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**INTERNAL** **AUDIT REPORT**

> **Of The**
>
> **Instrumentation Division**

**OCCUPATIONAL HEALTH and SAFETY MANAGEMENT SYSTEM** **(OHSAS)**

**Performed by:**

[Signature On File]{.underline}

**M. Davis, Lead Auditor**

[Signature On File]{.underline}

**M. Allocco, Auditor**

> [Signature On File]{.underline}
>
> **P. Bender, Auditor**
>
> [Signature On File]{.underline}

## **A. Bou, Auditor**

## 

## 

## 

## **Date Submitted: August 31, 2005** 

> **Audit Dates: July 26 - 28, 2005**

**1.0 ASSESSMENT PURPOSE**

> This internal assessment was conducted to determine whether the
> Instrumentation Division (IO) Occupational Health and Safety
> Management System (OH&S) Programs are documented and implemented in
> accordance with the Occupational, Health and Safety Management System
> OHSAS 18001 -- 1999 Standard.

**2.0 ASSESSMENT SCOPE & STRATEGY**

This assessment was structured to address all elements of OHSAS 18001 --
1999. Audit strategy consisted of personnel interviews at all levels of
the organization, document reviews, and facility inspections. The
following is a list of the elements of the standard:

1.  a\. OH&S Policy

    b\. Planning for Hazard identification, Risk Assessment and Controls

    c\. Legal and Other Requirements

    d\. OH&S Objectives

    e\. OH&S Management Programs

    f\. Structure and Responsibility

    g\. Training Awareness and Competence

    h\. Consultation and Communication

    i\. Documentation

    j\. Document and Data Control

    k\. Operational Control

    l\. Emergency Preparedness and Response

    m\. Performance Measurement and Monitoring

    n\. Accidents, Incidents, Nonconformances, Corrective and Preventive
    Action

    o\. Records and Records Management

    p\. Audit

> q\. Management Review

The assessment was conducted by:

-   Performing the assessment per SBMS Interim Procedure Number:
    [2004-18001-005](http://www.rhichome.bnl.gov/AGS/Accel/SND/18001 Web/18001 Audit Checklist.doc)
    Revision: 10 on 2-28-05.

-   Developing an assessment plan \[including qualifications of
    assessors\] (See **Attachment A**)

-   Conducting an Opening Meeting

-   Conducting the assessment per the plan:

    -   Following the checklist (See **Attachment E**)

    -   Conducting interviews with personnel (See **Attachment B**)

        -   Reviewing documents and records

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-   Conducting a Closing Meeting (See **Attachments C & D**)

3.  **SUMMARY**

This assessment revealed that the Instrumentation Division has programs
in place to achieve compliance to the elements of the OHSAS 18001
standard. Personnel responsible for implementing the OHSAS program have
developed a solid framework and have integrated OHSAS elements with
existing programs and processes. While major deficiencies were
identified in the following areas: "Planning for Hazard identification,
Risk Assessment and Controls", "Training Awareness and Competence", and
"Document and Data Control", and minor nonconformances in other
elements, achieving full compliance to the standard is considered
achievable, provided some additional resources are provided.

Interviews were conducted at all levels of the division, including
technical, management and administrative staff. Audit observations
identified that division staff and supervisors appeared to be very
safety conscious, and had a clear understanding of management's
expectation to take responsibility for working safely.

This assessment resulted in two Noteworthy Practices, three Major
Nonconformances, four Minor Nonconformances, two Observations and one
Opportunity For Improvement, detailed in the following section. It is
noted that the Instrumentation Division was actively taking measures to
address these findings as the audit was progressing.

**4.0 NOTEWORTHY PRACTICES, NONCONFORMANCES, OBSERVATIONS AND
OPPORTUNITY FOR IMPROVEMENT**

####### Definitions

-   **Noteworthy Practice**: 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.

-   **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.

-   **Observation:** Not a nonconformance, but something that could lead
    to a nonconformance, if allowed to continue uncorrected; or an
    existing condition without adequate supporting evidence to verify
    that it constitutes a nonconformance

-   **Opportunity for Improvement** A suggested means of improving an
    activity or fulfilling the intent of a requirement.

**4.1 Noteworthy Practices**

1\. The Activity Safety Review (ASR) program (forms, implementation,
signatures, etc.) appears to be very effectively implemented as
evidenced by the detailed documentation.

2\. The ASR table linking all associated programs and documents is an
effective tool, and may be considered a model for other organizations.

**4.2 Major Nonconformances**

[Major Nonconformance 1]{.underline}:

Requirement: OHSAS 18001, element 4.3.1, "Planning for Hazard
identification, Risk Assessment and Controls", states:\
"The organization shall establish and maintain procedures for the
ongoing identification of hazards, the assessment of risks, and the
implementation of necessary control measures. These shall include:

a)  routine and non-routine activities;

b)  activities of all personnel having access to the workplace
    (including subcontractors and visitors);

c)  facilities at the workplace, whether provided by the organization or
    others."

Status: At the time of the assessment, development of all identified
JRAs/ARAs and FRAs was not complete.

[Major Nonconformance 2]{.underline}:

Requirement: OHSAS 18001, element 4.4.2, "Training, Awareness and
Competence", states:

"The organization shall establish and maintain procedures to ensure that
its employees working at each relevant function and level are aware of:

a)  the importance of conformance to the OH&S policy and procedures, and
    to the requirements of the OH&S management system;

b)  the OH&S consequences, actual or potential, of their work activities
    and the OH&S benefits of improved personal performance;

c)  their roles and responsibilities in achieving conformance to the
    OH&S policy and procedures and to the requirements of the OH&S
    management system, including emergency preparedness and response
    requirements (see 4.4.7);

d)  the potential consequences of departure from specified operating
    procedures."

Status: At the time of the assessment, only about half of the division
staff members had taken a recently developed OHSAS awareness training,
titled "[Reducing Injuries and Accidents in the
Workplace](http://training.bnl.gov/course/id43_m.htm) (TQ-SAFEAWARE)".

[Major Nonconformance 3]{.underline}:

Requirement: OHSAS 18001, element 4.4.5, "Document and Data Control",
states:\
"The organization shall establish and maintain procedures for
controlling all documents and data required by this OHSAS specification
to ensure that:

b\) they are periodically reviewed, revised as necessary and approved
for adequacy by authorized personnel;"

Status: Several document control deficiencies were identified, and a
procedure describing document control does not exist.

**4.3 Minor Nonconformances**

[Minor Nonconformance 1]{.underline}:

Requirement: OHSAS 18001, element 4.4.1, "Structure and Responsibility,
states:

"Management shall provide resources essential to the implementation,
control and improvement of the OH&S management system".

Status: The was minimal evidence of management support in
developing/maintaining OHS programs (Examples include missing approval
signatures on documents, lack of status meetings, personnel resources)

[Minor Nonconformance 2]{.underline}:

Requirement: OHSAS 18001, element 4.4.3 "Consultation and Communication"
states:

"Employees shall be: - represented on health and safety matters".

Status: The Instrumentation Division Safety Committee does not include
worker level representatives.

[Minor Nonconformance 3]{.underline}:

Requirement: OHSAS 18001, element 4.4.7 "Emergency Preparedness &
Response" states:

\- The organization shall also periodically test such procedures where
practicable.

Status: Testing of emergency preparedness/response is not routinely
performed.

[Minor Nonconformance 4]{.underline}:

Requirement: OHSAS 18001, element 4.5.4 "Audit" states:

"OH&S management system audits are to be carried out,...."

Status: A Self-Assessment Plan for FY2005 has been drafted, but not
finalized, approved, and issued.

**4.4 Observations**

[Observation 1]{.underline}:

Requirement: OHSAS 18001, element 4.3.3 "Objectives" states:

"The organization shall establish and maintain documented occupational
health and safety objectives, at each relevant function and level within
the organization".

Status: There is no evidence that the status of achieving objectives is
periodically reviewed, including informing staff at each level.

[Observation 2]{.underline}:

Requirement: OHSAS 18001, element 4.4.1, "Structure and Responsibility"
states:

"The roles, responsibilities and authorities of personnel who manage,
perform and verify activities having an effect on the OH&S risks of the
organization's activities, facilities and processes, shall be defined,
documented and communicated in order to facilitate OH&S management".

Status: Revision of all staff R2A2s to include standard OHSAS language
has not been completed.

**4.5 Opportunity/Recommendation for Improvement**

1.  OHSAS 18001, element 4.5.1, "Performance Measurement & Monitoring".

Instrumentation Division SOP IO-OSH-001 states "... equipment used for
OSH are calibrated and maintained in accordance with SBMS subject area
*Calibration*. However, during the audit it was stated that
Instrumentation does not have this type of equipment. Recommend that SOP
wording be clarified/deleted as appropriate.

**5.0 ASSESSMENT RESOLUTIONS**

A summary of the assessment and associated findings was presented to the
Instrumentation Division management at a close out meeting held August
2, 2005. It was agreed that all nonconformances and observations
identified in the Section 4.0 would be tracked until closure using the
division's internal assessment form program.

**6.0 LIST OF ATTACHMENTS**

-   Attachment A -- Assessment Plan

-   Attachment B -- List of Personnel Interviewed

-   Attachment C -- Opening and Closing Meetings Attendance Lists

-   Attachment D -- Closeout Meeting Briefing

-   Attachment E -- Assessor's Assessment Checklist and notes (provided
    on the original hardcopy only)

**ATTACHMENT A**

Assessment Plan

Occupational Safety and Health Management Systems (OHSAS) 18001

Assessment of Instrumentation Division

[Objective]{.underline}

The objective is to conduct an assessment to:

> 1\. Assess the effectiveness of Instrumentation Division's
> implementation of an OHSAS 18001: 1999 program.
>
> 2\. Determine conformance to OHSAS 18001:1999

[Scope]{.underline}

This assessment will review all the elements of the standard, as
implemented by Instrumentation Division. Audit strategy will consist of
personnel interviews at all levels of the organization; document
reviews; surveillances and facility inspections.

[Assessment Team and Qualifications]{.underline}

M. Davis, Lead, Environmental & Waste Management Services Division
(EWMSD):

Lloyd's Register Quality Assurance OHSAS 18001 Internal Auditor &
Foundation Training; ISO 14000 EMS Lead Auditor

P. Bender, Facilities & Operations Directorate:

Lloyd's Register Quality Assurance OHSAS 18001 Internal Auditor &
Foundation Training; Asbestos; OSHA 30-hour training class; ES&H
Representative

M. Allocco, Environmental & Waste Management Services Division (EWMSD):

ISO 14000 EMS Lead Auditor; Hazwoper experience; OSHA 10-hour training
class; Training Coord.

A. Bou, Environmental & Waste Management Services Division (EWMSD):

Lloyd's Register Quality Assurance OHSAS 18001 Internal Auditor &
Foundation Training, EWMS OHSAS Rep.

[Assessment Criteria]{.underline}

The following are applicable to this assessment:

Occupational Safety and Health Management Systems -- Specification,
British Standards Institution (BSI) OHSAS 18001:1999

[OHSAS 18001 Interim
Procedures](https://sbms.bnl.gov/standard/47/4700t011.htm)

Instrumentation Division OHS program documents

Applicable Instrumentation Division Internal SOPs

[Proposed Schedule]{.underline}

> Pre-planning and Desktop Assessment: July 21 -- 25, 2005
>
> Opening meeting July 25, 2005
>
> Assessment: July 26 -- 28, 2005
>
> Closeout meeting July 28, 2005 (tentative)
>
> Draft Report: Aug. 5, 2005
>
> Factual Accuracy Review: Aug. 5 -- 9, 2005

Final Report: Aug. 31, 2005

[Assessment Strategy]{.underline}

-   Perform assessment per **Interim Procedure Number:
    [2004-18001-005](http://www.rhichome.bnl.gov/AGS/Accel/SND/18001 Web/18001 Audit Checklist.doc)
    Revision: 10 on 2-28-05**

-   Use developed
    [checklist](http://www.rhichome.bnl.gov/AGS/Accel/SND/18001 Web/18001 Audit Checklist.doc)

-   Conduct interviews with personnel (See Attachment 1)

-   Review documents and records

[OHSAS Element: Associated Auditor]{.underline}

a.  OHS Policy (4.2): M. Davis

b.  Planning for Hazard Identification & Risk (4.3.1): P. Bender

c.  Legal and Other Requirements (4.3.2): M. Allocco

d.  Objectives (4.3.3): M. Davis

e.  OHS Management Program(s) (4.3.4): M. Davis

f.  Structure and Responsibility (4.4.1): M. Davis

g.  Training, Awareness & Competence (4.4.2): M. Allocco

c\. Consultation and Communication (4.4.3): M. Davis

d.  Documentation (4.4.4): M. Allocco

e.  Document & Data Control (4.4.5): M. Allocco

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f.  Operational Control (4.4.6): P. Bender

g.  Emergency Preparedness & Response (4.4.7): P. Bender

h.  Performance Measurement & Monitoring (4.5.1): P. Bender

i.  Accidents, Incidents, Nonconformances, Corrective and Preventive
    Action (4.5.2): P. Bender

j.  Records & Records Management (4.5.3): M. Allocco

k.  Audit (4.5.4): M. Davis

l.  Management Review (4.6): M. Davis

[Assessment Report Format]{.underline}

The Assessment report will include:

1\. Purpose/scope

2\. Assessment dates and Assessment team

3\. Identification of areas and functions assessed and documentation
reviewed

4\. Assessment results and conclusions

*5.* Areas for improvement

6\. Noteworthy practices

7.  Objective evidence of conformance/nonconformance

#### 

Refer to Attachment 1 - Assessment Schedule

####  

#### Attachment 1

##### Assessment Schedule

(Tentative -- all times and participants are subject to change)

> Opening Meeting: July 25, 2005 0930-10:00

-   Discuss of Audit Plan -- Audit Team, R. DiNardo, other
    Instrumentation Div. personnel as necessary

> Day 1 -- July 26, 2005

+--------------+--------------------------------+----------------------+
| ## Time      | **Assessment Focus**           | **Intervi            |
|              |                                | ewees/Participants** |
|              | (Note: Elements of focus will  |                      |
|              | extend beyond those identified |                      |
|              | at auditor's discretion)       |                      |
+==============+================================+======================+
| 0900 -- 1100 | OHSAS Implementation Overview  | [Audit               |
|              |                                | Team]{.underline}    |
| Time TBD     | All OHSAS elements             |                      |
|              |                                | R. DiNardo           |
|              | ###### Inte                    |                      |
|              | rviews with Senior Management  | [Mark                |
|              |                                | Davis]{.underline}   |
|              | Legal/Other Requirements       |                      |
|              | (4.3.2);                       | V. Radeka; P.        |
|              | Objectives/Targets/OSHMPs      | O'Connor             |
|              | (4.3.3, 4.3.4)                 |                      |
|              |                                |                      |
|              | Structure & Responsibility     |                      |
|              | (4.4.1), Management            |                      |
|              | Review(4.6), Consultation &    |                      |
|              | Communication (4.4.3)          |                      |
|              |                                |                      |
|              | Legal/Other Requirements       |                      |
|              | (4.3.2)                        |                      |
+--------------+--------------------------------+----------------------+
| 1200         | Lunch                          |                      |
+--------------+--------------------------------+----------------------+
| Times        | Occupational Safety & Health   | ###### Audit Team    |
|              | (OSH) Policy (4.2); OSH        |                      |
| TBD          | Hazards/Risks (4.3.1);         | Instr. Risk          |
|              | Operational Control (4.4.7);   | Assessment           |
|              | Objectives/Targets/OSHMPs      | Participants         |
|              | (4.3.3, 4.3.4)                 |                      |
|              |                                | (Divided among       |
|              |                                | auditors)            |
+--------------+--------------------------------+----------------------+
|              | Operational Control, Emergency | ###### M. Davis      |
|              | Preparedness, Response,        |                      |
|              | Consultation & Communication   | R. Angona (LEC)      |
|              | (4.4.3), etc.                  |                      |
+--------------+--------------------------------+----------------------+
|              | Operational Control; OSH       | ###### M. Allocco    |
|              | Hazards/Risks (4.3.1);         |                      |
|              | Consultation & Communication   | G. Smith (Work       |
|              | (4.4.3); etc.;Policy (4.2);    | Control & ALARA      |
|              |                                | Coord, Bldg. Mgr.)   |
+--------------+--------------------------------+----------------------+
|              | Operational Control, OSH       | ###### Auditor X     |
|              | Hazards/Risks (4.3.1),         |                      |
|              | Consultation & Communication   | Printed Circuit      |
|              | (4.4.3); Policy (4.2);         | Fabr. Group (J.      |
|              |                                | Mead, staff)         |
+--------------+--------------------------------+----------------------+

> Day 2-- July 27, 2005

+-------------+-------------------------------+-----------------------+
| ## Time     | **Assessment Focus**          | **Interv              |
|             |                               | iewees/Participants** |
+=============+===============================+=======================+
| 0830 --     | OSH Hazards/Risks (4.3.1;     | ###### P. Bender      |
| 1030        | Policy (4.2);                 |                       |
|             | Objectives/Targets/OSHMPs     | Machine Shop          |
|             | (4.3.3, 4.3.4); Structure &   | (Beuttenmuller &      |
|             | Responsibility (4.4.1);       | staff)                |
|             | Training, Awareness,          |                       |
|             | Competence (4.4.2)            | ###                   |
|             | Consultation & Communication  | ### Davis/Allocco/Bou |
|             | (4.4.3)                       |                       |
|             |                               | Detector Group (G.    |
|             |                               | Smith & staff)        |
+-------------+-------------------------------+-----------------------+
| 1045 --     | Field observations            | Line managers and     |
| 1200        |                               | staff (as needed)     |
+-------------+-------------------------------+-----------------------+
| 1200        | Lunch                         |                       |
+-------------+-------------------------------+-----------------------+
| 1300 - 1700 | Various OHSAS elements        | ###### P. Bender      |
|             |                               |                       |
|             | Non-Conformances and          | Laser, Optics, Fabr   |
|             | Corrective/Preventive Action  | Group                 |
|             |                               |                       |
|             | Performance Measurement &     | ####                  |
|             | Monitoring; Records and       | ## Bender/Allocco/Bou |
|             | records management, (4.4.6,   |                       |
|             | 4.4.7, 4.5.1, 4.5.2, 4.5.3)   | J. McGown (Bldg Mgr,  |
|             |                               | Work Control          |
|             |                               | Coord.) - Accidents,  |
|             |                               | Incidents,            |
|             |                               |                       |
|             |                               | ###### Allocco/Bou    |
|             |                               |                       |
|             |                               | D. Grabowski --       |
|             |                               | Business Manager      |
+-------------+-------------------------------+-----------------------+

> Day 3 -- July 28, 2005

+-------------+-------------------------------+-----------------------+
| ## Time     | **Assessment Focus**          | **Interv              |
|             |                               | iewees/Participants** |
+=============+===============================+=======================+
| 0830 --     | Audit Team meeting -- draft   | Audit Team            |
| 12:00       | results/conclusions           |                       |
+-------------+-------------------------------+-----------------------+
| 1200        | Lunch                         |                       |
+-------------+-------------------------------+-----------------------+
| 1300--      | Audit Team meeting -- draft   | Audit Team            |
|             | results/conclusions, and      |                       |
| 1500        | prepare draft closeout        | Audit Team, R.        |
|             | briefing                      | DiNardo,              |
| 1500        |                               | Instrumentation Mgmt  |
|             | Closeout Briefing             |                       |
+-------------+-------------------------------+-----------------------+

Rev. 1 July 25, 2005

> **ATTACHMENT B**
>
> **[List of Personnel Interviewed]{.underline}
> [Responsibility]{.underline}**
>
> R. Angonna Printed Circuit Fabrication Group, Local
>
> Emergency Coordinator

M. Brathwaite Assistant to Business Oper Mgr.

R. Di Nardo ES&H Coord, Work Control Mgr, Training Coord., OHSAS Rep.,
EMS Rep., etc.

D. Elliott Semiconductor Detector Processing Group

D. Grabowski Business Operations Manager H. Hansen Printed Circuit
Fabrication

C. Holmstrom Machine Shop

W. King Machine Shop

J. McGowan Work Control Coord., Building Manager, etc.

V. Radeka Division Head

T. Rao Supervisor, Laser Applications Group

N. Schaknowski Gas & Liquid Detectors Group

J. Smedley Laser Applications Group

G. Smith Supervisor, Gas & Liquid Detectors Group

T. Tsang Laser Applications Group

G. Von Achen Gas & Liquid Detectors Group

J. Walsh Laser Applications Group

**ATTACHMENT C**

Opening and Closing Meeting's Attendance Lists

The Opening Meeting was held July 25, 2005 and attended by:

Audit Team Members: M. Davis, P Bender, M Allocco, A, Bou

Instrumentation Division: R. DiNardo

The Closeout Meeting was held August 2, 2005 and attended by:

Audit Team Members: M. Davis, P Bender, M Allocco, A. Bou

Instrumentation Division: M. Brathwaite,R. DiNardo, D. Grabowski, J.
McGowan, P. O'Connor, V. Radeka, G. Smith

SHS Division: R. Selvey

**ATTACHMENT D**

Internal Assessment of Instrumentation Division

OHSAS 18001

Closeout Meeting - Summary of Findings

August 2, 2005

[Audit Dates:]{.underline} July 25--28, 2005

[Audit Team:]{.underline}

M. Davis, (Lead) Environmental & Waste Management Services Division
(EWMSD):

P. Bender, Facilities & Operations Directorate

M. Allocco, EWMSD

A. Bou, EWMSD

[Overall]{.underline}:

Staff were very cooperative & appeared to be very safety conscious --
OHSAS was just an enhancement/reinforcement of what they were already
doing.

Good safety controls in higher risk areas.

Staff clearly understood that management expects them to take personal
responsibility to work safely.

Implementation of OHSAS -- very good framework and integration with
existing programs

\- Still a ways to go -- but achievable, provided adequate resources are
dedicated.

[Findings]{.underline}:

The following findings represent areas that require management attention
in order to fully implement the requirements of OHSAS program in
accordance with 18001 -- 1999: requirements:

**3** **Major Nonconformances 4 Minor Nonconformance**

**2 Observations 1 Opportunity/Recommendation for Improvement**

**2 Noteworthy Practices**

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.

Noncompliance - Non-adherence to an applicable regulatory requirement.

Recommendations (opportunity for improvement) - A suggested means of
improving an activity or fulfilling the intent of a requirement.

Observation - Not a nonconformance, but something that could lead to a
nonconformance, if allowed to continue uncorrected; or an existing
condition without adequate supporting evidence to verify that it
constitutes a nonconformance

**Major Nonconformance 1**: Element 4.3.1 [Planning for Hazard
Identification & Risk]{.underline}. The organization shall establish and
maintain procedures for the ongoing identification of hazards, the
assessment of risks, ....

[Finding:]{.underline} Development of all identified JRAs and FRAs/ARAs
is not complete.

**Major Nonconformance 2**: Element 4.4.2, [Training, Awareness &
Competence.]{.underline} The organization shall establish and maintain
procedures to ensure that its employees working at each relevant
function and level are aware of ... the importance of conformance to
the OH&S policy and procedures, and to the requirements of the OH&S
management system

[Finding]{.underline}: Only \~50% of staff have completed the BNL *TQ
Safe Aware* Training.

**Major Nonconformance 3**: Element 4.4.5, [Document & Data
Control.]{.underline} The organization shall establish and maintain
procedures for controlling all documents and data required by this OHSAS
specification....

[Finding]{.underline}: Several document control deficiencies were
identified, and a procedure describing document control does not exist.

Examples provided in separate attachment.

**Minor Nonconformance 1**: Element 4.4.1, [Structure and
Responsibility]{.underline}, states that management shall provide
resources essential to the implementation, control and improvement of
the OH&S management system.

[Finding]{.underline}: Minimal evidence of management support in
developing/maintaining OHS programs (Examples include missing approval
signatures on documents, lack of status meetings, personnel resources)

**Minor Nonconformance 2**: Element 4.4.3 [Consultation and
Communication.]{.underline} Employees shall be: represented on health
and safety matters.

[Finding]{.underline}: The Instrumentation Division Safety Committee
does not include worker level representative(s).

**Minor Nonconformance 3** Element 4.4.7 [Emergency Preparedness &
Response.]{.underline} The organization shall also periodically test
such procedures where practicable.

Finding: Testing of emergency preparedness/response is not routinely
performed.

**Minor Nonconformance 4** Element 4.5.4 [Audit]{.underline}. OH&S
management system audits are to be carried out,....

[Finding]{.underline}: A Self-Assessment Plan for FY2005 has been
drafted, but not finalized, approved, and issued.

**Observation 1** Element 4.3.3, [Objectives]{.underline}, states, "the
organization shall establish and maintain documented occupational health
and safety objectives, at each relevant function and level within the
organization".

[Finding]{.underline}: There is no evidence that the status of achieving
objectives is periodically reviewed, including informing staff at each
level.

**Observation 2** Element 4.4.1, Structure and Responsibility, states,
"The roles, responsibilities and authorities of personnel who manage,
perform and verify activities having an effect on the OH&S risks of the
organization's activities, facilities and processes, shall be defined,
documented and communicated in order to facilitate OH&S management.

[Finding]{.underline}: Revision of all staff R2A2s to include standard
OHSAS language has not been completed.

**Opportunity/Recommendation for Improvement** Element 4.5.1,
[Performance Measurement & Monitoring.]{.underline} IO-OSH-001 states
"... equipment used for OSH are calibrated and maintained in accordance
with SBMS subject area *Calibration*. However, it was stated that
Instrumentation does not have this type of equipment. Clarify/delete
wording as appropriate.

[During this audit the following noteworthy practices were
identified:]{.underline}

**Noteworthy Practice 1:** The Activity Safety Review program (forms,
implementation, signatures, etc.) appears to be very effectively
implemented.

**Noteworthy Practice 2:** The ASR table linking all associated
programs, documents is an effective tool, and a model for other
organizations.

[Document & Data Control Findings:]{.underline}

As per the SBMS Internal Controlled Documents all controlled documents
must contain the following elements at a minimum:

Document title

Effective date

Revision

Approvals

In addition Clause 4.4.5 of OHSAS 18001 states, The organization shall
maintain procedures for controlling all documents and data required by
the specifications to ensure that b) they are periodically reviewed,
revised as necessary and approved for adequacy by authorized personnel.

Examples of document control issues within IO are:

-   A small sampling of ASRs was reviewed including #2 and #16. The
    original copy of ASR #2 did contain Line manager signatures
    (Approvals as per the Controlled document subject area) on
    Attachments 8.1 through 8.6.

As per the standard, documents relating to OHSAS 18001 shall be
periodically reviewed.

-   Although some documents such as the JRAs and FRAs were listed as
    having an annual review in the Management System Description all
    other documents need to have their review schedule spelled out
    either in a centralized document or on each document.

-   The Printed Circuit Board Laboratory maintains their Standard
    Operating Procedures (SOPs). Upon review there were no approval
    signatures and dates. Although the SOPs had revision dates it was
    unclear that the copy provided was the most recent version since
    there was no effective date on the SOP. Finally, there is no
    requirement for periodic review. The Laser laboratory also maintains
    their own SOPs. These should be reviewed to ensure they meet the
    requirements of SBMS and OHSAS 18001.

Section d) of the standard states, obsolete documents and data are
promptly removed from all points of issue and points of use or otherwise
assured against unintended use.

-   The Departmental Training and Qualifications Plan of agreement dated
    7/7/2000 was still on the IO web site although this document was
    obsolete.

**ATTACHMENT E**

Assessor's Assessment Checklist notes (provided on the original hardcopy
only)