The Lawrence Berkeley National Laboratory (LBNL) Issues Management Program encompasses issue identification, causal analysis, corrective action development, tracking and implementation, and corrective action verification of completion and validation of effectiveness. The program also includes monitoring and analysis of adverse trends and conditions, and sharing of lessons learned and best practices.
The issues that are relevant to this program pertain to any safety or operational event, condition, or circumstance that:
- results or could result in injury, damage, loss, or noncompliance (Example: actual or near miss incidents);
- represents a program, safety or operational deficiency (Example: audit or assessment finding, performance weakness); or
- adversely affects the achievement of mission, strategic and business objectives (Example: operational, strategic and reputational risks).
Typically, issues are discovered through actual adverse incidents, near miss incidents, audits, assessments, safety concerns, safety walkthroughs/inspections, metrics, trending and analysis, process improvement initiatives and risk assessments. This list is not inclusive, as there may be other mechanisms used to discover issues.
Issues and Management Process
The Issues Management process is a risk based, graded approach that involves identifying issues, analyzing issues, mitigating issues through corrective actions; documenting issues, evaluating the completion, effectiveness and endurance of corrective actions; and communicating and sharing issues through lessons learned. The process is described in more detail below.
- Gathering preliminary information to characterize the issue and/or risk exposure
- Determining issue / risk significance as high, medium or low severity
- Performing Causal Analysis based on issue / risk significance
- Root Cause (high severity)
- Apparent Cause (medium severity)
- Performing Extent of Condition Reviews
- Developing Corrective Action Plan / Corrective Actions
- Implementing Corrective Action Plan / Corrective Actions
Documenting Issues and Mitigation
- Documenting and tracking issues and corrective actions in the CATS Database
Evaluating Issue Mitigation
- Verifying corrective action completion through objective evidence
- Performing Effectiveness Reviews (high severity)
- Performing Data Monitoring and Analysis (trending and analysis)
- Developing and Disseminating Lessons Learned / Best Practices
Program Manuals and Tools
Below is a general work flow of the issues management process, along with the Program Manuals and tools to support the Issues Management Program and processes implementation.
- LBNL/PUB-5519 (1), Issues Management Program Manual, Rev. 6
- LBNL/PUB-5519 (2), Causal Analysis Program Manual, Rev. 5
Training courses are offered upon request on the following Issues Management Program elements:
- Division Director RCA Process Overview
- RCA Team Training
- Apparent Cause Analysis
- BLI2010, Corrective Action Development Training (online training module)
- BLI2018, CATS Tutorial
- Effectivness Review Overview
Root Cause Analysis Templates:
Effectiveness Review Templates:
- Effectiveness Review Lines of Inquiry Template
- Effectiveness Review Analysis Template
- Effectiveness Review Report Template
Lessons Learned/Best Practices Templates:
DATABASE USER MANUALS
- OIA-OCA-0001, CATS Database User Manual, Rev. 3
- OIA-OCA-0002, Lessons Learned / Best Practices Database User Manual, Rev. 0
Please contact Theresa Triplett @ext. 7401 questions pertaining to the Issues Management Program, including request for training and formal root cause analysis reports.