Appendix 24 CF#5 Report Template
ISM Core Function Teams Assessment Plan
January 2008
Appendix 24 – CF#5 Report Template
Assessment Title / ISM Core Function #5 (Feedback and Continuous Improvement) Independent Assessment (Cycle I)Date / February 8, 2008 / Assessment # / IA-2008-07
(obtained from QA/CI)
Purpose & Scope:
The purpose of this assessment was to evaluate the effectiveness and identify opportunities for improvement for Core Function #5 – Feedback and Continuous Improvement - of the Integrated Safety Management System. The expectations for criteria to be evaluated and activities to be conducted to perform the evaluation for this assessment are summarized below.
Inspection Criteria:
- Line management has effectively developed and implemented a feedback and improvement process at the work activity level.
- Interview facility managers, project managers, and facility organizations, workers, ES&H or other appropriate personnel.
- Review work planning and control processes and procedures, work packages, and assessment/oversight/feedback activity documentation. Interview personnel including project personnel, subject matter experts, managers, work control managers, foremen, supervisors, environment, safety, and health support personnel, and operations/technician personnel.
- Observe work, including pre- and post-activity briefs and reviews. Review evidence of feedback and improvement such as post job reviews and other correspondence used to elicit feedback and improve performance.
The following personnel participated in the assessment
Summary of Assessment:
Provide a narrative summary of areas assessed. Description is to include adequate details to enable an independent reviewer to comprehend the depth and breadth of the assessment. Details to include key elements of the assessed activity or process and the status of their acceptability. When applicable, define the status of implementation of actions related to previous issues relevant to the assessed area.
Results:
Define the issues (findings, observations, noteworthy practices) identified during the assessment. All findings require corrective action to eliminate the non-conformance. Cognizant management will decide whether or not to pursue corrective actions for observations. Issues with corrective actions should be documented on a Corrective Action Form (Attachment D) and entered into CATS; the CATS identification number should be included in the report. Identify the status of each issue (open, pending or closed), issue owner, and estimated completion of required corrective and/or preventive actions. Clearly state all required follow-up actions with due dates and owners.
- Are formal post-activity review processes (e.g., post-job reviews, operations reviews) established and effectively used?
Evaluated
FEL
Accelerator
Facilities & Logistics
Engineering
Physics – Hall A
Physics – Hall B
Physics – Hall C
12 Gev
ESH&Q
- Do subject matter experts, workers, supervisors, and line managers recognize, report, evaluate, and address accidents, incidents, near misses, injuries, illnesses, exposures and opportunities for improvement in a timely manner and in accordance with established procedures?
Evaluated
FEL
Accelerator
Facilities & Logistics
Engineering
Physics – Hall A
Physics – Hall B
Physics – Hall C
12 Gev
ESH&Q
- Is feedback from workers effectively solicited and used during work planning, execution, and closeout?
Evaluated
FEL
Accelerator
Facilities & Logistics
Engineering
Physics – Hall A
Physics – Hall B
Physics – Hall C
12 Gev
ESH&Q
- Is worker participation in safety programs (e.g., behavior based safety, safety committees) encouraged and effective?
Evaluated
FEL
Accelerator
Facilities & Logistics
Engineering
Physics – Hall A
Physics – Hall B
Physics – Hall C
12 Gev
ESH&Q
- Are lessons learned identified and incorporated into the work planning and authorization process?
Evaluated
FEL
Accelerator
Facilities & Logistics
Engineering
Physics – Hall A
Physics – Hall B
Physics – Hall C
12 Gev
ESH&Q
- Do assessment activities by line oversight include observation of work activities by managers, supervisors, and subject matter experts?
Evaluated
FEL
Accelerator
Facilities & Logistics
Engineering
Physics – Hall A
Physics – Hall B
Physics – Hall C
12 Gev
ESH&Q
- Are deficiencies and weaknesses identified during work activities appropriately documented and managed in accordance with site issues management processes? Are associated corrective actions developed and implemented as required?
Evaluated
FEL
Accelerator
Facilities & Logistics
Engineering
Physics – Hall A
Physics – Hall B
Physics – Hall C
12 Gev
ESH&Q
- Have findings related to work planning and control from previous Independent Oversight assessments been effectively corrected?
Evaluated
FEL
Accelerator
Facilities & Logistics
Engineering
Physics – Hall A
Physics – Hall B
Physics – Hall C
12 Gev
ESH&Q
- For issues identified by the current inspection, what prevented contractor line oversight activities from identifying and correcting the problems?
Evaluated
FEL
Accelerator
Facilities & Logistics
Engineering
Physics – Hall A
Physics – Hall B
Physics – Hall C
12 Gev
ESH&Q
Ensure that the below narratives identify the appropriate division(s) or that the entry is applicable to all divisions.
Summary of Assessment Activities
Findings
Observations/Opportunities for Improvement
Noteworthy Practices
Effectiveness Evaluation:
State the team’s conclusion on effectiveness of the area or activity assessed. When applicable, discuss the implementation of previous corrective or preventive actions in the assessment effectiveness statement.
Performed by: / Date:
Lead Assessor
Reviewed by: / Date:
Manager, QA/CI
Reviewed by: / Date:
Associate Director, ESH&Q
Approved by: / Date:
Chief Operations Officer
Approved by: / Date:
Director Jefferson Laboratory
Appendix 241 of 6
CF#5 Report Template Page 1