EVENT ASSESSMENT REPORT o?gaamea No: ER new I Event it) No: DTG 8: Location: EHJ 2510412012 0?:35 Lead Seetion I Department: Ships Staff Base Section(s) invoicedleA I Vesseiie) involved: systems Amer; . - Failure Midde Electrical! Equipment Failure Personnel Failure Mechanical Design Incon'ect Diagnosis Civil Structure Manufacture Non-compliance Radiological Maloperation Inappropriate Action Administrative Stores Performance Berthing . installation Spatial Error Contractor MaintenanceiRepair Programme pressure Maintenance Incorrect Equipment - Other Weapons Worn Equipment Documentation MAR Other (state) Not avaiiable Other (state) Inadequate Incorrect Other (state) EVENT DESCRIPTION: Failure of z: . to issue to materiel as reqairedlby HOP 4923! Date Closed Out: 22NOV12 Page 1 of 3 Revision if is the of the user to ensure they are working with the {aresi'revfsion Printed: 10f06i2015 NUCLEAR SAFETY EVENT ASSESSMENT REPORT Category: Date agreed by {Jii??iiz??i INES Level: Beiow Scale try further investi ation Rec aired: - INVESTIGATION REPORT AND SUPPORTING DOCUMENTS: See attached NRPA Event Report?OBHZ Name: NEED I Title: MEG I Tel No: I Date: BY THE ASSURANCE DEPARTMENT: ROOT CAUSES Failure to comply with a Nuclear Procedure. HUMAN FACTORS Poor Training- The Quarter Master failed to understand the requirement to issue accident to all non ships staff iaw NOP 402(3) - CORRECTIVE PREVENTIVE ACTIONS (CPAs) See attached Event Report RECOMMENDATIONS See attached Event Report LESSONS See attached ?vent Report AB COMMENTS This event has highiighted a failing with ships staff in regard to training their Quartermasters in the control of NOP 402$). A fuii understanding and appreciation of this procedure is essential to controlling an effective exctusion zone It is to the credit of?seif correcting cuiture that extra training has atready been implemented. It is aiso noted that the PAS have further endeavored to enforce the issuing of by em boio?ening the specific statement that directs the issuing of both accident and occupational COMMENTS The attached Event Report gives a detailed account of the circumstances that led to members of a FOST team entering the Exclusion Zone without being issued with Accident Dosimetry as required by The report provides a frank and open account of the event, inciuding prior training. identifies the root cause of the issue, provides evidence that lessons have been learnt and that actions have been taken to prevent a repeat occurrence. The root cause of this event was the failing of the ?to with a procedure for which he had been given speci?c and directed training. The actions taken by Ship?s Staff are adequate and appropriate and are supported by the changes to the procedure being implemented by the FAG. Page 2 of 3 Revision 7" it is the of the user to ensure they are working with the iaiesr revision Printed: 10i06f2015 Assessing Of?cer: (NSAM) Actions Required Target Agreed By Date . 1. Nil. 2. 3- Assessing Of?cer Signed: Title: Date: recommendationsiactiens now completed. Comments: Signed: - Title: Date: NSE ctesed-eut: Review Required: Yes 1' Ne Date sent to Life Time Records: Signed: Title: Date: Review Required: I ReviewDate: I By Whom: Comments: Signed: Title: Date: Fgge 3 of 3 Revision It is the of the user to ensure they are working with the latest rat-vision Printed: 10f06t2015