Approved 10/27/97 REQUIREMENT B. Near Miss Occurrences Unusual Occurrence A near miss to one of the reporting classifications under preceding categories where the conditions necessary to cause an Unusual Occurrence existed (i.e., all barriers to event initiation were compromised). Off-Normal (1) A near miss to one of the reporting classifications under preceding categories where the conditions necessary to cause an Off-Normal Occurrence existed (i.e., all barriers to event initiation were compromised). (2) A near miss to one of the reporting classifications under preceding categories where the conditions necessary to cause a reportable occurrence were prevented from existing by one remaining barrier after other barriers had been compromised (i.e., one additional independent failure/degradation was necessary for event initiation to be possible). INTERPRETATION An electrical outage occurred when a truck struck a power pole guy wire, causing the pole to break and fall down. The power pole guy wire came in contact with the cab of the vehicle and the broken pole and 13.8 kV power line came to rest next to and parallel to the vehicle. An electrical 13.8 kV breaker tripped due to protective relay action causing an outage to a large portion of the area. Should this occurrence be reported only as an unplanned electrical outage under Group 1.H ON(2) or also as a near miss (Group 10.B UO) to Group 3.A -- Occupational Illness/Injuries, UO(1) -- "Any occurrence due to DOE operations resulting in a fatality or terminal injury or illness"? What is the occurrence category of this occurrence? Intent: This occurrence should be categorized as an Unusual Occurrence identifying both Nature of Occurrences 10.B UO and 1.H ON(2). Additional Information: To determine the occurrence category, refer to DOE M 232.11A Section 5.2, Event or Condition Categorization, which states, "If the category is not clear or the occurrence exceeds the threshold of more than one criteria, the occurrence shall be categorized at the higher level being considered." This event is an unplanned electrical outage and reportable as an OffNormal Occurrence under Group 1.H ON(2). However, the downed pole and live 13.8 kV line in close proximity to the vehicle also makes the occurrence a near miss to Group 3.A -- Occupational Illness/Injuries, UO(1) -- "Any occurrence due to DOE operations resulting in a fatality or terminal injury or illness." In this case, it appears that all barriers to event initiation were compromised and the conditions necessary to cause an Unusual Occurrence existed. |
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