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Policy Area

ESH-Environment Safety & Health

Procedure Number

ESH100.4.FI.1

Procedure Title

Perform ES&H Line Self-Assessment Activities

Procedure Manager

BENDURE, ALBERT O.

Status

Active

Subject Matter Expert

  • Robert S. Goetsch (Bob)
  • Dennis J Beyer (CA)

Applicability, Exceptions, and Consequences

This corporate procedure applies to all Members of the Workforce who perform ES&H line self-assessment (SA) activities.  

Exceptions to, or deviations from this procedure must be approved through the Executive Policy Sponsor or Policy Area Manager, if delegated. Click here to view Contacts for Corporate Policy System Policies, Processes, and Procedures. See CG100.1.7, Request an Exception to a Policy, Process, or Procedure, for directions on how to obtain an exception to this procedure.

Granting or permitting exceptions or violations of policy, process, or procedure without authority, regardless of position or title, may be cause for disciplinary action up to and including termination of employment. Violating a policy, process, or procedure may be cause for disciplinary action up to and including termination of employment.

IMPORTANT NOTICE: A printed copy of this document may not be the document currently in effect. The official version is located on the Sandia National Laboratories Sandia Restricted Network (SRN).

Procedure Overview

This procedure provides detailed requirements – planning, scheduling, and conducting ES&H line self assessments (SAs) as required by ESH100.4.FI.5, Perform and Document Management Surveillances, provides supplemental guidance and instruction for conducting management surveillances.) These SAs include the following activities:

  • Identifying, communicating, and correcting performance or compliance issues.
  • Observing, assessing, and improving work processes.
  • Reviewing effective implementation of flow-down requirements.
  • Identifying findings, observations, noteworthy practices, and lessons learned.

 

Procedure Requirements

SA Instruction

Activity Responsible Individual Required Action
Ensure SA Instruction Vice Presidents (VPs)
  • Ensure appropriate self-assessment (SA) instruction is identified and developed per the division SA process. 
  • Ensure direct reports (participants in line SA activities) receive appropriate instruction.
Complete SA Instruction Center Directors
  • Complete SA instruction.
  • Ensure direct reports (participants in line SA activities) receive appropriate instruction.
Complete SA Instruction Senior Managers
  • Complete SA instruction.
  • Ensure Members of the Workforce (participants in line SA activities) receive appropriate instruction.
Complete SA Instruction Managers
  • Complete SA instruction.
  • Ensure Members of the Workforce (participants in line SA activities) receive appropriate instruction.
Complete SA Instruction Members of the Workforce
  • Complete appropriate SA instruction, as assigned by management.
  • Adhere to SA instruction (i.e., instruction in performing SAs, documenting results in the Laboratory Enterprise Self-Assessment [LESA] database and, as appropriate, in the Corrective Action Tracking System [CATS]).

Define Expectations and Schedule the SA

Activity Responsible Individual Required Action
Define Expectations Vice Presidents
  • Integrate ES&H into overall mission performance.
  • Include self-assessment (SA) activities in VP action plans and VP performance management forms (PMFs).
  • Define expectations for division line ES&H SA program in accordance with ESH100.4.FI.5, Perform and Document Management Surveillances.
  • Establish metrics to measure the effectiveness of the Integrated Safety Management System (ISMS) Description core functions.
  • Drive cultural change by reinforcing expectations, demonstrating commitment to safety, rewarding performance, and establishing a presence in the workplace.
  • Manage corporate issues in accordance with CG100.6.8, Identify and Manage Corporate Issues.
Establish SA Schedule Vice Presidents
  • Perform a risk review of the analyses of previous years' SA reports as input for establishing the risk-based division annual SA plan.
  • Ensure that the division annual SA plan incorporates center annual SA plans combined with any corporate-directed SAs.
    • Include any policy area self-assessments (PASA) identified by sponsoring managers in the annual SA plan.
    • Adhere to the Corporate SA Plan, which may include division SAs that are ES&H focus areas and the timetable established for their completion.
  • Submit division annual SA plan to the Vice President of Enterprise Transformation. Notes:
    • Centers should consider including assessments of flow-down of requirements in their SA plans.
    • Radiological activities are assessed, at a minimum, every 3 years in accordance with ESH100.2.RAD.1, Implement Radiation Protection Procedures.
  • Establish expectations for division line ES&H SA performance based on a review of the results of the division’s previous years' ES&H performance and SA data (e.g., to include any PASA identified by CG100.6.2, Develop and Maintain the Integrated Assessment Schedule, CG100.6.3, Perform Assessments, and CG100.6.4, Perform Policy Area Assessments of the Policy). Communicate division SA expectations to direct reports at the beginning of the performance year and encourage positive behavior and discernment of opportunities for improvement.
  • Ensure that expectations for SAs are communicated through all levels of the organization.
  • Make resources available to perform SAs.
  • Establish performance goals and metrics.

Set Business Priorities and Schedule and Communicate Expectations

 

 Center Directors
  • Risk-review the previous years' findings and CAs in order to set the center business priorities, and use this information to set the content and number of organizational SAs.
  • Integrate ES&H into overall mission performance.
  • Communicate center SA expectations to direct reports at the beginning of the performance year and encourage positive behaviors and discernment of opportunities for improvement.
  • Perform SA activities documented in division annual SA plan.
  • Include ES&H ownership in performance management forms (PMFs) (both their own PMFs and those of their direct reports).
  • Develop a center SA plan in conjunction with senior managers.
  • Define expectations for the center line ES&H SA program.
  • Drive cultural change by reinforcing expectations, demonstrating commitment to safety, rewarding performance, and establishing a presence in the workplace.
  • Support ES&H assessments of line implementation requirements per the ES&H procedures and program.

Set Business Priorities and Communicate Expectations

 

 Senior Managers
  • Risk-review the previous years' findings and CAs in order to set the center business priorities, and use this information to set the content and number of organizational SAs.
  • Integrate ES&H into overall mission performance.
  • Communicate self-assessment (SA) expectations to direct reports at the beginning of the performance year and encourage positive behavior and discernment of opportunities for improvement.
  • Establish an organization self-assessment (SA) strategy based on the annual center SA expectations.
  • Include ES&H ownership in performance management forms (PMFs) (both their own PMFs and those of their direct reports).
  • Define expectations for the organization’s line ES&H SA program.
  • Drive cultural change by reinforcing expectations, demonstrating commitment to safety, rewarding performance, and establishing a presence in the workplace.
  • Support ES&H assessments of line implementation requirements per the ES&H procedures and program.

Set Business Priorities and Communicate Expectations

 

 Managers
  • Integrate ES&H into overall mission performance.
  • Communicate SA expectations to direct reports at the beginning of performance year and encourage positive behavior and discernment of opportunities for improvement.
  • Interact with Members of the Workforce in a coaching manner.
  • Perform SAs per the established organization SA strategy and based on the annual center SA plan.
  • Include ES&H ownership in PMFs (their own PMFs and those of their direct reports).
  • Define expectations for the department’s line ES&H SA program.
  • Drive cultural change by reinforcing expectations, demonstrating commitment to safety, rewarding performance, and establishing a presence in the workplace.
  • Support ES&H assessments of line implementation requirements per the ES&H procedures and program.

Establish SA Annual Schedule and Demonstrate Department Commitment 

 

 Members of the Workforce
  • Integrate ES&H into overall mission performance.
  • Perform, as assigned, SAs per the established department SA strategy and based on the annual center SA expectations.
  • Include ES&H ownership in their performance management forms (PMFs).
  • Drive cultural change by meeting management’s safety expectations.
  • Support ES&H assessments of line implementation requirements per the ES&H procedures and program.

Perform SA

Activity Responsible Individual Required Action
Review and Ensure Resources Vice Presidents
  • Ensure SAs are performed per division annual self-assessment (SA) plan.
  • Review the ongoing analysis of division SA activities in order to:
    • Establish content, number, and dates for the division annual SA plan.
    • Set SA performance goals.
  • Ensure resources are available to perform SAs.
Analyze Results and Resources Center Directors
  • Ensure SAs are performed per center ES&H SA plan.
  • Analyze center SA results in order to:
    • Establish content, number, and dates for the center ES&H SA plan.
    • Measure and set center SA performance goals.
    • Determine systemic and cross-organizational issues.
  • Ensure resources are available to perform SAs.
Perform SAs, Analyze Results, and Ensure Resources Senior Managers
  • Perform assigned SAs per center ES&H SA plan.
  • Analyze organization SA results in order to:
    • Measure and set the organization’s SA performance goals.
    • Determine systemic and cross-organizational issues.
  • Ensure resources are available to perform SAs.
Perform SAs, Analyze Results, and Ensure Resources Managers
  • Perform assigned SAs per center ES&H SA plan. Notes:
    • Managers have a thorough knowledge or technical understanding of the site’s work planning and execution processes as described in the Integrated Safety Management System (ISMS) Description, Sections 2.1.2, "Safety Management Functions," and 2.1.3, "Guiding Principles."
    • Identification of unsafe work conditions or operations during the course of assessment activities result in the suspension of the activity and an immediate report to management.
  • Ensure resources are available to perform SAs.
  • Identify the space and/or activity to be assessed.
  • Identify management, and if appropriate, Members of the Workforce who perform the assessments.
  • Determine the date the assessment is to be conducted to meet the center ES&H SA plan.
  • Review documentation prior to the assessment. These documents should include (if appropriate), but are not limited to:
    • Primary hazard screenings (PHS) and applicable authorization basis documents.
    • Past SAs and corrective actions.
    • Applicable technical work documents (TWDs).
    • Training records.
    • Performance/flow-down requirements and expectations.
    • Results of applicable ES&H programmatic SAs.
    • Selection of tools over and above a checklist, if required. Note: See ESH100.4.FI.5, Perform and Document Management Surveillances, for more information.
    • Verification and/or validation of CAs from previous findings.
  • Observe work activities to ensure that there are no deviances from documented work controls and corporate process requirements (e.g., ES&H procedures).
  • Analyze department SA results to:
    • Measure and set department SA performance goals.
    • Determine systemic and cross-department issues.
Perform SAs and Keep Activities Current Members of the Workforce
  • Perform assigned SAs per center ES&H SA plan.
  • Keep work activities and space assessment ready.
  • Seek guidance (as needed) from SMEs and other corporate resources.

Gather SA Data

Activity Responsible Individual Required Action
Use Checklists, Identify Deficiencies, and Document Results Vice Presidents
  • Use the appropriate checklists and perform SAs according to the established division annual self-assessment (SA) plan.
  • Ensure that SA results are documented in the Laboratory Enterprise Self-Assessment (LESA) application and address them per ESH100.4.FI.5, Perform and Document Management Surveillances.
    • Address findings and observations per ESH100.4.FI.5, Perform and Document Management Surveillances.
    • Document noteworthy practices.
Use Checklists, Identify Deficiencies, and Document Results Center Directors
  • Use the appropriate checklists and perform SAs according to the established center ES&H SA plan.
  • Identify deficiencies and, when appropriate, support addressing deficiencies immediately upon identification.
  • Ensure that SA results are documented in the LESA and address them per ESH100.4.FI.5, Perform and Document Management Surveillances.
    • Address findings and observations per ESH100.4.FI.5, Perform and Document Management Surveillances.
    • Document noteworthy practices.
Use Checklists, Identify Deficiencies, and Document Results Senior Managers
  • Use the appropriate checklists and perform SAs according to the established center ES&H SA plan.
  • Identify deficiencies and, when appropriate, support "Just Do Its."
  • Ensure that SA results are documented in the LESA and address them per ESH100.4.FI.5, Perform and Document Management Surveillances.
    • Address findings and observations per ESH100.4.FI.5, Perform and Document Management Surveillances.
    • Document noteworthy practices.
Identify Deficiencies, Document Results, and Address Findings and Observations Managers
  • Use the appropriate checklists and perform SAs according to the established center ES&H SA plan.
  • Identify deficiencies and, when appropriate, support "Just Do Its.”
  • Ensure that SA results are documented in the Laboratory Enterprise Self-Assessment (LESA) application and address them per ESH100.4.FI.5, Perform and Document Management Surveillances.
    • Address findings and observations per ESH100.4.FI.5, Perform and Document Management Surveillances.
    • Document noteworthy practices.
Gather Self-Assessment Data Members of the Workforce
  • Use the appropriate checklists and perform assigned SAs according to the established center ES&H SA plan. Note: When checklists are used, SA results shall be entered into the Laboratory Enterprise Self-Assessment (LESA) application per ESH100.4.FI.5, Perform and Document Management Surveillances.
  • Support “Just Do Its,” when appropriate.
  • Collect information and/or evidence to determine whether ES&H performance meets flow-down of requirements and corporate expectations.
  • Gather sufficient information to validate conclusions and report results.
  • Ensure that SA results are documented in LESA and address them per ESH100.4.FI.5, Perform and Document Management Surveillances.
    • Address findings and observations per ESH100.4.FI.5, Perform and Document Management Surveillances.
    • Document noteworthy practices.
  • Ensure that SA results (including concerns and problems, opportunities for improvement) are documented in the LESA application, and report SA results to management.

Notes:

    • Report potential non-conformances with nuclear safety requirements or worker safety and health requirements to the Safety and Security Regulatory Support Office (see ESH100.4.RPT.6, Identify, Report, and Correct Nuclear and Worker Safety Issues and Nonconformances). Issues are identified and reported up the management chain per CG100.6.8, Identify and Manage Corporate Issues.
    • Identification of unsafe work conditions or operations during the course of assessment activities result in the suspension of the activity and an immediate report to management.

Communicate SA Data

Activity Responsible Individual Required Action
Communicate Division Results Vice Presidents Communicate and report division self-assessment (SA) results regularly to direct reports and Laboratory Leadership Team (LLT). Note: If significant safety issues are identified during SA, see ESH100.3.1, Prepare for and Manage Emergencies , for reporting requirements. The OOPS process can be used as a tool to help complete the reporting requirements.
Communicate Center Results Center Directors Communicate center SA results to the division vice president, peers, and center staff. Note: If significant safety issues are identified during SA, see ESH100.3.1, Prepare for and Manage Emergencies, for reporting requirements. The OOPS process can be used as a tool to help complete the reporting requirements.
Communicate SA  Results Senior Managers Communicate SA results to center director, peers, direct reports, and staff. Note: If significant safety issues are identified during SA, see ESH100.3.1, Prepare for and Manage Emergencies, for reporting requirements. The OOPS process can be used as a tool to help complete the reporting requirements.
Communicate SA  Results Managers Communicate SA results to senior manager, peers, and staff. Note: If significant safety issues are identified during SA, see ESH100.3.1, Prepare for and Manage Emergencies, for reporting requirements. The OOPS process can be used as a tool to help complete the reporting requirements.
Communicate SA  Results Members of the Workforce Communicate SA results to management and peers. Note: If significant safety issues are identified during SA, see ESH100.3.1, Prepare for and Manage Emergencies, for reporting requirements. The OOPS process can be used as a tool to help complete the reporting requirements.

Analyze SA Data

Activity Responsible Individual Required Action
Use Metrics and Analyze Data Vice Presidents
  • Use metrics to measure the effectiveness of the Integrated Safety Management System (ISMS) Description core functions.
  • Analyze division SA data.
  • Review SA completion against division performance goals.
  • Identify systemic and recurring deficiencies.
  • Review existing and historical findings to identify trends.
  • Review lessons learned and identify noteworthy practices.
Use Metrics, Analyze Data, and Review Findings and Lessons Learned Center Directors
  • Use metrics to measure the effectiveness of the ISM core functions.
  • Analyze center SA data.
  • Review SA completion against center SA performance goals.
  • Identify systemic and recurring deficiencies.
  • Review existing and historical findings to identify trends.
  • Review lessons learned and identify noteworthy practices.
Use Metrics, Analyze Data, and Review Findings and Lessons Learned Senior Managers
  • Use metrics to measure the effectiveness of the ISM core functions.
  • Analyze organization SA data.
  • Identify systemic and recurring deficiencies.
  • Review existing and historical findings to identify trends.
  • Review lessons learned and identify noteworthy practices.
Use Metrics, Analyze Data, and Review Findings and Lessons Learned Managers
  • Use metrics to measure the effectiveness of ISM core functions.
  • Analyze department SA data.
  • Identify systemic and recurring deficiencies.
  • Review existing and historical findings to identify trends.
  • Review lessons learned and identify noteworthy practices.
Discover Issues Members of the Workforce
  • Look for underlying issues that contribute to systemic and recurring deficiencies.

Develop Corrective Actions

Activity Responsible Individual Required Action
Ensure CAs’ Effectiveness and Efficiency Vice Presidents Ensure that the corrective actions (CAs) (per CG100.6.6, Perform Corrective Actions, CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews, and CG100.6.14, Conduct Independent Validation of Closed CATS Findings)are effective and efficient and verify appropriate involvement and implementation by Members of the Workforce.
Develop CAs and Ensure Completion and Implementation Center Directors
  • Develop CAs per CG100.6.6, Perform Corrective Actions, CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews, CG100.6.14, Conduct Independent Validation of Closed CATS Findings. Note:  The process responsibility, track to completion, documentation of completion, and process effectiveness are part of the correction process documented in CG100.6.6, Perform Corrective Actions, CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews, CG100.6.14, Conduct Independent Validation of Closed CATS Findings.
  • Make resources available to ensure CAs are completed on time.
  • Ensure CAs are implemented effectively and efficiently, and verify appropriate involvement and implementation by Members of the Workforce.
  • Verify that related CAs previously implemented have corrected the deficiency and that the CA remains effective.
Develop CAs and Ensure Completion and Implementation Senior Managers
  • Develop CAs per CG100.6.6, Perform Corrective Actions, CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews, CG100.6.14, Conduct Independent Validation of Closed CATS Findings.
  • Make resources available to ensure CAs are completed on time.
  • Ensure CAs are implemented effectively and efficiently and verify appropriate involvement and implementation by Members of the Workforce, interacting with Members of the Workforce in a coaching manner as needed.
  • Verify that related CAs previously implemented have corrected the deficiency and that the CA remains effective.
Develop CAs and Ensure Completion and Implementation Managers
  • Develop CAs per CG100.6.6, Perform Corrective Actions, CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews, CG100.6.14, Conduct Independent Validation of Closed CATS Findings. Make resources available to ensure CAs are completed on time.
    • Assign an owner for each CA.
    • Identify the resources necessary to complete the CA.
  • Ensure CAs are implemented effectively and efficiently. Verify appropriate involvement and implementation by Members of the Workforce, and interact with Members of the Workforce in a coaching manner as needed.
  • Verify that related CAs previously implemented have corrected the deficiency.
  • When the CA is completed, verify CA completion, communicate to upper management.
  • Ensure CA process is followed per CG100.6.6, Perform Corrective Actions, CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews, CG100.6.14, Conduct Independent Validation of Closed CATS Findings.
Participate in CAs Members of the Workforce
  • Take actions on minor issues in real time – "Just Do It."
  • Participate in causal analyses on findings as appropriate, per CG100.6.6, Perform Corrective Actions, CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews, CG100.6.14, Conduct Independent Validation of Closed CATS Findings.
  • Support the implementation of CAs, as appropriate.
  • Support the verification of previously implemented CAs, as appropriate, to ensure the deficiency has been corrected and the CA remains effective.

Implementing Tools

Guidance

  • Guidance for Planning, Conducting and Documenting Quality Assessments

Websites

  • Root Cause/Causal Analysis.
  • Integrated Safety Management System (ISMS) Description.
  • OOPS process.
  • Primary Hazard Screening (PHS)

Tools

  • Laboratory Enterprise Self-Assessment (LESA).
  • Corrective Action Tracking System (CATS).

Requirement Drivers (Prime Contract Baseline Directives)

DOE O 226.1A DOE O 413.1B DOE O 414.1C DOE O 450.1A DOE M 450.4-1 DOE 5480.19, Chg 2

Additional Drivers

  • Management and Operating Contract Between Sandia Corporation and DOE, DE-AC04-94AL85000, Section H, "Special Contract Requirements," H-3 Integrated Laboratory Management System.
  • Lockheed-Martin Corporation, Environment Safety and Health Self-Assessment Process, Corporate Functional Procedure ESH-10 (only available on the Lockheed-Martin internal network and password is required – see ES&H Librarian).

Related Processes and Procedures

Processes

Procedures

  • CG100.5.1, Define and Maintain the Corporate Quality Assurance Program.
  • CG100.5.2, Assign Quality Assurance Responsibilities to Policy Areas.
  • CG100.5.3, Determine Need for Project, Facility, or Organization QA Program Document.
  • CG100.6.2, Develop and Maintain the Integrated Assessment Schedule.
  • CG100.6.3, Perform Assessments.
  • CG100.6.4, Perform Policy Area Assessments of the Policy.
  • CG100.6.6, Perform Corrective Actions.
  • CG100.6.7, Conduct Independent Audits.
  • CG100.6.8, Identify and Manage Corporate Issues.
  • CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews.
  • CG100.6.14, Conduct Independent Validation of Closed CATS Findings.
  • ESH100.1.EP.1, Implement the Environmental Management System (EMS).
  • ESH100.2.RAD.1, Implement Radiation Protection Procedures.
  • ESH100.3.1, Prepare for and Manage Emergencies. 
  • ESH100.3.3, Implement Conduct of Operations.
  • ESH100.4.FI.5, Perform and Document Management Surveillances.
  • ESH100.4.RPT.6, Identify, Report, and Correct Nuclear and Worker Safety Issues and Nonconformances.
  • ESH100.4.RPT.7, Report on Safety and Security Regulatory Compliance.

 

Change Summary

Date Summary
10/13/2011

Administrative

Modified

  • Changed subject matter expert from Yolanda Padilla-Vigil to Bob Goetsch.

  • Replaced SAPLE links for subject matter experts with links directly to e-mail.
06/07/2011

Administrative

Modified

Changed website name from "Primary Hazard Screen" to Primary Hazard Screening." (Forms, Links & Tools)
06/06/2011

Administrative

Modified

  • Updated titles to applicable procedures listed under "Related Corporate Processes & Procedures."
  • Replaced CG100.5.4, Implement Conduct of Operations with ESH100.3.3, Implement Conduct of Operations. (Related Corporate Processes & Procedures)
  • Updated title to the H-3 clause under "Additional Drivers."
  • Updated title to CG100.6.3, CG100.6.4, and CG100.6. where applicable throughout the document.

Added

  • CG100.5, Ensure Quality; CG100.6, Assure Performance Process; and ESH100.3, Perform Work under "Processes." (Related Processes and Procedures)
  • ESH100.3.1, Prepare for and Manage Emergencies under "Procedures." (Related Processes and Procedures)
  • Primary Hazard Screen (PHS) under "Websites."  (Forms, Links & Tools)
05/18/2011

Administrative

Added

  • Guidance document, Guidance for Planning, Conducting and Documenting Quality Assessment. (Forms, Links & Tools)
  • The omitted "Perform SAs, Analyze Results, and Ensure Resources" activity title for managers within the "Perform SA" table.  (Requirements & Instructions)
12/01/2010

Administrative

Modified

  • Corrected link to "policy area self-assessments (PASA)." (Requirements & Instructions, Define Expectations and Schedule the SA)
  • Replaced "executive policy sponsors (EPS)" text with "sponsoring managers" and revised the link. (Requirements & Instructions, Define Expectations and Schedule the SA)
  • Corrected link to "report SA results to management."  (Requirements & Instructions, Gather SA Data)
11/29/2010

Administrative

Modified

  • Corrected link to Integrated Safety Management System (ISMS). (Forms, Links & Tools)
  • Corrected title to ESH100.1.EP.1, Implement the Environmental Management System (EMS). (Related Corporate Processes and Procedures)
  • Updated SAPLE link to subject matter expert for system consistency.
  • Un-merged cells in Requirements & Instructions for display purposes.
  • Updated all dictionary terms to contain term identification numbers for system consistency.
09/03/2010

Administrative

Modified

  • Changed CA Contact from Terry Garner to Dennis Beyer.
05/13/2010

Administrative

Modified

  • Updated glossary term hyperlinks throughout document.