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Approved: 08-19-03
Review Date: 08-19-05
OCCURRENCE REPORTING
AND PROCESSING OF
OPERATIONS INFORMATION
U.S. DEPARTMENT OF ENERGY
Office of Environment, Safety and Health
SUBJECT: OCCURRENCE REPORTING AND PROCESSING OF OPERATIONS
INFORMATION
1. PURPOSE. This Manual provides detailed requirements to supplement DOE O 231.1A,
Environment, Safety, and Health Reporting, dated 08-19-03. This Manual is approved for use
by all DOE Elements and their contractors.
2. REFERENCE. DOE O 231.1A, Environment, Safety, and Health Reporting, dated 08-19-03.
3. CANCELLATION. DOE M 232.1-1A, Occurrence Reporting and Processing of Operations
Information, dated 7-21-97. Cancellation of a Manual does not, by itself, modify or otherwise
affect any contractual obligation to comply with the Manual. Cancelled Manuals that are
incorporated by reference in a contract remain in effect until the contract is modified to delete
the references to the requirements in the cancelled Manuals.
4. CONTACT. Beneficial comments and any pertinent data that may improve this document
should be sent to the Office of Environment, Safety and Health (Office of Corporate
Performance Analysis) at 301-903-3393.
BY ORDER OF THE SECRETARY OF ENERGY:
KYLE E. McSLARROW Deputy
Secretary
CONTENTS
SECTION PAGE
1. SCOPE 1
2. PURPOSE 1
3. APPLICABILITY 1
4. RESPONSIBILITIES 2
4.1 Assistant Secretary for Environment, Safety and Health 3
4.2 Secretarial Officers/Deputy Administrators (NNSA) 3
4.3 Director, Office of Security 4
4.4 Director, Office of Emergency Operations, NNSA 5
4.5 Heads of Field Elements 5
4.6 Program Managers 6
4.7 Facility Representatives 7
4.8 Facility Managers 8
5. OCCURRENCE REPORTING 9
5.1 Event or Condition Identification 10
5.2 Event or Condition Categorization 10
5.3 DOE HQ Operations Center Prompt Notifications 11
5.3.1 Operational Emergencies 11
5.3.2 Prompt Notifications for Significance Category 1, 2, 3, and 4
Reportable Occurrences. 11
5.4 Written Notification Report 13
5.4.1 Occurrence Report Preparation 14
5.4.2 Notification Report Submittal Schedule 15
5.5 Occurrence Investigation and Analysis 15
5.6 Occurrence Report Closure 17
5.7 Short Form Reports 19
5.8 Performance Analysis and Identification of Recurring Occurrences 19
5.9 Training. 20
CONTENTS (continued)
SECTION PAGE
6. REPORTING CRITERIA 20
6.1 Major Criteria Groups 21
6.2 Categorizing Instructions 21
6.3 Occurrence Reporting Criteria 22
Group 1 - Operational Emergencies 22
Group 2 - Personnel Safety and Health 22
Group 3 - Nuclear Safety Basis 25
Group 4 - Facility Status 27
Group 5 - Environmental 29
Group 6 - Contamination/Radiation Control 30
Group 7 - Nuclear Explosive Safety 33
Group 8 - Transportation 34
Group 9 - Noncompliance Notifications 35
Group 10 - Management Concerns/Issues 36
7. INFORMATION SECURITY REQUIREMENTS 37
8. UTILIZATION OF REPORTABLE OCCURRENCE INFORMATION 37
8.1 Operational Database 37
8.2 Utilization 38
9. IMPLEMENTING PROCEDURES 38
10. INSTRUCTIONS FOR COMPLETING AN OCCURRENCE REPORT 38
11. OCCURRENCE REPORTING MODEL AND CAUSAL ANALYSIS TREE 39
12. REFERENCES 42
13. DEFINITIONS 43
ATTACHMENT 1: DEPARTMENT OF ENERGY ORGANIZATIONS TO WHICH
DOE M 231.1-2 IS AND IS NOT APPLICABLE 1
ATTACHMENT 2: CONTRACTOR REQUIREMENTS DOCUMENT 1
SECTION 1. SCOPE.
This Manual and DOE Order 231.1A, Environment, Safety, and Health Reporting, dated
08-19-03, set forth the minimum set of occurrence reporting requirements for Department of
Energy (DOE) Departmental Elements, including the National Nuclear Security
Administration (NNSA), and contractors responsible for the management and operation of
DOE-owned and DOE-leased facilities, including NNSA facilities. These requirements
include categorizing occurrences related to safety, environment, health, or operations
("Reportable Occurrences"); notifying DOE of these occurrences; and developing and
submitting documented follow-up reports. These occurrence reporting directives further
require that the notifications be timely in accordance with the significance of the occurrence,
and that the written reports contain appropriate information describing the occurrence,
significance, causal factors, and corrective actions. No exemption to this minimum set of
occurrence reporting requirements is permitted.
SECTION 2. PURPOSE.
This Manual provides detailed information for reporting occurrences and managing
associated activities at DOE facilities, including NNSA facilities. It complements DOE O
231.1A, Environment, Safety, and Health Reporting and its use is required by that Order.
Information gathered in response to the requirements in this Order and Manual is used for
analysis of the Department's performance in environmental protection and the safety and
health of its workers and the public. This information is also used to develop lessons learned
and document events that impact DOE operations.
SECTION 3. APPLICABILITY.
a. DOE Elements. Except for the exclusions in paragraph c of this section, this Manual
applies to all DOE Elements, including NNSA, as listed in Attachment 1.
Where a responsibility or authority is assigned to an organization that is restructured,
the responsibility or authority will be reassigned to the appropriate successor
organization as explicitly determined by the appropriate Lead Program Secretarial
Officer.
b. Site/Facility Management Contractors.
(1) The Contractor Requirements Document (CRD), Attachment 2, sets forth
requirements of this Manual that will apply to site/facility management
contractors whose contracts include the CRD.
(2) Except for the exclusions in paragraph c of this section, this CRD must be
included in all site/facility management contracts.
(3) This Manual does not apply to other than site/facility management contractors.
Any application of any requirements of this Manual to other than site/facility
management contractors will be communicated separately from this Manual.
(4) The office identified in the Responsibilities section is responsible for telling
contracting officers which site/facility management contractors are affected.
Once notified, contracting officers are responsible for incorporating the CRD into
the contracts of affected site/facility management contractors via the laws,
regulations, and DOE directives clause of the contracts.
(5) As the laws, regulations, and DOE directives clause of site/facility management
contracts state, regardless of the performer of the work, the site/facility
management contractor with the CRD incorporated into its contract is responsible
for compliance with the requirements of the CRD. An affected site/facility
management contractor is responsible for flowing down the requirements of this
CRD to subcontracts at any tier to the extent necessary to ensure the site/facility
management contractor's compliance with the requirements. In doing so, the
contractor must not unnecessarily or imprudently flow down requirements to
subcontracts. That is, the contractor will both ensure that it and its subcontractors
comply with the requirements of this CRD and only incur costs that would be
incurred by a prudent person in the conduct of competitive business.
c. Exclusions.
(1) Power Marketing Administration reporting of major electrical power outages,
disturbances, and fuel shortages subject to the emergency power system
reporting requirements prescribed in 10 CFR 205, and 350-354, Report Of
Major Electric Utility Systems Emergencies.
(2) Activities under the authority of the Director, Naval Nuclear Propulsion,
pursuant to Executive Order 12344, as set forth in Public Laws 98-525 and
106-65.
SECTION 4. RESPONSIBILITIES.
The following provides primary responsibilities for implementation of the Occurrence
Reporting Program. Other specific responsibilities are provided elsewhere in the Manual.
4.1 Assistant Secretary for Environment, Safety and Health.
a. Develops, promulgates, and maintains policies to implement and sustain an
effective Occurrence Reporting Program, including the computerized
Occurrence Reporting and Processing System.
b. Provides formal Departmental interpretation of the requirements of this
Manual, in coordination with the Secretarial Offices and the National Nuclear
Security Administration (NNSA) for NNSA facilities.
c. Develops, promulgates, and maintains guidance materials, and conducts
workshops, as necessary, for implementing the requirements of this Manual.
d. Monitors reports relative to reporting activities at DOE facilities to assess
implementation of this Manual and to identify needed improvements.
e. Monitors and audits implementation of this Manual related to the Office of
Environment, Safety and Health functional areas of responsibility.
f. Periodically analyzes occurrence reporting data to identify significant issues
and trends across the Department.
g. In conjunction with the Chief Information Officer, operates, maintains, and
further develops the supporting computer data system, the Occurrence
Reporting and Processing System (ORPS).
4.2 Secretarial Officers/Deputy Administrators (NNSA).
a. Delegate responsibilities and authority for implementing this Manual,
including designating Program Managers.
b. Establish agreements with Heads of Field Elements to ensure support for the
Facility Representative and Program Manager in accordance with this Manual.
c. Review occurrence reporting data and identify circumstances that are
indicative of deteriorating or poor program performance in their respective
areas of authority.
d. Provide the Headquarters Operations Center (HQ OC) with a prioritized list of
emergency management duty officers and their contact numbers to permit
notification on a 24 hour-a-day, 7 day-a-week basis.
e. Ensure training programs are established for both DOE and contractor
personnel.
f. Ensure the requirements in the CRD for DOE M 231.1-2 are applied to
applicable contracts within 3 months after approval of this Order.
g. Ensure initiators of procurement requests identify in procurement requests
whether the requirements in the CRD for DOE M 231.1-2 are to be applied to
the award or sub awards resulting from the procurement request and any
special instructions for the application of the CRD.
4.3 Director, Office of Security
a. Formulates Department-wide policy regarding the protection and control of
both classified matter and unclassified controlled information, which includes
Official Use Only and Unclassified Controlled Nuclear Information (UCNI)
policy.
b. Resolves any security issues with respect to occurrence reporting.
c. Director, Office of Operations Support.
1. Maintains a 24-hour-a-day/7-day-a-week capability at the DOE HQ OC to
receive and log Operational Emergency notifications per DOE O 151.1A,
Comprehensive Emergency Management System, to process Prompt
Notifications of Significance Category 1 Reportable Occurrences, and to
process Prompt Notifications of other occurrences requiring immediate
notification to DOE HQ from Departmental Operations/Field/Site Offices
and facilities per this Manual.
a) Receives Prompt Notifications of Operational Emergencies orally.
b) Receives by e-mail the Prompt Notifications of Significance Category
1 Reportable Occurrences and other occurrences requiring immediate
notification to DOE HQ.
c) When called as follow-up to an e-mail notification, confirms the
receipt of the e-mail transmitting the Prompt Notification of
Significance Category 1 Reportable Occurrences and other
occurrences requiring immediate notification to DOE HQ.
2. Logs receipt of all Prompt Notifications and immediately conducts oral
notifications to the emergency management duty officer of the Secretarial
Officers/Deputy Administrators (NNSA) with responsibility for the
facility, site, or activity involved in the operational emergency or
occurrence.
a) The DOE HQ OC will immediately call the appropriate emergency
management duty officer and provide information from the Prompt
Notification. Notifications by the DOE HQ OC will be made for all
Operational Emergencies, Significance Category 1 Reportable
Occurrences, and other occurrences requiring immediate notification
to DOE HQ regardless of the time or day of the week.
b) The DOE HQ OC will forward an e-mail copy of Prompt Notifications
of Significance Category 1 Reportable Occurrences, and other
occurrences requiring immediate notification of DOE HQ to the
emergency management duty officer who was called.
4.4 Director, Office of Emergency Operations, NNSA
a. Develops, promulgates, and maintains policies related to reporting criteria,
classifications, definitions, and prompt notification requirements for
Operational Emergencies.
b. Provides formal Departmental interpretation of the requirements for
classifying Operational Emergencies.
c. Develops, promulgates, and maintains guidance materials, and conducts
workshops, as necessary, on identification and classification of Operational
Emergencies.
d. Monitors reports relative to reporting activities at DOE facilities to assess
implementation of the Operational Emergency portion of the Occurrence
Reporting Program and to identify needed improvements.
4.5 Heads of Field Elements.1
a. Ensure that agreements are established with responsible Secretarial Officers or
Deputy Administrators (NNSA) on the working relationship between the
Secretarial Officer or Deputy Administrator and the Field Element for the
purpose of carrying out the requirements of this Manual.
b. Assess capability and performance of the facility personnel in carrying out the
requirements of this Manual, in accordance with established agreements with
the responsible Secretarial Officers or Deputy Administrators (NNSA).
c. Provide technical support as necessary to Facility Representatives and line
management staff in responding to any reportable occurrence, in accordance
with established agreements with the responsible Secretarial Officers or
Deputy Administrators (NNSA).
d. Designate and direct Facility Representatives and Designees to fulfill the
responsibilities required by this Manual.
e. Ensure the requirements in the CRD for DOE M 231.1-2 are applied to
applicable contracts within 3 months after approval of this Order.
f. Ensure initiators of procurement requests identify in procurement requests
whether the requirements in the CRD for DOE M 231.1-2 are to be applied to
the award or sub awards resulting from the procurement request and any
special instructions for the application of the CRD.
4.6 Program Managers. In addition to other requirements prescribed by this Manual,
Program Managers are responsible for the following:
a. Reviewing activities related to reportable occurrences, including reporting and
the development of programs and procedures.
b. Ensuring that a system for Prompt Notification and categorization of
reportable occurrences has been established for their DOE programs and for
facilities under their cognizance.
c. Ensuring that the Headquarters Operations Center (HQ OC) is informed of
how the Headquarters Program Manager or Designees can be reached at all
times.
d. Ensuring that lessons learned and generic or programmatic implications are
identified and elevated to the Secretarial Officer or Deputy Administrator
(NNSA) for appropriate action.
e. Ensuring that actions are taken to prevent recurrence of significant events.
f. Reviewing and assessing reportable occurrence information from facilities
under their cognizance to assess the Facility Manager's and Facility
Representative's evaluation of significance, causes, generic implications, and
corrective actions implementation and closeout, and to ensure that DOE and
contractor staff involved in these operations perform the related functions.
g. Ensuring that Occurrence Reports and operations information from other
organizations are disseminated to appropriate DOE and contractor activities
within their cognizance, are reviewed for generic implications, and are used to
improve operations.
h. Ensuring that Occurrence Reports are prepared and transmitted in accordance
with DOE information security requirements (see Section 7).
i. Notifying the cognizant Secretarial Officer or Deputy Administrator (NNSA)
of all Significance Category 1 Occurrences.
j. Interacting with the Facility Representative and HQ oversight organizations as
necessary, and inform and advising their respective management of their
findings.
k. Elevating any unresolved issues regarding actions or determinations on a
reportable occurrence to the Secretarial Officer or Deputy Administrator
(NNSA) and, if necessary, the Secretary for resolution and direction.
4.7 Facility Representatives.2 In addition to other requirements prescribed in this
Manual, Facility Representatives or designee, or selected line management staff if a
Facility Representative is not assigned, are responsible for the following:
a. Evaluating facility implementation of the notification and reporting process to
ensure it is compatible with and meets the requirements of this Manual.
b. Maintaining day-to-day operational oversight of contractor activities, as
described in DOE-STD-1063-2000, Facility Representatives.
c. Ensuring that occurrences that may have generic or programmatic
implications are identified and elevated to the Head of the Field Element for
appropriate action.
d. Ensuring that facility personnel act to minimize and prevent recurrence of
significant events.
e. Reviewing and assessing reportable occurrence information from facilities
under their cognizance to determine the acceptability of the Facility
Manager's evaluation of the significance, causes, generic implications, and
corrective action implementation and closeout, and to ensure that facility
personnel involved in these operations perform the related functions.
f. Ensuring that Occurrence Reports are prepared and transmitted in accordance
with DOE information security requirements (see Section 7).
g. Interacting with facility personnel and Field Element oversight organizations
as necessary and informing and advising their respective managements of
their findings.
h. Elevating any unresolved issues regarding actions or determinations on a
reportable occurrence to the Program Manager for resolution and direction.
i. Being available at all times to satisfy the requirements of this Manual.
4.8 Facility Managers. In addition to other requirements prescribed in this Manual,
Facility Managers are responsible for the following:
a. Ensuring procedures are implemented for notification and reporting that meet
the requirements of this Manual.
b. Actively monitoring day-to-day operations and performance of
facilities/activities under their cognizance.
c. Identifying and sharing with others lessons learned and generic or
programmatic implications from occurrences and taking actions to minimize
or prevent recurrence.
d. Determining causes and generic implications, and implementing corrective
actions and closeout activities for reportable occurrences.
e. Reviewing and assessing reportable occurrence information for their
facility(ies) to assess generic implications and corrective action(s)
implementation, closeout, and effectiveness, as required; to identify and report
recurring events, and to ensure that facility personnel involved in these
operations perform the related functions.
f. Ensuring that Occurrence Reports and operations information from other
organizations are disseminated to appropriate facility personnel within their
cognizance, are reviewed for generic implications, and are used to improve
operations.
g. Preparing and transmitting Occurrence Reports in accordance with DOE
information security requirements (see Section 7).
h. Being available at all times to satisfy the requirements of this Manual.
SECTION 5. OCCURRENCE REPORTING.
To implement the occurrence categorization, notification, reporting, and processing system,
the key responsible personnel must be identified and procedures developed, approved, and
implemented to ensure that all of the occurrence reporting requirements, as delineated in
DOE O 231.1A and this Manual, are met. The Facility Manager must be available at all
times to carry out the responsibilities for the categorization, notification, and reporting
requirements. Facility operators are required to ensure that occurrences resulting from
activities performed by subcontractors in support of facility operation are reported in
accordance with the provisions of this Manual.
For reportable occurrences, facility personnel are required to categorize the occurrences,
notify DOE as required, and prepare and submit Occurrence Reports. This Section addresses
the process for meeting these requirements, including roles and actions for key facility
personnel and the steps to be taken to ensure performance. In Section 11, the Occurrence
Reporting Model summarizes the various time limits, levels of investigation and analysis,
corrective action development and tracking, approvals, and lessons learned development by
Significance Category.
The documentation and distribution requirements will be satisfied by utilization of a
centralized unclassified DOE operational database, the computerized Occurrence Reporting
and Processing System (ORPS). However, under no circumstances will Occurrence Reports
containing classified information or Unclassified Controlled Nuclear Information (UCNI) be
entered into the ORPS database. Requirements regarding security classification are provided
in Section 7.
Occurrences involving foreign personnel, governments, organizations, entities or influence
must be reported by the Facility Manager to the Office of Counterintelligence or the Office
of Defense Nuclear Counterintelligence, as appropriate. Such reporting is not intended to
interfere with or delay any actions directed toward protection of personnel or property.
5.1 Event or Condition Identification.
a. Occurrences may be identified by direct observation of equipment or process
malfunctions, log or record reviews, operator recognition of their own or others'
errors, or other means.
b. Operations personnel must take appropriate immediate action to stabilize and/or
place the facility/operation in a safe condition and ensure that any potential
environmental effects are stabilized and workers are treated for injuries
sustained. Also, actions should be taken to preserve conditions for continued
investigation; however, these actions are not to interfere with establishing a safe
condition.
c. The facility staff and operators must, upon identification of an abnormal or
suspected abnormal event or condition, promptly notify the appropriate line
management and the Facility Manager of the event status and record and/or
archive all pertinent information, including details concerning the discovery of
the occurrence and actions taken to stabilize or place the facility/operation in a
safe condition.
5.2 Event or Condition Categorization. The Facility Manager must categorize all
occurrences, except Operational Emergencies, within 2 hours of discovery by the
cognizant facility staff following the site/facility-specific procedures developed in
accordance with Section 9 of this Manual. The significance categories, as outlined in
the Occurrence Reporting Model (Section 11), are for those occurrences of interest
for complex-wide occurrence reporting and are described very generally below.
More definitively, Section 6, Reporting Criteria, provides very specific reporting
criteria and assigns the appropriate significance category to each criterion. Local
implementing procedures may increase the reporting requirements but may not
decrease the requirements below.
a. Operational Emergencies (OE). Operational Emergencies are defined in DOE O
151.1A, Comprehensive Emergency Management System. Operational
Emergency Occurrences are the most serious occurrences and require an
increased alert status for onsite personnel and, in specified cases, for offsite
authorities. The prompt notification requirements, definitions, criteria, and
classifications of operational emergencies and appropriate responses are provided
in DOE O 151.1A. Written Occurrence Reports must be completed in accordance
with this Manual.
b. Significance Category 1. Occurrences in this category are those that are not
Operational Emergencies and that have a significant impact on safe facility
operations, worker or public safety and health, regulatory compliance, or
public/business interests.
c. Significance Category R. Occurrences in this category are those identified as
recurring, as determined from the periodic performance analysis of occurrences
across a site.
d. Significance Category 2. Occurrences in this category are those that are not
Operational Emergencies and that have a moderate impact on safe facility
operations, worker or public safety and health, regulatory compliance, or
public/business interests.
e. Significance Category 3. Occurrences in this category are those that are not
Operational Emergencies and that have a minor impact on safe facility operations,
worker or public safety and health, regulatory compliance, or public/business
interests
f. Significance Category 4. Occurrences in this category are those that are not
Operational Emergencies and that have some impact on safe facility operations,
worker or public safety and health, public/business interests.
If the consequences are not fully determined or the event exceeds the threshold of
more than one criterion (see Section 6), then the event must be categorized at the
higher criteria level being considered. The occurrence criterion must be continuously
reevaluated and changed, as needed, when new information becomes available.
5.3 DOE HQ Operations Center Prompt Notifications.
5.3.1 Operational Emergencies. The requirements for the prompt and follow-up
notifications to DOE (including NNSA) and other agencies and the appropriate
emergency responses to be taken are provided in DOE O 151.1A,
Comprehensive Emergency Management System. The specific procedures on
how these events are categorized and how and when DOE is notified are
included in the site/facility-specific emergency response plans or procedures. If
an event has been declared an Operational Emergency, the Facility Manager
will be responsible for the written Notification Report and for the completion of
all other occurrence reporting requirements, as described below.
5.3.2 Prompt Notifications for Significance Category 1, 2, 3, and 4 Reportable
Occurrences.
a. The Facility Manager must notify the DOE Facility Representative (in a
manner determined locally) and the DOE Headquarters Operations Center
(DOE HQ OC), as required, of the following reportable occurrences as
soon as practical (i.e., promptly), but no later than 2 hours after
categorization:
1) All Significance Category 1 occurrences require a Prompt Notification
to the Facility Representative and DOE HQ OC.
2) All Significance Category 2 occurrences require a Prompt Notification
to the Facility Representative and, if directed by the Facility
Representative, to the DOE HQ OC.
3) All Significance Category 3 occurrences require a prompt notification
to the Facility Representative.
4) Additionally, specific Significance Category 2, 3, and 4 occurrences
(identified as requiring prompt notification with an asterisk in the
reporting criteria listed in Section 6) require prompt notification to the
Facility Representative and DOE HQ OC.
b. The DOE HQ OC will relay notifications to the appropriate HQ-level
Program Manager and make any further notifications, as required.
c. The Facility Manager may use the local Field/Site Emergency Operations
Center to expedite establishing the communication link required and to
record and archive conversations. The prompt notification process is as
follows:
1) The Facility Manager must e-mail the prompt notification of the
reportable occurrence to the DOE HQ OC, and follow up with a phone
call to the DOE HQ OC to ensure receipt of the e-mail.
2) The Prompt Notification must clearly state/select the Significance
Category (1, R, 2, 3, or 4) and identify the specific reporting criteria
associated with the occurrence.
3) Prompt Notification to the DOE HQ OC must include information on
the following items:
a) Occurrence Significance Category
b) Location and description of the event
c) Date and time of discovery
d) Damage and casualties
e) Impact of event on other activities and operations
f) Protective actions taken or recommended
g) Weather conditions at the scene
h) Level of media interest at scene/facility/site.
i) Other notifications made
4) All information should be clear and succinct. Avoid jargon.
Uncommon or site/facility-specific abbreviations and acronyms should
be fully described.
5) The Facility Manager must follow the appropriate security procedures
if the notification to DOE may contain classified or sensitive
information.
6) If the occurrence is recategorized, then the occurrence must be
reconsidered for prompt notification. If appropriate, the Facility
Manager must notify the Facility Representative and the DOE HQ OC
as soon as practical, but within the prompt notification time
requirements of the new Significance Category for the recategorized
occurrence and provide the Occurrence Report number. The DOE HQ
OC will make any required internal DOE HQ notifications.
7) Follow-up notifications must be made to DOE for any further
degradation in the level of safety or impact on the environment, health,
or operations of the facility or other worsening conditions subsequent
to the previous notification. If a degradation results in upgrading the
event to an Operational Emergency, the DOE HQ OC must be notified
in accordance with DOE O 151.1A, Comprehensive Emergency
Management System.
5.4 Written Notification Report. The Facility Manager must prepare the written
Notification Report (including all required fields and all other fields for which
information is known) as discussed in DOE G 231.1-1, Occurrence Reporting and
Performance Analysis Guide, and distribute it per Section 5.6.e. Direct entry into the
computerized Occurrence Reporting and Processing System (ORPS) satisfies this
requirement. Any changes in the reporting criteria of the occurrence, which result in
a change, either lower or higher, to the Significance Category, must be documented in
an Update Report and submitted within the timeframe required for the Notification
Report under the new Significance Category. A discussion on the change in
categorization must be included in the Description of Occurrence field in the Update
Report.
5.4.1 Occurrence Report Preparation. In preparing the Notification Report, and
subsequently the Final Report, the following writing instructions must be
followed:
a. The report should enable the general reader to understand the basic "what,
who, when, where, how" of the event, the safety issues involved, and the
actions taken.
b. The Subject/Title and the first paragraph of the Occurrence Description
should relay the essential nature of the event (i.e., a summary of the
occurrence in newspaper style).
c. All information should be clear and succinct. Avoid redundant and
unnecessary text, and lengthy "log book" accounts, unless a discussion of
the event in chronological order is considered essential to understanding
the event.
d. Complex and more significant occurrences should warrant a greater level
of detail. Significance Category 4 occurrences would likely need only a
short paragraph under Occurrence Description. However, all reports
should present enough information so that the general reader understands
why the event needs to be reported and what the effect is.
e. Avoid jargon and uncommon or site/facility-specific abbreviations and
acronyms. If used, acronyms should be initially spelled out.
f. Unless necessary to record and explain the event (e.g., suspect/counterfeit
items or material), use general descriptions of equipment, procedures, etc.,
rather than presenting lengthy detailed titles and the numbers and letters
assigned to those items.
g. Quantify the level of contamination, dose, release, and damage (e.g.,
estimate the acres of wild land burned) when possible, instead of merely
stating a reportable limit was exceeded.
h. Use active rather than passive voice whenever possible. For example,
write, "the electrician severed the conduit" rather than "the conduit was
severed."
i. When appropriate for clarification, photos, sketches, and drawings must be
maintained with the occurrence report record. In addition, sites are
encouraged but not required to make photos, sketches, and drawings
available via a Web page, with the Web page address included as a
hyperlink in the ORPS report.
5.4.2 Notification Report Submittal Schedule. The written Notification Report must
be submitted according to the following schedule:
a. Reports for Operational Emergencies and Significance Category 1
Occurrences. Before the close of the next business day from the time of
categorization (not to exceed 80 hours).
b. Reports for Significance Categories R and 2 Occurrences. Before the
close of the next business day from the time of categorization.
c. Reports for Significance Category 3 Occurrences. No later than close of
business on the second business day from the time of categorization.
d. Reports for Significance Category 4 Occurrences. Only a Short Form
Report is required by close of business the second business day from the
time of categorization.
5.5 Occurrence Investigation and Analysis. The following steps describe an acceptable
process for submitting Update Reports and conducting the investigation and analysis
of a specific occurrence. DOE 5480.19, Conduct Of Operations Requirements For
DOE Facilities, and DOE-STD-1045-93, Guide to Good Practices for Notifications
and Investigation of Abnormal Events, should be considered when establishing a
program for investigation of occurrences. In cases of conflict between DOE 5480.19
or DOE-STD-1045-93 and this Manual, the requirements of this Manual must be
followed.
In general, the investigative process is used to gain an understanding of the
occurrence, its causes, and the corrective actions necessary to prevent recurrence or
only remedy the problem, based on the significance of the occurrence. If DOE is
doing a Type A or B investigation, the Facility Manager is not required to perform an
identical investigation. However, the Facility Manager is still required to do the
preliminary assembly of information to turn over to the DOE Accident Investigation
Board, in accordance with DOE O 225.1A, Accident Investigation.
a. The Facility Manager should use the graded approach described in the
Occurrence Reporting Model (Section 11) when determining the level of effort
required for the investigation into the causes of the occurrence. The graded
approach is based on the significance, severity, or risk associated with the event
or condition.
For Operational Emergencies, in general, the investigation, problem analysis,
and corrective action process should parallel the process for Significance
Category 1 occurrences. However, the Facility Manager should consider a
graded approach when determining the level of effort for the investigation into
the cause of the Operational Emergency. The graded approach is based on
whether the Operational Emergency was directly caused by DOE operations or
resulted from non-DOE operations or natural phenomena. For example,
investigations of an Operational Emergency involving the release of hazardous
materials might require an accident investigation or the assembly of a team of
investigators and subject matter experts. Investigation of an Operational
Emergency resulting from a DOE facility being required to implement
protective actions because a non-DOE activity offsite released hazardous
materials or an Operational Emergency resulting from an earthquake may not
require root cause determination because the initiating event was clearly beyond
DOE's control.
b. All causes must be identified as required in the Occurrence Reporting Model
(Section 11) and included in the occurrence report. The cause codes to be used
for reporting are provided in the Causal Analysis Tree (Section 11). Guidance
on selecting the appropriate cause code is provided in DOE G 231.1-2,
Occurrence Reporting Causal Analysis Guide. The Cause Description field
should include a brief discussion to clearly link the event to the cause code(s).
For those occurrences that require a formal root cause analysis, any of the site
approved root cause analysis methodologies are permitted. The methodology
used must be included in the Cause Description field of the occurrence report.
In addition to determining the causes of the occurrence, any weaknesses in the
facility's implementation of the ISM program must be identified and entered in
the ISM field, as discussed in DOE G 231.1-1, Occurrence Reporting and
Performance Analysis Guide.
c. In addition to submitting an Update Report when the Significance Category of
the occurrence has been changed (as stated in Section 5.4), the Facility Manager
must submit and distribute an Update Report for all occurrences, with the
exception of Significance Category 4 occurrences, if there is any significant and
new information about the occurrence. The status of the investigation, recurring
consequences, and the identification of additional component defects are
activities associated with the occurrence and must be included in Update
Reports.
d. Using a graded approach as described in the Occurrence Reporting Model (see
Section 11), the Facility Manager should consult in a timely manner with the
Facility Representative and the Program Manager, as appropriate, for their
assessment, if any, of the occurrence.
5.6 Occurrence Report Closure. The following steps describe an acceptable process for
closing out the Final Report for all occurrences except those categorized as
Significance Category 4:
a. The Final Report must be prepared by the Facility Manager and submitted as
soon as practical but within 45 calendar days after initial categorization of the
occurrence. The Final Report must be prepared using the writing instructions
listed in Section 5.4.1 and must document the following:
(1) The significance, nature, and extent of the event or condition;
(2) The causes of the event or condition (including the root cause, as required)
using the codes provided in the Causal Analysis Tree (Section 11);
(3) The immediate actions taken and the corrective action(s) to be taken (see
Section 5.6.f), as required by the Occurrence Reporting Model (Section
11); and
(4) The lessons learned.
b. If the required analysis cannot be completed within 45 calendar days after initial
categorization, an Update Report must be submitted within the 45 days. The
Update Report must provide a detailed explanation of the delay and provide an
estimated date for submittal of the Final Report. This information must be
reported in the "Evaluation" block of the Occurrence Report. It is expected that
the analysis of most occurrences will be completed and the Final Report
submitted within the 45 calendar days. However, for certain occurrences, such
as those requiring an accident investigation, it is understood that the information
required for the Final Report may not be available within this time. For
occurrences resulting in an accident investigation, all causes (direct,
contributing, and root) identified in the accident investigation report, as well as
the corrective actions developed in response to the judgments of need, must be
included in the Final Report.
c. For Operational Emergencies and Significance Category 1, R, and 2 Final
Reports, the Facility Representative must review, approve, and add any
comments, as necessary, within 14 calendar days after receipt of the report. For
Operational Emergencies and Significance Category 1 Final Reports, after the
Facility Representative has approved the occurrence report, the Program
Manager must review, approve, and add any comments to the Final Report
within 14 calendar days. If the ORPS database is being used, the Facility
Representative and Program Manager's comments should be provided through
ORPS. Facility Representative and Program Manager comments are not
required for their approval of the report.
d. If the Final Report is not approved by the Facility Representative or the
Program Manager, the Facility Representative or Program Manager who is
rejecting the report must provide the reason for disapproval in the comment
section of the report at the time the action is taken. The revised Final Report
must be resubmitted within 21 calendar days of the disapproval. If it cannot be
resubmitted within this time, an Update Report must be submitted within the 21
calendar days explaining the delay and providing an estimated date for
resubmittal of the Final Report. This information must be reported in the
"Evaluation" block of the Occurrence Report.
e. All Occurrence Reports must be distributed as soon as practical to the
following:
- Facility Representative
- Program Manager
- Heads of all Field organizations (including NNSA)
- Office of Environment, Safety and Health (Office of Performance
Assessment and Analysis) and Administrator (NNSA) and
- DOE Management and Operations or Integrating contractors
If the Occurrence Reports are entered into the ORPS database, the distribution
requirement is automatically satisfied.
f. As prescribed on the Occurrence Reporting Model (Section 11) and depending
on the Significance Category, the Facility Manager must track all corrective
actions to closure, including independent verification or sampling at the facility
level and also evaluate the effectiveness of the corrective actions to prevent
recurrence (if applicable). Site/contractor corrective action programs must
include management of Significance Category 4 occurrences, whose corrective
actions are not managed through ORPS.
g. The cognizant Facility Manager may use the ORPS database to track the status
of Final Report corrective actions. For those facilities that do not choose to use
ORPS to track the status of their corrective actions, the specific corrective
action tracking number from the local corrective action tracking system must be
entered into ORPS. Any changes made to the corrective actions tracked in the
local corrective action system must follow the site's approved change process
and should be updated in ORPS. For Significance Category 2 and higher
reports, any text change to a corrective action previously entered in ORPS must
be updated in ORPS with Facility Representative approval. A status report of
all incomplete Occurrence Reports (not Final) and incomplete corrective actions
(for those sites who choose to track the status of their corrective actions using
ORPS) will be available at any time from the ORPS database. Retain all
supporting information pertaining to each occurrence or report (e.g., graphs,
analyses, and formal investigation reports) in accordance with Departmental
Records Disposition Schedules, as required by 36 CFR Chapter 12, Subchapter
B, RECORDS MANAGEMENT.
5.7 Short Form Reports. A Short Form Report, as described in DOE G 231.1-1,
Occurrence Reporting and Performance Analysis Guide, must be prepared and
submitted for all Significance Category 4 occurrences no later than 2 business days
after categorization of the occurrence. This report will satisfy all of the written
reporting requirements for these occurrences.
5.8 Performance Analysis and Identification of Recurring Occurrences. Each contractor
at a site and managers at DOE owned and operated sites must perform ongoing, but as
a minimum quarterly, analyses of events during a 12-month period to look for trends.
This periodic performance analysis must evaluate occurrences of all significance
categories plus contractor-/operator-determined non-reportable events in order to
prevent serious events from occurring. Quarterly performance analysis results must
be reported to contractor and DOE line management in order to achieve
improvements.
Occurrences identified as recurring require a new occurrence report to be submitted
for notification of the recurring issue, with investigation, root cause analysis, and
corrective actions subsequently required. Previous individual Occurrence Report
Numbers associated with the recurring issue must be provided in the Similar
Occurrence Report Numbers field. The reporting organization should select the
appropriate reporting criteria associated with the recurring issue. If no specific
reporting criteria can be identified, the Reporting Criteria should be listed as Group
10, Criteria #2.
Recurring occurrences must be categorized and reported collectively as a Significance
Category R occurrence, even if each individual occurrence had been originally
categorized at a higher or lower significance level (e.g., as Significance Category 1 or
4 or even as non-reportable occurrences). See the Occurrence Reporting Model
(Section 11) to learn the requirements for a Significance Category "R" occurrence.
More information on the performance analysis process for all occurrence reports and
specifics on recurring occurrences are provided in DOE G 231.1-1, Occurrence
Reporting and Performance Analysis Guide.
DOE Headquarters' Office of Environment, Safety and Health must perform a
semiannual analysis of all reportable occurrences during a 12-month period to look
for trends. In those cases where recurring events are discovered, these events must
promptly and formally be brought to the attention of the Program Office(s) for
identification of appropriate corrective actions.
5.9 Training. Specific training programs for the requirements of this Manual must be
established for both DOE (including NNSA) and contractor personnel for facilities
under their cognizance. These training programs must include the following:
a. Indoctrination in the objectives and process of occurrence reporting as defined in
the occurrence reporting requirements documents.
b. Identification of reportable occurrences and their categorization, notification, and
associated reporting requirements; analysis, determination, and coding of causes;
identification of generic implications; and management of corrective actions.
c. Utilization of ORPS, including input of occurrence reports and obtaining
information from the database.
d. Utilization of the Causal Analysis Tree.
e. Where applicable, the preparation of occurrence reports that may include
classified information or unclassified controlled information (e.g., OUO or
UCNI), including the sanitization of the report for entry into ORPS.
SECTION 6. REPORTING CRITERIA.
The following are the reporting criteria, categorized into 10 major groups and appropriate
subgroups related to DOE operations. This list provides a minimum set of requirements
necessary to develop local procedures and report occurrences applicable to local operations.
Categorization of occurrences must be done at the criterion level.
Site/contractor corrective action programs will manage actions for important events that do
not meet the ORPS reporting herein (as well as Significance Category 4 occurrences, whose
corrective actions are not managed through ORPS).
The reporting of safeguards and security events is addressed by DOE N 471.3, Reporting of
Events of Security Concern. Such events are no longer reported in ORPS unless they involve
other consequences that met the ORPS reporting criteria presented herein.
This Manual does not absolve the cognizant parties from making required reports to other
agencies.
6.1 Major Criteria Groups. The 10 major groups of categorized occurrences are as
follows.
Group 1 - Operational Emergencies
Group 2 - Personnel Safety
Group 3 - Nuclear Safety Basis
Group 4 - Facility Status
Group 5 - Environmental
Group 6 - Contamination/Radiation Control
Group 7 - Nuclear Explosive Safety
Group 8 - Transportation
Group 9 - Noncompliance Notifications
Group 10 - Management Concerns/Issues
6.2 Categorizing Instructions
1. An event can meet multiple reporting criteria that establish it as an occurrence.
All of the specific reporting criteria applicable for an occurrence must be
identified. Some criteria are "secondary" in that they complement other
reporting criteria that require occurrence reporting. In these cases, all of the
applicable criteria must be recorded. Each criterion is denoted by its Group,
Subgroup (if applicable), and sequence number (#). Thus, for example, the
violation of a safety limit is denoted as Group 3, Subgroup A, Sequence (1) or
"3A(1)."
2. The reporting criteria presented below list a specific Significance Category (SC)
for each criterion, between the sequence number (#) and the criterion text.
Significance Categories are designated as "OE" for Operational Emergencies,
"R" for recurring occurrences, or 1, 2, 3, or 4. Thus, for example, the
Significance Category for a Stop Work Order issued by a DOE office, criterion
4B(1), is SC 2.
3. Operational Emergencies, Significance Category 1, and some other occurrences in
lesser significance categories require prompt notification to the DOE HQ OC.
Asterisks (*) next to the significance categories below denote those
occurrences requiring prompt notification to the DOE HQ OC. Section 5.3.2
of this Manual defines the prompt notification requirements.
4. DOE O 151.1A describes initiating events that are considered Operational
Emergencies. DOE O 225.1A defines when Type A or B accident investigations
should be initiated. While some Operational Emergencies and some other ORPS
occurrences involve conditions that would be sufficient to initiate accident
investigations, criterion 10(1) herein will report the actual initiation of Type A or
B accident investigations.
6.3 Occurrence Reporting Criteria
Group 1 - Operational Emergencies
# SC Criterion
(1) *OE An Operational Emergency not needing further classification, as
defined in DOE 151.1A, Chapter 5, Paragraph 2.
(2) *OE An Alert, as defined in DOE 151.1A, Chapter 5, Paragraph 3a.
(3) *OE A Site Area Emergency, as defined in DOE 151.1A, Chapter 5,
Paragraph 3b.
(4) *OE A General Emergency, as defined in DOE 151.1A, Chapter 5,
Paragraph 3c.
Group 2 - Personnel Safety and Health
Subgroup A Occupational Illnesses/Injuries
# SC Criterion
(1) *1 Any occurrence due to DOE operations resulting in a fatality or
terminal injury/illness. For fatalities caused by overexposures, the
intent of this criterion is to report those caused by acute rather than
chronic effects.
(2) *1 Any single occurrence requiring in-patient hospitalization of three
or more personnel.
(3) 2 Any single occurrence resulting in three or more personnel having
Days Away, Restricted or Transferred (DART) cases per 29 CFR
Part 1904.7.
(4) *2 Personnel exposure to chemical, biological or physical hazards
above limits established by the Occupational Safety and Health
Administration (refer to 29 CFR Part 1910) or American
Conference of Governmental Industrial Hygienists, whichever is
lower, and that requires the administration of medical treatment
beyond simple first aid on the same day as the exposure. [29 CFR
1904.7(b)(5)(i) and (ii) define "medical treatment" and "first aid."]
(5) 3 Personnel exposure to chemical, biological or physical hazards
above limits established by the Occupational Safety and Health
Administration (refer to 29 CFR Part 1910) or American
Conference of Governmental Industrial Hygienists.
(6) 3 Any single occurrence resulting in a serious occupational injury.
A serious occupational injury is an occupational injury that:
(a) Requires hospitalization for more than 48 hours,
commencing within 7 days from the date the injury was
received;
(b) Results in a fracture of any bone (except simple fractures of
fingers, toes, or nose, or a minor chipped tooth);
(c) Causes severe hemorrhages or severe damage to nerves,
muscles, or tendons;
(d) Damages any internal organ; or
(e) Causes second- or third-degree burns, affecting more than
five percent of the body surface.
Subgroup B Fires/Explosions
# SC Criterion
(1) *1 Any unplanned fire or explosion within primary
confinement/containment boundaries for nuclear or hazardous
material within a facility.
[Note: Facility specific documents need to define what constitutes
the primary confinement/containment boundary.]
(2) *2 Any unplanned fire or explosion in a nuclear facility that activates
a fire suppression system (e.g., halon discharge, sprinkler heads
activating), is extinguished by a fire department, or disrupts normal
facility operations.
[Note: The activation or degradation of Safety Class and Safety
Significant fire suppression systems are addressed by Group 4
Criteria.]
(3) *3 Any unplanned fire or explosion in a non-nuclear facility that
a) Activates a fire suppression system,
b) Takes longer than 10 minutes to extinguish following the
arrival of fire protection personnel, or
c) Disrupts normal operations in a high hazard facility.
(4) *4 Any wild land fire (e.g., forest fire, grassland fire) or other fire
outside of a DOE facility that has the potential to threaten the
facility.
Subgroup C Hazardous Energy Control
# SC Criterion
(1) 2 Failure to follow a prescribed hazardous energy control process
(e.g., lockout/tagout) or disturbance of a previously unknown or
mislocated hazardous energy source (e.g., live electrical power
circuit, steam line, pressurized gas) resulting in a person contacting
(burn, shock, etc.) hazardous energy.
(2) 3 Failure to follow a prescribed hazardous energy control process
(e.g., lockout/tagout) or a site condition that results in the
unexpected discovery of an uncontrolled hazardous energy source
(e.g., live electrical power circuit, steam line, pressurized gas).
This criterion does not include discoveries made by zero-energy
checks and other precautionary investigations made before work is
authorized to begin.
Group 3 - Nuclear Safety Basis
Subgroup A Technical Safety Requirement Violations
# SC Criterion
(1) *1 Any violation of a Hazard Category 1, 2, or 3 nuclear facility's
Technical Safety Requirement (or Operational Safety
Requirement) Safety Limit.
[Note: Safety Limits are high-level Technical Safety Requirement
controls, used infrequently across the DOE Complex. As defined
in 10 CFR 830.3, a Safety Limit is a limit on process variables
associated with those safety class physical barriers, generally
passive, that are necessary for the intended facility function and
that are required to guard against the uncontrolled release of
radioactive materials.]
(2) 2 Any violation or noncompliance of a Hazard Category 1, 2, or 3
nuclear facility's Technical Safety Requirement (or Operational
Safety Requirement) Limiting Control Setting, Limiting Condition
for Operation, Administrative Control, or Surveillance
Requirement.
Exception: An event consisting solely of a surveillance test
performed after the prescribed surveillance period, and in which
the equipment was found to be capable of performing its specified
safety function. (See separate criterion for late surveillance tests
below.)
(3) 3 Any violation or noncompliance of a hazard control specified in a
Hazard Category 1, 2, or 3 nuclear facility's DOE approved
Documented Safety Analysis [issued pursuant to 10 CFR 830.204
and including Basis for Interim Operation (BIO), etc.], or DOE
issued Safety Evaluation Report that are not addressed by Criteria
3A(1) and 3A(2).
Exceptions:
(a) An event consisting solely of a violation of a safety
management program (e.g., quality assurance, personnel
training) cited in the Documented Safety Analysis.
(b) An event consisting solely of a surveillance test performed
after the prescribed surveillance period, and in which the
equipment was found to be capable of performing its
specified safety function. (See separate criterion for late
surveillance tests below.)
(4) 4 An event consisting solely of a surveillance test performed after
the prescribed surveillance period, and in which the equipment was
found to be capable of performing its specified safety function.
Subgroup B Documented Safety Analysis Inadequacies
# SC Criterion
(1) 2 Determination of a positive Unreviewed Safety Question (USQ)
that reveals a currently existing inadequacy in the documented
safety analysis [e.g., Safety Analysis Report (SAR) or Basis for
Interim Operation (BIO)].
(2) 3 Declaration of a potential inadequacy of the documented safety
analysis (a potential positive USQ), per 10 CFR 830.203(g).
Subgroup C Nuclear Criticality Safety
# SC Criterion
(1) *1 A loss of multiple nuclear criticality process-condition controls,
where processes include operation, transport, and storage of
fissionable materials, such that no valid controls are available to
prevent a criticality accident.
(2) 2 A loss of one or more nuclear criticality process-condition controls
such that an accidental criticality is possible from the loss of an
additional process-condition control, where processes include
operation, transport, and storage of fissionable materials.
Group 4 - Facility Status
[Note: The criteria below apply to both nuclear and non-nuclear facilities, where
applicable.]
Subgroup A Safety Structure/System/Component Degradation
# SC Criterion
(1) 3 Performance degradation of any Safety Class or Safety Significant
Structure, System, or Component (SSC) that prevents satisfactory
performance of its design function when it is required to be
operable.
(2) 4 Performance degradation of any Safety Class SSC when not
required to be operable.
Subgroup B Operations
# SC Criterion
(1) *2 A Stop Work Order issued by a DOE office.
(2) 2 Actuation of a Safety Class Structure, System, or Component
(SSC), or its alarms, resulting from an actual unsafe condition.
Spurious alarms (e.g., due to electronic noise, radon/thoron decay)
should not be reported.
(3) 3 Actuation of a Safety Significant Structure, System, or Component
(SSC), or its alarms, resulting from an actual unsafe condition.
Spurious alarms (e.g., due to electronic noise, radon/thoron decay)
should not be reported.
(4) 3 Any facility evacuation, not including a precautionary evacuation,
in response to an actual event. If the event fell under another
reporting criterion, then evacuation should be reported as well by
noting multiple reporting criteria for the single occurrence.
(5) 4 A facility operational event caused by deviating from a written
procedure or using an inadequate procedure resulting in an adverse
effect on safety, such as: an inadvertent facility or operations
shutdown (i.e., a change of operational mode or curtailment of
work or processes), facility or operations shutdown due to alarm
response procedures, inadvertent process liquid transfer, or
inadvertent release of hazardous material from its engineered
containment.
(6) *4 A facility or operations shutdown (i.e., a change of operational
mode or curtailment of work or processes) directed by
management for safety reasons.
(7) 4 A facility or site stand-down resulting from safety reasons
reportable as an occurrence or occurrences.
[Note: This is a secondary reporting criterion and does not require
a separate occurrence report.]
(8) 4 Any event or condition that would prevent immediate facility or
offsite emergency response capabilities.
Subgroup C Suspect/Counterfeit and Defective Items or Material
# SC Criterion
(1) 3 Discovery of any suspect/counterfeit item or material found in a
Safety Class or Safety Significant Structure, System, or
Component (SSC).
A suspect item or material is one whose documentation,
appearance, performance, material, or other characteristics may
have been misrepresented by the vendor, supplier, distributor, or
manufacturer. A counterfeit item or material is one for which
sufficient evidence exists that deliberate misrepresentation has
occurred.
(2) 4 Discovery of any suspect/counterfeit item or material other than
office supplies, office equipment, or household products.
(3) 4 Discovery of any defective item or material, other than a
suspect/counterfeit item or material, in any application whose
failure could result in a loss of safety function, or present a hazard
to public or worker health and safety.
A defective item or material is any item or material that does not
meet the commercial standard or procurement requirements as
defined by catalogues, proposals, procurement specifications,
design specifications, testing requirements, contracts, or the like.
It does not include parts or services that fail or are otherwise found
to be inadequate because of random failures or errors within the
accepted reliability level.
Group 5 - Environmental
Subgroup A Releases
# SC Criterion
(1) *2 Any release (onsite or offsite) of a hazardous substance, material,
waste, or radionuclide from a DOE facility, that is above permitted
levels and exceeds the reportable quantities specified in 40 CFR
302 or 40 CFR 355.
(2) 2 Any discharge that exceeds 100 gallons of oil of any kind or in any
form, including, but not limited to, petroleum, fuel oil, sludge, oil
refuse, and oil mixed with wastes other than dredged spoil. For
operations involving oil field crude or condensate, any discharge of
100 barrels or more is reportable under this criterion.
(3) 4 Any release (onsite or offsite) of a hazardous substance, material,
waste, or radionuclide from a DOE facility that is above permitted
levels and exceeds 50 percent of the reportable quantities specified
in 40 CFR 302 or 40 CFR 355.
(4 4 Any release (onsite or offsite) of a hazardous substance, material,
waste, or radionuclide from a DOE facility that must be reported to
outside agencies in a format other than routine periodic reports.
(However, oil spills of less than 10 gallons and with negligible
environmental impact need not be reported in ORPS.)
Subgroup B Ecological and Cultural Resources
# SC Criterion
(1) 2 Any occurrence causing significant impact to any ecological
resource for which DOE is a trustee (e.g., destruction of a critical
habitat, damage to an historic/archeological site, damage to
wetlands).
Group 6 - Contamination/Radiation Control
Subgroup A Loss of Control of Radioactive Materials
# SC Criterion
(1) 2 Identification of radioactive material offsite due to DOE
operations/activities that exceeds applicable DOE-approved
authorized limits (pursuant to DOE O 5400.5). This applies to
items/areas consisting of radioactive material. This does not apply
to items with surface radioactive contamination. See Criterion
6B(1) below for criteria for identification of items with surface
radioactive contamination.
(2) 2 Loss of radioactive material that exceeds 100 times the quantities
specified in 10 CFR Part 835, Appendix E (excluding consumer
products such as smoke detectors), or loss of accountability of such
material for more than 24 hours. The 24-hour time period begins
when the loss of accountability is discovered.
(3) 3 Loss of radioactive material which exceeds 1 times and no greater
than 100 times the quantities specified in 10 CFR Part 835,
Appendix E (excluding consumer products such as smoke
detectors) or loss of accountability of such material for more than
24 hours. The 24-hour time period begins when the loss of
accountability is discovered.
Subgroup B Spread of Radioactive Contamination
# SC Criterion
(1) 2 Identification of radioactive contamination offsite due to DOE
operations/activities that exceeds applicable DOE-approved
authorized limits (pursuant to DOE 5400.5) or, if there are none,
the values found in 10 CFR Part 835, Appendix D.
[Note: All releases of property containing or potentially
containing residual radioactivity are subject to requirements in
DOE 5400.5. Compliance with 10 CFR Part 835, Appendix D
values does not necessarily satisfy the requirements in DOE
5400.5.]
(2) 2 Identification of onsite radioactive contamination greater than 100
times the total contamination values in 10 CFR 835 Appendix D
and that is found outside of the following locations:
Contamination Areas, High Contamination Areas, Airborne
Radioactivity Areas, Radiological Buffer Areas, and areas
controlled in accordance with 10 CFR 835.1102(c). For tritium,
the reporting threshold is 100 times the removable contamination
values in 10 CFR Part 835, Appendix D.
[Notes:
(a) This does not apply to contamination from residual
radioactive material meeting applicable DOE-approved
authorized limits.
(b) This also does not apply to legacy radioactive
contamination, which will be reported under a separate
criterion below.
(c) The exclusion from reporting contamination in a
Radiological Buffer Area applies only when the area has
been established next to a Contamination Area, High
Contamination Area or Airborne Radioactivity Area and its
exit requirements have adopted guidance from Article
338.2 of DOE-STD-1098-99.]
(3) 3 Identification of onsite radioactive contamination greater than 10
times the total contamination values in 10 CFR 835 Appendix D
and that is found outside of the following locations:
Contamination Areas, High Contamination Areas, Airborne
Radioactivity Areas, Radiological Buffer Areas, and areas
controlled in accordance with 10 CFR 835.1102(c). For tritium,
the reporting threshold is 10 times the removable contamination
values in 10 CFR Part 835, Appendix D.
[Notes:
(a) This does not apply to contamination from residual
radioactive material meeting applicable DOE-approved
authorized limits.
(b) This also does not apply to legacy radioactive
contamination, which will be reported under a separate
criterion below.
(c) The exclusion from reporting contamination in a Radiological
Buffer Area applies only when the area has been established
next to a Contamination Area, High Contamination Area or
Airborne Radioactivity Area and its exit requirements have
adopted guidance from Article 338.2 of DOE-STD-1098-99.]
(4) 4 Identification of onsite legacy radioactive contamination greater
than 10 times the total contamination values in 10 CFR 835
Appendix D and that is found outside of the following locations:
Contamination Areas, High Contamination Areas, Airborne
Radioactivity Areas, Radiological Buffer Areas, and areas
controlled in accordance with 10 CFR 835.1102(c). For tritium,
the reporting threshold is 10 times the removable contamination
values in 10 CFR Part 835, Appendix D.
[Notes:
(a) Legacy radioactive contamination is radioactive contamination
resulting from historical operations that are unrelated to current
activities.
(b) This does not apply to contamination from residual
radioactive material meeting applicable DOE-approved
authorized limits.
(c) The exclusion from reporting contamination in a
Radiological Buffer Area applies only when the area has
been established next to a Contamination Area, High
Contamination Area or Airborne Radioactivity Area and its
exit requirements have adopted guidance from Article
338.2 of DOE-STD-1098-99.]
Subgroup C Radiation Exposure
# SC Criterion
(1) *1 Determination of a dose that exceeds the limits specified in 10
CFR Part 835, Subpart C, Occupational Radiation Protection or
DOE O 5400.5, Chapter II, Item 1 [i.e., 100 mrem Total Effective
Dose Equivalent (TEDE) for offsite exposures to a member of the
public].
(2) 2 Any unmonitored exposure that exceeds the values for providing
personnel dosimeters and bioassays as stated in 10 CFR 835.402(a)
or 10 CFR 835.402(c).
(3) 3 Any single occupational exposure that exceeds an expected
exposure or dosimetry result by: (1) 500 mrem Committed
Effective Dose Equivalent (CEDE), or (2) the greater of 10 percent
or 100-mrem effective dose equivalent due to external exposure.
(4) 3 Determination of an estimated annual dose that exceeds 10 mrem
Total Effective Dose Equivalent (TEDE) for offsite exposures to a
member of the public from air pathways only.
Subgroup D Personnel Contamination
# SC Criterion
(1) *2 Any occurrence requiring offsite medical assistance for
contaminated personnel, including transporting a person to an
offsite medical facility or bringing offsite medical personnel onsite
to perform treatment or decontamination.
(2) 2 Identification of personnel or clothing contamination offsite due to
DOE operations that exceeds the values for total contamination
found in 10 CFR Part 835, Appendix D. For tritium use the values
for removable contamination found in 10 CFR Part 835, Appendix
D.
(3) 4 Any onsite contamination of personnel or clothing (excluding site-
provided protective clothing) that exceeds 10 times the values for
total contamination identified in 10 CFR Part 835, Appendix D.
The contamination level must be based on direct measurement and
not averaged over any area. This criterion does not apply to
tritium contamination.
Group 7 - Nuclear Explosive Safety
# SC Criterion
(1) *1 Damage to a nuclear explosive that results in a credible threat to
nuclear explosive safety.
(2) 2 The unauthorized introduction of electrical energy into a nuclear
explosive.
(3) 2 The unauthorized compromise of a nuclear explosive safety feature
when installed on a nuclear explosive.
(4) 2 Inadvertent substitution of a nuclear explosive for a nuclear
explosive-like assembly (NELA) or vice versa.
(5) 2 A violation of a nuclear explosive safety rule (NESR).
(6) 2 Damage to a training unit during training operations indicative of a
hazard to a nuclear explosive.
(7) 3 The use of uncertified personnel or unauthorized
equipment/tooling during a nuclear explosive operation.
(8) 3 A violation of the two-person concept of operations.
(9) 3 Revocation of the Personnel Assurance Program (PAP)
certification of an individual (for cause).
Group 8 - Transportation
# SC Criterion
(1) *1 Any offsite transportation incident involving hazardous materials
that would require immediate notice pursuant to 49 CFR Part
171.15, namely:
(a) As a direct result of hazardous materials:
(i) A person is killed,
(ii) A person receives injuries requiring hospitalization,
(iii) Estimated property damage exceeds $50,000,
(iv) An evacuation of the general public occurs lasting 1
hour or more,
(v) One or more transportation arteries or facilities are
closed or shut down for 1 hour or more, or
(b) Fire, breakage, spillage, or suspected radioactive
contamination occurs involving shipment of radioactive
materials, or
(c) Fire, breakage, spillage, or suspected contamination occurs
involving shipment of infectious substances (etiologic
agents), or
(d) There has been a release of a marine pollutant in a quantity
exceeding 450 liters (119 gallons) for liquids or 400
kilograms (882 pounds) for solids, or
(e) The operational flight pattern or routine of an aircraft is
altered.
(2) 3 Any offsite transport of hazardous material, including radioactive
material, whose quantity or nature (e.g., physical or chemical
composition) is different than intended, such that the receiving
organization's operations were impacted/disrupted or the transport
resulted in the initiation of corrective actions by the originating
organization.
(3) 4 Any onsite transport of hazardous material, including radioactive
material, whose quantity or nature (e.g., physical or chemical
composition) is different than intended, such that the receiving
organization's operations were impacted/disrupted or the transport
resulted in the initiation of corrective actions by the originating
organization.
(4) 4 Any packaging or transportation activity involving the onsite
release of radioactive materials, etiologic agents, hazardous
substances, hazardous waste, or marine pollutants.
Group 9 - Noncompliance Notifications
# SC Criterion
(1) 3 Any enforcement action (other than associated with the Price
Anderson Amendment Act) involving 10 or more cited violations,
and/or an assessed fine of $10,000 or more.
[Note: This criterion applies to the enforcement action as initially
received from the regulator. Thus the enforcement action would
still be reportable even if the fine is later reduced below $10,000 or
the number of violations reduced below 10.]
(2) 4 Any written notification from an outside regulatory agency that a
site/facility is considered to be in noncompliance with a schedule
or requirement (e.g., Notice of Violation, Notice of Intent to Sue,
Notice of Noncompliance, Warning Letter, Finding of Violation,
Finding of Alleged Violation, Administrative Order, or a similar
type of notification or enforcement action).
Group 10 - Management Concerns/Issues
# SC Criterion
(1) 2 Any event resulting in the initiation of a Type A or B accident
investigation as categorized by DOE O 225.1A, Accident
Investigation.
[Note: This reporting criterion may raise the significance category
of an occurrence already reported under separate criteria. Multiple
reporting criteria should be noted when appropriate.]
(2) 1-4† An event, condition, or series of events that does not meet any of
the other reporting criteria, but is determined by the Facility
Manager or line management to be of safety significance or of
concern to other facilities or activities in the DOE complex. One
of the four significance categories should be assigned to the
occurrence, based on an evaluation of the potential risks and the
corrective actions taken.
[† Note: An SC 1 occurrence report requires Prompt Notification.]
(3) 1-4† A near miss, where no barrier or only one barrier prevented an
event from having a reportable consequence. One of the four
significance categories should be assigned to the near miss, based
on an evaluation of the potential risks and the corrective actions
taken.
[† Note: An SC 1 occurrence report requires Prompt Notification.]
(4) *4 Any occurrence that may result in a significant concern by affected
state, tribal, or local officials, press, or general population; that
could damage the credibility of the Department; or that may result
in inquiries to Headquarters.
(5) *4 Any occurrence of such significant immediate interest to offsite
personnel and organizations that it warrants prompt notification to
the DOE Headquarters Operations Center (DOE HQ OC), and
which is not already designated elsewhere in this set of reporting
criteria to have prompt notification [denoted by having an asterisk
(*) next to the significance category].
SECTION 7. INFORMATION SECURITY REQUIREMENTS.
Occurrence Reports containing any classified information, Unclassified Controlled Nuclear
Information (UCNI), or other controlled information must not be entered into the ORPS
database. Facility Managers must ensure that a review is performed prior to ORPS data entry
to preclude contamination of the database with classified, UCNI, official use only, or other
controlled information.
Any ORPS report determined to be classified or controlled by current classification or
control guidance must be submitted using the appropriate secure transmission means.
However, with the exception of entry into the ORPS database, all other reporting
requirements identified in this Manual must be met. In addition, an unclassified version of
the occurrence report that has been sanitized of all controlled information must be submitted
to ORPS within the required time frames specified in Section 5.
Implementing procedures should identify the requirements for distribution of reports
containing classified or controlled information. In those instances where UCNI data may still
be present in the ORPS database, appropriate security procedures related to the handling of
such data need to be followed.
[Note: Occurrence reports involving incidents of counterintelligence concern (e.g., foreign
persons, governments, organizations, entities or influence) will not be entered or referenced
in the ORPS database.]
SECTION 8. UTILIZATION OF REPORTABLE OCCURRENCE INFORMATION.
8.1 Operational Database. The Office of Environment, Safety and Health (EH-1) is
responsible for maintaining an unclassified central database, the Occurrence
Reporting and Processing System (ORPS). Occurrence Report documentation and
distribution requirements will be satisfied by utilization of ORPS, with the exception
of those involving classified information or UCNI. Reports for occurrences involving
classified information or UCNI will be prepared in written form. After the classified
information and UCNI is removed, the report must be entered into ORPS.
8.2 Utilization. Each Facility Manager must collect and disseminate to their personnel
information from occurrences related to their facilities and similar DOE facilities.
This information includes both lessons learned and good practices. Each Facility
Manager should use this information for trending and analysis and for early
identification and correction of deteriorating conditions.
One of the major purposes of this reporting system is to provide feedback of safety
and operational information identified in the Occurrence Reports to other DOE
facilities. In addition, Headquarters oversight and assessment organizations should
use ORPS information to prepare Safety Notices and other feedback documents.
These uses are dependent on the quality of the information reported, which means the
information should be thorough and accurate. To this end, Occurrence Reports
should contain sufficient information about the facility operations and the occurrence
to facilitate action by other personnel who are unfamiliar with details of the facility,
equipment, process, or procedures.
Operations and engineering units, as well as other support organizations, should be
involved in the identification and assessment of reportable occurrences. Site
information, such as operations logs and engineering evaluations, should be used in
this process.
Engineering judgment should be used during the review of events and conditions to
ensure that precursors to occurrences are identified and reported. An occurrence that
is not serious, given the conditions under which it happened, might under different
initial conditions be a precursor to a serious event at the same or other facilities.
SECTION 9. IMPLEMENTING PROCEDURES.
Contractors at facilities must develop and maintain implementing procedures for the
occurrence reporting and utilization requirements stated in this Manual within 90-days of the
requirements in the Contractor Requirements Document being incorporated into their
contracts. For DOE-owned and -operated facilities, the responsible DOE organization must
implement the requirements of this Manual within 90-days of the Manual approval date.
SECTION 10. INSTRUCTIONS FOR COMPLETING AN OCCURRENCE REPORT.
Specific instructions on the reporting of occurrences via hard copy or the electronic database,
the Occurrence Reporting and Processing System (ORPS), are listed in DOE G 231.1-1,
Occurrence Reporting and Performance Analysis Guide. The documentation and
distribution requirements of this Manual will be satisfied by utilization of ORPS. All reports
containing classified information or Unclassified Controlled Nuclear Information (UCNI)
must be submitted in hard copy in accordance with established security requirements (see
Section 7). In addition, an unclassified version of the Occurrence Report that has been
sanitized of all controlled information must be submitted to ORPS within the time frames
specified in Section 5.
SECTION 11. OCCURRENCE REPORTING MODEL AND CAUSAL ANALYSIS
TREE
OCCURRENCE REPORTING MODEL
SECTION 12. REFERENCES
a. 10 CFR Parts 205, 350 - 354, Report of Major Electric Utility Systems Emergencies.
b. 10 CFR Part 820, Procedural Rules For DOE Nuclear Activities
c. 10 CFR Part 830, Nuclear Safety Management
d. 10 CFR Part 835, Occupational Radiation Protection
e. 29 CFR Part 1904, Recording and Reporting Occupational Injuries and Illnesses
f. 29 CFR Part 1910, Occupational Safety and Health Standards
g. 36 CFR Chapter 12, Subchapter B, Records Management
h. 40 CFR Part 61, National Emission Standards for Hazardous Air Pollutants
i. 40 CFR Part 302, Designation, Reportable Quantities, and Notification
j. 40 CFR Part 355, Emergency Planning and Notification
k. 49 CFR, Parts 106-180, 200-250, and 350-399, Transportation
l. DOE G 231.1-1, Occurrence Reporting Performance Analysis and Reporting Guide
m. DOE G 231.1-2, Occurrence Reporting Causal Analysis Guide
n. DOE G 1324.5B, Implementation Guide for use with 36 CFR Chapter XII -- Subchapter B
Records Management
o. DOE O 151.1A, Comprehensive Emergency Management System
p. DOE O 225.1 A, Accident Investigations
q. DOE O 231.1A, Environment, Safety, and Health Reporting
r. DOE O 471.2A, Information Security Program
s. DOE O 471.1A, Identification and Protection of Unclassified Controlled Nuclear Information
t. DOE M 471.1A, Identification and Protection of Unclassified Controlled Nuclear Information
Manual
u. DOE O 471.3-1, Identifying and Protecting Official Use Only Information
v. DOE M 471.3-1, Identifying and Protecting Official Use Only Information
w. DOE N 471.3, Reporting Incidents of Security Concern
x. DOE M 475.1-1A, Identifying Classified Information
y. DOE 5400.5, Radiation Protection of the Public and the Environment
z. DOE 5480.19, Conduct of Operations Requirements for DOE Facilities
aa. DOE 5480.30, Nuclear Reactor Safety Design Criteria
bb. DOE-STD-1045-93, Guide to Good Practices for Notifications and Investigation of Abnormal
Events
cc. DOE-STD-1063-2000, Facility Representatives
dd. DOE-STD-3009-94, Preparation Guide for U.S Department of Energy Nonreactor Nuclear
Facility Documented Safety Analyses
ee. DOE-STD-7501-99, The DOE Corporate Lessons Learned Program
ff. Executive Order 12333, United States Intelligence Activities. w. National Defense
Authorization Act for Fiscal Year 2000, Public Law 106-65
SECTION 13. DEFINITIONS.
The following is a list of definitions designed to avoid repetition in the body of the document.
a. BUSINESS DAY. The normal administrative day of the reporting organization (e.g.,
Monday through Friday, 0800 to 1700) during which normal work activities are conducted.
It is not meant to encompass the 24 hours in a day, even if the facility is operated or
maintained on a 24-hour basis.
b. CONDITION. Any as-found state, whether or not resulting from an event, that may have
adverse safety, health, quality assurance, operational or environmental implications. A
condition is usually programmatic in nature; for example, errors in analysis or calculation;
anomalies associated with design or performance; or items indicating a weakness in the
management process are all conditions.
c. DISCHARGE. Includes, but is not limited to, any spilling, leaking, pumping, pouring,
emitting, emptying, or dumping of oil, but excludes discharges in compliance with a permit
under Chapter 402 of the Clean Water Act (CWA); discharges resulting from circumstances
identified and reviewed and made a part of the public record with respect to a permit issued
or modified under Chapter 402 of the CWA and subject to a condition in such permit; or
continuous or anticipated intermittent discharges from a point source, identified in a permit
or permit application under Chapter 402 of the CWA, that are caused by events occurring
within the scope of relevant operating or treatment systems.
d. DISCOVERY DATE AND TIME. The discovery date and time is when the facility staff
discovered or became aware of the event or condition. The facility staff is those personnel
assigned to the facility and cognizant of the area in which the event or condition is
identified.
e. DOSE EQUIVALENT
1) Committed Dose Equivalent. The predicted total dose equivalent to a tissue
or organ over a 50-year period after a known intake of a radionuclide into the
body. It does not include contributions from external dose. (See DOE O
5400.5 for further definitions.)
2) Committed Effective Dose Equivalent (CEDE). The sum of the committed
dose equivalents to various tissues in the body, each multiplied by the
appropriate weighting factor. (See DOE O 5400.5 for further definitions.)
3) Effective Dose Equivalent. The summation of the products of the dose
equivalent received by specified tissues of the body and a tissue-specific
weighting factor. (See DOE O 5400.5 for further definitions.)
4) Total Effective Dose Equivalent (TEDE). The sum of the effective dose equivalent
for external exposures and the committed dose equivalent for internal exposures.
f. EVENT. Something significant and real-time that happens (e.g., pipe break, valve failure,
loss of power, environmental spill, earthquake, tornado, flood).
g. FACILITY. Any equipment, structure, system, process, or activity that fulfills a specific
purpose. Examples include accelerators, storage areas, fusion research devices, nuclear
reactors, production or processing plants, coal conversion plants, magnetohydrodynamic
experiments, windmills, radioactive waste disposal systems and burial grounds,
environmental restoration activities, testing laboratories, research laboratories,
transportation activities, and accommodations for analytical examinations of irradiated and
unirradiated components.
h. FACILITY MANAGER. That individual, or designee, usually but not always a contractor,
with direct line responsibility for operation of a facility or group of related facilities,
including authority to direct physical changes to the facility. For purposes of this Manual, a
Facility Manager could also be responsible for a program or activity.
i. FACILITY REPRESENTATIVE. For each major facility or group of lesser facilities, an
individual or designee assigned responsibility by the Head of Field Element/Operations
Organization (including NNSA) for monitoring the performance of the facility and its
operations. This individual should be the primary point of contact with the facility
operating personnel and will be responsible to the appropriate Secretarial Officer/Deputy
Administrator (NNSA) and Head of Field Element/Operations Organization for
implementing the requirements of this Manual.
j. FEDERALLY PERMITTED RELEASE. Any release that satisfies the definition of
"federally permitted release" in 40 CFR 302.3.
k. HAZARDOUS SUBSTANCE OR MATERIAL.
(1) Department of Energy - Hazardous Material. Any solid, liquid, or gaseous material
that is chemically toxic, flammable, radioactive, or unstable upon prolonged storage,
and that exists in quantities that could pose a threat to life, property, or the
environment.
(2) Department of Transportation - Hazardous Materials (see 49 CFR 171.8 and
172.101). A substance or material, including a hazardous substance, which has been
determined by the Secretary of Transportation to be capable of posing an
unreasonable risk to health, safety, and property when transported in commerce and
which has been so designated.
(3) Comprehensive Environmental Response, Compensation and Liability Act
Hazardous Substances (see 40 CFR 302).
(4) Occupational Safety and Health Administration (OSHA) Hazardous Chemical (see
29 CFR 1910.1000 and 29 CFR 1910.1200). Any chemical which is a physical or a
health hazard.
(5) Superfund Amendments and Reauthorization Act Title 3 Extremely Hazardous
Substances (see 40 CFR 355). These are not defined but appear on lists in Appendix
A and Appendix B of 40 CFR 355.
l. ITEM.
(1) An all-inclusive term used in place of the following: appurtenance, sample,
assembly, component, equipment, material, module, part, structure, subassembly,
subsystem, system, unit, or support systems, documented concepts, or data.
(2) When used in reference to nuclear material, a visible, single piece or container of
nuclear material with a unique identification and known nuclear material mass.
m. LESSONS LEARNED. A "good work practice" or innovative approach that is identified
and shared, or an adverse work practice or experience that is shared to avoid recurrence.
n. MEMBER OF THE PUBLIC. Persons who are not occupationally associated with DOE
facilities or operations; (i.e., persons whose assigned occupational duties do not require
them to enter the DOE site).
o. NON-REPORTABLE EVENT. An event that falls within the ORPS Reporting Groups,
does not exceed any of the specific ORPS Reporting Criteria, and the reporting organization
has determined to be included in the required ORPS Performance Analysis activity.
p. NOTIFICATION REPORT. The initial documented report, to the Department, of an event
or condition that meets the reporting criteria defined in this Manual.
q. OCCURRENCE. One or more (i.e., recurring) events or conditions that adversely affect, or
may adversely affect, DOE (including NNSA) or contractor personnel, the public, property,
the environment, or the DOE mission. Events or conditions meeting the criteria thresholds
identified in this Manual or determined to be recurring through performance analysis are
occurrences.
r. OCCURRENCE INVESTIGATION. An investigation conducted according to site-specific
procedures and/or when determined by DOE procedures that a Type A or B investigation is
required.
s. OCCURRENCE REPORT. A documented evaluation of an event or condition that is
prepared in sufficient detail to enable the reader to assess its significance, consequences, or
implications and to evaluate the actions being proposed or employed to correct the condition
or to avoid recurrence.
t. OFFSITE TRANSPORTATION EVENT. Involves movement of materials that are
considered to be in commerce, thus requiring compliance with Department of
Transportation Hazardous Materials Regulations.
u. OIL. Oil of any kind or in any form, including but not limited to petroleum, fuel oil, sludge,
oil refuse, and oil mixed with wastes other than dredged spoil.
v. ONSITE TRANSPORTATION EVENT. Movement of materials not in commerce and
subject to DOE onsite procedures and safety requirements.
w. PERFORMANCE DEGRADATION. Failure or degradation of a facility, process, system,
or component that reduces the reliability of critical components of the facility whose loss or
degradation prevents the system from performing its intended function. Performance
degradation does not include: (1) a burned out power indicator light on a piece of radiation
monitoring equipment which does not prevent the equipment from detecting elevated
radiation levels and alarming as designed; (2) a piece of equipment that is determined to be
out of calibration on the conservative side (such as a low level alarm that alarms at a higher
value than it should); or (3) the temporary loss of a component where redundant components
are maintained operable or in operation and the authorization basis is not compromised.
x. PERSONNEL EXPOSURE. An incident of contact or encounter with a hazardous
chemical, physical, biological, or energetic agent at one of the exchange boundaries of the
organism (e.g., skin, respiratory system, eyes, ears, or digestive system). "Exposure" does
not refer to a situation where personnel, protected by appropriate personal protective
equipment, are subjected to an environment whose ambient conditions present a harmful
level of any one, or combination of, the hazards.
y. PRIMARY CONFINEMENT. Provides confinement of hazardous material to the vicinity
of its processing. This confinement is typically provided by piping, tanks, glove boxes,
encapsulating material, and the like, along with any off gas systems that control effluent
from within the primary confinement.
z. PROGRAM MANAGER. The individual designated by and under the direction of a
Secretarial Officer/Deputy Administrator (NNSA), who is directly involved in the operation
of facilities under his or her cognizance, and holds signature authority to provide technical
direction through Heads of Field Elements/Operations Offices (including NNSA) to
operating personnel for these facilities.
aa. PROMPT NOTIFICATION. Timely reporting of the occurrence to the DOE Field Office
and the DOE Headquarters Operations Center as required by the Significance Category and
the reporting criteria of the occurrence.
bb. PROTECTIVE CLOTHING. Clothing identified for radiological use such as yellow
coveralls, hoods, booties, rubber overshoes, and PC gloves. These are articles designed for
radiological use and are removed at the exit of the radiological area. Company supplied
coveralls, laboratory coats, modesty clothing, street clothes, or other clothing not identified
as anti-contamination clothing (anti Cs) are to be considered personal clothing for the
purposes of ORPS reporting.
cc. RELEASE. Any spilling, leaking, pumping, pouring, emitting, emptying, discharging,
injecting, escaping, leaching, dumping, or otherwise disposing of substances into the
environment. This includes abandoning/discarding any type of receptacle containing
substances in an unenclosed containment structure but does not include permitted
containment structures.
dd. REPORTABLE OCCURRENCE. Occurrence to be reported in accordance with the criteria
defined in this Manual.
ee. REPORTABLE QUANTITY. For any Comprehensive Environmental Response,
Compensation and Liability Act hazardous substance, including radionuclides and
Superfund Amendments and Reauthorization Act Title 3 extremely hazardous substances,
with quantities established in 40 CFR Part 302 and Part 355 respectively, release of which
requires notification unless Federally permitted.
ff. SAFETY CLASS STRUCTURES, SYSTEMS, OR COMPONENTS (SAFETY CLASS
SSCs). The structures, systems, or components, including portions of process systems,
whose preventive or mitigative function is necessary to limit radioactive hazardous material
exposure to the public, as determined from safety analyses. (10 CFR 830.3)
gg. SAFETY SIGNIFICANT STRUCTURES, SYSTEMS, OR COMPONENTS (SAFETY
SIGNIFICANT SSCs). The structures, systems, or components that are not designated as
safety class structures, systems, or components, but whose preventive or mitigative function
is a major contributor to defense in depth and/or worker safety as determined from safety
analyses. (10 CFR 830.3)
hh. SECRETARIAL OFFICER. Secretarial Officers are the Secretary, Deputy Secretary, and
Under Secretaries; and the Assistant Secretaries and Staff Office Directors reporting to the
Secretary either directly or through the Deputy Secretary or Under Secretary. The following
designations are also used to identify Secretarial Officers with specific responsibilities in
various areas. (1) A Program Secretarial Officer (PSO) is an Assistant Secretary, Office
Director, or NNSA Deputy Administrator. In the context of field operations, a PSO funds
work at a particular site, facility or laboratory and is a "customer" of the field office. (2) A
Lead Program Secretarial Officer (LPSO) is a PSO to whom designated field offices directly
report and who has overall landlord responsibilities for the assigned direct reporting
elements. (3) A Cognizant Secretarial Officer (CSO) is a term used in the context of field
operations to designate a PSO, not the LPSO, who is responsible for a laboratory or
bounded set of facilities within a field office's jurisdiction.
ii. TECHNICAL SAFETY REQUIREMENTS (TSRS). The limits, controls, and related
actions that establish the specific parameters and requisite actions for the safe operation of a
nuclear facility and include, as appropriate for the work and the hazards identified in the
documented safety analysis for the facility: safety limits, operating limits, surveillance
requirements, administrative and management controls, use and application provisions, and
design features, as well as a bases appendix. (10 CFR 830.3)
jj. TRAINED INVESTIGATOR. An individual who has been qualified to perform causal
analysis in response to a reportable occurrence. The individual should be able to
satisfactorily complete the identification of Apparent Causes associated with an occurrence
using the Causal Analysis Tree. The individual must also be qualified by their company to
perform formal Root Cause analysis. For events that trigger a Type A or Type B DOE
Investigation, the requirements contained in DOE O 225.1A, Accident Investigations, take
precedence relative to the minimum qualifications of individuals performing the
investigation/causal analysis.
kk. TRANSPORTATION EVENT. Any real-time occurrence involving any of the following
transportation activities: materials classification, packaging, marking, labeling, placarding,
temporary storage incident to transport, shipping paper preparation, loading/unloading,
separation/segregation, securing, blocking and bracing, routing, accident reporting, driver
and vehicle qualifications, movement of materials, communications and notifications.
Transportation events with injuries or fatalities may also require reporting in accordance
with Group 2 criteria.
ll. UNREVIEWED SAFETY QUESTION (USQ). A situation where (1) the probability of the
occurrence or the consequences of an accident or the malfunction of equipment important to
safety previously evaluated in the documented safety analysis could be increased, (2) the
possibility of an accident or malfunction of a different type than any evaluated previously in
the documented safety analysis could be created, (3) a margin of safety could be reduced, or
(4) the documented safety analysis may not be bounding or may be otherwise inadequate.
(10 CFR 830.3)
DEPARTMENT OF ENERGY ORGANIZATIONS TO WHICH
DOE M 231.1-2 IS APPLICABLE
Office of the Secretary
Chief Information Officer
Office of Civilian Radioactive Waste Management
Office of Congressional and Intergovernmental Affairs
Office of Counterintelligence
Departmental Representative to the Defense Nuclear Facilities Safety Board
Office of Economic Impact and Diversity
Office of Electric Transmission and Distribution
Office of Energy Efficiency and Renewable Energy
Energy Information Administration
Office of Environment, Safety and Health
Office of Environmental Management
Office of Fossil Energy
Office of General Counsel
Office of Hearings and Appeals
Office of Independent Oversight and Performance Assurance
Office of the Inspector General
Office of Intelligence
Office of Management, Budget and Evaluation and Chief Financial Officer
National Nuclear Security Administration
Office of Nuclear Energy, Science and Technology
Office of Policy and International Affairs
Office of Public Affairs
Office of Science
Secretary of Energy Advisory Board
Office of Security
Office of Worker and Community Transition
Office of Energy Assurance
Southeastern Power Administration
Southwestern Power Administration
Western Area Power Administration
DEPARTMENT OF ENERGY ORGANIZATIONS TO WHICH
DOE M 231.1-2 IS NOT APPLICABLE
Bonneville Power Administration
CONTRACTOR REQUIREMENTS DOCUMENT
DOE M 231.1-2, Occurrence Reporting and Processing of Operations Information
Regardless of the performer of the work, the contractor is responsible for compliance with the
requirements of this CRD. The contractor is responsible for flowing down the requirements of this
CRD to subcontracts at any tier to the extent necessary to ensure the contractor's compliance with the
requirements. In doing so, the contractor must not unnecessarily or imprudently flow down
requirements to subcontracts. That is, the contractor will both ensure that it and its subcontractors
comply with the requirements of this CRD and only incur costs that would be incurred by a prudent
person in the conduct of competitive business.
SECTION 1. OCCURRENCE REPORTING
For reportable occurrences, contractors must categorize the occurrences, notify DOE as required,
and prepare and submit Occurrence Reports. At sites with more than one facility management
contractor, contractors may make arrangements for one of the contractors to prepare and submit
reports for the entire site. However, each contractor is responsible for ensuring that Occurrence
Reports are submitted for activities within its scope of work.
The documentation and distribution requirements will be satisfied by utilization of a centralized
unclassified DOE operational database, the computerized Occurrence Reporting and Processing
System (ORPS). However, under no circumstances will Occurrence Reports containing classified
information or Unclassified Controlled Nuclear Information (UCNI) be entered into the ORPS
database. Requirements regarding security classification are provided in Section 3.
Occurrences involving foreign personnel, governments, organizations, entities or influence must be
reported by the contractor to the Office of Counterintelligence or the Office of Defense Nuclear
Counterintelligence, as appropriate. Such reporting is not intended to interfere with or delay any
actions directed toward protection of personnel or property.
1.1 Event or Condition Identification.
a. The contractor may identify occurrences by direct observation of equipment or process
malfunctions, log or record reviews, operator recognition of their own or others' errors,
or other means.
b. The contractor must take appropriate immediate action to stabilize and/or place the
facility/operation in a safe condition and ensure that any potential environmental effects
are stabilized and workers are treated for injuries sustained. Also, actions should be
taken to preserve conditions for continued investigation; however, these actions are not
to interfere with establishing a safe condition.
c. The contractor must, upon identification of an abnormal or suspected abnormal event or
condition, promptly notify the appropriate contractor line management of the event
status and record and/or archive all pertinent information, including details concerning
the discovery of the occurrence and actions taken to stabilize or place the
facility/operation in a safe condition.
1.2 Event or Condition Categorization. The contractor must categorize all occurrences, except
Operational Emergencies, within 2 hours of discovery following the site/facility-specific
procedures developed in accordance with this CRD. The significance categories [outlined
in the Occurrence Reporting Model, Section 11 of DOE M 231.1-2] are for those
occurrences of interest for complex-wide occurrence reporting and are described very
generally below. More definitively, Reporting Criteria, listed in Section 2 below, provide
very specific reporting criteria and assigns the appropriate significance category to each
criterion. Local implementing procedures may increase the reporting requirements but may
not decrease the requirements below.
a. Operational Emergencies (OE). Operational Emergency Occurrences are the most
serious occurrences and require an increased alert status for onsite personnel and, in
specified cases, for offsite authorities. [Operational Emergencies are defined in DOE O
151.1A, Comprehensive Emergency Management System. The prompt notification
requirements, definitions, criteria, and classifications of operational emergencies and
appropriate responses are provided in DOE O 151.1A.] Written Occurrence Reports,
however, must be completed in accordance with this CRD.
b. Significance Category 1. Occurrences in this category are those that are not Operational
Emergencies and that have a significant impact on safe facility operations, worker or
public safety and health, regulatory compliance, or public/business interests.
c. Significance Category R. Occurrences in this category are those identified as recurring,
as determined from the periodic performance analysis of occurrences across a site.
d. Significance Category 2. Occurrences in this category are those that are not Operational
Emergencies and that have a moderate impact on safe facility operations, worker or
public safety and health, regulatory compliance, or public/business interests.
e. Significance Category 3. Occurrences in this category are those that are not Operational
Emergencies and that have a minor impact on safe facility operations, worker or public
safety and health, regulatory compliance, or public/business interests
f. Significance Category 4. Occurrences in this category are those that are not Operational
Emergencies and that have some impact on safe facility operations, worker or public
safety and health, public/business interests.
If the consequences are not fully determined or the event exceeds the threshold of more than
one criterion (listed in Section 2 below), then the event must be categorized at the higher
criteria level being considered. The occurrence criterion must be elevated, maintained, or
lowered, as information is made available.
1.3 DOE HQ Operations Center Prompt Notifications.
1.3.1 Operational Emergencies. If an event has been declared an Operational Emergency,
the contractor will be responsible for the written Notification Report and for the
completion of all other occurrence reporting requirements, as described below. [The
requirements for the prompt and follow-up notifications to DOE and other agencies
and the appropriate emergency responses to be taken are provided in DOE O 151.1A,
Comprehensive Emergency Management System. The specific procedures on how
these events are categorized and how and when DOE is notified are included in the
site/facility-specific emergency response plans or procedures. ]
1.3.2 Prompt Notifications for Significance Category 1, 2, 3, and 4 Reportable Occurrences.
a. The contractor must notify the DOE Facility Representative (an individual
designated by the Head of the Field Element/Operations Organization) in a
manner determined locally and the DOE Headquarters Operations Center (DOE
HQ OC), as required, of the following reportable occurrences as soon as practical
(i.e., promptly), but no later than 2 hours after categorization:
1) All Significance Category 1 occurrences require a prompt notification to the
Facility Representative and DOE HQ OC.
2) All Significance Category 2 occurrences require a prompt notification to the
Facility Representative and, if directed by the Facility Representative, to the
DOE HQ OC.
3) All Significance Category 3 occurrences require a prompt notification to the
Facility Representative.
4) Additionally, specific Significance Category 2, 3, and 4 occurrences
(identified as requiring prompt notification with an asterisk in the reporting
criteria listed in Section 2 below) require prompt notification to the Facility
Representative and DOE HQ OC.
b. The contractor may use the local Field/Site Emergency Operations Center to
expedite establishing the communication link required and to record and archive
conversations. The prompt notification process is, as follows:
1) The contractor must e-mail the prompt notification of the reportable
occurrence to the DOE HQ OC, and follow up with a phone call to the DOE
HQ OC to ensure receipt of the e-mail and to clarify any areas that may not
be clear.
2) The Prompt Notification must clearly state/select the Significance Category
(1, R, 2, 3, or 4) and identify the specific reporting criteria associated with
the occurrence.
3) Prompt Notification to the DOE HQ OC must include information on the
following items:
a) Occurrence Significance Category
b) Location and description of the event
c) Date and time of discovery
d) Damage and casualties
e) Impact of event on other activities and operations
f) Protective actions taken or recommended
g) Weather conditions at the scene
h) Level of media interest at scene/facility/site.
i) Other notifications made
4) All information should be clear and succinct. Avoid jargon. Uncommon or
site/facility-specific abbreviations and acronyms should be fully described.
5) The contractor must follow the appropriate security procedures if the
notification to DOE may contain classified or sensitive information.
6) If the occurrence is recategorized, then the occurrence must be reconsidered
for prompt notification. If appropriate, the contractor must notify the Facility
Representative and the DOE HQ OC as soon as practical, but within the
prompt notification time requirements of the new Significance Category for
the recategorized occurrence and provide the Occurrence Report number.
7) Follow-up notifications must be made to DOE for any further degradation in
the level of safety or impact on the environment, health, or operations of the
facility or other worsening conditions subsequent to the previous notification.
If a degradation results in upgrading the event to an Operational Emergency,
the DOE HQ OC must be notified. [See DOE O 151.1A, Comprehensive
Emergency Management System.]
1.4 Written Notification Report. The contractor must prepare the written Notification Report
(including all required fields and all other fields for which information is known) [described
in DOE G 231.1-1, Occurrence Reporting and Performance Analysis Guide] and distribute
it per Section 1.6.e below. Direct entry into the computerized Occurrence Reporting and
Processing System (ORPS) satisfies this requirement. Any changes in the reporting criteria
of the occurrence, which result in a change, either lower or higher, to the Significance
Category, must be documented in an Update Report and submitted within the timeframe
required for the Notification Report under the new Significance Category. A discussion on
the change in categorization must be included in the Description of Occurrence field in the
Update Report.
1.4.1 Occurrence Report Preparation. In preparing the Notification Report, and
subsequently the Final Report, the following writing instructions must be followed:
a. The report should enable the general reader to understand the basic "what, who,
when, where, how" of the event, the safety issues involved, and the actions
taken.
b. The Subject/Title and the first paragraph of the Occurrence Description should
relay the essential nature of the event (i.e., a summary of the occurrence in
newspaper style).
c. All information should be clear and succinct. Avoid redundant and unnecessary
text, and lengthy "log book" accounts, unless a discussion of the event in
chronological order is considered essential to understanding the event.
d. Complex and more significant occurrences should warrant a greater level of
detail. Significance Category 4 occurrences would likely need only a short
paragraph under Occurrence Description. However, all reports should present
enough information so that the general reader understands why the event needs
to be reported and what the effect is.
e. Avoid jargon and uncommon or site/facility-specific abbreviations and
acronyms. If used, acronyms should be initially spelled out.
f. Unless necessary to record and explain the event (e.g., suspect/counterfeit items
or material), use general descriptions of equipment, procedures, etc., rather than
presenting lengthy detailed titles and the numbers and letters assigned to those
items.
g. Quantify the level of contamination, dose, release, and damage (e.g., estimate the
acres of wild land burned) when possible, instead of merely stating a reportable
limit was exceeded.
h. Use active rather than passive voice whenever possible. For example, write, "the
electrician severed the conduit" rather than "the conduit was severed."
i. When appropriate for clarification, photos, sketches, and drawings must be
maintained with the ORPS occurrence report record. In addition, sites are
encouraged but not required to make photos, sketches, and drawings available
via a Web page, with the Web page address included as a hyperlink in the ORPS
report.
1.4.2 Notification Report Submittal Schedule. The written Notification Report must be
submitted according to the following schedule:
a. Reports for Operational Emergencies and Significance Category 1 Occurrences.
Before the close of the next business day from the time of categorization (not to
exceed 80 hours).
b. Reports for Significance Categories R and 2 Occurrences. Before the close of
the next business day from the time of categorization.
c. Reports for Significance Category 3 Occurrences. No later than close of
business on the second business day from the time of categorization.
d. Reports for Significance Category 4 Occurrences. Only a Short Form Report is
required by close of business the second business day from the time of
categorization.
1.5 Occurrence Investigation and Analysis. The following steps describe an acceptable process
for submitting Update Reports and conducting the investigation and analysis of a specific
occurrence. [DOE 5480.19, Conduct Of Operations Requirements For DOE Facilities, and
DOE-STD-1045-93, Guide to Good Practices for Notifications and Investigation of
Abnormal Events, should be considered when establishing a program for investigation of
occurrences. In cases of conflict between DOE 5480.19 or DOE-STD-1045-93 and this
CRD, the requirements of this CRD must be followed.]
In general, the investigative process is used to gain an understanding of the occurrence, its
causes, and the corrective actions necessary to prevent recurrence or only remedy the
problem, based on the significance of the occurrence. If DOE is doing a Type A or B
investigation [defined in DOE O 225.1A], the contractor is not required to perform an
identical investigation. [However, the contractor is still required to do the preliminary
assembly of information to turn over to the DOE Accident Investigation Board, in
accordance with DOE O 225.1A, Accident Investigation.]
a. The contractor should use a graded approach [described in the Occurrence Reporting
Model, Section 11 of DOE M 231.1-2] when determining the level of effort required
for the investigation into the causes of the occurrence. This graded approach is based
on the significance, severity, or risk associated with the event or condition.
For Operational Emergencies, in general, the investigation, problem analysis, and
corrective action process should parallel the process for Significance Category 1
occurrences. However, the contractor should consider a graded approach when
determining the level of effort for the investigation into the cause of the Operational
Emergency. For this purpose, the graded approach is based on whether the
Operational Emergency was directly caused by DOE operations or resulted from non-
DOE operations or natural phenomena. For example, investigations of an Operational
Emergency involving the release of hazardous materials might require an accident
investigation or the assembly of a team of investigators and subject matter experts.
Investigation of an Operational Emergency resulting from a DOE facility being
required to implement protective actions because a non-DOE activity offsite released
hazardous materials or an Operational Emergency resulting from an earthquake may
not require root cause determination because the initiating event was clearly beyond
DOE's control.
b. All causes must be identified as required and included in the occurrence report. [See
the Occurrence Reporting Model, Section 11 of DOE M 231.1-2. The cause codes to
be used for reporting are provided in the Causal Analysis Tree, also in Section 11.
Guidance on selecting the appropriate cause code is provided in DOE G 231.1-2,
Occurrence Reporting Causal Analysis Guide.] The Cause Description field should
include a brief discussion to clearly link the event to the cause code(s). For those
occurrences that require a formal root cause analysis, any of the site approved root
cause analysis methodologies are permitted. The methodology used must be included
in the Cause Description field of the occurrence report. Additionally, the Cause
Description Field must include a brief discussion to describe the linkage of the
identified cause codes to the associated causal factors for the event. In addition to
determining the causes of the occurrence, any weaknesses in the facility's
implementation of the ISM program must be identified and entered in the ISM field, as
discussed in DOE G 231.1-1, Occurrence Reporting and Performance Analysis Guide.
c. In addition to submitting an Update Report when the Significance Category of the
occurrence has been changed (as stated in Section 1.4), the contractor must submit and
distribute an Update Report for all occurrences, with the exception of Significance
Category 4 occurrences, if there is any significant and new information about the
occurrence. The status of the investigation, recurring consequences, and the
identification of additional component defects are activities associated with the
occurrence and must be included in Update Reports.
d. Using a graded approach as described in the Occurrence Reporting Model (see Section
11, DOE M 231.1-2), the contractor should consult in a timely manner with the
Facility Representative and the Program Manager, as appropriate, for their assessment,
if any, of the occurrence.
1.6 Occurrence Report Closure. The following steps describe an acceptable process for closing
out the Final Report for all occurrences except those categorized as Significance Category 4:
a. The Final Report must be prepared by the contractor and submitted as soon as
practical but within 45 calendar days after initial categorization of the occurrence. The
Final Report must be prepared using the writing instructions listed in Section 1.4.1 and
must document the following:
(1) The significance, nature, and extent of the event or condition;
(2) The causes of the event or condition (including the root cause, as required), using
the codes provided in the Causal Analysis Tree (see Section 11, DOE M 231.1-
2);
(3) The immediate actions taken and the corrective action(s) to be taken, as required
by the Occurrence Reporting Model (see Section 11, DOE M 231.1-2); and
(4) The lessons learned.
b. If the required analysis cannot be completed within 45 calendar days after initial
categorization, an Update Report must be submitted within the 45 days. The Update
Report must provide a detailed explanation of the delay and provide an estimated date
for submittal of the Final Report. This information must be reported in the
"Evaluation" block of the Occurrence Report. It is expected that the analysis of most
occurrences will be completed and the Final Report submitted within the 45 calendar
days. However, for certain occurrences, such as those requiring an accident
investigation, it is understood that the information required for the Final Report may
not be available within this time. For occurrences resulting in an accident
investigation, all causes (direct, contributing, and root) identified in the accident
investigation report, as well as the corrective actions developed in response to the
judgments of need, must be included in the Final Report.
c. If the Final Report is not approved by the Facility Representative or the Program
Manager as appropriate, then the contractor must submit the revised Final Report
within 21 calendar days of the disapproval. If it cannot be resubmitted within this
time, an Update Report must be submitted within the 21 calendar days explaining the
delay and providing an estimated date for resubmittal of the Final Report. This
information must be reported in the "Evaluation" block of the Occurrence Report.
d. All Occurrence Reports must be distributed as soon as practical to the following:
- Facility Representative
- Program Manager
- Heads of all Field organizations (including NNSA)
- Office of Environment, Safety and Health (Office of Performance Assessment and
Analysis) and Administrator (NNSA) and
- DOE Management and Operations or Integrating contractors
If the Occurrence Reports are entered into the ORPS database, the distribution
requirement is automatically satisfied.
e. Depending on the Significance Category, the contractor must track all corrective
actions to closure, including independent verification or sampling of corrective actions
identified to prevent recurrence, at the facility level and also evaluate the effectiveness
of the corrective actions to prevent recurrence (if applicable). Site/contractor
corrective action programs will include management of Significance Category 4
occurrences, whose corrective actions are not managed through ORPS.
The cognizant contractor may use the ORPS database to track the status of Final
Report corrective actions. For those facilities that do not choose to use ORPS to track
the status of their corrective actions, the specific corrective action tracking number
from the local corrective action tracking system must be entered into ORPS. Any
changes made to the corrective actions tracked in the local corrective action system
must follow the site's approved change process and should be updated in ORPS. For
Significance Category 2 and higher reports, any text change to a corrective action
previously entered in ORPS must be updated in ORPS with Facility Representative
approval. A status report of all incomplete Occurrence Reports (not Final) and
incomplete corrective actions (for those sites who choose to track the status of their
corrective actions using ORPS) will be available at any time from the ORPS database.
f. Retain all supporting information pertaining to each occurrence or report (e.g., graphs,
analyses, and formal investigation reports). [See Departmental Records Disposition
Schedules, in 36 CFR Chapter 12, Subchapter B, RECORDS MANAGEMENT.]
1.7 Short Form Reports. A Short Form Report must be prepared and submitted for all
Significance Category 4 occurrences no later than 2 business days after categorization of the
occurrence. [Short Form report is described further in DOE G 231.1-1, Occurrence
Reporting and Performance Analysis Guide.] This report will satisfy all of the written
reporting requirements for these occurrences.
1.8 Performance Analyses and Identification of Recurring Occurrences. Each contractor at a
site must perform ongoing, but as a minimum quarterly, analyses of events during a 12-
month period to look for trends. This periodic performance analysis must evaluate
occurrences of all significance categories plus contractor-determined non-reportable events
in order to prevent serious events from occurring. Contractors must report quarterly
performance analysis results to contractor and DOE line management in order to achieve
improvements.
Occurrences identified as recurring must be submitted by the contractor as a new occurrence
report for notification of the recurring issue, with investigation, root cause analysis, and
corrective actions identified. Previous individual Occurrence Report Numbers associated
with the recurring issue must be provided in the Similar Occurrence Report Numbers field.
The reporting organization should select the appropriate reporting criteria associated with
the recurring issue. If no specific reporting criteria can be identified, the Reporting Criteria
should be listed as Group 10, Criteria #2.
Recurring occurrences must be categorized and reported collectively as a Significance
Category R occurrence, even if each individual occurrence had been originally categorized
at a higher or lower significance level (e.g., as Significance Category 1 or 4 or even as non-
reportable occurrences). [See Occurrence Reporting Model, Section 11 of DOE M 231.1-2,
requirements for a Significance Category "R" occurrence. More information on the
performance analysis requirements for all occurrence reports and specifics on recurring
occurrences are provided in DOE G 231.1-1, Occurrence Reporting and Performance
Analysis Guide.]
1.9 Training. Appropriate training programs for the requirements of this CRD must be
established for contractor personnel. These training programs must include the following:
a. Indoctrination in the objectives and process of occurrence reporting as defined in the
occurrence reporting requirements documents.
b. Identification of reportable occurrences and their categorization, notification, and
associated reporting requirements; analysis, determination, and coding of causes;
identification of generic implications; and management of corrective actions.
c. Utilization of ORPS, including input of occurrence reports and obtaining information
from the database.
d. Utilization of the Causal Analysis Tree (see Section 11, DOE M 231.1-2).
e. Where applicable, the preparation of occurrence reports that may include classified
information or unclassified controlled information (e.g. OUO or UCNI), including the
sanitization of the report for entry into ORPS.
SECTION 2. REPORTING CRITERIA.
The following are the reporting criteria, categorized into 10 major groups and appropriate
subgroups related to DOE operations. This list provides a minimum set of requirements necessary
to develop local procedures and report occurrences applicable to local operations. Categorization of
occurrences must be done at the criterion level.
Contractor corrective action programs will manage actions for important events that do not meet the
ORPS reporting herein (as well as Significance Category 4 occurrences, whose corrective actions
are not managed through ORPS).
The reporting of safeguards and security events is addressed by DOE N 471.3, Reporting of Events
of Security Concern. Such events are no longer reported in ORPS unless they involve other
consequences that met the ORPS reporting criteria presented herein.
This Manual does not absolve the cognizant parties from making required reports to other agencies.
2.1 Major Criteria Groups. The 10 major groups of categorized occurrences are as follows.
Group 1 - Operational Emergencies
Group 2 - Personnel Safety
Group 3 - Nuclear Safety Basis
Group 4 - Facility Status
Group 5 - Environmental
Group 6 - Contamination/Radiation Control
Group 7 - Nuclear Explosive Safety
Group 8 - Transportation
Group 9 - Noncompliance Notifications
Group 10 - Management Concerns/Issues
2.2 Categorizing Instructions
1. An event can meet multiple reporting criteria that establish it as an occurrence. All of
the specific reporting criteria applicable for an occurrence must be identified.
Some criteria are "secondary" in that they compliment other reporting criteria that
require occurrence reporting. In these cases, all of the applicable criteria must be
recorded. Each criterion is denoted by its Group, Subgroup (if applicable), and sequence
number (#). Thus, for example, the violation of a safety limit is denoted as Group 3,
Subgroup A, Sequence (1) or "3A(1)."
2. The reporting criteria presented below list a specific Significance Category (SC) for
each criterion, between the sequence number (#) and the criterion text. Significance
Categories are designated as "OE" for Operational Emergencies, "R" for recurring
occurrences, or 1, 2, 3, or 4. Thus, for example, the Significance Category for a Stop
Work Order issued by a DOE office, criterion 4B(1), is SC 2.
3. Operational Emergencies, Significance Category 1, and some other occurrences in lesser
significance categories require prompt notification to the DOE HQ OC. Asterisks (*)
next to the significance categories below denote those occurrences requiring
prompt notification to the DOE