# Presentation: 008101

## Department of Energy Validation Review of the LBNL ISM Corrective Action PlanJune 27, 2006

**David C. McGraw****Chief Operating Officer****Associate Laboratory Director for Operations**

## Emergency Evacuation Route: Building 50A Room 5132

**50 Complex Bldg. Mgr.   John Hutchings  x7505**
- _[jehutchings@lbl.gov](mailto:jehutchings@lbl.gov)_
**Deputy Bldg. Mgr.   Jose Olivares****	****x6871**
- _[jaolivares@lbl.gov](mailto:jaolivares@lbl.gov)__ _

## Agenda: DOE Validation Review of the LBNL ISM Peer Review Corrective Action Plan

|             Tuesday, June 27, 2006
	8:00	Team Organization Mtg. 90-1099
	9:00	DOE Caucus/BSO Staff
	9:45	Break-Travel to Bldg. 50A-5132
	 10:00 – 12:00 Briefing from LBNL
	      10:00   Welcome – Director Steve Chu
	       10:10   Welcome - David McGraw
       10:30  CAP Development Process – 	                   Howard Hatayama                 
	       11:30   Additional Q&A
	12:00 	Team/BSO Lunch
	1:00	Team Interviews
	3:00	Begin Report Writing |            Wednesday, June 28, 2006
	7:30   	Report Writing and Outbrief		Presentation 90-1099
	11:30 	Lunch (Team w/BSO)
	1:00   	Travel to Bldg. 50B-4205
	1:30   	Outbrief with BSO 
	2:00   	Outbrief with LBNL
	3:30   	End of Visit |
| --- | --- |

## Berkeley Lab Director

**Chief Safety Officer**
**Sets the culture and values for safety, environmental protection, and ISM**
**Provides the resources and support that employees and safety programs need**
**Holds staff accountable for safety performance  **

## Director’s Actions

**Directed line managers and PI’s to walk all their spaces to correct safety issues, January 2006**
**Personally walked spaces with ALDs**
**Conducting brown-bag sessions around the Lab**
**Directed Division Directors to reinforce line management responsibility for safety, February 2006**
**Incorporated safety into every Sr. Leadership Council, Division Directors and area meetings**
**Commissioned broad-based CAP development team under the leadership of the Acting EH&S Division Director**
**Approved and submitted CAP to DOE**
**Issued memo to all staff on supervisor and individual responsibility for safety and on managing project schedules to ensure work is done safely, June 2006**

## From Poster Child to Problem Child

**What happened to ES&H Program at Berkeley Lab?**
**Is there a lesson for other Office of Science Labs in our experience?**
**Do **_**we**_** understand the lesson?**
**Loss of focus on resources and leadership required for proper execution**
**Not paying enough attention to the leading indicators we were collecting**
**A sense of complacency due to past success**
**Contributing factors**
**Leadership changes starting in 2003**
**Contract competition in 2004**

## The Orbach Letter and the Need for Intervention:2005-2006 Safety Record and Other Leading Indicators

**Missed TRC and DART goals in FY05 **
**Poor laser safety practices: use of interlocks, inadequate inventory**
**Electrical safety incidents**
**Breakdown of administrative safety controls at the Advanced Light Source**

## Leading Indicators and the Need for Intervention

**Communications between LBNL and BSO on safety matters needed significant improvement**
**LBNL and BSO leadership consensus on need for improved safety performance**
**BSO calls on UCOP for increased safety oversight**
**UCOP commissioned ISM Peer Review January 5, 2006**

## Peer Review Letter

## LBNL Peer Review Reviewers

**Reviewers****	****	****	****	**** **
**William A. Bookless, Chair ~ LLNL****	****	**
**John Cornuelle ~ SLAC**
**Dennis Derkacs ~ LANL **
**Tom Dickinson ~ NSLS – Brookhaven Laboratory**
**George Goode ~ Brookhaven Laboratory**
**James Johnson, Jr. ~ Howard University**
**Jim Smathers ~ UCLA**
**Three DOE Observers**
**W. Earl Carnes ~ DOE Headquarters**
**Ted Pietrok ~ PNSO**
**Carol Ingram ~ BSO**

## Structured Approach

**Backlook of Recent Incident Investigations**
**Root Cause Analysis**
**A Corrective Action Plan**

## LBNL Leadership Team is Committed to ES&H Execution

**Accountability at all levels**
**Clarity around roles and responsibilities**
**More attention to work controls**
**Continuous improvement**
**Robust metrics**
**Benchmarking**
**Robust Lessons Learned**
**Adequate resources**
**Executive team visibility**
**An improved governance model**
**Implementing the Corrective Action Plan**

## In Addition....

**We look forward to recommendations from this validation visit.....**

##  Integrated Safety Management Peer Review Corrective Action Plan Development Process

**Howard K. Hatayama ****Acting Director****Environmental Health and Safety Division**
**Department of Energy Validation Review of the ****LBNL ISM Corrective Action Plan**
**June 27, 2006 **

## Outline For Today

**Corrective Action Plan (CAP) Development**
**Cross-cutting CAP Development Team**
**Development process **
**Extent of condition/backlook review**
**Root cause analysis**
**Corrective actions development**
**Corrective actions summary**
**Current status and next steps**

## Corrective Action Plan Development Process

**Team formation**
**Working Group**
**CAP Development Team**
**Plan development process**
**Extent of condition/backlook review**
**Root cause analysis**
**Corrective actions development**
**Interim actions implemented while CAP was developed**

## Path to Recovery

**Indications of decline in safety program**

**Increased TRC & DART, number & severity of ORPS, etc. **

**Intervention**

**DOE/BSO**
**UCOP**
**LBNL**

**2005**

**2006         **

**Peer Review**

**Report, 2/10 **

**Issues, 3/24**

**Extent of condition: ****Peer Review+Backlook**

**Root Cause**

**Report, 4/26**

**CAP, 6/1**

**Implementation of  CAP, Validation & Continuous Improvement**

**2006-07**

## Extent of Condition Backlook Review

**Purpose: *****Understand the extent of condition of issues identified by the Peer Review by leveraging the work and knowledge gained from previous assessments and reports***
**Working Group reviewed eight other assessments and reports covering the period 2003-05**
**CAP Development Team brainstormed, clarified and critiqued common themes in two intense sessions**

***Result: More comprehensive and pertinent list of issues***

## Issues to Root Cause Analysis

** ****Peer Review Issues**

**  ****Issues from 8 other assessments = “Backlook”**

**Working Group applies ORPS categories to **
**         ****search for common themes**

-      **CAP Development Team brainstorms, clarifies,**
**    ****analyzes, reaches consensus on common themes**

**Working Group synthesizes Team consensus into *****Issues ***
***                ******(Peer Review + Backlook) 3/24/06***

**         ****Root Cause Analysis performed resulting in *****Peer  ***
***     ******Review/Backlook Issues Root Cause Analysis, 4/25/06***

**Working Group bins root causes into 5 categories to **
**         ****Facilitate corrective action development**

## LBNL ISM Peer ReviewCorrective Action Plan Development Team

## Backlook: Assessments and Reports Reviewed

**2006**
**Report of the RSC Sub-committee to Investigate and Review ALS Shielding Control Procedures, January**
**Berkeley Lab FY05 50 OSHA Recordable Cases: Root Causes and Lessons, January**
**2005**
**Crane, Hoist, Rigging & Forklift Safety Program Assessment, October **
**Causal Analysis of 15 Electrical Incidents that Occurred at Berkeley Lab from July 2002 to June 2005, October**
**Building 58 Electrical Near Miss Accident: Status Report on Corrective Actions, September**
**LBNL Building 58 Electrical Safety Event, June **
**LBNL Electrical Safety Self-Assessment, April**
**2003**
**Laser Safety Program Review Panel Report, July**

## Path to Recovery

**Indications of decline in safety program**

**Increased TRC & DART, number & severity of ORPS, etc. **

**Intervention**

**DOE/BSO**
**UCOP**
**LBNL**

**2005**

**2006         **

**Peer Review**

**Report, 2/10 **

**Issues, 3/24**

**Extent of condition: ****Peer Review+Backlook**

**Root Cause**

**Report, 4/26**

**CAP, 6/1**

**Implementation of  CAP, Validation & Continuous Improvement**

**2006-07**

## Root Cause Analysis

**Proceeded with formal Root Cause Analysis based on advice from DOE and acknowledged benefits**
**Used trained TapRooters**
**Examined the consolidated list of issues – ****“Issues - (Peer Review + Backlook), March 24, 2006”**
**Results documented in “Peer Review/Backlook Issues Root Cause Analysis, April 26, 2006”**

## Root Cause Analysis Teams

_**Team 1**_
**Richard Debusk, EHS**
**Mike Ruggieri, EHS**
**Michelle Flynn, OCA**
**Dennis Derkacs, Advisor**
**Jack Bartley, EHS**

_**Team 2**_
**Weyland Wong, ENG**
**Pat Thomas, AFRD**
**John Chernowski, OCA**
**Dennis Derkacs, Advisor**
**Jack Bartley, EHS**

## Root Cause Methodology

**A formal root cause analysis was performed against the issues in the Backlook and Peer Review to support effective corrective action development**
**The proactive method of TapRoot root cause analysis was used**
**Proactive TapRoot begins with assessment issues rather than incident sequence of events**
**LBNL considers TapRoot to be a human performance improvement tool**
**Helps identify and correct latent organizational weaknesses**

## TapRoot Steps

**1. Validate basic cause (provided from Peer Review and Backlook)**
**2.****	****Use TapRoot Root Cause Tree to identify basic cause categories**
**Human performance, equipment, natural disaster/sabotage, other**
**3.****	****If human performance is identified as a category, use Human Performance Troubleshooting Guide to identify basic cause categories (15 questions)**
**4.****	****Evaluate any basic cause category selected to determine root cause**

## An Example of How the Issues Were   Validated and Root Causes Identified                           

**ISM Principle 3 – Competence Commensurate with Responsibilities**
**Issue 3.1 - There is not a uniform process for educating managers, supervisors, and coordinators on how to make safety an integrated part of activities in the workplace**
**It is not clear that all managers are trained to conduct meaningful safety walkarounds**
**The role of the safety coordinator varies across LBNL**
**The minimum qualifications and training of safety coordinators should be determined and formalized**

**Reference:  “Issues (Peer Review/Backlook),” page 3**

## Analysis of Issue 3.1 Through to Identification of Root Cause 3.1.2

## Analysis of Issue 3.1 Through to Identification of  Root Cause 3.1.2

## Results Of Root Cause Analysis

**Each issue has a number of root causes**
**The list of root causes was refined**
**Duplication was eliminated**
**The TapRoot language was tailored with LBNL- specific terms (standard practice)**

## Management of Root Causes

**Organizing options:**
**Sequential listing**
**ISM Principles**
**Alignment with ISM Principles and Lab organizational structure**
**Institution-wide**
**Technical/professional**

## Alignment with ISM Principles and Lab Organizational Structure

**Chose alignment option to:**
**Enhance understanding of the causes **
**Facilitate team assignments**
**Recognize interdependence of root causes**
**Add coherence to development of corrective actions**

## Resulting Categories

**Line management (LM) execution of ES&H **
**ES&H assurance mechanisms**
**Educating managers, supervisors and division safety coordinators (SCs)**
**Proactive posture on ES&H**
**Lab-wide work control program**

## Path to Recovery

**Indications of decline in safety program**

**Increased TRC & DART, number & severity of ORPS, etc. **

**Intervention**

**DOE/BSO**
**UCOP**
**LBNL**

**2005**

**2006         **

**Peer Review**

**Report, 2/10 **

**Issues, 3/24**

**Extent of condition: ****Peer Review+Backlook**

**Root Cause**

**Report, 4/26**

**CAP, 6/1**

**Implementation of  CAP, Validation & Continuous Improvement**

**2006-07**

## Corrective Actions Development Process

**CAP Team assigned to each of 5 categories, 5/5/06**

**Corrective Action Teams develop proposed actions**

**   ****Proposed actions reviewed with CAP team to test**
**appropriateness feasibility and eliminate redundancy **

**Working Group prepares draft CAP **

**Draft CAP reviewed by Safety Coordinators, Associate**
**              ****Laboratory Directors, Lab Director**

**CAP submitted on June 1, 2006**

## Corrective Action Teams

| LM Execution of ES&H | ES&H Assurance | Educate Managers & SCs | Proactive ES&H | Work Control Program |
| --- | --- | --- | --- | --- |
| Don Lucas, Staff Scientist, EETD

Michael Banda, Div. Deputy, CRD

Richard Debusk, Group Leader, EHS | John Chernowski, Manager, OCA

Michelle Flynn, Prog. Manager, OCA
 | Guy Bear, Deputy Director, FAC

Weyland Wong, Safety Manager, ENG

Jack Bartley, EHS | Eugene Lau, Deputy Director, EHS

Michael Ruggieri, Specialist, EHS

Peter Lichty, Occupational Medical Director, EHS | Richard Kadel, Staff Scientist, Physics

Rick Kelly, Fac & EHS Manager, MSD

Scott Taylor, Staff Scientist, LSD
 |

**Dennis Derkacs** – Advisor
**Kurt Deshayes** – Project Management

**  ****Questions on the CAP Development Process?**

## Key Elements of the Corrective Action Plan

**Corrective Actions, when implemented, will result in sustainable improvements in the five categories:**
**Line Management execution of ES&H (12 actions)**
**ES&H Assurance (26 actions)**
**ES&H Training and Communication (19 actions****)**
**More proactive ES&H (11 actions)**
**Work Planning and Hazard Control (20 actions)**
**Of this set**
**32 actions underway**
**7 actions complete or substantially complete**

## Line Management Execution of ES&H

***What are we fixing?***
**Responsibility for safety is not clearly defined below the principle investigator/staff scientist**
**Excessive span of control makes working safely a challenge**
***How are we fixing it?***
**Define safety management responsibilities for lead post-docs and graduate students**
**Increase frequency of management walkarounds**
**Incorporate changes in Lab policies and procedures**

## Line Management Execution of ES&H

***What have we done about it already?***
**Performed walkarounds of all spaces **
**Developed management walkaround training**
**Enhanced processes and training in Divisions**

## ES&H Assurance Mechanisms

***What are we fixing?***
**Weakened ES&H technical program assurance**
**Ability of assurance systems to identify weakness in execution of ES&H**
***How are we fixing it?***
**Establish current baseline of ES&H assurance and re-build**
**Review effectiveness of walkarounds, Integrated Functional Appraisal (IFA) and Management ES&H Review (MESH) and revise criteria**
**Revise partnership agreement with UCB regarding ES&H **

## ES&H Assurance Mechanisms

***What have we done about it already?***
**Revised FY06 IFA and MESH criteria**
**Revised division Self Assessment criteria for 2006-07 assessment year**

**Lawrence Berkeley National Laboratory**

**2006 Integrated Functional Appraisal**

## Educating Managers, Supervisors, and Coordinators

***What are we fixing?***
**Current safety oversight training for managers, supervisors, post-docs and graduate students needs to be aligned with roles and responsibilities **
**Roles, responsibilities, minimum qualifications and training requirements for Safety Coordinators**
***How are we fixing it? ***
**Enhance mentoring, safety awareness and training of post-docs and graduate students **
**Refine walkaround training based on formal requirements and feedback from initial roll-out**
**Evaluate Safety Coordinator program and revise**

## Educating Managers, Supervisors, and Coordinators

***What have we done about it already?***
**Developed walkaround training**
**Established Safety Coordinator review team**

## Proactive Posture on ES&H

***What are we fixing?***
**Cultural attitudes towards risk-taking and ES&H risk management**
**Fear and anxiety related to incident reporting**
***How are we fixing it?***
**Develop an enhanced communications strategy focused on: quality of work and concern for ES&H**
**Revise ISM plans, PRDs, and training for line managers to identify and mitigate ES&H risks **
**Re-orient response away from blame and towards staff safety, lessons learned and preventative measures**
**Communications to encourage incident reporting**

## Proactive Posture on ES&H

***What have we done about it already?***
**Revisions to incident investigations procedure to make it less onerous**
**Director’s memo to all Laboratory staff, 6/9/06**

## Lab Wide Work Control Program

***What are we fixing?***
**Managing of changes-people/equipment/scope**
**Informality in line management authorized work**
**Inadequate change control-staff/equipment/resources**
***How are we fixing it?***
**Complete transition of AHDs to electronic and review effectiveness**
**Formalize policy and procedures for lesser hazards**
**Review/revise hazard identification policies for facilities, sub-contractors, and vendors**
**Develop methods to ensure implementation of AHDs**

## Lab Wide Work Control Program

***What have we done about it already?***
**Focused FY06 IFA on implementation of formal authorizations**

## Current Status and Next Steps

**Continue implementing interim actions**
**Identify leads/teams for new CAP tasks**
**Establish Change Control Board**
**Follow-up on DOE Validation Team recommendations**
**Implement and close-out corrective actions**
**Validation and on-going assurance**

## So what have we learned from all this?

**A great deal of humility**
**Never lose focus on safety**
**Pay attention to **_**leading**_** indicators**
**We **_**will**_** improve**
**We will meet aggressive metrics**

## Our Goal: A safer Laboratory through improved execution of Integrated Safety Management

**Active and effective participation of managers, from senior leadership to the mentors in the workplace, as Safety Managers**
**Tailor training, implement a  comprehensive Work Planning and Hazard Control Program, enable proactive EH&S professionals**