Subject Area: Integrated Safety Management System (ISMS ... · Subject Area: Integrated Safety...

SAD-OTSAM-450, Rev. 2

1

Management System: Safety and Health

Subject Area: Integrated Safety

Management System (ISMS) Description

Management System Owner: John Sattler

Point of Contact: Ken Armstrong

Issue Date: 3/3/16

CBC MS Revision: 2

1.0 Introduction

Purpose and Objectives:

This Integrated Safety Management System Description (ISMSD) defines how the U.S

Department of Energy, Environmental Management Consolidated Business Center (EMCBC)

and participating Small Sites implement DOE O 450.2, Integrated Safety Management (ISM)

and conduct work following the seven ISM Guiding Principles, the five ISM Core Functions, and

incorporates the four Supplemental Safety Culture Principles (adopted from the EM ISMSD).

The EMCBC ISMS also integrates important aspects of the EMCBC Quality Assurance Program

and Environmental Management System into the ISMS process and describes how this process is

used to identify the flow down of requirements critical not only to safety but also to the

environment and to the quality of the EMCBC services. This ISMSD also describes how the

EMCBC participating small sites ensure that the EMCBC small site contractors meet the

expectations of the Department of Energy Acquisition Regulation (DEAR) clause 48 Code of

Federal Regulations 970.5223-1, Integration of Environment, Safety, and Health into work

planning and execution by establishing the requirements to develop, implement, and maintain

ISM Systems.

Overview of the ISM System:

The EMCBC ISMSD program is developed around the EMCBC Mission, Vision, Values and

Goals as defined in the EMCBC Strategic Plan (December 2015).

Mission: To provide an integrated services center with a valued, dedicated and well-trained staff to execute exemplary core business and technical services that are focused on the safe, compliant and efficient execution of EM activities at supported sites.


2

The EMCBC has two primary mission assignments as noted above:

Execute Core Business Services (such as contracting and cost estimating)

Execute Core Technical Services (such as environmental, safety and quality oversight)

These activities although non-operation in nature still have direct impact on the performance of

work in the field. Using the guidance in Attachment 7 of DOE G 450.4-1C, Integrated Safety

Management System Guide, the following shows how each applicable EMCBC mission affects

the Safety, Quality, and Environmental impact of DOE and small site personnel.

The EMCBC Strategic Plan contains three over-riding goals – People, Mission Delivery and

Effectiveness/Efficiency. The EMCBC Strategic Plan goals are then broken down into

objectives, strategies and actions that discuss how the EMCBC defines the scope, identifies

requirements, mitigates hazards, executes the mission and then continuously learns and improves

processes.

PROVIDE CORE BUSINESS SERVICES: Translating missions into meaningful scopes of work Define scopes of work in sufficient detail to identify the applicable hazards and

requirements Flow down requirements to contractors through contract mechanisms

PROVIDE CORE TECHNICAL SERVICES: Establish Safety, Quality and Environmental programs Perform oversight and self-assessments to assure compliance

Maintain operational awareness of operational activities and share Lessons Learned Establish Federal Occupational Safety and Health Plans to assure the safety of our

federal workers.

Mission Vision

Goals

Values

Objectives

Strategies

Actions

People

Mission Delivery

Effectiveness/Efficiency


3

The EMCBC Goals are accomplished through programs, policies, and procedures. These

programs, policies, and procedures also implement the guiding principles and core functions of

the EMCBC ISMSD as defined in the EMCBC ISMS Implementation Matrix, (Attachment A).

The EMCBC ISMS program is applicable to the EMCBC but may be adopted by the EMCBC

Small Sites provided the EMCBC ISMS Implementation Matrix is reviewed and modified to

adequately describe the implementing policies, procedures, and programs.

2.0 Implementation of the Five Core Functions

Core Function 1: Defining Scope of Work: Missions are translated into work, expectations are set, tasks are identified and prioritized,

quality assurance standards are applied, reporting is formulated and resources are

allocated.

The EMCBC Strategic Plan (Goal 1) defines how each EMCBC function establishes a

workload baseline. The EMCBC provides a wide range of business and technical services

based on Service Level Agreements with customer sites, and providing line management and

oversight of the Small Sites. Based on these requirements, the EMCBC develops a workload

baseline which is a compilation of EMCBC customer requirements and the associated

staffing requirements (e.g., required credentials, estimate of hours required to perform tasks).

The workload baselines mentioned in the Strategic Plan are derived from the two primary

missions of the EMCBC:

a) Provide Core Business Services: The EMCBC procurement process uses the

Integrated Project Team concept to translate missions into meaningful scopes of

work. The Integrated Project Team formed from Contracting Officers, Technical

Subject Matter Experts, and knowledgeable site personnel define contract scopes of

work in sufficient detail to identify the applicable hazards and requirements. In

addition, the IPT Team identifies and flows down requirements to contractors through

contract mechanisms.

b) Provide Core Technical Services: The EMCBC works with the small sites and

service level agreement sites to identify specific needs such as ISMS Declaration

support, ISMS Assessments, QA Assessments, Environmental Opportunity

Assessments, Safety Conscious Work Environment Assessments, Document Reviews

Strategy – Workload Baseline, Manpower Assessment and Succession Plan Establish a Workload Baseline that identifies all EMCBC customer requirements and the associated staffing requirements (e.g., required credentials, estimate of hours required to perform tasks). Perform subsequent Manpower Assessment to identify existing staff capabilities, current workload assignments and associated performance metrics.


4

and other Oversight needs on an annual basis. The EMCBC also has the overriding

responsibility to provide for an environment where worker safety is our first priority.

Work at EMCBC office locations is defined by the Strategic Plan and analyzed using

PP-OTSAM-450-01, EMCBC Federal Occupational Safety and Health (FEOSH)

Plan.

Core Function 2: Identifying the Hazards: Hazards associated with work are identified, analyzed and categorized.

a) Provide Core Business Services: The EMCBC technical support staff, technical

support contractors and other subject matter experts are utilized to identify

requirements associated with the work scope (Statement of Work or Performance

Work Statement) in each procurement action and resulting contract. Each statement

of work is thoroughly analyzed to assure that significant safety, environmental, and

quality aspects are identified and communicated to the contractor. Applicable Federal

Regulations and applicable DOE Directives are compiled for inclusion in the Request

for Proposal. In addition, other significant requirements are included such as project

agreements and significant correspondence.

b) Provide Core Technical Services: The EMCBC identifies hazards to the public and

environment through multiple Federal processes. These include but are not limited to

the EMCBC and project level National Environmental Policy Act processes. The

EMCBC uses quality assurance oversight mechanisms such as management and

independent assessments, document reviews, readiness reviews and other activities to

assure that significant safety, environmental, and quality aspects are identified and

communicated to the contractor. Worker safety hazards analysis for Federal work

activities at the EMCBC help develop an understanding of the potential for the

hazards to affect the health and safety of the Federal worker, the public, and the

environment. The EMCBC uses PP-OTSAM-450-01, FEOSH Plan and SAP-

OTSAM-450-03, Job Hazard Analysis Procedure to identify hazards in the

workplace as well as periodic work space inspections.

Core Function 3: Developing and Implementing Hazard Controls:

Applicable standards and requirements are identified and agreed upon; controls to prevent

or mitigate hazards are identified and implemented.

a) Provide Core Business Services: The EMCBC flows down requirements to

contractors through contract mechanisms. The EMCBC considers legal and

contractual authorities, its policies, local or regional issues and its obligations and

responsibilities to EMCBC small sites. These requirements are typically documented

in the statement of work and by listing the applicable Federal Regulations and

applicable DOE Directives. This process is documented in the Office of Contracting

in IP-540-11, Management of an Integrated Project Team (IPT)/Source Evaluation

Board (SEB) at the EMCBC. In addition, other significant requirements are included

such as project agreements and significant correspondence.


5

b) Provide Core Technical Services: The EMCBC uses quality assurance oversight

mechanisms such as management and independent assessments, document reviews,

readiness reviews and other activities to assure that significant safety, environmental,

and quality aspects are identified and communicated to the contractor. For design

review and construction activities in EMCBC facilities, the EMCBC utilizes the

processes of the General Services Administration to support the design review and

construction of new space. Significant environmental aspects are determined based on

the relative impact to the environment for the work scope performed by the EMCBC

and documented in MSD-OD-111, Rev. 2, EMCBC Environmental Management

System Description. Federal worker safety hazard mitigation is accomplished through

PP-OTSAM-450-01, FEOSH Plan, SAP-OTSAM-450-03, Job Hazard Analysis

Procedure. Recurring FEOSH inspections of Federal workspace helps to ensure

continued due diligence in maintaining and proper hazard controls are appropriate

and functioning. Personal Protective Equipment (PPE) is provided through SAP-

OTSAM-445-02, Purchasing Personal Protective Equipment Procedure. In addition,

the EMCBC anticipates and plans for mitigation of emergencies through PP-

OTSAM-151-02, EMCBC Occupant Emergency Plan.

Core Function 4: Performing Work within Controls:

Readiness is confirmed and work is performed safely.

a) Provide Core Business Services: The EMCBC performs oversight of contractors in

a number of ways. Monthly Performance Reviews (PMRs), input into the DOE

Project Assessment and Reporting System (PARS II) and other project related

reporting systems. Oversight of contractor business performance is accomplished

through the Federal Project Directors, the Contracting Officers and the contracting

officer technical representatives.

b) Provide Core Technical Services: The EMCBC uses quality assurance oversight

mechanisms such as management and independent assessments, document reviews,

readiness reviews and other activities to assure that both DOE Field office and

Contractor personnel are operating within defined parameters. Results of EMCBC

assessments are presented in formal assessment reports with deficiencies being

written to document the non-conformance. Deficiencies are tracked to closure

through the contractor, small site, or SAP-OTSAM-414B-01, EMCBC Corrective

Action Procedure. Monthly performance metrics are also an important tool for

monitoring implementation of safety, quality, and environmental policies. Managers

and personnel perform self-assessments to assure that EMCBC systems and processes

are being used as described. In addition recurring FEOSH inspections of Federal

work space are conducted using SAP-OTSAM-414C-01, Assessment/Management

Assessment and Oversight Procedure to ensure work is performed within the bounds

defined and proper hazard controls are appropriate and functioning.


6

Core Function 5: Provide Feedback and Continuous Improvement:

Feedback information on the adequacy of controls are gathered, opportunities for improving the

definition and planning of work are identified and implemented, line and independent oversight

is conducted, and if necessary, regulatory and enforcement actions occur.

Continuous improvement is one of the cornerstones (Objective 3.3) of the EMCBC Strategic

Plan (Goal 3: Effectiveness/Efficiency) and is promulgated through multiple measures that

support all aspects of the EMCBC work scope.

a) Provide Core Business Services: This is a cornerstone of the EMCBC Strategic

Plan and is promulgated through multiple measures that support all aspects of the

EMCBC work scope. The EMCBC utilizes the Lessons Learned process for quality

for continuous improvement. As an example: Following each significant contract

award, Source Evaluation Boards generate lessons learned for future use within the

DOE contracting community.

b) Provide Core Technical Services: The EMCBC uses Operating Experiences and

Lessons Learned in accordance with EMCBC procedures to flow lessons learned

down from Headquarters and incorporate lessons learned from other DOE-EM

projects. Worker safety is improved through continuous improvement in all aspects of

Federal work activities. The EMCBC implements Customer Satisfaction Surveys and

uses the results to improve performance. The EMCBC uses Self-Assessment and

Management Assessment activities to assess compliance with procedural or

regulatory requirements. The results of Self-Assessments and Management

Assessments are used for continuous improvement opportunities.

3.0 Implementation of the Seven ISM Guiding Principles, and Four

Supplemental Safety Culture Principles

Principle 1: Line Management Responsibility for Safety: EMCBC and Small Site Line Management are responsible and accountable for protection of

the public, workers, and the environment. This is documented in the EMCBC Strategic Plan

and flows down through the EMCBC Mission and Function Statement, EMCBC Functions

Responsibilities and Authorities (FRA), Procurement Authorities, Delegations of safety,

environmental and quality authorities, and responsibilities outlined in individual position

descriptions and performance plans.

Continuous Improvement Using results from the APR, customer surveys and other sources, implement a continuous improvement culture that drives innovation in delivering results.


7

Principle 2: Clear Roles and Responsibilities: Clear and unambiguous lines of authority and responsibility for ensuring safety is

documented, communicated, and maintained through the FRA and the EMCBC Management

System.

Principle 3: Competence Commensurate with Responsibilities: EMCBC employees possess the experience, knowledge, skills, and abilities necessary to

discharge their responsibilities. These are documented in formal qualification programs such

as PD-361-03, Rev. 1, Technical Qualification Program (TQP) and SAP-OTSAM-414D-01,

Qualification of Assessment Personnel procedure and Individual Development Plans.

Principle 4: Balanced Priorities:

EMCBC resources are effectively allocated to address safety and programmatic and

operational considerations. When necessary, technical support contractors are available to

support EMCBC and small site needs. Protecting the public, workers, and the environment is

an overriding priority as documented in the EMCBC Strategic Plan and EMCBC

Management Systems. Priorities for program and technical support are captured in the

EMCBC Fiscal Year Action Plans. Individual organizational planning is accomplished and

documented in plans such as the Office of Technical Support and Asset Management

(OTSAM) Integrated Assessment Schedule and the Office of Contracting Workload

Management System.

Principle 5: Identification of Safety Standards/Requirements (S/R):

Before EMCBC work is performed, the associated hazards are evaluated, and an agreed-upon

set of safety S/R are established which provide adequate assurance that the public, workers,

and the environment are protected from adverse consequences. The EMCBC FEOSH Job

Hazard Analysis process is used for safety hazards and applicable standards. For Integrated

Acquisition, Financial & Project Management and Program & Technical Support these

requirements are typically documented in the statement of work and by listing the applicable

Federal Regulations and applicable DOE Directives using the Office of Contracting

procedures including management of an Integrated Project Team (IPT)/Source Evaluation

Board (SEB) at the EMCBC.

Principle 6: Hazard Controls Tailored to Work Being Performed:

The EMCBC uses administrative and engineering controls to prevent and mitigate hazards

and tailors them to the work and associated hazards. The EMCBC identifies and tailors

hazard controls through EMCBC PP-OTSAM-450-01, FEOSH Plan and SAP-OTSAM-450-

03, Job Hazard Analysis Procedure.

Principle 7: Operations Authorization: The conditions and requirements for operations to be initiated and conducted are agreed upon

and clearly established. Although the EMCBC does not perform work authorization, the

EMCBC has line responsibility for the small sites. Program and Technical Support personnel

assist in Baseline Reviews, Readiness Reviews, ISMS, QA and other reviews in accordance

with procedures such as SAP-OTSAM-414C-04, Rev. 1, Document Reviews Procedure,

SAP-OTSAM-414C-02, Rev. 3, Independent Assessments Procedure and, SAP-OTSAM-


8

414C-01, Rev. 3, Assessment/Management Assessment and Oversight to ensure that

conditions and requirements for operations are in place prior to work authorization. Contracts

are authorized through IP-540-15, Rev.1A, Review and Approval of Proposed Sales,

Procurement, Financial Assistance and Subcontract Actions Procedure.

EM Safety Culture Principle 1: Individual Attitude and Responsibility for Safety: Every EMCBC individual accepts responsibility for safe mission performance. EMCBC

employees are coached through monthly safety meetings and news letters to demonstrate a

questioning attitude, challenge assumptions, investigate anomalies, and considering potential

adverse consequences of planned actions. Through the PP-OTSAM-450-01, FEOSH Plan,

each EMCBC employee is mindful of work conditions that may impact safety, and assist

each other in preventing unsafe acts or behaviors.

EM Safety Culture Principle 2: Operational Excellence: The EMCBC achieves sustained, high levels of operational performance, encompassing all

DOE and contractor activities to meet mission, safety, productivity, quality, environmental,

and other objectives. The EMCBC achieves this through a focus on operations, quality

decision-making, open-communications, deference to expertise, and systematic approaches

to eliminate or mitigate error-likely situations.

EM Safety Culture Principle 3: Oversight for Performance Assurance: The EMCBC has established a competent, robust, periodic and independent oversight

program that provides feedback that verifies expectations are being met and identifies

opportunities for improvement. The EMCBC accomplishes this through the Management

Assessment and Independent Assessment processes. These assessments verify that standards

and requirements are being met. The EMCBC performs assessments in accordance with an

integrated assessment schedule for continuous safety and performance improvement.

EM Safety Culture Principle 4: Organizational Learning for Performance

Improvement: The EMCBC demonstrates excellence in performance monitoring, problem analysis, solution

planning, and solution implementation through our SAP-OTSAM-414B-01, EMCBC

Corrective Action Procedure and IP-230-01, Rev.2, EMCBC Corporate Operating

Experience and Lessons Learned Procedure. The EMCBC encourages openness and trust,

and cultivates a continual learning environment.

4.0 Management Commitments and Expectations

The DOE-EM ISMSD provides the overarching DOE-EM commitment and expectations for

safety. In summary, safety is first. It overrides every other priority. In addition, safety is the

responsibility of every employee and it is the expectation of the EMCBC management that

each employee embrace their role in the implementation of the safety systems described in

this ISMSD. This commitment is expressed in the EMCBC Strategic Plan Values which are

People, Service and Safety:


9

Responsibilities and management expectations of each EMCBC employee are also described

in PP-OTSAM-450-01, EMCBC Federal Employees Occupational Safety and Health Plan.

In addition, the PO-OTSAM-451-01, EMCBC Environmental Management Policy has been

published to demonstrate our organizational commitment to ensure a healthy and protective

environment for workers and the public through every day sustainable practices that adhere

to applicable environmental protection laws, regulations and standards.

5.0 Integration of ISMS, Environmental Management System, and Quality

Assurance Plan

The EMCBC Strategic Plan defines the primary strategic themes (work scope) of the

EMCBC and establishes goals for achieving the EMCBC mission. The ISMS management

process defines how significant safety, environmental, and quality aspects are identified,

controlled, work is performed and feedback is obtained. Significant quality and

environmental management aspects are integrated into the ISMS process using the five Core

Functions. The EMCBC EMS requires work to be done in a four step process consistent with

the five Core Functions. This is commonly referred to as the “Plan-Do-Check-Act-Cycle”.

Significant environmental aspects are identified, managed, assessed, and reviewed using the

same management process as significant safety aspects.

6.0 Implementation of Safety Management at Small Sites

Safety Management flows down to the DOE-EM small sites through prime contracts.

EMCBC assures the flow down of safety management using DOE-EM Line Management

beginning with the Federal Project Directors of each small site. DOE Oversight and

Contractor Assurance are used to verify and validate implementation of safety. The tools and

mechanisms used rely on site specific plans, procedures and resources supplemented where

needed by EMCBC plans, procedures and Federal employee resources.

7.0 Measuring Safety Performance

The DOE-EM ISMSD provides the Safety Performance Objectives, Measures and

Commitments that the EMCBC strives to meet. The EMCBC FEOSH Plan ensures

continuous monitoring/inspections to verify a safe working environment is maintained.

Regular feedback to management concerning occupational safety and health hazards is

Safety at all times: • Our highest priority is to support the EM program in protecting

employees, the public and the environment. • We foster a culture that encourages and embraces the opinions of

workers and customers. • We conduct our work using the core functions and guiding principles of

Integrated Safety Management (ISM).


10

provided and work related injuries/illnesses are reported in the Computerized Accident

Incident Reporting System (CAIRS). Data for the CAIRS system is collected through the

SAP-OTSAM-450-04, Reporting Injuries procedure. Monitoring of Environmental

Management goals and performance measurement is described in the EMCBC

Environmental Management System (EMS) Program Description.

8.0 Contents

Procedures Procedure Content

SAP-OTSAM-445-02, Purchasing

Personal Protective Equipment

Describes how the EMCBC employees

purchase personal protective equipment.

SAP-OTSAM-450-03, Job Hazard

Analysis

Describes the process for identifying

work-related hazards faced by employees

in Department occupied space, at DOE

sites, or while on official travel.

Defines the process for conducting Job

Hazard Analysis (e.g., job safety analysis

and comprehensive safety and health

surveys)

SAP-OTSAM-450-04 Reporting

Injuries

Describes the process for reporting

injuries or illnesses including data entry

into the Computerized Accident Incident

Reporting System (CAIRS).

SAP-OTSAM-414C-01,

Assessment/Management

Assessment and Oversight

Describes the process for conducting

Management Assessments and Oversight

of both DOE and Contractor Activities.

9.0 Related Information

9.1 Requirements

10 CFR 830, Nuclear Safety Management

DOE O 226.1B, Implementation of Department of Energy Oversight Policy

DOE O 231.1B Admin Change 1, Environment, Safety and Health Reporting

DOE O 440.1B Admin Change 1, Worker Protection Management for DOE

(including The National Nuclear Security Administration) Federal Employees

DOE O 450.2, Integrated Safety Management

DOE 414.1D, Quality Assurance


11

9.2 References

DOE-HDBK-3027-99, Integrated Safety Management Systems Verification Team

Leader’s Handbook

DOE G 450.4-1C, Integrated Safety Management Guide

EMCBC Strategic Plan

9.3 Other Documents

Federal Employee Occupational Safety and Health Program (FEOSH) Plan

Figure 1: Flow Down of DOE Goals

EMCBC ISMS Implementation Matrix

10.0 Definitions - See EMCBC MS Definition List


12

EMCBC RECORD OF REVISION

DOCUMENT TITLE: Integrated Safety Management System (ISMS) Description

If there are changes to the controlled document before the two-year review cycle, the revision

number stays the same; one of the following will indicate the change:

l Placing a vertical black line in the left margin adjacent to sentence or paragraph that was

revised; or

l Placing the words GENERAL REVISION at the beginning of the text. This statement is

used when entire sections of the document are revised.

If changes and updates occur at the two-year review cycle, the revision number increases by one.

Rev. No. Description of Changes Revision on Pages Date ______

0 Initial Document 8-9-12

1 Significant revision as ISMS All 5-15-14

Description Document

2 Changes reflect update of FEOSH Multiple 3-3-16

Plan, addition of FEOSH Procedures,

and the newly revised Strategic Plan

FM-OD-410B-02-F1, Rev. 0

Subject Area: Integrated Safety Management System (ISMS ... · Subject Area: Integrated Safety...

Documents

Transcript of Subject Area: Integrated Safety Management System (ISMS ... · Subject Area: Integrated Safety...