+-------------------------+-------------------+---+--------------------+
| **BROOKHAVEN NATIONAL   |                   |   | Procedure No.      |
| LABORATORY**            |                   |   | IO-SOP-01          |
|                         |                   |   |                    |
| # INDEP                 |                   |   | Revision No. 5     |
| ENDENT OVERSIGHT OFFICE |                   |   |                    |
|                         |                   |   | Page 1 of 11       |
| Title:                  |                   |   |                    |
|                         |                   |   |                    |
| Conducting Independent  |                   |   |                    |
| Oversight Assessments,  |                   |   |                    |
| Special Studies, and    |                   |   |                    |
| Investigations          |                   |   |                    |
+-------------------------+-------------------+---+--------------------+
| [Table of               |                   |   |                    |
| Contents]{.underline}   |                   |   |                    |
|                         |                   |   |                    |
| > [Section]{.underline} |                   |   |                    |
| > [Page]{.underline}    |                   |   |                    |
|                         |                   |   |                    |
| 1.  PURPOSE 2           |                   |   |                    |
|                         |                   |   |                    |
| > 2.0 RESPONSIBILITIES  |                   |   |                    |
| > 2                     |                   |   |                    |
| >                       |                   |   |                    |
| > 3.0 DEFINITIONS 3     |                   |   |                    |
| >                       |                   |   |                    |
| > 4.0 PREREQUISITES 3   |                   |   |                    |
| >                       |                   |   |                    |
| > 5.0 PRECAUTIONS 4     |                   |   |                    |
| >                       |                   |   |                    |
| > 6.0 PROCEDURE 4       |                   |   |                    |
| >                       |                   |   |                    |
| > 7.0 RECORDS 7         |                   |   |                    |
| >                       |                   |   |                    |
| > 8.0 REFERENCES 7      |                   |   |                    |
|                         |                   |   |                    |
| 9.  ATTACHMENTS 7       |                   |   |                    |
+-------------------------+-------------------+---+--------------------+
| **PREPARED BY:**        | **REVIEWED BY:**  | * |                    |
|                         |                   | * |                    |
| [\_\_\_\_\_\_\_\        | [\_\              | A |                    |
| _\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_ | P |                    |
| \_\_\_\_\_]{.underline} | \_\_\_\_\_\_\_\_\ | P |                    |
| Author/Date             | _\_\_\_\_\_\_\_\_ | R |                    |
|                         | \_\_]{.underline} | O |                    |
| J. Usher                |                   | V |                    |
|                         | C. Dimino         | E |                    |
| **Filing Code:**        |                   | D |                    |
| OS-13-03                | PAAA Coord.       | B |                    |
|                         |                   | Y |                    |
|                         | \_\_\_\           | : |                    |
|                         | _\_\_\_\_\_\_\_\_ | * |                    |
|                         | \_\_\_\_\_\_\_\_\ | * |                    |
|                         | _\_\_\_\_\_\_\_\_ |   |                    |
|                         |                   | [ |                    |
|                         | P. Sparrow        | \ |                    |
|                         |                   | _ |                    |
|                         | Sr. Admin.        | \ |                    |
|                         | Secretary         | _ |                    |
|                         |                   | \ |                    |
|                         | \_\_\_\           | _ |                    |
|                         | _\_\_\_\_\_\_\_\_ | \ |                    |
|                         | \_\_\_\_\_\_\_\_\ | _ |                    |
|                         | _\_\_\_\_\_\_\_\_ | \ |                    |
|                         |                   | _ |                    |
|                         | J. Mortimer       | \ |                    |
|                         |                   | _ |                    |
|                         | Admin. Secretary  | \ |                    |
|                         |                   | _ |                    |
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+-------------------------+-------------------+---+--------------------+

+--------------------------------------------------+-------------------+
| BROOKHAVEN NATIONAL LABORATORY                   | Procedure No.:    |
|                                                  | IO-SOP-01         |
| INDEPENDENT OVERSIGHT OFFICE                     |                   |
|                                                  | Revision No: 5    |
|                                                  |                   |
|                                                  | Page 2 of 11      |
+--------------------------------------------------+-------------------+
| Title:                                           |                   |
|                                                  |                   |
| Conducting Independent Oversight Assessments,    |                   |
| Special Studies, and Investigations              |                   |
+--------------------------------------------------+-------------------+

**1.0 PURPOSE**

> This procedure establishes the processes for conducting Independent
> Oversight (IO) assessment activities. IO assessments provide
> Laboratory management concise information pertaining to:

-   The overall performance relative to strengths and weaknesses of the
    Self-Assessment Program and, upon request, other management systems,
    programs, or processes

-   Adherence to Laboratory policies, standards, procedures, contractual
    requirements, and business goals

-   Identification of causal factors contributing to observed weaknesses
    or anomalous performance

-   Noteworthy management practices (strengths)

> IO assessments are intended to provide feedback on management and
> program effectiveness, efficiency, and adequacy, and to identify areas
> for improvement.
>
>  

####### 2.0 RESPONSIBILITIES 

> **IO Manager:** Oversees all assessment/investigation programs,
> processes, functions, and activities conducted under the aegis of
> Independent Oversight Office. The IO Manager is responsible for the
> following:

-   Approves the IO Program Plan for Assessments including assessment
    schedules

-   Approves requests to conduct unscheduled assessments, special
    studies, or investigations

-   Notifies stakeholders of approved unscheduled assessments

-   Appoints Lead Assessors

-   Verifies that Lead Assessors are qualified

-   Approves the assessment plan as prepared by the Lead Assessor

-   Approves the final assessment report

-   Determines if follow-up on progress or effectiveness of actions is
    necessary

> **Lead Assessor:** The Lead Assessor is responsible for the following:

-   Documents assessment criteria in an assessment plan

-   Selects assessors and technical specialists for the assessment

-   Requests administrative support for the assessment

-   Verifies that assessment team members are qualified

-   Verifies that assessment team members do not have direct
    responsibilities in the organization or the area being assessed

-   Manages and directs the assessment team

-   Prepares draft and final assessment reports

######## 

> **IO Senior Administrative Secretary:** The IO Senior Administrative
> Secretary maintains an assessment documentation package for each
> assessment.

+--------------------------------------------------+-------------------+
| BROOKHAVEN NATIONAL LABORATORY                   | Procedure No.:    |
|                                                  | IO-SOP-01         |
| INDEPENDENT OVERSIGHT OFFICE                     |                   |
|                                                  | Revision No: 5    |
|                                                  |                   |
|                                                  | Page 3 of 11      |
+--------------------------------------------------+-------------------+
| Title:                                           |                   |
|                                                  |                   |
| Conducting Independent Oversight Assessments,    |                   |
| Special Studies, and Investigations              |                   |
+--------------------------------------------------+-------------------+

####### DEFINITIONS

> **Adequate:** Sufficient for a specific requirement.
>
> **Areas for Improvement:** Those areas identified as weaknesses or
> areas where actions are needed to achieve optimal performance
> consistent with appropriate requirements.
>
> **Assessment:** A planned, documented, and structured evaluation for
> effectiveness, adequacy, and implementation to predetermined
> standards. Assessments also include unscheduled special studies and
> investigations requested by BNL managers throughout the fiscal year.
>
> **Effectiveness:** A measure of the degree to which a process achieves
> its performance expectations and anticipated outcomes.
>
> **Efficiency:** Effective operation as measured by comparison of
> production to cost (as in energy, time, and money).
>
> **Guidelines:** Methods that are considered good practice but which
> are not mandatory.
>
> **Standard:** A government or industry-endorsed description of
> essential characteristics of an item or activity. Standards are the
> norms or criteria against which the performance of an activity is
> measured. Within the Laboratory, standards are an approved set of
> requirements used to conduct work.
>
> **Strength:** Performance that exceeds expectations in terms of
> efficiency and/or effectiveness and provides a model for others to
> follow; a positive condition.
>
> **Technical Specialist:** An individual who has expertise in the
> assessment subject matter.
>
> **Validation:** The act of checking or determining whether data,
> information, and/or conclusions are current, accurate, and complete.
>
> **Weakness:** A condition that is in direct violation of a code,
> regulation, order, procedure, standard, policy, contract, or specific
> requirement; a nonconformance and/or noncompliance. Also, a condition
> that can have a significant adverse effect on the quality of a
> program, project, service, or process; a negative condition.

4.  **PREREQUISITES**

> Staff selected to be Assessment Team Leaders or Assessors for specific
> assessments shall have experience or training commensurate with the
> scope, complexity, or special nature of the activities to be assessed
> and shall be independent of any direct responsibility for the
> performance of the activities which they will assess.
>
> Prospective Assessment Team Leaders shall have verifiable evidence
> that education and experience have been accumulated as outlined below.

-   Education - A technical bachelor's degree or higher level degree
    from an accredited institution in engineering, physical sciences,
    mathematics, quality assurance, environmental or business
    management.

-   Experience - Technical experience in engineering, manufacturing,
    construction, operation, maintenance, research, environmental,
    quality assurance, or assessment/auditing.

+--------------------------------------------------+-------------------+
| BROOKHAVEN NATIONAL LABORATORY                   | Procedure No.:    |
|                                                  | IO-SOP-01         |
| INDEPENDENT OVERSIGHT OFFICE                     |                   |
|                                                  | Revision No: 5    |
|                                                  |                   |
|                                                  | Page 4 of 11      |
+--------------------------------------------------+-------------------+
| Title:                                           |                   |
|                                                  |                   |
| Conducting Independent Oversight Assessments,    |                   |
| Special Studies, and Investigations              |                   |
+--------------------------------------------------+-------------------+

-   Other Credentials of Professional Competence (when appropriate) -
    Certification of competency in engineering, science, or quality
    assurance specialties issued and approved by a state agency or
    national professional or technical society.

-   The prospective Assessment Team Leader shall have the capability to
    communicate effectively both in writing and verbally.

> Note: The Independent Oversight (IO) Office Manager may consider other
> performance factors applicable to auditing which may not be explicitly
> called out in this procedure. Examples of these factors are
> interpersonal skills, leadership, sound judgment, maturity, analytical
> ability, tenacity, past performance, and quality assurance or accident
> investigation training courses. The IO Manager may waive specified
> education and/or experience requirement with documented justification.
>
> Specific indoctrination for assessment team members: outside technical
> specialists, consultants, adjunct staff, and other supporting
> personnel shall be performed and documented. This indoctrination
> should, at a minimum, include review of the following:

-   Assessment objectives and criteria

-   Assessments process, performance, and reporting as defined by this
    procedure and the assessment plan

-   Orientation on the organization/area to be assessed

-   Applicable BNL procedures

5.  **PRECAUTIONS**

> None

6.  **PROCEDURE**

> The procedural steps for planning/scheduling assessments, assigning
> assessment personnel, conducting assessments, reporting assessment
> results, and assessment follow-up are described below and depicted in
> the IO Assessment Process Flow Chart (Attachment 1). Procedural steps
> apply specifically to IO evaluations of BNL line organizations'
> self-assessment programs but are also applied, as deemed appropriate
> by the IO Manager, to other assessments, special studies, and
> investigations conducted under the aegis of the IO Office.

**6.1 Planning/Scheduling Assessments**

1.  The IO Manager, in consideration of BNL contractual and regulatory
    requirements, and in consultation with appropriate stakeholders
    (Level 0 and Level 1 BNL managers, Management System Stewards and
    Points-of-Contact), determines the list of scheduled IO assessments
    for the current fiscal year.

2.  The IO Manager reviews and approves requests from Level 0 and Level
    1 BNL managers for unscheduled assessments.

3.  The IO Manager ensures that BNL managers and other stakeholders
    affected by unscheduled assessments including special studies and
    investigations are formally notified.

4.  The IO Manager appoints a Lead Assessor responsible for a series of
    assessments or for an individual assessment.

+--------------------------------------------------+-------------------+
| BROOKHAVEN NATIONAL LABORATORY                   | Procedure No.:    |
|                                                  | IO-SOP-01         |
| INDEPENDENT OVERSIGHT OFFICE                     |                   |
|                                                  | Revision No: 5    |
|                                                  |                   |
|                                                  | Page 5 of 11      |
+--------------------------------------------------+-------------------+
| Title:                                           |                   |
|                                                  |                   |
| Conducting Independent Oversight Assessments,    |                   |
| Special Studies, and Investigations              |                   |
+--------------------------------------------------+-------------------+

5.  The IO Manager reviews the qualifications of the prospective Lead
    Assessor and verifies his/her qualifications per Section 4.0.

6.  The Lead Assessor in consultation with the IO Manager and other
    stakeholders (including technical specialists and other members of
    the assessment team as appropriate) develops a draft assessment plan
    including assessment objectives and scope, assessment criteria
    (including requirements basis), assessment methodology, assessment
    team members, and assessment schedule. The necessary rigor of the
    assessment methodology is determined at this time. Specific
    assessment methodology guidelines are identified.

7.  The IO Manager and stakeholders review the draft assessment plan.

8.  The Lead Assessor addresses stakeholder concerns in finalizing the
    draft assessment plan.

9.  The IO Manager approves the final assessment plan.

10. The Lead Assessor ensures that BNL managers affected by the
    assessment are formally notified of the assessment plan and
    schedule.

**6.2 Assigning Assessment Personnel**

1.  The Lead Assessor, in consultation with the IO Manager and
    appropriate stakeholders, determines whether or not an assessment
    team is necessary. The Lead Assessor may conduct the assessment
    without a team.

2.  The Lead Assessor selects assessment team members including
    technical specialists.

3.  The Lead Assessor verifies that team members are qualified per
    Section 4.0.

4.  The Lead Assessor verifies that team members do not have direct
    responsibilities for the organization or the area being assessed.

5.  The Lead Assessor indoctrinates team members as described in Section
    4.0.

6.  The Lead Assessor determines the need for administrative support and
    requests identified support.

**6.3 Conducting Assessments**

1.  The Lead Assessor conducts a pre-assessment entrance meeting
    (in-briefing) with appropriate stakeholders to communicate
    assessment scope and schedule, discuss assessment methodology, and
    identify appropriate points-of-contact.

2.  The Lead Assessor ensures that appropriate documents are available
    for review, interviews are scheduled, and performance observations
    are scheduled.

3.  The Lead Assessor ensures that data collection proceeds according to
    the approved assessment methodology and that the methodology is
    revised if necessary.

4.  The Lead Assessor ensures that data is validated with appropriate
    stakeholders.

5.  The Lead Assessor conducts internal team meetings to verify that the
    assessment is proceeding as scheduled and to enable the analysis of
    data collected.

+--------------------------------------------------+-------------------+
| BROOKHAVEN NATIONAL LABORATORY                   | Procedure No.:    |
|                                                  | IO-SOP-01         |
| INDEPENDENT OVERSIGHT OFFICE                     |                   |
|                                                  | Revision No: 5    |
|                                                  |                   |
|                                                  | Page 6 of 11      |
+--------------------------------------------------+-------------------+
| Title:                                           |                   |
|                                                  |                   |
| Conducting Independent Oversight Assessments,    |                   |
| Special Studies, and Investigations              |                   |
+--------------------------------------------------+-------------------+

6.  The Lead Assessor ensures that results of data analysis including
    identification of strengths, weaknesses, causal factors, and areas
    for improvement are documented as the assessment proceeds.

7.  The Lead Assessor provides updates to stakeholders on status and
    preliminary results of the assessment.

8.  The Lead Assessor notifies stakeholders when the assessment is
    complete.

**6.4 Reporting Assessment Results**

1.  The Lead Assessor prepares a first draft of the assessment report.
    An example report format is provided in Attachment 2.

2.  The Lead Assessor ensures that weaknesses are clearly identified as
    nonconformances and/or noncompliances with specific requirements in
    the report.

3.  The assessment team reviews and revises the draft report.

4.  The Lead Assessor schedules and conducts an out-briefing with
    appropriate BNL managers and other stakeholders to summarize
    assessment results and transmit the draft report for factual
    accuracy review.

5.  The Lead Assessor finalizes the draft report to address stakeholder
    comments.

6.  The Lead Assessor and team members approve (sign) the report.

7.  The IO Manager reviews and approves (signs) the final report.

**6.4.8** The Lead Assessor ensures that the approved final report is
distributed to appropriate stakeholders including the PAAA Coordinator.

**6.5 Following up on Assessments**

1.  The Lead Assessor ensures that an action plan is developed by the
    appropriate stakeholders to address the weaknesses and areas for
    improvement identified by the assessment. This action plan is
    entered into Institutional ATS per BNL ESH Standard 1.2.1.

2.  The IO Manager, in consultation with the Lead Assessor and
    stakeholders, determines if additional follow-up on progress or
    effectiveness of actions by the IO Office or designees is necessary.

**7.0 RECORDS**

> Assessment records will be managed in accordance with BNL/DOE records
> management requirements. The IO Senior Administrative Secretary will
> maintain an assessment documentation package for each assessment.
> These records include but are not limited to the following:

-   Assessment plan

-   Final assessment report

-   Correspondence and notification

-   Electronic files of assessment documents

-   Digital photos

-   Records of interviews

+--------------------------------------------------+-------------------+
| BROOKHAVEN NATIONAL LABORATORY                   | Procedure No.:    |
|                                                  | IO-SOP-01         |
| INDEPENDENT OVERSIGHT OFFICE                     |                   |
|                                                  | Revision No: 5    |
|                                                  |                   |
|                                                  | Page 7 of 11      |
+--------------------------------------------------+-------------------+
| Title:                                           |                   |
|                                                  |                   |
| Conducting Independent Oversight Assessments,    |                   |
| Special Studies, and Investigations              |                   |
+--------------------------------------------------+-------------------+

> The record copyholder for all documentation generated by this
> procedure is the Independent Oversight Office

**8.0 REFERENCES**

1.  SBMS Subject Area: Training and Qualifications

2.  SBMS Subject Area: Environmental Assessments

3.  ESH Standard 1.2.1, "Corrective Action Management and Tracking for
    External and Internal Assessments"

```{=html}
<!-- -->
```
9.  **ATTACHMENTS**

**9.1** Independent Oversight Assessment Process (Attachment 1)

2.  Example of Independent Oversight Report Format (Attachment 2)

# 

#  {#section-2 .unnumbered}

**Attachment 2: Example of Independent Oversight Report Format**

**Brookhaven National Laboratory**

**Independent Oversight Office**

**Title of Report**

## Report Number

##### Date

Name of Individual Assessment Team Leader Date

Name of Individual Assessment Team Member Date

Name of Individual Assessment Team Member Date

Name of Individual Assessment Team Member Date

Approved By:

Robert C. McNair, Manager, Date

Independent Oversight Office

**[Executive Summary:]{.underline}**

This summary is a brief synopsis of what the assessment/investigation
was and why it was performed. A more detailed paragraph (or two) in this
format will be placed under "Introduction" in the body of the report.

**Overall Conclusions**

Briefly explain the conclusions of the assessment. Additional detail
will be provided in the body of the report.

**Strengths**

In bulleted format, list the strengths that are found during the
assessment. These will be explained in detail within the body of the
report.

**Areas for Improvement**

In bulleted format, list the areas for improvement noted during the
assessment. These will be explained in detail within the body of the
report.

**Ongoing Corrective Actions**

Provide analysis of any corrective actions relevant to the assessment
that are already taking place.

**Root Cause and Contributing Factors**

Provide a brief description of root cause(s) and contributing factors.

**Recommended Actions**

Provide a bulletized listing of recommended actions. Identify both
long-term and near-term recommended actions, if applicable.

\- Long-Term Recommended Actions

\- Near-Term Recommended Actions

**[Body of Report]{.underline}:**

1.  **Introduction**

Provides the basic background information such as assessment purpose,
scope, objectives, dates, audit team members, and procedures used. Also
include a brief description of the activities assessed.

2.  **Facts**

This is a discussion of fact based on information obtained from data
collection and validation. For an investigation, this incorporates what
happened including background information and findings. Subheadings for
each issue should be included here. These subheadings should be tailored
specifically for each assessment. These subheadings should include
examples of specific objective evidence.

3.  **Conclusions**

**3.1 Overall Conclusions**

This is a discussion of the overall conclusions based on data validation
and analysis. They need to parallel those listed in the Executive
Summary.

**3.2 Strengths**

Same as in Executive Summary, but more detail added. They need to
parallel those listed in the Executive Summary.

**3.3 Areas for Improvement**

Same as in Executive Summary, but more detail added. They need to
parallel those listed in the Executive Summary.

**3.4 Ongoing Corrective Actions**

Discuss any appropriate corrective actions that were identified and
established during the course of the assessment. These need to parallel
those listed in the Executive Summary.

**3.5 Root Cause(s) and Contributing Factors**

Provide root causes and contributing factors, as applicable.

**4.0 Recommended Actions**

Discuss recommended actions. These may be identified further as
long-term and short-term recommended actions. These need to parallel
those listed in the Executive Summary.

**4.1 Long-Term Recommended Actions**

**4.2 Short-Term Recommended Actions**

**Appendix A -- Figures**

**Appendix B -- List of Interviews**

List the names and titles of people interviewed during the course of the
assessment.

# Appendix C -- Documents Referenced

List regulations, orders, policies, and standards containing
requirements or expectations relevant to this assessment. These
documents should represent the criteria used to evaluate performance in
the course of this assessment.

**Appendix D - Documents Reviewed**

List documents, manuals, procedures, and/or other records reviewed in
the course of the assessment.

#