**ISM/Safety Improvement Project WBS 7.3.4**

**Employee Concerns Program Evaluation and Lessons Learned from DOE
Office of ES&H Evaluation Reports**

Stasia Scocca, QMO Requirements Management Coordinator

Steven Coleman, ISM Project Manager

**Brookhaven National Laboratory Employee Concerns Program**

**1.0 Background**

In the first quarter of fiscal year 2007, the Quality Management Office
Requirements Management Coordinator and Integrated Safety Management
(ISM) Project Manager reviewed the Argonne National Laboratory (ANL),
Savannah River Laboratory (SRL), and Stanford Linear Accelerator (SLAC)
Complex Department of Energy (DOE) Environment, Safety and Health (ES&H)
Evaluation Reports to identify lessons learned as well as opportunities
for improvement for the BNL Employees Concerns Program (ECP). The
lessons learned review identified a number of areas for potential
improvement or enhancement to the overall ECP. The Requirements
Coordinator and ISM Project Manager determined that an evaluation should
be performed to determine if the ECP implementation is operating as
intended and required.

**2.0 Scope**

Key scope areas identified originated from the review of DOE ES&H report
findings, and subsequent development of lines of inquiry that would be
used to ascertain the effectiveness of the ECP.

> **2.1 ECP findings at ANL, SRL and SLAC are as follows:**
>
> 2.1.1 Employee concerns processes are not well defined or established
> in controlled documents, and the documentation of the details of the
> concerns, analysis/investigation, and disposition does not show
> consistent and sufficient formality and rigor.

2.  Human Resources are not adequately defined in that technical aspects
    are referred to and managed by other organizations, no overall
    control and oversight by HR, and associated documentation is
    fragmented.

3.  The ES&H Division hotline records and service/Support Desk logs do
    not always fully describe the concerns or adequately reflect final
    resolutions.

4.  Although most aspects of the ECP are adequately implemented, formal
    annual management assessments of the ECP have not been conducted for
    several years. *(DOE O 442.1A requires management assessments of the
    ECP program)*

5.  There is no advertisement of the ECP in visitor or new employee
    orientation or refresher training.

6.  The ECP is not governed by a current instruction/procedure that
    defines requirements (e.g. confidentiality measures, investigation
    and reporting timeframes, disposition reviews, and feedback to the
    concerned individual), and ANL has not performed surveys of the
    users or conducted assessments of the implementation of the program.

7.  Stanford Site Office (SSO) has not placed sufficient management
    attention and priority on ensuring that the implementing ECP
    procedure requirements are effectively implemented. *(DOE O 442.1A
    requires contractors to assist DOE in the implementation of the
    ECP)*

8.  SSO has not ensured appropriate posting of ECP and hotline
    information to ensure that site employees are aware of DOE ECP and
    their rights and responsibilities to report concerns through this
    process.

> **2.2 Lines of Inquiry (LOIs)**

1.  How are the ECP and ES&H Concerns Program integrated?

2.  How do we ensure that contractor and subcontractor employees are
    advised that they have the right and responsibility to report
    concerns relating to ES&H, or management of DOE-related activities?

3.  When was the last time the ECP was assessed? Do you perform self
    assessments of the ECP?

4.  The Record of Decision indicates that there is an Internal Employee
    Concerns Program Procedure; is that procedure still in use? When was
    the last time it was revised?

5.  Who do you report ECP status to? The online description states that
    the ECP reports to the Deputy Director for Operations (DDO)? Does he
    receive a formal report? How is this report provided?

6.  How is the DDO informed of the ECP status? What is your role with
    the ECP?

**3.0 Employee Concerns Program Strengths and Weaknesses**

> **3.1 Strengths**

1.  Elements of the ECP are being flowed down to subcontractors and
    guests through the Contractor Vendor Orientation (CVO) classroom
    training, and Guest Site Orientation web-based training.

2.  10 CFR 708, *Whistleblower Protection for Contractor Employees
    Rule,* requirements are flowed down to contractors and
    subcontractors through Procurement and Property Management (PPM)
    Terms and Conditions.

> **3.2 Weaknesses**

1.  The structure of the ECP reporting, and ownership of the program is
    not clear. The external requirement document Record of Decision
    specifies that the Human Resources Management System is responsible
    for the requirement. The Employee Concerns Program is administered
    through Human Resources but is owned by the Deputy Director for
    Operations.

2.  No apparent integration of the ES&H Concerns Program and
    institutional ECP.

3.  BNL cannot demonstrate how 10 CFR 708, *Whistleblower Protection for
    Contractor Employees Rule,* is satisfied or complied with. There is
    no Record of Decision. The rule is invoked by BSA Prime Contract
    Clause I.61.

4.  There are no apparent mechanisms to ensure Institutional Stewardship
    of ECP processes. There have been no assessments of the ECP. The ECP
    is administered through an internal standard operating procedure
    managed by the Human Resource Employee Concerns Manager.

5.  Five (5) concerns have not been addressed and are a year overdue
    (4/30/2006).

6.  It is unclear of the differences between the Employee Relations,
    Employee Concerns, and ES&H Concerns Programs.

**4.0 Employee Concerns Program Requirements**

+---------+--------+---------+-----------+----------------------------+
| **Requ  | **In   | **C     | **Record  | **Record of Decision       |
| irement | cluded | aptured | of        | Implementation             |
| Doc     | in BSA | in      | D         | Information**              |
| ument** | Prime  | Requi   | ecision** |                            |
|         | Co     | rements |           |                            |
|         | ntract | Man     |           |                            |
|         | (      | agement |           |                            |
|         | Y/N)** | System  |           |                            |
|         |        | (Y/N)** |           |                            |
+---------+--------+---------+-----------+----------------------------+
| **Order | Yes    | Yes     | ROD       | Internal Employee Concerns |
| 4       |        |         | completed | Program Procedure;         |
| 42.1A - |        |         | by HR MS  | Employee Guide; Employee   |
| DOE     |        |         |           | Concerns Poster            |
| E       |        |         |           |                            |
| mployee |        |         |           |                            |
| C       |        |         |           |                            |
| oncerns |        |         |           |                            |
| Pr      |        |         |           |                            |
| ogram** |        |         |           |                            |
+---------+--------+---------+-----------+----------------------------+
| **Order | Yes    | Yes     | RODs      | [HR]{.underline} -         |
| 226.1 - |        |         | completed | Supervisors Personnel      |
| Impleme |        |         | by HR,    | Manual: 20.0 Employee      |
| ntation |        |         | CEGPA,    | Relations; Employee        |
| of      |        |         | and WSH   | Concerns Program           |
| Dep     |        |         | MSs for   | Description; Appointment   |
| artment |        |         | A         | of Employee Concerns       |
| of      |        |         | ttachment | Program Manager; Employee  |
| Energy  |        |         | 2,        | Concerns Program Posters;  |
| Ov      |        |         | Appendix  | Annual publication of      |
| ersight |        |         | A,        | information on the         |
| P       |        |         | Section 4 | Employee Concerns Program  |
| olicy** |        |         | -- Worker | in the Brookhaven Bulletin |
|         |        |         | Feedback  |                            |
|         |        |         |           | [CEGPA]{.underline} -      |
|         |        |         |           | Two-way communication      |
|         |        |         |           | mechanisms for staff to    |
|         |        |         |           | express their input on any |
|         |        |         |           | matter of concern (Monday  |
|         |        |         |           | Memo Queries and Comments  |
|         |        |         |           | & Public Affairs email -   |
|         |        |         |           | pubaf).                    |
|         |        |         |           |                            |
|         |        |         |           | [WSH]{.underline} -        |
|         |        |         |           | Investigation of           |
|         |        |         |           | Incidents, Accidents, and  |
|         |        |         |           | Injuries Subject Area      |
+---------+--------+---------+-----------+----------------------------+
| *       | No     | No      | No        |                            |
| *Manual |        |         |           |                            |
| 44      | (will  | (not    | (not      |                            |
| 2.1-1 - | be     | until   | until     |                            |
| Di      | added) | added   | added to  |                            |
| ffering |        | to      | contract) |                            |
| Profe   |        | co      |           |                            |
| ssional |        | ntract) |           |                            |
| O       |        |         |           |                            |
| pinions |        |         |           |                            |
| Manual  |        |         |           |                            |
| for     |        |         |           |                            |
| Te      |        |         |           |                            |
| chnical |        |         |           |                            |
| Issues  |        |         |           |                            |
| In      |        |         |           |                            |
| volving |        |         |           |                            |
| ES&H**  |        |         |           |                            |
+---------+--------+---------+-----------+----------------------------+

**Related Requirements**

+---------+------+---------+------------+----------------------------+
| **Requ  | **   | **C     | **Record   | **Record of Decision       |
| irement | Incl | aptured | of         | Implementation             |
| Doc     | uded | in      | Decision** | Information**              |
| ument** | in   | Requi   |            |                            |
|         | BSA  | rements |            |                            |
|         | P    | Man     |            |                            |
|         | rime | agement |            |                            |
|         | Cont | System  |            |                            |
|         | ract | (Y/N)** |            |                            |
|         | (Y/  |         |            |                            |
|         | N)** |         |            |                            |
+---------+------+---------+------------+----------------------------+
| **C     | Yes  | Yes     | RODs       | [HR]{.underline} -         |
| ontract |      |         | completed  | Employee Concerns Program  |
| Clause  |      |         | by HR,     | Description; Appointment   |
| I.61 -  |      |         | Ac         | of Employee Concerns       |
| Whistl  |      |         | quisition, | Program Manager; Employee  |
| eblower |      |         | and Legal  | Concerns Program Posters;  |
| Pro     |      |         | MSs        | Annual publication of      |
| tection |      |         |            | information on the         |
| for     |      |         |            | Employee Concerns Program  |
| Con     |      |         |            | in the Brookhaven Bulletin |
| tractor |      |         |            |                            |
| Empl    |      |         |            |                            |
| oyees** |      |         |            | [                          |
|         |      |         |            | Acquisition]{.underline} - |
|         |      |         |            | Standard Terms and         |
|         |      |         |            | Conditions in Purchase     |
|         |      |         |            | Orders/Subcontracts        |
|         |      |         |            |                            |
|         |      |         |            | [Legal]{.underline} -      |
+---------+------+---------+------------+----------------------------+
| **10    | Inv  | No      | No ROD     |                            |
| CFR 708 | oked |         |            |                            |
| -- DOE  | by   |         |            |                            |
| Con     | Cont |         |            |                            |
| tractor | ract |         |            |                            |
| E       | Cl   |         |            |                            |
| mployee | ause |         |            |                            |
| Pro     | I.61 |         |            |                            |
| tection |      |         |            |                            |
| Pr      |      |         |            |                            |
| ogram** |      |         |            |                            |
+---------+------+---------+------------+----------------------------+

**5.0 Employee Concerns Program Recommendations**

> 5.1 The structure of the ECP should be reviewed for adequacy and
> efficacy.

a.  Consider benchmarking the reporting framework and program of other
    laboratories.

b.  Consider centralization of the ECP, including records and
    documentation for both ES&H and ECP reports.

```{=html}
<!-- -->
```
2.  Link the ES&H Concerns process to the Laboratory ECP.

```{=html}
<!-- -->
```
a.  Add the ES&H Hotline ext. 8800 to the ECP Poster.

b.  Add the ECP and DOE contact information to the ES&H Concerns
    website. ***(Completed 4/5/07)***

    2.  Determine how the differing professional opinions process will
        be integrated with the ECP and who will be responsible.

    3.  Consider defining the various employee concerns functional
        processes in a program description.

    4.  Add link to the ES&H Concerns website to the 'Employee Support
        at Brookhaven' website. ***(Completed 4/18/07)***

    5.  Add 10 CFR 708 to the requirements of the Human Resources
        Management System and complete a Record of Decision. Prime
        Contract Clause I.61 - *Whistleblower Protection for Contractor
        Employees*, requires BNL to comply with the requirements of "DOE
        Contractor Employee Protection Program" at 10 CFR part 708.

    6.  Resolve and close the 5 open ECP cases that have been open for
        over a year.

    7.  Revise the Worker Safety & Health Record of Decision for DOE
        Order 226.1 to include the ES&H Hotline and Concern Form.

    8.  Revise the Human Resources Record of Decision for DOE Order
        442.1A to include 'Appointment of Employee Concerns Program
        Manager' and 'annual publication of information on the Employee
        Concerns Program in the Brookhaven Bulletin' (to match the Order
        226.1 Record of Decision).

**6.0 Benchmarks**

> 6.1 Oak Ridge National Laboratory:
>
> 6.1.1 The Concerns Program reports to the Director of the Audit &
> Oversight Directorate.

i.  Staff concerns come to the Concerns Program Office; concerns are
    then transferred or delegated to the appropriate functional area or
    handled by the Concerns Office (depending on the type of concern).

ii. If a concern is transferred to a functional area (i.e. Diversity,
    Security, Human Resources, Safety/Health), a response will be sent
    to the Concerns Office so the issue may be closed.

iii. There is a 30 day timeframe for concern resolution.

iv. The Concerns Program Office consists of half a FTE.

v.  The Audit & Oversight Director is considering making the Concerns
    Office role a rotating position (rotating every 1 to 2 years).

vi. The Concerns Program and Safety/Health Concerns is somewhat
    integrated.

```{=html}
<!-- -->
```
a.  If the Concerns Office receives a Safety/Health concern, they
    transfer the concern to that office.

b.  However, if an employee goes directly to the Safety/Health Office,
    the Concerns Office may not know, and will not receive information
    or a report on the issue.

    2.  ORNL has a Concerns Program Subject Area, under their Integrated
        Performance Management System.

    3.  There is an appeals process for concerns, which goes directly to
        the Director of Audit & Oversight (does not appear to be
        captured in the subject area).

> 6.2 Pacific Northwest National Laboratory:
>
> 6.2.1 The Concerns Program has been associated with the Internal Audit
> and Oversight organization. The PNNL staff concerns manager
> communicated that Battelle Corporate, Idaho and Oak Ridge National
> Laboratories programs are under the auspices of internal audit and
> oversight programs.
>
> 6.2.2 The Staff Concerns Manager is dedicated full-time to the PNNL
> Staff Concerns Program. The staff concerns manager receives all
> employee concerns and is responsible for forwarding to the appropriate
> subject matter expert (e.g., diversity office, ES&H division, etc.).
> Human Resources Department is closely involved with all elements of
> the investigation and resolution of a staff concern.
>
> 6.2.3 PNNL has a Staff Concerns Subject Area that details the process
> for raising and addressing staff concerns. Although the concerns
> process is clearly articulated in the subject area, the staff concerns
> manager advises staff to first try to resolve the issue with his or
> her supervisor or management chain of command before elevating to the
> staff concerns manager.

**7.0 Interviewees**

Michael Bebon, Deputy Director for Operations

Monica Chavez, Staff Concerns Manager, Pacific Northwest National
Laboratory

Susan Foster, Employee Concerns Program Manager

Jim Tarpinian, Environment, Safety, Health & Quality Assistant
Laboratory Director

Patricia Williams, Safety and Health Services Division Manager

Steven Bonnett, Audit and Management Advisory Services, Oak Ridge
National Laboratory

Patrick Wright, Integrated ES&H Program Manager, Pacific Northwest
National Laboratory

**8.0 References**

10 CFR 708 -- DOE Contractor Employee Protection Program

Brookhaven National Laboratory Employee Concerns Program Poster

Contract Clause I.61 - Whistleblower Protection for Contractor Employees

Contractor / Vendor Safety and Health Orientation. Course HP-Q-006.

DOE Independent Oversight Inspection of Argonne National Laboratory
Environment, Safety, and Health Programs Report. May 2005.

DOE Independent Oversight Inspection of Savanna River Site Environment,
Safety, and Health and Emergency Management Programs Report. May 2004

DOE Independent Oversight Inspection of Stanford Linear Accelerator
Complex Environment, Safety, and Health Programs Report. January 2007.

DOE Guide 442.1-1, Department of Energy Employee Concerns Guide

DOE Order 226.1, Implementation of Department of Energy Oversight Policy

DOE Order 442.1A Department of Energy Employee Concerns Program

Employee Concerns Program Reporting Form

Employee Concerns Program Manager Internal Employee Concerns Program
Operating Procedure. Dated June3, 2005.

Employee ESH Hotline Reporting Form: Concern No: 2007-02. Dated January
29, 2007.

Employee Support at Brookhaven Web Page. Retrieved April 1, 2007 from
<http://intranet.bnl.gov/employeesupport>.

External Requirement Document Record of Decision for DOE O 442.1A

Guest Site Orientation Training Handout. Retrieved April 1, 2007 from
<http://training.bnl.gov/course/tqgso/section01/printout.htm>.

Oak Ridge National Laboratory (ORNL) Concerns Program Subject Area.
Retrieved April 10, 2007 from
<http://train.ornl.gov/sbms/SBMSearch/subjarea/cp/cp_sa.cfm>

Pacific Northwest National Laboratory (PNNL) Staff Concerns Subject
Area. Retrieved April 10, 2007 from
<https://sbms.pnl.gov/standard/0x/0x01d0a0.htm>.