EVALUATION OF THE
Integrated Safety Management System at
Lawrence Berkeley National Laboratory
Out-Briefing
September 27, 2006
Overview of Presentation
• Team Members/Areas of Focus
• Objectives, Scope and Approach
• Summary of Results
– Institutional Processes
– Facilities and Operations
– Large Scale User Facilities
– Bench Scale R&D
– Worker Safety
– Waste Management & Environmental Protection
• Recommendations
• Path Forward
11/16/2011 2
Team Members
Larry Kelly, DOE ORO Berkeley Site Office
David Allen, DOE ORO
Ed Lessard, BNL Large Scale R&D, User Facilities, CF1-5, GP3
Tom Mullen, ANL
Larry McClellan, PNNL Laboratory/Bench Scale Activities, CF1-5, GP3
Pat Wright, PNNL
Mike Bebon, BNL Facilities and Operations, CF1-5, GP3
Chris Johnson, BNL
Carol Scott, ORNL Worker/Industrial Safety, Waste Management,
Doug Schlagel, McT Environmental Protection, CF1-5, GP3
Steve Coleman, BNL
Bob McCallum, McT Contractor Assurance, Self-Assessment
Kyle Turner, McT Corrective Action Management, Work Smart
Standards, GP1-2, CF5
11/16/2011 3
Objectives, Scope and Approach
OBJECTIVES AND SCOPE
• Determine the overall effectiveness of the LBNL ISMS in satisfying
the DOE requirements for ISM
• Examine ISMS as it is designed and implemented at LBNL – at the
institutional, division & activity levels
– Understand how personnel implement ISM in practice – what they do, how
they do it, why they do it, how they know it is right
– Determine the extent to which the ISMS – as articulated in documents and
implemented in practice – is consistent with DOE expectations
• Use criteria/expectations outlined by
– The DOE HQ Office of Health, Safety and Security (formerly SP)
– Key DOE Policies, Orders & Guides (e.g., P226.1, O226.1, O414.1C,
P450.4, G450.4, and others)
– These were used as the basis for lines of inquiry
11/16/2011 4
Contractor Assurance, Self Assessment, CAM – CF5
Bob McCallum and Kyle Turner
• A documented, structured process exists at the institutional level for
assuring that contractual commitments – including performing work
safely, meeting mission and customer expectations, and continuous
improvement – are evaluated
– The UC Assurance Plan for LBNL establishes the basic institutional functionalities
for conducting contractor assurance activities, including identification of roles and
responsibilities for Laboratory management
• Institutional initiatives are being undertaken to improve ISMS
performance across LBNL
– Reconfiguration of the IFA process is expected to improve the effectiveness of this
assessment function and will be essential in identifying institutional-wide
performance and in supporting performance measurement and assurance
– The Lessons Learned (LL) program is being enhanced to provide “push”
notifications to persons whose activities relate to LLs via correlation with risk and
performance characterized in individual Job Hazard Questionnaires (JHQ)
11/16/2011 5
Contractor Assurance, Self Assessment, CAM – CF5
Bob McCallum and Kyle Turner
• LBNL has not fully implemented an integrated, comprehensive
Corrective Action Management Program providing guidance and
processes for managing corrective actions to effective closure
– A database tool (CATS) is being implemented for tracking corrective
actions to closure
– Additional (DOE-expected) functions have not been fully defined and/or
implemented
• Guidance on preferred causal analysis tools and their application space
• Guidance on triggers for and methods used for the conduct of extent of
condition reviews
• Complying with internal guidance on significance (medium risk actions are
addressed within 10 days)
• Guidance on the level of formality and methods for verification of action
closure
• Guidance on triggers for and methods used to conduct effectiveness reviews
11/16/2011 6
Contractor Assurance, Self Assessment, CAM – CF5
Bob McCallum and Kyle Turner
• Elements of the Self Assessment (SA) processes applied at LBNL are
not fully rigorous in terms of comprehensive and effective
measurement of organizational performance
– Current SAs are conducted using a pre-established checklist that is structured
around – and limited to – evaluation of organizational performance with regard
implementation of Core Functions 1 through 5
– SAs do not appear to examine performance to mission or functionality
requirements, nor do they establish the degree to which associated objectives
are being achieved
– SAs conducted to the standard checklist do not clearly reflect a risk-prioritized
evaluation of organizational activities, organizational risk, and the associated
priority for assessment
– SAs do not clearly measure performance against institutional ESH objectives,
and they do not align across all organizational elements to reflect an integrated
basis for LBNL performance measurement
11/16/2011 7
Contractor Assurance, Self Assessment, CAM – CF5
Bob McCallum and Kyle Turner
• The implementation approach for the OIA does not clearly reflect a
framework for monitoring and verifying the maturation of
institutional assurance processes
– For example, OIA monitoring of the SA process does not clearly focus on
process effectiveness, rather, as currently being practiced, the OIA validates
data developed in the organizational SAs
– OIA does not appear to be proactively evaluating implementation of the Quality
Assurance Program
11/16/2011 8
Line Accountability, Roles and Responsibilities – GP1 & 2
Bob McCallum and Kyle Turner
• Senior laboratory management has a strong sense of ownership and
accountability for safety performance
– There is a clear expectation by laboratory management that this level of safety
ownership must be reflected at all organizational levels of the Laboratory and is
integral with leading edge science
• Initiatives and practices to communicate and implement line
management ownership of safety are being instituted
– Senior management has recognized that full communication and understanding of
expectations for safety ownership has not fully permeated the LBNL organization,
and actions are being taken to address this
– Supervisor training has been developed and is being delivered that provides clear
expectations for safety performance, and there is evidence that disciplinary actions
based on safety performance have been and are being taken by the Laboratory
– The Laboratory Director has issued several laboratory-wide communications
regarding safety expectations, and the EHS directorate has developed a “1 Minute
4 Safety” tool for use by line managers
11/16/2011 9
Line Accountability, Roles and Responsibilities – GP1 & 2
Bob McCallum and Kyle Turner
• There does not appear to be a single, overarching set of Laboratory
safety principles and expectations for individual position descriptions
– These descriptions generally distinguish between line and ESH responsibilities
– However, safety responsibilities and expectations are documented in numerous
command media leading to the potential for conflict and confusion
– Clarity in communications of these expectations is limited by the lack of clear
hierarchy and relationships among command media
– There is no single, highest level set of essential safety behaviors and
expectations for line managers, subject matter experts, and staff in general
• Safety leadership and implementation of line management
responsibilities for safety are highly variable across LBNL organizations
– Variability in safety leadership and practice exhibited across LBNL by PIs
– Project documents sometimes approved by EHS personnel, not line or project
manager; JHAs sometimes developed by EHS personnel without line participation
– Deviations from established safety requirements (e.g., proper PPE, maintenance of
laboratory space safety configuration) reflect a lack of line management
engagement and/or effective communication of and feedback on safety expectations
11/16/2011 10
Line Accountability, Roles and Responsibilities – GP1 & 2
Bob McCallum and Kyle Turner
• Worker involvement in safety activities is not consistent across LBNL
– Formal worker safety committees have been established in some organizations (e.g.,
at ALS to review findings from safety inspections and consult with management on
safety issues)
– This is not an institutionalized practice
– Workers are not consistently involved in developing safety practices
• The institution does not have a consensus regarding the value of and
specific expectations for Safety Liaisons
– There is no set of consistent expectations that define the Safety Liaison role(s)
– There is no set of triggers, which signals Safety Liaison engagement
– The combination of programmatic and liaison requirements leads, in some cases, to
situations where personnel cannot effectively function in all areas where their
involvement is required to implement ISMS requirements
– Most Safety Liaisons correctly emphasize helping their assigned organization perform
work safely
– Assigned Safety Liaisons are not consistently receiving performance adequate
11/16/2011 11
Line Accountability, Roles and Responsibilities – GP1 & 2
Bob McCallum and Kyle Turner
• There appear to be limited safety accountability mechanisms for
Post-Docs and Graduate Students
– The usual methods used to correct negative behavior (i.e., disciplinary action)
appear to be unavailable
– Unless the PI and HR decide to terminate a Post-Doc or Graduate Student,
the only threat in the event of improper behavior is to withhold approval of the
Post-Doc’s or Graduate Student’s thesis, or withhold recommendations for
future appointment at other institutions
11/16/2011 12
Work Smart Standards – GP5
Bob McCallum and Kyle Turner
• LBNL has a documented, structured change management process for
identifying and evaluating the applicability of new requirements and
translating these requirements, as applicable, into the formal WSS set
– Advisory and Steering Committees established
– Good collaboration between BSO and LBNL
– Standards Review Teams
– Guidance packages for process implementation
• Elements of the process for translating new WSS requirements into
implementing practices are not formalized or completely understood
– Change control processes exist for the RPM and PUB-3000
– The Safety Review Committee has authority for approval of changes to PUB-3000
– The role of the SRC is not codified in PUB-3000
– Lack of institutional guidance for translating new requirements into lower level
implementing procedures
– There is some uncertainty on how industrial requirements are processed and
incorporated into implementing constructs (e.g., procedures)
11/16/2011 13
Work Smart Standards – GP5
Bob McCallum and Kyle Turner
• Institutional command media are not clear regarding the hierarchy
and relationship between documents
– Organizational and functional relationships among the RPM, PUB-3000, Operational
Assurance Plan (being translated to the Quality Assurance Plan), ISM Plan, ESH SA
plan, and UC Assurance Plan are not clearly established in terms how guidance
flows from institutional level policies to implementation
– There are separate discussions of responsibilities and authorities for the same
positions in multiple documents; there is no single set of safety behaviors
– The relationship between the OAP/QAP Appendix A risk ranking methodology and
work planning constructs (PUB-3000) is not clear; current document does not yet
have a consensus standard
– The role of the Safety Review Committee in the requirements change control
process is not reflected in the process guidance documents (PUB-3000)
– In institutional documents, guidance on many ESH elements (e.g., oxygen deficiency
hazards, magnetic field hazards, use of safety glasses, transfer of liquid helium
tanks in an elevator) are not sufficiently comprehensive to ensure that underlying
11/16/2011
requirements are met without additional subordinate guidance 14
Facilities and Operations – CF2 & 3
Mike Bebon and Chris Johnson
• Craft workers and supervisors reported easy access to EHS staff
specialist support 24/7
• Blackberry Gate project using daily Hazard Analysis/Planning
process; checklist signed by LBNL Construction Manager, contractor
and workers
• Contractor ES&H Plans are required and are approved by LBNL
before construction start
– Construction Safety Engineer routinely adds appropriate requirements to
contractor H&S plans
– EHS requirements summarized in separate section of construction contract
specifications
• Cross shop inspections are performed quarterly
11/16/2011 15
Facilities and Operations – CF2 & 3
Mike Bebon and Chris Johnson
• HEAR database is unreliable as source of facility hazards
• Facilities hazards are not readily available; system relies on worker
and supervisor “institutional knowledge”
• Contractor H&S Plans are based on cost, not risk
• Signed/approved contractor EHS plans are not maintained at jobsite
• Some documents are approved by EHS rather than Project Manager
• Contractor activity-level plans are not always explicit on required PPE
• Dig Permit is for 5 days requiring frequent renewal (every 7 days);
process perceived as “cumbersome”
• Expired dig permit was posted at jobsite
11/16/2011 16
Facilities and Operations – CF4 & 5
Mike Bebon and Chris Johnson
• Foundry construction contract included financial incentives for safety
• Craft recognized requirement for radiation coverage
• PMT shift change was strong in content, format, technique, execution
• WOW program is effective
• Safety system taken out of service without formal impairment process
• Safety coverage on construction projects may be inadequate
• Contractor/key supplier safety performance is not summarized or
formally used in subsequent contractor selection processes
• Worker feedback & lessons learned information is not documented and
not readily trended, shared across shops, and used in work planning
11/16/2011 17
Facilities and Operations – GP3
Mike Bebon and Chris Johnson
• Requirement established by Laboratory Director for supervisor
training by FY07
• Safety performance outside LBNL is a criteria in contractor selection
• New Facilities supervisors given orientation by Safety Coordinator
• JHQs tailored for additional specific employee needs; minimum
training requirements established for all crafts
• Supervisors readily check worker training status
• Causal analysis training is beginning to be offered
• Project Managers are required to take 10 hour OSHA Course
11/16/2011 18
Facilities and Operations – GP3
Mike Bebon and Chris Johnson
• Some supervisors do not review the completed JHA form before
work begins
• There is no process to validate hazard recognition skill for Facilities
crafts
• No Laboratory-level standards exists for Safety Coordinator position
• Allocation of EHS Liaison to facilities (20%) may be inadequate
• Contractor employees are not formally trained in Laboratory-wide
hazards
• Building Manager T&Q expectations not clearly defined
11/16/2011 19
Large Scale User Facilities – CF1
Tom Mullen and Ed Lessard
• ALS has a strong beamline and experimental safety
review process
• The Molecular Foundry has a strong (if unauthorized)
hazards assessment and control policy for nanoparticles
• Worker-planned work may not adhere to the documented
work-planning requirements
• Communications related to day-to-day work planning are
weak
11/16/2011 20
Large Scale User Facilities – CF2 & 3
Tom Mullen and Ed Lessard
• AHD process documents hazards and controls associated
with experiments
• Divisions reviewed have several policies in place that limit or
eliminate hazard exposure
• PUB-3000 does not provide guidance for hazard assessment
at a level to ensure uniform safe practices site wide
– Institutional level practices are more effective when established with
Division-level input
• ALS does not ensure engineered safety systems are
operational before startup
• Existing hazard controls may not be sufficient to ensure safe
operations
11/16/2011 21
Large Scale User Facilities – CF4 & 5
Tom Mullen and Ed Lessard
• Most hazard controls seem to be well established in the Divisions visited
• The Safety Committee system appears to be very robust
– Strong Safety Circles in both Divisions
– ALS Staff Safety Committee aims at continual improvement/excellence in safety
• ALS Management is strongly motivated to improve safety
• PUB-3000 does not ensure uniform LBNL practices
• ALS has a weekly Operators “critique” meeting
– These meetings are excellent conduits for feedback and improvement in the
Divisions
• ALS staffing cutbacks have resulted in safety vulnerabilities that need
correcting
• Workers are not consulted in creating safety management systems and
practices
11/16/2011 22
Large Scale User Facilities – GP3
Tom Mullen and Ed Lessard
• The JHQ process is formal, comprehensive and updated
annually by each supervisor
• Training excellence exists in some areas
• Training policies at NCEM are very strong
• Roles and responsibilities are not established for personnel
• LBNL lacks requirements for safety training by vendors
11/16/2011 23
Bench Scale R&D – CF1
Pat Wright and Larry McClellan
• Several Divisions have or are implementing a process to identify
hazards at the proposal stage of a project
– Earth Sciences Division (ESD) has a Proposal Stage Safety Questionnaire
– Materials Sciences Division is considering reinstituting a “defunct” process
to identify hazards pre-proposal
• At least one Division has a stated expectation that new work in a
workspace must be approved by the PI/Lab Manager
– ESD has a written/posted expectation that all work is discussed with the PI
that owns the space
• Implementation of the Partnership Agreement with UCB does not
currently support clear identification of the scope of work for
LBNL activities performed in UCB labs
11/16/2011 24
Bench Scale R&D – CF2 & 3
Pat Wright and Larry McClellan
• The Safety Coordinator program is highly successful
– Most Safety Coordinators have some organizational construct under them (e.g., Safety Committee, Safety
Wardens) that support safety communication and hazard identification
– Safety Coordinators appear to be well aware of work and provide a vital connection between lab workers and
institutional processes
• At least one Division has a process for analyzing all significant hazards of one
class of research work and documenting job-specific controls
– The ESD Offsite Safety and Environmental Protection Plan provides a best practice approach to addressing
the unique offsite work hazards
• While high hazard work (radiological, high power lasers, highly toxic gases) is
typically well analyzed and formally authorized, much potentially hazardous
work is left to “skill of the craft.”
– Other DOE Science Labs have much lower thresholds for documented analysis and authorization of
potentially hazardous work
• PNNL uses Hazard Awareness Summaries to identify workspace-specific hazards such as chemicals,
vacuum systems, and hotplates
• PNNL uses Chemical Process Permits to analyze chemical hazards, and document hazard controls
such as type of gloves and fume hoods.
• BNL uses Job Hazard Analysis for 57 different jobs in RHIC to document job-specific hazards such as
walking & working surfaces, use of hoists, and requirements for PPE
• ORNL uses a Research Safety Summary to identify, analyze, and control all R&D hazards including
standard laboratory chemicals, biological (BSL1) work, and non-ionizing radiation
11/16/2011 25
Bench Scale R&D – CF2 & 3 (continued)
Pat Wright and Larry McClellan
• The flow-down of ISM elements and philosophy to R&D
subcontractors is largely non-existent
– PI directs procurement organization to let contract, but vendor/contractor is
expected to establish appropriate controls (without an institutional process for
identifying hazards or minimum expectations for risk mitigation)
• Control of off-site drilling in a quartz mine was left to the drilling subcontractor to plan
and control with no input from LBNL
• Control of hazards for vendor work in a Potter lab was left to the expert judgment and
procedures of the vendor with informal overview by the research scientist and no
safety expert (e.g., electrical safety) overview by LBNL
• Workers do not appear to be involved in identification and mitigation
of management of hazards as part of the work planning process;
there is no mechanism for them to contribute to the final product
– SRC involvement in Pub 3000 is good, but process needs to be better
institutionalized
– Work group planning at PI level is typically good, but informal
– Worker involvement in formal work planning (e.g., AHD) is typically limited to
“Read & Sign” – misses valuable opportunity for worker input and buy-in
11/16/2011 26
Bench Scale R&D – CF4
Pat Wright and Larry McClellan
• Review of workspaces and interviews with staff indicated that work is
typically performed safely and within established controls
– Staff are concerned about safety and take what they perceive to be appropriate measures to
assure their own safety
– Injury & illness experience does not indicate a breakdown in safety performance
– Instances were observed where staff violated safety requirements (e.g., use of safety glasses)
• There is a significant difference between Divisions in the safety culture
and discipline of operations that is apparent in work performance
– Housekeeping in workspaces and maintenance/condition of equipment
– Degree of engagement and leadership - as exhibited by the Division Director and PIs in terms
of frequency and effectiveness of communication
– Assessment processes, including engagement of Division Directors, PIs, Safety Coordinators,
and staff in self-assessment
– Level of detail and effectiveness of organization/facility-specific training
– Formality of operations (e.g., documented processes and work controls)
• Safety is not expressed as a universal value
Safety is viewed as a priority (often contingent on circumstances)
11/16/2011 27
Bench Scale R&D – CF5
Pat Wright and Larry McClellan
• Lessons Learned are distributed based on JHQ identification of hazard
interactions
• Effective communication of Lessons Learned and deployment to staff
needs improvement
– Six of nine students who use super glue did not recall seeing the LL
– Students reported that they had been required to get rid of their super glue
(to which they responded by hiding their super glue)
– Lessons Learned are not consistently seen as communicating valuable information
• Assessment is excessively focused on unsafe conditions
Activities are not routinely assessed
– This is the next logical progression of the self-assessment process
• The Corrective Action management program has serious deficiencies
– There is no evidence that extent of condition reviews are performed
– Effectiveness reviews (on corrective actions) are typically not performed,
although the Physical Biosciences Division (PBD) verifies completion of corrective actions
– There is limited assurance that CATS actions are closed out in a timely manner
11/16/2011 28
Bench Scale R&D – GP3
Pat Wright and Larry McClellan
• EH&S Liaisons are highly qualified professionals who exhibit
necessary interpersonal skills, and are dedicated to both the
Laboratory’s success and their professional ethics
• Safety Coordinators get special training for their role
• The JHQ process is rigorously used across the Laboratory to drive
worker qualification
• Some organizations have a structured process provide safety
orientation to new staff (especially students)
– PBD provides an excellent, documented orientation to new staff
• The facility manager rigorously controls access to laboratory spaces, documents facility
specific training via checklist, and has a communication plan identified for when new
hazards are introduced into the workplace
11/16/2011 29
Bench Scale R&D – GP3
Pat Wright and Larry McClellan
• The practice of allowing workers who have not been trained to work
under escort by other (trained) workers is questionable
– Untrained workers are allowed to work “under the direct supervision” of another
qualified worker for up to six months
– Expectations for what constitutes “direct supervision” are not clear and there is
considerable diversity in the interpretation of this requirement
• Interviews indicated that students in some parts of the organization may work for
considerable periods of time (e.g., days) without being directly observed by a qualified
worker
– There is no assurance in some parts of the organization that workers not yet
trained possess the LBNL-specific knowledge and skills necessary to discharge
their responsibilities, as required by the LBNL ISM plan
11/16/2011 30
Worker Safety – CF1
Carol Scott, Doug Schlagel, and Steve Coleman
• The Radiological Work Authorization work planning process
requirement of a personal interview and proposed work location
review between the PI and Health Physicist is a noteworthy practice
• Workers do not appear to be effectively and consistently involved in
work planning, including development of project documentation
• “Significant change” is not clearly defined when modifications to work
authorizations and planning documents are required
• Activity thresholds driving increased rigor in work planning (PUB-
3000, Chapter 6, Appendix B) appear to permit a significant amount of
risk acceptance without formal management planning & involvement
• EHS division authorization of AHDs dilutes line management
ownership of responsibility for safety
• Decisions to conduct design reviews on construction projects are
based on fiscal thresholds, not EHS risk evaluation
11/16/2011 31
Worker Safety – CF 2 & 3
Carol Scott, Doug Schlagel, and Steve Coleman
• Safety Coordinators play an instrumental role in hazard identification
• Hazard identification is expert-based and relies on individual decisions
to consult EHS subject matter expertise and may allow incomplete
hazard identification when required expertise is not sought out
– Particularly true for Line Management Authorized work
• Workers do not appear to be effectively and consistently involved in
the hazard identification process
• Enhanced controls for usage of x-ray systems in Building 70A were
identified as a noteworthy practice
• Identification and application of hazard controls is not consistent with
the hazards identified (inconsistent PPE usage)
– Personal expertise often cited as hazard control
11/16/2011 32
Worker Safety – CF4
Carol Scott, Doug Schlagel, and Steve Coleman
• In general, there is a strong observed worker ethic to perform work safely
• There is some evidence that management may not be assuring
compliance with existing laboratory-level procedures
• A clear authorization to commence work does not exist for line
management authorized work (typical readiness activities not performed)
• Personnel appear to understand their responsibility and authority to stop
work in unsafe situations that are less than imminent
– PUB-3000, Chapter 1 defines this responsibility for situations considered to be an
imminent danger where it could reasonably be expected to cause death or serious
injury, or environmental harm; it does not reflect worker responsibilities to limit work
activities when the unsafe situation is not imminent
• There does not appear to be an institutional process to identify and
control out-of-service equipment
11/16/2011 33
Worker Safety – CF5
Carol Scott, Doug Schlagel, and Steve Coleman
• The Engineering Division is proactively communicating the concepts
of ISM to division personnel
• A significant number of safety inspections are performed
• There appear to be multiple safety walkthroughs in most divisions;
however, the worker is not directly involved in these inspections
• Some staff interviewed reported a few situations where incidents
were not reported; work-arounds to avoid perceived repercussions
• The EHS Division develops a set of expectations that are assessed
by each Division annually; it is not clear how assessment findings
and lessons learned are shared and utilized by other Divisions
• Division self-assessments are largely limited to safety inspections
and responses to EHS expectations (limited trending of results)
11/16/2011 34
Worker Safety – GP3
Carol Scott, Doug Schlagel, and Steve Coleman
• A broad cross-section of training is offered to qualify personnel
– Interviewees consistently referred to laboratory-level training as the initial
source of safety awareness, followed by job-specific training as a means for
ensuring workplace safety
– In several divisions, laboratory staff are assigned to mentors who provide on-
the-job training until individuals are deemed proficient
• Worker awareness of perceived low-risk hazards is expert-based and
not formally analyzed
– Interviewees consistently referred to their educational knowledge and
experience as a primary resource for ensuring workplace safety with respect to
perceived low-risk hazards (e.g., chemical safety)
• Division Safety Coordinators are not consistently assigned based on
prior safety management experience, potentially limiting the
awareness of EHS hazards
11/16/2011 35
Waste Management/Environmental Protection – CF1-3
Carol Scott, Doug Schlagel, and Steve Coleman
• Potential hazardous waste generating activities are commonly identified
early in the work planning process (involvement of Generator
Assistants and Waste Generators)
• Identification of environmental protection issues in work planning is
expert-based and dependant on consultation for complete analysis
– Effective identification of environmental protection issues is dependant on the
knowledge base of EHS Liaisons for formal authorizations and Division Safety
Coordinators for line management authorizations
– Inclusion of environmental expertise is not automatic
– It does not appear that workers commonly associate environmental protection with
the ISMS process
• Master inventory of Satellite Accumulation Areas (SAA) does not exist
– Procedures document a requirement to limit storage of hazardous wastes in SAAs
to 9 months, but without a complete inventory, compliance cannot be assured
11/16/2011 36
Waste Management/Environmental Protection – CF4 & 5, GP3
Carol Scott, Doug Schlagel, and Steve Coleman
• The hazardous waste management program appears to be an
effective and valued program at all levels
• The Environmental Management System (EMS) undergoes an
annual assessment conducted by the Contractor Assurance
Group
• Identification of waste minimization opportunities is included in
the Division feedback from their annual assessment of EHS
expectations
• Division Safety Coordinators and EHS Liaisons are not
consistently assigned based on prior environmental protection
experience, and all must be cognizant of necessity to consult
with subject matter expertise
11/16/2011 37
Recommendations
• Re-emphasize line accountability and responsibility for safety;
strengthen implementing processes to reflect these principles by
– Assuring that safety behaviors/expectations are clear, formal, and understood
(see next recommendation)
– Assuring that line management authority is unambiguous, universally
understood, and accepted by emphasizing that:
• Line managers provide assurance and approval
of all hazard analyses and work authorization documentation
• Safety leadership and safety performance expectations are explicitly
communicated to and understood by Line Managers including PIs
• Line managers actively involve workers in work planning
– Assuring that existing procedures are both fully understood
and are being consistently followed:
• For example, promoting consistent and complete compliance with controls (PPE)
identified in laboratory procedures and ensuring requirements are explicit
11/16/2011 38
Recommendations
• Restructure and refine institutional EHS/ISMS documents with
the following focus and objectives
– Clarify the hierarchy, functionality, and relationship between institutional
documents (e.g., RPM, PUB-3000, OAP/QAP, Assurance Plan, etc.)
– Provide an overarching set of Laboratory safety principles and
expectations for individual position descriptions
• Highest level set of essential safety behaviors and expectations for line
managers, subject matter experts, and staff in general
• Clarify expectations for Safety Liaisons
• Establish Laboratory-level T&Q standards for Safety Coordinators
– Establish an explicit process for translating new requirements into
implementing practices
• Codify role of Safety Review Committee in Laboratory procedure
• Ensure process for translating new requirements into lower level procedures
codified
• Ensure that process for identifying relevant industrial requirements is
systematic, formalized and understood
11/16/2011 39
Recommendations
• Increase the rigor of the performance management process by
– Enhancing Laboratory-level processes
• Assuring performance objectives are derived from overarching goals/objectives
• Assuring performance objectives are basis for monitoring organizational and
functional performance
• Providing means to monitor and verify the maturation of the systems
– Assuring that trending and analysis activities comprehensively examine performance
data and provide a basis for improvements
– Assuring that OIA systematically evaluates performance of the Laboratory’s
assurance processes (e.g., Quality Assurance Program)
• More thoroughly identifying, communicating, and taking advantage of the best
practices that are in use in some Divisions
– Enhancing functional and/or organizational processes, for example –
• Using a formal process to evaluate subcontractor performance
• Maintaining subcontractor performance records for use in future selections
• More consistently documenting and sharing worker feedback
11/16/2011 40
Recommendations
• Fully implement an integrated Corrective Action Management
System, with the following objectives
– Establishing clear responsibilities for action ownership through the entire
process
– Providing enhanced functionalities
• Guidance on preferred causal analysis tools and their application
• Guidance on triggers for and methods used to conduct extent of condition
reviews
• Guidance on the level of formality and methods used to verify action closure
• Guidance on triggers for and methods used to conduct effectiveness reviews
– Monitoring system effectiveness in achieving its objectives
11/16/2011 41
Recommendations
• Strengthen Laboratory self-assessment processes by
– Structuring the Division self-assessment process around Division-specific
EHS and operational performance objectives that are aligned with
institutional expectations
– Incorporating expectations (methods, scope, etc.) associated with MESH
reviews into Division self-assessments
– Incorporating a prioritization process for identifying and conducting Division
self-assessment activities based on mission objectives and evaluation of
risks to the organization
– Conducting institution-wide program evaluations (e.g., IFAs) on a risk-
prioritized basis, which are designed to assure that program improvements
are identified and the program is fully integrated with other systems
– Providing assurance that these processes/programs are conducted
effectively, are implemented properly, and result in identifiable improvements
to performance (e.g., OIA function)
11/16/2011 42
Recommendations
• Increase the rigor and consistency of the work planning
and control processes, with the following focus and
objectives
Research and Development
– Develop and deploy minimum standards and expectations for allowing
workers to interact with hazards before they have been fully qualified
(including whether unsupervised work with certain hazards will be
allowed, the level of supervision required, etc.)
– Re-examine the very high (as compared to other Laboratories) threshold
of hazard that triggers the use of more formal hazard analysis and
authorization
– Develop effective and efficient ways to identify, communicate, and
demonstrate control of lower risk/common hazards (e.g., routine use of
chemicals, sharps, etc.)
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Recommendations
• Increase the rigor and consistency of the work planning and
control processes, with the following focus and objectives –
Facilities and Operations
– Establish a process to ensure workers are skilled in hazard recognition
– Assure that hazard information is current through implementing the HEAR database
upgrades
– Tailor Maximo-generated JHA checklists for specific crafts to improve relevancy and
encourage use
– Post approved & current construction authorization and safety documents at jobsites
– Streamline the penetration (Dig) permit process
– Assure that the documented process for Operations & Maintenance maintainability
reviews of engineering drawings and specifications (prior to construction) is being
followed
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Recommendations
• Assure that the ISMS-related elements of LBNL-UCB
relationship are consistently articulated and clearly
understood, including
– Institutional accountability for safety management and
performance of LBNL funded work conducted in UCB-controlled
spaces
– Comprehensive identification of laboratory locations and
individuals performing LBNL funded work in UCB-controlled
spaces
– Processes by which LBNL is assured that the UCB laboratories
achieve “equivalent protection” for LBNL funded work conducted
in UCB-controlled spaces
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Assessment Team Path Forward
• Factual Accuracy Report
– Nominally 2 weeks
– Agreed upon outline
• Laboratory Review
– Prefer consolidated comments
• Final Report
– 1 week after receiving comments
• Questions/Comments/Adjourn
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