ISM CORE FUNCTION TEAM
SUMMARY REPORT
ISM CORE FUNCTION TEAMS
CYCLE 1 REPORT
Introduction 3
1.0 Core Function Team #1 3
1.1 Team Members 3
1.2 Summary of Assessment 3
1.3 Participants 3
1.4 Findings 5
1.5 Observations / Opportunities for Improvement 5
1.6 Noteworthy Practice 8
1.7 Other Results 11
2.0 Core Function Team #2 12
2.1 Team Members 12
2.2 Summary of Assessment 12
2.3 Participants 12
2.4 Findings 13
2.5 Observations / Opportunities for Improvement 13
2.6 Noteworthy Practices 14
2.7 Other Results 14
3.0 Core Function Team #3 15
3.1 Team Members 15
3.2 Summary of Assessment 15
3.3 Participants 17
3.4 Findings 17
3.5 Observations / Opportunities for Improvement 18
3.6 Noteworthy Practices 20
3.7 Other Results 21
4.0 Core Function Team #4 22
4.1 Team Members 22
4.2 Summary of Assessment 22
4.3 Participants 23
4.4 Findings 24
4.5 Observations / Opportunities for Improvement 25
4.6 Noteworthy Practices 28
4.7 Other Results 29
5.0 Core Function Team #5 32
5.1 Team Members 32
5.2 Summary of Assessment 32
5.3 Participants 32
5.4 Findings 34
5.5 Observations / Opportunities for Improvement 35
5.6 Noteworthy Practices 35
5.7 Other Results 35
All team input attached as Appendices 1-5
Introduction
The following report has been prepared to summarize activities and results of Independent Assessment IA-2008-3, 4, 5, 6, and 7. For detailed information on the assessment process please refer to the document titled “ISM Core Function Team Assessment Plan (Cycle 1)” dated January 2008.
1.0 Core Function Team #1
The following summary information was taken from the full Core Function Team #1 report which appears as Appendix 1 of this report.
1.1 Team Members
· Debra Brand
· Howard Fenker
· Byron Golden
· John Riesbeck
· Kelly Tremblay
1.2 Summary of Assessment
Assessment activities included interviews and document review.
1.3 Participants
Organization / Division / InterviewedFEL / Gun Test Stand / George Neil
Carlos Hernandez-Garcia
Bubba Bullard
Accelerator / Operations / Arne Freyberger
Michael Epps
Accelerator / SRFINT / Charlie Reece
Jeff Saunders
Chris Dreyfuss
Facilities/Logistics / Mechanical / John Sprouse
John Kelly
Caroll Jones
Mike Sprouse
Scott Weiss (contractor)
Facilities/Logistics / Property / John Sprouse
Thomas Briggs
William Brisiel
Engineering / Mechanical / Will Oren
Butch Dillon-Townes
Larry Munk
Engineering / EESIC / Will Oren
Omar Garza
Pete Francis
Physics / Hall A / Kees De Jager
Ed Folts
Hall A technicians
Physics / Hall B / Volker Burkert
Doug Tilles
Tom Carstens
Physics / Hall C / Steve Wood
Walter Kellner
Andy Kenyon
12 GeV / Claus Rode
Jim Parkinson
Tim Witlach
ESH&Q / Bob May
Jennifer Williams
1.4 Findings
F/M Property
· No SOP for unloading hazardous chemicals, for example HF.
· SOP for Lead Storage has no Signatures or tracking numbers
1.5 Observations / Opportunities for Improvement
ESH&Q Health & Safety Programs
· Observation: Clear definition of technical support staff to identify IH related tasks once ESH&Q staff has identified hazards or potential hazards. (What I mean by this is what documentation tells technical staff how to carry out a specific task).
· Opportunities for Improvements :More technical support staff to assist with mitigating hazards
JLAB 12 GeV Project
Opportunities for Improvements:
· Organizational Charts - the 12 GEV organizations chart under Home Page/Division and Departments is out of date. The correct chart seems to be on the Home Page/12GEV. Modify linkage or make sure we can update the web pages. PA was contacted on 1/23 and the work was already in progress. Update has not yet occurred. All groups are not represented.
· One possible interviewee stated that due to such unfamiliarity with ISM that they would not be the correct person to be interviewed. Concern about the number of people who are unfamiliar with ISM.
FEL
Opportunities for Improvements:
· Cover sheet for a SOP had typed signatures in one location versus the actual signatures. Is the record keeping process defined clearly enough in the ES&H chapter. Is the typed name OK as long as we have original signatures on the document? ES&H chapter 3310 states “copy of working document”. The signed cover sheet should also be posted.
· When searching for the FEL OSP and SOPs, it was noted that not all of the FEL SOPs have the FEL designation. This appears to be handled by ESH&Q division. Examples include:
§ A-03-011 Testing Chamber with Quartz Disk – FEL Tech Shop
§ A-04-007-SOP FEL Linac Maintenance and Safety
§ A-05-002-L FEL Facility User Lab 6
§ A-06-001-LSOP High Power Optics, FEL Rm 209
§ A-06-003-LSOP Drive laser Alignment in Vault for REL, FEL Rm 107
· The FEList does not roll-up individual FEList items that are required for each experiment.
· Website Search – FEList and Atlist. The search feature did not provide the websites. The link had to be provided.
FM Mechanical
Opportunities for Improvements:
· There is no obvious system in place to notify effected personnel other than the personal experience of SOTR and technicians ( suggest to be required by customer when initiating work request)
F/M Property
Opportunities for Improvements:
· Define Hazardous material that can not be unloaded at S & R or that needs immediate processing (how do workers know which HAZMATS can be received or delivered directly to customer?)
o Lead SOP has no Division serial number and can not be found in ESH data base
Hall-B
Opportunities for Improvements:
· ESH sign-off of AHA’s is not performed. Will ES&H sign-off be required for the HBlist program?
· Continue formalizing the HBList to include risk code calculation.
Hall-C
Opportunities for Improvements:
· Identify those tasks that are recurring in nature and establish standard procedures for them.
· ESH sign-off of AHA’s is not performed. Will ES&H sign-off be required for the HCList program?
· Continue formalizing the HCList to include risk code calculation.
Accelerator - SRFINT
Opportunities for Improvements:
· More technical support for R&D group projects
Accelerator Ops
Opportunities for Improvements:
· Clear definition of outsourcing(support, system experts) for specific tasks
Engineering – ESSIC
Opportunities for Improvements:
· Better documentation of lessons learned.
· Initiating / investigate the use of a second person to assist (check for safety concerns) when techs are called in during the middle of the night.
· Some of the web information is scattered on older pages – suggest one clear site (the EESIC wiki site).
Hall A
Opportunities for Improvements:
· Merging of HAList with ATLis
· Sign offs or acknowledgement for activities in HAList.
· Easy link to the HAList
1.6 Noteworthy Practice
JLAB 12 GeV Project
Noteworthy Practices:
· A 12 GEV schedule developed in P3 shows planned work through 2015.
· Safety – An example is that even though work is mostly being performed by designers and planners, office ergonomics was highlighted. The lab’s industrial physician has been brought in to educate these workers about good posture, appropriate furniture and workstation accessories, etc.
FEL
Noteworthy Practices:
· OSP – Addendum to the OSP is specifically called out along with relevant SOPs.
· LSOP – FEL Laser Safety Operations Procedure – Warrants further review. As of January 28, 2008 this document was still in the review process. The LSOP will have final sign-off prior to laser operation. The LSOP is not needed for high voltage processing.
FM Mechanical
Noteworthy Practices:
· An ESH&Q staff member dedicated to facilities, and integrated into the entire job planning and or contract procurement process.
· Large contractors have access to MAXIMO task order system and can review and modify task orders as necessary to update ESH concerns or changes in Scope of Work.
F/M Property
Noteworthy Practices:
· Open two way communication at all levels
· STOP work program encouraged by management to staff
· Worker input used in shipping and receiving process to help stream line process
Hall-B
Noteworthy Practices:
· 90/10 Rule (10% thought given to working safely, 90% doing the work safely)
· Standard installation work procedures exist and more are being drafted.
· At Friday meetings, sometimes an ES&H manual chapter is reviewed and summarized for all to hear.
ESH&Q Health & Safety Programs
Noteworthy Practices:
· All procedures and records well documented
· On –line home page contains many links to needed records and information
Hall-C
Noteworthy Practices:
· Good housekeeping discipline
· Thorough briefing and interaction with workers before observed task started
Accelerator – SRFINT
Noteworthy Practices:
· 90/10 Rule (10% thought given to working safely, 90% doing the work safely)
· SOPs, work instructions exist and more are being drafted.
· Daily Production meetings and weekly project planning meetings
· Friday safety meeting ( various safety topics), 2 week outlook production meeting
· Pansophy
Accelerator Ops
Noteworthy Practices:
· Standard work procedures exist and more are being drafted.
· Weekly Budget and Planning meetings.
· ATlis
· Accel Ops is in the process of integrating ATlis and Ops Documents
· Lesson Learned review of previous task
Engineering – ESSIC
Noteworthy Practices:
· Use of ATLis task list.
· System owners are experts and pro-active in responding and suggesting operation improvements.
· Cohesion of OPS and ICS in the maintaining of machine operability using OPS PRs.
· Development of the ICS Wiki as a source of information.
· Trust in the ability of the technical staff.
· Responsiveness to lab mission of keeping the beam operations at the forefront in a safe manner.
Engineering – Mechanical Engineering
Noteworthy Practices:
· Design review process – early involvement of interested parties.
· Checking of drawings by two engineers independently to ensure correctness.
· Utilization of procurement’s vendor feedback system.
Hall A
Noteworthy Practices:
· Implementation of the HAList
· Work package document development.
· Hazard analysis for every item within the work package
1.7 Other Results
None
2.0 Core Function Team #2
The following summary information was taken from the full Core Function Team #2 report which appears as Appendix 2 of this report.
2.1 Team Members
· Bill Vulcan (leader)
· Joe Beaufait (leader)
· Harry Fanning
· Manny Nevarez
· Dave Hamlette
2.2 Summary of Assessment
The purpose of this investigation was to determine if line management and workers were conducting and documenting Task Hazard Analysis for all work done at Jefferson Labs.
Because of the large number of groups to be covered and the difficulty in scheduling, actual task reviews, during a time of machine operation, our team concentrated on interviewing a representative sample of group and line managers. We individually interviewed two to three people a week, asking twelve questions, pre determined by our task group. In addition, where documents such as, work orders, ATlis, FElist, Alist and others were sited we checked that the systems are current and in use.
2.3 Participants
CF Team #2 interviewed twenty seven people across six groups. Our goal was to check any group large enough to have its own policy. Management and office groups were omitted to save time
2.4 Findings
Target group (Physics)
When asked about Task Hazard Analysis, the interviewee responded that their group did not do it. Although, it has been shown that this individual has, in fact, done THA’s for large projects, an overall sampling of the workers in the group, showed that they were not aware of any hazard analyses being done for daily tasks. The interview was terminated after this initial question and no response was recorded for the following areas.
Injector (Accelerator)
This group may work under a standing OSP however, the interview seemed to reveal a lack of daily planning. There was no reference, to any activity, that would leave a written indication that hazard analysis had been done.
Overall
The decision to involve ESH&Q was ambiguous across the lab. Statements like, “when the job falls outside of my knowledge” were common. A statement in the ESH&Q manual setting a formal hazard level cut off for the notification of Safety group should be added.
2.5 Observations / Opportunities for Improvement
· If a THA involved no hazard or all hazard class 0/1 no paperwork was filed. It is recommended that the online form be upgraded so that THAs can be saved online when completed. This will leave a record of the analysis, even if it results in zero hazards.
· Many individuals expressed a feeling of concern over the objective nature of the hazard level matrix. Supervisors that had the Dupont, Stop, training felt that it significantly helped them understand and use the matrix.
· Hall C Physics was using ESAD and COO document for installation and activation of experiment but, was not documenting daily activities. They have already implemented a version of ATlis called Clist to cover this shortfall.
2.6 Noteworthy Practices
· Accelerator Operability, using ATlis, has a fantastic program that not only walks the user through the THA but automatically informs EHS&Q regardless of hazard level. Required protective equipment and job analysis are printed on the work order. This system has been modified and adapted across many groups at the lab. Where it is used it gives daily documentation of hazard analysis and planning, even where hazards are small. This system has been adopted by Hall A, Hall C, FEL and others. It is rapidly becoming the standard at the lab.
· It was uniformly stated across the lab that everyone had stop work authority. Even where it may have been overlooked in individual briefings, the cultural understanding was that any individual could stop any job for justifiable cause.
2.7 Other Results
· Overall it was found that most groups have a healthy Hazard Analysis Program in place however, some have room for improvement. These weaknesses have now been documented and can be addressed.
· A lab wide weakness in the documentation, of when it was necessary to involve EHS&Q in planning, was noted.
· The interviews and tasks associated with this cycle of review have already raised the understanding and awareness of ISM across the lab.
3.0 Core Function Team #3
The following summary information was taken from the full Core Function Team #3 report which appears as Appendix 3 of this report.