NIST S 7101-24_Incident Reporting and Investigation_01042021.pdf

NIST S 7101.24 (Uncontrolled Copy in Print) Page 1

INCIDENT REPORTING AND 4

INVESTIGATION 5

NIST S 7101.24 7

Approval Date: 01/04/2021 8 Deployment Start Date: 07/26/2017 9

Effective Date1: 10/01/2017 10

1. PURPOSE 13

This suborder establishes the requirements and roles and responsibilities for the reporting and 14 investigation of work-related safety incidents and near misses to determine why these events 15 occurred and what actions must be taken to prevent their recurrence, and for the dissemination 16 throughout the organization of the related incident information and lessons identified. In 17 addition, this suborder provides administrative requirements for complying with Federal 18 Occupational Safety and Health Administration (OSHA) Injury and Illness Recordkeeping and 19 Reporting Requirements. 20

2. BACKGROUND 23

NIST management is committed to the safety of everyone who works for, works at, or visits 24 NIST. As part of this commitment, NIST strives to prevent safety incidents by effectively 25 managing risk in all its activities. Essential to effectively managing risk is to learn as much as 26 possible from incidents that have occurred and to take actions to prevent their recurrence. 27 Success in this depends, in turn, on the prompt reporting of incidents and on the timely 28 completion and use of the results of comprehensive incident investigations. Therefore, NIST 29 shall report and investigate incidents in a thorough and timely manner, and share incident reports 30 and lessons identified effectively throughout the organization. This incident data will be 31 analyzed to identify systemic weaknesses in the NIST occupational safety and health (OSH) 32 management system, leading to corrective actions to address those weaknesses. 33

1 For revision history, see Appendix A.

NIST S 7101.24 (Uncontrolled Copy in Print) Page 2

3. APPLICABILITY 37

a. The provisions of this suborder apply to NIST employees and covered associates2 engaged in 38 work-related activities (see Section 7, DEFINITIONS). 39

b. The requirements of this Suborder apply to the following types of events, as defined in 41 Section 7: 42

(1) Incidents: 44

(a) Injury; 46

(b) Illness; 48

(c) Exposure; 50

(d) Contamination by radioactive material; 52

(e) Spill / release; 54

(f) Property damage; and 56

(g) Other events with actual safety or environmental impacts; and 58

(2) Near misses. 60

c. The requirements of this suborder do not apply to unsafe conditions or practices, unless they 62 result in an incident or near miss event.3 63

d. This suborder does not address the following topics: 65

(1) Emergency communications from staff members and first responders, other than 67 communications for reporting of Immediate Notification Incidents as outlined in Section 68 6d of this suborder, through Organizational Unit (OU) management and emergency 69

2 As per NIST O 7101.00: Occupational Safety and Health Management System, a NIST associate permitted to perform work at a NIST workplace and subject to NIST policies and procedures to the extent allowed by law and the terms of the associate’s agreement. Covered associates include Foreign and Domestic Guest Researchers (including contractors who perform NIST R&D/technical work); Research Associates; Intergovernmental Agency Personnel Act assignees; Facility Users; Volunteer Students; and other federal employees who perform work at NIST workplaces.

3 Unsafe conditions and practices should be reported through appropriate channels in accordance with procedures established in NIST S 7101.02: Employee Reporting of Unsafe or Unhealthful Working Conditions.

https://oshe.nist.gov/apps/docs/programs/Documents/NIST%20O%207101-00%20-%20Occupational%20Safety%20and%20Health%20Order_080216.docx

NIST S 7101.24 (Uncontrolled Copy in Print) Page 3 communication channels, to the NIST Director and Associate Directors, the Department 70 of Commerce, and others pursuant to an emergency or potentially serious incident. 71 Employees should refer to the Office of Facilities and Property Management web page 72 for guidance: https://inet.nist.gov/ofpm; 73

(2) Specific steps that employees and covered associates should take pursuant to sustaining 75 work-related occupational injuries or illnesses. Employees should refer to the Office of 76 Human Resources Management Workers Compensation Program at 77 https://inet.nist.gov/ohrm/services/owcp; and 78

(3) Requirements associated with consequence management, i.e., policies, procedures, and 80 forms related to workers’ compensation, automobile accidents, and personal property 81 claims. 82

4. EXTERNAL REFERENCES 85

a. 29 Code of Federal Regulations (CFR) Part 1904, Recording and Reporting Occupational 86

Injuries and Illnesses 87

b. 29 CFR Part 1960, Basic Program Elements for Federal Employee Occupational Safety and 89 Health Programs and Related Matters 90

5. APPLICABLE NIST OCCUPATIONAL SAFETY AND HEALTH DIRECTIVES 93

a. NIST O 7101.00: Occupational Safety and Health Management System 94

b. NIST Suborder (S) 7101.23: Safety Education and Training 96

c. NIST S 7101.02: Employee Reporting of Unsafe or Unhealthful Working Conditions 98

d. NIST S 7101.55: Hearing Protection 100

6. REQUIREMENTS 103

a. General Requirements 104

(1) All incidents and near misses shall be reported by employees and covered associates to 106 their OU line management using OU implementation procedures established per the 107 requirements of Section 6f. 108 https://inet.nist.gov/ofpm https://inet.nist.gov/ohrm/services/owcp https://www.ecfr.gov/cgi-bin/text-idx?SID=60b57e501656e3e5d05329c932edb10c&mc=true&node=pt29.5.1904&rgn=div5 https://www.ecfr.gov/cgi-bin/text-idx?SID=60b57e501656e3e5d05329c932edb10c&mc=true&node=pt29.5.1904&rgn=div5 http://www.ecfr.gov/cgi-bin/text-idx?SID=eb5bf8c9886b794acb2da59a20ca0175&mc=true&node=pt29.9.1960&rgn=div5 http://www.ecfr.gov/cgi-bin/text-idx?SID=eb5bf8c9886b794acb2da59a20ca0175&mc=true&node=pt29.9.1960&rgn=div5

NIST S 7101.24 (Uncontrolled Copy in Print) Page 4

(2) Each such incident or near miss (“event”) shall be documented and investigated to 110 identify why it occurred and what actions are needed to prevent recurrence. 111

(3) The NIST web-based application titled Incident Reporting and Investigation System 113

(IRIS) shall be used to document events subject to this Suborder, including the relevant 114 investigations. The following general requirements shall apply: 115

(a) Report Format - Events will be documented using one of two formats, based 117 generally on the complexity and seriousness of the event (see Section 7, Definitions): 118

i. Streamlined Format (Streamlined Report only); or 120

ii. Standard Format (Initial Report followed by Investigation Report). 122

(b) Reporting Timeframes 124

i. Streamlined and Initial Reports shall be submitted into the IRIS application 126 within two (2) business days of line management being notified4, if possible. 127

ii. Investigation Reports shall be recorded in IRIS within 20 (twenty) business 129 days of line management being notified, if possible. 130

b. Initial Evaluation and Information Gathering 132

As per OU implementation procedures, OU Line Management shall evaluate each event 133 reported to: 134

(1) Verify the applicability of this Suborder; 136

(2) Classify each event as an incident or near miss, based on the definitions in Section 7. 138

(3) Evaluate each incident to determine if it meets the definition of an Immediate 140

Notification Incident (see Section 7, Definitions). 141

(a) When an Immediate Notification Incident is identified, the reporting procedure 143 outlined in Section 6c below shall be followed immediately and OSHE shall assume 144 responsibility for subsequent reporting and investigation requirements. 145

4 Cases involving OSHA Recordable Standard Threshold Shift hearing losses shall be entered into IRIS within two (2) business days of line management being notified by letter that the case has either been confirmed by retest, or that a retest will not be taken. Please see NIST S 7101.55: Hearing Protection for additional information regarding these types of incidents.

NIST S 7101.24 (Uncontrolled Copy in Print) Page 5

(4) Determine which IRIS report format (Streamlined or Standard) will be used and collect 146 information needed to submit a Streamlined or Initial Report, as appropriate. 147

(a) OU management shall consider the significance of the circumstances of the event to 149 determine which format is required to be used. 150

(b) The Standard Format shall be used for the following: 152

i. Immediate Notification Incidents; 154

ii. Incidents known by the OU to be OSHA Recordable cases (see Section 7, 156 Definitions) unless the OU has received prior approval from the Incident 157 Reporting and Investigation (IRI) Program Manager (PM) to use the 158 Streamlined Format; and 159

iii. Incidents that result in contamination with or exposure to radioactive material. 161

(c) The OU IRIS Administrator and the Incident Reporting and Investigation (IRI) 163

Program Manager (PM) (see Section 7, Definitions) have the authority to require 164 the use of the Standard Format for an event. 165

(5) Identify OUs involved in the event, specifically: 167

(a) Identify all OUs with employees involved; 169

(b) Identify the OU with responsibility for the space where the event occurred; and 171

(c) Identify the OU with responsibility for the equipment involved. 173

c. Immediate Notification Incident Procedure 175

(1) Immediate Notification Incidents shall be reported to OSHE as soon as possible as per the 177 following procedure: 178

(a) During normal business hours: 180

i. Call OSHE at x5375, Option 3. 182

ii. If no one picks up, send an email to serious.injury@nist.gov. 184 mailto:serious.injury@nist.gov

NIST S 7101.24 (Uncontrolled Copy in Print) Page 6

(b) Outside of normal business hours, send an email to serious.injury@nist.gov. 186

(2) For each Immediate Notification Incident, the following information shall be provided to 188

OSHE: 189

(a) A brief description of the incident; 191

(b) The location of the incident; 193

(c) The time of the incident; 195

(d) The category of incident, as follows: 197

i. Fatality; 199

ii. In-patient hospitalization; 201

iii. Amputation; or 203

iv. Loss of an eye; 205

(e) The number of employees and/or covered associates who suffered the incident; 207

(f) The names of the employee(s) and/or covered associate(s) who suffered the incident; 209

(g) An OU point of contact with phone number; and 211

(h) Periodic updates of the status of the employees(s) or covered associate(s) involved 213 and/or changes to previously provided information. 214

(3) The NIST CSO shall confirm the reported incident meets the definition of an Immediate 216 Notification Incident. 217

(4) The NIST CSO shall report confirmed Immediate Notification Incidents to the 24-Hour 219 OSHA hotline at (800) 321-OSHA, within the following timeframes: 220

(a) Work-related fatality – within 8 hours of finding out; and 222

(b) Work-related amputation, loss of an eye, or in-patient hospitalization of one or more 224 employees or covered associates – within 24 hours of finding out. 225 mailto:serious.injury@nist.gov

NIST S 7101.24 (Uncontrolled Copy in Print) Page 7

(5) The NIST CSO shall report the following information to OSHA, for each Immediate 226 Notification Incident: 227

(a) The establishment name (e.g. NIST Gaithersburg, NIST Boulder, etc.) 229

(b) The NIST contact person and phone number 231

(c) The information in items 6c(2)(a)-(f) above. 233

(6) After notifying OSHA of an Immediate Notification Incident, the NIST CSO shall submit 235 the following reports into IRIS: 236

(a) An Initial Report per the requirements of Sections 6a(3)(b)i and 6d; and 238

(b) An Investigation Report per the requirements of Sections 6a(3)(b)ii and 6e. 240

d. Submittal of Streamlined and Initial Reports 242

A Streamlined or Initial Report shall be submitted for each event, based upon the format 243 selected in Section 6b above, and subject to the following requirements: 244

(1) OU Responsibility for Streamlined or Initial Report Submittal 246

(a) For an Immediate Notification Incident, OSHE, with participation from the OU(s) 248 involved, shall develop and submit the required report. 249

(b) For an event that involves individuals, space, and equipment from only one OU, that 251 OU shall submit the required report. 252

(c) For an event involving multiple individuals and/or space and/or equipment from 254 different OUs, the OU IRIS Administrators from all OUs involved shall coordinate 255 with each other to identify the OU to develop and submit the required report, with 256 appropriate support from the other OU(s). 257

(d) For an event where no individuals are involved (e.g., a fire that occurred in a building 259 after hours or a chemical spill in a laboratory when no one was present), the OU 260 responsible for the space in which the event occurred shall submit the required report. 261

NIST S 7101.24 (Uncontrolled Copy in Print) Page 8

(2) IRIS Submitter Requirements 266

(a) Streamlined and Initial Reports shall be entered into IRIS only by employees 268 designated and trained as OU IRIS Report Submitters. 269

(b) Streamlined and Initial Reports should not be submitted by employees directly 271 involved in the event. 272

(3) Streamlined Report Content 274

Streamlined Reports shall include the following information: 275

(a) General Information: 277

i. Name, OU, Division, and Group of the individual submitting the report; 279

ii. Type of event (e.g., Injury, Near Miss, Property Damage, etc.); 281

iii. Date and time of event, if known; 283

iv. Location of the event and type of space (e.g., laboratory, office, hallway); and 285

v. When OU line management was first notified of the event; 287

(a) Individuals Involved - For each person involved in an event, the following 289 information shall be included: 290

i. Name; 292

ii. Position; 294

iii. Employment Status: 296

(i) Employee; 298

(ii) Associate; or 300

(iii) Visitor; 302

NIST S 7101.24 (Uncontrolled Copy in Print) Page 9

iv. Status of the individual as a result of the event: 306

(i) Injured; 308

(ii) Became Ill; 310

(iii) Exposed; or 312

(iv) Combination of i-iii above; or 314

(v) None of the above; 316

v. If injured, ill, or exposed: 318

(i) A description of the injury, illness, or exposure; 320

(ii) A description of the immediate care given; 322

(iii) If the individual will miss any days of work, if known; and 324

(iv) If the individual will be restricted or transferred to another job because 326 of the event, if known. 327

(c) Event Description 329

i. A brief description of the activity leading up to or taking place at the time of 331 the event; 332

ii. A description of what happened, or for a near miss, what could have 334 happened; 335

iii. A description of any immediate measures taken to respond to the event, 337 including any actions taken to prevent workers from exposure to hazards; 338

iv. A description of why the event occurred, including identification of any 340 hazard(s) that directly caused or almost caused the event; 341

v. A description of the measures taken to prevent recurrence, including the 343 abatement actions taken or planned to address any hazard(s) identified in Step 344 iv above; 345

NIST S 7101.24 (Uncontrolled Copy in Print) Page 10

(i) For abatement actions that will take 30 calendar days or longer to 346 implement, an abatement plan must be uploaded, including the 347 planned completion date and the name of the individual(s) responsible 348 for implementing the plan. 349

(d) Property Damage 351

i. A brief description of any damage to government property, other than 353 motorized vehicles; 354

ii. A brief description of any damage to personal property, other than motorized 356 vehicles; and 357

iii. A brief description of any damage to motorized vehicles. 359

(4) Initial Report Content for Standard Format shall include the following information: 361

(a) General Information: 363

i. Name, OU, Division, and Group of the individual submitting the report; 365

ii. Type of event (e.g., Injury, Near Miss, Property Damage, etc.); 367

iii. Date and time of event, if known; 369

(i) For cases involving OSHA Recordable Standard Threshold Shift 371

(STS) hearing losses, the date the STS is confirmed by letter shall be 372 entered. 373

iv. Location of the event and type of space (e.g., hallway); 375

v. When OU line management was first notified of the event; 377

vi. The OU responsible for the space where the event occurred; 379

vii. The OU responsible for any equipment involved in the event, if applicable; 381 and 382

viii. The OU responsible for leading the investigation, based on the guidelines 384 contained in Section 6(e)(1). 385

NIST S 7101.24 (Uncontrolled Copy in Print) Page 11

(i) If an OU other than the OU submitting the Initial Report is designated 386 to lead the investigation, the name of the individual in Line 387 Management from the designated OU who accepted responsibility for 388 the investigation must be documented. 389

(b) Individuals Involved - For each person involved in an event, the following 391 information shall be included: 392

i. Name; 394

ii. Position; 396

iii. Employment Status: 398

(i) Employee; 400

(ii) Associate; or 402

(iii) Visitor; 404

iv. Status of the individual as a result of the event: 406

(i) Injured; 408

(ii) Became Ill; 410

(iii) Exposed; 412

(iv) Contaminated by radioactive material; 414

(v) Combination of i-iv above; or 416

(vi) None of the above; 418

v. If injured, ill, or exposed: 420

(i) A description of the injury, illness, or exposure; 422

(ii) A description of the immediate care given; 424

NIST S 7101.24 (Uncontrolled Copy in Print) Page 12

(iii) If the individual will miss any days of work, if known; and 426

(iv) If the individual will be restricted or transferred to another job because 428 of the event, if known. 429

(c) Event Description 431

i. A brief description of the activity leading up to or taking place at the time of 433 the event; 434

ii. A description of what happened, or for a near miss, what could have 436 happened; 437

iii. A description of any immediate measures taken to respond to the event, 439 including any actions taken to protect workers from exposure to hazards; 440

(d) Property Damage 442

i. A brief description of any damage to government property, other than 444 motorized vehicles; 445

ii. A brief description of any damage to personal property, other than motorized 447 vehicles; and 448

iii. A brief description of any damage to motorized vehicles; 450

(5) OU Review of Streamlined and Initial Reports 452

(a) Prior to submittal to IRIS, the OU IRIS Administrator shall review the Streamlined 454 and Initial Reports submitted from within their OU for: 455

i. Appropriate selection of format; 457

ii. Appropriate selection of event type; 459

iii. Completeness of report; and 461

iv. Quality of report. 463

NIST S 7101.24 (Uncontrolled Copy in Print) Page 13

(b) If the Submitter of an Initial Report has designated a different OU to lead the 465 investigation, that designated OU shall have the opportunity to review and comment 466 on the Initial Report during the OU Review step. 467

(c) During the OU Review step, the OU IRIS Administrator shall designate one of the 469 following two notification options for how the report will be communicated: 470

i. Post Only 472

(i) Streamlined Reports, Initial Reports and Investigation Reports 474 designated as “Post Only” shall be posted to IRIS where they will be 475 viewable by the NIST staff. 476

(ii) An email containing a summary of the Streamlined Report, Initial 478

Report, or Investigation Report shall be sent only to the OU IRIS 479 Report Submitter, the OU IRIS Administrator, all investigators (for an 480 Investigation Report), and the IRI PM. 481

ii. Post with Notification 483

(i) Streamlined Reports, Initial Reports, and Investigation Reports 485 designated as “Post with Notification” shall be posted to IRIS where 486 they will be viewable by the NIST staff. 487

(ii) An email containing a summary of the Streamlined Report, Initial 489

Report, or Investigation Report shall be sent to the OU IRIS Report 490 Submitter, the OU IRIS Administrator, all investigators (for an 491 Investigation Report), the IRI PM, and notification subscribers as per 492 their subscription service preferences. 493

e. Conduct and Documentation of Incident Investigations 495

For each event utilizing the Standard Report Format, an investigation shall be conducted and 496 an Investigation Report submitted, per the following requirements. 497

(1) OU Responsibility for Leading Investigations 499

(a) For Immediate Notification Incidents, OSHE, with participation from the OU(s) 501 involved, shall lead the investigation. 502

NIST S 7101.24 (Uncontrolled Copy in Print) Page 14

(b) For events that involve individuals and space from only one OU, that OU shall lead 504 the investigation. Please note Section 6e(1)(e) for additional clarification. 505

(c) For events involving multiple individuals and/or space(s) and/or equipment from 507 different OUs, the OU IRIS Administrators from all OUs involved shall identify the 508 OU that will lead the investigation, with appropriate participation from the other 509 OU(s). The OU leading the investigation shall provide the Lead Investigator. 510

i. If an agreement cannot be reached, the IRI PM shall designate the OU 512 responsible for leading the investigation. Please note Section 6e(1)(e) for 513 additional clarification. 514

ii. If multiple OUs are involved in the investigation, each OU shall have the 516 opportunity to review and comment on the Investigation Report prior to its 517 submission by the lead OU. 518

(d) For events where no individuals are involved (e.g., flooding that occurred in a 520 laboratory after hours or collapse of a bookshelf in an office when no one was present 521 in the room), the OU responsible for the space in which the incident or near miss 522 occurred shall lead the investigation. Please note Section 6e(1)(e) for additional 523 clarification. 524

(e) If at any time it is determined that another OU is responsible for the activity in which 526 the event occurred, or for the apparent cause of the event, or will be assigned a 527 corrective action, that OU will participate in or lead the investigation, or, if the 528 investigation is already underway, participate for the remainder of the investigation, 529 as necessary and appropriate. 530

(2) Investigator Requirements 532

(a) Investigations shall be led and documented in IRIS by an OU Lead Investigator 534 designated by the OU leading the investigation, and trained per the requirements of 535 Section 6g. 536

(b) An individual should not serve as an OU Lead Investigator for an event where there is 538 a conflict of interest (e.g. for an event that directly involved them or for an event 539 involving their direct supervisor.). 540

NIST S 7101.24 (Uncontrolled Copy in Print) Page 15

(3) OSHE Participation in Investigations 544

(a) Based on the nature of an incident or near miss, OSHE may require the inclusion of 546 OSHE subject matter experts on the investigation team. This requirement will apply, 547 at a minimum, to incidents related to the following NIST Safety Programs: 548

i. Biosafety; 550

ii. Electrical Safety; 552

iii. Ergonomics; 554

iv. Fire and Life Safety suborders; 556

v. Hazardous Waste Accumulation; 558

vi. Hearing Protection; 560

vii. Ionizing Radiation Safety; 562

viii. Laser Safety; and 564

ix. Other programs on a case-by-case basis. 566

(b) OSHE shall aid in conducting investigations upon request. 568

(4) Investigation Reports shall include the following information: 570

(a) Name and OU of the Lead Investigator; 572

(b) Name and OU of other members of the investigation team; 574

(c) A brief description of the investigative process; 576

(d) The essential findings of the investigation and supporting information, including; 578

i. A general (narrative) description of what happened and why; 580

ii. Any updates to information provided in the Initial Report; 582

NIST S 7101.24 (Uncontrolled Copy in Print) Page 16

iii. Pictures, sketches, videos, etc. (as needed); 584

iv. The causal factor(s); and 586

v. The root cause(s). 588

(e) At least one corrective action per root cause, including: 590

i. A description of each specific corrective action, including interim steps as 592 needed; 593

ii. Identification of persons responsible for implementation of corrective actions; 595

iii. Identification of the expected time to complete corrective actions; 597

(i) For corrective actions expected to require more than 30 calendar days 599 to complete, a corrective action plan must be uploaded and approval 600 from line management documented; 601

iv. Identification of individuals in line management responsible for verifying that 603 corrective actions are complete; and 604

(f) Any lessons identified, as defined in Section 7, for sharing with the broader NIST 606 community, including recommendations for follow-up by OSHE. 607

(5) OU Review of Investigation Reports 609

(a) Prior to submittal to IRIS for posting, the responsible OU IRIS Administrator shall 611 review Investigation Reports for completeness and quality. 612

(b) Each OU represented on the investigation team shall have the opportunity to review 614 and comment on the Investigation Report during the OU Review step. 615

(c) The OU IRIS Administrator shall designate a notification method for the 617

Investigation Report per Section 6d(5)(c). 618

f. OU Implementation Procedures 620 Each OU shall establish implementation procedures and responsibilities for carrying out the 621 requirements of this suborder including, but not limited to, the following: 622

NIST S 7101.24 (Uncontrolled Copy in Print) Page 17

(1) Reporting of incidents and near misses to OU management by employees and covered 624 associates, e.g., whom they must contact and by what means; 625

(2) Evaluating and classifying reported events per Section 6b above; 627

(3) Reporting of Immediate Notification Incidents to the NIST CSO; 629

(4) Determining the recording format for the event (i.e., Streamlined or Standard format), per 631

Section 6b(4) and the notification method per Section 6d(5)(c); 632

(5) Designating staff members with the following roles: 634

(a) OU IRIS Submitter(s); 636

(b) Lead Investigator(s); and 638

(c) OU IRIS Administrator(s). 640

(6) Training of OU staff members to meet the OU Implementation Procedures and the 642 requirements of a Lead Investigator per Section 6g; 643

(7) Drafting and vetting of Streamlined Reports and Initial Reports; 645

(8) Drafting and vetting of Investigation Reports, including determination that corrective 647 actions are appropriate to prevent recurrence of the incident or near miss while not 648 inadvertently introducing other hazards; 649

(9) Ensuring corrective actions are: 651

(a) Implemented in a timely fashion; 653

(b) Implemented in such a manner as to prevent recurrence of the incident or near miss 655 while not inadvertently introducing other hazards; and 656

(c) Tracked to closure; 658

(10) Sharing lessons identified, as appropriate, within the OU and identifying lessons to 660

OSHE that should be shared to a wider audience; 661

NIST S 7101.24 (Uncontrolled Copy in Print) Page 18

(11) Ensuring information required for regulatory documentation of injuries and illnesses 663 (e.g., OSHA 301 Forms for each OSHA Recordable injury or illness) is provided to 664 OSHE within seven calendar days of it being requested by the IRI PM; and 665

(12) For each OSHA Recordable case resulting in days away from work, restricted work, 667 and/or transfer to another job (OSHA Recordable DART case, as defined in Section 7), 668 ensuring work duty status information (e.g., full duty, restricted, unable to work) is 669 maintained and provided to the IRI PM as requested. 670

g. Training and Information 672

(1) All training shall be conducted and recorded in accordance with the requirements of the 674

NIST S 7101.23: Safety Education and Training. 675

(2) OU IRIS Report Submitters and OU IRIS Administrators shall complete training 677 provided by OSHE on the use of the IRIS application. 678

(3) Lead investigators shall complete training regarding incident investigation principles and 680 methods from either OSHE or equivalent training provided by an outside source 681 approved by the OSHE IRI PM5. 682

(4) OU staff shall be informed by the OU of those aspects of the OU Implementation 684

Procedures (see Section 6f) applicable to their roles in incident reporting and 685 investigation. 686

h. OSHE Management of IRI 688

(1) Processing of Streamlined and Initial Reports 690

(a) The IRI PM shall ensure that Streamlined and Initial Reports to be posted publicly to 692

IRIS do not contain information that can be used to identify specific individuals or 693 that can be used with other sources to identify such individuals; 694

(b) The IRI PM shall review submitted Streamlined and Initial Reports for appropriate 696 selection of the reporting format selected (Streamlined or Standard) per Section 6b(4) 697 and notification method selected per Section 6d(5)(c). 698

5 OSHE shall maintain a list of currently approved equivalent incident investigation courses provided by outside sources.

NIST S 7101.24 (Uncontrolled Copy in Print) Page 19

(c) The IRI PM shall post Streamlined and Initial Reports to IRIS within 2 business days 700 of submission, if possible. 701

(2) Processing of Investigation Reports 703

(a) The IRI PM shall ensure that Investigation Reports to be posted publicly to IRIS do 705 not contain information that can be used to identify specific individuals or that can be 706 used with other sources to identify such individuals; 707

(b) The IRI PM shall review submitted Investigation Reports for appropriate selection of 709 notification method per Section 6d(5)(c). 710

(c) The IRI PM shall post Investigation Reports to IRIS within 2-3 business days of 712 submission; if possible. 713

(3) IRI Notifications 715

(a) Notifications of Streamlined Reports, Initial Reports, and related Investigation 717

Reports shall be communicated to the NIST staff using the IRIS application. 718

i. NIST employees in a supervisory role shall receive notifications when 720 Streamlined Reports, Initial Reports, and Investigation Reports are posted. 721

ii. NIST staff shall be afforded the opportunity to receive email notifications 723 when Streamlined Reports, Initial Reports, and Investigation Reports are 724 posted, utilizing the IRIS application subscription service. 725

(b) For each NIST establishment identified in Section 6h(6)(b)(i) below, the CSO shall 727 sign and post the OSHA Form 300A – Summary of Work-related Injuries and 728 Illnesses (“annual summary”) from the previous calendar year on the NIST Safety 729 Web Page and in at least one conspicuous physical location at the establishment. The 730 annual summary shall be posted from February 1 to April 30. 731

(c) The IRI PM shall provide a weekly summary of IRI Program activity to the NIST 733

Director, Associate Directors, and OU Directors. 734

(d) The NIST CSO shall provide a monthly summary of IRI Program activity to the NIST 736 Leadership Board. 737

NIST S 7101.24 (Uncontrolled Copy in Print) Page 20

(4) Monitoring and Measurement 740

(a) The IRI PM shall collect data and compile metrics necessary to evaluate the 742 effectiveness of this program, including, but not limited to: 743

i. Number and types of events reported; 745

ii. Length of time for staff to report to line management; 747

iii. Time taken to submit Streamlined and Initial Reports into IRIS; 749

iv. Percentage of Streamlined and Initial Reports submitted within 2 business 751 days; 752

v. Time taken to submit Investigation Reports into IRIS; 754

vi. Percentage of Investigation Reports submitted within 20 business days; 756

vii. Backlog of investigations open longer than 20 business days; and 758

viii. Total number of OSHA Recordable cases and OSHA Recordable DART 760 cases. 761

(5) IRI Compliance Evaluation 763

(a) The IRI PM shall conduct an internal compliance evaluation of the regulatory 765 recordkeeping requirements outlined in Section 6h(6)(b) of this program on at least an 766 annual basis. A standard checklist shall be developed and used. 767

(b) Results of internal compliance evaluations shall be documented and maintained as a 769 record per Section 6h(6)(a). 770

(c) Corrective actions shall be implemented as soon as practical to address findings of 772 non-compliance. 773

NIST S 7101.24 (Uncontrolled Copy in Print) Page 21

(6) IRI Recordkeeping 780

(a) NIST-Required Recordkeeping 782

i. Personal information that is collected in reports and investigations shall be 784 maintained securely in the IRIS application. 785

ii. Personal information that is collected in reports and investigations shall be 787 accessible to the IRI Program Manager, OSHE IRIS Administrator, OU IRIS 788 Administrator(s), the OU Submitter, members of the Investigation Team, the 789 relevant supervisor(s), and the employee(s) directly involved. 790

iii. For each injury and illness incident, the IRI PM shall classify the event using 792 the U.S. Department of Labor Bureau of Labor Statistics (BLS) Occupational 793 Injury and Illness Classification System. This will include classification of: 794

(i) Nature of Event or Exposure; 796

(ii) Nature of Injury or Illness; 798

(iii) Part of Body Affected; and 800

(iv) Source of Injury or Illness. 802

iv. The IRI PM shall retain training records as identified in Section 6g using the 804 IT application supporting the NIST Safety Education and Training Program. 805

v. The IRI PM shall retain results of annual internal compliance evaluations as 807 described in Section 6h(5). 808

(b) OSHA Required Recordkeeping 810

i. The IRI PM shall maintain a list of NIST establishments for which separate 812 OSHA records will be maintained, pursuant to 29 CFR 1904.30. 813

ii. For injuries and illnesses resulting from an incident, the IRI PM shall 815 document case details, including medical treatment, sufficient to make and 816 record a determination of the OSHA status of each case as one of the 817 following: 818 https://www.ecfr.gov/cgi-bin/text-idx?SID=60b57e501656e3e5d05329c932edb10c&mc=true&node=pt29.5.1904&rgn=div5

NIST S 7101.24 (Uncontrolled Copy in Print) Page 22

(i) OSHA Recordable; 820

(ii) OSHA Recordable DART; and 822

(iii) Not an OSHA Recordable. 824

iii. For each injury or illness determined to be an OSHA Recordable, the IRI PM 826 shall send a request for a completed OSHA 301 Form – Injury and Illness 827 Incident Report to the OU IRIS Administrator of the employee. Completed 828 OSHA 301 Forms shall be retained by the IRI PM for each OSHA Recordable 829 case. 830

iv. For each OSHA Recordable DART case, the IRI PM shall utilize the IRIS 832 application to obtain (from the supervisor of the employee), update, and 833 document DART information. 834

v. For the establishments identified in Section 6h(6)(b)(i), the IRI PM shall 836 maintain the OSHA Form 300 – Log of Work-Related Injuries and Illnesses. 837

vi. For the establishments identified in Section 6h(6)(b)(i), the IRI PM shall 839 maintain the OSHA Form 300A – Summary of Work-related Injuries and 840 Illnesses. 841

vii. The IRI PM shall maintain a record of all information initially provided to 843 OSHA for each Immediate Notification Incident, and all subsequent 844 correspondence related to the incident. 845

viii. The IRI PM shall provide any information described in this section to external 847 entities (e.g., DOC, BLS) as requested. 848

(c) The retention period for the records identified in this section shall be not less than 850 five years from the end of the calendar year that these records cover. 851

7. DEFINITIONS 854

a. Abatement – Action taken to eliminate a recognized safety hazard or deficiency. 855

b. Abatement Plan – A set of planned actions to abate a recognized hazard and their estimated 857 completion dates. 858

NIST S 7101.24 (Uncontrolled Copy in Print) Page 23

c. Causal Factor – An action or condition, or lack thereof, related to equipment, people, 860 management, or the environment that an event occurred in, that caused or contributed to the 861 severity or likelihood of an event. 862

d. Condition – Any state, as found, whether or not it resulted from an event, that may have 864 adverse safety, health, environmental, or operational implications. 865

e. Contamination by Radioactive Material – The unintended/unexpected presence of radioactive 867 material on, or in, an individual. 868

f. Corrective Action – Action to eliminate the cause of a detected nonconformity or other 870 undesirable situation. 871

g. Corrective Action Plan – A set of planned actions to eliminate the cause of a detected 873 nonconformity or other undesirable situation such as the root cause of an incident. 874

h. Event – For the purposes of this suborder, a real-time occurrence. 876

i. Exposure – Contact by an individual through touching, breathing, or consuming a harmful 878 chemical or biological substance; or unintended / unexpected dose to an individual from an 879 ionizing radiation field. Any exposure that results in an injury or illness shall be classified as 880 an injury or illness. 881

j. Hazard – Source, situation, or act with a potential for harm in terms of human injury or ill 883 health, adverse impact on the environment, damage or loss of equipment or property, or a 884 combination of these. 885

k. Illness – Any abnormal condition or disorder, other than one resulting from a work-related 887 injury, caused by one-time, continued, or repeated exposure to environmental factors 888 associated with employment, including acute and chronic illnesses or diseases that may be 889 caused by inhalation, absorption, ingestion, or direct contact. OSHA Recordable STS 890 hearing loss cases are included in this definition. 891

l. Immediate Notification Incident – A work-related incident that results in any of the following 893 to one or more employees or covered associates (reference 29 CFR 1904.39): 894

(1) Death, within 30 (thirty) calendar days of the incident; 896

(2) In-patient hospitalization within 24 hours of the incident; or 898 https://www.ecfr.gov/cgi-bin/text-idx?SID=60b57e501656e3e5d05329c932edb10c&mc=true&node=pt29.5.1904&rgn=div5

NIST S 7101.24 (Uncontrolled Copy in Print) Page 24

(3) An amputation or loss of an eye within 24 hours of the incident. 900

m. Incident – A work-related event in which any of the following, individually or in 902 combination, occurred: an injury or illness; an unauthorized spill or release of hazardous or 903 regulated material to the environment; property damage; exposure; or contamination by 904 radioactive material. 905

n. Initial Report – A report that contains the items listed in Section 6d(4). 907

o. Injury – Any wound or condition of the body caused by external force, including physical 909 stress or strain that results from a work accident or from exposure in the work environment, 910 e.g., amputation, bruise, burn, contusion, cut, fracture. The injury is identifiable as to time 911 and place of occurrence and member or function of body affected, and is caused by a specific 912 event or incident, or series of events or incidents, within a single day or work shift. 913

p. Investigation – The systematic process of analyzing the events leading up to an event, 915 gaining an understanding of what caused it, identifying actions to prevent recurrence, and 916 documenting the results in a written Investigation Report. 917

q. Investigation Report – A report that contains the items listed in Section 6e(4). 919

r. Lessons Identified – Information (such as Extent of Condition Reviews) resulting from an 921 investigation that, if acted upon by an organization and the individuals therein, will reduce 922 the probability of recurrence of that and similar events. 923

s. Near Miss – Also known as a “near hit,” “near-accident,” or “close call,” a work-related 925 event that did not result in any of the following, either individually or in combination, but 926 had a plausible likelihood of doing so: an injury or illness; a spill or release of hazardous or 927 regulated material to the environment; property damage; exposure; or contamination by 928 radioactive material. 929

t. OSHA Recordable case – Any injury or illness that meets the general recording criteria 931 established by OSHA at 29 CFR 1904.7. In general, this includes any work-related injury or 932 illness that results in death, days away from work, restricted work or transfer to another job, 933 medical treatment beyond first aid, or loss of consciousness. Work-related cases involving 934 cancer, chronic irreversible disease, a fractured or cracked bone, or a punctured eardrum are 935 always OSHA Recordable. 936 https://www.ecfr.gov/cgi-bin/text-idx?SID=60b57e501656e3e5d05329c932edb10c&mc=true&node=pt29.5.1904&rgn=div5

NIST S 7101.24 (Uncontrolled Copy in Print) Page 25

u. OSHA Recordable DART case – Any OSHA Recordable case that results in death, days 938 away from work, restricted work or transfer to another job, as established by OSHA at 29 939

CFR 1904.7. 940

v. OU Responsible for the Space – OU to which the space has been assigned by the Office of 942 Facilities and Property Management. 943

w. Property Damage – Incident resulting in loss or harm to property. 945

x. Root Cause – A causal factor of an event that, if corrected, would prevent the recurrence of 947 that and similar events. 948

y. Spill / Release – An unauthorized spill or release of hazardous or regulated material to the 950 environment. 951

z. Streamlined Format – Format used for relatively simple and generally minor events that can 953 be resolved without significant corrective actions. (Abatement actions may be necessary.) 954 These cases will be documented in a single Streamlined Report containing information on 955 what happened, why it occurred, and how it can be prevented from happening again. A 956 separate Investigation Report is not required. 957

aa. Streamlined Report - A report containing the items listed in Section 6d(3). 959

bb. Standard Format – Format used to document more significant and/or more complex events 961 that require a higher level of investigation and significant corrective actions. This can 962 include near misses. These cases will be documented in an Initial Report, followed by an 963 Investigation Report that establishes the root cause(s) of the incident or near miss, and the 964 corrective actions. 965

cc. Work-Related – A condition wherein an injury, illness, or fatality was caused, contributed to, 968 or significantly aggravated, or could have been, by an event or exposure at work or on 969 official business away from work (reference 29 CFR 1904.5). 970

8. ACRONYMS 973

a. BLS – United States Bureau of Labor Statistics 974

b. CFR – Code of Federal Regulations 976 https://www.ecfr.gov/cgi-bin/text-idx?SID=d545a4db083979d75f41a5a411d34314&mc=true&node=pt29.5.1904&rgn=div5 https://www.ecfr.gov/cgi-bin/text-idx?SID=d545a4db083979d75f41a5a411d34314&mc=true&node=pt29.5.1904&rgn=div5 https://www.ecfr.gov/cgi-bin/text-idx?SID=60b57e501656e3e5d05329c932edb10c&mc=true&node=pt29.5.1904&rgn=div5

NIST S 7101.24 (Uncontrolled Copy in Print) Page 26

c. DART – Days away from work, restricted work, or transfer to another job 978

d. DOC – Department of Commerce 980

e. EOC – Extent of Condition 982

f. IRI PM – Incident Reporting and Investigation Program Manager 984

g. IRIS – Incident Reporting and Investigation System 986

h. OSH – Occupational Safety and Health 988

i. OSHA – Occupational Safety and Health Administration 990

j. OU – Organizational Unit 992

k. STS – Standard Threshold Shift 994

9. RESPONSIBILITIES 997

a. OU Directors are responsible for: 998

(1) Ensuring the establishment of OU procedures, the implementation of which will result in 1000 the requirements of Section 6 applicable to the OU being met 1001

(2) Ensuring the OU procedures are implemented; 1003

(3) Ensuring the quality and timeliness of Streamlined, Initial, and Investigation Reports; 1005

(4) Ensuring that applicable lessons identified are shared within their OU, as appropriate; and 1007

(5) Ensuring that all-required follow-up actions are completed and effective. 1009

b. OU IRIS Administrators are responsible for: 1011

(1) Coordinating efforts with other OUs when multiple OUs are involved in an incident 1013 through personnel, space, or equipment, to ensure that the reporting and investigation 1014 requirements of this program are met; 1015

NIST S 7101.24 (Uncontrolled Copy in Print) Page 27

(2) Reviewing incident reports and incident investigations for completeness, quality, 1017 accuracy, and appropriateness of the selected format (Streamlined or Standard); 1018

(3) Designating the notification method that will be used for each incident; and 1020

(4) Designating OU Submitters and OU Lead Investigators for their respective OUs. 1022

c. Lead Investigators are responsible for organizing, conducting and documenting incident 1024 investigations, including EOC reviews as assigned, to effectively identify causal factors and 1025 root cause(s) of incidents and near misses, and appropriate corrective actions necessary to 1026 prevent recurrence. 1027

d. Supervisors are responsible for: 1029

(1) Reporting all incidents as soon as practically possible to their management in accordance 1031 with OU policies and procedures; 1032

(2) Ensuring that equipment and facilities involved in incidents are shut down if necessary 1034 and restored to use only after hazards have been mitigated; 1035

(3) Preserving the scenes of incidents intact to the extent possible to facilitate incident 1037 investigations; 1038

(4) Supporting incident investigations as prescribed by their OU-level policies; 1040

(5) Reviewing IRIS incidents, evaluating and communicating lessons learned applicable to 1042 activities under their span of control, and taking appropriate actions to prevent similar 1043 incidents; 1044

(6) Completing required documentation for OSHA Recordable injury and illness cases, 1046 including OSHA 301 Forms and other relevant information as requested by the OSHE 1047 IRI PM; and 1048

(7) Providing the OSHE IRI PM with updated case information (e.g., current duty status, 1050 days away, etc.) for employees that incur OSHA Recordable injuries. 1051

e. NIST Employees and Covered Associates are responsible for: 1053

(1) Reporting (or having someone else report) incidents and near misses immediately to their 1055 supervisor or sponsor; and 1056

NIST S 7101.24 (Uncontrolled Copy in Print) Page 28

(2) Providing complete and accurate information in support of incident investigations and 1057 recordkeeping, as necessary and as prescribed by the OU-level policies. 1058

f. IRI PM is responsible for: 1060

a. Maintaining this suborder and providing guidance as requested by NIST personnel; 1062

b. Reviewing IRIS cases and data to identify trends indicative of systemic issues, 1064 facilitating identification of tactics to address them. 1065

c. Facilitating the communication of lessons learned across the NIST community. 1067

d. Ensuring NIST-level training as required by this suborder is available; 1069

e. Maintaining a list of incident investigation courses provided by external sources that meet 1071 the equivalent training requirement established at 6g(3); and 1072

f. Carrying out duties as established within this suborder to maintain compliance with 1074

OSHA Injury and Illness Recordkeeping regulations. 1075

10. AUTHORITIES 1078

There are no authorities specific to this suborder alone. 1079

11. DIRECTIVE OWNER 1082

Chief Safety Officer 1083

12. APPENDICES 1086

None 1087

NIST S 7101.24 (Uncontrolled Copy in Print) Page 29

Appendix A. Revision History 1089

Revision No.

Approval Date

Responsible Person Brief Description of Change; Rationale

0 • None – Initial document

1 07/26/17 07/26/17 • Revised order of document for clarity and flow.

• Added regulatory injury and illness recordkeeping requirements.

• Added incident types for radiation events

• Incorporated changes designed to differentiate near miss events from incidents.

• Added a streamlined process for less complex events.

• Added options for how notifications for events are made, based on relevance of events to NIST staff.

• Added ownership of equipment involved in an event as a criterion for determining OU responsibility.

• Added process for review of reports at the OU level prior to submittal to OSHE for posting.

• Added requirements for abating direct hazards.

• Added requirements for IRIS Submitters and Lead Investigators to be designated and trained.

• Updated and clarified the process for submitting Immediate Notification Incidents.

• Added requirement for OSHE to conduct an annual compliance evaluation.

2 1/4/2021 April Camenisch • Updated links to suborders.

Appendix A. Revision History