# Presentation: 138415

**Self-Assessments:**
**Are We Doing What We **
**Say We Are Doing?**

**Kent Oelrich**
**SASIG Workshop**
**April 19-20**
**Seattle, WA**

- Physical, Technical, and Program Division

- This Presentation is
-  UNCLASSIFIED

***SASIG Workshop 2005***

**Agenda**

***SASIG Workshop 2005***

- Status of ISSM
- Relationship of ISSM to Self-Assessments
- Significance of Self-Assessments
- Developing a Self-Assessment Program
- Self-Assessment Process

## Integrated Safeguards and Security Management (ISSM)

***SASIG Workshop 2005***

- In his March 8, 2004 Memo, Administrator Brooks reiterates his commitment to ISSM:
- “adequately protect the nuclear deterrent”
- “embedding consideration of safeguards and security into everyday work processes”
- “individual employee commitment to conducting all work in a secure manner”
- DOE Policy 470.1, *Integrated Safeguards and Security Management (ISSM) Policy*, was issued May 8, 2001

## Workers are responsible for...

***SASIG Workshop 2005***

- Understanding security plans and requirements and access procedures that apply to them.
- Stopping work if they see a security risk – no approval is necessary –  and correcting the situation or informing the responsible manager.
- Completing required security training and qualifications before performing work.
- Notifying fellow workers and visitors of security requirements and where to get security assistance.
- Sharing opportunities for security improvement with supervisors or security contacts.

**Notes:**
Phase I
Phase II:	

## Supervisors are responsible for...

***SASIG Workshop 2005***

- Evaluating new or changed work activities to ensure that applicable security requirements are identified and in place.  Is any work or work product sensitive or classified?
- Ensuring that workers have appropriate security knowledge and qualifications.
- For matrix employees, communicating those requirements to the worker’s payroll organization.
- Verifying that visitors, guests, students, and vendors either have the training necessary prior to entering certain Laboratory areas or are escorted by a qualified individual.

**Notes:**
Phase I
Phase II:	

## ISSM at work

***SASIG Workshop 2005***

**We need to work together to effectively carry out the DOE mission...**

- Continuously examine work for security issues
- Know what needs to be protected and why
- Provide feedback for improving secure work practices
- Know where to go for help

**Notes:**
Phase I
Phase II:	

## ISSM and the new Draft DOE Order

**ISSM and the new Draft DOE Order**

***SASIG Workshop 2005***

- The companion manuals to Draft DOE Order 470.S, *Safeguards and Security Program*, refer to the DOE Policy on ISSM as the objective
- “Fulfill the policy in DOE P 470.1, *Integrated Safeguards and Security  Management Policy (ISSM)*...”
- Draft Manual 470.S-1, *S&S Program Planning and Management Manual*
- “Fulfill the policy in DOE P 470.1, ISSM, by integrating physical protection into operations to the extent and in the manner determined by program line managers.”

## ISSM and the new Draft DOE Order

**ISSM and the new Draft DOE Order**

***SASIG Workshop 2005***

- Draft Manual 470.S-2, *Physical Protection*
- “Fulfill the policy in DOE P 470.1, ISSM.....The Physical Protection Program must be integrated with other programs such as safeguards and security program management, protective force, information security, personnel security, and nuclear material control and accountability.”
- Draft Manual 470.S-3, *Protective Force*
- “Fulfill the policy in DOE P 470.1, ISSM, by integrating PF into operations to the extent and in the manner determined by program line managers.”
- Draft Manual 470.S-6, *Nuclear Material Control and Accountability*
- “DOE Policy 470.1, ISSM, is the Department’s philosophical approach.....The goals of ISSM include individual responsibility and adherence to the security requirements in this Manual.”

- “Achieve continual improvement in ISSM with consistent application of ISSM principles across all organization levels and across all laboratory facilities.” –UC Contract

## How are we doing? How do we know?

***SASIG Workshop 2005***

- Self-Assessments have evolved into the primary tool for measuring the impact of ISSM
-  Assists DOE sites to achieve their security program missions
-  Provides focus on the management systems required to meet S&S objectives
-  Used to pursue performance improvement as a routine business practice
-  Used to evaluate the adequacy and effectiveness of processes and business practices

**Requires commitment to constant evaluation and improvement**

**...****another good reason to do SAs**

***SASIG Workshop 2005***

- It’s a requirement...
- Required under DOE O 470.1, Attachment 1,Chapter 10, *Self-Assessment Program*
- Validates UC Contract Appendix F Performance Requirements

**Poor self-assessments will take you down a very dangerous path...**

-  The credibility of our Security Programs will be significantly damaged if an auditor identifies indisputable topical area Findings after a self-assessment report contained no discrepancies for that topical area.

***SASIG Workshop 2005***

**LLNL Self-Assessment Implementation Strategy**

***SASIG Workshop 2005***

- Create an integrated site-wide performance-based S&S assessment program
- Provide a complete perspective of work performance & management systems, from informal observation of individual work activities to formal assessments of site-wide security programs
- Establish complementary layers of assessment oversight and support using a graded approach

**Complementary Layers of Assessments**

***SASIG Workshop 2005***

- Topical/Sub-topical Self-Assessments
- Management Assessments
- Independent Assessments
- External Assessments

**Complementary Layers of Assessments**

***SASIG Workshop 2005***

**Each category serves a distinct & complementary purpose**
**Relationship of the four assessment categories:**
**Assessment scope generally widens from bottom to top**
**Potential for uncovering problems should decrease as one moves up the pyramid**

**External**
**Assessment**

**Independent **
**Assessment**

**Management **
**Assessment**

**Topical/Sub-topical Assessments**
- Program foundation: surveillances, daily oversight,
- compliance reviews, informal peer reviews, LSPTS and other informal, everyday assessments

**Topical/Sub-Topical Areas**

***SASIG Workshop 2005***

| 
Program Management
Program Management
Program Planning
Personnel Development and Training
FOCI
S&S Plans
Surveys and Self-Assessments
Resolution of Findings
Incidents and Infractions |  | 
Information Security
Classification Guidance
Classified Matter Protection and Control
Special Access Programs and Intel Info
Classified Automated Info Systems
TSCM
OPSEC
Unclassified AISS
Protected Distribution System
Communications Security |
| --- | --- | --- |
|  | Personnel Security
Access Authorization
Security Awareness
Control of Visits
Unclassified Visits and Assignments
Personnel Assurance Program
Personnel Security Assurance Program |  |
| Protection Program Operations
Protective Force
Security Systems
Physical Security
Security Badges
Transportation Security
 |  | Nuclear Materials Control & Accountability
Program Administration
Material Accountability
Material Control
 |

**The Assessment Process**

***SASIG Workshop 2005***

**Planning**

** **** ****Conducting**

** ****Reporting**

**Closing**

**   ****Developing**

**Planning and Preparation**

**Conducting an Assessment**

**Reporting Assessment Results**

**Developing a Corrective Action Plan**

**Closing Out Corrective Actions**

**The Assessment Plan**

***SASIG Workshop 2005***

- Purpose and scope
- Assessed organization(s)
- Team members
- Start and completion dates
- Sets schedule
- Performance criteria
- Points of contact
- Management approval

**Preparing for an Assessment**

***SASIG Workshop 2005***

- Assemble the Assessment Team
- Identify available resources and discuss logistics
- Determine assessment method to be used
- Set an assessment schedule
- Notify assessed organization(s)
- Issue Assessment Plan
- Develop checklist(s)!

**The Checklist**

***SASIG Workshop 2005***

- Identify documents that outline requirements
- Used for gathering and recording information
- Developing checklists:
- Items should be factual and objective
- Rephrasing requirements should not change their meaning
- Thorough enough to provide confidence in results
- Each item should address one piece of information or procedure step
- Some procedures may be appropriate to use as checklists

**Conducting an Assessment**

***SASIG Workshop 2005***

- Team Responsibilities
- Opening meeting
- Gather and record information/evidence
- Minimize intrusions into the assessed organization
- Investigate to the necessary depth and breadth
- Analyze the data; compare evidence to requirements
- Discuss deficiencies/observations with assessed individual/organization

**Reporting Results**

***SASIG Workshop 2005***

- Document the deficiencies and observations
- Closing meeting
- Perform a factual accuracy review
- Generate the assessment report
- Record results

**The report is the product of the assessment. It communicates assessment results to those involved...and those not involved.**

**Developing a Corrective Action Plan**

***SASIG Workshop 2005***

- Understand deficiency
- Perform causal analysis
- Identify extent of conditions
- Develop plan to address analysis and underlying deficiency
- Monitor plan and updated as needed

**Causal Analysis**

- _The Why Staircase_

***SASIG Workshop 2005***

- Step 1:  Form your natural team
- Step 2:  Write the event question
- Step 3:  Attack the event by building a cause chain
- Direct cause:  First cause in chain.  Cause that directly resulted in the event.
- Contributing causes:  Any cause after the direct cause.  Causes that by themselves would not have resulted in the event.
- Root cause:  A contributing cause at the end of a branch or chain.  Where there are multiple last causes the team may select the most significant.
- Step 4: Test the chain by working it backwards

**D**

**Event**

**C**

**C**

**C**

**Why?**

**Why?**

**Why?**

**Why?**

**R**

**What makes a good action?**

***SASIG Workshop 2005***

- Be **SMARTER** in the development of actions
_**S**_pecific: One action per corrective action
_**M**_easurable: Has verifiable end point
_**A**_ccountable: Known and accepted responsibility
_**R**_easonable: Practical and Actionable
_**T**_imely: Avoid being too optimistic
_**E**_ffective: Prevents or reduces recurrence
_**R**_eviewed: Addresses problems without residual effects

**Closing a Deficiency**

***SASIG Workshop 2005***

- Closure should only occur when the problem has been resolved
- Never close a deficiency just because the actions were all completed.
- Closure of each action must be supported by evidence documentation
- Documentation should match the closure criteria originally outlined for the action

**Verification of Closure**

***SASIG Workshop 2005***

- All deficiencies should be independently verified
- Issue owner should verify for themselves that all actions are complete and effective
- Independent verifier should understand the area under review and issues management process
- Field verification/effectiveness review should be conducted 3–6 months after completion of original action plan
- A management review board should be established to perform a review of evidence documentation for obvious errors

**Remember as in all things, it takes less time to do it right the first time than to redo it over and over again.**

**Summary**

***SASIG Workshop 2005***

- Status of ISSM
- Relationship of ISSM to Self-Assessments
- Significance of Self-Assessments
- Developing a Self-Assessment Program
- Self-Assessment Process

**Are We Doing What We Say We Are Doing?**