Chapter 1
GENERAL ES&H REQUIREMENTS, RESPONSIBILITIES, AND WORK PRACTICES

Approved by Joe Dionne
Revised 02/13

Contents

1.1 Policy
1.2 Scope
1.3 Applicability
1.4 Exceptions
1.5 Introduction to the ES&H Manual
1.6 ISM Overview: General Process  
1.7 Roles and Responsibilities
1.8 Definitions
1.9 Required Work Processes

Work Process A. Developing or Revising ES&H Policies and Programs
Work Process B. The Use of “Shall,” “Must,” “Should,” and “May” in EHSS Documents

1.10 Source Requirement Documents
1.11 Reference Documents

NOTE:
  Denotes a new section.
Denotes the beginning of changed text within a section.
Denotes the end of changed text within a section.

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1.1. Policy

The Lawrence Berkeley National Laboratory (Berkeley Lab) Environment Safety & Health (ES&H) Manual, previously known as PUB-3000, describes the detailed and technical work processes used to control hazards in Berkeley Lab workplaces and environments in accordance with Laboratory policy. The standards in this manual are designed to:

The ES&H Core Policy supported by this Program is found in the Laboratory’s Requirements and Policy Manual (RPM) and is re-stated here:

  1. Berkeley Lab policy requires all work to be performed safely with full regard to the well-being of workers, affiliates, the public, and the environment. Keys to implementing this policy are the following core safety values:
    1. The institution demonstrates a strong commitment to safety by integrating safety into all facets of work.
      1. Managers, supervisors, and work leads are actively involved and demonstrate leadership in performing work safely.
      2. Individuals take ownership to work safely and continuously strive to improve.
      3. Individuals demonstrate an awareness and concern for the safety of others and strive to prevent harm to other workers, the general public, and the environment.
  2. Berkeley Lab has adopted the DOE Integrated Safety Management System (ISMS) approach for establishing ES&H policies and programs. This is a requirement in Contract 31, Clause I.86, DEAR 970.5223-1, Integration of Environment, Safety, and Health into Work Planning and Execution (Dec 2000).

1.2 Scope

These requirements are intended to address all hazards that may be encountered.

1.3 Applicability

The requirements of the Berkeley Lab ES&H Manual apply to all Berkeley Lab employees, affiliates, contractors, and visitors to the Berkeley Lab main site, its off-site locations, and field operations.

1.4 Exceptions

None

1.5 Introduction to the ES&H Manual

The ES&H Manual is a collection of documents within the RPM that describes how LBNL integrates ES&H technical program requirements into the operating conditions found at LBNL. Separate ES&H programs have been developed for most ES&H technical areas. Following the principles of ISM and the LBNL ISMS Manual, technical programs use a graded approach to describe requirements at the activity, division, and institutional levels. While the technical requirements of each program area are unique (e.g., lead, ionizing radiation, or waste management), the administrative procedures used to manage these programs have commonalities that are leveraged to make it easier for workers to implement at the activity level and ensure compliance at the institutional level. At the division or facility level, ES&H technical program requirements are tailored to the physical conditions present and balance the need to work efficiently and safely while meeting institutional protection and compliance requirements. The ES&H Manual is designed and implemented to support and promote a strong safety culture at LBNL using the functions and principles of ISM. In this manual, EHSS is used to refer to the LBNL Environment, Health, Safety, and Security Division and its activities; ES&H is used to refer to the Environment, Safety & Health discipline and associated DOE regulations and requirements.

ISM Core Functions:

  • Define the scope of work
  • Analyze the hazards
  • Develop and implement hazard controls
  • Perform work within controls
  • Provide feedback for continuous improvement

 

An ISM System Overview is found in the ES&H Core Policy of the RPM.

ISM Guiding Principles:

  • Line management responsibility for safety
  • Clear roles and responsibilities
  • Competence commensurate with responsibilities
  • Balanced priorities
  • Identification of safety standards and requirements
  • Hazard and environmental controls tailored to the work being performed
  • Operations are authorized by management before work is started

The ES&H Manual also contains programs that cross technical areas such as Authorization Basis, Training, and Emergency Preparedness. The administrative procedures within these programs are designed to assist line management in meeting their ISM responsibilities during the normal course of doing business at the laboratory. This General ES&H Requirements chapter provides the overarching general requirements, responsibilities, and work practices for integrating ES&H into LBNL work at the activity, division, and institutional levels. The ES&H Manual is updated and revised on an on-going basis using the process described in Work Process A. The terms “shall,” “must,” “should,” and “may” in EHSS documents are used to differentiate between requirements and recommendations as described in Work Process B.

Berkeley Lab articulates its overarching environmental, safety and health policies and programs through its Integrated Environment, Safety & Health Management Plan (PUB-3140, ISM Plan). The policies and programs are established per the framework set by the principles and guidelines of ISM. Policy and technical program implementation, review, continuous improvement, and change are aligned with ISM guidelines and the Laboratory’s Requirements Management and Document Management policies. The ES&H technical program areas are defined by DOE Contract 31, the ES&H Standards Set in Appendix I of Contract 31, and applicable federal, state, and local regulations.

1.6 ISM Overview: General Process

  1. Line Management Responsibility and Accountability for ES&H
    1. Line management and work leads are responsible and accountable for the protection of the public, workers, and the environment. More specifically, laboratory line managers and work leads are responsible for integrating ES&H into work and for ensuring active, rigorous communication with the workforce.
    2. ES&H vision and goals are articulated by identifying specific targets, developing and implementing plans, securing resources, and managing and maintaining facilities and operations (including work activities and processes). Integrating ES&H into all phases of planning and implementing work processes is critical to the success of LBNL. ES&H must be part of the planning process by identifying potential hazards, applicable standards, controls that need to be integrated into the design and specifications, and competencies required to work safely. While line management and work leads are responsible for addressing ES&H concerns through work planning, implementation, and operations, the EHSS Division provides primary technical support through its EHSS Liaisons.
  2. Clear Roles and Responsibilities
    1. Responsibilities for safety are shared by all. Safety Line Management, the management chain of command that carries out the Laboratory Director’s ES&H concerns for worker safety, has a special responsibility for modeling safe behaviors and setting goals for a strong safety culture. Above the lowest formal organizational unit in each division, the chain is defined by the succession of direct reports, including supervisors and managers, who make job assignments, oversee work, appraise performance, and determine salaries. Below the lowest formal organizational unit, the chain may include non-management work leads and area safety leaders who guide the day-to-day activities of one or more workers.
    2. Supervisors and managers are part of the formal management chain and are responsible for adherence to all ES&H policies and safe work practices. Work leads derive authority from their managers or supervisors to ensure that day-to-day work, operations, and activities assigned to them are conducted safely and within established work authorizations.
    3. Every individual working in an LBNL workplace must be familiar with and implement applicable LBNL safety standards. Clear, unambiguous lines of authority and responsibility for ensuring safety must be established at all organizational levels. Institutional, divisional ,functional, and individual responsibilities for environment, safety, and health at LBNL are defined below. Detailed roles and responsibilities are listed in Section E. Roles and Responsibilities that follows.
  3. Competence Commensurate with Responsibilities
    1. Personnel need to possess the experience, knowledge, skills, and abilities to discharge their responsibilities. Competency is demonstrated through education, experience, qualifications, training, and fitness for duty. The minimum requirements for staff competency are set forth in the Operating and Quality Management Plan (PUB-3111, Section 1.33). However, LBNL supervisors or work leads shall ensure that all employees, contractors, and affiliates possess sufficient knowledge, skills, and experience to perform work safely. As a minimum, all employees, contractors, and affiliates must:
    2. Know the hazards associated with a work activity and the appropriate controls in place to minimize the hazard
    3. If necessary, know how to implement the controls. Operational knowledge includes training, certification, and/or experience, as determined by the immediate supervisor or work lead. As part of identifying the hazard and establishing controls for any activity, the supervisor or work lead should identify the appropriate level of training and experience (including certification if required by applicable standards). Employees, contractors, and affiliates must not perform work unless they have satisfied the training, experience, and/or certification requirements identified by the supervisor or work lead.
    4. Know how to recognize a failure of the hazard control system, cease work immediately, and take necessary steps to re-establish appropriate hazard controls. Failure of any hazard control system must be reported to the immediate supervisor, work lead, or LBNL contact person as soon as possible. If failure causes imminent danger, then the Stop Unsafe Work Policy must be followed.
    5. Be familiar with all sections of the ES&H Manual (formerly PUB-3000) that relate to the work being performed
  4. Balanced Priorities
    1. Priorities need to be established and resources effectively allocated to address safety, programmatic, and operational considerations. Work cannot be carried out unless there is appropriate consideration of ES&H resource needs in the work process. ES&H resource needs must be taken into account during planning, design and specification, implementation, and ongoing conduct of the work. No work will be conducted at LBNL where there are recognized hazards until controls tailored to the work being performed are in place. Before each new project or significant change to any process or work activity (including research) begins, a work process analysis of hazards to workers, the public, and the environment is to be conducted in accordance with the Safe Work Authorizations Program of the ES&H Manual. The objective is to ensure that hazard controls effectively mitigate the hazards associated with the work and in the process do not unnecessarily impede research.
    2. A Project Coordination Committee is responsible for balancing priorities at the institutional level. The Project Coordination Committee is facilitated by the Facilities Division and consists of representatives from each of LBNL’s resource divisions and the Office of Planning and Development. The Committee performs two functions: (1) informs all resource divisions of upcoming projects and allows for advance coordination when required, and (2) provides a broad-based review of projects using a priority rating system. A list of recommended prioritized projects is compiled during Committee review. This list is submitted to the Facilities Division Director and the Environment/ Health/Safety/ Security Division Director for review. Both the Facilities and EHSS division directors advise the Associate Laboratory Director for Operations / Chief Operating Officer on preparing a final list of projects to fund. Projects that are not funded are periodically reviewed with the proposing division throughout the year and may be resubmitted for funding during the next Unified Call Process.
  5. Identification of ES&H Standards and Requirements
    1. All new work activities or changes to existing work that introduce new hazards or increase the hazard level need to be reviewed to analyze hazards, identify safety standards and requirements, and establish appropriate controls. The Safe Work Authorizations Program of the ES&H Manual details the LBNL process for identifying hazards and determining requirements. The current set of standards identified in the ES&H Standards Set (Appendix I of Contract 31) is used as a basis to determine the appropriate requirements. EHSS Division Liaisons are available to assist in identifying hazards, determining the applicable standards, and developing appropriate cost-effective controls that meet LBNL ES&H policies. EHSS Division Liaisons need to be consulted if the scope of hazards exceeds the safety envelope established by LBNL ES&H standards.
    2. New and modified ES&H policies, standards, and requirements are identified and implemented through the Requirements Management process and committee. In collaboration with either standing or ad hoc user committees, EHSS Division subject matter experts craft strategies, procedures, and methods to implement these changes. The Safety Advisory Committee reviews the EHSS proposals and ensures that proposed implementation strategies consider the needs of the various divisions. This change management process is iterative and promotes a strong safety culture where individual activity, division, and institutional requirements are met. This process is described in detail in Work Process A.
  6. Establishment of Hazard Controls
    1. To prevent and mitigate hazards, controls must be tailored to the work being performed, the risk of harm posed by the work, and the extent or degree of harm that could occur while performing the work. This tailoring of controls to hazards based upon risk is generally referred to as the “graded approach.”
    2. The preferred hierarchy of controls is:
      1. Elimination or substitution of the hazards
      2. Engineering controls
      3. Administrative controls
      4. Personal protective equipment
      5. The tailoring process should include:
      6. Identifying controls for specific hazards
      7. Establishing boundaries for safe operation
      8. Implementing and maintaining controls
    3. LBNL ES&H professionals are available to assist in identifying the appropriate level of hazard control.
  7. Work Is Authorized
    1. All work must be authorized by management before work begins. Safety conditions and requirements need to be formally established and in place before work is initiated. All activities involving potentially hazardous conditions shall be carried out in conformance with the ES&H Manual and, as necessary, appropriate work authorizations such as Radiation Work Authorizations (RWAs), Activity Hazard Documents (AHDs), and Radiological Work Permits (RWPs). The Safe Work Authorizations Program of the ES&H Manual outlines a protocol for the form and content of LBNL work authorizations.
    2. Low-hazard activities can be authorized by first-level line management. Higher-hazard activities require joint review and approval by the EHSS Division and line management (e.g., via RWA, AHD, etc.). Contact the EHSS Division health and safety professionals for help determining the hazard level of an activity.
    3. Line Management (Low-Hazard) Authorization. Bench-level activities that do not require EHSS participation in hazard identification and mitigation are authorized by line management. Appropriate hazards and controls must be established for activities, even though they fall below the threshold of EHSS Division review level. Guidelines for hazards and controls are indicated in the ES&H Manual. The hazard review and establishment of controls are the responsibility of line management. EHSS Division safety professionals will assist if requested. Health-hazardous compressed gases classified as an NFPA Class 1 hazard are an example of low-level hazards that require only line management authorization.
    4. EHSS Division / Line Management (High-Hazard) Authorization. Activities requiring the EHSS Division participation in the hazard identification and mitigation process are identified in the technical programs of the ES&H Manual. Hazard identification, establishment of controls, and authorization are the joint responsibility of line management and appropriate EHSS Division safety professionals. An example of hazards at the joint EHSS/line management authorization level is a high health-hazard compressed gases classified as an NFPA Class 3 or 4 hazard. Applicable documents include Activity Hazard Documents (AHDs) and/or Radiological Work Authorizations (RWAs).
  8. Subcontractor Flow-Down of Safety and Health Requirements. Subcontractors, including service providers, provide LBNL a variety of on-site services including construction activities; building and ground maintenance; food services; training and consultation; and installation, testing, calibration, repair, and maintenance of instruments. Federal regulation 10 CFR 851 requires a written Worker Safety and Health Program (WSHP) to protect workers who are employed at a DOE facility. It also requires LBNL to flow down its requirements to subcontractors. Procurement guidelines delineate WSHP requirements for subcontractors including construction and general service subcontractors. For specific information about LBNL’s construction safety program for subcontractors, refer to the ES&H Manual, Construction Health and Safety, and sJHA Process—Subcontractor Job Hazard Analysis.
  9. Requesting a Variance from LBNLSafety Policy. In the rare case that an ES&H policy prevents a work activity from being performed, even though it may be demonstrated that it can be performed in a safe and healthful manner, a variance from the policy may be requested. Each variance request is reviewed on a case-by-case basis and either authorized or an alternate means of compliance within requirements is developed. See Variance from Berkeley Lab ES&H Policies.

1.7 Roles and Responsibilities

Every person working in an LBNL workplace must be familiar with and implement the LBNL safety standards that are applicable to them. Clear, unambiguous lines of authority and responsibility for ensuring safety must be established at all organizational levels.

The principal roles and responsibilities of the various stakeholders in the ISMS are listed in the table below.

Role

Responsibility

Workers
(Employees and Affiliates)

1. Must protect themselves, other workers, the public, and the environment

  • Conduct their work activities safely and in an environmentally sound manner
  • Know how to respond to emergencies and incidents
  • Immediately stop any activities, including the activities of others, that pose an imminent danger to personnel or the environment, and report these activities to their supervisors or work leads (i.e., implement the Stop Work Policy)

2. Must integrate ES&H into all work activities

  • Participate in activity-based hazard analysis processes related to their work
  • Develop an awareness of these hazards, and protect others in the area
  • Obtain authorization from their work leads or supervisors to perform work using approved LBNL work authorization methods
  • Obtain training to safely perform potentially hazardous tasks and to recognize the associated hazards, and only work when appropriate safety controls and procedures are in place
  • Have access to LBNL ES&H program documents (including the ES&H Manual), DOE ES&H publications, OSHA Form 300 (a record-keeping log), and exposure assessments and investigation reports for incidents in which they are involved
  • Minimize the volume and toxicity of LBNL-generated waste and maintain chemical inventories as low as reasonably achievable
  • Be accountable to LBNL for willful disregard of ES&H procedures

3. Must actively communicate ES&H and Integrated Safety Management issues

  • Notify their supervisors or work leads if they feel unqualified or insufficiently trained to do the task at hand or have any questions about performing tasks safely
  • Report unsafe activities, safety violations, and near-hits to Safety Line Management
  • Notify their Safety Line Management about conditions that may develop into unsafe situations
  • Raise concerns, send suggestions, and report ES&H issues to Safety Line Management, EHSS staff, or DOE without fear of reprisal
  • Report occupationally incurred injuries and illnesses to their supervisors or work leads and Health Services at the first opportunity
  • Participate in incident investigations as requested by Safety Line Management

Supervisors and Managers

In addition to their individual responsibilities as workers, Supervisors and Managers:

1. Must protect their staff, other workers, the public, and the environment

  • Ensure that staff members under their supervision are properly trained in emergency procedures
  • Provide sufficient resources (staff, time, training, equipment, and funding) for all applicable safety responsibilities

2. Must integrate ES&H into all work activities

  • Ensure that all staff under their supervision complete all applicable work- authorization documents relevant to their work, activities, and operations
  • Review and revise applicable work authorizations (i.e., JHAs, AHDs) annually or whenever the scope of work changes or hazards change.
  • Ensure that the required controls and formal training are completed and implemented before unescorted work begins
  • Verify that worker competence and on-the-job training are commensurate with work assignments before allowing unescorted work to proceed
  • Monitor work activities on a regular basis and take action to enforce safety rules
  • Ensure that all materials and equipment — regardless of origin — used or applied in performance of LBNL work are used, maintained, and serviced in a manner that ensures the protection of the environment, safety, and health

3. Must actively communicate ES&H and Integrated Safety Management issues

  • Know the federal regulation for workers’ rights to a safe and healthful workplace (10 CFR 851)
  • Promptly report all significant accidents, injuries, near-hits, and significant mishaps in accordance with the requirements of the Incident Reviewing and Reporting Program of the ES&H Manual. Ensure that their staff members report occupational injuries and illnesses to Health Services at the earliest opportunity.
  • Investigate all significant accidents and take actions to prevent recurrence
  • Ensure that safety deficiencies are entered into the Corrective Action Tracking System (CATS) and corrected in a timely manner
  • Promptly respond to applicable reports of incidents and recommendations for ES&H improvements
  • Inform their workers of the command chain for Safety Line Management up to the Laboratory Director
  • Communicate pertinent safety issues and applicable Lessons Learned in staff meetings and/or through other mechanisms
  • Coordinate with area safety leaders for their technical area work spaces to ensure that the hazards associated with their operations are identified and communicated

4. Must recognize language and cultural barriers

  • Must ensure that all individuals for whom they are responsible comprehend the ES&H hazards to which they are exposed and the protective measures available
  • Methods for learning ES&H hazards include, but are not limited to, standardized training or explanations through a translator, oral or written instructions, or demonstrations of procedures.
  • Cases involving an employee or participating guest with language or cultural barriers may be different.
  • Develop a tailored approach to ensure that the individual understands ES&H hazards and the responsibilities related to performing work safely at LBNL. 

5. Additional supervisor and manager responsibilities when using work leads

  • Must determine the need for using work leads under their areas of supervision
  • If needed, must assign workers to work leads with the cognizance of the work leads and the permission of the work leads’ supervisors
  • Must ensure that work leads under their supervision understand their roles and responsibilities
  • Provide their work leads with sufficient resources (staff, time, training, equipment, and funding) to fulfill all assigned safety responsibilities
  • Cannot delegate responsibilities to a work lead for work activities for which that person has no oversight or knowledge

Work Leads

These are persons who are delegated with select safety responsibilities by their supervisors and managers. Work leads are expected to apply these responsibilities under their Supervisors or Managers authority to perform these specific assignments. Work leads may decline to accept safety responsibilities with the permission of their supervisor.

Area Safety Leaders

Area safety leaders are coordinators and are not part of Safety Line Management. An area safety leader is an individual assigned by the division controlling a technical area to oversee coordination of safety issues within the area. The area safety leader may also be a manager, supervisor, or work lead. They are usually designated when multiple organizations do work within the technical area.
Area safety leaders must:

  • Coordinate with supervisors, managers, and work leads who work in the technical area to ensure that the hazards associated with their operations are identified and communicated to all occupants
  • Ensure that hazards associated with their areas are posted

Casual Visitors and Sponsors

Sponsors must:

  • Ensure that casual visitors are provided a safe environment while visiting LBNL
  • Provide clear instructions to casual visitors as to what they may do and where they may go 

Casual visitors must:

  • Follow instructions given by their sponsor
  • Obey all safety instructions given to them by any LBNL worker

Division Directors

  • Ensure that LBNL’s ES&H policies are observed within their divisions. They are also responsible for adhering to the principles of LBNL’s ISMS Management Plan.
  • Ensure that their division employee performance assessment process is used to hold each employee accountable for his or her respective ES&H obligations, responsibilities, and performance
  • Develop and implement a Division ISM Implementation Plan tailored to the work and hazards found in their divisions
  • Investigates the circumstances surrounding situations identified as imminent dangers and ensures that appropriate corrective actions and Lessons Learned are developed, implemented, and disseminated
  • Ensures dissemination of ES&H directives and information to their staff
  • Ensures that their divisions provide sufficient resources for division ES&H efforts
  • Advises the Directorate on ES&H policy implementation
  • Ensures that, within their divisions, clear roles and responsibilities for compliance with all applicable ES&H policies are defined
  • Establishes and implements a self-assessment program in accordance with LBNL policies
  • Establishes committees, as needed, to consider ES&H problems and recommend solutions to Safety Line Management
  • Ensures that their divisions’ research projects, work locations, and unique work activities are evaluated for potential hazards, and that safety controls are specified and implemented using the appropriate institutional hazard and work authorization systems (including, but not limited to CMS, AHD, the Laser Database)

Associate Laboratory Director for Operations / Chief Operating Officer
  • Is responsible for ES&H policy making and implementation and the daily operation of the ES&H program
  • Delegates responsibility for developing and publishing LBNL ES&H policy and developing and operating effective service and support programs to ensure that LBNL ES&H objectives and requirements are met
  • Delegates responsibility for stopping unsafe work activities in the absence of cognizant line management or work leads to the EHSS Division Director and his or her staff
  • Manages appeals for denials of variances on LBNL policy and requests for variances from DOE orders and regulations
  • Manages the Ethics Hotline employees-concerns reporting program

Laboratory Director

  • Has the ultimate responsibility for safety at LBNL and, in particular, for the establishment and administration of ES&H policies
  • Ensures that environment, health, and safety policies meet the applicable requirements of the U.S. Department of Energy (DOE)
  • Is responsible for the implementation of the ISM Plan
  • Carries out the ES&H policy under the terms of a contract between the University of California and DOE
  • Delegates, in his or her absence, overall ES&H responsibility to senior management in the normal chain of command
  • Delegates responsibility for ES&H policy making and implementation and daily operation of the ES&H program to the Associate Laboratory Director for Operations / Chief Operating Officer

EHSS Division Director
  • Develops, maintains, publishes, and supports the implementation of the LBNL ES&H policy and procedures as described in the ES&H Manual and other supporting documents
  • Develops and operates effective service, support, and compliance programs that provide line management with the information and support needed to work safely
  • With the Office of Contract Assurance (OCA), conducts ES&H assurance activities to ensure the effective implementation of ES&H policies and programs and the safe performance of work activities
  • Serves as the Electrical Safety Authority Having Jurisdiction (AHJ) who is responsible for ensuring compliance with electrical safety requirements that pertain to maintaining safe electrical work practices and workplace conditions under 29 CFR 1910, Subpart S; 29 CFR 1926, Subparts K and V; NFPA 70 and 70E; and other standards and codes for worker electrical safety
  • Serves as the Fire and Life Safety Code AHJ who is responsible for ensuring compliance with fire and life safety requirements found in 29 CFR 1910, Subparts E and L; 29 CFR 1926, Subpart F; and applicable NFPA standards. The DOE Berkeley Site Office retains authority to grant equivalencies, exemptions, or variances.
  • Stops unsafe work activities in the absence of cognizant line management or work leads
  • May ask that a request for a variance be studied by the Safety Advisory Committee (SAC) and its appropriate subcommittees
  • Approves or denies in writing requests for variances

 

Environment, Health, Safety, and Security (EHSS) Division

    • Provides professional and technical expertise, follow-up services, and integrated ES&H policy to the Laboratory's research and support programs to protect workers, the public, and the environment
    • 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
    • Supports and provides expertise directly to each Laboratory worker who seeks ES&H advice and help or who voices a concern

 

Office of Contractor Assurance
    • Manages the Division ES&H Self-Assessment Program
    • Provides support to the EHSS Division Director in ES&H technical assurance and DOE Contract 31, Appendix B Self-Assessments (see the Organizational Self-Assessment Policy in the RPM)
    • Supports the SAC in planning and conducting Peer Reviews
    • In consultation with the EHSS Division Director, analyzes the results of all self-assessment reports to improve the effectiveness of the technical and management aspects of Laboratory ES&H programs

Building Managers

  • Must ensure that the required building management functions are staffed properly by one or more qualified individuals and that building duties are carried out effectively
  • Must ensure the safety and emergency preparedness of their respective buildings
  • Must coordinate construction and maintenance activities within their buildings
  • Must oversee the space management of their respective buildings
  • Must act as the liaison with visitors and regulatory agencies visiting the respective buildings

 

Division Safety Coordinator (DSC)

  • Reports directly to their division directors or deputies and is responsible for administering the division’s ES&H program
  • Supports division line managers or work leads in the execution of their safety responsibilities and helps integrate safety into all work activities
  • Promotes a safety culture where everyone takes responsibility for his or her own safety and looks out for the safety of others
  • Serves as a point-of-contact for all division staff regarding the implementation and interpretation of ES&H policies, procedures, and programs
  • Upon request, provides Performance Management Plan (PMP) input to the division director on the safety performance of division staff
  • Serves as a member of the Division Safety Committee or equivalent organization
  • Helps develop and implement division-specific safety training if needed
  • Consults and coordinates with the EHSS Division and other resources as needed. The EHSS Division provides DSCs with technical guidance on the interpretation and application of ES&H policies, procedures, and programs.
  • Is familiar with division staff, facilities, work activities, and potential hazards
  • Serves as the division point-of-contact for the Environment, Safety & Health (ES&H) Standards Set for LBNL. Perform an ongoing review of work with division staff to identify hazards that may require inclusion of new standards in the ES&H Standards Set for LBNL.
  • Serves as member of, or chairs, the Division Safety Coordinators’ Committee, and attends this and other meetings as necessary
  • Coordinates and manages required safety documentation, which includes:
    • Division ISM Plan
    • ES&H Training
    • Supervisors’ Accident Analysis Reporting (SAAR) System (approval authority)
    • CATS (approval authority)
    • Walkaround inspection reports (Walkaround program manager)
    • Work authorizations
    • Chemical Management System (CMS)
    • Hazard Management System (HMS)
    • Occurrence Reporting and 10 CFR 851 reporting
    • Laser Inventory Database
    • Satellite Accumulation Area (SAA) / Waste Accumulation Area (WAA) records
    • Ergonomic records
  • Manages the safety-related corrective action process for the division. This includes ensuring that the appropriate CATS item is assigned to the correct individual, addressed and corrected as scheduled, and closed in the system.
  • As an assurance mechanism that supports line managers or work leads, assesses the adequacy of hazard controls through frequent inspections and monitoring of work activities as defined by the division’s ISM Plan, and facilitates the implementation of appropriate hazard controls
  • Serves as a conduit for feedback on how safety is implemented (including division point-of-contact for Lessons Learned)
  • Manages the annual division self-assessment by participating in the development of objectives, training and leading assessment teams, writing and coordinating the approval of the annual assessment report, and ensuring that findings are entered into CATS and closed on schedule
  • Serves as the division point-of-contact for ES&H audits originating outside the division
  • Supports the investigation of incidents, including injuries, accidents, and other safety and environmental incidents

EHSS ALD Liaisons

EHSS Division Liaisons are designated for each Associate Laboratory Directorate (ALD). They provide a convenient, single EHSS point of contact between a customer division and the EHSS Division and function as the troubleshooter and problem-resolution facilitator. This relationship does not preclude any LBNL employee from directly approaching an EHSS professional or subject matter expert to address a particular issue or need. The EHSS Division Liaison:

  • Serves as the designated EHSS point of contact to ALDs
  • Requests that the appropriate technical support be provided to implement and interpret LBNL ES&H policies
  • Knows the customer division’s work activities, personnel, and associated hazards, and assists in hazard identification and the development of controls appropriate to the hazard and work being performed
  • Provides consultation to allow for resolution and closeout of the customer division’s ES&H issues or concerns
  • Develops and/or leads cross-functional EHSS teams when necessary to assess complex operations and equipment
  • Participates in a customer division’s self-assessment as requested and other ES&H assessments as required
  • Serves as the Lead to coordinate an EHSS review of formal authorizations (e.g., Activity Hazard Documents (AHDs), which involves brokering the schedule of review dates with subject matter experts (SMEs) and the customer, and coordinating overall signoff
  • Participates in incident reviews of illnesses, injuries, accidents, and other safety and environmental incidents as requested by the incident investigation manager
  • In relation to assigned divisions or facilities, and in collaboration with his or her respective Division Safety Coordinators (DSCs), supports, as requested, the elements of the ES&H program. Examples include:
    • Division ISM Plan: Provides supporting technical information
    • Training and Job Hazards Analysis (JHA) records: Monitors training completion status, and helps ensure that technical assistance is provided in the development of division-specific training
    • Corrective Action Tracking System (CATS): Closes out ES&H-related items
    • Walkaround inspection reports: Provides technical interpretation
    • Chemical Management System (CMS): Provides technical guidance and coordinates support
    • Hazard Management System (HMS): Serves as technical resource and monitors status
    • Occurrence Reporting and 10 CFR 851 reporting: Serves as a technical resource
    • Laser Inventory Database: Serves as a technical resource, and monitors status
    • SAA/WAA issues: Assists with compliance
    • Ergonomic safety: Serves as a technical resource

Safety Advisory Committee (SAC)

The SAC is an interface between the research and operations divisions of Berkeley Lab, as well as between the ES&H technical programs (mainly in the EHSS Division) and assurance and assessment activities of the Office of Contractor Assurance (OCA), see RPM, Policy Area – Quality Assurance. To effectively execute this role, the SAC has direct access to the Laboratory Director and the Senior Management Team. Its responsibilities include:

    • Making recommendations to the EHSS Division Director on the development and implementation of ES&H policy, guidelines, codes, and regulatory interpretation
    • Conducting reviews of special safety problems and providing recommendations for possible solutions to the Laboratory Director, Associate Laboratory Director for Operations (ALDO) / Chief Operating Officer (COO), and the EHSS Division Director, as requested
    • Providing advice and counsel to the ALDO/COO by reviewing appeals from the Laboratory divisions when any division and the EHSS Division do not agree on the interpretation or application of criteria, rules, or procedures. Such advice and counsel may include options for a resolution.
    • The SAC has established six permanent subcommittees — traffic, electrical, emergency preparedness, laser, mechanical, and Division Safety Coordinators — to assist in the review of ES&H issues and concerns and the development of recommendations for institutional implementation. These subcommittees report to the SAC.
    • To properly execute its responsibilities under its charter, the SAC Chair may set up additional subcommittees made up of subject matter experts to address specific health and safety matters. Such subcommittees may become long-standing expert subcommittees or may be of short duration depending upon technical support requirements.
    • In addition, the SAC chair, in cooperation with OCA, is charged by the Laboratory Director with conducting the portion of institutional self-assessment known as Peer Review. These reviews are designed to ensure management systems consistent with ISM are in place in all Laboratory divisions and that these systems are leading to the effective implementation of the Laboratory's ES&H program. All members of the SAC are expected to serve on Peer Review subcommittees. Peer Review results are submitted directly to the Division Director.

Requirements Management Committee (RMC)

The RMC is an institutional committee chartered by the ALDO/COO. It reviews and oversees disposition of Requirements Review Cases related to requirements, Laboratory policies, and, on a case-by-case basis, Laboratory implementing documents. It is responsible for overseeing the Requirements Management process to ensure that:

  • Each requirements review case related to an institutional requirement is logged into the RM database
  • Each review case has at least one record of decision (ROD) and an analysis that supports the decision, both of which must be filed in the RM database
  • For those cases that result in change to policy or its related supporting documents, a ROD on whether an implementation plan is needed is filed in the RM database (along with the implementation plan, if deemed necessary)
  • Flow-down from requirement into implementing documents is demonstrated and managed

The RMC applies cross-functional knowledge on requirements matters and:

  • Assesses the Laboratory wide impacts of new or changed requirements and adopts a holistic response
  • Reviews and recommends best qualified team members to address requirements analyses, implementation mechanisms and plans, policy and procedure documents:
    • Such team members include Policy Area Managers, working group (WG) members, and subject matter experts (SME)
    • Ensures teams are cross-functionally represented
    • Recommends collaboration with other Laboratory standing committees whenever possible
      • Reviews and applies cross-functional knowledge and judgment on WG, PAM, SME work products (analyses, implementation plans, policies):
        • Ensures analyses and plans lead to practical implementation (taking into consideration cost, breadth of impact, simplicity, etc.)
        • Ensures risk analysis and problem solving techniques and best practices have been applied
  • Advises responsible Senior Line Manager on WG, PAM, and SME work products
  • Drives for process simplicity. Seeks resolution and decision-making at the lowest levels possible. Reviews processes at least annually and makes improvements for efficiency and effectiveness.
  • Reviews communications plan to ensure effectiveness and thoroughness
  • Champions RM and institutional document management processes

OCA Requirements Management Program Manager (RM PM)
  • Manages the Laboratory’s requirements management and institutional document management processes. Is the main driver and champion of these processes. Has author, review, and recommendation responsibilities for quality and completeness of RM process and institutional document management process documentation.
  • Serves as the Laboratory’s contact point on requirements and institutional document management-related matters. Is the focal point for receipt of new or modified requirements accepted into Contract 31 or mandated by applicable federal, state, or local laws, standards or regulations. Notifies Requirements Management Committee (RMC) of such matters.
  • Is a member of the RMC
  • Leads RMC and other cross-functional teams in solving problems using risk based-analysis techniques
  • Works with RMC members and the RMC chair as required to meet the RMC’s and RMC members’ responsibilities within the framework of the RM process
  • Coordinates inputs from the RMC members, the working groups, and the responsible Senior Line Manager. Presents to RMC for discussion and resolution.
  • Applies broad knowledge of operations functions to:
    • Assess the quality, accuracy, efficiency and effectiveness of recommendations generated by the RMC and the working groups
    • Seek resolution of issues or conflicts related to Laboratory policy or document matters at the lowest levels possible
  • Oversees management of Laboratory’s policy manual
  • Maintains the Requirements Management (RM) database for tracking requirements, their associated policy areas (PA), owners, records of implementing mechanisms, and their flow-down to implementing documents
  • Maintains accuracy and currency of the RM tracking system
  •  Has review and approval responsibility for quality and completeness of requirement, policy, and document metadata.

 

EHSS Division Requirements Management Program Coordinator
  • Serves as editor of the LBNL Environment, Safety & Health Manual
  • Represents the EHSS Division on the institutional Requirements Management Committee
  • Is nominated by the EHSS Division Director and chartered for appointment to the RMC by ALDO/COO for a three-year term
  • Must have and apply experience and breadth of knowledge of requirements, policy, and specific functional operation in his or her respective areas of expertise
  • Must have and apply good working knowledge and experience of general Laboratory operations
  • Must be trained on LBNL RM and document management processes
  • Is the communications conduit between the EHSS Division and RMC for Division policy-related efforts, whether initiated by the Division or by other functions
  • Has authority (as delegated by his or her Senior Line Manager) to accept RMC actions or assignments on behalf of his or her respective functional area
  • Communicates actions and assignments to respective Senior Line Manager on regular basis
  • Must consistently attend and participate at RMC meetings or find an alternate if absence is necessary
  • Applies skills and experience in risk analysis and problem solving techniques
  • May be assigned to other RM roles (working group, Policy Area Manager, functional document control administration). [Note: assignment to multiple roles is not recommended, though in the short term is recognized as necessary.]

 

1.8 Definitions

NOTE: Some functions and definitions overlap, depending on the specific situation.

Term

Definition

Affiliate

Non-Laboratory employees engaged in on-site Laboratory activities. Affiliates are subject to training in safety and other subjects. They are also issued a Berkeley Lab identification badge. Affiliates may receive system accounts, research access to facilities, and a per diem allowance for housing and living expenses. Examples: facility users, scientific collaborators, students.

area

An entity that is separately listed in the LBNL Space Database maintained by Facilities Division and assigned to a division for programmatic use. Areas may be further described by their functional use (e.g., laboratories, shops, offices, conference rooms).

Area Safety Leader

The individual assigned by the division controlling the technical area to oversee coordination of safety issues within the area

EHSS

 Environment, Health, Safety, Security Division

employee

An individual who is hired by LBNL to provide services on a regular basis in exchange for compensation

ES&H

Environment, Safety & Health; the discipline, interchangeable with “safety”

ES&H Coordinating Committee

The ES&H Coordinating Committee is formed when a significance level A or B program or project is ready for the LBNL Director review. The purpose of the ES&H Coordinating Committee is to advise the LBNL of the readiness and effects of implementing the program. The EHSS Division Director identifies and contacts the most affected division directors and other senior LBNL management personnel to serve on the Committee. The SME provides a briefing to the members of the Committee to ensure that they are ready to advise the LBNL Director on the new policy or program.

faculty scientist

Faculty scientists hold dual appointments at LBNL and an academic institution (usually UC Berkeley). When they perform work at or for LBNL, they are Staff members. Work includes being a HEERA supervisor, matrix supervisor, or work lead for one or more workers. See Supervisory Employees in the RPM Glossary.

HEERA

 Higher Education Employer-Employee Relations

host

 A host provides oversight to users at user facilities. A host has ultimate responsibility for safety at an assigned scientific station and ensures that all users receive proper training and oversight. A host may be a matrix supervisor, HEERA supervisor, or a work lead.

ISM

Integrated Safety Management

JHA

Job Hazards Analysis

key personnel

This is a Contract 31 term that includes the Senior Management Group and LBNL Counsel, Director of EHSS Division, Director of the Facilities Division, and the Director of the Office of Institutional Assurance.

Berkeley Lab, the Laboratory, LBNL

Lawrence Berkeley National Laboratory

Line Manager, Line Management

Managers are individuals responsible for formulating and administering policies and programs of LBNL; collectively, they are the Line Management. Typically, this includes some level of responsibility for staffing, performance review, work direction and evaluation, and/or finance. The formal “chain of command” management structure at LBNL starts at the top with LBNL Director and ends with Supervisors or Matrix Supervisors. Examples include, but are not limited to program heads, group leaders, department heads, division deputies, superintendents, administrators, supervisors.

Matrix Supervisor

A Matrix Supervisor is responsible for providing day-to-day technical direction and oversight, including responsibilities for proper execution of ES&H activities of employees and affiliates within their purview. A Matrix Supervisor is required to be HEERA-designated and can be in a division separate from the employee’s home division. The Matrix Supervisor can act as the host and point of contact on behalf of the division for affiliates and visitors of LBNL. A Matrix Supervisor partners with the HEERA Supervisor on matters of staffing, performance review, work direction, and evaluation.

mentor

A mentor is a work lead for a student. Mentors do not need to be line managers, HEERA-designated supervisors, or LBNL employees.

OJT

 On-the-job training

Principal Investigator (PI)

 Most U.S. Federal and State agencies that support scientific and technical research use the interchangeable titles “Principal Investigator” or “project director” for the scientist or researcher responsible for the technical leadership and administrative accountability of a project. A PI is ultimately responsible for the administration, direction, and management of the project and for its results. Often, funding for the project is also the PI’s responsibility. The designation is specific to a single contract and terminates with the closing of that project. The designation is thus of a different character than for such ongoing leadership positions as division director, department head, and group leader. A PI is always part of line management, and from a safety line management perspective, the PI is no different from any other staff. A PI’s role may include being a HEERA Supervisor or Matrix Supervisor.

RPM

LBNL Requirements and Policy Manual, PUB-201

safety

Safety is used generically to cover all aspects of Environment, Safety & Health (ES&H) including regulatory requirements and is interchangeable with ES&H.

Safety Line Management

The unbroken linear safety management chain linking the LBNL Director to each worker. Above the lowest organizational unit in each division, the chain is defined by the succession of direct reports that establish job assignments, appraise performance, and determine salaries. Below this level, the chain can include workers at any level and may include non-management work leads who guide the day-to-day activities of one or more workers.

Senior Management

Senior Management includes the Senior Management Group plus the division directors, Chief Human Resources Officer, Chief Procurement Officer, Laboratory Counsel, Internal Audit Manager, Laboratory Security Manager, and Public Affairs Manager. This group is also known as “Upper Management.”

Senior Management Group (SMG)

The Senior Management Group includes the LBNL Director, deputy directors, associate laboratory directors, and the Chief Financial Officer.

staff

 Anyone who works at LBNL and has been issued a current LBNL badge

student/student intern

Students or student interns often work at LBNL in different positions. Students can be employees or affiliates. Students are part of the Safety Line Management, no matter what their positions. Types of students employed at LBNL are:

  • Interns: A special class of Students who work at the Berkeley Lab for education purposes
  • Graduate Student Research Assistants (GSRAs): Registered graduate students of the University of California (UC)
  • Student Assistants: Hired for variable-time or fixed-percent-time work schedules. These students can be high school, undergraduate, or graduate students from any institution.

subcontractor

An individual worker or company hired by LBNL to perform a specific task as part of an overall project

subject matter expert (SME)

An SME has been designated by the group leader to provide technical direction to the LBNL population in a specific area. The SME is the focal point and responsible for all technical questions in that area.

supervisor (HEERA)

Supervisory employees are defined by the Higher Education Employer-Employee Relations Act (HEERA) as "any individual, regardless of the job description or title, having authority in the interest of the employer to hire, transfer, suspend, lay off, recall, promote, discharge, assign, reward or discipline other employees, or responsibility to direct them, or to adjust their grievances, or to effectively recommend such action, if, in connection with the foregoing, the exercise of such authority is not of a merely routine or clerical nature, but requires the use of independent judgment. Employees whose duties are substantially similar to those of their subordinates shall not be considered to be supervisory employees."

Technical Area

Technical areas generally include laboratories, shops, workrooms, and similar areas. Offices, conference rooms, food preparation, and consumption areas such as the cafeteria, kitchenettes, and break rooms are generally not technical areas.

user

 A subset of employees or affiliates who come to LBNL as users at one or more of its various user facilities. They may be LBNL employees from other divisions than the user facility or under a completely different management structure (other UC, DOE, or private/public enterprises). Users bring their own scientific work and are responsible for its execution. While here, they are responsible for understanding and implementing LBNL safety requirements. They work under the auspices of an LBNL host.

work

 Work is defined broadly to include all LBNL activities undertaken by staff independent of sponsor, program, or location of activities.

work lead

 A work lead is anyone who directs, trains, or oversees the work and activities of one or more workers. Work leads provide instruction on working safely and the precautions necessary to use equipment and facilities safely and effectively. Work leads do not need to be line managers, HEERA-designated supervisors, or LBNL employees.

worker

 Defined broadly to include anyone who performs work at or for LBNL

RMC

Requirements Management Committee: an institutional committee

Requirements review case

An instance or a question related to a requirement that has been logged into the Requirements Management database for disposition by the RM Committee

1.9 Work Processes

Work Process A. Developing or Revising ES&H Policies and Programs

The EHSS Division follows the LBNL Requirements Management Process, document number 04.04.001.003; Developing, Reviewing and Approving Non-Policy Institutional Documents Procedure, document number 10.06.001.101; and Developing, Reviewing and Approving Institutional Policy Documents Procedure, document number 10.06.001.102. This includes steps of identifying the Subject Matter Expert (SME) for a particular requirement, analyzing meanings and impacts of a new or changed requirement, and then setting forth applicable implementation mechanisms for the requirement to ensure flow-down to the workforce. Additionally, user input and management’s review and approval are key elements of the process. Implementing mechanisms include, but are not limited to, documents, training programs, communication, and definitions of roles and responsibilities. All institutional documents are subject to the Laboratory’s Managing Institutional Documents Process, document number 10.06.001.001 and Document Management Policy, document number 10.06.001.000. The Document Management Process imposes a “graded” rating for documents: major, minor, editorial. All major changes to institutional policies must be reviewed by the Laboratory Requirements Management Committee (RMC). Minor changes to institutional policies must be reviewed by the EHSS Requirements Management (RM) Representative. However, if cross-functional actions are needed, the EHSS RM Representative can recommend an RMC review. Additionally, the EHSS RM Representative must review major and minor changes to institutional non-policy documents and can recommend an RMC review if cross-functional activity is involved.

EHSS SMEs and their managers follow the steps below for developing or revising ES&H policies and programs:

  1. SME receives a new or modified ES&H requirements, such as a:
    1. Regulation
    2. DOE order
    3. Contractual requirement
  2. SME prepares a preliminary analysis comparing the new requirements to existing requirements (gap analysis).
  3. SME analyzes the proposed new or changed requirement and policy/program changes and determines the significance rating using the LBNL Analyzing Requirements and Determining Significance Rating from Impact and Risk Analysis Procedure, document number 04.04.001.101.
  4. Manager or SME enters the proposed changes into the Requirements Change Database. For assistance with this step, contact the EHSS RM Representative.
  5. EHSS RM Representative reviews the proposed change and significance rating to ensure they are properly aligned.
  6. Based on the significance rating, the SME and department manager:
    1. Determine whether a working group is required 
    2. Draft an Implementation Plan using guidance from Developing, Reviewing, Approving an Implementation Plan, document number 04.04.001.102 and the Implementation Plan Form, document number 04.04.001.202
  7. EHSS RM Representative reviews the Implementation Plan to ensure it includes applicable program elements.
  8. SME documents the plan on the Implementation Plan Form. Applicable elements of an Implementation Plan are based on the significance rating and may include:
    1. Review and refinement of the gap analysis
    2. User input/establishing a working group
    3. Benchmarking
    4. Alpha, beta, or pilot testing
    5. Cost/benefit analysis
    6. Alternative and preferred approach analysis
    7. Communication plan
  9. SME, and working group if appropriate, drafts the new or changed policy and/or program.
  10. SME presents the preferred approach supported by the Implementation Plan to the approving manager[1] and, at management’s discretion, the Laboratory Counsel or the Safety Advisory Committee (SAC) or subcommittee.
  11. SME, and working group if appropriate, finalizes the new or changed policy, program, and/or procedure based on the input of the approving manager, line management, the Laboratory Counsel, SAC, RMC (for policies), and/or subcommittee input.
  12. Approving manager approves the new or changed policy and/or program.
  13. SME implements the new or changed policy and/or program following the Implementation Plan, and communicates the new requirements to affected populations.
  14. SME submits all documentation to be filed to the EHSS RM Representative.
  15. After the new or changed policy and/or program is implemented, the SME evaluates it through the Technical Assurance Program and, as necessary, gathers user feedback to identify potential improvements.

Process for Urgent Compensatory Situations

Occasionally, there may be a need to quickly implement a requirement- or policy-related change. Such "stop work" or "stop practice" mandates must have at least EHSS Division Director authority. These high-urgency situations are still subject to completion of the applicable elements of the Requirements Management process. However, the Requirements Management elements may be worked on in parallel or in a different sequence. EHSS, through assigned SMEs, is expected to drive completion. Because the matter is urgent, emphasis on communication is likely needed. The following is an example of re-ordering the RM process for a highly urgent situation:

Work Process A Footnote

1. Approving manager may be EHSS Division Line Management, the Chief Operating Officer, or the Laboratory Director depending on the significance rating.

Work Process B. The Use of “Shall,” “Must,” “Should,” and “May” in EHSS Documents

EHSS uses “shall,” “must,” “should,” and “may” statements in the following manner to convey requirements and best practices:

1.10 Source Requirements Documents

1.11 Reference Documents

Other References and Best Management Practices

Document Number

Title

04.04.001.000

Requirements Management Policy

04.04.001.003

LBNL Requirements Management Process Description

04.04.001.101

Procedure: Analyzing Requirements and Determining Risks and Impacts

04.04.001.102

Procedure: Developing, Reviewing, Approving an Implementation Plan

04.04.001.103

Procedure: Parsing Requirements

04.04.001.202

Form: LBNL Implementation Plan Template

04.04.001.201

Form: Analyzing Requirements and Determining Risks and Impacts

04.04.001.203

Form: Parsing Requirements

10.06.001.102

Procedure: Developing , Reviewing, Approving Institutional Policy Documents

 

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