Executive Summary Template for Safety Management

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					                                                                                                        HP80.7




                                       2006 Gap Analysis
                                                      of the
          OCCUPATIONAL HEALTH AND SAFETY MANAGEMENT SYSTEM
                                                        for
             OHSAS 18001 PHASE 1, 2 & 3 ORGANIZATIONS




                                              Final Report
                                           September 28, 2006



                                    Analysis Performed by: R. Selvey, SHSD


                                              Report Approved by:
    Signature on file                                        Signature on file
______________________                 ________            ______________________                  ________
R. Selvey, Report Preparer              date                J. Tarpinian, BNL OSH Representative      date

                                                            Signature on file
                                                           ______________________                ________
                                                            P. Williams, ESH&Q OSH Representative    date



                             Under Contract with the United States Department of Energy
                                        Contract No. DE-AC02-98CH10886
Gap Analysis for OHSAS 18001 PHASE 1, 2 & 3 Organizations FY2006                        Page 2 of 8




EXECUTIVE SUMMARY
Overall, this gap analysis found the BNL Occupational Safety & Health (OSH) Program written
program currently satisfies the OHSAS 18001 requirements in the organizations registered in
Phase 1 and 2 and those undergoing the registration process in Phase 3. The Phase 1 & 2
organizations have just completed registration surveillance without major nonconformances.
Phase 3 organizations are progressing toward registration at a pace in advance of that achieved in
the Phase 1 and 2 organizations.

Lessons have been learned from the past Internal Audits and NSF registration audits and
surveillances that have allowed BNL to modify or improve OSH programs processes to
strengthen the OSH program and eliminate audit findings. The main reoccurring OSH processes
that need refinement are the formulation/wording of objectives and record/document control and
management. All nonconformances from the previous year’s Internal Audits and the NSF
Registration Audits have been closed.

Five BNL Directorates have achieved OHSAS registration of their full organizations (HENP,
BES, and NSLS) or registration of selected divisions within their organization (F&O and
ESH&Q). All Phase 1 and 2 registered organizations have complete documentation packages on
their web sites. Most Phase 3 organizations have either completed most of their needed elements
or have placeholders for needed developed documents in their programs that are under
development.

The main concern for the OHSAS 18001 program in the coming year is the need to migrate
interim site program level documents into a permanent SBMS document management format.


1.0 INTRODUCTION
A gap analysis of the Brookhaven National Laboratory Occupational Safety & Health (OSH)
Management System was performed on June 23, 2006. It supplements a gap analysis performed
in April 2004 in preparation for the Phase 1 registration effort.

The purpose of the 2006 gap analysis was to determine whether BNL organizations are on track
to maintaining or obtaining OSHAS 18001 registration management system. This report
contains a description of the scope, approach and findings of the analysis.

In addition, this gap analysis verified if gaps from the 2004 analysis had been effectively closed.


2.0 SCOPE
The scope of this gap analysis is to review and check the existence of site level and line
organization written OHSAS 18001 documentation and web sites. It did not include an in-depth
evaluation of the content of documents. The internal audit process is used to explore the content
of site and line organization documentation.
Gap Analysis for OHSAS 18001 PHASE 1, 2 & 3 Organizations FY2006                     Page 3 of 8




This analysis supplements the OHSAS 18001 internal Gap Analysis of 2004 which covered
program elements and line organization implementation of the site program. This analysis
examined the programs of all BNL organizations- Phase 1, 2, and 3. The following elements of
the specification were checked for their existence in each organization’s program:

 Risk Assessment and Controls
 OH&S Objectives
 OSH Management Programs
 Document and Data Control
 Performance Measurement and Monitoring
 Management Review


3.0 ANALYSIS APPROACH
The OSH Management System gap analysis was conducted per an Analysis Checklist in Section
5 by the OSHAS 18001 Phase 2 & 3 Project Manager. The analysis consisted of review of
written documentation and follow-up phone calls if necessary. No formal interviews or walk-
through inspections of operations and work areas was done.

The records of the analysis are maintained by SHSD in file code HP80.7.


4.0 DEFINITIONS
Findings of the Internal Audit are characterized on the follow scale:

Major Nonconformance: A lack of an element, procedure, or a non-fulfilled requirement that
puts the process/system at jeopardy, and could lead to significant impact on quality,
environment, ES&H, operations, or reliability.

Minor Nonconformance: An observed lapse in a program, process, procedure, or requirement,
usually single incidents that do not have a significant impact on the quality, environment, ES&H,
operations, or reliability.

Opportunity for Improvement (Recommendation): A suggested means of improving an activity
or fulfilling the intent of a requirement.

Noteworthy Practice: (A BNL used term that describes) performance that exceeds expectations
in terms of efficiency and/or effectiveness and provides a model for others to follow. A
noteworthy practice is a positive condition or strength.


5.0 FINDINGS
Gap Analysis for OHSAS 18001 PHASE 1, 2 & 3 Organizations FY2006                              Page 4 of 8




2006 Gap Analysis Findings
OHSAS 18001 Clause                       Status
                                         Policy is in-place at lab level and in all organization’s
                                         documentation.
                                         The recommendation to simplify the Policy’s content has
OSH Policy 4.2                           been made during the site level internal audit. A team within
                                         ESH&Q has drafted a revised Policy. It has been circulated
                                         to line organizations for comments. It is in the final stages of
                                         approval at the time of this gap analysis.
                                         JRA and FRAs are in-place in all Phase 1 & 2 organization’s
                                         documentation.
Planning for hazard
                                         JRA and FRAs are completed or under development in Phase
identification, risk assessment
                                         3 organizations. These need to the completed prior to the
and risk control 4.3.1
                                         Onsite Readiness Review for Phase 3 but all are on track to
                                         closure of this gap.
                                         Requirements management is addressed in a generic manner
                                         at the lab level. More detail on OSH requirement tracking is
                                         specified in SHSD SME level procedures:
                                         o Minor Non-Conformance: It is completed for Industrial
                                              Hygiene as documented in IH50700. Evidence of
                                              requirements tracking is maintained although personnel
Legal & Other Requirements
                                              shortage leads to longer intervals in checking
4.3.2
                                              requirements than the procedure states.
                                         o Major Non-Conformance: The process is draft for
                                              Safety Engineering in SE50700, with no evidence of
                                              tracking taking place.
                                         [Both these finding are being tracked also in ATS in the
                                         ESH&Q FY06 Internal Audit.]
                                         Objectives are in-place in all Phase 1 & 2 organization’s
                                         documentation.
                                         Objectives are completed or under development in Phase 3
                                         organizations.
                                         Opportunity for Improvements: All Phase 3 organizations
Objectives 4.3.3
                                         need to review their Objectives to make sure they reflect
                                         only improvement initiatives and not goals to maintain
                                         existing performance that is satisfactory. As in FY05, SHSD
                                         should review each organization’s objectives and make
                                         recommendations.
                                         [Future Major Non-conformance:] OHSAS 18001 details
                                         exists as Interim Procedures at the site level. Interim
                                         Procedures are due to expire in 12/31/06. Will need to be
OSH Management Programs                  converted into a permanent format.
4.3.4                                    A BNL Site level OHSAS 18001 Management System
                                         Description is finalized in SBMS.
                                         OSH Manuals are in-place in all Phase 1 & 2 organization’s
                                         documentation.
Gap Analysis for OHSAS 18001 PHASE 1, 2 & 3 Organizations FY2006                            Page 5 of 8




OHSAS 18001 Clause                       Status
                                         ESH&Q Directorate’s OSH Manual is completed and
                                         undergoing final review and approval.
                                         Phase 3 Support Organization’s Reporting to the Director’s
                                         Office (SORD) OSH Manual is completed or under\going
                                         approval by managers.
                                         OSH Manuals are completed in all other non-SORD Phase 3
                                         organizations.
                                         Site level SBMS document has appropriate wording for
Resources, roles,
                                         template R2A2.
responsibilities and authority
                                         [Completeness of R2A2s in organization is checked in
4.4.1
                                         internal audits and registration audits.]
Competence, Training, &                  A site level web based class on OHSAS 18001 elements is in
Awareness 4.4.2                          place. It is incorporated into staff Job Training Assessments.
Consultation & Communication
                                         BNL tracks site level OSH communications via CEGPA.
4.4.3
Documentation 4.4.4                      [Not reviewed. This will be covered in Internal Audits.]
                                         A matrix is in-place in all Phase 1 & 2 organization’s
                                         documentation.
Document & Data Control                  A matrix is completed or under development in Phase 3
4.4.5                                    organizations.
                                         [Field review of the accuracy and compliance to the matrices
                                         was not done. This will be covered in Internal Audits.]
                                         Operational Control is addressed in JRA/FRA records. In-
Operational Control 4.4.6                place in all Phase 1 & 2 organization’s documentation.
                                         Completed or under development in Phase 3 organizations.
                                         [Not reviewed at the department/division level to determine
                                         implementation. This will be covered in Internal Audits.]
Emergency Preparedness &
                                         Three OHSAS 18001 published Desk Top scenarios have
Response 4.4.7
                                         been distributed for line organizations to use as a tool in
                                         emergency preparedness.
Performance Monitoring &                 [Not reviewed. This will be covered in Management
Measurement 4.5.1                        Reviews.]
Accidents, incidents,
                                         [Not reviewed. This will be covered in Management
nonconformances, corrective
                                         Reviews.]
and preventive Action 4.5.2
                                         A matrix is in-place in all Phase 1 & 2 organization’s
                                         documentation.
Records and records                      A matrix is completed or under development in Phase 3
management 4.5.3                         organizations.
                                         [Field review of the accuracy and compliance to the matrices
                                         was not done. It is covered in Internal Audits]
                                         Phase 1 & 2 organization internal audits were performed in
Internal Audit 4.5.4                     Feb/March 2006 on schedule.
                                         Phase 3 organization’s internal audit is scheduled for
Gap Analysis for OHSAS 18001 PHASE 1, 2 & 3 Organizations FY2006                          Page 6 of 8




OHSAS 18001 Clause                       Status
                                         July/Aug/.September 2006.
                                         An Internal Audit of Phase 3 Management Reviews and
                                         Internal Audits will be completed in October 2006.
                                         A site level Management review was performed in
                                         December 2005. Next is due in Dec 2006.
                                         Phase 1 & 2 organization Management Reviews were
Management Review 4.6                    performed in September /October 2005. Next is due on
                                         September 2006.
                                         Phase 3 organizations’ first management reviews will be
                                         completed in September 2006.



Review of the 2004 Gap Analysis for Closure
2004 Gap                       2006 Status
No OHSAS 18001 Program         There is no program description linked from the SBMS tool
Description exists             bar. A Management System Description (June 2004) is
                               written and available by searching the SBMS files. It is not
                               linked from the MS tool bar in SBMS. The content of the
                               Management System description along with the OHSAS
                               18001 Interim Procedures fully documents the site level
                               program.
No Management System-          The OSH Management System is completed. It is not
combine Facility Safety,       merged with the other management systems. Preliminary
WH&S, and WP&C                 meetings have been held to determine the feasibility of
                               combining the OSH management system with other similar
                               systems. However, new regulations may require separate
                               management systems. The combining of Management
                               System will be done only if the System Owners and line
                               organizations determine there is value to the overall
                               programs.
No Subject Area for risk       Interim Procedures in SBMS Facility Risk Assessments
assessments                    2004-18001-01 and Job Risk Assessments 2004-18001-02
                               are posted on the SBMS web site.
Worker participation in OH&S   The SBMS Interim OHSAS 18001 Procedures address
must be addressed in a Subject worker participation.
Area
Requirement Management         A review of the SBMS level document indicates no changes
Subject Area does not address  were made. No record of a change in the subject area to
the frequency of review and    correct the finding of the 2004 OHSAS 18001 gap analysis is
updates for legal and other    indicated in the Revision History. The site level document
requirements.                  provides generic, instead of topic specific guidance. SHSD
                               developed internal procedures IH50700 and SE 50700 (draft)
                               that state a period (at least quarterly) for searching sources of
                               required drivers.
Gap Analysis for OHSAS 18001 PHASE 1, 2 & 3 Organizations FY2006                          Page 7 of 8




2004 OHSAS 18001 Gap                     There is no evidence that any of this 2004 Attachment 1’s
Analysis Report, Attachment 1:           finding were addressed in SBMS. A few were checked and
18001 and SBMS                           the changes were not found. The Revision History of several
                                         subject areas were checked and no record of addressing these
                                         changes were noted. [Note: These were not tracked to be
                                         changed until the full site is OHSAS 18001 Registered. As
                                         of Dec 2006, these changes will be needed.]


Following the Corrective and Preventive Action Subject Area, these 2006 Gap Analysis findings
need to be analyzed and a determination made as to what corrective and preventive actions are to
be taken. Also, the effectiveness of the actions needs to be evaluated. The Nonconformances will
be entered into the BNL institutional level Assessment Tracking System (ATS) for formal
tracking to closure.

The following finding of this gap analysis will be tracked in ATS:

1.0 Legal & Other Requirements 4.3.2 [These actions [1.1 and 1.2] were also identified in
     the SHSD 2006 OSH Internal Audit and will be tracked in that FATS assessment
     Corrective Action Plan].
        1.1 Minor Non-Conformance: SHSD Industrial Hygiene Group needs to follow the
            time intervals in checking requirements documented in IH50700. Document
            reviews on a quarterly basis or change the policy to a longer interval that still allows
            requirements to be adequately tracked.
               1.1.1 Perform an OSH requirement review of IH drivers in 1st quarter in FY07.
               1.1.2 Perform an OSH requirement review of IH drivers in 2nd quarter in FY07.
               1.1.3 Perform an OSH requirement review of IH drivers in 3rd quarter in FY07.
               1.1.4 Perform an OSH requirement review of IH drivers in 4th quarter in FY07.
               [Note: This is also being tracked in the ESH&Q Directorate FY06 OSH Internal
               Audit.]

        1.2 Major Non-Conformance: SHSD Safety Engineering needs to
              1.2.1 Finalize SE50700 to document process and interval for driver reviews.
              1.2.2 Perform an OSH requirement review of SE drivers in 1st quarter in FY07.
              1.2.3 Perform an OSH requirement review of SE drivers in 2nd quarter in FY07.
              1.2.4 Perform an OSH requirement review of SE drivers in 3rd quarter in FY07.
              1.2.5 Perform an OSH requirement review of SE drivers in 4th quarter in FY07.
              [Note: This is also being tracked in the ESH&Q Directorate FY06 OSH Internal
              Audit.]

2.0 OSH Management Programs 4.3.4 Future Major Non-Conformance: Convert the
     SBMS OHSAS 18001 Interim Procedures into permanent program (Subject Areas, Program
     Description, or other documentation form) by December 31, 2006 or extend the Interim
     Procedures while the conversion process is occurring. [Note: the conversion process should
     not occur until after the Phase 3 organizations are registered in December 2006. Because
     the window of time between Phase 3 registration and Interim Procedures expiration will be
Gap Analysis for OHSAS 18001 PHASE 1, 2 & 3 Organizations FY2006                         Page 8 of 8




     short (2 weeks), an extension of the Interim Procedures is a probable, justified path.]

3.0 Site OSH Management Representative schedules a process to address the 2004 OHSAS
     18001 Gap Analysis Report, Attachment 1 closure actions once Phase 3 organizations are
     registered in December. [These changes to SBMS should not occur until after the Phase 3
     organizations are registered.]




6.0 ATTACHMENTS none


7.0 REFERENCES
        7.1 BNL 2004 OHSAS 18001 Gap Analysis Report and Attachments.
        7.2 BNL Standards Based Management System

				
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