ISM Core Function Teams

ISM Core Function Teams Assessment Plan (Cycle I)

January 2008

Jefferson Laboratory

ISM Core Function Teams

Assessment Plan (Cycle I)

Table of Contents

1.0 Purpose and Scope

2.0Background

2.1Summary of upcoming DOE Inspection...... 4

2.2Role of the ISM Core Function Teams...... 4

3.0Definitions

4.0Expectations/Preparations...... 5

4.1General Expectations...... 5

4.2Complete Required Training...... 5

4.3Review of ISM and Assessment Procedure – Required Reading...... 6

4.4Review of Core Functions...... 7

4.5Requirments...... 8

5.0Assessment Conduct...... 9

5.1Schedule...... 9

5.2Team Members and Responsibilities...... 10

5.3Assessment Activities and Guidance...... 11

5.4Deliverables/Products...... 13

Appendix 1ISM Core Teams Assessment Kickoff Meeting Briefing

Appendix 2DOE P 450.4, Safety Management System Policy

Appendix 3DOE P 450.7, Department of Energy Environment, Safety and Health (ES&H) Goals

Appendix 4Jefferson Lab ISMS Program Description

Appendix 5JLab SSAC Executive-Level Independent Assessment of the JLab ISMS, November 2006

Appendix 6Inspection of Environment, Safety, and Health Programs at the Brookhaven National Laboratory, November 2007

Appendix 7Inspection of Environment, Safety, and Health Programs at the Stanford Linear Accelerator Center, January 2007

Appendix 8Independent Assessment Procedure

Appendix 9ES&H Manual, Chapter 6105 – Office Safety

Appendix 10Core Function #1 - Recommended activities and lines of inquiry

Appendix 11Core Function #2 - Recommended activities and lines of inquiry

Appendix 12Core Function #3 - Recommended activities and lines of inquiry

Appendix 13Core Function #4 - Recommended activities and lines of inquiry

Appendix 14Core Function #5 - Recommended activities and lines of inquiry

Table of Contents

Appendix 15HSS CRAD 64-10, Work Planning and Control Implementation Inspection Criteria, Approach, and Lines of Inquiry, 11/26/07

Appendix 16HSS CRAD 64-11, Essential Systems Functionality Inspection Criteria, Approach, and Lines of Inquiry, 11/26/07

Appendix 17HSS CRAD 64-20, Feedback and Continuous Improvement Inspection Criteria and Approach – Contractor, 12/4/07

Appendix 18HSS CRAD 64-30, Hazardous Waste Management Implementation Inspection Criteria, Approach, and Lines of Inquiry, 12/4/07

Appendix 19HSS CRAD 64-31, Chemical Management Implementation Inspection Criteria, Approach, and Lines of Inquiry, 11/27/07

Appendix 20Report Template – ISM Core Function #1 (Define the Scope of Work) Independent Assessment (Cycle I)

Appendix 21Report Template – ISM Core Function #2 (Analyze the Hazards) Independent Assessment (Cycle I)

Appendix 22Report Template – ISM Core Function #3 (Develop and Implement Controls) Independent Assessment

Appendix 23Report Template – ISM Core Function #4 (Perform Work Within Controls) Independent Assessment (Cycle I)

Appendix 24Report Template – ISM Core Function #5 (Feedback and Continuous Improvement) Independent Assessment (Cycle I)

Appendix 25Template – IA Corrective Action Form

Appendix 26Template – Presentation Outline to the Director’s Safety Council

1.0 Purpose and Scope

The purpose of this Integrated Safety Management (ISM) Core Function Teams Assessment Plan is to provide the necessary guidance and tools to assessment team members to facilitate an effective assessment process. This document serves as the Independent Assessment Plan required by the Jefferson Lab (Lab) Independent Assessment Procedure.

The scope of this effort is to evaluate Labactivities from an ISM Core Function Perspective to understand areas needing attention prior to the Department of Energy (DOE) Inspection of environment, safety, and health (ES&H) programs at Jefferson Lab scheduled to be conducted in June 2008.

2.0 Background

2.1Summary of Upcoming DOE Inspection

The U.S. DOE Office of Independent Oversight, within the Office of Health, Safety and Security (HSS) is tasked with performing appraisals of the ES&H programs at DOE sites. The DOE Inspection Team will evaluate the effectiveness of the Lab ES&H program and its implementation. This will include an evaluation of the effectiveness and understanding by Lab personnel of the Integrated Safety Management System (ISMS).

Think of the ISMS as the formal, organized process whereby people plan, perform, assess, and improve the safe conduct of any activity conducted at the Lab with the goal of ensuring that personnel and the environment are protected. These processes are applied with a graded approach depending on the complexity of the activity and the hazards involved. The Lab ES&H program documents (i.e., ES&H Manual, Environmental Management System Plan, SOPs, Quality Assurance Plan) specify the requirements that, when followed, help ensure the goal of personnel and environment protection. Recognize that the ISMS is designed to integrate the requirements and processes associated with not only ES&H but with the Environmental Management System (EMS) and Quality Assurance Program requirements and processes as well. The requirements for these programs and the ISMS are intended to be intertwined and dependent upon each other to ensure maximum effectiveness.

2.2Role of the ISM Core Function Teams

The role of the ISM Core Function Teams is to evaluate Lab operations against the ISM five core functions and ES&H program requirements applicable to activities being assessed. The teams are then to document what was evaluated and identify noted requirement non-compliance and opportunities for improvement.

The results of these team assessments will be used to adjust Lab processes, only where necessary, to ensure compliance with requirements but more importantly to ensure activities are conducted in a manner that result in the protection of personnel and the environment.

The five ISM Core Functions are:

Define the Scope of Work
Analyze the Hazards
Develop and Implement Controls
Perform Work Within Controls
Feedback and Continuous Improvement

3.0 Definitions

Finding

non-compliance with a requirement

Observation/Opportunity for Improvement

deviation from best management practice – may not be a “quick fix”
minor deviation from procedural requirements that are isolated and considered to be a “quick fix”

Noteworthy Practice

positive aspects of a program that could be used as a model for other similar programs across the Lab

4.0 Expectations/Preparations

4.1General Expectations

Your management expects you to:

Become knowledgeable of your assigned core function and how it is demonstrated through JLab existing policies and processes
Thoroughly collect information as outlined in this assessment plan
Provide unvarnished feedback and findings to the Director’s Safety Council
Participate in planning and implementation of corrective actions
Conduct follow-up to fill information gaps and verify that corrective actions are in place and operating correctly

You can expect your management to:

Allow you to conduct your Core Function Team assignments within normal working hours
Provide you the support and access necessary to conduct these activities
Recognize the importance of your role

4.2Complete Required Training

Each team member must complete (or be current on) the following training prior to participating in assessment activities (as applicable). Web based training can be accessed with the following link -

All
Auditor/Assessment Basics (QACI001)
For unescorted access to the Accelerator fenced area
Security Awareness Training for Users (GEN034U)
EMS Awareness (Initial Training Only) (SAF127)
General Employee Radiation Training (GERT) (SAF800)
For unescorted access to Radiological Controlled Areas (RCAs)
Radiological Worker Training I: Fundamentals (SAF801F)
Escorted and unescorted access to RCAs requires obtaining a TLD

4.3Review of ISM and Assessment Procedure – Required Reading

Before conducting assigned assessment activities first read and become familiar with information in the following. Note that electronic versions of these documents and forms are available on the JLab ISM webpage.

ISM Core Teams Assessment Kickoff Meeting Briefing (Appendix 1)
DOE P 450.4, Safety Management System Policy (Appendix 2)
DOE P 450.7, Department of Energy Environment, Safety and Health (ES&H) Goals (Appendix 3)
Jefferson Lab ISMS Program Description(Appendix 4)
JLab SSAC Executive-Level Independent Assessment of the JLab ISMS, November 2006 (Appendix 5)
Inspection of Environment, Safety, and Health Programs at the Brookhaven National Laboratory, November 2007 (Appendix 6)
Inspection of Environment, Safety, and Health Programs at the Stanford Linear AcceleratorCenter, January 2007 (Appendix 7)
Independent Assessment Procedure (Appendix 8)
ES&H Manual, Chapter 6105 – Office Safety (Appendix 9)
Core Function #1 - Recommended activities and lines of inquiry (Appendix 10)
Core Function #2 - Recommended activities and lines of inquiry (Appendix 11)
Core Function #3 - Recommended activities and lines of inquiry (Appendix 12)
Core Function #4 - Recommended activities and lines of inquiry (Appendix 13)
Core Function #5 - Recommended activities and lines of inquiry (Appendix 14)
HSS CRAD 64-10, Work Planning and Control Implementation Inspection Criteria, Approach, and Lines of Inquiry, 11/26/07 (Appendix 15)
HSS CRAD 64-11, Essential Systems Functionality Inspection Criteria, Approach, and Lines of Inquiry, 11/26/07 (Appendix 16)
HSS CRAD 64-20, Feedback and Continuous Improvement Inspection Criteria and Approach – Contractor, 12/4/07 (Appendix 17)
HSS CRAD 64-30, Hazardous Waste Management Implementation Inspection Criteria, Approach, and Lines of Inquiry, 12/4/07 (Appendix 18)
HSS CRAD 64-31, Chemical Management Implementation Inspection Criteria, Approach, and Lines of Inquiry, 11/27/07 (Appendix 19)
Report Template – ISM Core Function #1 (Define the Scope of Work) Independent Assessment (Cycle I) (Appendix 20)
Report Template – ISM Core Function #2 (Analyze the Hazards) Independent Assessment (Cycle I) (Appendix 21)
Report Template – ISM Core Function #3 (Develop and Implement Controls) Independent Assessment (Cycle I) (Appendix 22)
Report Template – ISM Core Function #4 (Perform Work Within Controls) Independent Assessment (Cycle I) (Appendix 23)
Report Template – ISM Core Function #5 (Feedback and Continuous Improvement) Independent Assessment (Cycle I) (Appendix 24)
Template – IA Corrective Action Form (Appendix 25)
Template – Presentation Outline to the Director’s Safety Council (Appendix 26) (to be developed and provided prior to the presentation)

4.4Review of Core Functions

CORE FUNCTION #1 – DEFINE THE SCOPE OF WORK

Core function #1 is satisfied when missions are translated into work, expectations are set, and tasks are identified. Scope of work includes our basic and applied research, systems operations, maintenance, construction and other support activities.
JLab expectations for core function #1 is that each work planning and execution tool, regardless of the implementing organization, has a well-defined process to identify the nature of the required work, the schedule, and the costs of the activities. The level of detail of the scope of work varies in relation to its complexity and potential risks. In all cases, multi-disciplined teams are used to create, or review, the scope of work documents and workers are involved in the planning processes.

CORE FUNCTION #2 – ANALYZE THE HAZARDS

Core function #2 is satisfied when all potential hazards associated with the work are identified, analyzed, and categorized.
JLab expectations for core function #2 is thatevery work planning activity should identify and categorize work related hazards and develop an understanding of the potential for the hazard to adversely affect the health and safety of the worker, public, or the environment. This hazard analysis process can vary in complexity based on activity type, hazard type, and hazard parameters; and builds upon previous analyses conducted on tasks ranging from routine facility maintenance to accelerator and laser operations. Multi-disciplined teams are used with emphasis on identifying subject matter experts with significant Jefferson Lab experience.

CORE FUNCTION #3 – DEVELOP AND IMPLEMENT CONTROLS

Core function #3 is satisfied when applicable standards and requirements are identified and agreed upon, controls to prevent/mitigate hazards are identified, the safety envelope is established, and controls are implemented.
JLab expectations for core function #3 is that during every Jefferson Lab work planning process, parameters of the identified hazards are used to select or design engineering, administrative, and personal protective equipment controls and pollution prevention/waste minimization options to be integrated with the work activity. The type of control to be specified is tailored to the work activity and the associated hazards. In most cases, the controls are based on best practices and lessons learned gained from previous, similar activities as captured in the Jefferson Lab’s ES&H Manual and Jefferson Lab Standard Operating Procedures. Some work activities may require unique controls, which are typically documented in Temporary SOPs, activity-specific safety plans and/or delivered to workers through specific training activities. In all cases, site-wide ES&H requirements and industry standards are identified, mechanisms are put in place to satisfy the requirements and the controls are documented in work authorization documents.

CORE FUNCTION #4 – PERFORM WORK WITHIN CONTROLS

Core function #4 is satisfied when readiness is confirmed and work is performed safely in accordance with the controls specified in the applicable work control document
JLab expectations for core function #4 is that each work process has a defined authorization protocol for concluding that Core Functions 1-3 have been satisfied, and establishes defined roles and responsibilities for authorizing work to proceed in accordance with identified controls. Additionally, each work planning and execution tool assures that the hazards and controls are discussed with all workers prior to commencing work; that the controls will remain in place for the duration of the activity; and that all workers are qualified to participate in the activity.

CORE FUNCTION #5 – FEEDBACK AND CONTINUOUS IMPROVEMENT

Core function #5 is satisfied when feedback information on the adequacy of controls is gathered, opportunities for improving the definition and planning of work are identified and implemented, line management and independent oversight is conducted, and, if necessary, regulatory enforcement actions occur.
JLab expectations for core function #5 is that lessons learned are collected and shared to improve the performance of the ISMS. Jefferson Lab has established lessons learned collection, evaluation, and communication tools which are available to all site organizations and employees. The routine activities of the Worker’s Safety Committee are one example of a lab-wide mechanism. Organizations or groups within organizations have additional tools and meetings that best support their activities and work tempo. In all cases, routine and non-routine events and ISMS performance is discussed and documented so the results are available for future planning activities.

4.5Requirements

The assessment is to be conducted from two different perspectives. First, using the guidance in the provided lines of inquiry for each ISM core function,evaluate whether or not the JLab programmatic infrastructure supports an effective ISMS. Second, evaluate whether or not activities at JLab are conducted in accordance with the requirements in existing JLab program and procedure documents applicable to the activities being reviewed/observed. If during the assessment it is noted that JLab documents are not in compliance with requirements in DOE directives or other federal/state requirements, these discrepancies are to be noted so they can be addressed.

5.0 Assessment Conduct

5.1Schedule

Cycle I
7 -11 January / Kick-off meeting, perform required reading, and make preparations for conduct of assessment
14 January –
8 February / Conduct assessment activities (Cycle I)
Weekly / Teams brief COO and facilitators on status of assessment activities

Team #1 – Mondays
Team #2 – Tuesdays
Team #3 – Wednesdays
Teams #4 & 5 – Thursdays

8 February / Provide draft report to the assessed organizations for a factual and technical accuracy review
11 February / Teams brief Director’s Safety Council
15 February / Comments from assessed organization due back to teams
19 February / Teams complete revision of reports, as necessary, based on comments from assessed organizations
19 February / Teams submit Cycle I final reports for review and approval
14 January – 29 February / Complete identified corrective actions resulting from assessment activities
Cycle II
3 – 7 March / Teams plan for next round of assessments
10 March –
4 April / Conduct assessment activities
Weekly / Teams brief COO and facilitators on status of assessment activities

Team #1 – Mondays
Team #2 – Tuesdays
Team #3 – Wednesdays
Teams #4 & 5 – Thursdays

4 April / Provide draft report to the assessed organizations for a factual and technical accuracy review
11 April / Comments from assessed organization due back to teams
14 April / Teams brief Director’s Safety Council
15 April / Teams complete revision of reports, as necessary, based on comments from assessed organizations
15 April / Teams submit Cycle II final reports for review and approval

The teams are to keep the facilitator apprised of scheduled activities via email (i.e., observation of specific work activities or meetings) for the upcoming week. The COO and the facilitator(s) may observe some of these activities or meetings with the teams.

5.2Team Members and Responsibilities

Assessment Facilitators

Bill Rainey

Rick Dion

Co-Chair/Mgr Sup/Team Lead

Co-Chair/WSC

Team Member

CF#1

Kelly Trembley

John Riesbeck

Byron Golden

Debra Brand

Howard Fenker

CF#2

Bill Vulcan

Joe Beaufait

Harry Fanning

Manny Nevarez

Dave Hamlette

CF#3

Phil Mutton

William Berkley

Brad Cumbia

Kevin Jordon

John Kelly

CF#4

Tom Briggs

Derrick Dail

Tom Hassler

John LeRose

James Coleman

Ned Walker

CF#5

Neil Wilson

Brian Bevins

Tina Menefee

Richard Williams

Cindy Saban

Brian Kross

5.2.1Responsibilities

Facilitator

Complete training (see section 4.2) necessary to participate in assessment activities

Coordinate overall assessment logistics

Mentor teams (as necessary)

In coordination with the team leaders and the QA/CI group, ensure findings and observations/opportunities for improvement are entered into CATS

Team Lead

Complete training (see section 4.2) necessary to participate in assessment activities

Familiarize themselves with the requirements in the Independent Assessment Procedure

Conduct the assessment and report results in accordance with the report template

Include CATS sequence numbers in the report

Co-Chair

Complete training (see section 4.2) necessary to participate in assessment activities

Personnel designated as Co-Chair’s for the assessment are to assume a leadership role for the assessment team in coordination with the team leader

Team Member

Complete training (see section 4.2) necessary to participate in assessment activities

Participate in assessment activities