Chapter 1
GENERAL POLICY AND RESPONSIBILITIES

Approved by Joe Dionne
Revised 10/12

Contents

1.1 Policy
1.2 Scope
1.3 Applicablity
1.4 Roles and Responsibilities
1.5 Definitions
1.6 Required Work Processes

Work Process A. Work Process for Developing or Revising ES&H Policies and Programs
Work Process B. Reporting Employees’ ES&H Concerns
Work Process C. Occupational Injury and Illness Record Keeping and Reporting
Work Process D. Requesting a Variance from the LBNL Safety Policy

1.7 References

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1.1 Policy

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. LBNL seeks continuous improvement and sustained excellence in the quality of all Environment, Safety, and Health (ES&H) programs.

To achieve these goals, LBNL has adopted the seven guiding principles and five core functions of the Integrated Safety Management System (ISMS) in Department of Energy (DOE) DEAR Clause 970.5204-2. They are part of LBNL’s detailed safety policies and procedures.

It is also the policy of LBNL that all new ES&H programs or major revisions comply with the ES&H Policy and Requirements Management System methodology to provide for effective program implementation.

1.2 Scope

The ES&H Policy and Requirements Management System is the methodology used to initiate, develop, and approve LBNL ES&H programs and policies. This system includes requirements analysis, implementation method development, the proactive involvement of affected users, and formal management approval of the program. The goal of this system is to develop or revise ES&H programs so that they comply with all requirements and provide for effective program implementation.

This system is initiated when a new or revised ES&H requirement or regulatory document is received by LBNL, or the need for a significant revision of an existing ES&H program is identified. New requirements are normally transmitted to LBNL by official correspondence, but may also be identified through other means. The need for significant revisions of existing ES&H programs can come from many sources, such as:

1. A DOE or another assessment finding;
2. A DOE or other contractual requirement (e.g., DOE/LBNL Contract modification);
3. New regulatory (e.g., OSHA) or consensus standards (e.g., ANSI);
4. Experience at LBNL indicating a change is needed;
5. Lessons Learned: Is the program change based on an incident? If so, what lessons were learned from those incidents? Do these necessitate a change to LBNL requirements?

1.3 Applicability

This requirement applies to all ES&H programs including programs referenced in PUB-3000 but implemented by other documents or systems. Affected staff members participate in the development or revision of ES&H programs to ensure the goals of compliance and effectiveness are met.

Keys to implementing this policy are the following core safety values:

• The institution demonstrates a strong commitment to safety by integrating safety into all facets of our work.
• Managers and supervisors are actively involved and demonstrate leadership in performing work safely.
• Individuals take ownership for safety and continuously strive to improve.
• Individuals demonstrate an awareness and concern for the safety of others.

1.4 Roles and Responsibilities

LBNL employees, contractors, and casual and participating visitors at LBNL or its off-site locations are required to be familiar with and observe LBNL safety (Work Smart) standards. LBNL articulates this policy through its Integrated Environment, Health and Safety Management Plan (PUB-3140, ISMS Management Plan). These standards are designed to protect people from injury and illness and to protect property and the environment from damage or loss or degradation due to accidents or other causes. Like research integrity, scientific discipline, and fiscal responsibility, safety is a product of culture and sound management. To achieve a truly integrated systems approach to doing work safely, ES&H programs and activities will need to be an integral part of work from initial planning through final execution.
The purpose of pursuing Integrated Safety Management (ISM) is to:

• consolidate progress in ES&H efforts and initiatives,
• establish clear lines of authority and accountability, and
• fulfill contractual obligations by integrating safety management practices with other institutional management practices.

Fundamental to the attainment of ISM are personal commitment and accountability, mutual trust, open communication, continuous improvement, worker involvement, and full participation of all interested parties. To achieve ISM, LBNL has adopted the following seven guiding principles, which are discussed below and reflected in LBNL’s detailed policies and procedures. In addition, principal investigators, managers, supervisors, and work leads are expected to incorporate these principles into the management of their work activities. While these principles apply to all work, the exact implementation of these principles is flexible and can be tailored to the complexity of the work and the severity of the hazards.

1.4.1 Line Management Authority and Accountability for ES&H

Line management and work leads are accountable for the protection of the public, the 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.

ES&H vision and goals are articulated by identifying specific targets, developing and implementing plans, securing resources, and operating 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 EH&S Division provides primary technical support through its EH&S Liaisons.

1.4.2 Safety Line Management and Individual ES&H Roles and Responsibilities

Every individual (employee and nonemployee alike) performing work at or for LBNL is accountable for:

• Working safely and protecting his or her own health
• Protecting the public, other workers, and the environment from known hazards
• Integrating ES&H into all work activities, and
• Active and rigorous communication of ES&H and Integrated Safety Management issues

Responsibilities for safety are shared by all. The following ES&H considerations must be part of all work processes: define scope of work, identify hazards, determine applicable standards and controls to be implemented, define skills required by workers to work safely and in an environmentally sound manner, and ensure all of these ES&H elements are in place before work is authorized to proceed. In addition, safety must be a primary consideration in all endeavors including non-job-specific activities such as walking, driving, or riding a bicycle.
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 organizational unit, the chain may include nonmanagement work leads and area safety leaders  who guide the day-to-day activities of one or more workers.

Supervisors and managers are part of the formal management chain, and they are responsible for adherence to all EH&S policies and safe work practices. Work leads and area safety leaders derive authority from their managers and/or supervisors to ensure that day-to-day work, operations, and activities assigned to them are conducted safely and within established work authorizations.

ES&H Roles and Responsibilities

Every person 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, functional, and individual responsibilities for environment, safety, and health at LBNL are defined below.

1.4.2.1 Casual Visitor and Sponsor Roles and Responsibilities
Sponsors must:

• Ensure that casual visitors are provided a safe environment while visiting LBNL, and
• 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, and
• Obey all safety instructions given to them by any LBNL worker.

1.4.2.2 Employee and Participating Guest Roles and Responsibilities

All employees and participating guests must:

Protect themselves, other workers, the public, and the environment.

• Conduct 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 Stopping Unsafe Work Policy).

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(s) 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 PUB-3000), DOE ES&H publications, OSHA Form 300 (a record-keeping log), and exposure assessments and investigation reports for incidents in which they were 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.

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, EH&S 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.

1.4.2.3 Matrixed Employees

An employee is considered a matrixed employee if the supervisor of the employee has assigned the employee to another group, department, or division outside the employee’s home division. The matrixed employee typically receives daily directionfrom the host group, department, or division. The matrixed employee's home supervisor or home division remains responsible for performance assessment and the number, duration, and types of assignments.

The host organization typically provides physical space and the tools/equipment/infrastructure required to achieve the priorities and objectives of the host organization.

The employee’s supervisor or work lead from the home division retains all health and safety responsibilities pertaining to matrixed employees, except where some of the responsibilities have been transferred to the host division through a formal Memorandum of Understanding (MOU) between the two organizations.

In situations where an employee is assigned to provide support to more than one host organization, the responsibility for employee health and safety remains with the home supervisor or work lead and cannot be transferred by an MOU.

The following table outlines the default configuration of authority and responsibility for both the home and host organization. As needed, the default configuration can provide a basis for the home and host division to negotiate and tailor a specific MOU to best address local conditions and requirements:

Whenever an MOU is established, it remains the responsibility of the home supervisor or work lead to ensure that the MOU is appropriately implemented, fully distributed, and properly communicated.

In the absence of an MOU, the home supervisor or work lead remains fully responsible and accountable for all aspects of the subordinate’s workplace safety and health.

1.4.2.4 Supervisor and Manager Roles and Responsibilities

In addition to their individual responsibilities, supervisors and managers 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.

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 annually and/or whenever the scope of work or hazards changes.
• Ensure that before work begins, the required controls and formal training are completed and implemented.
• Before allowing work to proceed, verify that worker competence and on-the-job training are commensurate with work assignments.
• Monitor work activities on a regular basis and take action to enforce safety rules.
• Ensure that all materials and equipment—regardless of origin—applied in performance of LBNL work are used, maintained, and serviced in a manner that ensures the protection of the environment, safety, and health.

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 accidents, injuries, near-hits, and significant mishaps in accordance with the requirements of PUB-3000, Chapter 5 (Occupational Safety),  Section 5.1 (Incident Reviewing and Reporting). Ensure that their staff members report occupational injuries and illnesses to Health Services at the earliest opportunity.
• Investigate all 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/or recommendations for ES&H improvements.
• Inform workers of their safety line management chain.
• 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.

Recognize Language and Cultural Barriers.

Managers and supervisors 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. Line management must develop a tailored approach to ensure that the individual understands ES&H hazards and his or her responsibilities related to performing work safely at LBNL.

Additional Supervisor and Manager Responsibilities When Using Work Leads

In addition to the responsibilities described above, supervisors and managers must also:

• Determine the need for using work leads under their areas of supervision.
• If needed, assign workers to work leads with the cognizance of the work leads and the permission of the work leads’ supervisors.
• 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) for their work leads to fulfill all assigned safety responsibilities.  

1.4.2.5 Work Leads

Supervisors and managers do not always directly oversee the work of their direct reports. In these situations, supervisors and managers may delegate select safety responsibilities identified above to one or more work leads. A supervisor or manager cannot delegate responsibilities to a work lead for work activities for which that person has no oversight or knowledge.

1.4.2.6 Division Director Roles and Responsibilities

Division directors should:

• Ensure that LBNL’s ES&H policies are being 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.
• Investigate the circumstances surrounding situations identified as imminent dangers, and ensure that appropriate corrective actions and Lessons Learned are developed, implemented, and disseminated.
• Ensure dissemination of ES&H directives and information to their staff.
• Ensure that their divisions provide sufficient resources for division ES&H efforts.
• Advise the Directorate on ES&H policy implementation.
• Ensure that, within their divisions, clear roles and responsibilities for compliance with all applicable ES&H policies are defined.
• Establish and implement a self-assessment program in accordance with LBNL policies.
• Establish committees, as needed, to consider ES&H problems and recommend solutions to safety line management.
• Ensure 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 LBNL Hazard Management Systems (HMS) and other applicable systems.

1.4.2.7 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 EH&S 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 (see Work Process D, Requesting a Variance from LBNL Safety Policy)
• Manages the EthicsLine employees-concerns reporting program

1.4.2.8 Laboratory Director

• Has the ultimate responsibility for safety at LBNL and, in particular, for the establishment and administration of ES&H policies  
• Assures 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 LBNL ISMS Management 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

1.4.2.9 EH&S Division Director

• Develops, maintains, publishes, and supports the implementation of the LBNL ES&H policy and procedures as described in the Health and Safety Manual (PUB-3000) and other supporting documents
• Develops and operates effective service, support, and compliance programs that provide line management 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 (see Work Process D, Requesting a Variance from LBNL Safety Policy)
• Approves or denies in writing requests for variances (see Work Process D, Requesting a Variance from LBNL Safety Policy)

1.4.2.10 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.

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.

1.4.2.11 Building Managers

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.
• Ensure the safety and emergency preparedness of their respective buildings.
• Coordinate construction and maintenance activities.
• Oversee the space management of their respective buildings.
• Act as the liaison with visitors and regulatory agencies visiting the respective buildings.

1.4.2.12 Division Safety Coordinators (DSCs)

Division safety coordinators (DSCs) must:

• Report directly to their division directors or deputies, and be responsible for administering the division’s ES&H program.
• Support division line managers or work leads in the execution of their safety responsibilities. Help integrate safety into all work activities.
• Promote a safety culture where everyone takes responsibility for his or her own safety and looks out for the safety of others.
• Serve as a point-of-contact for all division staff regarding the implementation and interpretation of ES&H policies, procedures, and programs.
• Upon request, provide Performance Review and Development (PRD) input to the division director on the safety performance of division staff.
• Serve as a member of the Division Safety Committee or equivalent organization
• Help develop and implement division-specific safety training if needed.
• Consult and coordinate with the EH&S Division and other resources as needed. The EH&S Division provides DSCs with technical guidance on the interpretation and application of ES&H policies, procedures, and programs.
• Be familiar with division staff, facilities, work activities, and potential hazards.
• Serve as the division point-of-contact for the Environment, Safety, and 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.
• Serve as members of (or chairs) of the Division Safety Coordinators’ Committee, and attend this and other meetings as necessary.
• Coordinate and manage required safety documentation, which includes:
• Division ISM Plan 
• 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 / Waste Accumulation Area (SAA / WAA)  records
• Ergonomic records
• Manage the 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, assess the adequacy of hazard controls through frequent inspections and monitoring of work activities as defined by the division’s ISM Plan. Facilitate the implementation of appropriate hazard controls.
• Serve as a conduit for feedback on how safety is being implemented (including division point-of-contact for Lessons Learned).
• Manage 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.
• Serve as the division point-of-contact for ES&H audits originating outside the division.
• Support the investigation of incidents, including injuries, accidents, and other safety and environmental incidents.

1.4.2.13 EH&S Division Liaisons

EH&S Division Liaison Duties

EH&S Division Liaisons are designated for each assigned LBNL division or facility; they provide a convenient, single EH&S point of contact between a customer division (typically via the Division Safety Coordinator and the EH&S Division (EHSD), and function as the troubleshooter and problem-resolution facilitator. This relationship does not preclude any LBNL employee from directly approaching an EH&S professional/subject matter expert to address a particular issue or need. The EH&S Division Liaison:

• Serves as the designated point of contact to assigned divisions or LBNL facilities.
• 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 fosters a cross-functional team approach when necessary to assess identified hazards and applicable control measures, complex operations, and equipment.
• Participates in a customer division’s self-assessment as requested, and other ES&H assessments as required.
• For first-aid cases, uses the Investigator’s Report form to enter SAAR codes; submits the completed Investigator’s Report for OSHA-recordable cases.
• Serves as the Review Team Lead to coordinate an EH&S review of Activity Hazard Documents (AHDs); becomes familiar with, and provides guidance and coordinates support for, all customer divisions’ formal work authorizations as necessary.
• Participates in incident reviews of illnesses, injuries, accidents, and other safety and environmental incidents, and assists with coordinating EHSD subject matter experts.
• For Facilities Division project reviews, coordinates EHSD Team reviews of hazards and controls; signs off on final plans, if required.
• In relation to assigned divisions or facilities, and in collaboration with his/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.

1.4.2.14 EH&S Division Requirements Management Representative

The EH&S Division Requirements Management (RM) Representative manages the ES&H Manual by assisting SMEs/program managers in navigating the document management/change process, verifying significance ratings, ensuring proper approvals are obtained, and reviewing communications and implementation plans.  The RM Representative also coordinates and communicates EH&S Contract 31 modifications to EH&S Division managers and SMEs.  The RM Representative serves on the LBNL institutional Requirements Management Committee (RMC) and:

• Is the communications conduit between the Division and RMC for Division policy-related efforts, whether initiated by the Division or by other functions
• Has authority (as delegated by his/her senior line manager) to accept RMC actions or assignments on behalf of EH&S
• Communicates actions and/or assignments to respective senior line managers on a regular basis
• Reviews and oversees the disposition of Requirements Review Cases related to requirements, EH&S policies, and EH&S implementing documents on a case-by-case basis
• Oversees the EH&S RM process and ensures that each Requirements Review Case:
• Is logged into the RM database
• Has at least one record of decision and an analysis that supports the decision
• May determine the necessity of an implementation plan
• Demonstrates the flow-down of a requirement into an implementing document by using the RM Database to track decision-making

1.4.3 Employee Involvement and Worker Rights

Worker involvement in safety and health is essential to the success of LBNL’s ISMS. Workers are encouraged to identify safety and health problems and to develop solutions, and their involvement is actively sought throughout the work review, authorization, and execution process. Line management and work leads must ensure that workers are given the opportunity to participate in the analysis of hazards, and the determination of appropriate work controls for work activities.

Worker involvement is promoted through:

• Participation in divisional safety committees and Safety Review Committee subcommittees (such as Traffic and Pedestrian Safety Subcommittees)
• Participation in accident review teams
• “All hands” safety meetings
• Safety Spot Awards program
• EH&S online suggestion box and e-mail safety concern programs
• Directorate-level feedback programs
• LBNL newsletters and Web sites
• Participation in divisional self-assessments
• Participation in the Safety Walkaround Program

Workers have the right to participate in activities related to the ES&H Program on official time, including those activities listed above.

Workers have the right of access to:

• DOE safety and health publications
• Documents describing the LBNL Worker Safety and Health Program, such as the Worker Safety & Health Program (WSHP) and the ISMS
• Safety and health standards, controls, and procedures applicable to LBNL as identified in such documents as the Health and Safety Manual (PUB-3000) and the Chemical Hygiene Safety Plan
• Information related to the ES&H Program and to the performance measurement of safety and health
• The “Worker Protection for DOE Contractor Employees” poster that informs workers of their rights and responsibilities
• Results of inspections and accident investigations
• Limited information on any record-keeping log (OSHA Form 300) with access subject to Freedom of Information Act requirements and restrictions
• DOE Form 5484.3 (the DOE equivalent of OSHA Form 301, Injury and Illness Incident Report) that contains the employee’s name as the injured or ill worker

Workers have the right to observe exposure monitoring or measurement of hazardous agents, and to be provided with the results of their own exposure monitoring. When personnel exposure monitoring is conducted on individuals, the monitored employee and their supervisor receive a copy of the exposure assessment (see Chapter 4 (Industrial Hygiene)).

Workers shall be notified when monitoring results indicate they have been overexposed to hazardous materials. Written notification of monitoring results is provided by the industrial hygienist conducting the exposure monitoring to the employee (and employee's supervisor) in accordance with the specific OSHA requirements for that substance. Where no criterion exists, monitoring results will be provided within 15 days of receiving analytical results from the laboratory performing the analyses (see Chapter 4 (Industrial Hygiene)).

Workers have the right to a representative authorized by workers to accompany the DOE Director or his or her authorized representative during the physical inspection of the workplace for the purpose of aiding the inspection. When no authorized worker representative is available, the DOE Director or authorized representative must consult, as appropriate, with workers on matters of worker safety and health.

1.4.4 Competence Commensurate with Responsibilities

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 1.3; and the Regulations and Procedures Manual (RPM), Chapter 2. However, LBNL supervisors or work leads shall ensure that all employees, contractors, visitors, and guests possess sufficient knowledge, skills, and experience to perform work safely. As a minimum, all employees, contractors, visitors, and guests must:

• Be knowledgeable of the hazards associated with a work activity and the appropriate controls in place to minimize the hazard.
• If necessary, know how to operate 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, visitors, and guests must not perform work unless they have satisfied the training, experience, and/or certification requirements identified by the supervisor or work lead.
• Must 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 should be reported to the immediate supervisor, work lead, or LBNL contact person as soon as possible. (If failure causes imminent danger, then the Stopping Unsafe Work Policy must be followed.)
• Be familiar with all sections of PUB-3000 that relate to the work being performed.

1.4.5 Balanced Priorities

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) is commenced, a work process analysis of hazards to workers, the public, and the environment is to be conducted in accordance with Chapter 6 (Safe Work Authorizations) of PUB-3000. The objective is to ensure that hazard controls support and advance research and all other work activities and not impede them.

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, and Safety Division Director for their review. Both the Facilities and EH&S 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.

1.4.6 Identification of ES&H Standards and Requirements

All new work activities or changes to existing work (which introduce new hazards or increase the hazard level) need to be reviewed to analyze hazards, identify safety standards/requirements, and establish appropriate controls. Chapter 6 (Safe Work Authorizations) of PUB-3000 details the LBNL process for identifying hazards and determining requirements. EH&S Division Liaisons are available to assist in identifying hazards, determining the applicable standards, and developing appropriate cost-effective controls that will meet LBNL ES&H policies. EH&S Division Liaisons need to be consulted if the scope of hazards exceeds the safety envelope established by LBNL ES&H standards.

1.4.7 Establishment of Hazard Controls

To prevent and mitigate hazards, administrative and engineering controls should 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.

The tailoring process should include:

• identifying controls for specific hazards
• establishing boundaries for safe operation
• implementing and maintaining controls.

LBNL ES&H professionals are available to assist in identifying the appropriate level of hazard control.

Examples of performing work within safety controls include:

• Floor Loading Protection. The rated floor load approved by the building official must not be exceeded. The loads approved by the Facilities Division in every building must be marked on plates made from an approved design. The plates must be conspicuously placed in the appropriate area.
• Access to LBNL. Access to LBNL and its facilities is controlled. Casual and participating visitors’ access is set forth in the Regulations and Procedure, Section 1.06 (LBNL Site Access). Children aged 18 and under are not allowed at LBNL except when part of a management-approved tour or accompanied by an employee or parent. Children must not be left unattended. Pets may not be brought to LBNL. Seeing-eye dogs may be brought on site by their owners.
• Housekeeping. All workplaces, passageways, storerooms, and service rooms must be kept clean, dry, orderly, and sanitary. Floors, workplaces, and passageways must be kept in safe condition. Debris from sweeping, solid and liquid wastes, and garbage must be removed as often as necessary to keep the workplace sanitary and to minimize the fire fuel loading.
• Aisles and Passageways. All required aisles and exit passages must be kept clear of storage items and obstructions. Permanent aisles and passageways must be marked appropriately. Aisles and passageways must be in good repair. Sufficient safe clearance for aisles, loading docks, doorways, and turns must be made where mechanical handling equipment is used.
• Covers and Guardrails. Covers and guardrails must be used to protect personnel from the hazards of open floors, tanks, ditches, elevated construction openings, and similar areas where a person may be injured falling through or into an opening or pit.

1.4.7.1 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 PUB-4000, Chapter 10 (Construction Safety Manual Administrative Policies) and Procurement’s Guide for On-Site Subcontractor Safety Plans.)

1.4.8 Authorization Basis

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 PUB-3000 and appropriate work authorizations such as Radiation Work Authorizations (RWAs), Activity Hazard Documents (AHDs), and Radiological Work Permits (RWPs). Chapter 6 (Safe Work Authorizations) of PUB-3000 outlines a protocol for the form and content of LBNL work authorizations.

Low-hazard activities can be authorized by line management. Higher-hazard activities require joint review and approval by the EH&S Division and line management (e.g., via RWA, AHD, etc.). Contact the EH&S Division health and safety professionals for help determining the hazard level of an activity.

• Line Management (Low-Hazard) Authorization. Bench-level activities that do not require EH&S 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 EH&S Division review level. Guidelines for hazards and controls are indicated in PUB-3000. The hazard review and establishment of controls are the responsibility of line management. EH&S Division safety professionals will assist if requested. Health-hazard compressed gases classified as an NFPA Class 1 Hazard are an example of hazards that require line management authorization.

• EH&S Division / Line Management (High-Hazard) Authorization. Activities requiring the EH&S Division to participate in the hazard identification and mitigation process are identified in the technical chapters of PUB-3000. Hazard identification, establishment of controls, and authorization are the joint responsibility of line management and appropriate EH&S Division safety professionals. An example of hazards at the joint EH&S/line management authorization level is 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).

1.5 Definitions

(NOTE: Some functions/definitions overlap, depending on the specific situation.)

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

casual visitor: an individual visiting LBNL for one week or less and who is not engaged in Laboratory research or using Laboratory facilities. Included in this category are those who are giving or attending seminars, those who are visiting LBNL for limited scientific discussions or as nonparticipants solely to observe research in progress, radiotherapy patients, job seekers, tour groups, Employee family/friends, retired Employees with occasional reason to visit the site, and the press.

DOE: U.S. Department of Energy

EHSD: the Environment, Health, and Safety Division

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

ES&H: Environment, Safety, and Health; interchangeable with “safety.”

ES&H Coordinating Committee: The ES&H Coordinating Committee is formed when a Significance Level 3 program or project is ready for the Lab Director review.  The purpose of the ES&H Coordinating Committee is to advise the Lab Director of the readiness and effects of implementation of the program.  The EHS Division Director will identify and contact the most affected Division Directors and other senior Lab management personnel to serve on the Committee.  The SME will provide a briefing to the members of the Committee to assure that they are ready to advise the Lab 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.

guest: There are two general categories for Guests of LBNL:

• invited guests: individuals invited to attend a meeting, present a lecture, or conduct a seminar at LBNL who will receive an honorarium or payment for travel expenses
• participating guests: non-Laboratory employees who are engaged in Laboratory Work activities.

HEERA: Higher Education Employer-Employee Relations

host: provides oversight to users at user facilities. A host has ultimate responsibility for safety at an assigned scientific station, and assures 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 plus LBNL Counsel, Director of EH&S Division, Director of the Facilities Division, and the Director of the Office of Institutional Assurance.

Lab, Laboratory, LBNL, 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, etc.

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 Guests 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 Guests and visitors of LBNL. A Matrix Supervisor partners with the HEERA Supervisor on matters of staffing, performance review, Work direction, and/or 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 Regulations and Procedures Manual

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

Safety Line Management: the unbroken linear safety management chain linking 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 nonmanagement 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 LBNL  Director, deputy director(s), 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 Guests. 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 lab for education purposes.
• Graduate Student Research Assistants (GSRAs): GSRAs must be registered graduate students of the University of California (UC).
• Student Assistants - Hired to work 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 for all technical questions in that area and responsible

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 guests 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: 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, and/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

1.6 Required Work Processes

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

The EH&S 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/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 Document Management 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 EH&S Requirements Management (RM) Representative; however, if cross-functional actions are needed, the EH&S RM Representative can recommend an RMC review. Additionally, the EH&S 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.

EH&S 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 requirement(s), such as a:
1. Regulation
2. DOE order
3. Contractual requirement
2. SME prepares a preliminary analysis comparing the new requirement(s) to existing requirement(s) (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, Risk and Impact 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 EH&S RM Representative.
5. The EH&S 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 and
2. Drafts 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. EH&S 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, and/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/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/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/changed policy and/or program.
13. SME implements the new/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 EH&S RM Representative.
15. After the new/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 EH&S 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. EH&S, through the assigned SME(s), 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.

• Division Director assigns SME, who notifies the Division's RM Representative and Requirements Management Program Manager within 24 hours.
• SME completes the Communication Plan (guidance found in the Implementation Plan Form) and Significance Rating. Plans are reviewed by the Division Director or designee.
• SME and the Division Director or designee determines the Working Group members.
• SME initiates communications to affected groups (including oversight committees, if applicable) within 48 hours.
• Any written interim procedures or processes that are distributed to affected groups must comply with the document control process, including approvals, change, and version control.
• The Requirements Management Process must be initiated by opening a Requirements Management Case in the Requirements Management Database within 48 hours.
• SME completes the applicable Requirements Management Process steps, which may or may not be in parallel with initial communications and written interim procedures.

1.7 References

• Applicable standards listed in Appendix G of the Contract between DOE and the University of California (copies available from the EH&S Division)
• Integrated Environment, Health & Safety Management Plan, LBNL/PUB-3140, Lawrence Berkeley National Laboratory
• Operating and Quality Management Plan, LBNL/PUB-3111, Lawrence Berkeley National Laboratory
• Regulations and Procedures Manual (RPM), LBNL/PUB-201, Lawrence Berkeley National Laboratory
• Worker Safety and Health Program, LBNL/PUB-3851, Lawrence Berkeley National Laboratory

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

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