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NSLS ESH Highlight #31

What Do I Report?

Date: August 13, 2002
Editor: R. Casey, N. Gmür

As a part of its contractual agreement with the DOE, the Lab is expected to report certain types of incidents within 2 hours of discovery. In order to produce such a rapid response, it is very important for each staff member and user to promptly report to the NSLS all occurrences that have the potential for safety significance or meet other criteria identified below. Some of these events will be obvious to you; others that we are required to report may not be as clear at the time of discovery and will require review by NSLS and other Lab staff to determine reportability. The NSLS ESH Staff provides coordination of the reporting process. Please make sure that all unusual events are promptly reported to your supervision (by staff) or to the NSLS Control Room (by Users) at any time of the day so that the evaluation and reporting process (if warranted) can be initiated. Categories of reportable events and examples of actual incidents that require reporting to DOE within 2 hours of discovery are given below.

Types of Reportable Events
  • Violation of the accelerator safety envelope (e.g. an interlock test is overdue),
  • Fires (e.g. fires taking more than 10 minutes to extinguish, or automatic fire suppression is activated by a fire),
  • Safety system failures (e.g. interlock system fails),
  • Loss of radioactive materials (e.g. missing radioactive source, or spread of radioactive contamination beyond a Controlled Area),
  • Procedure violations (e.g. an interlock is bypassed without permission),
  • Environmental releases (e.g. unauthorized release of radioactive or hazardous material, or oil spill >10 gal. to soil.),
  • Personnel safety (e.g. exposure to hazardous material above limits, or injury resulting in inpatient hospitalization),
  • Security related events (e.g. criminal acts, bomb threats, substance abuse),
  • Programmatic impact (e.g. delays in start-up of greater than 1 month which result in failure to meet approved performance goal, or damage to equipment greater than $10,000),
  • Defective items (e.g. suspect or counterfeit items),
  • Near miss/potential concerns (e.g. electric shock).

Examples of Previous Incidents

The list below provides examples of operational incidents that have occurred in the past. Some of these did not meet the DOE reporting criteria. Others did. The 2 hour reporting rule for an event can be highly dependent on the circumstances and consequences of the incident. Each event needs review so be sure to promptly report unusual events to your supervisor or to the Control Room to initiate the review process.

  • Leaking PCB capacitor (did not require reporting)
  • Acid waste bottle ruptures and sprays acid in room (did require reporting)
  • Fire in klystron power supply (did require reporting)
  • Fire in a waste basket (did not require reporting)
  • Gas cylinder incorrectly filled by manufacturer with an explosive mixture (did not require reporting)
  • Breakage of a Beryllium window (did not require reporting)
  • Cryogenic dewar ruptures as a result of plugged vent line (did require reporting)
  • Researcher arrives at the NSLS with restricted materials not described in their Safety Approval Form (did not require reporting)
  • Lead glass cover not replaced on an X-ray beamline view port prior to operation (did not require reporting)
  • Working near exposed surfaces energized to greater than 50 volts without a permit (did require reporting).

Please do not hesitate to report an event. The purpose is to make sure that the issue has been safely addressed and that lessons learned from the event can be passed onto others.

Please contact Nick Gmür (x2490) or any NSLS ESH Staff member if you have questions or comments.