Source: http://www.docstoc.com/docs/131817990/Contractor-Assurance-System-HSS-CRAD-Jefferson-Lab
Timestamp: 2014-03-09 09:39:59
Document Index: 150182544

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Contractor Assurance System HSS CRAD Jefferson Lab
Contractor Assurance System                                                                HSS CRAD 64-20 (Part 1 of 6)
Criteria/ Lines of Inquiry                                                                                                                                       Actual
Line                                                                                                                                 Compliant                         Action   Target Comp   Comp            CATS
#                                                                           Item #        JLab Compliance Description                (Y/N)     Corrective Actions   Manager       Date       Date          ACTION
1 Criteria - Contractor management has established a comprehensive
and integrated contractor assurance system for ensuring the protection
of the public, workers, environment and national security assets through
continuous improvement for environment, safety, and health;
safeguards and security; cyber security; and emergency management.
The contractor&#39;s assurance system programs and processes are in
accordance with the policy and key elements outlined in DOE Policy
226.1, Department of Energy Oversight Policy, DOE Order 226.1 A,
Implementation of Department of Energy Oversight Policy, Attachment
1, quality assurance requirements (as stated in 10 CFR 830, Subpart A,
DOE Order 4 14.1 C, Quality Assurance, or other applicable
regulations), other applicable DOE directives, and contract terms and
2       1. A program description document that fully details the programs and        2.a
processes that comprise the contractor assurance system has been
developed, approved by contractor management, and forwarded to
DOE for review and approval. The program description is reviewed and
updated annually and forwarded to DOE for review and approval.
3       2. The contractor assurance system includes assessment activities (self-     3.a
assessments, management assessments, and internal independent
assessments as defined by laws, regulations, and DOE directives such
as quality assurance program requirements) and other structured
operational awareness activities; incident/event reporting processes,
including occupational injury and illness and operational accident
investigations; worker feedback mechanisms; issues management;
lessons-learned programs; and performance indicators/measures.
4       3. The contractor&#39;s assurance system monitors and evaluates all work         4.a
performed under their contract, including the work of subcontractors.
5       4. Contractor assurance system data is formally documented and               5.a
available to DOE line management. Results of assurance processes
are periodically analyzed, compiled, and reported to DOE line
management as part of formal contract performance evaluation.
6       5. Contractors have established and implemented sufficient processes         6.a
(e.g., self-assessments, corporate audits, third-party certifications or
external reviews, performance indicators) for measuring the
effectiveness of contractor assurance system elements.
7       6. Requirements and formal processes have been established and               7.a
implemented that ensure personnel responsible for managing and
performing assurance activities possess appropriate experience,
knowledge, skills, and abilities commensurate with their responsibilities.
Draft A                                                                                                           1 of 5                                                                                                 3/6/08
Contractor Assurance System                                                                          HSS CRAD 64-20 (Part 1 of 6)
Criteria/ Lines of Inquiry                                                                                                                                                             Actual
Line                                                                                                                                           Compliant                                 Action     Target Comp    Comp            CATS
#                                                                         Item #                  JLab Compliance Description                  (Y/N)         Corrective Actions       Manager         Date        Date          ACTION
8 Lines of Inquiry - 1. Processes - Are the processes that constitute the   8.a
Contractor Assurance System formal and documented and, when taken
together, meet the requirements of DOE 0 226.1 A?
9       a. Does the contractor assurance system program description                9.a    The TJNAF Contractor Assurance System                  Y                   NA                     NA         NA           NA
document (or equivalent) require and adequately describe a                        Program Description document dated October 31,
comprehensive and integrated set of processes and activities to identify          2007 implies that the elements in this LOI are
and address program and performance deficiencies, and opportunities               required and adequately describes the integrating
for improvement; provide the means and requirements to report                     processes and activities.
deficiencies to the responsible managers and authorities; establish and           SUPPORTING DOCUMENTS:
effectively implement corrective and preventive actions; and share                Issues Management Procedure,
lessons learned across all aspects of operations as specified in DOE 0            Assessment Procedures (IA/MSA),
226.1 A, Attachment l?                                                            Integrated Assessment Schedule Procedure,
Corporate Operating Experience (QA Procedure),
ES&amp;H Manual Chapter 5200,
Corrective Action Tracking,
10      b. Does the contractor assurance system include self-evaluations of        10.a   Addressed in the Integrated Assessment Schedule        Y                   NA                NA              NA           NA
compliance with applicable laws, regulations, national standards, DOE             Procedure (4.1.1)
directives, and DOE-approved plans and program documents, site-
specific procedures/manuals, criteria review and approach documents,
contractual performance objectives, and other contractually mandated
11      c. Does the contractor assurance system require monitoring and             11.a   The TJNAF Contractor Assurance System                  Y        Revise the TJNAF             B. Lenzer    4/30/2008    4/16/2008 IA-2008-08-24
evaluation of all work performed under their contracts, including                 Program Description document dated October 31,                  Contractor Assurance
subcontractors?                                                                   2007 does not specifically address the monitoring               System Program Description
and evaluation of subcontractor&#39;s.                              to clearly denote that the
Monitoring and evaluation of work performed is                  work of subcontractors is
done IAW the following:                                         also monitored and
- Quarterly Self Assessments against PEMP                      evaluated
- Contractor Assurance System Program
Description, Section 13
- The PEMP is intended to cover all work covered
- SOTR Policy and Procedures
- Procured Services Section of the ES&amp;H Manual ,
Draft A                                                                                                                       2 of 5                                                                                                         3/6/08
Contractor Assurance System                                                                             HSS CRAD 64-20 (Part 1 of 6)
Criteria/ Lines of Inquiry                                                                                                                                                                     Actual
Line                                                                                                                                                 Compliant                                   Action     Target Comp    Comp            CATS
#                                                                                    Item #             JLab Compliance Description                  (Y/N)         Corrective Actions         Manager         Date        Date          ACTION
12 d. Has the contractor established processes and mechanisms, such as                  12.a Established in the following:                              Y                   NA                   NA             NA          NA
use of corporate audits, third party certifications, or other external                   - Independent Assessment Schedule Procedure
reviews in designing and implementing the contractor&#39;s assurance                         - Annual Assessment Schedule
system for measuring the effectiveness of program elements?                              - External Organization performed a review of the
initial design and implementation processes of
CAS, MSA-08-01,TJNAF Contractor Assurance
- In addition, DOE reviewed and approved the
- Future external evaluations of CAS are included
on the assessment schedule
13      e. Has the contractor defined their processes for review and                    13.a A Requirements Management Procedure is                    N        Include a process for review    Lenzer      4/30/2008              IA-2008-08-21
communication to DOE management, problems identified with DOE                        currently being developed which addresses the                      of problems identified with
directives or site-specific requirements that conflict, are unclear, or are          elements of this LOI                                               DOE directives or site
incomplete?                                                                                                                                             specific requirements that
Director&#39;s Review Process                                         conflict, are unclear or
communicate them to DOE
when finalizing the
14      f. Has the program description document been approved by contractor            14.a   Approved by JLab Management 11/1/07. DOE                 Y                       NA                 NA           NA           NA
management and DOE?                                                                   approved via memorandum November 21, 2007
15      2. Training and Qualification - Are personnel implementing Contractor          15.a
Assurance System processes adequately trained and qualified to
perform assigned oversight activities (in accordance with DOE 0 226.1
A, DOE M 360.1-1 B, and DOE M 426.1-1 A)?
16      a. Has the contractor defined the requirements for experience,                 16.a   Requirements defined in:                                 Y        1) Complete development of     B. Lenzer    4/30/2008    4/16/2008 IA-2008-08-01 &amp; -02
knowledge, skills and abilities for personnel implementing the                        - Individual Training Plans (ITP) specify KSA&#39;s for               the Training and
assurance system elements?                                                            CAS related positions                                             Qualification Procedure
- Training and Qualification Procedures (under                    2) Training Matrix for QA/CI
development) identifies the KSA&#39;s for CAS related                 personnel.
17      b. Has the contractor established, maintained, and implemented                 17.a   Qual. Standard elements contained in:                    Y                    NA                    NA           NA           NA
appropriate qualification standards for personnel with oversight                      - Internal Independent Auditor provides oversight.
responsibilities?                                                                     - ESH&amp;Q Program personnel provide oversight
- Job Descriptions contain qual. expectations
- Qual. standards exist for QACI personnel
- Specific Assessor training
18      c. Has the contractor provided and ensured completion of appropriate           18.a   Addressed in:                                            Y                    NA                    NA           NA           NA
training for personnel who manage and perform assurance functions, in                 - Individual Training Plans (ITP)
that they must possess experience, knowledge, skills, and abilities                   - Management Self Assessment (MSA) Procedure
commensurate with their responsibilities?                                             requires assessors complete assessor training
19      3. Implementation of Program Responsibilities - Are Contractor                 19.a
Assurance System responsibilities appropriately implemented?
Draft A                                                                                                                            3 of 5                                                                                                            3/6/08
Contractor Assurance System                                                                         HSS CRAD 64-20 (Part 1 of 6)
Criteria/ Lines of Inquiry                                                                                                                                                        Actual
Line                                                                                                                                          Compliant                                 Action   Target Comp     Comp           CATS
#                                                                              Item #           JLab Compliance Description                   (Y/N)          Corrective Actions      Manager       Date         Date         ACTION
20 a. Has the contractor monitored and evaluated all work performed               20.a The TJNAF Contractor Assurance System                     Y       Revise the TJNAF              Lenzer     4/30/2008   4/16/2008 IA-2008-08-24
under their contracts, including subcontractors?                                   Program Description document dated October 31,                    Contractor Assurance
2007 does not specifically address the monitoring                 System Program Description
and evaluation of subcontractor&#39;s.                                to clearly denote that the
Monitoring and evaluation of work performed is                    work of subcontractors is
done IAW the following:                                           also monitored and
- Quarterly Self Assessments against PEMP                        evaluated
21      b. Is DOE line management provided with unfettered access to facilities 21.a Addressed as follows:                                      Y                   NA                  NA          NA           NA
and contractor activities and to contractor assurance system data?             - CAS Program Description addresses that DOE
has unfettered access
- Also, DOE has complete access to INSIGHT
22      c. Does the contractor submit to DOE for annual review and approval a     22.a The TJNAF Contractor Assurance System                    Y                   NA                  NA          NA           NA
revised contractor assurance system program description document (or           Program Description document dated October 31,
equivalent).                                                                   2007, section 11.0 requires review and submittal of
the contractor assurance program description
document to DOE annually.
23      4. Assurance System Oversight Results and Corrective Action Process - 23.a
Are the results of Contractor Assurance System activities appropriately
validated, documented, communicated, classified, evaluated, tracked
and resolved&#39;?
24      a. Are deficiencies in programs or performance identified during          24.a Program defined In the following:                        Y        Assure the Trending        B. Lenzer    4/30/2008    4/16/2008 IA-2008-08-07
assessment activities communicated to appropriate management for               - Independent Assessment procedure                                Analysis Procedure
resolution through a structured issues management process that                 - Management Self Assessment procedure                            addresses communication to
identifies causes and provides effective recurrence controls?                  - Issues Management Procedure (including CATS)                    appropriate management.
** Review Trending Analysis Procedure (in
process) **
Key Performance Indicators (KPI&#39;S),
ANNUAL WORK PLANNING,
Draft A                                                                                                                     4 of 5                                                                                                        3/6/08
Criteria/ Lines of Inquiry                                                                                                                                          Actual
Line                                                                                                                                   Compliant                         Action   Target Comp   Comp            CATS
#                                                                          Item #           JLab Compliance Description                (Y/N)     Corrective Actions   Manager       Date       Date          ACTION
25 b. Are the results of assurance system processes periodically analyzed     25.a Addressed in:                                          Y               NA             NA           NA         NA
and reported to DOE in support of formal contract evaluations?                 - PEMP
- Quarterly Reports (Trend Analysis Report)
- IA and MSA Results
- Quarterly D2ORPS Analysis Report
- QA/CI Reps meets with DOE every 2 months to
update the results and programs
- Status on the health of the QACI CAS program
routinely developed
**ALL FEED INTO PEMP
Draft A                                                                                                               5 of 5                                                                                               3/6/08
Assessment and Performance Measurement                                                     HSS CRAD 64-20 (Part 2 of 6)
Line                    Criteria/ Lines of Inquiry
#                                                                                                                       Compliant                          Action     Target  Actual Comp
Item #        JLab Compliance Description             (Y/N)      Corrective Actions   Manager   Comp Date     Date    CATS ACTION
26      Criteria – Contractor management has established a             26.a 10 CFR 830, Subpart A is not applicable to
rigorous and credible assessment program that                       Jlab.
evaluates the adequacy of programs, processes, and
performance on a recurring basis. Formal mechanisms
and processes have been established for collecting
both qualitative and quantitative information on
performance, and this information is effectively used as
the basis for informed management decisions to
improve performance. The contractor&#39;s assessment
and performance measurement programs and
processes are in accordance with the policy and key
elements outlined in DOE Order 226.1 A,
Implementation of Department of Energy Oversight
Policy, Attachment 1; quality assurance requirements
(as stated in 10 CFR 830, Subpart A, and DOE Order
414. 1C, Quality Assurance, and other applicable
regulations or DOE directives); and contract terms and
27      conditions.
1. Line management has established and implemented 27.a
a rigorous assessment program for performing
comprehensive evaluations of all functional areas,
programs, facilities, and organizational elements,
including subcontractors, with a frequency, scope and
rigor based on appropriate analysis of risks. The scope
and frequency of assessments are defined in site plans
and program documents, include assessments of
processes and performance-based observation of
activities and evaluation of cross-cutting issues and
programs, and meet or exceed requirements of
applicable DOE directives.
28      2. Rigorous self-assessments are identified, planned,       28.a
and performed at all levels periodically to determine the
effectiveness of policies, requirements, and standards
and the implementation status.
29      3. Appropriate independent internal assessments are         29.a
identified, planned, and performed by contractor
organizations or personnel having the authority and
independence from line management to support
30      4. Line managers have established programs and              30.a
processes to routinely identify, gather, verify, analyze,   30.b
31      5. Line managers effectively utilize performance
measures to demonstrate performance improvement or
deterioration relative to identified goals, in allocating
resources and establishing performance goals, in
development of timely compensatory measures and
corrective actions for adverse trends, and in sharing
good practices and lessons learned.
Draft A                                                                                                                    1 of 5                                                                                          3/6/08
Assessment and Performance Measurement                                                        HSS CRAD 64-20 (Part 2 of 6)
Line                   Criteria/ Lines of Inquiry
#                                                                                                                          Compliant                         Action     Target  Actual Comp
Item #          JLab Compliance Description                 (Y/N)     Corrective Actions   Manager   Comp Date     Date    CATS ACTION
32      Lines of Inquiry - 1. Process - Are the processes for
assessment and performance measurement formal and
documented and, when taken together, meet the
requirements of DOE Order 226.1 and DOE Order
414.lC?
33      a. Has the contractor established appropriate, formal              Formal self-assessment processes and                  Y              NA             NA         NA         NA
processes and procedures for conducting self-                      procedures are established in the following
assessments and internal independent assessments of                documents:
all programs, processes, and performance of facilities,            - Management Self Assessment Procedure
systems, and organizational elements, including                    - Independent Assessment Procedure
subcontractors?                                                    -Integrated Assessment Schedule Procedure
- Work Observation Process Program
Description and Procedure (under
These assessment processes can be applied to
the evaluation of all programs, processes, and
performance of facilities, systems, and
organizational elements, including
34      b. Do these processes and procedures adequately                    subcontractors.
Formal assessment requirements are detailed           Y              NA             NA         NA         NA
detail the requirements for all types of assessment and            in these procedures:
performance measurement activities, such as                        - Management Self Assessment Procedure
management walkthroughs, surveillance and inspection               - Independent Assessment Procedure
activities, formal assessments and reviews, and post-              -Integrated Assessment Schedule Procedure
job reviews?                                                       - Work Observation Process Procedure (under
5100 Internal Inspections
KPIs, PEMP and reports
Other activities, such as Management
walkthroughs, inspections, etc are detailed in
other documents such as the ES&amp;H Manual.
Post-job Reviews is under development (see
Acc. CRAD Matrix CA94a)
35      c. Have guidance and support tools such as checklists,             Yes - CRADs and LOIs for all formal                   Y              NA             NA         NA         NA
templates, and databases been provided?                            assessments.
IA, MSA, Issues Management, Work
PEMP, KPIs on Insight
36      d. Has the contractor established appropriate and                  IA, MSA, Issues Management System, Trend              Y              NA             NA         NA         NA
formal processes and procedures for identifying,                   Analysis Procedure, PEMP, HPWT Procedure,
monitoring, analyzing data measuring the performance               Continuous Improvement and Value
of facilities, programs, and organizations and for                 Engineering Program
identifying and implementing needed actions and
opportunities for performance improvement?
Draft A                                                                                                                       2 of 5                                                                                         3/6/08
Assessment and Performance Measurement                                                                HSS CRAD 64-20 (Part 2 of 6)
#                                                                                                                                Compliant                               Action     Target  Actual Comp
Item #           JLab Compliance Description                     (Y/N)         Corrective Actions     Manager   Comp Date     Date    CATS ACTION
37      e. Do self-assessment processes encourage and                       Personnel conducting MSAs are required to                 Y                   NA               NA         NA          NA
facilitate the involvement of workers, supervisors, and             take web based assessor training.
managers to develop assessment skills and abilities?                QAC-001
Coaching assistance provided by outside
DuPont Safety Leadership Training
38      f. Have adequate processes, procedures, and guidance                PEMP, KPIs NOTE: compliance description                           Ensure an effective      B. Lenzer   4/30/2008            IA-2008-08-04
been developed to ensure an effective performance                   to be improved                                                    Performance Indicator
indicator program?                                                                                                                    Program exists
39      g. Have the appropriate performance indicators and                  Trend Analysis Procedure (under development)               Y                  NA                NA        NA         NA
parameters been selected to effectively measure                     CATS Trending Tool
performance and identify adverse trends in a timely                 PEMP Metrics
manner to ensure prompt mitigation and corrective                   KPIs
40      h. Do assessment and performance measurement           40.a         Assessment program procedures (Independent                 Y                  NA                NA        NA         NA
program procedures provide appropriate linkages to the              Assessment Procedure &amp; Management Self
issues management, corrective action, and reporting                 Assessment Procedure) provide linkage to the
processes?                                                          CATS and the reporting processes as a subset
of the issues management program.
40.b      Performance measurement program linkage.                   Y                  NA                NA        NA         NA
Formal external and internal assessments
performed on PEMP results, any resulting
findings, are dispositioned in the issues
management process and entered into CATS.
41      2. Training &amp; Qualification - Are personnel
implementing the assessment and performance
measurement program processes adequately trained
and qualified to perform assigned oversight activities?
42      a. Has the contractor defined the requirements for        42.a      The requirements for KSAs for personnel                    Y                  NA                NA        NA         NA
experience, knowledge, skills and abilities for personnel           implementing assessment activities are
implementing assessment and performance                             specified in the Management Self Assessments
measurement activities?                                             procedure.
KSAs for JLab personnel performing IAs is part
of their job descriptions. Subcontractors hired
to perform IAs are screened for certification and
qualification and also take the JLab WBT
43      b. Has the contractor provided and ensured completion 43.a          course.
The Quality Assurance Plan, Section 10.2.3,                Y                  NA                NA        NA         NA
of appropriate training for personnel implementing                  Assessor Qualifications, specifies that a
assessment and performance measurement activities?                  process for qualification/certification of
personnel performing assessment be
established. This training is available in Training
module &quot;Auditor/Assessment Basics
(QACI001).
Draft A                                                                                                                             3 of 5                                                                                               3/6/08
43      b. Has the contractor provided and ensured completion
of appropriate training for personnel implementing                                                Assessment and Performance Measurement                                                                    HSS CRAD 64-20 (Part 2 of 6)
assessment and performance measurement activities?                                                                                                                                                 Feedback and Continuous Improvement
#                                                                                                                            Compliant                                 Action       Target   Actual Comp
Item #          JLab Compliance Description                 (Y/N)        Corrective Actions        Manager     Comp Date      Date    CATS ACTION
43.b    Site Policy and Procedure currently being              Y     1) Complete development of     B. Lenzer    4/30/2008  4/16/2008 IA-2008-08-01 &amp;02
developed which will address this LOI                        the Training and
Qualification Procedure and
2) Training Matrix for QA/CI
Requirements defined in:                              Y     1) Complete development of     B. Lenzer   4/30/2008   4/16/2008   IA-2008-08-01 &amp;02
- Individual Training Plans (ITP) specify KSA&#39;s             the Training and
for CAS related positions                                   Qualification Procedure and
- Training and Qualification Procedures (under              2) Training Matrix for QA/CI
development) identifies the KSA&#39;s for CAS                   personnel.
43.c     Addressed in:                                          Y                 NA                   NA          NA          NA
- Individual Training Plans (ITP)
- Management Self Assessment (MSA)
Procedure requires assessors complete
44      3. Implementation of Program Responsibilities - Are
assessment and performance measurement program
responsibilities appropriately implemented?
45      a. Does line management routinely monitor and                       Integrated Assessment Schedule, MSA, Work              Y                 NA                   NA          NA          NA
observe the activities of their workforce to ensure                 Observation Program, Safety Warden Area
activity, facility, and institutional requirements and              Inspections, &quot;Assessment Topic Spreadsheet&quot;
management expectations are met?
46      b. Are formal, rigorous, effective self-assessments                 Integrated Assessment Schedule, MSA, Work              Y                 NA                   NA          NA          NA
conducted at all levels and in all organizations to                 Observation Program, Safety Warden Area
determine the adequacy of programs and performance                  Inspections, &quot;Assessment Topic Spreadsheet&quot;
and identify deficiencies needing correction and areas
and means for performance improvement?
47      c. Are institutional programs periodically evaluated for            Integrated Assessment Schedule, MSA, Work              Y                 NA                   NA          NA          NA
adequacy, including assessment of implementation by                 Observation Program, Safety Warden Area
line and support organizations?                                     Inspections, &quot;Assessment Topic Spreadsheet&quot;
48      d. Are appropriate and effective independent                        Integrated Assessment Schedule, MSA, Work              Y                 NA                   NA          NA          NA
assessments performed, including evaluations of                     Observation Program, Safety Warden Area
assurance system effectiveness?                                     Inspections, &quot;Assessment Topic Spreadsheet&quot;
49      e. Is the subject, scope, and frequency of self- and                Integrated Assessment Schedule, MSA, Work              Y                 NA                   NA          NA          NA
independent assessments based on a formal analysis                  Observation Program, Safety Warden Area
that addresses elements such as risk; regulatory or                 Inspections, &quot;Assessment Topic Spreadsheet&quot;
standards based requirements; type and complexity of
work activities, facilities, and conditions; past
performance; trend analyses; or management
50      f. Are planned assessments documented on an                         Integrated Assessment Schedule, MSA, Work              Y                 NA                   NA          NA          NA
appropriate schedule that is maintained to reflect                  Observation Program, Safety Warden Area
pertinent information and status (e.g., additions,                  Inspections, &quot;Assessment Topic Spreadsheet&quot;
completions, cancellations, and substitutions)?
Draft A                                                                                                                         4 of 5                                                                                                      3/6/08
Assessment and Performance Measurement                                                                   HSS CRAD 64-20 (Part 2 of 6)
#                                                                                                                          Compliant                                  Action     Target  Actual Comp
Item #           JLab Compliance Description               (Y/N)         Corrective Actions        Manager   Comp Date     Date    CATS ACTION
51      g. Have subcontractors implemented appropriate and                  Integrated Assessment Schedule, MSA, Work           Y                   NA                  NA         NA          NA
effective self-assessment programs, and is the                      Observation Program, Safety Warden Area
contractor&#39;s subcontractor oversight program effectively            Inspections, &quot;Assessment Topic Spreadsheet&quot;
evaluating performance, providing feedback to
subcontractors, and ensuring correction of process and
performance deficiencies?
52      h. Are assessment activities sufficiently performance-              Integrated Assessment Schedule, MSA, Work            Y                 NA                    NA        NA          NA
based, including an appropriate focus on observation of             Observation Program, Safety Warden Area
work, inspection of field conditions, review of evidence            Inspections, &quot;Assessment Topic Spreadsheet&quot;
of compliance and effective performance, and
effectiveness of corrective actions for previously
identified deficient conditions?
53      i. Is the performance indicator program periodically                Performance Indicator program parameters are         Y      Add Performance Indicator   B. Lenzer   4/30/2008   4/10/2008   IA-2008-08-03
reviewed to ensure the most appropriate sets of data                continually reviewed and revised as necessary               Program to assessment
and data analysis parameters are being employed?                                                                                Topic Spreadsheet.
54      j. Is performance data being sufficiently analyzed, with            PEMP                                                 Y                 NA                    NA        NA          NA
conclusions drawn and presented to management, and
needed actions identified and taken?
55      k. Are the processes and performance of assessment                  Integrated Assessment Schedule Procedure             Y                 NA                    NA        NA          NA
and performance measurement programs evaluated for
effectiveness on an appropriate frequency?
Draft A                                                                                                                       5 of 5                                                                                                     3/6/08
Event Reporting                                                                                    HSS CRAD 64-20 (Part 3 of 6)
Line                            Criteria/ Lines of Inquiry                           Item #            JLab Compliance Description              Compliant       Corrective Actions           Action      Target       Actual      CATS ACTION
#                                                                                                                                               (Y/N)                                     Manager      Comp       Comp Date
56      Criteria - Contractor management has implemented formal programs to
identify issues and report, analyze, and address operational events,
57      1. Formal programs and processes have been established to identify        57.a       ES&amp;H Manual Chapters 5100, 5200 and 5300             Y                    NA                     NA          NA          NA
issues and report, analyze, and address operational events, accidents,               Formal programs and processes established
and injuries. Events, accidents, and injuries are promptly and thoroughly
reported and investigated, including the identification and resolution of
root causes and management and programmatic weaknesses, and
distribution of lessons learned in accordance with applicable DOE
directives (e.g., Manual 231.1-2, Occurrence Reporting and Processing 57.b           Events, accidents, and injuries promptly and         Y                    NA                     NA          NA          NA
of Operations Information; Manual 231.1 -1A, Environment, Safety and                 thoroughly investigated and reported.
Health Reporting Manual; Order 225.1 A, Accident Investigations; and 57.c
DOE Order 5480.19 is not applicable at Jlab.
Order 5480.19, Conduct of Operations Requirements for DOE
Not in the Jlab contract.
58      Facilities). of operational events, accidents, and injuries are
conducted in accordance with applicable nuclear, security, environment,
occupational safety and health, and quality assurance requirements,
applicable DOE directives, and contract terms and conditions. Trending
analysis of events, accidents, and injuries are performed in accordance
with structured/formal processes and applicable DOE directives (e.g.,
Manual 23+B151.1-2).
59      Lines of Inquiry - 1. Oversight Program - Are the processes for event
identification, reporting and investigation formal and documented and
meet the requirements of DOE directives?
60      a. Have appropriate, formal processes and procedures been                            Chapter 5200 and 5300                                         Include CAIRS reporting in     B. May       4/30/2008               IA-2008-08-22
established to detail the requirement for the identification,                        Trending Analysis Procedure (under development)               the ES&amp;H Manual (5000
documentation, investigation, analysis, reporting, and management of                 Issues Management Procedure                                   series)
issues for operational events (including non-reportable incidents),
accidents, occupational injuries and illnesses, and quality assurance
and nuclear safety issues?
61      b. Do processes require timely and appropriate identification,                       Chapter 5200 and 5300                                         Include CAIRS reporting in     B. May       4/30/2008               IA-2008-08-22
documentation, and local notification of operational events, incidents,              Trending Analysis Procedure (under development)               the ES&amp;H Manual (5000
accidents, occupational injuries and illnesses and nuclear safety                    Issues Management Procedure                                   series)
62      2. Training &amp; Qualification - Are personnel implementing event
identification, reporting, and investigation processes adequately trained
and qualified to perform assigned oversight activities (in accordance
with DOE O 226.1 A, DOE M 360.1 - I B, and DOE M 426.1 - 1 A)?
63 a. Has the contractor defined the requirements for experience,                  63.a     Site Policy and Procedure currently being            Y        1) Complete development of      B. Lenzer   4/30/2008   4/16/2008 IA-2008-08-01 &amp; -02
knowledge, skills and abilities for personnel implementing event                         developed which will address this LOI                         the Training and
identification, reporting, and investigation activities?                                                                                               Qualification Procedure and
Draft A                                                                                                                           1 of 3                                                                                                              3/6/08
Event Reporting                                                                                      HSS CRAD 64-20 (Part 3 of 6)
Line                            Criteria/ Lines of Inquiry                           Item #            JLab Compliance Description                  Compliant        Corrective Actions          Action      Target     Actual     CATS ACTION
#                                                                                                                                                   (Y/N)                                     Manager       Comp    Comp Date
63.b     Requirements defined in:                                 Y        1) Complete development of      B. Lenzer   4/30/2008 4/16/2008 IA-2008-08-01 &amp; -02
- Individual Training Plans (ITP) specify KSA&#39;s for               the Training and
CAS related positions                                             Qualification Procedure and
64      b. Has the contractor provided and ensured completion of appropriate 64.a            Qual. Standard elements contained in:                    Y                    NA                      NA        NA         NA
training for personnel implementing event, accident, occupational injury             - Internal Independent Auditor provides oversight.
and illness, and nuclear safety issue management activities?                         - ESH&amp;Q Program personnel provides oversight
64.b     Addressed in:                                            Y                    NA                      NA        NA         NA
- Management Self Assessment (MSA) Procedure
requires assessors complete assessor training
65      3. Implementation of Program Responsibilities - Are event identification,
reporting and investigation responsibilities appropriately validated,
documented, communicated, classified, evaluated, tracked and
66      a. Is reporting of operational events, accidents, occupational injuries              CAIRS (Not Formalized, but is being used)                Y        Include CAIRS reporting in     B. Lenzer    4/30/2008            IA-2008-08-22
and illnesses, and nuclear safety issues conducted in accordance with                Chapter 5200 and 5300                                             the ES&amp;H Manual (5000
applicable nuclear, security, environment, occupational safety and                   Integrated Assessment Procedure and Schedule                      series)
health, and quality assurance requirements, applicable DOE directives,               specify periodic assessments that verify programs
and contract terms and conditions?                                                   are in compliance with applicable DOE directives,
and contract terms and conditions
ORPS and PAAA reporting and entry of
appropriate events in CATS.
67      b. Are immediate and compensatory measures to operational events,                    ES&amp;H Manual Chapter 3330 and Chapter 5300                Y        NA                             NA              NA         NA
accidents, occupational injuries and illnesses and nuclear safety issues             Chapter 3510 Emergency Management Plan
sufficiently defined and taken as part of line management initial                    Issues Management Procedure
response to operational events, in the development of follow-on
corrective action plans?
68      c. Are operational events, accidents, occupational injuries and illnesses            Issues Management Procedure                              Y        NA                             NA              NA         NA
and nuclear safety issues promptly and rigorously reported to                        ES&amp;H Manual Chapter 5300 Occurrence
management, documented, and investigated in accordance with formal                   Reporting Procedure
issues management processes that identify causes and recurrence                      ES&amp;H Manual Chapter 5200 Incident/Injury
controls, management and programmatic weaknesses, and the need to                    Investigation
communicate lessons learned?
69      d. Are corrective and preventive actions resulting from investigation of             Issues Management Procedure (CATS)                       Y        NA                             NA              NA         NA
events, accidents, and occupational injuries and illnesses formally
managed to completion and effective in preventing recurrence?
70      e. Are events, accidents, occupational injuries and illnesses, and                   ES&amp;H Manual Chapter 5300 Occurrence                      Y        NA                             NA              NA         NA
nuclear safety issues reported to DOE and other regulatory entities in a             Reporting Procedure
timely and thorough manner as required by directives and regulations?                ES&amp;H Manual Chapter 5200 Incident/Injury
Draft A                                                                                                                            2 of 3                                                                                                                3/6/08
Event Reporting                                                                               HSS CRAD 64-20 (Part 3 of 6)
Line                            Criteria/ Lines of Inquiry                          Item #            JLab Compliance Description               Compliant        Corrective Actions      Action     Target       Actual     CATS ACTION
#                                                                                                                                               (Y/N)                                 Manager     Comp       Comp Date
71      f. Are operations and engineering organizations, including support                  5200 Incident/Injury Investigation                    Y        NA                         NA             NA          NA
organizations, appropriately involved in the identification, assessment,
and development of corrective action plans of reportable events,
accidents, and occupational injuries and illnesses?
72      g. Are trending analyses of events (including non-reportable incidents),            Trend Analysis Procedure (under development)          Y        Complete development of    B. Lenzer   4/30/2008   4/16/2008 IA-2008-08-11
accidents, and occupational injuries and illnesses performed in                                                                                    Trend Analysis Procedure
accordance with structured/formal processes and applicable DOE
73      h. Are the processes and performance of event, accident, occupational               ES&amp;H Manual 1300 Appendix T1 Content Review           Y        NA                         NA             NA          NA
injury and illness, and nuclear safety issue management properly                    states that all chapters are to be reviewed on a
evaluated for effectiveness on an appropriate frequency?                            predetermined schedule
Reviewed as part of the PEMP Process
Draft A                                                                                                                            3 of 3                                                                                                        3/6/08
Operating Experience and Lessons Learned                                                                              HSS CRAD 64-20 (Part 4 of 6)
Line                           Criteria/ Lines of Inquiry                          Item                                                      Compliant       Corrective Actions           Action         Target    Actual
#                                                                                  #                                                         (Y/N)                                     Manager       Comp Date Comp Date
JLab Compliance Description                                                                                                      CATS ACTION
74      Criteria – Contractor management has established formal programs to
communicate operating experience/lessons learned during work
activities, process reviews, and incident/event analyses to potential
users and applied to future work activities (in accordance with DOE 0
226.1A and DOE 0 21 0.2).
C4.1. Formal processes are in place to identify applicable lessons        75.a A Draft Corporate Operating Experience                  Y        Ensure that the Corporate      Bill Rainey    4/10/2008    4/10/2008
learned from external and internal sources and any necessary                   Procedure exists                                                 Operating Experience
corrective and preventive actions, disseminate lessons learned to                                                                               Procedure requires (1)
targeted audiences, and ensure that lessons learned are understood                                                                              Management involvement
and applied.                                                                                                                                    and responsibility for lessons
learned and (2) clearly
communicates that LL are
not just for safety                                                    IA-2008-08-30
75.b                                                         N        Add Lesson Learned               B. May       4/30/2008
Control Document Planning
and Pre-job brief processes
and QA Work Controls and
75                                                                                                                                                                                                                             IA-2008-08-06
C4.2. Formal programs and processes have been established and             76.a Established mechanisms include:                         Y        1) Investigate examples of a    Bill Rainey       1)                   IA-2008-08-26
implemented to solicit feedback from workers and work activities on the        - Director&#39;s Safety Council                                      process to solicit worker                     4/30/2008
effectiveness of work definition, hazard analyses and controls, and            - Worker&#39;s Safety Committee                                      feedback.
implementation for all types of work activities, and to apply lessons          - MCC 8 &#39;o&#39;clock meeting                                         2) Incorporate appropriate                                             IA-2008-08-29
learned.                                                                       - FEL Meeting                                                    key elements of example                       2) 5/30/08
- Toolbox meetings                                               process(es) into the JLab
- material handling committee                                    process.
- electrical safety committee
76.b                                                         N        Develop and implement a         Bill Rainey   5/30/2008
process to respond to
76                                                                                                                                                      worker feedback                                                        IA-2008-08-13
3. Line managers effectively identify, apply, and exchange lessons      77.a Addressed in:                                             N        Build in to the tools a         Bill Rainey   4/30/2008
learned with the rest of the DOE complex. Lessons learned identified by      - New Corporate Operating Experience Procedure                     checkbox that requires
other DOE organizations and external sources are reviewed and                (once implemented it is expected that this                         managers to certify that they
applied by line management to prevent similar incidents/events.              procedure will effectively address this requirement)               have reviewed provided
77                                                                                                                                                      Lesson Learned                                                         IA-2008-08-10
Lines of Inquiry - 1. Oversight Program - Are the processes which          78.a
constitute the operating experience/lessons learned program formal and
documented and, when taken together, meet the requirements of DOE
Order 226.1A and DOE Order 210.2, DOE Corporate Operating
78      Experience Program?
a. Has the contractor established and implemented a formal program         79.a Addressed in Corporate Operating Experience            Y                     NA                    NA            NA           NA
that screens lessons learned from external sources for local applicability      Procedure and if necessary tracked until
and evaluates site conditions and processes to determine if actions are         implemented in CATS
needed to apply applicable lessons learned and ensure that actions
79      deemed necessary are implemented?
Draft A                                                                                                                     1 of 4                                                                                                                   3/6/08
Operating Experience and Lessons Learned                                                                          HSS CRAD 64-20 (Part 4 of 6)
Line                            Criteria/ Lines of Inquiry                            Item                                                        Compliant       Corrective Actions           Action       Target    Actual
#                                                                                     #                                                           (Y/N)                                     Manager     Comp Date Comp Date
JLab Compliance Description                                                                                                  CATS ACTION
b. Has the contractor identified an institutional program coordinator and    80.a Jlab-wide LL program coordinator identified;              N        Establish Lessons Learned        B. May     4/30/2008
contacts/coordinators in line and support organizations?                          Divisional LL coordinators not yet identified                      Coordinators in the Divisions
who are responsible for all
Lessons Learned which
include all aspects (safety,
environmental, process,
quality.etc) within their
80                                                                                                                                                                                                                             IA-2008-08-18
c. Has the contractor established and implemented processes that             81.a Addressed as follows:                                     Y                     NA                    NA          NA        NA
identify, document, disseminate and apply lessons learned from                    - one distribution method is the Electronic
investigations of incidents/accidents and occupational injuries, including        Newsletter Weekly Briefs
near misses, and from work activities that warrant communication to               - ES&amp;H Chapter 5200,
other organizations?                                                              - Corp. Op.. Experience Procedure processes
81                                                                                        - Quarterly Trend Reports
d. Has the contractor established tools and services to encourage and        82.a Corporate Operating Experience Procedure and              Y                     NA                    NA          NA        NA
facilitate the documentation and communication of lessons learned                 lessons learned section of intranet
such as templates, guidance documents, and subject matter expert
82      assistance?
e. Do work planning and training for design, construction, research,         83.a                                                           N        Build a step into the work       B. May     4/30/2008
operations, and maintenance processes include triggers to prompt or                                                                                  planning process to verify
record the research and application of potentially applicable lessons                                                                                Lesson Learned are
learned?                                                                                                                                             evaluated for applicability
and applied, as appropriate                                       IA-2008-08-09
83.b                                                           N        Incorporate LL expectations      Ullman     5/30/2008
into annual safety training
IA-2008-08-23
83.c                                                           N        Assure there is a lessons        Lenzer     4/15/2008
learned section in the AWP
83                                                                                                                                                           process                                                           IA-2008-08-08
f. Has the contractor established tools that encourage and facilitate the    84.a Limited tools available - lessons learned section of      N        For access to an external LL     Lenzer      4/8/2008
research of lessons learned, such as a searchable database and links              Jlab intranet has limited search capabilities and                  DB, contact CSC workplace,
to external source sites?                                                         does not include all site lessons learned                          Forth Worth                                                       IA-2008-08-19
84.b                                                           N        Select and facilitate access C. Ficklen     4/25/2008
for additional key individuals
to the DOE Lessons
Learned database (Including
Training Coordinator.)                                            IA-2008-08-25
84.c                                                           N        Establish a Searchable,         B. Lenzer    5/1/2008
central, Lessons Learned
database available via
84                                                                                                                                                           INSIGHT                                                           IA-2008-08-17
Draft A                                                                                                                          2 of 4                                                                                                               3/6/08
Line                            Criteria/ Lines of Inquiry                          Item                                                       Compliant       Corrective Actions            Action        Target    Actual
#                                                                                   #                                                          (Y/N)                                      Manager      Comp Date Comp Date
JLab Compliance Description                                                                                                   CATS ACTION
2. Training &amp; Qualification - Are personnel implementing operating         85.a
experience/lessons learned processes adequately trained and qualified
to perform assigned oversight activities (in accordance with DOE 0
85      226.1 A, DOE M 360.1 - 1 B, and DOE M 426.1 -1 A)?
C4L2.a. Has the contractor provided and ensured completion of              86.a                                                          N        1) Develop training and      B. Lenzer        4/30/2008              1) IA-2008-08-27
appropriate training on the expectations, requirements, and processes                                                                             2) provide training to                                               2) IA-2008-08-28
for the development, identification, sharing, and application of lessons                                                                          appropriate personnel on
learned&#39;?                                                                                                                                         expectations associated with
86                                                                                                                                                        Experience Procedure (LL)
3. Implementation of Program Responsibilities - Are operating              87.a                                                                   (Chain Teach Process)
experience/lessons learned program responsibilities appropriately
87      implemented?
a. Are appropriate sources of lessons learned being regularly and                 Routinely reviewed by Jlab wide LL coordinator;        N        Establish Lessons Learned         B. May      4/30/2008
rigorously screened by the coordinator(s) and/or subject matter experts           Division LL coordinators not yet established                    Coordinators in the Divisions
and line organizations for applicability and the need for action?                                                                                 and ensure that they have
88                                                                                                                                                                                                                             IA-2008-08-18
b. Have work planners, supervisors, managers, subject matter experts,                                                                    N        Select and facilitate access C. Ficklen       4/27/2008
and training staff subscribed to the DOE lessons learned database?                                                                                for additional key individuals
89                                                                                                                                                        Training Cord.)                                                      IA-2008-08-25
c. Are screening and technical review activities and results documented           Corporate Operating Experience                         N        During development of the Bill Rainey         4/30/2008   4/7/2008
and tracked to demonstrate and manage program implementation?                     Specific LL that are flowed down to Divisions are               Corp. Op Exp, assure
discussed and flowed (Worker&#39;s Safety                           program document
Committee)                                                      incorporates documenting,
tracking, screening, and
90                                                                                                                                                        technical review activities                                          IA-2008-08-14
d. Is the disposition of process and performance deficiencies identified                                                                 N        Ensure the Corp. Op. Exp. Bill Rainey         4/30/2008   4/7/2008
through lessons learned processes managed in accordance with the                                                                                  Procedure contains the
formal issues management and corrective action tracking system                                                                                    requirement to enter any
process(es)?                                                                                                                                      appropriate Corrective
Actions from LL into CATS.
91                                                                                                                                                                                                                             IA-2008-08-15
e. Is lessons learned information readily available to potential users?                                                                  N        Establish a Searchable,          B. Lenzer    4/30/2008
92                                                                                                                                                        INSIGHT                                                              IA-2008-08-17
f. Are innovative, successful practices shared as well as negative                                                                       N        Check to make sure the          Bill Rainey   4/30/2008   4/7/2008
lessons learned?                                                                                                                                  Corp. op Exp procedure
contains the requirement to
share innovative and
93                                                                                                                                                        successful practices                                                 IA-2008-08-16
Draft A                                                                                                                         3 of 4                                                                                                               3/6/08
Operating Experience and Lessons Learned                                                                HSS CRAD 64-20 (Part 4 of 6)
Line                            Criteria/ Lines of Inquiry                            Item                                                    Compliant        Corrective Actions     Action      Target    Actual
#                                                                                     #                                                       (Y/N)                                Manager    Comp Date Comp Date
JLab Compliance Description                                                                                       CATS ACTION
g. Are internally generated lessons learned evaluated for their potential           Corp. Op Exp and we have examples                   Y        NA                        NA             NA
value to other DOE facilities and shared with the DOE complex as
94      appropriate?
h. Are lessons from experiences within and outside the contractor                   Lessons Learned are communicated internally in      N        Implement Lessons Learned B. Lenzer   1/31/2009
organization effectively communicated and used in work planning and                 some divisions but not all.                                  program
95      training?                                                                                                                                                                                                    IA-2008-08-20
i. Do safety committees or other boards provide effective feedback,
including reviewing performance, analyzing data for lessons learned,
96      and assigning and formally tracking action items for improvement?
j. Is contractor facility management collecting and disseminating to their          There are numerous safety committees on site.       Y        NA                        NA             NA
staff both lessons learned and good practices from operational events               Meeting minutes are developed and include
97      related to their facilities and similar DOE facilities?                             documented corrective actions
k. Are internally identified lessons learned being reported to the DOE                   Corp. Op Exp and we have examples                   Y        NA                        NA             NA
operating experience program for sharing with the DOE complex when
98 appropriate?
l. Have metrics to measure program performance, use, and
99 effectiveness been established?
m. Has the adequacy of the operating experience/lessons learned                          FY &#39;09 Assessment Schedule to include               Y        NA                        NA             NA
program been adequately assessed by the contractor on an appropriate                     assessment of COO/LL. Date and assessment
100 frequency?                                                                               type to be determined.
Draft A                                                                                                                         4 of 4                                                                                                      3/6/08
Issues Management                                                                        HSS CRAD 64-20 (Part 5 of 6)
Line                                                                                                                                                 Compliant                         Action   Comp       Actual
#                               Criteria/ Lines of Inquiry                         Item #            JLab Compliance Description                     (Y/N)     Corrective Actions   Manager    Date    Comp Date     CATS ACTION
Criteria - Contractor management has established a comprehensive,
structured issues management system that provides for the timely and
effective resolution of deficiencies and meets the requirements of DOE
Order 226.1 and DOE Order 414.lC.
1. Program and performance deficiencies, regardless of their source,                 The Corrective Action Tracking System (CATS),             Y
are captured in a system or systems that provide(s) for effective                    managed under the Issues Management
analysis, resolution, and tracking. Issues management system elements                Procedure, is the Jefferson Laboratory process for
include structured processes for determination of risk, significance, and            documenting, tracking, trending, reporting,
priority of deficiencies; evaluation of scope and extent of condition;               verifying and validating (as appropriate) corrective
determination of reportability under applicable requirements;                        actions for program and performance deficiencies.
identification of root causes; identification and documentation of                   Chapter 5200 Event Reporting and Causal
corrective actions and recurrence controls to prevent recurrence;                    Analysis
identification of individuals/organizations responsible for corrective               Work Observation Tool and related procedure
action implementation; establishment of milestones based on                          (both in process)
significance and risk for completion of corrective actions; tracking                 Chapter 5300 Occurrence Reporting, Appendix T4
progress; verification of corrective action completion; and validation of            Price Anderson Reporting Procedure
corrective action implementation and effectiveness.
2. Issues management processes include mechanisms to promptly                        This is assured through a combination of ES&amp;H             Y
identify the potential impact of a deficiency and take timely actions to             Manual chapters and the Issues Management
address conditions of immediate concern, including stopping work,                    Procedure.
system shutdown, emergency response, reporting to management, and                    Chapter 5200 Event Reporting and Causal
compensatory measures pending formal documentation and resolution                    Analysis
of the issue.                                                                        Work Observation Tool and related procedure
Chapter 5300 Occurrence Reporting, Appendix T4
Price Anderson Reporting Procedure
ES&amp;H Manual Chapter 3510 Emergency
ES&amp;H Manual Chapter 3330 Stop Work
Accelerator Operations Directives (AOD)
Experimental Hall Conduct of Operations
Procedures for each experiment
QA/CI Unreviewed Safety Issue Procedure
103                                                                                           Experimental Hall Conduct of Operations
3. Processes for analyzing deficiencies, individually and collectively,              Procedures for through the Issues
This is assured each experiment Management                Y
have been established that are designed to effectively identify                      Procedure, CATS, Event Reporting and reports to
programmatic or systemic issues. Line management effectively                         senior management.
monitors progress and optimizes the allocation of assessment                         Chapter 5200 Event Reporting and Causal
resources in addressing known systemic issues.                                       Analysis
QA/CI Trend Analysis Procedure (in process)
Significance Level 1 and below issues, identified at
the division level, are not required to be entered
into CATS nor evaluated for programmatic or
(This issue was presented to the DSC. It was
Draft A                                                                                                                            1 of 5                                                                                                  3/6/08
Issues Management                                                                                     HSS CRAD 64-20 (Part 5 of 6)
Line                                                                                                                                               Compliant                                  Action    Comp         Actual
#                               Criteria/ Lines of Inquiry                      Item #             JLab Compliance Description                     (Y/N)         Corrective Actions        Manager     Date      Comp Date      CATS ACTION
4. Processes for communicating issues up the management chain to                  This is assured through the use of the Issues               Y
senior management have been established and based on a graded                     Management System and CATS.
approach that considers hazards and risks. Line management receives               Director&#39;s Safety Council (DSC)
periodic information on the status of identified deficiencies and                 Monthly notification of management corrective
corrective actions and holds organizations and individuals accountable            action status in DSC meeting.
for timely and effective completion of actions. Line management has               Insight Page notifies individuals of open CATS
executed graded mechanisms such as independent verification and                   items.
performance-based evaluation to ensure that corrective action and                 E-mails sent, on a graded basis, when items are
recurrence controls are timely, complete and effective. Closure of                overdue.
corrective actions and deficiencies are based on objective, technically
sound, and verified evidence. The effectiveness of corrective actions is
determined on a graded basis and additional actions are completed as
Lines of Inquiry - 1. Oversight Program - Are the processes that
constitute the Contractor issues management program formal and
106 documented and meet the requirements of DOE 0 226.1 A&#39;?
a. Have comprehensive processes and procedures been established                        Yes.                                                       Y
and implemented that provide for the consistent, timely, and effective                 CSC integrated quality information systems with
collection, analysis, and resolution of process and performance                        CATS to improve visibility of trends and related
deficiencies and other issues, regardless of their source? Are separate                information.
processes and tracking tools compatible and sufficiently integrated to                 Key performance indicators are included on Insight
facilitate consistent implementation, trending, and performance                        Page.
measurement?                                                                           Separate Processes are compatible at or above
Level 2. All these go into CATS.
determined that no further action is required at this
Divisions are required to report on DSC/KPIs
associated with Lessons Learned, incidents and
107                                                                                        events, during the Director&#39;s Safety Council
b. Does the issues management program include processes (including                     Yes                                                        Y
Occurrence Reporting and Processing System and Price-Anderson                          See below
Amendments Act [PAAA]) and tools that address the following essential
108 elements:
i . Determining risk, significance and priority?                                       Yes                                                        Y        Include CAIRS reporting in   B. May     4/30/2008               IA-2008-08-22
Chapter 5300 Occurrence Reporting, Appendix T4                      the ES&amp;H Manual (5000
Price Anderson Reporting Procedure                                  series)
109                                                                                        Issues Management Procedure
ii. Evaluating the scope and extent of condition or deficiency?                   Yes                                                        Y
110                                                                                        Issues Management Procedure
Draft A                                                                                                                          2 of 5                                                                                                              3/6/08
Issues Management                                                                      HSS CRAD 64-20 (Part 5 of 6)
Line                                                                                                                                           Compliant                         Action   Comp       Actual
#                              Criteria/ Lines of Inquiry                          Item #           JLab Compliance Description                (Y/N)     Corrective Actions   Manager    Date    Comp Date     CATS ACTION
iii. Determining and ensuring reportability in accordance with DOE or                Yes                                                  Y
regulatory requirements?                                                             Chapter 5300 Occurrence Reporting, Appendix T4
111                                                                                           Issues Management Procedure
iv. Analyzing for root and contributing causes using a graded approach?              Yes                                                 Y
112                                                                                           Issues Management Procedure
v. Development of effective corrective action plans that include                     Yes                                                 Y
recurrence controls that address identified root and contributing                    Chapter 5300 Occurrence Reporting, Appendix T4
causes?                                                                              Price Anderson Reporting Procedure
113                                                                                           Issues Management Procedure
vi. Assigning and changing ownership of issues, action plan                          Yes                                                 Y
development and corrective action implementation?                                    Chapter 5300 Occurrence Reporting, Appendix T4
114                                                                                           Issues Management Procedure
vii. Milestones for completion of corrective/preventive actions and                  Yes                                                 Y
requirements for revisions of milestone dates&#39;?                                      Chapter 5300 Occurrence Reporting, Appendix T4
viii. Tracking of progress of actions?                                               Yes                                                 Y
ix. Verification that actions are complete&#39;?                                         Yes                                                 Y
117                                                                                           Issues Management Procedure
x. Validation of the effectiveness of corrective/preventive actions using            Yes                                                 Y
a graded approach?                                                                   Chapter 5300 Occurrence Reporting, Appendix T4
118                                                                                           Issues Management Procedure
xi. Ensuring that the status of issues management is communicated to                 Yes                                                 Y
management and individuals and organizations are held accountable for                Chapter 5300 Occurrence Reporting, Appendix T4
performing their assigned responsibilities for managing issues?                      Price Anderson Reporting Procedure
Draft A                                                                                                                        3 of 5                                                                                                3/6/08
Issues Management                                                                         HSS CRAD 64-20 (Part 5 of 6)
Line                                                                                                                                               Compliant                         Action   Comp       Actual
#                             Criteria/ Lines of Inquiry                        Item #             JLab Compliance Description                     (Y/N)     Corrective Actions   Manager    Date    Comp Date     CATS ACTION
c. Have formal policies and processes been established and                        Yes                                                         Y
communicated for rapidly determining if deficiencies or conditions pose           Chapter 5200 Event Reporting and Causal
immediate and/or significant risk of harm to workers, the public, or the          Analysis
environment and provide for interim actions such as stopping work,                Work Observation Tool and related procedure
system shutdown, or other compensatory measures pending formal                    (both in process)
processing of the issue?                                                          Chapter 5300 Occurrence Reporting, Appendix T4
Management D29
120                                                                                        Procedures for each experiment
2. Training &amp; Qualification - Are personnel implementing contractor               Yes
issues management processes adequately trained and qualified to                   QA/CI Training and Qualification Procedure (under
perform assigned oversight activities (in accordance with DOE 0 226.1             development)
A, DOE M 360.1-1 B, and DOE M 426.1 - 1 A)?                                       ES&amp;H Manual Chapter 4000 Series Training Policy
121                                                                                        (See #15 through 18 of this spreadsheet)
a. Has the contractor defined the requirements for experience,                    Yes                                                        Y
knowledge, skills and abilities for personnel implementing issues                 Job Descriptions for positions with issue
management activities?                                                            management responsibilities
b. Has the contractor provided and ensured completion of appropriate                   Yes                                                        Y
123 training for personnel implementing issues management activities?                      ITPs
3. Implementation of Program Responsibilities - Are contractor issues
management program responsibilities appropriately implemented?
a. Are issues (including lower level deficiencies) periodically formally               Yes                                                        Y
analyzed collectively to identify adverse trends or areas of weakness                  QA/CI Issues Management Procedure
that require corrective or preventive actions?                                         QA/CI Trending Analysis Procedure (in process)
Separate Processes are compatible at or above
Deficiencies of any level, identified with IAs and
MSAs, or externally identified are entered into
125                                                                                        CATS.
Draft A                                                                                                                          4 of 5                                                                                                  3/6/08
Issues Management                                                                               HSS CRAD 64-20 (Part 5 of 6)
Line                                                                                                                                       Compliant                              Action     Comp      Actual
#                             Criteria/ Lines of Inquiry                Item #              JLab Compliance Description                    (Y/N)       Corrective Actions     Manager       Date   Comp Date     CATS ACTION
b. Are adverse trends and needed corrective actions formally              Yes                                                         Y     Complete development of   B. Lenzer   4/30/2008 4/16/2008 IA-2008-08-11
documented and addressed using the formal issues management               QA/CI Issues Management Procedure                                 Trending Analysis
process?                                                                  QA/CI Trending Analysis Procedure (in process)                    Procedure.
126                                                                                events, during the Director&#39;s Safety Council
c. Are the processes and performance for the issues management            There have been internal and external                       Y
program properly evaluated for effectiveness on an appropriate            assessments of the Issues Management Program
4. Program Effectiveness - Are the contractor issues management
processes effective in ensuring that site operations are performed
128 safely, securely, and in compliance with applicable requirements&#39;?
a. Are the above issues management program elements being                      Yes                                                         Y
effectively implemented?                                                       Validated during the November 2007 DOE CAS
Effectively implemented by following the Issues
Management Procedure as evidenced by the
assessments being performed and the issues
being continually identified. One of the key focus
areas is on analysis of leading indicators for
129                                                                                prevention of safety/security issues.
Draft A                                                                                                                  5 of 5                                                                                                        3/6/08
Worker Feedback                                                                                  HSS CRAD 64-20 (Part 6 of 6)
Line                                                                    Item                                                           Compliant                                Action      Comp       Comp
#                      Criteria/ Lines of Inquiry                       #           JLab Compliance Description                        (Y/N)          Corrective Actions     Manager       Date       Date       CATS ACTION
130 Criteria - Contractor management has established a                         DOE M 442.1-1 is not in the contract.
comprehensive, structured issues management system that
provides for the timely and effective resolution of employee
concerns and feedback on safety performance from workers
that meets the requirements of DOE Order 226.1 A and DOE
Order 442.1 A, Department of Energy Employee Concerns
Program. Additionally, an effective differing professional
opinion process or program has been established and
implemented in accordance with the Contractor Requirements
Document associated with DOE M 442.1 - 1, Differing
Professional Opinions Manual.
131 Lines of Inquiry - 1. Oversight Program - Are the processes
which constitute the contractor worker feedback programs
formal and documented and, when taken together, meet the
requirements of DOE directives?
132 a. Has an effective employee concerns program been                         Yes                                                                 Review how well the        R. Barbosa   4/30/2008            IA-2008-08-31
established and implemented that encourages the reporting of              Worker Safety Committee (WSC) advertised                            Employee Concern Program
employee concerns and provides thorough, documented                       periodically (as least once a year with contact info)               is communicated and report
investigations, with timely and effective corrective actions and          Non-Supervisor workers are on all safety related                    back to M. Dallas.
recurrence controls that are tracked to completion?                       committees
WSC Chair member of Director&#39;s Safety Council
ES&amp;H Manual Concern Reporting Chapter
Employee concern hotline.
These mechanisms are used and advertised on
site periodically. Corrective actions are tracked to
Admin Manual 210 Employee Issues and
Formal HR Employee Concern Program
133 b. Are confidentiality and anonymity protections and rights to             Yes                                                        Y        NA                        NA               NA
appeal clearly communicated to employees and effectively                   ES&amp;H Manual Concern Reporting Chapter
implemented during the resolution of concerns?                             Addressed
134 c. Do site processes require/encourage formal reviews or                   Grievance
Post Job Review process is not in place                    N        Develop and implement a   B. May        4/30/2008            IA-2008-08-12
documented feedback from performers and supervision after                                                                                      Post Job Review Process
completion of maintenance, experimental activities, or
operational evolutions?
135 d. Has an effective differing professional opinion process or              N/A
program been established and implemented, in accordance
with the Contractor Requirements Document associated with
DOE M 442.1 - 1, Differing Professional Opinion Manual ?
Were DPOs appropriately supported?
136 2. Training &amp; Qualification - Are personnel implementing
Contractor Worker Feedback program processes adequately
trained and qualified to perform assigned oversight activities
(in accordance with DOE O 226.1 A, DOE M 360.1-1 B, and
DOE M 426.1-1 A)?
Draft A                                                                                                                        1 of 3                                                                                                           3/6/08
Worker Feedback                                                                                   HSS CRAD 64-20 (Part 6 of 6)
Line                                                                 Item                                                         Compliant                                  Action     Comp       Comp
#                      Criteria/ Lines of Inquiry                    #            JLab Compliance Description                     (Y/N)      Corrective Actions           Manager      Date       Date       CATS ACTION
137 a. Has the contractor defined the requirements for experience,        Job descriptions for HR personnel are on file.              Y     NA                             NA             NA
knowledge, skills and abilities for personnel implementing
employee concerns and worker feedback activities?
138 b. Has the contractor provided and ensured completion of              Contractor Assurance System Program                         Y     NA                             NA             NA
appropriate training for personnel implementing employee             Description
concerns, differing professional opinions, and worker feedback
139 3. Implementation of Program Responsibilities - Are contractor
employee concerns and worker feedback responsibilities
appropriately implemented?
140 a. Are the mechanisms and processes for employees to (1)              Worker Safety Committee (WSC) advertised                    N     Verify that SAF100             B. Ullman   4/30/2008   4/7/2008 COMPLETE
report and get resolution to safety concerns; and (2) report a       periodically (as least once a year with contact info)             addresses employee
differing professional opinion clearly communicated to               Non-Supervisor workers are on all safety related                  concern program
employees through vehicles such as new employee and                  committees
refresher training, posters, intranet sites?                         WSC Chair member of Director&#39;s Safety Council
Differing professional opinion N/A
141 b. Are worker feedback information, differing professional            Safety Concerns - EH&amp;S Concern Report; ES&amp;H                 N     Develop and implement a          B. May    4/30/2008            IA-2008-08-13
opinions, and safety concerns expressed by employees and             Concern Hotline; Safety Warden program                            worker feedback process to
the activities and supporting information for disposition of                                                                           include solicitation, collection
feedback and concerns formally documented/logged?                                                                                      and response.
142 c. Are investigations of employee concerns, differing                 Safety Concerns - EH&amp;S Concern Report; ES&amp;H                 Y
professional opinions, and feedback information thoroughly           Concern Hotline; Safety Warden program
performed without conflict of interest and with the involvement      Admin Manual Chapter 210 Employee Concern
of technical expertise as appropriate?                               Program
143 d. Is employee confidentiality maintained as requested and as         ES&amp;H Concerns report                                        Y
detailed in program documents?                                       ES&amp;H Manual
144 e. Are corrective/preventive actions taken as a result of             ES&amp;H Concerns report                                        Y
investigating employee concerns, differing professional              ES&amp;H Manual
opinions, and feedback processes appropriate and managed             Admin Manual
in a formal manner in accordance with contractor procedures?
145 f. Are the resolutions of employee concerns and differing               ES&amp;H Concerns report                                      Y
professional opinions communicated to concerned individuals             ES&amp;H Manual
with a solicitation of concurrence and identification of appeal         Admin Manual
Draft A                                                                                                                   2 of 3                                                                                                            3/6/08
Worker Feedback                                                                        HSS CRAD 64-20 (Part 6 of 6)
Line                                                                  Item                                                        Compliant                           Action   Comp     Comp
#                     Criteria/ Lines of Inquiry                      #              JLab Compliance Description                  (Y/N)      Corrective Actions    Manager    Date     Date      CATS ACTION
146 g. Are the processes and performance for the employee                    Per the ES&amp;H Manual 1300 Appendix T1 Manual              Y     NA                      NA           NA
concerns, differing professorial opinions, and worker feedback          Review Process all ES&amp;H Manual Chapters are
programs formally and adequately evaluated for effectiveness            reviewed on a three year basis. Contractor
on an appropriate frequency?                                            Assurance System assessment to periodically
include worker feedback process effectiveness.
Periodicity to be determined based on results of
FY &#39;09 assessment.
Draft A                                                                                                                   3 of 3                                                                                                 3/6/08
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