Chapter 05 – Injury Response and Review

Approved by Melanie Alexandre
Revised 6/20

5.1 Policy
5.2 Scope
5.3 Applicability
5.4 Exceptions
5.5 Roles and Responsibilities
5.6 Definitions
5.7 Required Work Processes

Work Process A. Actions Following a Work-Related Injury or Illness Event
Work Process B. Notifications Following a Work-Related Injury, Illness or Near Miss
Work Process C. Procedure for Reviewing a Work-Related Injury or Illness
Work Process D. Causal Analysis
Work Process E. Corrective Actions
Work Process F. Investigation Reports

5.8 Source Requirements
5.9 Reference Documents
5.10 Appendices

Appendix A. Investigation Assistant Tool Kit
Appendix B. ISM Analysis Tool Kit
Appendix C. ISM Builder

Note:
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5.1 Policy

The Injury Response and Review policy for reporting and reviewing work-related injury or illness defines actions to ensure that Lawrence Berkeley National Laboratory (Berkeley Lab) exercises sound business practice and meets regulatory requirements. Key Berkeley Lab expectations under this policy include:

Notifying line management of all work-related injuries and illness
Notifying Health Services of all work-related injuries and illnesses
Ensuring appropriate health care is provided to all employees reporting a work-related injury or illness
Reviewing the event to:
- Determine cause
- Initiate control measures that will prevent or reduce the likelihood of recurrence

5.2 Scope

All work-related injuries, illnesses, and significant mishaps that, under slightly different circumstances, could have resulted in injury or illness will be investigated, analyzed, and reported in accordance with the requirements of this chapter, 10 CFR 851, 29 CFR 1904, DOE Order 225.1B, DOE Order 231.1B, DOE Order 232.2, and DOE Order 414.1D.
Notification is required to ensure that:

Necessary emergency and first response is enacted
Line and senior management are promptly apprised of an event
Follow-up investigation, analysis, and reporting are initiated

Investigation and analysis are intended to:

Determine the underlying causes of an event
Develop and initiate control measures that will eliminate or reduce the likelihood of recurrence
Correct hazards or institutional deficiencies that caused or contributed to the event

Report preparation is intended to:

Document the event
Document the investigation, analysis, and findings
Document recommendations for correcting identified issues

The Injury Review Program in the Environment/Health/Safety (EHS) Division manages the investigation and analysis of work-related injury and illness cases.

5.3 Applicability

This policy applies to all Berkeley Lab employees, visitors, affiliates, and subcontractors performing work at Berkeley Lab.

5.4 Exceptions

None

5.5 Roles and Responsibilities

Role	Responsibility
Approver	Any individuals may be designated as an approver (representing line management, supervisor, SME, or other capacity) as determined appropriate by the Division Safety Coordinator and Injury Review Program
Associate Laboratory Director (ALD) Liaison	As a subject matter expert (SME), contributes his or her expertise and supports the review process at the request of a Division Safety Coordinator or the Injury Review Program
Division Health and Safety Representative	As a subject matter expert (SME), contributes his or her expertise and supports the review process at the request of a Division Safety Coordinator or the Injury Review Program
Division Safety Coordinators (DSC)	Facilitate line-management ownership of the injury review by integrating their division’s Integrated Safety Management (ISM) Plan with the injury-review process Facilitate line-management ownership of issues management after an injury review
Environment/Health/Safety (EHS) Subject Matter Expert	Contributes SME expertise and supports the review process at the request of a Division Safety Coordinator or the Injury Review Program
Injured employee	Notifies supervisor and Health Services of work-related injury, illness, or other incident Participates in the injury review
Injury Investigator	Provides professional skills and tools for injury investigation, causal analysis, recurrence-control development, and report preparation for all injury-review cases
Injury and Illness Program Manager	Determines whether a review will be division-owned or institutional In collaboration with the affected division, assigns investigators for all injury reviews When appropriate for minor cases, waives the requirement for a review when a review is unlikely to add value
Reviewer	SMEs and other line management with vested interest in the case as well as individuals named for peer and quality review of an Injury Illness Report
Supervisor/work lead for injured employee	Participates in the injury-review process Reviews, contributes to the review (as appropriate), and approves incident review report With assistance from the Division Safety Coordinator, enters corrective actions into the Corrective Action Tracking System (CATS)

5.6 Definitions

Term	Definition
Division ownership	The injured employee’s division bears responsibility and accountability for controlling factors related to event causes and can initiate controls to prevent recurrence
Division Line Management	The injured employee’s supervisor or other line-management representatives, as defined in that division’s Integrated Safety Management (ISM) Plan (such as the Division Safety Coordinator, a work lead, a principal investigator, or another individual with delegated authority and accountability)
Institutional ownership	The responsibility and accountability for factors related to the event causes and for implementing controls to prevent the recurrence of an event have an institutional foundation
Incident	An unplanned event that resulted in injury, illness, other loss, or a near miss
Near miss	An unplanned event that under slightly different circumstances could or would have resulted in injury, illness, or other loss.
Occupational injury or illness	An injury or illness that occurs while performing a work-related activity on an employer-controlled property or in an employer-controlled space; while performing certain other activities on an employer-controlled property or in an employer-controlled space during regular work hours; while performing a sanctioned work-related activity away from the employer-controlled property or space; or while travelling on work-related business
Work-related injury or illness	An occupational injury or illness

5.7 Required Work Processes

The following work processes provide the essential guidance for ensuring the following actions are taken once a work-related injury or illness has occurred:

Emergency and immediate follow-up actions
Notifications following a work-related injury, illness, or near miss
Review and investigation
Causal analysis
Corrective actions
Investigation reports

Work Process A. Actions Following a Work-Related Injury or Illness Event
Work Process B. Notifications Following a Work-Related Injury, Illness or Near Miss
Work Process C. Procedure for Reviewing a Work-Related Injury or Illness
Work Process D. Causal Analysis
Work Process E. Corrective Actions
Work Process F. Investigation Reports

Work Process A. Actions Following a Work-Related Injury or Illness Event

Emergency Situations — Immediate Steps to Take

For any Berkeley Lab facility life-threatening emergency — Call 911 (from Berkeley Lab phone, non-Berkeley Lab phone, or cell phone).

For all work-related injuries and non-life-threatening emergencies occurring between 7 a.m. and 4:30 p.m. on regular business days, contact Berkeley Lab Health Services — call (510) 486-6266 (during off-hours, call (510) 486-6999).
1. In case of fire, explosion, gas leak, chemical incident, radiological incident, environmental incident, or any other emergency or accident:
  1. Evacuate personnel from the immediate area to prevent further injury.
  2. Contact emergency responders by calling 911 (from an on- or off-site phone).
    1. Give all information needed to dispatch appropriate aid to the scene.
    2. Identify who you are, where you are calling from, the phone number you are calling from, the nature of the emergency, and the extent of the injury, spill, or other pertinent condition.
    3. Stay on the phone until released by the dispatcher.
  3. Assign someone to meet the emergency crew and provide directions to the incident location.
2. Do not move injured individuals unless necessary to prevent further injury.
3. Apply first aid to stop severe bleeding and/or restore breathing immediately if you are qualified to do so.
4. REFER TO THE EMERGENCY GUIDE FOR DETAILED INSTRUCTIONS. THIS GUIDE IS POSTED IN WORKSPACES THROUGHOUT THE LABORATORY. All Berkeley Lab employees should know where the nearest Emergency Guide is located in their workspaces and periodically review the guide’s contents. Supervisors, work leads, or others designated with responsibility for workspaces should review and update their guides regularly.
Preservation of Other-Than-Minor-Event Scenes
1. Each event of this type will be investigated by a Berkeley Lab Injury Review Team or, for severe and significant events, a DOE federal Accident Investigation Board (AIB). In case of a serious injury (or serious incident without serious injury), the scene must be secured and preserved until the review team has released the area.
2. In all cases, secure the scene and consult your Division Safety Coordinator, EHS Division Liaison, or EHS Division Health and Safety Representative to determine whether the scene must be preserved for review.
3. Until emergency services or management arrive on scene, the area supervisor or lead employee is in charge of the scene. After an incident occurs, take the following actions:
  1. Verify that emergency assistance is present, or call 911 (on or off site) for assistance (or call (510) 486-6999 during off-hours).
  2. Preserve the scene. Do not permit any equipment or vehicles involved in the incident to be moved. Do not allow passersby access to the scene or to interact with equipment or materials at the scene.
  3. When possible, obtain photographs, particularly of transient evidence such as debris, liquid spills, or scuff marks.
  4. Ask witnesses to remain in the vicinity while providing a statement to the responding investigator only if it is safe to do so. Otherwise, obtain names and contact information of witnesses before they leave.
  5. Have witnesses write a statement documenting their observations, including conditions or events leading up to the incident.
4. A Berkeley Lab Injury Review Team will be assigned for all work-related injury or illness events that meet DOE reporting requirements and require an Occurrence Reporting and Processing System (ORPS) report.
5. A Berkeley Lab Injury Review Team will be assigned to investigate significant work-related injury or illness events that do not meet DOE reporting criteria but are of concern to Berkeley Lab management. Determining the need for an assigned team will be made on a case-by-case basis for the following types of cases:
  1. All work-related injury and illness cases reported to Health Services
  2. Near-miss cases with the potential for injury or harmful exposure that, at the time, did not result in an injury or another adverse condition
  3. Other reported near misses as deemed appropriate
Event Types: Injury or illness events at Berkeley Lab can be described by one of four categories according to severity. The categories are listed below, by decreasing severity:
1. Events Requiring a DOE Federal Accident Investigation Board (AIB) include:
  1. A fatality
  2. A disabling injury or illness requiring five or more days of hospitalization
  3. Any single accident resulting in three or more DOE, Berkeley Lab, or subcontractor employees losing workdays
  4. Radiation exposure that exceeds allowable limits
  5. Environmental release of hazardous material (See the ES&H Manual Environmental Releases, Chapter 51 for more information)
  6. Estimated loss of, or damage to, DOE property in excess of $2.5 million
  7. Any accident or series of accidents for which a DOE federal AIB is deemed appropriate by the DOE Secretary or Deputy Secretary
2. Serious Events: Work-related injury or illness cases requiring hospitalization or other significant medical treatment and many ORPS reportable events
3. Minor Events: Work-related injury or illness cases involving first-aid treatment, minor medical treatment, low-level occurrence reports, etc.
4. Near-Miss or Report-Only Events: Work-related events that under different circumstances could or would have resulted in bodily harm requiring some level of first aid or medical treatment

Work Process B. Notifications Following a Work-Related Injury, Illness, or Near-Miss Event

Incident Notifications: Once immediate emergency actions have been taken (i.e., once emergency services have been summoned and the scene has been secured):
1. Employee reports event or near miss to the supervisor or other available management
Occupational Injury and Illness Cases: All occupational injury and illness cases must be reported to the employee’s supervisor and to Health Services. Refer to ES&H Manual Chapter 3, Health Services, for further details.
1. If emergency medical attention for LIFE-THREATENING or other SEVERE injury or illness is needed AT ANY TIME during or outside regular business hours, CALL 911 (ON SITE or OFF SITE).
2. For NON-LIFE-THREATENING work-related injury, illness, or exposure while on the Berkeley Lab site or nearby off-site facilities:
  1. Report to Health Services, Building 26, (510) 486-6266, between 7 a.m. and 4:30 p.m. on regular business days or (510) 486-6999 during off-hours.
3. If the supervisor is the first to be notified, he or she will direct the injured employee to report to Health Services for evaluation and treatment or summon emergency services if needed.
  1. When the injured employee does not or cannot report to Health Services at the time of injury, the supervisor must promptly notify Health Services of the injury.
4. Health Services sends a notification of injury or illness e-mail via the Comprehensive Health, Environmental, and Safety System (CHESS) to the:
  1. Injured employee’s supervisor
  2. Division Safety Coordinator
  3. Division Director
  4. Employee
  5. Injury and Illness Program Manager
5. For work-related injury, illness, or exposure that occurs while away from the Berkeley Lab site or at nearby off-site facilities, the injured employee or employee’s supervisor must notify Health Services as soon as possible during regular business hours.
6. For Laboratory employees or affiliates who are also UC Berkeley students and have been treated for work-related injuries at the UC Berkeley campus Tang Student Medical Center, Health Services must also be notified of their injury or illness.
Motor Vehicle Accidents: See Chapter 60 Traffic and Pedestrian Safety.
Property Damage: Events that result in property damage may require reporting. Consult with your Division Safety Coordinator, or with the EHS Division Office at (510) 486-5251.
Other Incidents: Various radiological events, chemical exposures, and environmental releases also require notifications. Consult with your Division Safety Coordinator, EHS Division Liaison, or EHS Division Health and Safety representative for assistance.

Work Process C. Procedure for Reviewing a Work-Related Injury or Illness

Reviewing Work-Related Injuries and Illnesses
1. Berkeley Lab will review all work-related injuries and illnesses to understand what caused them and to develop controls to prevent them from recurring.
2. Reviews of work-related injuries and illnesses are owned by the cognizant line management.
3. The EHS Division Injury Review Program assigns an investigator to support and facilitate the investigation and review process (data collection, causal analysis, and development of recommended controls to prevent recurrence) and to oversee preparation of a report for each review.
  1. The investigator will collaborate with the Division Safety Coordinator, supervisor, or other appropriate representative to tailor the review approach to the needs of the case at hand.
4. Once issues have been identified and controls to prevent recurrence have been recommended, line management is responsible for entering and tracking these issues in the Laboratory Corrective Action Tracking System (CATS) (see the Issues Management Program Manual) or other accepted tracking methods.
The Injury Review Process
1. Line management (typically represented through the Division Safety Coordinator) will be contacted by the Injury and Illness Program Manager or designee as soon as notification of injury or illness has been received from Health Services.
2. Define the scope of the event (this is guided by the assigned investigator) as:
  1. Events that require a DOE federal Accident Investigation Board investigation (for more information, see Work Process A.3, Event Types, above)
  2. Serious events or injury cases requiring medical treatment. These can include ORPS-reportable events, or events with minor outcome that, under different circumstances, could have resulted in a severe outcome.
  3. Minor events or injury cases involving minor treatment beyond first aid, first-aid treatment, sub-ORPS, near misses, report-only cases, etc.
3. Participate in the review effort. Review team members will be assigned by the Injury Review Program in collaboration with the Division Safety Coordinator or other line management and will have varying responsibilities, as defined in Section 5.5 Roles and Responsibilities.
4. Objectively collect data (injured-employee interview, witness statements, physical evidence, photographs, training, work-authorization review, procedures, etc.).
5. Analyze circumstances and actions that led to the event.
  1. Causal analysis will be performed by an assigned Injury Investigator or by line management under the Injury and Illness Program oversight (See Work Process D, Causal Analysis).
6. Develop/implement controls to prevent the event from recurring.
  1. Relate the results of the causal analysis to ISM, human performance, or other system/process weakness or deficiency if identified. Develop corrective actions that specifically focus on fixing the identified problem (See Work Process E, Corrective Actions).
7. Prepare report.
  1. An Injury Investigator prepares the report unless line management prefers to complete the report or work collaboratively on the report in CHESS.
  2. Division line management (and/or other parties with vested interest) approves the report in CHESS.
  3. All Injury Review Program documents are subject to submittal for peer review.
8. Line management evaluates corrective-action effectiveness in accordance with the Issues Management Program Manual.

Division Ownership Cases
1. If the case appears to relate to the injured employee’s division affiliation, the injured employee’s division line management must develop and implement controls to prevent injury recurrence.
2. Upon notification of an employee’s work-related injury or illness, the employee’s division line management initiates an investigation into the causes of the injury in accordance with the division’s internal protocol and ISM Plan.
  1. The Injury Review Program provides technical support to division line management for the investigation.
  2. An incident investigation team will be set up. Investigation team may include: Division Safety Coordinator, Supervisor, H&S Liaisons & Reps, Subject Matter Experts, and other designees.
  3. The Injury Investigator will facilitate a timely line management investigation guided by this procedure and the division’s ISM program.
    1. In cases of significant consequence (fatality, hospitalization, equipment failure, chemical or radiation release and exposure, etc.) especially when the event scene or evidence preservation is important, investigation must begin immediately upon notification.
    2. The owner division may opt to take full lead of the investigation pursuant to the procedure defined below but will do so under the oversight of the Injury Investigator.
    3. To plan and perform the review, the Injury Investigator collaborates with the safety coordinator, supervisor, and employee. Any other relevant parties (witnesses, infrastructure representatives, etc.) are contacted as necessary.
    4. The Injury Investigator:
      - Facilitates planning the review
      - Facilitates interviews
      - Facilitates collection of physical evidence and photographs
      - Helps identify Laboratory departments or personnel who could provide subject matter expertise or ownership when required
      - Ensures results are documented in CHESS.
Institutional Ownership Cases
1. If it appears that the case is not related to the injured employee’s division affiliation, the Injury Review Program initiates and conducts the investigation.
  1. The Injury and Illness Program Manager will respond to, or may assign, the investigation to one of the designated investigators.
  2. To plan and perform the review, the Injury Review Program Investigator contacts:
    1. The injured employee’s supervisor and Division Safety Coordinator to notify them of the institutional classification
    2. The injured employee
    3. Any other relevant parties (witnesses, infrastructure representatives, etc.)
  3. The Injury Investigator:
    1. Plans the review. Appropriate division line management participates in accordance with their division ISM program.
    2. Conducts interviews.
    3. Collects physical evidence and photographs.
    4. Identifies Laboratory departments or personnel who could provide subject matter expertise or ownership when required.

Other Institutional Reporting Systems: When an injury review is performed in response to an event that triggers other institutional reporting requirements (ORPS, Price Andersen Act [PAA], Noncompliance Tracking System [NTS], Vehicle Accident Report, environmental release, chemical spill, etc.), the Injury Investigator will assist in integrating the injury investigation and reporting with any other Berkeley Lab reporting requirements.
Online Investigation Tutorial: Investigation team members in need of guidance while collecting evidence may refer to the online investigation tutorial at the Occupational Injury and Illness Review Web page at http://www.lbl.gov/ehs/safety/ira/roles.shtml

Work Process D. Causal Analysis

Analysis and Corrective Action Development: The Injury Investigator will ensure that appropriate causal analysis is conducted to determine causes of the event in accordance with the Issues Management Program Manual.
A graded approach in the application of causal-analysis methods will be applied. For example, for minor events where no useful information is likely to result from an investigation (typically an injury that did not occur due to an ISM deficiency) the requirement for an investigation can be waived by the Injury and Illness Program Manager. Below is an incident risk rating tool used to examine potential consequences and likelihood of occurrence to inform decisions about the application causal analysis.
The Injury Investigator will use the causal analysis technique most appropriate for the event.
The Injury Investigator will use the selected causal ISM analysis tools to assist in the development of recommended corrective actions.
The Injury Investigator will review causal analysis results and recommended controls with the line management responsible for the investigation.
Online Assistance with ISM Analysis: Investigation team members in need of guidance on relating ISM to the injury causes identified may refer to the online analysis tutorial at the Occupational Injury and Illness Review Web page at http://www.lbl.gov/ehs/safety/ira/ia.shtml.

Work Process E. Corrective Actions

Issues Management — Preventing Recurrence
1. Once causes have been determined and recurrence controls identified and recommended, division line management follows the process described in the Issues Management Program Manual).
  1. Line management develops corrective actions to effectively implement the recommended recurrence controls.
  2. Issues and their corrective actions will be entered into CATS within five business days of identifying the issue (i.e., five business days after the final report is issued).
2. Issues entered in response to an injury review will use the CATS issue category “Injury/Illness.”
3. The Injury Investigator can help division line management construct corrective actions that address the causal factors and identified recurrence controls (see Work Process D, Causal Analysis above).
4. The Injury Investigator can provide guidance on the CATS new-issue entry coding and classification (issue type, assessment type, risk level, trend code, and external reporting/significant adverse condition check box).
5. Quality review of the corrective actions entered and their effectiveness when completed is the responsibility of line management and will be in accordance with the protocol in Issues Management Program Manual.
ISM Builder: Investigation team members may use the interactive ISM Builder tool here to associate direct, contributing, and root causes to the ISM Guiding Principles and Core Functions.

Work Process F. Investigation Reports

OSHA 301 Equivalent Report: The OSHA 301 equivalent report is generated in the CHESS system and delivered with the initial notification for all work-related injury or illness from Health Services.
1. The report is generated internally by CHESS and may be retrieved electronically at any time by Health Services staff or authorized investigation team members.
2. The report is generated as the case is entered into the data management system such that the seven-day completion window requirement for OSHA-recordable cases is achieved at the time of case intake at Health Services.
Investigation Report: The assigned Injury Investigator will prepare, or assist line management with, the injury investigation report in CHESS.
1. The report will:
  1. Satisfy the content requirements of DOE Form 5484.3
  2. Document investigation fact-finding
  3. Describe the activity and events leading up to the event
  4. Describe any apparent, direct, contributing, or root causes
  5. Describe the relationship of the causes to ISM deficiencies where applicable
  6. Recommend controls and lessons learned that will effectively prevent recurrence
2. Line-management ownership of the investigation will be demonstrated by line management’s signatory concurrence on the report and approval in CHESS.
3. Line management will review the report for factual accuracy.
4. If line management or investigation team members are unable to concur on an analysis or a report, differences in opinion will be documented by including a written statement of the minority opinion in the Conclusions section of the report. Documentation in support of the minority opinion can be uploaded as an attached file to the report.
5. The relevant division director will receive a copy of the report.
6. Copies of and access to the online CHESS version of the report will be given to Laboratory and line management who either have a vested interest in the investigation or have requested the information.
7. Investigation reports will be subject to quality and peer review.

5.8 Source Requirements

ES&H Manual Chapter 3, Health Services
DOE Order 231.1B, Admin Chg 1, Environment, Safety and Health Reporting
DOE Order 232.2A, Occurrence Reporting and Processing System
DOE Order 414.1D, Admin Chg 1, Quality Assurance
California Code of Regulations, Title 8, Section 3203, Injury and Illness Prevention Program
Cal/OSHA 14300

5.9 Reference Documents

Document number	Title	Type
–	Injury and Illness Prevention/Worker Safety and Health Program (PUB-3851), Section 4.6, Reporting Incidents and Hazards; and Section 7.7, Reviewing Safety and Health Experience	Federal Regulation
–	29 CFR 1904, Recording and Reporting Occupational Injuries and Illnesses	Federal Regulation
PUB-5519	Issues Management Program Manual	Manual
LBNL/PUB-533	Lawrence Berkeley National Laboratory Master Emergency Plan	Plan
DOE Order 225.1B	Accident Investigations	DOE Directive
DOE-HDBK-1208-2012	Accident Investigation and Prevention	DOE Handbook
02.13.002.001	Health Services	Program
07.03.001.001	Occurrence Reporting	Program
07.07.028.001	Traffic and Pedestrian Safety	Program
07.03.003.001	Environmental Releases	Program

5.10 Appendices

Appendix A. Investigation Assistant Tool Kit
Appendix B. ISM Analysis Tool Kit
Appendix C. ISM Builder