# Presentation: 104344

## 			EVALUATION OF THE Integrated Safety Management System atLawrence Berkeley National Laboratory

**Out-Briefing**
**September 27, 2006**

## Overview of Presentation

**Team Members/Areas of Focus**
**Objectives, Scope and Approach**
**Summary of Results**
**Institutional Processes**
**Facilities and Operations**
**Large Scale User Facilities**
**Bench Scale R&D**
**Worker Safety**
**Waste Management & Environmental Protection**
**Recommendations**
**Path Forward**

## Team Members

**Larry Kelly, DOE ORO****	****	****Berkeley Site Office**
**David Allen, DOE ORO****	****	**
**Ed Lessard, BNL****	****	****	****Large Scale R&D, User Facilities, ****CF1-5, GP3**
**Tom Mullen, ANL****	****	****	**
**Larry McClellan, PNNL****	****	****Laboratory/Bench Scale Activities, ****CF1-5, GP3**
**Pat Wright, PNNL****	****	****	**
**Mike Bebon, BNL****	****	****	****Facilities and Operations, ****CF1-5, GP3**
**Chris Johnson, BNL****	****	****	**
**Carol Scott, ORNL****	****	****Worker/Industrial Safety, Waste Management,**
**Doug Schlagel, McT****	****	****Environmental Protection, ****CF1-5, GP3**
**Steve Coleman, BNL****	****	****	**
**Bob McCallum, McT****	****	****Contractor Assurance, Self-Assessment**
**Kyle Turner, McT****	****	****	****Corrective Action Management, Work Smart ****	****	****	****	****Standards, ****GP1-2, CF5**

## Objectives, Scope and Approach

**OBJECTIVES AND SCOPE**
**Determine the overall effectiveness of the LBNL ISMS in satisfying the DOE requirements for ISM**
**Examine ISMS as it is designed and implemented at LBNL – at the institutional, division & activity levels**
- Understand how personnel implement ISM in practice – what they do, how they do it, why they do it, how they know it is right
- Determine the extent to which the ISMS – as articulated in documents and implemented in practice – is consistent with DOE expectations
**Use criteria/expectations outlined by**
- The DOE HQ Office of Health, Safety and Security (formerly SP)
- Key DOE Policies, Orders & Guides (e.g., P226.1, O226.1, O414.1C, P450.4, G450.4, and others)
- These were used as the basis for lines of inquiry

## Contractor Assurance, Self Assessment, CAM – CF5Bob McCallum and Kyle Turner

**A documented, structured process exists at the institutional level for assuring that contractual commitments – including performing work safely, meeting mission and customer expectations, and continuous improvement – are evaluated **
- The UC Assurance Plan for LBNL establishes the basic institutional functionalities for conducting contractor assurance activities, including identification of roles and responsibilities for Laboratory management
**Institutional initiatives are being undertaken to improve ISMS performance across LBNL**
**  **
- Reconfiguration of the IFA process is expected to improve the effectiveness of this assessment function and **will be essential** in identifying institutional-wide performance and in supporting performance measurement and assurance
- The Lessons Learned (LL) program is being enhanced to provide “push” notifications to persons whose activities relate to LLs via correlation with risk and performance characterized in individual Job Hazard Questionnaires (JHQ)

## Contractor Assurance, Self Assessment, CAM – CF5 Bob McCallum and Kyle Turner

**LBNL has not fully implemented an integrated, comprehensive Corrective Action Management Program providing guidance and processes for managing corrective actions to effective closure**** **
- A database tool (CATS) is being implemented for tracking corrective actions to closure
- Additional (DOE-expected) functions have not been fully defined and/or implemented
- Guidance on preferred causal analysis tools and their application space
- Guidance on triggers for and methods used for the conduct of extent of condition reviews
- Complying with internal guidance on significance (medium risk actions are addressed within 10 days)
- Guidance on the level of formality and methods for verification of action closure
- Guidance on triggers for and methods used to conduct effectiveness reviews

## Contractor Assurance, Self Assessment, CAM – CF5 Bob McCallum and Kyle Turner

**Elements of the Self Assessment (SA) processes applied at LBNL are not fully rigorous in terms of comprehensive and effective measurement of organizational performance**
- Current SAs are conducted using a pre-established checklist that is structured around – and limited to – evaluation of organizational performance with regard implementation of Core Functions 1 through 5
- SAs do not appear to examine performance to mission or functionality requirements, nor do they establish the degree to which associated objectives are being achieved
- SAs conducted to the standard checklist do not clearly reflect a risk-prioritized evaluation of organizational activities, organizational risk, and the associated priority for assessment
- SAs do not clearly measure performance against institutional ESH objectives, and they do not align across all organizational elements to reflect an integrated basis for LBNL performance measurement

## Contractor Assurance, Self Assessment, CAM – CF5 Bob McCallum and Kyle Turner

**The implementation approach for the OIA does not clearly reflect a framework for monitoring and verifying the maturation of  institutional assurance processes**
- For example, OIA monitoring of the SA process does not clearly focus on process effectiveness, rather, as currently being practiced, the OIA validates data developed in the organizational SAs
- OIA does not appear to be proactively evaluating implementation of the Quality Assurance Program

## Line Accountability, Roles and Responsibilities – GP1 & 2Bob McCallum and Kyle Turner

**Senior laboratory management has a strong sense of ownership and accountability for safety performance**
- There is a clear expectation by laboratory management that this level of safety ownership must be reflected at all organizational levels of the Laboratory and is integral with leading edge science
**Initiatives and practices to communicate and implement line management ownership of safety are being instituted**
- Senior management has recognized that full communication and understanding of expectations for safety ownership has not fully permeated the LBNL organization, and actions are being taken to address this
- Supervisor training has been developed and is being delivered that provides clear expectations for safety performance, and there is evidence that disciplinary actions based on safety performance have been and are being taken by the Laboratory
- The Laboratory Director has issued several laboratory-wide communications regarding safety expectations, and the EHS directorate has developed a “1 Minute 4 Safety” tool for use by line managers

## Line Accountability, Roles and Responsibilities – GP1 & 2Bob McCallum and Kyle Turner

**There does not appear to be a single, overarching set of Laboratory safety principles and expectations for individual position descriptions**
- These descriptions generally distinguish between line and ESH responsibilities
- However, safety responsibilities and expectations are documented in numerous command media leading to the potential for conflict and confusion
- Clarity in communications of these expectations is limited by the lack of clear hierarchy and relationships among command media
***There is no single, highest level set of essential safety behaviors and expectations for line managers, subject matter experts, and staff in general***
**Safety leadership and implementation of line management responsibilities for safety are highly variable across LBNL organizations**
- Variability in safety leadership and practice exhibited across LBNL by PIs
- Project documents sometimes approved by EHS personnel, not line or project manager; JHAs sometimes developed by EHS personnel without line participation
- Deviations from established safety requirements (e.g., proper PPE, maintenance of laboratory space safety configuration) reflect a lack of line management engagement and/or effective communication of and feedback on safety expectations

## Line Accountability, Roles and Responsibilities – GP1 & 2Bob McCallum and Kyle Turner

**Worker involvement in safety activities is not consistent across LBNL  **
- Formal worker safety committees have been established in some organizations (e.g., at ALS to review findings from safety inspections and consult with management on safety issues)
- This is not an institutionalized practice
- Workers are not consistently involved in developing safety practices
**The institution does not have a consensus regarding the value of and specific expectations for Safety Liaisons**
- There is no set of consistent expectations that define the Safety Liaison role(s)
- There is no set of triggers, which signals Safety Liaison engagement
- The combination of programmatic and liaison requirements leads, in some cases, to situations where personnel cannot effectively function in all areas where their involvement is required to implement ISMS requirements
- Most Safety Liaisons correctly emphasize helping their assigned organization perform work safely
- Assigned Safety Liaisons are not consistently receiving performance adequate

## Line Accountability, Roles and Responsibilities – GP1 & 2Bob McCallum and Kyle Turner

**There appear to be limited safety accountability mechanisms for Post-Docs and Graduate Students**
- The usual methods used to correct negative behavior (i.e., disciplinary action) appear to be unavailable
- Unless the PI and HR decide to terminate a Post-Doc or Graduate Student, the only threat in the event of improper behavior is to withhold approval of the Post-Doc’s or Graduate Student’s thesis, or withhold recommendations for future appointment at other institutions

## Work Smart Standards – GP5Bob McCallum and Kyle Turner

**LBNL has a documented, structured change management process for identifying and evaluating the applicability of new requirements and translating these requirements, as applicable, into the formal WSS set**
- Advisory and Steering Committees established
- Good collaboration between BSO and LBNL
- Standards Review Teams
- Guidance packages for process implementation
**Elements of the process for translating new WSS requirements into implementing practices are not formalized or completely understood**
- Change control processes exist for the RPM and PUB-3000
- The Safety Review Committee has authority for approval of changes to PUB-3000
- The role of the SRC is not codified in PUB-3000
- Lack of institutional guidance for translating new requirements into lower level implementing procedures
- There is some uncertainty on how industrial requirements are processed and incorporated into implementing constructs (e.g., procedures)

## Work Smart Standards – GP5Bob McCallum and Kyle Turner

**Institutional command media are not clear regarding the hierarchy and relationship between documents **
- Organizational and functional relationships among the RPM, PUB-3000, Operational Assurance Plan (being translated to the Quality Assurance Plan), ISM Plan, ESH SA plan, and UC Assurance Plan are not clearly established in terms how guidance flows from institutional level policies to implementation
- There are separate discussions of responsibilities and authorities for the same positions in multiple documents; there is no single set of safety behaviors
- The relationship between the OAP/QAP Appendix A risk ranking methodology and work planning constructs (PUB-3000) is not clear; current document does not yet have a consensus standard
- The role of the Safety Review Committee in the requirements change control process is not reflected in the process guidance documents (PUB-3000)
- In institutional documents, guidance on many ESH elements (e.g., oxygen deficiency hazards, magnetic field hazards, use of safety glasses, transfer of liquid helium tanks in an elevator) are not sufficiently comprehensive to ensure that underlying requirements are met without additional subordinate guidance

## Facilities and Operations – CF2 & 3Mike Bebon and Chris Johnson

**Craft workers and supervisors reported easy access to EHS staff specialist support 24/7**
**Blackberry Gate project using daily Hazard Analysis/Planning process; checklist signed by LBNL Construction Manager, contractor and workers**
**Contractor ES&H Plans are required and are approved by LBNL before construction start**
- Construction Safety Engineer routinely adds appropriate requirements to contractor H&S plans
- EHS requirements summarized in separate section of construction contract specifications
**Cross shop inspections are performed quarterly**

## Facilities and Operations – CF2 & 3Mike Bebon and Chris Johnson

**HEAR database is unreliable as source of facility hazards**
**Facilities hazards are not readily available; system relies on worker and supervisor “institutional knowledge”**
**Contractor H&S Plans are based on cost, not risk **
**Signed/approved contractor EHS plans are not maintained at jobsite**
**Some documents are approved by EHS rather than Project Manager**
**Contractor activity-level plans are not always explicit on required PPE**
**Dig Permit is for 5 days requiring frequent renewal (every 7 days);  process perceived as “cumbersome”**
**Expired dig permit was posted at jobsite**

## Facilities and Operations – CF4 & 5Mike Bebon and Chris Johnson

**Foundry construction contract included financial incentives for safety**
**Craft recognized requirement for radiation coverage**
**PMT shift change was strong in content, format, technique, execution**
**WOW program is effective**
**Safety system taken out of service without formal impairment process**
**Safety coverage on construction projects may be inadequate**
**Contractor/key supplier safety performance is not summarized or formally used in subsequent contractor selection processes**
**Worker feedback & lessons learned information is not documented and  not readily trended, shared across shops, and used in work planning**

## Facilities and Operations – GP3Mike Bebon and Chris Johnson

**Requirement established by Laboratory Director for supervisor training by FY07**
**Safety performance outside LBNL is a criteria in contractor selection**
**New Facilities supervisors given orientation by  Safety Coordinator**
**JHQs tailored for additional specific employee needs; minimum training requirements established for all crafts**
**Supervisors readily check worker training status**
**Causal analysis training is beginning to be offered**
**Project Managers are required to take 10 hour OSHA Course**

## Facilities and Operations – GP3Mike Bebon and Chris Johnson

**Some supervisors do not review the completed JHA form before work begins**
**There is no process to validate hazard recognition skill for Facilities crafts**
**No Laboratory-level standards exists for Safety Coordinator position**
**Allocation of EHS Liaison to facilities (20%) may be inadequate**
**Contractor employees are not formally trained in Laboratory-wide hazards**
**Building Manager T&Q expectations not clearly defined**

## Large Scale User Facilities – CF1 Tom Mullen and Ed Lessard

**ALS has a strong beamline and experimental safety review process**
**The Molecular Foundry has a strong (if unauthorized) hazards assessment and control policy for nanoparticles**
**Worker-planned work may not adhere to the documented  work-planning requirements**
**Communications related to day-to-day work planning are weak**

## Large Scale User Facilities – CF2 & 3Tom Mullen and Ed Lessard

**AHD process documents hazards and controls associated with experiments**
**Divisions reviewed have several policies in place that limit or eliminate hazard exposure**
**PUB-3000 does not provide guidance for hazard assessment at a level to ensure uniform safe practices site wide**
- Institutional level practices are more effective when established with Division-level input
**ALS does not ensure engineered safety systems are operational before startup**
**Existing hazard controls may not be sufficient to ensure safe operations  **

## Large Scale User Facilities – CF4 & 5Tom Mullen and Ed Lessard

**Most hazard controls seem to be well established in the Divisions visited**
**The Safety Committee system appears to be very robust**
- Strong Safety Circles in both Divisions
- ALS Staff Safety Committee aims at continual improvement/excellence in safety
**ALS Management is strongly motivated to improve safety **
**PUB-3000 does not ensure uniform LBNL practices**
**ALS has a weekly Operators “critique” meeting**
- These meetings are excellent conduits for feedback and improvement in the Divisions
**ALS staffing cutbacks have resulted in safety vulnerabilities that need correcting**
**Workers are not consulted in creating safety management systems and practices**

## Large Scale User Facilities – GP3 Tom Mullen and Ed Lessard

**The JHQ process is formal, comprehensive and updated ****annually by each supervisor**
**Training excellence exists in some areas**
**Training policies at NCEM are very strong**
**Roles and responsibilities are not established for personnel **
**LBNL lacks requirements for safety training by vendors**** **

## Bench Scale R&D – CF1 Pat Wright and Larry McClellan

**Several Divisions have or are implementing a process to identify hazards at the proposal stage of a project**
*Earth Sciences Division (ESD) has a Proposal Stage Safety Questionnaire*
*Materials Sciences Division is considering reinstituting a “defunct” process to identify hazards pre-proposal*
**At least one Division has a stated expectation that new work in a workspace must be approved by the PI/Lab Manager**
*ESD has a written/posted expectation that all work is discussed with the PI that owns the space *
**Implementation of the Partnership Agreement with UCB does not currently support clear identification of the scope of work for LBNL activities performed in UCB labs**

## Bench Scale R&D – CF2 & 3Pat Wright and Larry McClellan

**The Safety Coordinator program is highly successful**
- Most Safety Coordinators have some organizational construct under them (e.g., Safety Committee, Safety Wardens) that support safety communication and hazard identification
- Safety Coordinators appear to be well aware of work and provide a vital connection between lab workers and institutional processes
**At least one Division has a process for analyzing all significant hazards of one class of research work and documenting job-specific controls**
*The ESD Offsite Safety and Environmental Protection Plan provides a best practice approach to addressing the unique offsite work hazards  *
**While high hazard work (radiological, high power lasers, highly toxic gases) is typically well analyzed and formally authorized, much potentially hazardous work is left to “skill of the craft.”**
- Other DOE Science Labs have much lower thresholds for documented analysis and authorization of potentially hazardous work
*PNNL uses Hazard Awareness Summaries to identify workspace-specific hazards such as chemicals, vacuum systems, and hotplates*
*PNNL uses Chemical Process Permits to analyze chemical hazards, and document hazard controls such as type of gloves and fume hoods.*
*BNL uses Job Hazard Analysis for 57 different jobs in RHIC to document job-specific hazards such as walking & working surfaces, use of hoists, and requirements for PPE*
*ORNL uses a Research Safety Summary to identify, analyze, and control *_*all*_* R&D hazards including standard laboratory chemicals, biological (BSL1) work, and non-ionizing radiation*

## Bench Scale R&D – CF2 & 3 (continued)Pat Wright and Larry McClellan

**The flow-down of ISM elements and philosophy to R&D subcontractors is largely non-existent**
- PI directs procurement organization to let contract, but vendor/contractor is expected to establish appropriate controls (without an institutional process for identifying hazards or minimum expectations for risk mitigation)
*Control of off-site drilling in a quartz mine was left to the drilling subcontractor to plan and control with no input from LBNL*
*Control of hazards for vendor work in a Potter lab was left to the expert judgment and procedures of the vendor with informal overview by the research scientist and no safety expert (e.g., electrical safety) overview by LBNL*
**Workers do not appear to be involved in identification and mitigation of management of hazards as part of the work planning process; there is no mechanism for them to contribute to the final product**
*SRC involvement in Pub 3000 is good, but process needs to be better institutionalized*
*Work group planning at PI level is typically good, but informal*
*Worker involvement in formal work planning (e.g., AHD) is typically limited to “Read & Sign” – misses valuable opportunity for worker input and buy-in*

## Bench Scale R&D – CF4Pat Wright and Larry McClellan

**Review of workspaces and interviews with staff indicated that work is typically performed safely and within established controls**
- Staff are concerned about safety and take what they perceive to be appropriate measures to assure their own safety
- Injury & illness experience does not indicate a breakdown in safety performance
- Instances were observed where staff violated safety requirements *(e.g., use of safety glasses)*
**There is a significant difference between Divisions in the safety culture and discipline of operations that is apparent in work performance**
- Housekeeping in workspaces and maintenance/condition of equipment
- Degree of engagement and leadership *- as exhibited by the Division Director and PIs in terms of frequency and effectiveness of communication*
- Assessment processes, including engagement of Division Directors, PIs, Safety Coordinators, and staff in self-assessment
- Level of detail and effectiveness of organization/facility-specific training
- Formality of operations (e.g., documented processes and work controls)
**Safety is not expressed as a universal **_**value**_**  ****Safety is viewed as a **_**priority**_** (often contingent on circumstances)**

## Bench Scale R&D – CF5Pat Wright and Larry McClellan

**Lessons Learned are distributed based on JHQ identification of hazard interactions **
**Effective communication of Lessons Learned and deployment to staff needs improvement **
*Six of nine students who use super glue did not recall seeing the LL *
*Students reported that they had been required to get rid of their super glue **(to which they responded by hiding their super glue)*
*Lessons Learned are not consistently seen as communicating valuable information*
**Assessment is excessively focused on unsafe conditions****Activities are not routinely assessed**
- This is the next logical progression of the self-assessment process
**The Corrective Action management program has serious deficiencies **
- There is no evidence that extent of condition reviews are performed
- Effectiveness reviews (on corrective actions) are typically not performed, *although the Physical Biosciences Division (PBD) verifies completion of corrective actions*
- There is limited assurance that CATS actions are closed out in a timely manner

## Bench Scale R&D – GP3Pat Wright and Larry McClellan

**EH&S Liaisons are highly qualified professionals who exhibit necessary interpersonal skills, and are dedicated to both the Laboratory’s success and their professional ethics**
**Safety Coordinators get special training for their role**
**The JHQ process is rigorously used across the Laboratory to drive worker qualification**
**Some organizations have a structured process provide safety orientation to new staff (especially students)**
*PBD provides an excellent, documented orientation to new staff*
*The facility manager rigorously controls access to laboratory spaces, documents facility specific training via checklist, and has a communication plan identified for when new hazards are introduced into the workplace*

## Bench Scale R&D – GP3Pat Wright and Larry McClellan

**The practice of allowing workers who have not been trained to work under escort by other (trained) workers is questionable**
- Untrained workers are allowed to work “under the direct supervision” of another qualified worker for up to six months
*Expectations for what constitutes “direct supervision” are not clear and there is considerable diversity in the interpretation of this requirement*
*Interviews indicated that students in some parts of the organization may work for considerable periods of time (e.g., days) without being directly observed by a qualified worker*
- There is no assurance in some parts of the organization that workers not yet trained possess the LBNL-specific knowledge and skills necessary to discharge their responsibilities, as required by the LBNL ISM plan

## Worker Safety – CF1Carol Scott, Doug Schlagel, and Steve Coleman

**The Radiological Work Authorization work planning process requirement of a personal interview and proposed work location review between the PI and Health Physicist is a noteworthy practice**
**Workers do not appear to be effectively and consistently involved in work planning, including development of project documentation**
**“****Significant change” is not clearly defined when modifications to work authorizations and planning documents are required**
**Activity thresholds driving increased rigor in work planning (PUB-3000, Chapter 6, Appendix B) appear to permit a significant amount of risk acceptance without formal management planning & involvement**
**EHS division authorization of AHDs dilutes line management ownership of responsibility for safety**
**Decisions to conduct design reviews on construction projects are based on fiscal thresholds, not EHS risk evaluation**

## Worker Safety – CF 2 & 3Carol Scott, Doug Schlagel, and Steve Coleman

**Safety Coordinators play an instrumental role in hazard identification**
**Hazard identification is expert-based and relies on individual decisions to consult EHS subject matter expertise and may allow incomplete hazard identification when required expertise is not sought out**
**Particularly true for Line Management Authorized work**
**Workers do not appear to be effectively and consistently involved in the hazard identification process**
**Enhanced controls for usage of x-ray systems in Building 70A were identified as a noteworthy practice**
**Identification and application of hazard controls is not consistent with the hazards identified (inconsistent PPE usage)**
- Personal expertise often cited as hazard control

## Worker Safety – CF4Carol Scott, Doug Schlagel, and Steve Coleman

**In general, there is a strong observed worker ethic to perform work safely**
**There is some evidence that management may not be assuring compliance with existing laboratory-level procedures**
**A clear authorization to commence work does not exist for line management authorized work (typical readiness activities not performed)**
**Personnel appear to understand their responsibility and authority to stop work in unsafe situations that are less than imminent**
- PUB-3000, Chapter 1 defines this responsibility for situations considered to be an imminent danger where it could reasonably be expected to cause death or serious injury, or environmental harm; it does not reflect worker responsibilities to limit work activities when the unsafe situation is not imminent
**There does not appear to be an institutional process to identify and control out-of-service equipment**

## Worker Safety – CF5Carol Scott, Doug Schlagel, and Steve Coleman

**The Engineering Division is proactively communicating the concepts of ISM to division personnel**
**A significant number of safety inspections are performed**
**There appear to be multiple safety walkthroughs in most divisions;  however, the worker is not directly involved in these inspections**
**Some staff interviewed reported a few situations where incidents were not reported; work-arounds to avoid perceived repercussions**
**The EHS Division develops a set of expectations that are assessed by each Division annually; it is not clear how assessment findings and lessons learned are shared and utilized by other Divisions**
**Division self-assessments are largely limited to safety inspections and responses to EHS expectations (limited trending of results)**

## Worker Safety – GP3 Carol Scott, Doug Schlagel, and Steve Coleman

**A broad cross-section of training is offered to qualify personnel**
- Interviewees consistently referred to laboratory-level training as the initial source of safety awareness, followed by job-specific training as a means for ensuring workplace safety
- In several divisions, laboratory staff are assigned to mentors who provide on-the-job training until individuals are deemed proficient
**Worker awareness of perceived low-risk hazards is expert-based and not formally analyzed**
- Interviewees consistently referred to their educational knowledge and experience as a primary resource for ensuring workplace safety with respect to perceived low-risk hazards (e.g., chemical safety)
**Division Safety Coordinators are not consistently assigned based on prior safety management experience, potentially limiting the awareness of EHS hazards**

## Waste Management/Environmental Protection – CF1-3Carol Scott, Doug Schlagel, and Steve Coleman

**Potential hazardous waste generating activities are commonly identified early in the work planning process (involvement of Generator Assistants and Waste Generators)**
**Identification of environmental protection issues in work planning is expert-based and dependant on consultation for complete analysis**
- Effective identification of environmental protection issues is dependant on the knowledge base of EHS Liaisons for formal authorizations and Division Safety Coordinators for line management authorizations
- Inclusion of environmental expertise is not automatic
- It does not appear that workers commonly associate environmental protection with the ISMS process
**Master inventory of Satellite Accumulation Areas (SAA) does not exist**
- Procedures document a requirement to limit storage of hazardous wastes in SAAs to 9 months, but without a complete inventory, compliance cannot be assured

## Waste Management/Environmental Protection – CF4 & 5, GP3Carol Scott, Doug Schlagel, and Steve Coleman

**The hazardous waste management program appears to be an effective and valued program at all levels**
**The Environmental Management System (EMS) undergoes an annual assessment conducted by the Contractor Assurance Group**
**Identification of waste minimization opportunities is included in the Division feedback from their annual assessment of EHS expectations**
**Division Safety Coordinators and EHS Liaisons are not consistently assigned based on prior environmental protection experience, and all must be cognizant of necessity to consult with subject matter expertise**

## Recommendations

**Re-emphasize line accountability and responsibility for safety;  strengthen implementing processes to reflect these principles by**
- Assuring that safety behaviors/expectations are clear, formal, and understood (see next recommendation)
- Assuring that line management authority is unambiguous, universally understood, and accepted by emphasizing that:
- Line managers provide assurance and approval of all hazard analyses and work authorization documentation
- Safety leadership and safety performance expectations are explicitly communicated to and understood by Line Managers including PIs
- Line managers actively involve workers in work planning
- Assuring that existing procedures are both fully understood and are being consistently followed:
- For example, promoting consistent and complete compliance with controls (PPE) identified in laboratory procedures and ensuring requirements are explicit

## Recommendations

**Restructure and refine institutional EHS/ISMS documents with the following focus and objectives**
- Clarify the hierarchy, functionality, and relationship between institutional documents (e.g., RPM, PUB-3000, OAP/QAP, Assurance Plan, etc.)
- Provide an overarching set of Laboratory safety principles and expectations for individual position descriptions
- Highest level set of essential safety behaviors and expectations for line managers, subject matter experts, and staff in general
- Clarify expectations for Safety Liaisons
- Establish Laboratory-level T&Q standards for Safety Coordinators
- Establish an explicit process for translating new requirements into implementing practices
- Codify role of Safety Review Committee in Laboratory procedure
- Ensure process for translating new requirements into lower level procedures codified
- Ensure that process for identifying relevant industrial requirements is systematic, formalized and understood

## Recommendations

**Increase the rigor of the performance management process by**
- Enhancing Laboratory-level processes
- Assuring performance objectives are derived from overarching goals/objectives
- Assuring performance objectives are basis for monitoring organizational and functional performance
- Providing means to monitor and verify the maturation of the systems
- Assuring that trending and analysis activities comprehensively examine performance data and provide a basis for improvements
- Assuring that OIA systematically evaluates performance of the Laboratory’s assurance processes (e.g., Quality Assurance Program)
- More thoroughly identifying, communicating, and taking advantage of the best practices that are in use in some Divisions
- Enhancing functional and/or organizational processes, for example –
- Using a formal process to evaluate subcontractor performance
- Maintaining subcontractor performance records for use in future selections
- More consistently documenting and sharing worker feedback

## Recommendations

**Fully implement an integrated Corrective Action Management System, with the following objectives**
- Establishing clear responsibilities for action ownership through the entire process
- Providing enhanced functionalities
- Guidance on preferred causal analysis tools and their application
- Guidance on triggers for and methods used to conduct extent of condition reviews
- Guidance on the level of formality and methods used to verify action closure
- Guidance on triggers for and methods used to conduct effectiveness reviews
- Monitoring system effectiveness in achieving its objectives

## Recommendations

**Strengthen Laboratory self-assessment processes by**
- Structuring the Division self-assessment process around Division-specific EHS and operational performance objectives that are aligned with institutional expectations
- Incorporating expectations (methods, scope, etc.) associated with MESH reviews into Division self-assessments
- Incorporating a prioritization process for identifying and conducting  Division self-assessment activities based on mission objectives and evaluation of risks to the organization
- Conducting institution-wide program evaluations (e.g., IFAs) on a risk-prioritized basis, which are designed to assure that program improvements are identified and the program is fully integrated with other systems
- Providing assurance that these processes/programs are conducted effectively, are implemented properly, and result in identifiable improvements to performance (e.g., OIA function)

## Recommendations

**Increase the rigor and consistency of the work planning and control processes, with the following focus and objectives**
**Research and Development**
- Develop and deploy minimum standards and expectations for allowing workers to interact with hazards before they have been fully qualified (including whether unsupervised work with certain hazards will be allowed, the level of supervision required, etc.)
- Re-examine the very high (as compared to other Laboratories) threshold of hazard that triggers the use of more formal hazard analysis and authorization
- Develop effective and efficient ways to identify, communicate, and demonstrate control of lower risk/common hazards (e.g., routine use of chemicals, sharps, etc.)

## Recommendations

**Increase the rigor and consistency of the work planning and control processes, with the following focus and objectives – **
**Facilities and Operations**
- Establish a process to ensure workers are skilled in hazard recognition
- Assure that hazard information is current through implementing the HEAR database upgrades
- Tailor Maximo-generated JHA checklists for specific crafts to improve relevancy and encourage use
- Post approved & current construction authorization and safety documents at jobsites
- Streamline the penetration (Dig) permit process
- Assure that the documented process for Operations & Maintenance maintainability reviews of engineering drawings and specifications (prior to construction) is being followed

## Recommendations

**Assure that the ISMS-related elements of LBNL-UCB relationship are consistently articulated and clearly understood, including**
- Institutional accountability for safety management and performance of LBNL funded work conducted in UCB-controlled spaces
- Comprehensive identification of laboratory locations and individuals performing LBNL funded work in UCB-controlled spaces
- Processes by which LBNL is assured that the UCB laboratories achieve “equivalent protection” for LBNL funded work conducted in UCB-controlled spaces

## Assessment Team Path Forward

**Factual Accuracy Report**
- Nominally 2 weeks
- Agreed upon outline
**Laboratory Review**
- Prefer consolidated comments
**Final Report**
- 1 week after receiving comments
**Questions/Comments/Adjourn**