# Presentation: 211769

## Support Organizations Reporting to the Director’s Office ISO14001 Environmental Management System & OHSAS 18001 Occupational Heath and Safety System Management Review12/04/08

## Support Organizations Reporting to the Director’s Office ISO14001 Environmental Management SystemSORD EMS Management Review EMS Rep:  Anna Bou     12/04/08

## Agenda

**Agenda**

**Scope**
**Recent changes to EMS program**
**Significant Environmental Aspects**
**Results of Audits**
**Status of Objectives and Targets (Follow-up from FY07 MR)**
**Noteworthy E-practices and Improvements**
**Status of Corrective/Preventative Actions**
**Stakeholder Issues**
**FY09 Suggested Objectives (Improvements)**
**Request for feedback**

## Recent Changes

**Recent Changes**

_**Description of ESHD EMS Program:  **_
- Located at ESH EMS Web Site:  _[http://](http://intranet.bnl.gov/eshq/ems/)__[intranet.bnl.gov/eshq/ems](http://intranet.bnl.gov/eshq/ems/)__[/](http://intranet.bnl.gov/eshq/ems/)_
- The scope of ESH's EMS includes all activities internal to the ESH     Directorate, as well as all activities internal to the Director's Office (DO), Community, Education, Government & Public Affairs (CEGPA) and Finance Directorate (DI).
- Activities conducted by the above to support institutional systems are not included in the scope of this EMS, but instead covered under BNL's Institutional-Level EMS.

**Recommendations for change:**
**Decision A:** Combine the **ESH Directorate** + **BOP (SORD)** OHSAS _into one program_

**Decision B:** Combine the ESH Directorate + BOP **OSH Rep** +  **EMS Rep** _to one person_
- (Suggestion: A. Bou or N. Bernholc)

## Significant EnvironmentalAspects

**Significant Environmental****Aspects**

_**Information Technology Division (ITD)**_
- Storage or use of hazardous material (battery banks)
- Spills (potential)
- Hazardous waste (cleaners, light bulbs, aerosol cans, etc...)

_**Human Resources:  Occupational Medicine Clinic (OMC)**_
- Industrial & Hazardous waste (Photo Processor)
- Spill Potential (Photo Processor)
- Medical waste (Clinical)

## Significant EnvironmentalAspects

**Significant Environmental****Aspects**

_**CEGPA:  Office of Educational Programs (OEP) & Production Services**_
- Educational Demonstrations:
- Hazardous waste
- Spill Potential
- Production Services:
- Industrial waste (Press Ink)
- Liquid Discharges (Press cleaning)
- Atmospheric Discharges (Press Ink) Emissions Unit of Title V Permit, and use of filtration.

## Significant EnvironmentalAspects

**Significant Environmental****Aspects**

**Other groups don’t have significant aspects; however, they are still covered by the EMS.  **
**These organizations can and do contribute to continual improvement initiatives.**

## Results of Evaluations of Compliance

**Results of Evaluations of Compliance**

**Compliance Audits:**
**Tier I  **
**   **All findings closed
**New York State RCRA Audit**** (Sitewide)– **One Notice of Violation, none applicable to SORD organizations
**     ****EPD Multi-Topic Assessment**
-    No non-conformance or non-compliance issues identified.

## Systems Audits:
EMS Internal Assessment (February 2008)
One minor nonconformance:  An obsolete version of an OMC waste procedure (dated 2002) was not removed from circulation
One Observation:  The Correspondence and Commitment Tracking Subject Area is unclear as to whether external environmental inquiries received informally are required to be entered into CCTS.  Not clear that the system is being routinely used.  
NSF Recertification Assessment (June 2008) 
OFI – CEGPA – Consider capturing quality improvement and community involvement goals with positive ESH impacts when setting future objectives and target (Educational Program’s Open Space Stewardship Program).

**Systems Audits:**
**EMS Internal Assessment (February 2008)**
- One minor nonconformance:  An obsolete version of an OMC waste procedure (dated 2002) was not removed from circulation
- One Observation:  The Correspondence and Commitment Tracking Subject Area is unclear as to whether external environmental inquiries received informally are required to be entered into CCTS.  Not clear that the system is being routinely used.
**NSF Recertification Assessment (June 2008) **
- OFI – CEGPA – Consider capturing quality improvement and community involvement goals with positive ESH impacts when setting future objectives and target (Educational Program’s Open Space Stewardship Program).

**Results of EMS Assessments**

**Notes:**
Overall EMS internal audit issues:
Management Reviews missing required sections
EP work order not closed out to show an alarm was fixed.

## SORD
Objective: Train purchasers and specifiers on the requirements of the Environmentally Preferable Purchasing (EPP) Program by participating in EPP awareness training for all credit card holders.
Results:  EPP awareness training was provided to credit card holders in April 2008.  Training was also provided at the institutional level. 
**First objective written that applies to SORD as a whole – Improvement!

HR, Diversity Office, OMC, and CDC
Objective:  Improve Electronics Stewardship - Enable ENERGY STAR features on computer monitors

_***SORD***_
_**Objective:**_ Train purchasers and specifiers on the requirements of the Environmentally Preferable Purchasing (EPP) Program by participating in EPP awareness training for all credit card holders.
**Results:  **EPP awareness training was provided to credit card holders in April 2008.  Training was also provided at the institutional level.
***First objective written that applies to SORD as a whole – *_*Improvement!*_
_***HR, Diversity Office, OMC, and CDC***_
_**Objective:**_**  **Improve Electronics Stewardship - Enable ENERGY STAR features on computer monitors

**FY 08 Objectives and Targets**

## Noteworthy Practices 

**Noteworthy Practices **

_***CEGPA – Office of Educational Programs (OEP)***_
- _“__Computers for Learning” Program_
**Results:**  Donated 20 computers and monitors and 4 printers valued at $22K to LI schools.

## Other Improvements

**Other Improvements**

_***CEGPA – Production Services***_

- Added 100% recycled, Forest Stewardship Council (FSC) certified paper where possible.
- Used 100% biodegradable foam boards for displays.
- Soy inks reviewed for replacement due to metal content and discharge concerns.  No substitute available.
- Graphic Arts  – bicycle used as delivery option.

**Notes:**
Bicycle use about 5%, but shows positive attitude

## Other EMS Information

**Other EMS Information**

**Stakeholder Concerns – No issues with external stakeholders.**
**No formal “e”-related corrective and preventive actions.**

## FY09 Objectives - Suggestions

**FY09 Objectives - Suggestions**

- _Suggested EMS Objectives:_
- Improve Environmentally Preferable Purchasing Program (PEMP EO13423)
- Evaluate available biobased products as replacements for currently used materials.
- Refresher training to purchasers and credit card holders.
- Reduce paper consumption – promote a policy addressing the use of duplex printing and copying
- Ensure Electronic Product Environmental Assessment Tool (EPEAT) products are being purchased (ensure ENERGY STAR functions are enabled)

## FY 09 Objectives - Suggestions

**FY 09 Objectives - Suggestions**

- Assign personnel to turn off lights at the end of the day in remote facilities or install sensors
- Identify and implement at least one opportunity to use electronic signatures that will reduce printed copies and traveling time.

## FY09 Suggestions

**FY09 Suggestions**

**Any additional objectives or other suggestions?**

## Support Organizations Reporting to the Director’s Office - “SORD”

**Support Organizations Reporting to the Director’s Office - “SORD”**
**OSH Management Review**
**12/04/08 **
**OSH Rep: N. Bernholc**

## Management Review Scope –	Topics (per OHSAS 18001)

**Management Review Scope –****	****Topics (per OHSAS 18001)**

**Overview of Management System**
**Resource Assessment /Financial Investment**
**Evaluation of Completeness of Hazard evaluations**
**Review of OSH Performance – **
- Audits and Assessments
- Leading and Trailing Indicators
- Review of Performance on FY08 OSH Objectives
**Communication, participation and consultation**
**Changing Circumstances **
**Stakeholder concerns**
**Objectives for FY09 **
**Management Review Questions**

## Overview of the OSH Management System For SORD 

**Overview of the ****OSH Management System For SORD **

_**Written OSH Program: Centralized at Site level**_** **
- Site OHSAS Web Site
- Site Objectives and suggested objectives for line organizations to adopt
- Internal Audit
- OHSAS 18001 Subject Area
_**Written Program: Maintained at Division/Office Level**_
- Division OSH Web Sites will only contain the following.
- DISCUSS:  Will no longer have their own OSH Management.  *Should we be In process of removing it from the websites ?*
- Objectives
- Hazard List & Risk Assessments (JRA and FRA) – Should we reduce the individual JRA/FRA’s and use the site wide?
- Records and Document Control Management
- OSH Program Descriptions

## ESSH Policy

**ESSH Policy**

- The SORD organizations have posted copies of the Policy in their buildings.
- The Policy is also accessible from multiple BNL Web Sites
- No issues were raised in the Internal Audit or NSF Audits regarding BNL staff understanding or accessing the policy.

**Output: Decision & Action Related **
**to Possible Change **
- Record of Decision:   No new action
- or changes needed in Policy

## Resource Assessment 

**Resource Assessment **

| SORD OHSAS 18001- OSH Representative | Nicole Bernholc
 |
| --- | --- |
| Division/Office | OSH Point of Contact |
| CEGPA | Scott Bronson, Richard Backofen |
| Computational Science Center | Mary Lynn Heinrich |
| Northeast Regional Counterintelligence Office | Nicole Bernholc |
| Director’s Office (including Legal and Office of Strategic Planning ) | Nicole Bernholc |
| Diversity, HR/OMC | Terry Maugeri |
| Finance Directorate (Fiscal/Business Systems/Budget) | Toni Hoffmann |
| Information Services | Patricia Flood |
| Information Technology Division | Mary Lynn Heinrich |
| Internal Assessment & Oversight Office | Margaret Sparrow |
| Quality Management Office | Steven Stein |

## Financial InvestmentsOHSAS 18001 Program Resources/Cost

**Financial Investments****OHSAS 18001 Program Resources/Cost**

| OHSAS 18001 Program | Persons in this role | Person-hours
/year in FY08 | Estimated 
Cost |
| --- | --- | --- | --- |
| SORD Line Organization OSH Representatives POCs | 1 | 300 | 3,000 |
| SORD Line Organization OSH POCs | 8 |  |  |
| Total | -- | -- |  |

## Financial InvestmentsOHSAS 18001 & EMS 14001 Programs

|  | Person-hours
/year | Estimated 
Cost |
| --- | --- | --- |
| ESH Directorate & BOP EMS Representative (A. Bou) |  80 | $    8000 |
| ESH Directorate OHSAS Representative (R. Selvey) |  40 | $    4000 |
| BOP (SORD) OHSAS Representative (N. Bernholc) | 60 | $    6000 |

**Financial Investments****OHSAS 18001 & EMS 14001 Programs**

**Recommendations for change:**
**Decision A:** Combine the **ESH Directorate** + **BOP (SORD)** OHSAS _into one program_

**ESHD** OHSAS

**BOP** OHSAS

**ESHD** EMS

**BOP** EMS

-    A

- B

**Decision B:** Combine the ESH Directorate + BOP **OSH Rep** +  **EMS Rep** _to one person_
- (Suggestion: A. Bou or N. Bernholc)

## Hazard Assessment 

**Hazard Assessment**

| Common Hazards | Existing JRA |
| --- | --- |
| Ergonomics | *(Manual material handling; Moving;* Office work) |
| High voltage  |  |
| Noise |  |
| Travel * | Travel |
| Indoor Air |  |
| Egress |  |
| Driving *, Bicycling * | Driving; Bicycling  |

| Hazards limited to CEGPA, ITD, OMC and Child Development Center 
Non-ionizing Radiation (e.g. RF, microwaves)
Confined Space
Chemicals/toxic hazards
Flammable gasses/liquids/materials
Blood-borne Pathogens |
| --- |

## Review of OSH Performance Results of OHSAS 18001 Audits

**Review of OSH Performance ****Results of OHSAS 18001 ****Audits**

**Internal Audit**** **- Conducted by SHSD -  February- April 2008
- Corrective action on findings and OFIs are covered in ATS 4244
**Only minor or opportunities for improvement for SORD**
**All corrected by the time of the NSF audit**

**External Audit - Site registration by NSF**** **June 2008
- Corrective Action Plan developed and tracked in ATS 4226
**No findings for SORD organizations.**

## OSH Compliance- Internal Assessments 

**Industrial Hygiene Multiple Topic Self Assessment**
- Site written program and line implementation (Corrective actions are to be tracked in ATS.)
- Organizations selected those programs that were applicable to their line.
- Asbestos,
- Blood-borne Pathogens,
- Chemicals (Laboratory Standard and HazCom),
- Indoor Air Quality,
- Noise and Hearing Conservation,
- Personal Protective Equipment,
- 10 CFR 851 Compliance
- Corrections are mostly program corrections to Site-wide concerns.
- e.g.**  **Site written program and line implementation (Corrective actions are to be tracked in ATS.)
** ****OSH Major Non-conformances:**** 1**
- Many locations do not have the asbestos content labeled on building material (29CFR1926.1101(k)(8)(vii).)
- Chemicals: BNL program’s policies were not modified to reflect NFPA requirements. There is a gap between the *Fire Safety* Subject Area and* WWC*

**Review of OSH Performance**
**OSH Compliance- Internal Assessments**** **

## Review of OSH Performance Nationally Recognized Testing Lab (NRTL) Electrical Equipment Inspections (EEI)

**Review of OSH Performance**** ****Nationally Recognized Testing Lab (NRTL) ****Electrical Equipment Inspections (EEI)**

**Issues:  **
**Inadequate Resources** for:
**Organizing and program oversight** (Database)
-  Reputable manufacturer program allows credit for acceptable equipment.
-  EEI database will provide BNL-wide sharing of “Reputable manufacturer” inspections
**Completion of inspections**
- 30,000+ pieces of equipment need Authority Having Jurisdiction (AHJ) approval
- SHSD has committed to inspection all “Balance of Plant” equipment
- Inventory of Facilities & Operations, NSLS, CAD still unknown (or only estimated).
**Addressing growing number of items found not in compliance**

- In SORD only one investigation has been made.
- ITD investigation was NRTL approved.

## Review of OSH PerformancePerformance on Objectives for FY08

**Review of OSH Performance****Performance on Objectives for FY08**

| CEGPA | Completed |
| --- | --- |
| Computational Science Center | Completed |
| Director’s Office (including Legal, AND Office of Strategic Planning, Northeast Regional Counterintelligence Office) | Completed |
| HR | 3/5 completed  |
| OMC | 4/5 completed (one to be carried over. |
| Finance Directorate (Fiscal/Business Systems/Budget) | Completed |
| Information Services | Completed |
| Information Technology Division | Mary Lynn Heinrich |
| Internal Assessment & Oversight Office
Quality Office | Completed 
5 of 6 OSH completed.  |

## Review of OSH Performance Leading and Trailing Indicators 

**Review of OSH Performance ****Leading and Trailing Indicators**

**No injuries in :**
**Production Services (10 yrs)**
**Computational Science Center**
**Internal Audit and Oversight**
**Information Services**

**In the remaining SORD organizations: ****	**
**2 ****First Aid Cases**
**5**** DART/Total Recordable Cases**

## Injury Cases By DepartmentFiscal Year 2008

**Injury Cases By Department****Fiscal Year 2008**

| Comm. Involve. Gvt. & Pub Aff |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Case # | Injury
Date | General
Activity | Injury
Cause | First
Aid | DOE
Recordable | DART | Lost
Days | Restricted 
Days |
|  |  |  | Fall on same level |  | X | X |  48 | 99 |

| Director's Office |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Case # | Injury
Date | General
Activity | Injury
Cause | First
Aid | DOE
Recordable | DART | Lost
Days | Restricted 
Days |
|  | 09/25/2008 | Food Preparation | Sharp Edge - Contact with | X |  |  |  |  |

| Fiscal Division |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Case # | Injury
Date | General
Activity | Injury
Cause | First
Aid | DOE
Recordable | DART | Lost
Days | Restricted 
Days |
|  | 12/11/2007 | Office Work | Fall on same level | X |  |  |  |  |

| Human Resources |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Case # | Injury
Date | General
Activity | Injury
Cause | First
Aid | DOE
Recordable | DART | Lost
Days | Restricted 
Days |
|  | 08/06/2008 | Material Handling | Falling Object |  | X | X | 31 | 11 |

## Injury Cases By DepartmentFiscal Year 2008

**Injury Cases By Department****Fiscal Year 2008**

| Information Technology Division |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Case # | Injury
Date | General
Activity | Injury
Cause | First
Aid | DOE
Recordable | DART | Lost
Days | Restricted 
Days |
|  | 11/06/2007 | Walking | Slip/Trip |  | X | X | 47 | 0 |
|  | 11/19/2007
 | Walking
 | Fall on same level |  | X |  | 0 | 0 |
|  | 11/09/2007
 | Office work | Bodily Reaction |  | X |  | 0 | 0 |

## Tier I’s

**Tier I’s**

**Tier I’s  were done in all departments except 1 whose facilities are under construction.**
**A review of the data was done in several meetings held by S. Kane.**
**Most items were closed out within a reasonable time period.**

**Questions?  **
**Are the Tier I’s effective for your organizations?  **
**What help do you need? **

## Site-wide Communication OSH communications from external and internal interested parties (stakeholders)

**Site-wide Communication ****OSH communications from external and internal interested parties (stakeholders)**

**Initiatives in communication**
**Safety webinars (ASSE, NSC)**
**All hands meetings**
**Healthfest**
***Take 5***** video safety minute**
**ESSH Monthly Newsletter**
**Radiological News**
**SHSD webpage**
**BNL Bulletin / Monday Memo**
**ESH Coordinator Meetings**
**Director’s Supervisor Meetings**

## Additional SORD Department Communications

**Additional SORD Department Communications**

- Department(s) All-hands meetings
- Distribution of objective implementation process to individuals
- Training coordinators/ESH coordinators follow-up with staff to receive required training
- Special Department Training for objectives

## Effects of Foreseeable Changes to Legislation & Scope of Work

**Effects of Foreseeable Changes to Legislation & Scope of Work**

**OSH Program Areas**
***Ergonomics **** *Rules in 10 CFR 851: DOE audit in FY09.  SHSD tracking.
**EEOICPA/ NIOSH** may affect workload of OMC.
**Project reviews and Safety documentation** **such as I****nformation Technology Division Sigma 7 area; new building**

**Recommendation:**
**Verify that ergonomic hazards are identified in SORD and make sure a plan for resolving these items are in place.**
- Record of Decision:
- ___No additional actions
- ___New Action: Develop Plan

## FY09 OSH Objectives

| 1. | Objective: Human Performance Improvement (HPI): Initiate/increase human performance training for work planning, design, and/or reporting (such as participation in Fisher IT, Inc. or Shane Bush human performance training).
 | Org |
| --- | --- | --- |
|  | Provide HPI training to 80% of line organizations involved in risk-significant activities and processes as identified by the Human Performance Steering Team.
 |  |

**FY09 OSH Objectives**

## FY09 OSH Objectives

| 1. | Objective: Improve DART and TRC rate performance [PEMP 5.1.1.1, 5.1.1.2] |  |
| --- | --- | --- |
| 1.d.1 | Initiate awareness presentations of injuries related to overexertion, slips, falls, bodily reaction and repetitive motion. – This was started for QA last year   |  |
|  | Review statistical data on injuries with each line organization  |  |
|  | Conduct All-hands meeting with discussion of past injuries in line organization and other organizations |  |
| 1.d.2 | Increase Webinar for ESH Professionals of Line Organizations |  |
|  | Help prepare for 2009 Ergo Audit  - Identify ergonomic hazards  |  |
| 1.e.3 | Improve manual lifting and ergonomics training. |  |
| 1.e.4 | Target specific groups for proactive presentation/evaluation by the new Physical Therapist |  |
| 1.e.5 | Advertise the services of the new Physical Therapist for personal and work related injury therapy. |  |

**FY09 OSH Objectives**

## FY09 OSH Objectives

**FY09 OSH Objectives**

| 2. | Objective: Reduce Traffic violations and accidents.   
[PEMP 5.1.1.1, 5.1.1.2] |
| --- | --- |

| 2.A | Institute an appropriate organization level initiative to raise employee awareness of vehicle safely (such as use of DVD class.) |  |
| --- | --- | --- |
| 2.b. | Raise awareness of the requirement for disciplinary actions for repeated violations with supervisors. As per  the Disciplinary Actions  Subject area.     |  |

| 4. | Objective: Improve Chemical Storage in Flammable Cabinets |  |
| --- | --- | --- |
|  | Improve storage to no violations of NFPA requirements for flammable cabinets. (Target = 0 non-compliant cabinets) |  |

| 5. | Use site JRA /Eliminate redundant documents |  |
| --- | --- | --- |
|  | Participate on working group when formed  |  |

## 2009 Objectives -  Finalization 	

**2009 Objectives -  Finalization**** ****	**

**Treat organizations with office functions as one. Not every small organization needs to do an objective. **
**Decide which organization will work on a goal.   **
**Less is more.   Don’t pick too many objectives.  Do less but do it better. **
**ITD, OMC and CEGPA have the most objectives because they have the most potential hazards.  **
**ITD and CEGPA should pick an additional chemical goal.**

## FY09 OSH Objectives

**FY09 OSH Objectives**

**Output:  Decision & Actions Related to Possible Change:**
_**OSH Objectives**_**: **These Objectives and Improvement Initiatives were based on the proposed sitewide objectives.  They may be change if the sitewide objectives are modified.   They are  adequate to address issues from Internal OSH Audits, NSF Audit, known weakness, and improvements.
- Record of Decision:
- ___Accept these Objectives
- ___Additional Objectives or changes:

## Issues from FY07 SORD Management Review

**Issues from FY07 SORD Management Review**

| Issue
 | Resolution |
| --- | --- |
| Lack of ESH coordinator for Director’s Office Organizations  | Appointed N. Bernholc to the role
 |
| Question: 
Does having an individual outside the organization serve the needs of the organizations?  |  |

## Management Review Decisions

**Management Review Decisions**

**Is the OSH Management System **_**effective**_** in**** ****achieving policy commitment?**
**Is the OSHMS **_**effective**_** in achieving the objectives, targets and performance measures?**
**Is the OSHMS **_**adequate**_** in terms of:**
**Resource allocation?**
**Information systems?**
**Organizational issues – staff expertise; procedural requirements**

## Management Review Decisions

**Management Review Decisions**

**Are the objectives, targets and performance measures **_**suitable**_**, taking into account the following factors:**
- Injuries/illnesses?
- Current and future regulatory requirements?
- Business interests, technological capability?
- Internal organizational or process changes?
**Should **_**additional**_** objectives, targets or performance measures be established?**

## Any Additional Comments or Concerns?

**Any Additional ****Comments or Concerns?**

_**Thank you for your participation**_
**This ****PowerPoint presentation**** will be posted on the Site OSH Web Page**
**Minutes of this Meeting**** and a ****Record of Decision on Issues**** will be prepared and posted on the Site  OSH Web Page**