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ESH Manual Page: 5000: Incident Management and Notification
1.0 POLICY

It is the policy of the Sanford Underground Research Facility (hereafter referred to as the SURF) that any incident resulting in or having the potential for bodily injury, environmental damage, or property damage must be reported to the Environment, Health and Safety (EHS) Department. SURF will address each notification formally, through incident response and investigation.

2.0 SCOPE

This policy applies to all SURF employees, visiting scientists, contractors, and guests. This policy establishes the requirements for reporting and responding to non-emergency incidents. It also describes how all incidents, including emergencies are categorized and investigated. However, initial reporting and overall response to emergency events are addressed in the SURF’s Emergency Response Plan.

3.0 RESPONSIBILITIES

3.1. Employees

  • Reporting all incidents as specified in this policy, including submitting a First Report of Injury/Incident Form.
  • When requested, participating in incident reviews and investigations.

3.2. Laboratory Director

  • Arranging for an external investigation review for INS Category 1 incidents when required.
  • Approving all INS Category 1 incident investigation reports.

3.3. Environment, Health and Safety (EHS) Director

  • Assigning an INS Category to all Environmental, Health and Safety incidents, and initiating all INS notifications and reporting requirements.
  • Determining the investigation requirements for all EHS incidents.
  • Assembling the incident investigation team and overseeing the investigation for all EHS incidents.
  • Approving final investigation reports for all INS Category 2, 3, and 4 incidents.
  • When necessary, advising the Laboratory Director in the selection of an external review committee for INS Category 1 incidents.

3.4. Department Directors

  • Ensuring that all employees under their supervision are aware of the incident reporting requirements.
  • Where appropriate, appointing individuals as Designated Incident Investigators.
  • Communicating lessons learned to employees under their supervision.
  • Ensuring all corrective actions resulting from an incident involving employees or areas under their control are acted upon in a timely fashion.

3.5. Supervisor for Injured Employee or Incident Scene

  • Notifying EHS of incidents within the time periods specified in this policy and ensuring employees fill out a First Report of Injury/Incident Form.
  • When required, filling out the Incident Data Collection Form.
  • When necessary, completing further incident review including preparation of reports and development of corrective actions within the required timeframes.
  • Will take the lead role in the investigation of the incident or, as appropriate, work with the incident investigation team to complete the Investigation Corrective Actions Report.

3.6. EHS Department

  • Supporting the Line Management and Project Managers to complete the Incident Data Collection Form and identifying corrective actions and lessons learned.
  • Reviewing and approving the Incident Data Collection Form.
  • Supporting the Team to complete the Investigation Report.
  • Maintaining copies of all incident investigation reports.
  •  Maintaining the Action Tracking System.

3.7. Project Manager

  • Ensuring contractors under their supervision understand the requirement of this policy.
  • Assisting contractors in filling out the Incident Data Collection Form and submitting it to the EHS department.
  • Participating in any Incidents Investigations involving contractors under their supervision.
4.0 DEFINITIONS

Designated Incident Investigator – An individual, identified by a Department Director who has received training in investigation techniques, and is authorized to represent the department in an incident investigation.

Emergency –  A serious situation or occurrence that happens unexpectedly, poses an immediate risk to life, health, property, or environment, and demands immediate action.

Five (5) Whys Investigation - Investigation technique utilized for less severe incidents. It is a questions-asking method used to explore the cause/effect relationships underlying a particular problem. Ultimately, the goal of applying the 5 Whys method is to determine a root cause of a problem.

First Report of Injury/Incident Form – A form used by employees to report injuries and other significant incidents to their supervisors and EHS.

Incident Investigation – The systematic collection and analysis of information about suspected causes of an accident.

Incident – Any unplanned happening or event that results in or has the potential for personal injury, environmental damage, or property damage. This includes near misses and first aid cases.

Investigation Report – A summary of the material generated during the course of an incident investigation.

INS – Incident Notification System. This system defines how incidents are communicated to senior management, the State of South Dakota, and our funding agencies.

Incident Data Collection Form – Form used to collect information concerning an incident and used by EHS to determine the need for further investigation.

Investigation Team – Team assembled by Laboratory management for the purpose of conducting an incident investigation.

Near Miss - An unplanned event that did not result in recordable injury, illness, or damage – but had the potential to do so. This includes first aid only incidents.

Non-Emergency Incident – An incident of lower severity that may affect people, equipment, property, or the environment, but does not lead to the activation of the Emergency Response Plan.

OSHA Recordable injury – Any injury or illness that meets the OSHA definition for a recordable injury.

Preservation of an accident scene – Preventing movement of equipment or vehicles involved in the accident.

TapRoot Investigation – Investigation technique used for significant incidents. It is an in depth root cause analysis process.

5.0 REQUIREMENTS

5.1. Incident Types

a. For classification and reporting purposes, incidents at SURF are grouped into four categories related to their severity. The Significance Categories consider the impact on safe facility operations, worker or public safety and health, regulatory compliance, or public/business interests and are:

Significance Category 1: significant impact Significance Category 2: moderate impact Significance Category 3: minor impact Significance Category 4: minimal impact, i.e., incidents that do not meet the threshold of a category 3 incident, and near-misses.

5.2. Initial Incident Reporting and Response

Non-emergency incidents for the purpose of this policy are divided into two categories, injury and non-injury. Specific reporting requirements for both are discussed in the sections below. All non-emergency incidents must be reported to EHS within the time periods provided below. The primary contact in EHS for emergency incidents is the Emergency Response Coordinator (ERC). The primary contact for non-emergency incidents is EHS. The ERC will determine if some form of immediate response is required from the emergency management group. The ERC will then contact the EHS Director to initiate the incident categorization and the INS notification and reporting process.
Supervisors must be familiar with the Incident Notification System (INS) policy and the significance categories. The INS policy establishes what and how soon incidents are to be reported to senior management and the funding agencies. Supervisors are not required to categorize the incident nor formally initiate the incident notification system. However, they play an important role in the incident notification system. Any Significance Category 1 or 2 incidents must be reported to EHS immediately. Level 3 and 4 incidents must be reported with 24 hours.

5.2.1 Employee Injuries and Illnesses

If an employee is injured during work, regardless of the severity, they must verbally report the injury to their designated work lead or supervisor as soon as possible, but before leaving the facility. The same requirements exist for any employee that becomes sick at work, and feels the illness is work related. If the supervisor or work lead is not available, the employee may contact the Operations Duty Officer or EHS.
In addition to verbal notification, a First Report and Incident Investigation Form must be filled out for all work related injuries and illnesses. It must be submitted to the employee’s supervisor, work lead, Operations Duty Officer, or EHS before leaving the facility. Employees must fill out the First Report of Injury/Incident Form and contact EHS prior to seeking medical attention except for emergencies and non-emergencies that may require an immediate trip to the emergency room (i.e. a wound that may require sutures, but is not life threatening). In these cases, the First Report of Injury/Incident Form must be submitted as soon as reasonably possible. It is the responsibility of the work leads and supervisors to ensure these reporting requirements are met. Failure to follow this procedure will jeopardize the employee’s ability to receive worker’s compensation benefits.
Work leads and supervisors must contact EHS as soon as possible when they are notified of an injured or sick employee. A summary of reporting requirements to EHS are as follows:

  • Life threatening injury or any injury requiring transport by ambulance:
    • o Verbally - After calling 911, and as soon as physically possible without further jeopardizing the health of the victim. (In the event of a medical emergency, the reporting requirements set forth in the ERP must be followed, which involves immediate contact of the ERC).
    • o First Report of Injury/Incident Form – As soon as reasonably possible.
  • All other injuries and work related illnesses requiring medical attention:
    • o Verbally – Within one hour of the supervisor/work lead being notified, but prior to the employee being seen by the medical provider.
    • o First Report of Injury/Incident Form - As soon as reasonably possible, but before being seen by the medical provider
  • First-aid cases and muscle/skeletal pains:
    • o Verbally and First Report of Injury/Incident Form - Within 24 hours.

5.2.2 Non-Injury Related Incidents

Employees must record all non-injury incidents on a First Report and Incident Investigation Form. Incidents in this case refer to any occurrence that disrupts normal operations or had the potential to do so, or could have resulted in injured employees. Examples include damage to equipment, equipment failures, power outages, fuel spills, other environmental releases, and near miss accidents. In addition to recording events on the First Report and Incident Investigation Form, employees must also verbally report
any significant occurrences to their supervisor as soon as possible after the incident, but before leaving the facility. They must also work with their supervisor to fill out a First Report of Injury/Incident Form. If the supervisor or work lead is not available, the employee may contact the Operations Duty Officer or EHS.
All significant non-injury incidents must be reported to EHS within 24 hours. Any non- injury incident that could be categorized as an INS Category 1 or 2 requires immediate notification of the ERC and EHS. When required, the First Report and Incident Investigation Form must be submitted within 24 hours. Please contact EHS with questions concerning when the form is required.

5.3. Official INS Categorization and Incident Tracking

Upon notification of an incident (either verbally or via the First Report of Injury/Incident Form), the EHS Director will determine the official INS Category. EHS will then assign an incident tracking number and log the event in the incident database. A file will be created and managed by EHS for all reported incidents.
All Category 1 and 2 incidents must be verbally communicated to Laboratory Management, the State of South Dakota Office of Risk Management, and appropriate funding agencies as soon as possible by EHS. These requirements are outlined in the Incident Notification System.

5.4. Incident Data Collection Form

  • After the incident has been classified, supervisors may be required to fill out an Incident Data Collection Form. Filling out this form does not constitute conducting an investigation. The form is a tool that helps collect data that can then later be utilized as the basis for a more formal and thorough investigation. This form is required for all Category 1, 2, and most 3’s. This form includes sections to be filled out by the employee/supervisor as well as EHS. Please contact EHS with any questions concerning
  • when to utilize this form.
  • For events determined to be near-misses, a Risk-Based Near-Miss Screening Form will be filled out by supervisors and included with the First Report of Injury or Incident Form.
  • For events determined to be a non-near-miss category 4, EHS will determine further action, if any, that is to be taken.

5.5. Incident Investigation

After the INS category has been determined, the need for further reporting requirements and investigation is established.

5.5.1. General Requirements

General investigation requirements are as follows:

Significance Category 1- significant

  • Appointment of an Investigation Team.
  • Root cause analysis utilizing TapRoot analysis technique. (The EHS Director reserves the right to waive this requirement under certain situations).
  • The incident scene must be preserved until the Investigation Team has released the area.
  • An external review may be required for Category 1 incidents. (This determination is made by the Laboratory Director with input from the EHS Director).

Significance Category 2 - moderate

  • Appointment of an Investigation Team.
  • Root cause analysis utilizing TapRoot or Five (5) Whys analysis technique (to be determined by the EHS Director).
  • The incident scene must be preserved until the Investigation Team has released the area.
  • An external review may be required for Category 2 incidents. (This determination is made by the Laboratory Director with input from the EHS Director).

Significance Category 3 - minor and 4 - minimal

  • The EHS Director will assess the incident and determine the need for further investigation and reporting. The technique used is based on the severity of the incident.
  • Near-miss investigation guidelines will be stated in the Risk-Based Near-Miss Screening Form.

5.5.2. Investigation Teams

Investigation Teams will include a designated SURF Incident Investigator for all incidents deemed of sufficient severity or potential significance to require a detailed impartial analysis (i.e. Category 1 and 2 incidents). Other cases may be investigated in this manner at the discretion of the EHS Director. SURF Incident Investigators have been trained in incident investigation and root cause analysis and have been formally appointed or approved by the EHS Director.

When required, the EHS Director will select the investigation team for all incidents.
Team members will be selected based upon their knowledge of the incident and expertise in the task or area involved with the incident. In most cases, the team will consist of:

  • Designated Incident Investigator
  • Injured employee’s supervisor
  • Injured employee, if possible

5.5.3. Investigation and Corrective Action Reports

All formal and informal incident investigations will be lead by and are the responsibility of Line Management unless otherwise assigned by EHS. All formal investigations must be summarized in a report utilizing the Incident Investigation Report Guideline. This report will include a summary of the incident, the investigation findings, root causes, contributing causes, corrective actions, and any lessons learned. Reports for incidents that result in an OSHA recordable must include a discussion on why the incident was considered an OSHA recordable (i.e. the criteria used). When necessary, the report will include appendices containing photographs, flow charts, and TapRoot charts. All incident reports will be signed by line management (or the supervisors of those involved in the incident) signifying the report accurately describes the event. If the incident involves an employee injury or significant property damage, the employee(s) involved in the incident must sign the report.
Upon completion, the original signed Incident Investigation Report must be kept in the incident file.

5.6. Corrective Actions and Lessons Learned

Any corrective actions identified in the Investigation Reports must be recorded in the Action Tracking System. Lessons learned shall be communicated to employees either through e-mail, toolbox talks, “All Hands Meetings”, or similar communications. Corrective actions are assigned to specific individuals and tracked to completion. The Action Tracking System is reviewed on a quarterly basis.

5.7. Incident Files

All reported incidents will have an associated incident file, prepared and maintained by EHS. At a minimum, the file will consist of a cover sheet and a brief description of the incident. All paperwork, forms, and reports associated with the investigation will be kept in the file, including the First Report of Injury/Incident Form, the Incident Data Collection Form, finalized Investigation Report, and any additional correspondence or hand written notes.

6.0 REFERENCE AND RELATED DOCUMENTS

6.1. Related Documents

  •  Emergency Response Plan
  •  Incident Notification System
  •  First Report and Incident Investigation Form
  •  Risk-Based Near-Miss Screening Form
  •  Incident Data Collection Form
  •  Incident Investigation Report Guideline