# Presentation: 774640

## EHS 799Division ES&H Self-Assessment Training

**Michelle Flynn**
**Office of Contract Assurance**
**ext. 7073**

## Course Outline

**Course Outline**

**LBNL ES&H Self-Assessment Program**
**Division ES&H Self-Assessment**
**Roles and Responsibilities**
**Self-Assessment Performance Criteria**
**Planning Self-Assessment Activities**
**Performing Effective Self-Appraisals**
**Tracking and Reporting Self-Assessment Results**

## LBNL Self-Assessment Program

**LBNL Self-Assessment Program**

**Mechanism for assuring Integrated Safety Management (ISM)  is fully implemented and effective**
**Formal, internal process to evaluate ES&H programs and policies**
**Goals:**
**Evaluate safety systems**
**Assure safe workplace **
**Identification of noteworthy practices, deficiencies, and implementation of corrective actions**

## Four tiered self-assessment system

**Four tiered self-assessment system**

| Assessment | Type of Review | Performed By |
| --- | --- | --- |
| Division 
Self-Assessment |    Safety System |    Line Management |
| Safety Review Committee (Management of ES&H) | Safety Management | Peer Researchers
and Staff |
| ESH Technical Assurance | In Depth Technical | EH&S Personnel |
| Appendix B Self-Assessment (Contract Performance Measures | DOE/UC Contract | Functional Managers |

## Division ES&H Self-Assessment

**Division ES&H Self-Assessment**

**Demonstrate the division has an effective ISM program**
**Ensure work is conducted safely, with minimal adverse effects to workers, public, and environment**
**Promote continuous improvement of divisions’ ES&H programs**
**Promote Operational Awareness w/ DOE**
**Minimize formal audits**

## Roles and Responsibilities 

**Roles and Responsibilities**

| Division | Responsibilities | Field Activities |
| --- | --- | --- |
| Management |    Ensure robust program, corrective actions effectively implemented | Participate in inspections |
| Team Leaders | Coordinate activities, familiar w/ operations | Lead activities, track findings, corrective actions |
| Team Members | Familiar w/ activity requirements, protocol | Communicate findings to team leaders |
| Division Staff | General safety awareness | Implement corrective actions |

## Roles and Responsibilities

**Roles and Responsibilities**

**EH&S Division**
**EH&S Division Liaison program **
**Support division self-appraisal activities**
**Provide consultation and training**
**Provide input to performance measures**
**Training and support for safety walkarounds**

## Roles and Responsibilities

**Roles and Responsibilities**

**Office of Contract Assurance**
**Develop/modify annual performance measures in consultation with EH&S and division personnel**
**Publish annual performance measures and guidance **
**Validate self-assessment processes**
**Prepare annual Labwide self-assessment report**
**Assist divisions as requested**

## Self-Assessment Performance Criteria

**Self-Assessment Performance Criteria**

**Division ISM Plan **
**Goals and Opportunities for ES&H improvement**
**Annual institutional division ES&H self-assessment performance measures**

## Self-Assessment Performance Criteria

**Self-Assessment** **Performance Criteria**

**Division ISM Plan**
**Flow down of institutional requirements**
**PUB-3000 and Institutional ISM Implementation Plan**
**Tailored to divisional operations**
**	****Self-assessment provides opportunity to measure effectiveness of implementing division-specific criteria set forth in division ISM plan.**

## Self-Assessment Performance Criteria

**Self-Assessment Performance Criteria**

**Prior Year’s Self-Assessment**
**Division ES&H program improvement initiatives**
**Self-assessment process improvement opportunities identified by division and/or OCA**
**	****Self-assessment provides opportunity to measure effectiveness of actions taken to address ES&H goals and opportunities for improvement. **

## Self-Assessment Performance Criteria

**Self-Assessment Performance Criteria**

**Institutional Performance Measures**
**Based on 5 core functions of ISM.**
**OCA drafts based on the following input:**
**Significant PUB-3000 and institutional ISMS implementation plan objectives.**
**Effectiveness review of self-assessment processes.**
**Division representatives and EH&S program leads review and provide input.**

## Division ES&H Self-Assessment Program

**Division ES&H ****Self-Assessment Program**

**Planning**
**understand requirements, focus on performance criteria, select self-assessment teams and prepare checklists. **
**Performing self-appraisals**
**interviews, documentation review, ongoing safety walkarounds and formal inspections **
**Tracking and reporting deficiencies**
**issues management and the annual division ES&H self-assessment report. **

## Planning Self-Assessment Activities

**Planning Self-Assessment Activities**

**Understanding ES&H Requirements**
**Refer to applicable documents**
**PUB-3000 LBNL Health and Safety Manual**
**Worker Safety and Health Program**
**Chemical Hygiene and Safety Plan**
**Division ISM plan**
**Contact Division Self-Assessment Lead**
**Consult with EH&S Division Liaison and/or subject matter experts**
**Obtain training **
**Participate in formal inspections of other divisions**

## Planning Self-Assessment Activities

**Planning Self-Assessment Activities**

**Focus on performance criteria**
**Review performance criteria and annual guidance**
**Identify actions required to satisfy each criterion**
**Establish scope for formal inspections**
**Determine methods to appraise effectiveness of actions**
**Identify documentation, databases, etc. needed to evaluate division performance**
**Designate teams**
**Create checklists**
**Arrange for on-the-job training**
**Schedule appraisal team activities**

## Planning Self-Assessment Activities

**Planning Self-Assessment Activities**

**Self-Appraisal Teams**** **
**Knowledgeable of Laboratory policies, applicable ES&H requirements, and division procedures for ES&H compliance**
**Understand inspection techniques**

## Planning Self-Assessment Activities

**Planning Self-Assessment Activities**

**Inspection Checklist(s)**
- Comprehensive
- EH&S provides a walkaround checklist on homepage.
- Categorized by types of work environments or ES&H functional areas
- Division can provide their own walkaround checklist

## Performing Division Self-Appraisals	

**Performing Division Self-Appraisals****	**

**Methods**
**Interviews**
**Documentation reviews **
**Authorizations, training, ORPS, NTS, CATS**
**Past appraisal findings**
**Division self-assessment, MESH, ESH technical assurance, DOE reviews**
**Inspection findings**
**Walkarounds and formal inspections**

## Performing Division Self-Appraisals

**Performing Division Self-Appraisals**

**Ongoing Informal Inspections –  Safety Walkaround Program**
**EHS 27 - Performing an Effective Safety Walkaround**
**General and customized versions**
**Formal inspections**
**Self-appraisal teams**
**Planned in advance**
**Checklists**
**	**

## Issues Management 

**Issues Management **

**Identify and track deficiencies**
**deficiencies entered into Corrective Action Tracking System (CATS)**
**corrective actions effectively implemented**
**Data Analysis Roll up deficiencies and noteworthy practices**
**periodically analyze deficiencies (open and closed) to identify chronic and significant issues**
**identify root causes**
**identify common causal factors that, if corrected, will prevent deficiency recurrence**
**Lessons Learned and Best Practices**

## Division ES&H Self-Assessment Report

**Division ES&H Self-Assessment Report**

- Assess performance against the performance criteria
- Follow Division ES&H Self-Assessment Guidance, as applicable
- Analyze performance
- Describe actions taken to prevent recurrence of adverse events.
- Assess the effectiveness the corrective actions.
- Identify any potential lessons learned
- Describe results
- Identify future safety program improvements and goals
- Identify institutional issues
- Reports submitted to OCA once reviewed and approved by Division Director

## OCA Validation of Self-Assessment Process

**OCA Validation of Self-Assessment Process**

**Provide feedback on the comprehensiveness of the divisions’ self-assessment processes.**
**Validate a sampling of self-assessment results.**
**Identify noteworthy practices.**
**Identify opportunities for self-assessment process improvement.**
**Document institutional opportunities for improvement. **

## Institutional ES&H Self-Assessment Report

**Institutional ES&H Self-Assessment Report**

**Summary of all four ES&H self-assessment activities**
**Divisional noteworthy practices**
**Institutional opportunities for improvement**
**Source of lessons learned**

## Resources

**Resources**

_**[OCA website ](http://www.lbl.gov/DIR/OIA/)**_
**Division ES&H Self-Assessment Manual (LBNL/PUB-3105)**
**ES&H Self-Assessment Program (LBNL/PUB-5344)**
**Division ES&H Self-Assessment Performance Measures**
**Institutional ES&H Self-Assessment Report**
**Appendix B Contract Performance Report**
**CATS database**
**Lessons Learned and Best Practices database**

_**[OCA website ](http://www.lbl.gov/DIR/OIA/)**_
**Division ES&H Self-Assessment Manual (LBNL/PUB-3105)**
**ES&H Self-Assessment Program (LBNL/PUB-5344)**
**Division ES&H Self-Assessment Performance Measures**
**Institutional ES&H Self-Assessment Report**
**Appendix B Contract Performance Report**
**CATS database**
**Lessons Learned and Best Practices database**

## Good Examples from FY07 Reports

_**Analyze performance**_
**Describe actions taken to prevent recurrence of adverse events.**
**• *****ALS had one recordable case last year; an ergonomics injury resulting from longstanding issues. Root cause analysis identified the need to get early identification and treatment for discomfort. ALS identified outreach as the needed corrective action. This was a topic at one of the “Safety First” Thursday User Forums, presentations were given at both the SMT and the Division Safety Committee meetings and materials were prepared for individual safety circles [Appendix 8.1]. This was a focus of the Lab Director’s initiative on supervisor ergonomics walkarounds in April, and was also reinforced during the Self Assessment with questions on both the individual surveys and the inspection checklists. ***
_**Assess the effectiveness of the initiatives and corrective actions taken to address these issues.**_
**• *****Training completion is essentially unchanged from 2006. Considerable effort was made to improve the training completion statistics. In particular, implementation of the EH&S Calendar of Recurring EH&S Activities and the issuance of the PI Guide to EH&S included elements to improve performance in this area. These tools have not substantially improved the training completion metric. ***
***• ******Staff time has been very limited for performing the preventive evaluations, and little headway has been made on these. The ALS is committed to performing 3 evaluations per month and retiring the backlog by February of 2008. Identify future safety program improvements and goals.***
***• ******Add enhanced LOTO review and environmental / waste minimization review to QUEST. Check implementation of multi-container inventory sheets for gases and chemicals inside equipment.***
***• ******The Project Safety Questionnaire, which has been used in the past, needs to be evaluated for effectiveness and a mechanism needs to be put into place to assure that all questionnaires are completed.***
_**Identify institutional issues**_
***• ******Expand the web-based curriculum of safety training courses.***
***• ******Review LBNL policy on first aid kits in staff workspaces.***
***• ******Improve ergonomic database to prompt re-evaluations for staff moves.***

**Good Examples from FY07 Reports**

## Excerpts from Office of Contract Assurance Validation Reports

_**Provide feedback on the comprehensiveness of the divisions’ self-assessment processes**_
**• *****The Division described its new ES&H awareness questionnaire, but the report***
***includes no details on rate of return or lessons learned from the responses.***
_**Identify noteworthy practices**_
**• *****Team approach to performing self-assessment***
***• ******Division Director and/or Deputy involvement in safety committee and self-assessment***
***• ******Division-specific metrics***
_**Identify opportunities for self-assessment process improvement**_
**• *****Verify information provided by Group Leaders and self-assessment teams using***
***other sources, as applicable. For example, the Division Safety Committee can***
***independently verify the compliance history of RWAs by obtaining a RADAR***
***report from the Radiation Protection Group.***