operations event which may have affected the public, excluding safety and health, had the event occurred Information beneficial to public relations Action, activity, or practice that promotes benefits to the public