# Presentation: 425285

## Safety Update Integrated Safety Management Peer Review Status April 26, 2006

- Eugene Lau
- Deputy Director
- EH&S Division, LBNL

## Reasons for ISM Peer Review

- OS letter to UC Board of Regents
- FY05 Safety Performance
- BSO letter to UCOP
- FY06 1st Qtr Safety Performance
- Class IV lasers lack proper access control
- ALS shielding violations
- Ergo injuries
- Superglue eye injury

**Notes:**
12/22/05, Director of Office of Sci sent a ltr to the UC Board of Regents. 12/23/05 BSO ltr to UCOP

## LBNL Response

- Committed to & Conducted an independent Peer Review of safety management at LBNL
- Objective: Identify deficiencies in ISM implementation & root cause analysis of leading indicators
- Review conducted on Jan 17 – 20 , 2006 (3.5 days)
-  Report issued on Feb 10, 2006
- LBNL will develop a formal corrective action plan (CAP) to be approved & validated by DOE
- DOE will validate in July or August

## Peer Review Team 

- Bill Bookless, Chair, AD for Safety and Environmental Protection, LLNL
- James H. Johnson, Professor of Civil Engineering, Howard University, UC ES&H Panel Member
- Jim Smathers, Professor Emeritus of Radiation Oncology, UCLA, UC ESH& Panel Member
- John Cornuelle, Director of Operations, SLAC
- Tom Dickinson, Consultant on Accelerator Safety, BNL
- George Goode, Manager of Environmental and Waste Management Services, BNL
- Dennis Derkacs, ISM Program Manager, LANL
- DOE observers from EH, PNSO, BSO

## Out-Brief Highlights

- LBNL ISM system is sound with many strengths
- Laboratory staff were very open and frank, not inhibited by DOE observers
- Fear of reporting incidents noted at all levels
- Need to ensure more consistent implementation and communication from top to bottom and across divisions
- Principal Investigators are the most vulnerable link in the line management chain
- Work planning and control should be more comprehensive and consistently implemented

## CAP Team formed

- Review Issues identified by Peer Review Team
- Extent of Condition Review - 8 previous assessments
- A peer review team member was invited back for continuity & expert advice
- A formal root cause analysis was conducted

**Notes:**
PNSO continues to push for formal root cause analysis despite BSO’s acceptance of the current approach Need to do root cause analysis on the Peer Review report

## Issues Identified by CAP Team/Peer Review Report (actionable items?)

- Line mgt’s execution of safety responsibilities is a weakness
- No lab-wide way to educate mgrs on how to make safety as an integrated part of activities
- Facility inspection program needs improvement
- Span of control unmanageable
- PI’s and postdocs relationship
- Lab is in a very reactive posture
- Focus on TRC/DART rates has a negative impact
- Work Control program inadequate
- Assurance of Independent review of ES&H
- Insufficient resources & others...

## Interim Actions Addressing Peer Review Issues

- Management walk-around training developed and piloted
- Root cause analysis capability enhanced
- Incident investigation procedures being revised to reduce intimidation factor
- Integrated Functional Appraisals revised to focus on implementation of authorization documents
- Division S/A criteria revised to focus on leading indicators

## Interim Actions (continued)

- Hiring/backfilling key positions i.e. Laser Safety Officer, Electrical Safety Officer, Health Physicist
- Divisions taking a variety of actions to engage PI’s in safety i.e. meetings, training, realignment of responsibilities, increased walk-arounds
- Benchmarking with Intel on 3/27/06
- Seeking benchmarking relationship with Johnson & Johnson

## Current Status

- Weekly written status report to BSO
- Extent of condition/Back-look and consolidation of themes completed
- Formal Root Cause analysis of Peer Review Report is about completed
- Draft actionable items to go out to Divisions – next week?
- Draft CAP to be developed on May 12
- Final CAP to be submitted on June 1

## Current Illness and Injury Performance

## Open Forum 

- Best safety performance in a multi-cultural lab?

- Be Safe
- &
- Thank You!