# Presentation: 053819

## DOE Independent Validation Team Review of LBNL Corrective Action PlanOn site Closeout

- Paul Kruger, Team Leader
- June 28, 2006

## Validation Team

- Chartered by the SC Chief Operating Officer (COO) and Berkeley Site Office (BSO) Manager
- Team members:
- Paul Kruger, PNSO Manager (Team Leader)
- Roger Christensen, PNSO (Deputy Team Leader)
- Earl Carnes, EH
- Hattie Carwell, BSO
- Carol Ingram, BSO
- Larry Kelly, ORO
- Ted Pietrok, PNSO

**Notes:**

Work Authorization issue IG 
IG felt that staff were unable to access the work authorizations that contained a statement of work for the projects they were charging their time to.  Without this SOW, staff can not know if the work they are performing and charging their time to is consistent with the approved WAS.  Staff knowing that they are charging their time to an appropriate project is an internal control

IG also had issues with staff compliance with time keeping policies (daily recording of time when required, timely supervisory approval of time cards)
NOTE:  Battelle has recently failed their most recent floor check, they are, however taking aggressive actions to correct 

The instances of time charging fraud – these cases do not in any way support DCAA’s primary concern with the labor accounting system (they do not relate in any way to the work authorization question).  These instances do point to other problems (supervisor’s not appropriately discharging their responsibilities to review and approve time cards).  These problems were complicated by matrix staff assignments as well as span of control issues for supervisors (too many staff to adequately know their whereabouts, work hours, etc.)  

## Review Purpose

- Provide BSO Site Manager with evaluation of the adequacy of the LBNL development process for corrective actions in response to the LBNL Peer Review
- To that end, the team made no assessments nor performed any evaluations regarding the adequacy of the LBNL ISMS

## Review Approach

**A formal Validation Team Review Plan was developed and approved**
**The Team reviewed relevant documentation, including:**
**Peer Review Report**
**Validation Team Member Trip Report**
**LBNL Corrective Action Plan (CAP)**
**Root Cause and Extent of Condition Documentation**
**CAP process and CAP was reviewed against DOE Corrective Action Program expectations and criteria **
**Purpose of Team visit to LBNL was to gain additional insights regarding CAP development process and content of the CAP as well as to provide initial feedback (not a performance review)**

**Notes:**
Review team lead by Battelle VP of Internal Audit, included Oak Ridge Financial Service Center Division Director (Nancy Fitchpatrick), and other non-PNNL Battelle employees.  

## Conclusions

_**Noteworthy Areas**_
- Lab leadership commitment to safety improvement
- UC initiation of independent Peer Review
- Use of root cause analysis and training of staff in root cause technique
- Involvement of line management in defining the problems and developing the corrective actions
- Collaboration with safety leader in industry (e.g. Intel)

## Conclusions (cont)

_**Areas for Improvement**_
- The CAP does not provide clarity regarding how the 97 actions will integrate and contribute to specific improvements of Laboratory systems:
- no tie to Quality systems and processes
- some of the root causes are not clear
- some root causes do not appear to be adequately addressed by corrective actions.
- The CAP does not include discussion of the prioritization logic for implementing corrective actions

## Conclusions (cont)

_**Areas for Improvement (cont)**_
- The change control process does not appear to address active management of the set of corrective actions to achieve the ultimate desired outcomes
- The individual outcomes for corrective actions are not specifically stated in measurable terms
- The overall desired outcome is not clear

## Six Phases of Safety Excellence

**What is Safety?**

**Keep us out of jail/Don’t shut us down**

**Accidents cost too much**

**EHS is a top priority**

**EHS is a value**

**EHS is instinctive**

**EHS Performance           **

**Discipline/Compliance Focus**

**Self Assessment – Data Focus**

**Culture Focus**

**LBNL**

- Chart Origin:  Intel presentation to LBNL on March 27, 2006

## Supporting Concerns

- Emphasis on “certified” self assessment program contrasts with data that demonstrates self assessment was less than effective
- Appropriate benchmarks have not been identified considering the highest vulnerable population of temporary grad students, post docs and guests
- A cohesive strategy to address the variety of lab workforce groups is not clearly articulated
- No clearly identified organizational competence for analyzing and acting promptly to operational data
- It is not evident that the lab operates from the perspective of “proving it is safe”  versus “proving it is unsafe” and is thus vulnerable to normalization of deviation

## Summary

- LBNL is in an early phase of building safety excellence
- Keys to reaching next phase :
**Strengthened Systematic and integrated work planning and control processes**
**Open and honest reporting of incidents (reporting culture)**
**Proactive investigation of events and analysis of event data  **
**Line accountability for safety**
**Continued Management commitment and example**
**Robust self assessment program to include system effectiveness evaluation**
**Effective “lessons learned” program that aids feedback and continuous improvement**

## Recommendations

- The LBNL CAP can be accepted as a reasonable starting point if:
- BSO sets the expectations for safety excellence
- BSO works closely with LBNL to improve the clarity of corrective actions and develop appropriate metrics to evaluate success
- BSO performs oversight to ensure that expectations are being met

## Recommendations (cont)

- To better understand the opportunities for systems improvement, BSO & LBNL should consider performing rigorous self and external assessments of ISMS to ensure systematic approaches are in place

## Path Forward

- A draft Review Report will be provided by the Team to the BSO Manager within 3 weeks
- BSO will be responsible for monitoring and reporting status of corrective actions, validation of completion, and follow-on effectiveness reviews

## BACKUP  SLIDES

## Review Criteria

- Issues management system is in place
- Proper investigation and understanding of deficiencies is demonstrated
- Root causes and causal factors are identified
- Corrective actions are concise, executable and have clear outcomes
- Interim/Compensatory actions are identified where appropriate
- Corrective actions include participation by line organizations
- Completion dates are clearly established, reasonable, and achievable
- A systematic process for tracking and reporting actions is identified
- Mechanisms for independent validation/effectiveness review are identified
- CAP is approved and supported by senior management