LBNL ISMS Plan (PUB-3140) 
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Rev. 12/07
It is the policy of Lawrence Berkeley National Laboratory (LBNL) to perform all work safely with full regard to the well being of workers, guests, the public, and the environment.
Keys to implementing this policy are the following core safety values:
To fulfill this vision, LBNL implements the regulatory requirements of the Work Smart Standard Set (WSS Set) through a hierarchy of policies, procedures, and performance objectives in this document, the LBNL Integrated Environment, Health, and Safety Management Plan (ISMS, PUB-3140), the LBNL Health and Safety Manual (PUB-3000), and the following ES&H technically based major Implementation Plans:
1. Line Management Responsibilities
The first principle of Integrated Safety Management states that “Line management is directly responsible for the protection of the workers, the public, and the environment.” The second principle, in stating that “clear lines of authority and responsibility for ensuring safety shall be established and maintained at all organizational levels,” dictates that this responsibility cannot be delegated outside of the direct line of management personnel responsible for an organization’s direction, operations, performance, and effectiveness. Therefore, the Laboratory Director has the ultimate responsibility for safety at the Laboratory and, in particular, for the establishment and administration of environment, health, and safety policies that meet the safety challenges of Laboratory operations and activities as well as the requirements of DOE Contract 31 and the Work Smart Standard Set.
The Laboratory Director has delegated to all levels of management the authority to implement the environment, health, safety, and emergency-preparedness policies of the Laboratory:
Division directors and heads of independent departments are responsible for ensuring that the Laboratory’s environment, health, safety, and emergency-preparedness policies are being observed within their divisions.
Each LBNL manager or supervisor is responsible for ensuring that employees (including matrixed employees — see below), participating guests, contractors, students, and visitors under his or her supervision are properly trained in emergency and safety procedures, the concepts of the integrated safety management system, and the adherence to the five core functions. In addition, managers and supervisors have responsibilities, listed in Chapter 1 (General Policy and Responsibilities) of the Health and Safety Manual (PUB-3000), designed to provide a safe and healthful working environment, free from undue hazards, and to protect the environment. In exercising these responsibilities, managers may delegate authority and assign safety responsibility for a particular operation, activity, area, or group of workers to a work lead, but they retain accountability for worker, activity, and workplace safety. Prevention of injury, illness, safety violations and deficiencies, environmental pollution, or damage to property within managers’ jurisdictions is their responsibility.
The importance of identifying accountability in cases of delegated authority is applicable to employees from one division (home division) matrixed to another division (host division) to provide special technical expertise. The matrix employee’s individual safety (including fundamental safety training, safe use of equipment and instrumentation, and acknowledgment of the importance of safety) is the responsibility of the home supervisor. Identification and management of workplace hazards and their control in maintaining safety in the workplace or area are the responsibility of the host manager or supervisor. It is possible that the matrix employee may be assigned and authorized by the host facility manager as a work lead or safety line manager to operate and maintain a safe facility and/or activity and oversee worker safety of one or more staff of the host division; for example, to provide on-the-job training and direction to division staff in the safe use of equipment and instrumentation. The matrixed employee assigned as safety work lead is responsible for the safety of the staff assigned and authorized to operate equipment in the area, and for the safe operation and maintenance of the area. On the other hand, the host manager or supervisor of the facility is accountable for facility safety. The policy and implementation guidance for matrixed employees is covered in detail in PUB-3000, Chapter 1. Section 1.3.2.7 recommends developing a memorandum of understanding to alleviate concerns, and to clarify lines of authority in these situations.
2. The Environment, Health, and Safety (EHS) Division
The primary responsibility of the Environment, Health, and Safety (EHS) Division is to protect workers, the public, and our environment by providing professional and technical expertise and services as well as an integrated ES&H policy for the Laboratory's research and support programs. The EHS Division supports and acts as a partner with line management as it meets direct responsibilities to ensure that protection of workers, the public, and the environment is integrated into the primary research and support functions of each division or unit. Of equal importance, the EHS Division supports and provides expertise directly to each Laboratory worker who seeks ES&H advice and help, or who voices a concern. The Charter of the EHS Division, broadly based on the key core safety values in the opening statement and the responsibilities listed here, is published as Chapter 2 of PUB-3000.
3. The LBNL Integrated Environment, Health, and Safety Management (ISMS) Plan
The LBNL ISMS Management Plan provides guidance and performance expectations
both to operational and programmatic divisions to develop ISMS Plans specific
to their work, activities, facilities, operations, and staffing patterns. This
arrangement provides an effective and efficient means for each division to
develop and tailor an ISMS Plan to address their specific safety challenges. The
LBNL ISMS Plan and the divisional plans are updated at least annually to address
safety challenges derived from changes in programs or activities, and to reflect
improvements based on self-assessments and lessons learned. These relationships
and interfaces are depicted in the figure below, and described in detail in
the LBNL ISMS Plan (PUB-3140) .
Figure. LBNL Document Hierarchy: Functional relationship between the DOE contract and WSS and the LBNL ES&H policy and implementing elements
The LBNL ISMS Plan sets performance expectations based on the seven principles and five core functions of ISM at three levels: institutional, activity, and individual. Institutional expectations are specified in the Contract 31 Performance Evaluation and Measurement Plan. Activity and operational expectations are described in Section 8.01 (Quality Assurance) of the RPM, and details on the assessment of performance at this level are published in LBNL ES&H-Assessment Program (PUB-5344). Individual expectations are based on the safety-related roles and responsibilities of supervisors and work leads as well as of each staff member, including guests, subcontractors, and vendors as defined in Chapter 1 (General Policy and Responsibilities) of the Health and Safety Manual (PUB-3000). Annual performance reviews of staff include safety expectations as part of the process (see the HR form Institutional Requirements). Division ISMS Plans are required, and measured as part of the annual self-assessment process, to reflect the hierarchy of expectations for activities/operations and individuals. The goal is to provide specific, clear, and current safety expectations that evaluate performance vertically and horizontally across the organization to guide continuous improvement.
4. Implementation Plans
The Implementation Plans were developed in direct response to regulatory requirements;
for example, 10 CFR 835 (Occupational Radiation Protection) calls for a Radiological
Protection Plan, and 10 CFR 851 (Worker Health and Safety Program) led
to the Worker
Health and Safety Plan (PUB-3851). In
addition, all are derived from the recognition by the Laboratory of the need;
based on potential hazards to the worker, the public, and the environment;
for a more rigorous approach to work planning, hazard identification and control,
and performance of work. Therefore, a component common to these plans
is formal work authorizations. Work authorizations applicable to operations
and programs are covered in detail in PUB-3000. Examples of formal work
authorizations include research-related authorizations such as Activity Hazard
Documents for laser use, and Radiation Work Authorizations for the use of radioactive
material and radiation-producing machines. Examples of operational authorizations
include those for using forklifts, cranes, and hoists. Some of the authorizations
in these plans are applicable to specific facilities and the institution as
a whole. Examples of these are Safety Analysis Documents (SADs) and Accelerator
Safety Envelopes (ASEs) that establish the safe operating limits for accelerators,
and environmental and waste management permits from regulatory agencies. The
Implementation Plans are for the purpose of translating regulations and standards
in the WSS Set into technical programs. PUB-3000 translates the Plans
into more functional forms for integration and implementation of safety into
work and activities throughout the Laboratory.
To achieve their technical goals, the Implementation Plans include policies and procedures internal to the group responsible for each plan to implement the technical aspects of the program (e.g., environmental monitoring, chemical exposure monitoring, dosimetry); to update technical expertise, instrumentation, and standards; and to drive continuous improvement.
5. The LBNL Health and Safety Manual (PUB-3000)
The LBNL Health and Safety Manual (PUB-3000) consolidates ES&H policies, specific responsibilities, and guidance for implementation into a convenient online package. This comprehensive manual is based on the seven guiding principles of ISM, and is designed to implement the five core functions of ISM. The goal is to ensure that all work will be performed with full regard to the safety of workers, guests, the public, and the environment. LBNL performs work to meet the requirements of PUB-3000, which are based on the Work Smart Standards set. PUB-3000 addresses all the standards in the WSS in a manner designed to provide individual safety, a safe workplace, and to protect the environment. The manual is reviewed and revised on an ongoing basis to comply with new applicable standards and requirements, and to meet the challenges of new research and development activities, operations, and facilities.
Chapters in PUB-3000 provide technical information and guidance derived from the Work Smart Standards and the Implementation Plans. This information provides LBNL staff with policies, guidance, and sufficient technical information to develop work authorizations that mandate working safely in a safe workplace with minimal adverse impact on the environment. The impact of the OSHA-related plans (i.e., Worker Health and Safety Plan, Chemical Hygiene and Safety Plan) is broadly expressed across PUB-3000. Other plans are more specific and individually comprehensive but have ramifications for information in other chapters. Hence, each chapter in PUB-3000 provides cross-references to other chapters containing related or pertinent information. The more direct relationships are shown below:
In addition, Chapter 6 and Chapter 32 of PUB-3000 guide managers, supervisors, and work leads in understanding the need for work authorizations, and through the processes of hazard analysis and determining appropriate work authorizations. A successful formal work authorization process depends upon line management recognizing the need for rigorous work planning and authorization, and then committing to working and training staff to work within the authorized safety envelope. Success also depends upon each individual taking responsibility for his or her own safety and the safety of co-workers. These expectations are detailed in Chapters 6 and 1 of PUB-3000. Some chapters of PUB-3000 are applicable to all technical areas: for example, Chapter 14 (Lessons Learned), Chapter 24 (EH&S Training), and Chapter 15 (Occurrence Reporting).
1. Safety Review Committee (SRC)
The Safety Review Committee (SRC) interfaces between the research and operation programs of LBNL and the ES&H technical programs, mainly in the EH&S Division, and assurance and assessment activities of the Office of Contract Assurance (see RPM Section 8.01 (Quality Assurance)). SRC membership includes a representative from every Laboratory division, and members are appointed by the Laboratory Director. To effectively execute its role, the SRC has direct access to the Laboratory Director and the Senior Management Team.
The SRC performs research for and makes recommendations to the Laboratory Director on the development and implementation of Environment, Safety, and Health (ES&H) policy, guidelines, codes, and regulatory interpretation. It conducts reviews of special safety problems and provides recommendations for possible solutions to the Laboratory Director or the EH&S Division. The SRC also provides advice and counsel to the Associate Laboratory Director for Operations by reviewing appeals from a Laboratory division whose interpretation of criteria, rules, or procedures differs from that of the EH&S Division. Such advice and counsel may include options for a resolution. The SRC has established five permanent subcommittees (Electrical, Laser, Mechanical, Traffic, and Division Safety Coordinators) to assist in reviewing ES&H issues and concerns, and in developing recommendations for institutional implementation. These subcommittees report to the SRC.
In order for SRC to properly execute its responsibilities under its charter, the SRC Chair may set up additional subcommittees to address specific health and safety matters. Such subcommittees may become permanent expert subcommittees, or they may be temporary, depending on technical support requirements.
In addition, the SRC Chair, in cooperation with the Office of Contract Assurance, is responsible for scheduling and implementing Management of Environment, Safety, & Health (MESH) reviews. These self-assessment reviews are designed to ensure management systems are consistent with Integrated Safety Management (ISM) throughout all Laboratory divisions, and that these systems are leading to effective implementation of the Laboratory's ES&H program, including opportunities for improvement.
2. Radiation Safety Committee (RSC)
The Berkeley Lab Radiation Safety Committee (RSC) is the interface between the Radiation Protection Program and the scientific programs using radioactivity, radioactive sources, and/or machines producing ionizing radiation. The Committee is appointed by and reports to the Laboratory Director, and is responsible for advising LBNL Management on all matters related to occupational and environmental radiation safety. The Radiation Safety Committee reviews and recommends approval of radiation safety policies, and guides the EH&S Division and radiation user Divisions in carrying out these programs. The scope of its actions will generally include issues of broad institutional concern and impact, or areas of potential high consequence either in terms of safety or institutional needs. To this end, the RSC provides a forum to ensure that important radiation safety issues receive appropriate, balanced, and expert review before being acted upon.
The RSC is composed of members whose knowledge of the principles and practices of radiation hazards control, and experience and management in the use of radioisotopes or radiation-producing machines, are the basis of their appointment by the Laboratory Director. The membership shall reflect the diversity of scientific disciplines using radiation at LBNL. The LBNL Radiological Control Manager (RCM) serves as a full member of the RSC, and acts as the RSC liaison with other Berkeley Lab programs. In addition, the LBNL Safety Review Committee will provide at least one liaison to the RSC and ensure integration with larger institutional safety issues.
The RSC reviews Radiation Protection Program policies, and recommends approval or modification of them to Laboratory management. The scope of policy review is provided in the ISMS Management Plan and on the Radiation Protection Group Web site.
The RSC provides oversight to the radiation safety compliance inspections carried out by the Radiation Protection Program. If performance of radiation users or the EH&S Division is found to be unsatisfactory, the RSC may recommend appropriate remedies to the Laboratory Director, the EHS Division, or the appropriate division director.
The RSC shall also provide oversight to the Radiation Protection Program (RPP). The RSC evaluates RPP performance reports and implementation of procedures, obtains feedback from radiation users regarding RPP functions, and makes recommendations for improvement to the Laboratory Director, the EHS Division Director, or the RCM.
Radiation Work Authorizations (RWAs), Radiation Work Permits (RWPs), and Sealed Source Authorizations (SSAs) shall be reviewed and approved by the RSC. The RSC, in conjunction with the RCM, may at any time prohibit any controlled radiation activities that it deems to be unduly hazardous, or contrary to regulations or good practice. In such cases, the RSC shall inform the appropriate division director.
Throughout the year, meeting minutes and other reports shall be transmitted to the Laboratory Director in a timely fashion. The Committee shall meet with the Laboratory Director at least annually to discuss issues and review the Committee’s activities. An annual activity report shall be prepared for the Director. The highlights of this activity report may be presented at a division director's meeting.
3. Office of Contract Assurance (OCA)
The Office of Contract Assurance (OCA) is responsible for the LBNL Issues Management Program (IMP). The IMP encompasses the continuous monitoring of work programs, performance, and safety to promptly identify issues to determine their risk and significance, their causes, and to identify and effectively implement corrective actions to ensure successful resolution and prevent the same or similar problems from occurring.
Issues that are governed by this program include program and performance deficiencies or nonconformances that may be identified through employee discovery, internal or external oversight assessments, process improvement suggestions, and associated actions that require formal corrective action. Issues may also be identified or may result in Root Cause Analysis (RCA) reports, Price Anderson Amendment Act (PAAA) reports, Occurrence Reporting and Processing System (ORPS) reports, Accident Investigation reports, assessment reports, and External Oversight reports.
Analysis of issues, individually and collectively, is performed in order to identify programmatic or system issues, and to identify recurrence of issues, generic issues, trends, and vulnerabilities at a lower level before significant problems result.
Lessons Learned and Best Practices, based on LBNL’s and other facilities’ operating experiences, are developed to ensure ongoing improvement of safety and reliability, prevent the recurrence of significant adverse events, and determine implementation strategies that will help LBNL successfully meet the missions and goals set forth by the Department of Energy (DOE).
Many of the issues and concerns of the IMP are safety related. Therefore, OCA interfaces with the EHS Division in managing, coordinating, and supporting ES&H assurance activities; in particular, the Division Self-Assessment Program, the Management of Environment, Safety, and Health (MESH) Reviews, the ES&H Technical Assurance Program, and independent audits of technical programs as needed. OCA also provides technical support to the EHS Division Director for developing ES&H performance objectives and criteria for division self-assessments, ES&H technical assurance, and DOE Contract 31, Appendix-B self-assessments (see RPM Section 8.01).
The Laboratory’s ES&H program is derived from a hierarchy of governing documents, beginning with the DOE/LBNL contract and the WSS Set, flowing down to the LBNL ISMS Management Plan, EH&S technical Implementation Plans, and the Health and Safety Manual (PUB-3000). The Laboratory expects individuals and line management to follow the requirements of these documents. The Laboratory also recognizes that there is always room for improvement, and expects line managers, supervisors, work leads, and other Laboratory staff to apply lessons learned and the self-assessment processes (as described in RPM Section 8.01 (Quality Assurance)) to improve workplace safety.