EHS 799 Division ES

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EHS 799Division ESH Self-Assessment Training

• Michelle Flynn
• Office of Contract Assurance
• ext. 7073

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Course Outline

• LBNL ESH Self-Assessment Program
• Division ESH Self-Assessment
• Roles and Responsibilities
• Self-Assessment Performance Criteria
• Planning Self-Assessment Activities
• Performing Effective Self-Appraisals
• Tracking and Reporting Self-Assessment Results

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LBNL Self-Assessment Program

• Mechanism for assuring Integrated Safety
  Management (ISM) is fully implemented and
  effective
• Formal, internal process to evaluate ESH
  programs and policies
• Goals
• Evaluate safety systems
• Assure safe workplace
• Identification of noteworthy practices,
  deficiencies, and implementation of corrective
  actions

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Four tiered self-assessment system
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Division ESH Self-Assessment

• Demonstrate the division has an effective ISM
  program
• Ensure work is conducted safely, with minimal
  adverse effects to workers, public, and
  environment
• Promote continuous improvement of divisions ESH
  programs
• Promote Operational Awareness w/ DOE
• Minimize formal audits

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Roles and Responsibilities
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Roles and Responsibilities

• EHS Division
• EHS Division Liaison program
• Support division self-appraisal activities
• Provide consultation and training
• Provide input to performance measures
• Training and support for safety walkarounds

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Roles and Responsibilities

• Office of Contract Assurance
• Develop/modify annual performance measures in
  consultation with EHS and division personnel
• Publish annual performance measures and guidance
• Validate self-assessment processes
• Prepare annual Labwide self-assessment report
• Assist divisions as requested

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Self-Assessment Performance Criteria

• Division ISM Plan
• Goals and Opportunities for ESH improvement
• Annual institutional division ESH
  self-assessment performance measures

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Self-Assessment Performance Criteria

• Division ISM Plan
• Flow down of institutional requirements
• PUB-3000 and Institutional ISM Implementation
  Plan
• Tailored to divisional operations
• Self-assessment provides opportunity to measure
  effectiveness of implementing division-specific
  criteria set forth in division ISM plan.

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Self-Assessment Performance Criteria

• Prior Years Self-Assessment
• Division ESH program improvement initiatives
• Self-assessment process improvement opportunities
  identified by division and/or OCA
• Self-assessment provides opportunity to measure
  effectiveness of actions taken to address ESH
  goals and opportunities for improvement.

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Self-Assessment Performance Criteria

• Institutional Performance Measures
• Based on 5 core functions of ISM.
• OCA drafts based on the following input
• Significant PUB-3000 and institutional ISMS
  implementation plan objectives.
• Effectiveness review of self-assessment
  processes.
• Division representatives and EHS program leads
  review and provide input.

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Division ESH Self-Assessment Program

• Planning
• understand requirements, focus on performance
  criteria, select self-assessment teams and
  prepare checklists.
• Performing self-appraisals
• interviews, documentation review, ongoing safety
  walkarounds and formal inspections
• Tracking and reporting deficiencies
• issues management and the annual division ESH
  self-assessment report.

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Planning Self-Assessment Activities

• Understanding ESH Requirements
• Refer to applicable documents
• PUB-3000 LBNL Health and Safety Manual
• Worker Safety and Health Program
• Chemical Hygiene and Safety Plan
• Division ISM plan
• Contact Division Self-Assessment Lead
• Consult with EHS Division Liaison and/or subject
  matter experts
• Obtain training
• Participate in formal inspections of other
  divisions

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Planning Self-Assessment Activities

• Focus on performance criteria
• Review performance criteria and annual guidance
• Identify actions required to satisfy each
  criterion
• Establish scope for formal inspections
• Determine methods to appraise effectiveness of
  actions
• Identify documentation, databases, etc. needed to
  evaluate division performance
• Designate teams
• Create checklists
• Arrange for on-the-job training
• Schedule appraisal team activities

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Planning Self-Assessment Activities

• Self-Appraisal Teams
• Knowledgeable of Laboratory policies, applicable
  ESH requirements, and division procedures for
  ESH compliance
• Understand inspection techniques

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Planning Self-Assessment Activities

• Inspection Checklist(s)
• Comprehensive
• EHS provides a walkaround checklist on homepage.
• Categorized by types of work environments or ESH
  functional areas
• Division can provide their own walkaround
  checklist

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Performing Division Self-Appraisals

• Methods
• Interviews
• Documentation reviews
• Authorizations, training, ORPS, NTS, CATS
• Past appraisal findings
• Division self-assessment, MESH, ESH technical
  assurance, DOE reviews
• Inspection findings
• Walkarounds and formal inspections

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Performing Division Self-Appraisals

• Ongoing Informal Inspections Safety Walkaround
  Program
• EHS 27 - Performing an Effective Safety
  Walkaround
• General and customized versions
• Formal inspections
• Self-appraisal teams
• Planned in advance
• Checklists

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Issues Management

• Identify and track deficiencies
• deficiencies entered into Corrective Action
  Tracking System (CATS)
• corrective actions effectively implemented
• Data Analysis Roll up deficiencies and noteworthy
  practices
• periodically analyze deficiencies (open and
  closed) to identify chronic and significant
  issues
• identify root causes
• identify common causal factors that, if
  corrected, will prevent deficiency recurrence
• Lessons Learned and Best Practices

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Division ESH Self-Assessment Report

• Assess performance against the performance
  criteria
• Follow Division ESH Self-Assessment Guidance, as
  applicable
• Analyze performance
• Describe actions taken to prevent recurrence of
  adverse events.
• Assess the effectiveness the corrective actions.
• Identify any potential lessons learned
• Describe results
• Identify future safety program improvements and
  goals
• Identify institutional issues
• Reports submitted to OCA once reviewed and
  approved by Division Director

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OCA Validation of Self-Assessment Process

• Provide feedback on the comprehensiveness of the
  divisions self-assessment processes.
• Validate a sampling of self-assessment results.
• Identify noteworthy practices.
• Identify opportunities for self-assessment
  process improvement.
• Document institutional opportunities for
  improvement.

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Institutional ESH Self-Assessment Report

• Summary of all four ESH self-assessment
  activities
• Divisional noteworthy practices
• Institutional opportunities for improvement
• Source of lessons learned

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Resources

• OCA website
• Division ESH Self-Assessment Manual
  (LBNL/PUB-3105)
• ESH Self-Assessment Program (LBNL/PUB-5344)
• Division ESH Self-Assessment Performance
  Measures
• Institutional ESH Self-Assessment Report
• Appendix B Contract Performance Report
• CATS database
• Lessons Learned and Best Practices database

• OCA website
• Division ESH Self-Assessment Manual
  (LBNL/PUB-3105)
• ESH Self-Assessment Program (LBNL/PUB-5344)
• Division ESH Self-Assessment Performance
  Measures
• Institutional ESH Self-Assessment Report
• Appendix B Contract Performance Report
• CATS database
• Lessons Learned and Best Practices database

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Good Examples from FY07 Reports
Analyze performance Describe actions taken to
prevent recurrence of adverse events. ALS had
one recordable case last year an ergonomics
injury resulting from longstanding issues. Root
cause analysis identified the need to get early
identification and treatment for discomfort. ALS
identified outreach as the needed corrective
action. This was a topic at one of the Safety
First Thursday User Forums, presentations were
given at both the SMT and the Division Safety
Committee meetings and materials were prepared
for individual safety circles Appendix 8.1.
This was a focus of the Lab Directors initiative
on supervisor ergonomics walkarounds in April,
and was also reinforced during the Self
Assessment with questions on both the individual
surveys and the inspection checklists. Assess
the effectiveness of the initiatives and
corrective actions taken to address these
issues. Training completion is essentially
unchanged from 2006. Considerable effort was made
to improve the training completion statistics. In
particular, implementation of the EHS Calendar
of Recurring EHS Activities and the issuance of
the PI Guide to EHS included elements to improve
performance in this area. These tools have not
substantially improved the training completion
metric. Staff time has been very limited for
performing the preventive evaluations, and little
headway has been made on these. The ALS is
committed to performing 3 evaluations per month
and retiring the backlog by February of 2008.
Identify future safety program improvements and
goals. Add enhanced LOTO review and
environmental / waste minimization review to
QUEST. Check implementation of multi-container
inventory sheets for gases and chemicals inside
equipment. The Project Safety Questionnaire,
which has been used in the past, needs to be
evaluated for effectiveness and a mechanism needs
to be put into place to assure that all
questionnaires are completed. Identify
institutional issues Expand the web-based
curriculum of safety training courses. Review
LBNL policy on first aid kits in staff
workspaces. Improve ergonomic database to
prompt re-evaluations for staff moves.
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Excerpts from Office of Contract Assurance
Validation Reports
Provide feedback on the comprehensiveness of the
divisions self-assessment processes The
Division described its new ESH awareness
questionnaire, but the report includes no details
on rate of return or lessons learned from the
responses. Identify noteworthy practices Team
approach to performing self-assessment Division
Director and/or Deputy involvement in safety
committee and self-assessment Division-specific
metrics Identify opportunities for
self-assessment process improvement Verify
information provided by Group Leaders and
self-assessment teams using other sources, as
applicable. For example, the Division Safety
Committee can independently verify the compliance
history of RWAs by obtaining a RADAR report from
the Radiation Protection Group.