# Presentation: 432236

## FY06 Internal EMS/OHSAS Audit Closing Meeting

**March 8, 2006**

**FY06 Internal EMS/OHSAS Audit Closing Meeting**

**Lead Auditors:**
**Deborah Bauer – EMS**
**Bob Selvey - OHSAS**

## Summary of OSH Findings

- OHSAS 18001 Registered Phase 1 and Phase 2 organizations were audits
- CAD, SCMD, BES, F&O (EP, CF, SS), NSLS, IO, PO
- Phase 3 organizations are scheduled for Internal Audits in July:
- SSD, ESD, PPM, ESH&Q, Life Sci, ERP, EENS

## Summary of OSH Findings

- OHSAS 18001 Registered Phase 1 and Phase 2 organizations
- 7	Noteworthy Practice
- 0	Major Nonconformances
- Minor Nonconformances
- 5	Opportunities for Improvement

## Noteworthy Practices

_**Operation Control **_
- The is a strong formal procedure for design review and procurement of equipment in the NSLS QA manual  (NSLS)
- The cross reference table for Activity Safety Reviews linking all associated programs, documents is an effective tool. (IO)
_**Planning for Hazard Identification**_
- Continuing Improvement noted, after an accident investigation. Updated JRA and reviewed hazards associated with task. JRA -011 rev 1 (PO)
- A form is used to track accident reviews and also identify if this triggers a revision in JRAs. (F&O)

## Noteworthy Practices

_**Control of Documents **_
- F& O has developed excellent document control for hard copy items. **(F&O)**

## Minor Nonconformances

_**Resources, Roles, Responsibility and Authority**_
**In the R2A2 for tool crib operator, discuss more specifically about the calibration responsibilities of the tool crib operator.  e.g. the tool crib operator perform calibration and inspection of equipment as required. (F&O) **
**Two R2A2’s did not contain the OHSAS Responsibilities.   All R2A2’s should be updated tracked and verified to contain the OSHAS Responsibilities. (CAD)**

## Opportunities for Improvement

_**Legal and Other Requirements**_
- In F&O, When changes come in to SBMS personnel are assigned and tracked through the family ATS to review the changes and determine the impact.  This review is typically 60-90 days.  No specific implementation date is set so implementation may not occur for a lengthy time.  No guidance is given from SBMS regarding the speed of implementation required.  This is a site-wide problem. (Institutional)

_**Control of Documents**_
- Two JRA’s were completed and signed off without all team members being listed as participants. However through interviews it is clear that additional people were on the team. (CAD)

**Notes:**
During EMS implementation, complete system documentation was created for each organization in order to assure organizations could successfully register to the ISO Standard under a phased registration process.   Now that the Lab has fully registered under on Institutional Level EMS, complete system documentation is no longer needed for every organization.  With a maturing system, instances are seen where some documents have lost their value and are maintained out of habit (ex:  individual EMS Manuals or Program Descriptions, OCFs).  The upkeep is onerous and time consuming and, if not maintained properly, leads to errors and audit findings.  Consider reducing or eliminating EMS Documentation that is not required by the Standard and no longer has value for the owning organization. (Institutional)

## Opportunities for Improvement

_**Training/ Awareness**_
- Consider reviewing with individuals where to find JRAs on the web. (F&O)
_**Operational Control**_
- Review with staff the proper method for storage and maintenance of personal protective equipment.  In Staff Services motor pool it was observed that hearing protection was hung up or stored in tool boxes.  Personal protective equipment, can deteriorate or be soiled by improper storage. They need to be kept in a clean manner. If shared, they need to be cleaned in between usage.  (SSD)

## Sitewide Issue

- When changes to SBMS are identified, and notices go out,
- the _implementation requirements need to be included_
- (e.g. procedure goes into effect in ___ days from receipt).
- It is important for SBMS to obtain an implementation schedule from the subject matter experts and issue it at the same time as the notice.
- This function was done by the SBMS Steering Committee with the I&D Paper.  It is no longer captured.
- Impact may be on:
-  New Subject Areas, Program Descriptions
-  Major revisions
-  (Minor Revisions)

**Sitewide Issue**

## Thank you

- OSH Audit Team
- C. Weilandics- NSLS
- Ed Lacina, with K. Erickson, F. Horn-  CAD, SCMD, IO, PO
- N. Bernholc- F&O
- D. Robbins with J. Peters- BES
- ESH Coordinators and OSH Reps from the organizations audited whose openness and cooperation made the audit successful.