Chapter 1
GENERAL POLICY AND RESPONSIBILITIES

Contents

Approved by Howard Hatayama
Revised 07/08

1.1 Introduction
1.2 ES&H Policy
1.3 ES&H Management

1.4 Implementing ISM Using Five Core Functions

1.5 Stopping Unsafe Work
1.6 Reporting Employee Concerns
1.7 Requesting a Variance from Berkeley Lab Safety Policy
1.8 Glossary
1.9 Standards
1.10 References
1.11 Appendix

1.11.1 Appendix A. Process for Revising the LBNL Health & Safety Manual (PUB-3000)

 

NOTE:
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1.1 Introduction

Berkeley Lab is committed to performing all work safely and in a manner that strives for protection for employees, participating guests, visitors, subcontractors, the public, and the environment, commensurate with the nature and scale of work. In addition, Berkeley Lab seeks continuous improvement and sustained excellence in the quality of all E&HS programs.

To achieve these goals, Berkeley Lab has adopted the seven guiding principles and five core functions of the Integrated Safety Management System (ISMS), as prescribed in Department of Energy (DOE) DEAR Clause 970.5204-2, which are reflected in Berkeley Lab’s detailed policies and procedures.

1.2 ES&H 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. 

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.

1.3 EH&S Management

Berkeley Lab employees, contractors, and casual and participating visitors at the Lab or its off-site locations are required to be familiar with and observe Lab safety (Work Smart) standards. The Berkeley Lab 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 communications, continuous improvement, worker involvement, and full participation of all interested parties. To achieve ISM, Berkeley Lab has adopted the following seven guiding principles, discussed below, which are reflected in the detailed policies and procedures of the Laboratory. 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.

1.3.1 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 up and down the management line with the workforce.

The 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). Integration of ES&H considerations into all phases of planning and implementation through to the final work processes is critical to the success of Berkeley Lab. ES&H considerations must be part of the planning process, commencing with identification of what hazards may arise, what standards apply, what controls need to be integrated into the design and specification, and what competencies are required to work safely. While line management and work leads are responsible for assuring that ES&H concerns are addressed in work planning, implementation, and operation, the EH&S Division serves as a primary technical support resource through its EH&S Liaisons.

1.3.2 Clear Roles and Responsibilities for ES&H

As a condition of employment, every employee, visiting scientist, student, or other person performing work at the Laboratory or at one of the Laboratory’s off-site locations must be familiar with and implement applicable Laboratory safety standards. This responsibility includes taking the initiative to consult with resource groups when assistance or advice is needed to carry out operations safely. The Berkeley Lab organizational chart presents the organizational structure at the Laboratory.

Clear and 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 Berkeley Lab are defined below.

1.3.2.1 Laboratory Director

• Has the ultimate responsibility for safety at the Laboratory and, in particular, for the establishment and the administration of ES&H policies as prescribed in Work Smart Standards (WSS).



• Assures that environment, health, and safety policies meet the requirements of the Department of Energy as outlined in WSS.



• Is responsible for the implementation of the Berkeley Lab ISMS Management Plan.



• Carries out the ES&H policy under the terms of a contract between the University of California and the DOE.



• Delegates, in his or her absence, overall ES&H responsibility to senior management, in the normal chain of command.



• Delegates to the Deputy Director for Operations responsibility for ES&H policy-making, implementation, and daily operation of the ES&H program.

1.3.2.2 Associate Laboratory Director for Operations/Chief Operating Officer

• Is responsible for ES&H policy-making, implementation, and the daily operation of the ES&H program.



• Delegates to the EH&S Division Director 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 Section 1.7, Requesting a Variance from Berkeley Lab Safety Policy.)


• Manages “EthicsLine”/Employees Concerns reporting program.

1.3.2.3 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 Authority Having Jurisdiction (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. DOE-BSO 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 SRC and its appropriate subcommittees. (See Section 1.7, Requesting a Variance from Berkeley Lab Safety Policy.)


• Approves or denies in writing requests for variances. (See Section 1.7, Requesting a Variance from Berkeley Lab Safety Policy.)

1.3.2.4 Division Directors

• Ensure that the Laboratory’s ES&H policies are being observed within their divisions. They are also responsible for adhering to the principles of the Laboratory’s ISMS Management Plan.



• Ensure that, within their divisions, clear roles and responsibilities for compliance with all applicable ES&H policies are defined.



• Ensure that self-assessments are carried out, and that safety deficiencies are identified and promptly corrected.



• Ensure that the division’s research projects and unique activities are evaluated for potential hazards, and that safety controls are specified and implemented.



• Approve Activity Hazard Documents (AHDs) for formally authorized work, and ensure that their managers and work leads effectively implement activity-based hazard analyses for work that is authorized by lower levels of management.



• Investigate the circumstances surrounding situations identified as imminent dangers, and assure that appropriate corrective actions and lessons learned are developed, implemented, and disseminated.



• Arrange for any required remediation, and prepare an investigation and remedial action report for immediate submission to the Director of EH&S.



• Ensure that all requests for programmatic funding include sufficient resources for ES&H support.



• Ensure that no work is conducted in their division under unsafe conditions. Develop and implement a division safety walkaround program.



• Ensure that all work conducted is performed in accordance with established controls.

1.3.2.5 Supervisors, Managers, and Work Leads

Supervisors, Managers, and Work leads are part of the safety line management chain from every Worker to the Laboratory Director. Supervisors and Managers are part of the formal management chain, and they have the responsibility for adherence to all EH&S policies and safe work practices. Work leads derive authority from formal Laboratory Managers and/or Supervisors to assure that day-to-day work, operations, and activities in their assigned area(s) and activities are conducted safely and within established work authorizations.  

Supervisors, Managers, and Work Leads (by category) are to be specified in the Integrated Safety Management Plan for each division.

Safety Responsibilities of Supervisors, Managers, and Work Leads

• Ensure that the Laboratory’s environment, health, and safety policies are being observed with the aim of providing conditions for conducting work safely.


• Ensure that the Job Hazard Analysis documents relevant to the work, activities, and operations are completed.


• Take the initiative to consult with the appropriate support organization when safety related assistance or advice is needed.


• Assure that workers are properly trained in safety and emergency procedures, and that worker competence and on-the-job training are commensurate with their work assignments.


• Ensure that safety deficiencies identified through inspections and walk-arounds are entered into CATS and corrected in a timely manner.


• Ensure that before work begins that associated hazards and appropriate controls are identified, and the controls are implemented.


• Assure that appropriate authorizations are implemented and current.


• Promptly respond to reports of incidents or recommendations for ES&H improvements.

1.3.2.6 Employees, Contractors, and Casual and Participating Visitors

• Must attend the New Employee Safety Orientation (EHS 10) class within a month of being hired. This applies to visitors if, in the judgment of the LBNL supervisor, the visitor’s activities will involve entering accelerators or workshops, or exposure to hazards.



• Must complete a Job Hazards Questionnaire (JHQ) and fulfill all identified training requirements.



• Must participate in the activity-based, hazard-analysis process related to their work.



• Must be familiar with the sections of PUB-3000 that relate to the work they are performing at the Lab.



• Must be knowledgeable of the Berkeley Lab “Stop Unsafe Work Policy” whenever they encounter or become aware of an imminent-danger situation.



• Must not perform any work where there exists any existing or previously unrecognized hazards that are inherently dangerous to themselves, their coworkers, the public, or the environment. If employees, contractors, and casual and participating visitors encounter such a situation, they are to bring it to the attention of their supervisor or Division Safety Coordinator immediately. Work will not commence until the hazard(s) is/are resolved through elimination or control (either administrative or engineering controls).



• Owners of hazard control equipment, personnel protection, and hazard monitoring equipment must ensure that the equipment is in good order and working within operational parameters. Any equipment failing to satisfy operational requirements must be taken out of commission and repaired or replaced.



• Proceed with work only after ensuring that appropriate ES&H procedures have been implemented.



• Perform all work safely, and be aware of potentially hazardous operations and conditions.



• Minimize the volume and toxicity of LBNL-generated waste, and maintain chemical inventories as low as reasonably achievable.

1.3.2.7 Matrixed Employees

An employee is considered matrixed if the employee has a “home” division or department from which he/she is assigned to work in a “host” division or department and receives daily directions exclusively from the host organization. The host division or department also provides physical space and oversight.

• The employee’s supervisor or work lead from the home division or department retains all health and safety responsibilities pertaining to matrixed employees, except where some of the responsibilities have been transferred to the host division or department 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 home and host organizations, through a blanket MOU, are to identify the safety responsibilities for their respective supervisor, work leads, and employees. The following table specifies which responsibilities may be transferred to the host supervisor and those that must be retained by the home organization’s supervisor.

• Whenever an MOU is established, it remains the responsibility of the home supervisor or work lead to assure that the MOU is appropriately implemented.
  
  
• 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.

1.3.2.8 Building Managers

• 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.

1.3.2.9 Division Safety Coordinators (DSCs)

• Reporting directly to their division director or deputy, the Division Safety Coordinator (DSC) is 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 their 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 other 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 technical guidance to DSCs 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 LBNL Work Smart Standards Program. Perform an ongoing review of work with division staff to identify hazards that may require inclusion of new Standards in the LBNL Work Smart Standards set.


• Serve as a member of (or chair) the Division Safety Coordinators’ Committee, and attend this and other meetings as necessary.


• Coordinate and manages required safety documentation, which includes: 


• Division ISM Plan (principal author)


• Training and JHQ records (help ensure timely completion)


• SAAR (approval authority)


• CATS (approval authority)


• Walkaround inspection reports (Walkaround program manager)


• Work authorizations


• Chemical Management System


• Hazards and Equipment Authorization Review (HEAR)


• Occurrence Reporting and 10CFR851 reporting


• Laser inventory database


• SAA/WAA records


• Ergonomic records


• Manage the corrective action process for the division; this includes assuring that the CATS item is appropriate, 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. Facilitates 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, including: 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 external to the division, including Integrated Functional Appraisals, MESH reviews, etc.


• Support the investigation of incidents, including injuries, accidents, and other safety and environmental incidents.

1.3.2.10 EH&S Division Liaisons

EH&S Division Liaison Duties

EH&S Division Liaisons are designated for each assigned Laboratory division or Laboratory 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 Laboratory employee from directly approaching an EH&S professional/subject matter expert to address a particular issue or need. The EH&S liaison:

• Serves as the designated point of contact to assigned divisions or Laboratory facilities. 
• Requests that the appropriate technical support be provided to implement and interpret Lab 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 close-out of ES&H issues or concerns of the customer division.
• Develops and fosters a cross-functional team approach when necessary to provide assessment and consultation on identified hazards and applicable control measures, complex operations, and equipment.
• Participates in customer division self-assessments 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 formal work authorizations in the customer division 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 JHQ records: Monitors training completion status, and helps ensure that technical assistance is provided in the development of division-specific training.
• CATS: Closes-out ES&H-related items.
• Walkaround inspection reports: Provides technical interpretation.
• Chemical Management System: Provides technical guidance and coordinate support.
• Hazard and Equipment Authorization Review (HEAR): Serves as technical resource, and monitors status.
• Occurrence Reporting and 10CFR851 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.

1.3.2.11 Functional Organizations and Institutional Committees

1.3.2.11.1 EH&S Division

• Reviews the Lab’s ES&H programs, policies, and procedures against the ISM principles and core work functions, and provides necessary course corrections at the appropriate level to assure that the ISMS Management Plan is being implemented properly.
  
  
• Assesses all LBNL activities independently for compliance with the applicable safety rules and standards, and provides appropriate technical services.
  
  
• Publishes and revises PUB-3000, LBNL’s environment, health, and safety manual. See Appendix A, Process for Revising the LBNL Health & Safety Manual (PUB-3000).
  
  
• Reviews Activity Hazard Documents (AHDs) and hazardous operations.
  
  
• Inspects all LBNL activities for compliance with applicable safety rules and standards.
  
  
• Provides technical expertise and services in ES&H issues.
  
  
• Monitors closely experimental operations for which a variance has been granted for the duration of the variance. Ensures that the conditions of the variance are met and that safety is not compromised. (See Section 1.7, Requesting a Variance from LBNL Safety Policy.)
  
  
• Conducts with division representatives inspections for earthquake, emergency preparedness, electrical, industrial, and hazardous material safety.
  
  
• Provides technical support to customer division in the form of consultation and training.
  
  
• Performs EH&S Technical Assessments as required by PUB-5344, “ESH Safety & Health Self-Assessments Program.”
  
  

1.3.2.11.2 Facilities Division

• Is charged with the safe operation and maintenance of LBNL’s physical plant and facilities, including removing from service unsafe facilities and equipment maintained by the Facilities Division and repairing such.


• Serves as the Authority Having Jurisdiction (AHJ) for facilities electrical systems under NFPA 70, “National Electrical Code.”

1.3.2.11.3 Office of Contract Assurance (OCA)

• With the EH&S Director, conducts ES&H assurance activities to ensure the effective implementation of ES&H policies and programs, and the safe performance of work activities.
  
  
• Develops and manages the LBNL ES&H Self-Assurance Program.


• Coordinates certain external audit functions.

1.3.2.11.4 Engineering Division

• Ensures that all non-Facilities equipment, structures, and engineered experimental apparatus, with which Engineering Division personnel at LBNL are connected, are designed, engineered, and maintained in a safe manner and in conformance with all applicable EH&S requirements.


• Serves as the Authority Having Jurisdiction (AHJ) for research electrical systems under the authority of NFPA 70, “National Electrical Code.”

1.3.2.11.5 Facilities Construction Project Managers

• Instruct, before construction work begins, construction subcontractors and their employees to stop work immediately if their activities are identified as constituting an imminent danger.


• Serves as the primary LBNL line manager responsible for the safe execution of work under their jurisdiction.

1.3.2.11.6 Safety Review Committee (SRC)

Function

The Safety Review Committee (SRC) performs research for and makes recommendations to the Laboratory Director on the development and implementation of Environment, Safety, & Health (ES&H) policy, guidelines, codes, and regulatory interpretation. It conducts reviews of special safety problems and provides recommendations for possible solutions to the Laboratory Director and/or the ES&H Division. The SRC also provides advice and counsel to the Associate Laboratory Director for Operations by reviewing appeals from the Laboratory Divisions when any Division and the EH&S Division do not agree on the interpretation or application of criteria, rules or procedures. Such advice and counsel may include options for a resolution.

In addition, the SRC chair, in cooperation with the Office of Contract Assurance, is responsible for scheduling and conducting the portion of institutional self-assessment known as Management of Environment, Safety & Health (MESH) reviews. These reviews are designed to ensure management systems consistent with Integrated Safety Management (ISM) are in place in all Laboratory Divisions and that these systems are leading to effective implementation of the Laboratory's ES&H program. MESH reviews are normally triennial by Division and are conducted by an SRC sub-committee. Depending on the MESH review results and the Division response, the SRC shall have the option to recommend changing the interval by one year. All members of the SRC are expected to serve on MESH sub-committees.

To properly execute its responsibilities under this charter, the SRC Chair may appoint expert sub-committees to address specific health and safety matters. Such sub-committees may become long standing expert sub-committees, or they may be of short duration, depending upon the technical support requirement.

Membership/Composition

The Laboratory Director appoints the SRC Chair. SRC membership includes a representative from every Laboratory Division.

Division Directors and Department Heads nominate members of their organizations to the Chair and the Laboratory Director formally appoints them to the SRC. The EH&S Division Director or Division Deputy will also attend SRC meetings as resources for the committee.

Appointments are normally for three-year terms that can be renewed once. In addition to SRC members, the Chair may invite (based on SRC agenda) the following advisors:

• Chair of Human Subjects Committee
• Chair of Animal Welfare and Research Committee
• Chair of Radiation Safety Committee
• Chair of Biosafety Committee
• Laboratory Environmental Counsel

Membership Qualifications

The SRC is designed to be a committee of peers involved in the research and development activities of the Laboratory. In research-oriented divisions, members should be drawn from the scientific staff; participation by active experimental scientists is important to the functioning of the SRC. There are no specific prescribed qualifications for SRC members in terms of their position, experience, and training at the Laboratory. However, since the SRC is involved in determining Laboratory policy as described above, individuals who can effectively represent their Divisions should be nominated.  

SRC members are expected to:

• Possess an understanding of the 5 Core Functions and 7 Guiding Principles of Integrated Safety Management.
• Communicate regularly with senior Division management and other Division personnel as needed.
• Possess communications skills to comment, suggest, recommend, revise, advise, and influence the Laboratory’s approaches, methods, documents, and practices to continuously improve the Laboratory’s safety programs.
• Develop an understanding of PUB 3000 and related documents, and the processes for revising these documents.

Meeting Schedule

Meetings will be held as necessary, but at least every two months. When members are unable to attend, substitutes may be designated to attend specific meetings. If a member does not attend at least four meetings throughout the calendar year, the SRC Chair will consult the member's Division Director or Department Head to ask that a replacement be nominated. The SRC chair will designate a recording secretary. Minutes shall be recorded for every meeting; and once a year, the committee will submit a written and oral report of activities to the Director.

Provision for Amendment

The Chair shall submit to the Laboratory Director any recommendations for the amendment of this charter.

1.3.3 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 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 on divisional safety committees and Safety Review Committee subcommittees (such as Traffic and Pedestrian Safety Subcommittees)
• Participation on accident review teams
• “All hands” safety meetings
• Safety Spot Awards program
• EH&S on-line suggestion box and email 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 that is 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 recordkeeping log (OSHA Form 300) with access subject to Freedom of Information Act requirements and restrictions
• DOE Form 5484.3 (DOE equivalent of OSHA Form 301) 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.

1.3.4 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 Assurance Plan (OAP), Section 1.4; and the Regulations and Procedures Manual (RPM), Chapter 2. However, Lab 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, must 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 constitutes an imminent-danger situation, then the Stopping Unsafe Work Policy must be followed.)


• Be familiar with the all sections of PUB-3000 that relate to the work being performed.

1.3.5 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 for hazards to workers, the public, and the environment is to be conducted in accordance with Chapter 6 of PUB-3000. The objective is to ensure that hazard controls enhance and further the nature of research and all other work activities, and not impede it.

A Project Coordination Committee is responsible for balancing priorities at the institutional level. The Project Coordination Committee is facilitated by the Facilities Department and consists of representatives from each of the Laboratory’s resource divisions and the Office of Planning and Communications. The Committee performs two functions: (1) it informs all resource divisions of upcoming projects and allows for advance coordination when required, and (2) it provides a broad-based review of projects using a priority rating system. From the Committee review, a recommended list of prioritized projects is compiled. This in turn is submitted for collective review to the Facilities Manager and the Director of the Environment, Health & Safety Division, who in turn advise the Associate Laboratory Director for Operations/Chief Operating Officer regarding preparation of a final list. Projects that are not funded are periodically reviewed with the proposing division during the year, and may be resubmitted for funding during the next “Unified Call” process.

1.3.6 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 of PUB-3000, ES&H Documentation and Approvals, details the Lab process regarding identification of hazards and determination of requirements. The current set of standards identified in Appendix G is used as a basis to determine the appropriate 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 in the recognized standards.

1.3.7 Establishment of Hazard Controls

Administrative and engineering controls to prevent and mitigate hazards should be appropriately tailored to the work being performed and the risk of harm and the extent or degree of harm that could occur.

The tailoring process should include:

• identifying controls for specific hazards


• establishing boundaries for safe operation


• implementing and maintaining controls.

EH&S 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 department in every building must be marked on plates made from an approved design. The plates must be in the area to which they pertain and be conspicuous.


• Access to LBNL. Access to LBNL and its facilities is controlled. Casual and participating visitors’ access is set forth in LBNL/PUB-201, Regulations and Procedures Manual, 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.

1.3.7.1 Subcontractor Flow-Down of Safety and Health Requirements

Subcontractors, including service providers, provide a variety of on-site services to LBNL, 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 the Laboratory to flow down its requirements to subcontractors.  Procurement guidelines delineate WSHP requirements for subcontractors, including construction and general service subcontractors. (For specific information about the Laboratory’s construction safety program for subcontractors, refer to Chapter 10 of the PUB-3000, and Procurement’s Guide for On-Site Subcontractor Safety Plans.)

1.3.8 Authorization Basis

• The 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. Chapter 6 (Safe Work Authorizations) of PUB-3000 outlines a protocol for ensuring the form and content of authorizations. Examples for Berkeley Lab include Radiation Work Authorizations (RWAs), Activity Hazard Documents (AHDs), Radiological Work Permits (RWPs), etc.

• Activity Level Authorization. Activities are authorized by either line management or by joint EH&S/line management. EH&S Division health and safety professionals provide guidelines in PUB-3000 indicating the authorization level. Lower hazard activities are determined by EH&S safety professionals to be activities where line management review is adequate. Higher hazard activities are determined by EH&S safety professionals to require joint EH&S/line management review and authorization.
  
  
• Line Management Level 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. An example of hazards at the line management authorization level is health-hazard compressed gases with a NFPA Class 1 hazard classification.


• EH&S Level Authorization. Activities requiring EH&S participation 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 safety professionals. An example of hazards at the joint EH&S/line management authorization level is health-hazard compressed gases with a NFPA Class 3 or 4 hazard classification. Applicable documents would include AHDs and/or RWAs.

1.4 Implementing ISM Using Five Core Functions

The seven guideline principles are achieved through implementing the five core integrated safety management system functions, which must become part of every aspect of work at Berkeley Lab.

1.4.1 Define Scope of Work (Work Planning)

Missions are translated to work, expectations are set, tasks are identified and prioritized, and resources are allocated. A comprehensive hazard analysis was part of the 1996 Integrated Hazard Assessment (IHA) for each division or department. Each of the work activities identified was evaluated with respect to hazard and categorized with either a low, medium, or high level of concern. The determination was based on both the underlying risk and on the likelihood of occurrence in the light of controls present.

1.4.2 Analyze the Hazards

Hazards and risks associated with the work to be performed are identified, analyzed, and categorized as to impact on employees, public, and the environment.

All LBNL buildings must be inspected annually for fire safety; other inspections may include electrical, industrial, and general environmental safety. The LBNL Fire Department is responsible for conducting fire safety inspections. Other inspections are met through the LBNL Self-Assessment Program or other assessments.

EH&S teams make inspections for safety deficiencies. A division representative, and/or the Building Manager, accompanies EH&S on their inspections. The division representative identifies, reviews, and ranks safety deficiencies.

Fire Safety Inspection Reports are sent to building managers and Division Safety Coordinators to track corrective actions to completion. Each division completes an annual self-assessment report, which is sent to the Division Director, EH&S Division. Corrective actions are tracked by each division.

1.4.3 Develop and Implement Controls

Controls are established based on identified applicable standards and requirements to reduce the risks to acceptable levels. Acceptable levels are determined by responsible line management or work leads, but are always in conformance with all applicable laws and WSS.

1.4.4 Perform Work Within Controls

Activities are conducted in accordance with controls, procedures, requirements, and authorizations.

1.4.5 Feedback and Continuous Improvement

1.4.5.1 General

Information is gathered from employee suggestions, assessments, lessons learned, operational awareness, and worker/customer/regulator and stakeholder feedback, as appropriate, to improve the work activity.

Supervisors and work leads should regularly review work practices and operations in light of any new hazard information available or due to changes in actual work practices. Occurrence reporting, self assessment, peer reviews, and lessons learned can be used as ways of improving the cost-effectiveness and reliability of hazard controls (engineering and administrative). Based on findings from occurrence reporting and other assessments, improvements should be made to work planning, and in rare instances, be used as a basis for changing line management responsibility, roles and responsibilities, worker competence, or other appropriate parts of the work cycle.

1.4.5.2 Safety Walkaround Program

Safety walkarounds are performed regularly as an integral management function. The purpose of a safety walkaround is to observe work, inspect the workplace, and talk with workers and support staff about the safe performance of work. The focus should not be merely on deficiencies but also on building teamwork, mutual understanding, and respect between managers and those performing work.  Areas for improvement identified during the walkaround must be documented in CATS if a noncompliance is identified or if tracking and follow-up are needed. Each division will publish a program for implementing safety walkarounds as a component of their Division ISM Plan. The Division walkaround program will, at a minimum, delineate who is required to perform walkarounds, the frequency (a minimum frequency of quarterly for all work activities and workplaces is suggested), and the required reporting mechanism. Those Managers, Supervisors or Work Leads who will be performing walkarounds (as designated by the Division ISM plan) are required to complete EH&S Division sponsored training by January 2008 to prepare them to be effective in this role.

The EH&S Division will support the management walkaround program by providing programmatic guidance, initial and refresher training, a standard method that can be used to document the observations from safety walkarounds (checklist and/or database), and oversight/mentoring as needed and/or requested.

1.4.5.3 ES&H Assessments

To ensure continued effectiveness, periodic reviews of LBNL procedures and operations are conducted by each division, the EH&S Division, and the Safety Review Committee (SRC).  Each division will conduct an annual self-assessment utilizing guidelines provided by the Office of Institutional Assurance, and will also add to this minimum by including divisional areas of interest in self-assessments.  The EH&S Division shall assess the effectiveness of divisions’ programs and processes on a triannual basis (more frequently if deemed necessary or if required by regulation). The SRC shall conduct Management of ES&H Assessments or MESH Reviews also on a triennial basis.  Special assessments and peer reviews may also be conducted as needed under the coordination of the EH&S Director.

1.5 Stopping Unsafe Work

All Berkeley Lab employees, contractors, and participating guests are responsible for stopping work activities considered to be an imminent danger. Stopping unsafe work applies to all activities conducted at the Laboratory and to all off-site facilities operated by Laboratory personnel.[*]

An “imminent danger” is defined as any condition or practice that could reasonably be expected to cause death or serious injury, or environmental harm.

Whenever an employee, contractor, or participating guest encounters conditions or practices that appear to constitute an imminent danger, such individuals have the authority and responsibility to:

• Alert the affected employee(s) or contractor(s) engaged in the unsafe work creating an imminent-danger condition and request that the work be stopped.
  
• Call x6999 to report the incident; EH&S staff will investigate it.
  


• Notify the immediate supervisor and/or responsible division/department manager (if known).

EH&S staff will ensure that the supervisor or work lead is notified and will assist the supervisor in preparing a report to the EH&S Division Director, describing the unsafe activity and identifying corrective actions and responsibilities.

Work that has been stopped by a stop work request shall not be resumed until the safety issue is resolved to the satisfaction of the individual who stopped the work.

1.6 Reporting Employees' ES&H Concerns

Employees or former employees may file an ES&H concern with their immediate supervisor, higher level managers, Director of the EH&S Division, or the local DOE office. Concerns may be submitted by calling the Berkeley Lab Employee Hotline (800) 403-4744. This toll free number is available 24 hours every day and is operated by a third-party vendor for confidentiality and anonymity if so desired by the caller. Persons reporting improper activities are fully protected by the law and Lab policy against retaliation. Under 10 CFR 708, employees also may file their concerns (not limited to ES&H) with the DOE Chicago Office Employee Concerns Program Manager at (630) 252-2299. The LBNL HR Web site also has information regarding whistleblower policy, and provides a number of 24-hour hotlines of potential use to Lab employees.

Workers are responsible for bringing safety and health concerns promptly to the attention of the appropriate manager, supervisor, or work lead for resolution. Line management is then responsible for investigating the concern and implementing corrective action. If a satisfactory response is not received, the senior manager for the organization should be contacted, followed by the Director of the Environment, Health, and Safety Division.

1.7 Requesting a Variance from Berkeley Lab Safety Policy

Occasionally circumstances may arise where application of this policy and/or other chapters in this manual prevent work from being conducted without compromising safety. If it is necessary to perform this work, each circumstance will be brought to the attention of the EH&S Division in the form of a request for variance, identified below. Each request will be reviewed on a case-by-case basis.

Principal Investigators and/or other LBNL employees who have the concurrence from his/her cognizant division director may request in writing a variance from LBNL safety policy. Requests for variances go to the EH&S Division Director and must include:

• An explanation of the specific criteria, rules, or procedures for which the variance is being requested.



• An explanation of the need to perform the experiment in the proposed manner.



• A description of the experimental apparatus.



• A description of the measures to be taken to ensure that the variance will not compromise safety.



• A statement defining the period during which the variance is to be in effect.

For more information on variances, see Section 1.3.2, Clear Roles and Responsibilities for ES&H. If operations are suspended, the work stoppage must be investigated and reported in accordance with the relevant procedure specified in the Chapter 5, Section 5.1, of PUB-3000, Accident Investigation & Reporting, Occurrence Reporting Program, or Chapter 10 of PUB-3000, Construction Safety. Operations can resume when authorization has been granted by the EH&S Division Director or designee.

1.8 Glossary

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

Casual Visitor – An individual visiting the Laboratory 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 the Laboratory 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 – Department of Energy.

Employee – An individual who is hired by the Laboratory to provide services on a regular basis in exchange for compensation.

ES&H – Environment, Safety, and Health; interchangeable with Safety.

ESHD – the Environment, Safety, and Health Division.

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 the Laboratory:

• Invited Guests – Individuals invited to attend a meeting, present a lecture, or conduct a seminar at the Laboratory who will receive an honorarium or payment for travel expenses.
• Participating Guests – Non-Laboratory Employees who are engaged in Laboratory Work activities.

HEERA – The Higher Education Employer-Employee Relations Act, which outlines certain rules that LBNL must follow.

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.

JHQ – Job Hazards Questionnaire.

Key Personnel – This is a Contract 31 term that includes the Senior Management Group plus the Laboratory Counsel, Director of EH&S, Director of Facilities, and the Director of Institutional Assurance.

Lab, Laboratory, Berkeley Lab, LBNL – Lawrence Berkeley National Laboratory.

Line Manager, Line Management – Managers are individuals responsible for formulating and administering policies and programs of the Laboratory; 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 the Laboratory 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 the Laboratory.  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 need not 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 – Regulations and Procedures Manual.

Safety - Safety is used generically to cover all aspects of environment, health, and safety, including regulatory requirements; interchangeable with ES&H.

Safety Line Management – The unbroken linear safety management chain from the Laboratory 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 Laboratory  Director, deputy director(s), associate laboratory directors, and the Chief Financial Officer.

Staff - Anyone with an LBNL badge. 

Student/Student Intern – Students or Student Interns often work at the Laboratory 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 the Laboratory 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 – Individual worker or company hired by LBNL to perform a specific task as part of an overall project.

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."

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 who has varying degrees of Safety Line Management accountability.

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 need not be Line Managers, HEERA-designated Supervisors, or LBNL Employees.

Worker - Defined broadly to include anyone who performs Work at or for LBNL.

1.9 Standards

Applicable standards are listed in Appendix G of the contract between DOE and the University of California. Copies of these standards are available from EH&S.

1.10 References

• Integrated Environment, Health & Safety Management Plan, LBNL/PUB-3140, Lawrence Berkeley National Laboratory


• Operating and Assurance Program 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

1.11 Appendix

1.11.1 Appendix A. Process for Revising the LBNL Health & Safety Manual (PUB-3000)

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Table of Contents || Chapter 2>>

[*]Except locations and personnel under the jurisdiction of the Memorandum of Understanding Between UCB and LBL Concerning Environment, Health and Safety Policies and Procedures, Appendix VI, Policy on Authority for Stopping Unsafe Work at the University of California at Berkeley.