Chapter 33

Line Management Self-assessment Chapter Outline 1 Overview 2 2 Scope 3 3 Standards 3 4 Definitions 4 5 Requirements 4

5.1 General 4 5.1.1 Line Management Walkthroughs 4 5.1.2 Line Management-led ES&H Compliance Assessments 6 5.1.3 Annual Directorate ES&H Self-assessment and Report 8 5.1.4 Roles and Responsibilities 8

5.2 Procedures and Specific Requirements 10 5.3 Training 10

5.3.1 Line Management 10 6 Exhibits 10 7 References 11 8 Implementation 11 9 Ownership 11

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1 Overview This chapter describes the direct role of line management in conducting three types of environment, safety, and health (ES&H) assessments. The three types are management walkthroughs (Section 5.1.1), compliance assessments (Section 5.1.2), and the Annual Directorate ES&H Self-Assessment and Report (Section 5.1.3).

While there are ES&H assessment activities conducted by other elements within and external to SLAC, direct participation by line managers in self-assessment is essential to the success of the assessment process. No others are in a better position both to evaluate the managed activities and to effect changes than the line manager. Personal involvement by the line also yields the most meaningful information to be used in taking actions to maintain compliance and improve organizational performance.

Self-assessment is an important part of the ES&H Assurance System (described in the SLAC Integrated Safety and Environmental Management System Description [ISEMS]1) that helps ensure the SLAC Integrated Safety Management System (ISMS) and Environmental Management System (EMS) are fully implemented, and that effective feedback and continuous improvement mechanisms are in place for all ES&H programs. The SLAC ISEMS Description speaks in detail to all elements of the SLAC ES&H Assurance System (driven by requirements in DOE Order 226.1, “Implementation of DOE Oversight Policy”):

Assessments conducted by the line and described here:

– Line management walkthroughs

– ES&H compliance assessments led by line management as supported by ES&H subject matter experts (SMEs), safety officers, and peers

– Annual ES&H self-assessment report

Other important elements of self-assessment:

– Line involvement in ES&H internal goal and metric setting

– Flow down of ES&H goals through each directorate

– Quarterly reports to the ES&H Coordinating Council (ES&HCC) that may include directorate assessments of performance against both ES&H contract performance measures and internal goals and metrics

– Input to the quarterly ES&H report coordinated by the ES&H Division and submitted to DOE Stanford Site Office and Stanford University

– Annual area hazard analysis (AHA) reviews

– Annual job hazard analysis and mitigation (JHAM) process reviews

– Biennial safety assessment document (SAD) reviews

– Building manager inspections

1 SLAC Integrated Safety and Environmental Management System Description, (SLAC-I-720-0A00B-001), http://www-group.slac.stanford.edu/esh/general/isems/sms.pdf

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Independent internal and external assessments

Event reporting

Worker feedback mechanisms

Issues management

Lessons learned

Performance measures

2 Scope This chapter applies to

Program directors, line management, ES&H coordinators, and all personnel (both employees and non-employees, with the exception of subcontractors) of each SLAC directorate plus elements of the laboratory director’s office

The Office of Assurance (OA)

The ES&H Division

Institutional safety officers

3 Standards The contract (DE-AC02-76-SF00515) between the US Department of Energy and Stanford University

for operation of SLAC,2 in particular clauses I.088, “DEAR 970.5204-2 – Laws, Regulations, and DOE Directives”, and I.095, “DEAR 970.5223-1 – Integration of Environment, Safety and Health into Work Planning and Execution”

Related DOE directives

– DOE Order 226.1, “Implementation of Department of Energy Oversight Policy”3

– DOE Order 414.1C, “Quality Assurance”4

– DOE Guide 450.4-1B, “Integrated Safety Management System Guide”5

– DOE Order 450.1, “Environmental Protection Program”6

– DOE Guide 450.1-1, “Implementation Guide for Use with DOE Order 450.1, Environmental Protection Program”7

2 http://www-group.slac.stanford.edu/bsd/contract/ProformaSLACContract.pdf

3 http://www.directives.doe.gov/pdfs/doe/doetext/neword/226/o2261.html

4 http://www.directives.doe.gov/pdfs/doe/doetext/neword/414/o4141c.html

5 http://www.directives.doe.gov/pdfs/doe/doetext/neword/450/g4504-1bv1.html

6 http://www.directives.doe.gov/pdfs/doe/doetext/neword/450/o4501c1.html

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4 Definitions Corrective action tracking system (CATS). System in which corrective actions and opportunities for improvement from elements of the ES&H Assurance System are recorded and responsible persons assigned

ES&H coordinator. An individual charged with helping line management implement the SLAC ISEMS in an organizational element of SLAC, chiefly one of the four directorates

Line management. Officially designated managers and supervisors who have been entrusted with traditional authorities to manage science and operations programs in pursuit of the SLAC missions and objectives, make hiring decisions, manage employee performance, and provide a safe and environmentally sound workplace. Scientific programs are often built on people matrixed to a team. This creates shared responsibility for individuals by the supervisor of record and the matrixed supervisor that must be addressed through consultation between the two supervisors. Line management also includes other persons such as area and facility managers, responsible for administration of the line functions in both science and operations programs. Line management may designate another qualified person to perform specific duties, but remains responsible for that person’s conduct.

Program director. Head of one of the SLAC directorates

Program manager. A SLAC division director, assistant division director, department head, or manager of a science or support program within one of the SLAC directorates or the laboratory director’s office

Subject matter expert (SME). Staff possessing special expertise in an ES&H program, for example, industrial hygiene, confined space entry, or lead abatement. Some SMEs may be outside of the ES&H Division, for example, hoisting and rigging SMEs reside within the Conventional and Experimental Facilities Department.

Work smart standards (WSS). The set of ES&H-related standards that Stanford University is contractually obligated to follow. DOE and Stanford University agree on the inclusion of these standards in the contract for operating SLAC because the standards are either required by law/regulation or otherwise significantly contribute to the protection of workers, the public, and the environment.

5 Requirements 5.1 General

5.1.1 Line Management Walkthroughs

5.1.1.1 Purpose

Assess work behavior, assess adherence to mitigation measures identified in worker JHAMs, and reinforce safe work behavior while engaging staff in meaningful discussions about workplace safety

7 http://www.directives.doe.gov/pdfs/doe/doetext/neword/450/g4501-1.html

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5.1.1.2 Specific Responsibilities

Line Responsibilities

As further described in directorate ISEMS plans (see Section 3.6, “Feedback and Continuous Improvement”):

Clarify which line management elements (supervisors, higher level managers, facility managers, area managers) will conduct the walkthroughs. As the worker-supervisor relationship is especially important in promoting safe work behavior, the front-line supervisor should be the most involved manager in the walkthrough program.

Senior management walkthroughs to continue to be conducted in accordance with the procedure developed in response to C/A 11-5 in the Type A CAP and be documented on the required Senior Manager Safety Walkthrough Form (see Section 6, “Exhibits”). Such walkthroughs may be included in the record as part of the management walkthroughs described in Section 5.1.1, “Line Management Walkthroughs”

Assessments to be summarized in the annual directorate ES&H self-assessment report (see Section 5.1.3, “Annual Directorate ES&H Self-assessment and Report”)

ES&H Division Responsibilities

Develop simple walkthrough guidelines

Revise ES&H Course 139, “ES&H Self-inspection Training”,8 and train line management, or adopt a functionally equivalent training program

As requested, accompany the line on walkthroughs

Carry out management walkthroughs and compliance assessments of their own work areas, as directed by the Operations Directorate ISEMS plan9

Office of Assurance Responsibilities

Produce listings of which directorate owns or is the primary owner for all inside and outside space at SLAC

Work with ES&H to create guidelines for walkthroughs

Validate results of line self-assessments

5.1.1.3 Participants

Line management as described in directorate-level ISEMS plans

5.1.1.4 Frequency

The line will conduct walkthroughs of all occupied workspaces once each year. Frequency above the minimum is at management discretion and should be based on the potential for changing work

8 ES&H Course 139, “ES&H Self-inspection Training”, https://www-internal.slac.stanford.edu/esh-db/training/slaconly/bin/catalog_item.asp?course=139

9 Operations Directorate Integrated Safety Management (ISM) Plan, http://www-group.slac.stanford.edu/esh/general/isems/directorate/ISM_Ops.pdf

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scope/hazards and the need to have more frequent dialogue with staff. The directorates may chose to combine management walkthroughs with workspace compliance assessments described in Section 5.1.2.

5.1.1.5 Reports

Line management will document the results of walkthroughs and summarize them in their annual report (see Section 5.1.3, “Annual Directorate ES&H Self-assessment and Report”). Issues and deficiencies that were not corrected on the spot are to be recorded in CATS. Assessments where no deficiencies are to be recorded in CATS must still be appropriately documented. It is left to the directorates to decide on standards for documenting assessments that are not recorded in CATS.

5.1.2 Line Management-led ES&H Compliance Assessments

5.1.2.1 Purpose

Line management must assess how well it adheres to

1. Its own written procedures (SOPs, department procedures, or other forms of procedures) written to quality assurance standards described in the SLAC Assurance Program Description10

2. ES&H standards that apply and are evaluated in external compliance inspections

5.1.2.2 Specific Responsibilities

Line Responsibilities

As further described in directorate ISEMS plans (Section 3.6, “Feedback and Continuous Improvement”)

Clarify which line management elements (supervisors, higher level managers, facility managers, area managers) will conduct the assessments

Directorate to schedule but OA will assist upon request

Compliance assessments of work procedures to ensure the five core functions of ISM are implemented

Conduct workspace compliance assessments (see Section 6, “Exhibits”, Work Space Compliance Assessment Checklist)

Assessments to be summarized in the annual directorate ES&H self-assessment report (see Section 5.1.3, “Annual Directorate ES&H Self-assessment and Report”)

ES&H Division Responsibilities

Maintain compliance checklists

Provide training

Accompany the line

10 [ forthcoming ]

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Office of Assurance Responsibilities

Produce listings of which directorate owns or is the primary owner for all inside workspace and outside areas at SLAC and from the SLAC Quality Assurance program communicate which work processes have formal procedures

Validate results of line self-assessments

5.1.2.3 Participants

Compliance assessment teams will consist of

Line management representatives and usually the directorate-level ES&H coordinator

SLAC ES&H Division subject matter experts

Safety officers where appropriate (invited but not required to participate)

A representative from the DOE Stanford Site Office (invited but not required to participate)

Building managers (optional)

5.1.2.4 Frequency

All written procedures describing active work processes are to be assessed once every three years to ensure they adequately implement the five ISM core functions. Procedures for work processes that have been inactive for more than three years need only be assessed before work under the procedure is once again undertaken. Procedures that have been re-written within two years need not be assessed as the process to rewrite them assures the ISM core functions are adequately implemented.

All workspaces and outside areas are to have a line management ES&H compliance assessment once each year.

– For compliance assessments of workspaces and outside areas subject to an area hazard analysis (AHA), the assessment may be timed to coincide with the annual AHA validation.

– Directorates may elect to combine management walkthroughs and workspace/outside area compliance assessments.

– Where the line and ES&H subject matter experts participate in compliance assessments driven by the Building Manager Program Manual, the requirement under Section 5.1.2 is met.

Frequency above the minimum is at directorate discretion and should be based on the potential for work processes to change, the level of hazard addressed by the work procedure, whether or not the spaces are occupied, the hazards and compliance issues that exist, the potential for changing work scope/hazards, and perhaps most importantly the compliance history of a work process, workspace, or outside area.

5.1.2.5 Reports

All assessments are to be appropriately documented. Compliance assessments of work procedures will be in a narrative form and will include judgments on how well the procedure implements the five core ISM functions. Compliance assessments of work spaces against SLAC ES&H policy and requirements will use the Work Space Compliance Assessment Checklist (see Section 6, “Exhibits”). Issues and deficiencies from both types of assessments that were not corrected on the spot are to be recorded in CATS. Assessments where no deficiencies are to be recorded in CATS must still be appropriately documented. It

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is left to the directorates to decide on standards for documenting assessments that are not recorded in CATS.

5.1.3 Annual Directorate ES&H Self-assessment and Report

5.1.3.1 Purpose

Summary evaluation and report written by the line on ES&H performance and ISEMS implementation within each directorate

Each directorate is to measure its ES&H performance and the effectiveness of its ISEMS implementation by evaluating results of previously described walkthroughs and compliance assessments as well as other forms of assessment described in Section 1, “Overview”. This assessment and report emphasizes the principles of line management responsibility and accountability for safe work practices, work authorizations, and feedback and improvement.

5.1.3.2 Participants

Participants are to include line management of the directorate, the directorate ES&H coordinator, invited subject matter experts, and others appointed by the program director.

5.1.3.3 Frequency

The self-assessment must be done annually. The self-assessment performance period will be July 1 to June 30 and the report is to be issued each year by August 15. However, self-assessment activities should be ongoing throughout the entire performance year.

5.1.3.4 Reports

The program director will draft a report of the annual self-assessment based on a template designed to be consistent with directorate reports to the ES&HCC (see Section 6, “Exhibits”). The report provides input to the annual institutional ES&H report. Issues and deficiencies from this self-assessment are to be recorded in CATS. The report will include all assessment data including judgments on the following:

Effectiveness of ISEMS/ES&H communications by the line as reflected in summaries of staff meetings

Staff accountability for sound ES&H performance as demonstrated through a sampling of employee evaluations

Validation of JHAMs, position descriptions, and SLAC training assessments for completeness and relevance

Percent workspace assessed. OA will provide baseline data.

Percent work processes assessed. This is primarily for work processes that, under our new Assurance Program description, are committed to formal written procedures having significant ES&H issues.

5.1.4 Roles and Responsibilities

5.1.4.1 ES&H Division

With the Office of Assurance manage the ES&H Assurance System

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Develop standards, templates, checklists, and formats for line self-assessment activities

Manage the Corrective Action Tracking System (CATS)

Participate in compliance assessments

5.1.4.2 Office of Assurance

Responsible for the administration of the overall SLAC Assurance Program including the ES&H Assurance System

Validate results of all ES&H assessment activities and completion of ES&H corrective actions

Support SLAC directorates in conducting their annual management walkthroughs, compliance assessments, and the annual directorate ES&H self-assessments and report. This includes providing tools, templates, and listings of space ownership.

Schedule line management-led ES&H compliance audits on request

Inform the laboratory director of results of ES&H assessment activities including significant compliance levels and trends

5.1.4.3 Program Directors

Conduct senior management walkthroughs to demonstrate a commitment to all SLAC staff members that safety comes first

Ensure subordinate line managers conduct walkthroughs focused on workplace safety, safe work behavior, and workspace deficiencies as well as engaging staff in meaningful discussions about workplace safety

Ensure compliance assessments are conducted of work processes committed to formal work descriptions, such as departmental operating procedures, and of work spaces to assess compliance with ES&H policy and requirements that implement standards adopted in the SLAC Work Smart Standards (WSS)11

Conduct an annual ES&H self-assessment and issue an annual report that summarizes the directorate’s ES&H assessment activities and makes judgments on the implementation of the SLAC ISEMS

5.1.4.4 Line Managers and Supervisors

As described in directorate ISEMS plans, line managers and supervisors are responsible for conducting management walkthroughs and compliance assessments of both work processes and work spaces. They may also have a role in developing the annual ISEMS self-assessment report.

5.1.4.5 Institutional Safety Officers

Safety officers will accompany line managers and supervisors on management walkthroughs and compliance assessments when available.

5.1.4.6 SLAC Employees and Non-employees

SLAC employees and non-employees are responsible for conducting work safely and in compliance with all ES&H standards and requirements as translated through work authorizations and other forms of

11 “Work Smart Standards”, http://www-group.slac.stanford.edu/esh/general/isems/wss/

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performance expectations. To ensure a robust assurance program, all SLAC staff and workplaces are always subject to assessments, oversight and other assurance activities. This policy on assurance is not in conflict with the SLAC respectful workplace policy. This section does not apply, however, to subcontractors who are subject to oversight and assessment activities delineated in other chapters.

5.2 Procedures and Specific Requirements Procedures will be developed as appropriate, by the Office of Assurance working with the ES&H Division and the directorates, for each of the general requirements:

Line Management Walkthroughs

Line Management-led ES&H Compliance Assessments

Other ES&H Self-assessment Activities

Annual Directorate ES&H Self-assessment and Report

5.3 Training Training requirements are listed by role below.

5.3.1 Line Management

Line managers will complete training in self-assessment:

ES&H Course 139, “ES&H Self-inspection Training”,12 or a functionally equivalent training program offered by ES&H

6 Exhibits Senior Manager Safety Walkthroughs Procedure (SLAC-I-720-0A22C-001)13

Senior Manager Safety Walkthrough Form (SLAC-I-720-0A22R-001)14

Annual Directorate ISEMS Self-assessment Report Template (SLAC-I-720-0A18J-001)15

Line Management Self-Assessment: Management Walkthrough Checklist (SLAC-I-720-0A18J-002)16

Line Management Self-Assessment: Workspace Compliance Assessment Checklist (SLAC-I-720-0A18J-003)17

12 https://www-internal.slac.stanford.edu/esh-db/training/slaconly/bin/catalog_item.asp?course=139

13 https://www-internal.slac.stanford.edu/esh/forms/internal/WalkthroughProcedure.pdf

14 http://www-group.slac.stanford.edu/esh/forms/

15 http://www-group/esh/eshmanual/references/isemsReportTemplate.doc

16 http://www-group/esh/eshmanual/references/assessChecklistWalk.pdf

17 http://www-group/esh/eshmanual/references/assessChecklistWorkspace.pdf

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“CATS System”18

“ES&H Divisional Reports”19

7 References Management Systems

“Work Smart Standards”20

SLAC Integrated Safety and Environmental Management System Description (SLAC-I-720-0A008-001)21

SLAC Assurance Program Description [ forthcoming ]

“Quality Assurance and Compliance Documents”22

SLAC Environment, Safety, and Health Manual (SLAC-I-720-0A29Z-001)23

Chapter 1, “General Policy and Responsibilities”

Chapter 2, “Work Authorization”

Chapter 28, “Incident Investigation”

Chapter 31, “Institutional ES&H Committees”

8 Implementation The requirements of this chapter are effective upon publication unless otherwise noted here.

9 Ownership Department: ES&H Division Office

Program: Self-assessment

Owner: ES&H Division Associate Director, Sayed Rokni

18 https://www-internal.slac.stanford.edu/esh-db/slaccats/bin/start.asp

19 https://www-internal.slac.stanford.edu/esh/divisional/divreports/

20 http://www-group.slac.stanford.edu/esh/general/isems/wss/

21 http://www-group.slac.stanford.edu/esh/general/isems/sms.pdf

22 http://www-group.slac.stanford.edu/esh/divisional/qa.htm

23 http://www-group.slac.stanford.edu/esh/eshmanual/

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Senior Manager Safety Walkthroughs Director's Procedure

Senior Manager Safety Walkthroughs This procedure identifies a required process for SLAC senior managers to demonstrate concern that “Safety Comes First” through a planned set of area walkthroughs during each fiscal year. Field presence is a part of SLAC’s Integrated Safety and Environmental Management System (ISEMS), in particular to ensure demonstration to the staff senior management’s acceptance of and support for Guiding Principle 1: “Line Management Responsibility for Safety.”1

Background On October 15, 2004, the Acting Assistant Secretary for the U.S. Department of Energy (DOE) Office of Environment, Safety and Health appointed a Type A Investigation Board to investigate the electrical arc injury accident that occurred on October 11, 2004. The report was issued to the laboratory on December 14, 2004. The Board identified 12 Judgment of Needs; 8 of which SLAC has lead responsibility for developing corrective actions. On January 14, 2005, the Corrective Action Plan for the Judgments of Need Identified in the Type A Accident Investigation Report on the October 11, 2004, Electrical Arc Injury at the Stanford Linear Accelerator was submitted to DOE for final approval.

Judgment of Need 11 states that: “The SLAC Director needs to ensure that employees at all levels fully understand that concern for mission accomplishment does not outweigh the need for safe operations.”

Five Corrective Actions responded to the Judgment of Need. One of those corrective actions, CA 11-5, requires that “The Director and Associate Directors will conduct regular Safety Walkthroughs.”

Reference CA 11-5

Action

The Director and Associate Directors will conduct regular Safety Walkthroughs. While “All Hands” memos and meetings clearly deliver the safety-first message to all employees, members of the Directorate being on the sites of activities to observe and comment on the importance of safety in the field will personalize the message. Regular walkthroughs (approximately monthly) of selected areas with significant potential hazards (such as the accelerator, machine shops, experimental areas, construction areas, maintenance areas, chemical processing areas) will provide first hand knowledge to the Directors and employees alike that safety is first.

Responsible Manager: J. M. Dorfan Organization: Director’s Office Completion Date: February 3, 2005

1 Refer to the SLAC Integrated Safety and Environmental Management System Description (SLAC-I-720-

0A00B-001, http://www-group.slac.stanford.edu/esh/general/isems/sms.pdf)

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Senior Manager Safety Walkthroughs Director's Procedure

Action The following SLAC senior managers will schedule safety walkthroughs through their areas on a regular basis, but at least often enough to ensure that a safety walkthrough has been conducted in key areas under their responsibility each fiscal year.

• Jonathan Dorfan, Director • John Cornuelle, Director, Operations Directorate • Persis Drell, Director, Particle & Particle Astrophysics Directorate • John Galayda, Director, LCLS Directorate • Keith Hodgson, Director, Photon Science Directorate • Jerry Jobe, Associate Director, Business Services Division, Operations Directorate • Sayed Rokni, Acting Associate Director, ES&H Division, Operations Directorate

To support this process, a simple form has been prepared and shall be used to document these safety walkthroughs (see Attachment 1).

The form shall be completed to show the date of the safety walkthroughs and the areas/buildings visited. Upon completion, the form should be retained in the Director’s, Program Director’s, or Associate Director’s office for future reference. If none of the key check-offs have been selected or significant issues noted, follow-up action at the Directorate level may not be required. However, areas/buildings walked through shall be identified in the quarterly directorate safety reports to the ES&H Coordinating Council.

Any significant findings requiring special action, such as stop work or stop activity,2 should be immediately addressed and appropriate notifications made. Concerns or observations or at risk situations/behaviors that the Program Director or Associate Director feels are significant should be brought to the attention of the SLAC Director.

Some topic areas that could be explored during the walkthrough by discussion with employees in the area:

• JHAM/AHA completion for work observed • Training status and controls related to the hazards • Ideas for improving safety in their work area

The expectation is others will be documenting specific issues related to compliance items observed during a safety walkthrough, such as a directorate/division/department/group ES&H coordinator, and the focus of the senior manager safety walkthroughs is to promote recognition by their staff that “Safety Comes First” on a regular basis.

__________________ Jonathan Dorfan Director

2 Refer to ES&H Manual, Chapter 2, “Work Authorization”,

http://www-group.slac.stanford.edu/esh/general/work_authorization/policies.htm

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Senior Manager Safety Walkthrough Form Stanford Linear Accelerator Center

Retention/Disposition In Accordance With Director’s Procedure: “Senior Manager Safety Walkthroughs”

Directorate: Senior Manager: Stop Work/Activity?

Yes ____ No ____ DO Jonathan Dorfan, Dir. _______ Operations John Cornuelle, COO _______

PPA

Persis Drell, Deputy Director _______

PS

Keith Hodgson, Deputy Director _______

Require notifying SLAC Director? Yes __ No __

LCLS

John Galayda, Program Director _______

Operations (BSD)

Jerry Jobe, Associate Director _______

ES&H Coordinator Follow-up Required? Yes __ No __

Operations (ES&H)

Sayed Rokni, Acting Assoc. Director _______

Area/Building Manager Follow-up Required? Yes __ No __

Other __________________ _______

Areas/Buildings Visited: Project/Work Supervisors Follow-up Required? Yes __ No __ Notes (continue on back): Senior Manager Signature:

Date of Walkthrough:

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Senior Manager Safety Walkthrough Form Additional Notes:

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3 August 2006 SLAC-I-720-0A18J-001-R000 [assign new number] 1

Annual _______________ Directorate ISEMS Self-assessment Report

Period Covered:

Purpose: Summary evaluation and report written by the line on ES&H performance and ISEMS implementation within each directorate. Each directorate is to measure its ES&H performance and the effectiveness of its ISEMS implementation by evaluating results of previously described walkthroughs and compliance assessments as well as other forms of assessment described in the ES&H Assurance System within the ISEMS Description. This assessment and report emphasizes the principles of line management responsibility and accountability for safe work practices, work authorizations, and feedback and improvement.

1) Summary of Self-assessment Activities and Issues Identified

a) Management Walkthroughs

b) Compliance Assessments

i) Work Procedures

ii) Work Spaces

c) CATS

i) Entries

ii) Issues Open

iii) Trending Issues (as applicable)

2) Summary of Performance against ISEMS Measures

a) Contract Performance Measures (as set for the ____________ Directorate)

b) Internal Goals and Metrics

c) EMS Targets and Goals

3) Noteworthy Items

4) Summary Judgment on Effectiveness of ISEMS Implementation including

• Effectiveness of ISM/ES&H communications by the line as reflected in summaries of staff meetings

• Staff accountability for sound ES&H performance as demonstrated through a sampling of employee evaluations

• Validation of JHAMs, position description, and SLAC Training Assessments – completeness and relevance

• Report on % workspace assessed. OA will provide baseline data. • Report % work processes assessed. This is primarily for work processes that,

under our new Assurance Program description, are committed to formal written procedures having significant ES&H issues.

5) Areas for Future Focus

Line Management Self-assessment: Management Walkthrough Checklist Department: ES&H Division Office Program: Line Management Self-assessment Owner: ES&H Division Associate Director, Sayed Rokni Authority: ES&H Manual, Chapter 33, Line Management Self-assessment

Purpose The purposes of the management walkthrough are fourfold:

1. To increase dialogue with workers on creating a safe workplace and preventing accidents and incidents

2. To observe non-punitively worker behavior

3. To reinforce positively safe work behavior

4. To complement the Type A CAP senior management walkthroughs by having managers and supervisors at the lowest levels of the organization engaged in safety walkthroughs

Process Each directorate will define how its managers will conduct management walkthroughs. There are multiple levels of management and different types of managers, for example, area manager, building manager, and facility manager. It is not the intent of the management walkthrough program that each manager conducts walkthroughs of every occupied space. It this were done, a worker many be engaged as many times as there are management levels in a directorate.

Most walkthroughs should be conducted by first-line supervisors. The relationship between supervisors and individuals is the most important to develop as regards creating and maintaining a safe workplace. This does not preclude a directorate from deciding that multiple layers of management should conduct management walkthroughs but should ensure they are done in a complementary fashion. Further, management walkthroughs complement but do not take the place of senior management walkthroughs1 driven by the Type A Incident Investigation corrective action plan.

Management walkthroughs of occupied workspaces are to occur once each year or more frequently as a directorate decides is appropriate. The walkthroughs must be planned for a time when workers are present in their workspaces. Managers and supervisors must also ensure they have a full understanding of all the workplaces an individual may have. Some individuals work in the field and the supervisor and manager must extend the walkthroughs to those work environments.

1 Senior Manager Safety Walkthroughs Procedure (SLAC-I-720-0A22C-001), https://www-

internal.slac.stanford.edu/esh/forms/internal/WalkthroughProcedure.pdf

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Line Management Self-assessment: Management Walkthrough Checklist

Checklist Supervisors should ensure the following is accomplished for each walkthrough:

• Appropriate preparation and planning occurs before the walkthrough • Workers are present in their workspaces • Workers are positively engaged in a dialog about safety with particular emphasis on

accident and incident prevention • Safe work behaviors are positively reinforced and workers and their supervisors come

to agreement on ways to improve safety • The process should be non-punitive • Supervisors should assess and reach judgments on the following during the

walkthroughs • Orderliness of the workspace • Worker body positions and motions • Appropriateness of the tools the worker uses • Adequacy of procedures the worker uses • Availability, quality, and appropriateness of personal protective equipment the

worker uses

Documentation Directorates are free to specify how walkthroughs are documented. We suggest documenting walkthroughs by summarizing them in an e-mail to ES&H coordinators, who will summarize all self-assessment activity in their annual reports. Supervisors should check with their directorate ES&H coordinator to determine documentation method. Whatever the documentation method chosen, the supervisor should note

• What spaces were walked • Any unsafe acts that were observed and the causes of unsafe acts • Any areas for improvement to which she/he committed and what follow-up actions

need to be taken.

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Line Management Self-Assessment: Workspace Compliance Assessment Checklist Department: ES&H Division Office Program: Line Management Self-assessment Owner: ES&H Division Associate Director, Sayed Rokni Authority: ES&H Manual, Chapter 33, Line Management Self-assessment

Sections 1. Safe and Orderly Operating Conditions – All Spaces and Areas

2. Fire Safety and Emergency Planning – All Spaces and Areas

3. Earthquake Safety – All Spaces and Areas

4. Electrical Safety – All Spaces and Areas

5. Chemical Handling and Storage – Industrial and Technical Workspaces and Areas Only

6. Hazardous Waste – Industrial and Technical Workspaces and Areas Only

7. Compressed Gases – Industrial and Technical Workspaces and Areas Only

8. Other Hazards – Industrial and Technical Workspaces and Areas Only

9. Workspace Compliance Assessment Summary

1. Safe and Orderly Operating Conditions – All Spaces and Areas

All workspaces and areas

1.1 Is the area clean and orderly?

1.2 Is the area clear of tripping hazards, wet spots, grease/oils, protruding objects, miscellaneous debris?

1.3 Is unused equipment kept in a safe and orderly manner?

1.4 Are exits correctly marked, visible, accessible, a minimum width of 28 inches?

1.5 Is there sufficient lighting?

1.6 Are computer workstations evaluated and ergonomically configured for employees to prevent repetitive stress injuries?

1.7 Do workstations have sufficient clearance for workers?

Additional issues for industrial and technical workspaces and areas:

1.8 Are tools, equipment, portable ladders, and work areas maintained in an orderly, clean and safe manner?

1.9 Are shop areas and equipment (such as hand tools and portable and fixed power tools) inspected periodically and deficiencies corrected?

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Line Management Self-Assessment: Workspace Compliance Assessment Checklist

1.10 Are warning and hazard signs (both radiation and occupational safety) posted where they are required?

1.11 Are permanent aisles/passageways where forklifts are used properly marked?

1.12 Are open pits, tank ditches, and so on covered or provided with standard guard rail protection?

1.13 In elevated area(s), are the load limits for stored items clearly marked?

1.14 Are food and beverages stored only in refrigerators specifically marked for those items?

1.15 Are “No food or drink” areas clearly marked as such?

1.16 Does the noise level permit normal, working conversation and safe communication?

1.17 Are unguarded holes or openings in floors properly covered?

1.18 Is there sufficient ventilation?

1.19 Are fixed industrial stairs in good repair?

1.20 Is scrap stock cleaned from floor and work benches following each job or at the end of each day?

2. Fire Safety and Emergency Planning – All Spaces and Areas

All workspaces and areas

2.1 Are fire extinguishers clearly accessible; are their seals intact; are they properly mounted to wall-panels; are current inspection tags securely attached?

2.2 Have new extinguishers been ordered to replace missing, damaged, or discharged units?

2.3 Are backs of inspection tags initialed and dated by parties responsible for monthly checks?

2.4 Is there an 18-inch minimum clearance below all fire sprinklers; are sprinklers clear of interference by stored materials (boxes and so forth) and from any paint applied to the sprinkler heads?

2.5 Is the presence of combustible materials minimized?

2.6 Are exit-access corridors free of storage?

2.7 Are fire alarm pull stations and portable fire extinguishers visible, properly labeled, and inspected?

2.8 Are exterior building or trailer identification numbers posted for emergency response?

2.9 Are doors that are not exits but could be mistaken for exits clearly marked “NOT AN EXIT?”

2.10 Are evacuation maps posted on the walls?

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Line Management Self-Assessment: Workspace Compliance Assessment Checklist

2.11 Does emergency lighting turn on when the test button is pushed?

3. Earthquake Safety – All Spaces and Areas All workspaces and areas

3.1 Are all heavy objects below 5 feet; all shelves below 7 feet, 6 inches?

3.2 Are furniture and equipment that could tip and block an exit properly anchored?

3.3 Are stored materials stacked securely to prevent tipping, scattering, tripping?

3.4 Are bookcases (more than 3 feet high), filing cabinets (more than 3 feet high), shelves, racks, and storage cabinets seismically braced?

Additional issues for industrial and technical workspaces and areas:

3.6 Are heavy workbenches anchored?

3.7 Are wheels on large copy/blueprint machines properly blocked?

3.8 Are machine shop fixed equipment/electronic racks anchored?

3.9 Are air conditioners properly secured; cable trays braced at intervals of 10 feet or less?

4. Electrical Safety – All Spaces and Areas All workspaces and areas

4.1 Are relocatable Power Taps (power strips) used in a compliant manner? Use for fans and space heaters is unallowable.

4.2 Are space heaters provided with tip-over switch, as well as grounded with three-wire cord and plug, or labeled double-insulated, or constructed totally of plastic or bear the UL double-insulated symbol (a square within a square)?

4.3 Are coffee pots, clocks, and fans grounded with three-wire cords and plugs, or labeled double-insulated, or constructed totally of plastic, or bear the UL double-insulated symbol (a square within a square)?

4.4 Are all panels, disconnects, and other emergency disconnecting means clear with a 30-inch width and a 36-inch depth (42-inch for high voltage) plus a free access path (28-inch width)?

4.5 Are all panels and disconnects labeled and numbered?

4.6 Are all pieces of equipment/apparatus and their power supply cords in good condition (not damaged, frayed, missing components, or otherwise compromised)?

4.7 Are all electrical receptacles within 6 feet of water sources (sinks, hose barbs, showers) protected by ground fault circuit interrupter (GFCI) technology?

4.8 Are all switches, control cabinets, and other electrical installation access points accessible?

4.9 Are extension cords used in series or “daisy-chained” (which is unallowable)? Are extension cords only used as temporary power sources?

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Line Management Self-Assessment: Workspace Compliance Assessment Checklist

Additional issues for industrial and technical workspaces and areas:

4.10 Has any piece of equipment or apparatus been modified or adapted in any way that may be unsafe or noncompliant?

4.11 Does all equipment with more than one point of hazardous energy control have a posted lockout/tagout procedure?

4.12 Do all cords and equipment have necessary grounding and bonding?

4.13 Are all pieces of fixed equipment or fixed apparatus wired with a fixed wiring method (not an extension cord)?

4.14 Do all experiments and components with interlocks have an interlock testing log or other document?

4.15 Are all cords and cables bundled and protected from damage?

4.16 Are extension cords not run through walls, ceilings, floors, under mats, or across doorways and other openings?

4.17 Are all conductors and conducting parts shielded from employee contact?

4.18 Do all electrical junction boxes, switches and outlets have their covers on?

5. Chemical Handling and Storage – Industrial and Technical Workspaces and Areas Only

5.1 Are cabinets and containers properly labeled?

5.2 Are there separate disposal areas or containers for rags, glass, trash, and so forth?

5.3 Are bottles, cans, vials, flasks, and so on properly labeled with contents and date?

5.4 Are flammables stored in the appropriate cabinet and spill prevention and containment provided? Are storage cabinets of approved construction (for example, metal with self-closing doors)?

5.5 Are organics, acids, and bases stored apart from each other?

5.6 Are spill-containment materials readily available for simple or small spills?

5.7 Are appropriate containers emptied daily?

5.8 Are material safety data sheets (MSDSs) available for all hazardous substances present?

5.9 Are emergency eye washes and showers working and are managers documenting that they are being tested?

5.10 Are emergency showers working?

5.11 Has the industrial hygiene office been notified of any new work operations or changes in existing operations?

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Line Management Self-Assessment: Workspace Compliance Assessment Checklist

6. Hazardous Waste – Industrial and Technical Workspaces and Areas Only

6.1 Is a waste accumulation area (WAA) designated?

6.2 Are appropriate disposal cans available, properly labeled with contents and date, and clearly marked “Hazardous Waste?”

6.3 Are the accumulation start date and contact name provided on containers?

6.4 Are containers closed except when being filled or emptied?

6.5 Do containers have secondary containment?

6.6 Is there separate secondary containment for incompatible materials?

6.7 Are there separate containers for solvent solids wastes and oil and coolant solids wastes?

6.8 Is there a waste accumulation area logbook on hand?

7. Compressed Gases – Industrial and Technical Workspaces and Areas Only

7.1 Are cylinder bottles or six packs properly restrained; caps in place when not in use; tags attached showing full, empty, or in use?

7.2 Are cylinders clearly marked as to contents?

8. Other Hazards – Industrial and Technical Workspaces and Areas Only

8.1 Are lead soldering stations and lead storage areas clean and free of any lead debris?

8.2 Are lead bricks in good condition (not flaking or chalky in appearance) or wrapped in tape or encapsulated painted) to prevent deterioration?

8.3 Are painting and welding operations conducted in well ventilated areas?

8.4 Are exhaust systems functioning adequately to capture debris at/near the point of generation? Are sawdust collection bins cleaned out periodically?

8.5 Have exposed moving parts on equipment/machinery been guarded to prevent contact by employees?

8.6 Is personal protective equipment (PPE) stored properly?

8.7 Are areas of high noise or where potentially elevated levels of airborne chemical contaminants may exist being monitored by ES&H Division personnel and exposures controlled?

8.8 Are guard rails or other barriers in place to eliminate fall hazards from elevated surfaces (4 feet or higher) or stairs?

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Line Management Self-Assessment: Workspace Compliance Assessment Checklist

9. Workspace Compliance Assessment Summary

Workspaces and Areas Assessed Include buildings and room numbers whenever possible. Building __________, rooms _______________________________________________ Building __________, rooms _______________________________________________ Building __________, rooms _______________________________________________

Outside areas _______________________________________________________________________ _______________________________________________________________________

Inspection Items That Need Correction

Bldg/Room Correction Needed (included #)

Person responsible for correction (CATS Taskmaster)

Target Due date

Manager Conducting Workspace Compliance Assessment Signature: Ext.: Name: Date: After entering assessment into CATS,1 submit this form to CATS at M/S 84.

1 “CATS System”, https://www-internal.slac.stanford.edu/esh-db/slaccats/bin/start.asp

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Line Management Self-Assessment: Workspace Compliance Assessment Checklist

Instructions for Filling Out CATS Assessment Submission Form Assessment Submission Form Field

Enter

Name Your name, last name first Assessment Title Workspace Compliance Assessment Date of Assessment Month, day, and year Assessment Type Internal Department Your organizational element Responsible Person Who will be responsible for ensuring the corrective

actions are taken. This is usually the person doing the assessment. The individuals who you want to correct a deficiency is the “task master” and is designated on the form you will submit hardcopy to the CATS program manager.

Co-responsible Person If any Topic ES General Target end date The date by which all corrective actions should be

complete

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