Chapter 01 – General ES&H Requirements, Responsibilities, and Work Practices

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Approved by Maria Nappi
Revised 10/23

1.1 Policy
1.2 Scope
1.3 Applicability
1.4 Exceptions
1.5 Integrated Safety Management (ISM) Overview
1.6 Introduction to the ES&H Manual
1.7 Subcontractor Flow Down of Safety and Health Requirements
1.8 Workers’ ES&H Rights and Responsibilities
1.9 Employee ES&H Concerns Reporting Policy
1.10 Roles and Responsibilities
1.11 Definitions
1.12 Required Work Processes

Work Process A. Developing or Revising ES&H Policies and Programs
Work Process B. The Use of “Shall,” “Must,” “Should,” and “May” in EHS Documents
Work Process C. EHS Safety Evaluations of Used, Gifted, Loaned, Borrowed, or User-Owned Equipment
Work Process D: Working Alone Policy
Work Process E: Stop Work Policy
Work Process F: Requesting a Variance from Berkeley Lab Safety Policy

1.13 Source Requirement Documents
1.14 Reference Documents

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1.1. Policy

The Lawrence Berkeley National Laboratory (Berkeley Lab) Environment, Safety & Health (ES&H) Manual, previously known as PUB-3000, describes in detail the technical work processes and administrative procedures used to control hazards in workplaces and environments in accordance with Berkeley Lab policy. The standards in this manual are designed to:

Protect people from injury and illness, and to protect property and the environment from damage, loss or degradation due to accidents or other causes
Comply with the requirements of Berkeley Lab’s contract with DOE (Contract 31), the EHS technical program areas defined by the ES&H Standards Set in Appendix I of Contract 31, and applicable federal, state, and local regulations

ES&H Core Policy

Berkeley Lab policy requires all work to be performed safely with full regard to the well-being of workers, affiliates, 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 work.
Managers, supervisors, and work leads are actively involved and demonstrate leadership in performing work safely.
Individuals take ownership to work safely and continuously strive to improve.
Individuals demonstrate an awareness and concern for the safety of others and strive to prevent harm to other workers, the general public, and the environment.

Berkeley Lab has adopted the DOE Integrated Safety Management System (ISMS) approach for establishing ES&H policies and programs. This is a specific requirement in Contract 31, Clause I.131, Integration of Environment, Safety, and Health into Work Planning and Execution.

Berkeley Lab’s overall ES&H philosophy is as follows:

In the context of carrying out the Laboratory’s technical missions, ES&H policies and programs are the most important day-to-day consideration given the emphasis on carrying out science in a safe manner.
Accidents are preventable by each individual and responsible organization by paying close attention to potential hazards and taking appropriate action.
Responsible stewardship of environmental resources is an integral part of ES&H management, and results in the reduction of environmental impacts locally, regionally, and globally.
The Laboratory recognizes that humans are fallible and that everyone makes errors. The most common causes of human error are weaknesses in the organization, not lack of skill or knowledge. When events occur, management’s first reaction should be to look within the organization rather than to blame an individual.
Managers, supervisors, safety line managers, and work leads are responsible for ensuring that an adequate system is in place to carry out work safely while also being environmentally responsible. An identifiable line management chain is ultimately responsible for each work activity.
Each supervisor and safety line manager is expected to ensure that all individuals reporting to them understand the ES&H expectations, governing work controls, and the means by which they can safely and successfully perform their assignments while providing stewardship of the environmental resources in their care.
Each individual is directly responsible for ensuring their own safety and environmental stewardship, looking out for fellow workers, and promoting a safe, healthful, and environmentally sound workplace and community. Individuals may participate in setting policy, establishing coordinating processes, and assessing and improving activities. All individuals must follow ES&H-related work instructions. If the work instructions cannot be followed safely or present a new hazard, the employee is responsible for notifying the appropriate individuals and assisting, as appropriate, in modifying the work instructions.
Employees, subcontractors, and affiliates are held accountable for their performance with respect to ES&H policies and principles.
The Laboratory’s Integrated Environment, Safety & Health Management Plan (ISM Plan) describes the institutional management system requirements for all operations associated with this ES&H Core Policy. The Laboratory’s ES&H Manual (formerly PUB-3000) describes technical work processes in detail.
New – or changes to existing – ES&H policies or implementing programs and documents must comply with the Laboratory’s Requirements Management Policy.

1.2 Scope

These requirements are intended to address recognized and anticipated hazards encountered during Berkeley Lab research and support operations.

1.3 Applicability

The requirements of the Berkeley Lab ES&H Manual (previously known as PUB 3000) apply to all employees, affiliates, subcontractors, and visitors to the main site, off-site locations, and field operations.

1.4 Exceptions

None

1.5 Integrated Safety Management (ISM) Overview

Berkeley Lab articulates its overarching environmental, safety and health policies and programs through its Integrated Environment, Safety & Health Management Plan (ISM Plan). The policies and programs are established per the framework set by the principles and guidelines of ISM. All employees and visitors at Berkeley Lab are expected to exercise the ISM process whenever they plan or do work.

The following five core functions comprise the framework for ISM:

The seven guiding principles of ISM are as follows:

Line management responsibility for safety
Clear roles and responsibilities
Competence commensurate with responsibilities
Balanced priorities
Identification of safety standards and requirements
Hazard and environmental controls tailored to the work being performed
Operations are authorized

The ISM core functions and guiding principles are reflected in Berkeley Lab’s detailed policies and procedures. Principal investigators, managers, supervisors, and work leads are expected to incorporate these principles into the management of their work activities. They are also responsible for integrating ES&H requirements into work procedures, and for ensuring active, rigorous communication between the management chain and the workforce.

The Five Core Functions

The five ISM core functions, as a work planning and hazard control process, are generally summarized as follows:

1. Define the Scope of Work

Missions are translated into work, expectations are set, tasks are identified and prioritized, and resources are allocated.

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. A formal hazard analysis is performed using a graded approach, and tailored to the work and workers. Using Berkeley Lab’s work authorization system Work Planning and Control (WPC), each worker has WPC activities for the tasks they will perform. Subcontractors use a similar process called the Subcontractor Job Hazards Analysis (sJHA) for non-construction work, or the Construction JHA for construction work.
EHS provides a number of special-purpose institutional data tracking systems in which hazards must be identified for analysis and communication (e.g., Chemical Management System (CMS), Laser Management System, RADAR). The Hazard Management System (HMS) is used to collect baseline hazard information for a work location, in part, to determine if higher-level hazard analysis and authorization is required. It also provides a hub to compile institutional hazard identification and tracking systems. For example, the Facilities Division planning data system, Maximo, references the HMS to identify location-based hazards when planning work.

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 the ES&H Standards Set included in Contract 31, and as described in the hazard-control programs developed in the ES&H Manual.

4. Perform Work within Controls

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

5. Feedback and Continuous Improvement

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 must regularly review work practices and operations in light of any new hazard information or 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 are made to work planning and, in rare instances, used as a basis for changing line management responsibility, roles and responsibilities, worker competence, or other appropriate parts of the work cycle.
Divisions, with the support of EHS, assess effectiveness of ISM implementation under Berkeley Lab’s Institutional Assessment Process (Document Number 04.03.009.001, Rev. 1). Annual planning, led by the Office of Institutional Assurance, identifies risk-based focus areas for self-assessments, independent assessments, and joint assessments.

The Seven Guiding Principles

The seven ISM guiding principles set the context for the design and implementation of the five core functions. These principles are reflected in the policies, programs, and procedures that have been developed to fulfill environmental, safety and health requirements. The seven ISM guiding principles are:

Line management responsibility for safety
Clear roles and responsibilities
Competence commensurate with responsibilities
Balanced priorities
Identification of standards and requirements
Hazard controls tailored to work being performed
Operations authorization

The ISM guiding principles are described below.

Line Management Responsibility and Accountability for ES&H
1. Line management and work leads are responsible and accountable for the protection of the public, workers, and the environment. More specifically, laboratory line managers and work leads are responsible for integrating ES&H into work and for ensuring active, rigorous communication with the workforce.
2. ES&H vision and goals are articulated by identifying specific targets, developing and implementing plans, securing resources, and managing and maintaining facilities and operations (including work activities and processes). Integrating ES&H into all phases of planning and implementing work processes is critical to the success of Berkeley Lab. ES&H must be part of the planning process by identifying potential hazards, applicable standards, controls that need to be integrated into the design and specifications, and competencies required to work safely. While line management and work leads are responsible for addressing ES&H concerns through work planning, implementation, and operations, the EHS Division provides primary technical support through its subject matter experts (SMEs) and Division Liaisons.
3. Divisions, with the support of EHS, assess effectiveness of ISM implementation under Berkeley Lab’s Institutional Assessment Process (Document Number 04.03.009.001, Rev. 1). Annual planning, led by the Office of Institutional Assurance, identifies risk-based focus areas for self-assessments, independent assessments, and joint assessments.
Clear Roles and Responsibilities
1. Responsibilities for safety are shared by all. Safety Line Management, the management chain of command that carries out the Laboratory Director’s ES&H concerns for worker safety, has a special responsibility for modeling safe behaviors and setting goals for a strong safety culture. Above the lowest formal organizational unit in each division, the chain is defined by the succession of direct reports, including supervisors and managers, who make job assignments, authorize work, oversee work, and appraise performance. Below the lowest formal organizational unit, the chain may include non-management work leads and area safety leaders who guide the day-to-day activities of one or more workers.
2. Supervisors and managers are part of the formal management chain and are responsible for adherence to all ES&H policies and safe work practices. Work leads derive authority from their managers or supervisors to ensure that day-to-day work, operations, and activities assigned to them are conducted safely and within established work authorizations.
3. Every individual working in a Berkeley Lab workplace must be familiar with and implement applicable Berkeley Lab safety standards. Clear, unambiguous lines of authority and responsibility for ensuring safety must be established at all organizational levels. Institutional, divisional, functional, and individual responsibilities for environment, safety, and health at Berkeley Lab are defined below. Detailed roles and responsibilities are listed in Section 1.10.
Competence Commensurate with Responsibilities
1. Personnel need to possess the experience, knowledge, skills, and abilities to discharge their responsibilities. Competency is demonstrated through education, experience, qualifications, training, and fitness for duty. The minimum requirements for staff competency are set forth in the Operating and Quality Management Plan (PUB-3111, Section 1.33). However, Berkeley Lab supervisors or work leads shall ensure that all employees, contractors, and affiliates possess sufficient knowledge, skills, and experience to perform work safely. As a minimum, all employees, contractors, and affiliates must:
  1. Know the hazards associated with a work activity and the appropriate controls in place to minimize the hazard
  2. If necessary, know how to implement 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, and affiliates must not perform work unless they have satisfied the training, experience, and/or certification requirements identified by the supervisor or work lead.
  3. 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 must be reported to the immediate supervisor, work lead, or Berkeley Lab contact person (in the case of subcontractors) as soon as possible. If failure causes imminent danger, then the Stop Work Policy (Work Process E) must be followed.
  4. Be familiar with all sections of the ES&H Manual that relate to the work being performed.
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 Berkeley Lab 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) begins, a work process analysis of hazards to workers, the public, and the environment is to be conducted in accordance with the Work Planning and Control Program of the ES&H Manual. Equipment that is donated to Berkeley Lab must receive a safety evaluation using the process described in Work Process C. The objective is to ensure that hazard controls effectively mitigate the hazards associated with the work and in the process do not unnecessarily impede research.
Identification of ES&H Standards and Requirements
1. All new work activities or changes to existing work that introduce new hazards or increase the hazard level need to be reviewed to analyze hazards, identify safety standards and requirements, and establish appropriate controls. The Work Planning and Control Programof the ES&H Manual details the Berkeley Lab process for identifying hazards and determining requirements. The current set of standards identified in the ES&H Standards Set (Appendix I of Contract 31) is used as a basis to determine the appropriate requirements. EHS Division Liaisons are available to assist in identifying hazards, determining the applicable standards, and developing appropriate cost-effective controls that meet Berkeley Lab ES&H policies. EHS Division Liaisons should be consulted if the scope of hazards exceeds the safety envelope established by Berkeley Lab ES&H standards.
2. New and modified ES&H policies, standards, and requirements are identified and implemented through the Requirements Management process and committee. In collaboration with either standing or ad hoc user committees, EHS Division SMEs craft strategies, procedures, and methods to implement these changes. The SAC reviews the EHS proposals and ensures that proposed implementation strategies consider the needs of the various divisions. This change management process is iterative and promotes a strong safety culture where individual activity, division, and institutional requirements are met. This process is described in detail in Work Process A.
Establishment of Hazard Controls
1. To prevent and mitigate hazards, controls must be tailored to the work being performed, the risk of harm posed by the work, and the extent or degree of harm that could occur while performing the work. This tailoring of controls to hazards based upon risk is generally referred to as the “graded approach.”
2. The preferred hierarchy of controls is:
  1. Elimination or substitution of the hazards
  2. Engineering controls
  3. Administrative controls
  4. Personal protective equipment
3. The tailoring process should include:
  1. Identifying controls for specific hazards
  2. Establishing boundaries for safe operation
  3. Implementing and maintaining controls
4. Berkeley Lab ES&H professionals are available to assist in identifying the appropriate level of hazard control.
Work Is Authorized
1. All work must be authorized by management before work begins. 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 the ES&H Manual and, as necessary, appropriate work authorizations such as WPC Activities. The Work Planning and Control Program of the ES&H Manual outlines a protocol for the form and content of Berkeley Lab work authorizations.
2. Low-hazard activities can be authorized by first-level line management. Higher-hazard activities require joint review and approval by the EHS Division and line management (e.g. WPC Activities). Refer to the EHS Division website to contact EHS Division health and safety professionals who can assist in determining the hazard level of a work activity.
3. Line Management (Low-Hazard) Authorization. Bench-level activities that do not require EHS 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 EHS Division review level. Guidelines for hazards and controls are indicated in the ES&H Manual. The hazard review and establishment of controls are the responsibility of line management. EHS Division health and safety professionals will assist if requested. A health-hazardous compressed gas classified as an NFPA Class 1 hazard is an example of a low-level hazard that requires only line management authorization.
4. EHS Division / Line Management (High-Hazard) Authorization. Activities requiring EHS Division participation in the hazard identification and mitigation process are identified in the technical programs of the ES&H Manual. Hazard identification, establishment of controls, and authorization are the joint responsibility of line management and appropriate EHS Division health and safety professionals.
  
  An example of a hazard at the joint EHS/line management authorization level is a high health-hazardous compressed gas classified as an NFPA Class 3 or 4 hazard. Applicable authorization documents include Level 3 WPC Activities.

1.6 Introduction to the ES&H Manual

The ES&H Manual is a collection of documents that describes how Berkeley Lab integrates ES&H technical program requirements into operating conditions. Separate ES&H programs have been developed for most ES&H technical areas. Following the principles described in the Berkeley Lab Integrated Environment, Safety, & Health Management Plan or ISM Plan (discussed in the previous section), technical programs use a graded approach to describe requirements at the activity, division, and institutional levels. While the technical requirements of each program area (e.g., lead, ionizing radiation, or waste management) are unique, the administrative procedures used to manage these programs have commonalities that are leveraged to make it easier for workers to implement at the activity level and ensure compliance at the institutional level. At the division or facility level, ES&H technical program requirements are tailored to the physical conditions present and balance the need to work efficiently and safely while meeting institutional protection and compliance requirements. The ES&H Manual is designed and implemented to support and promote a strong safety culture using the functions and principles of ISM. In the ES&H Manual, the term “EHS” refers to the Berkeley Lab Environment, Health and Safety Division and its activities; it is differentiated from the term “ES&H”, which is used to refer to the Environment, Safety & Health discipline and associated DOE regulations and requirements.

The ES&H Manual also contains programs that cross technical areas such as Authorization Basis, Training, and Occurrence Reporting. The administrative procedures within these programs are designed to assist line management in meeting their ISM responsibilities during the normal course of doing business at Berkeley Lab. This General ES&H Requirements chapter provides the overarching general requirements, responsibilities, and work practices for integrating ES&H into Berkeley Lab work at the activity, division, and institutional levels. The ES&H Manual is updated and revised on an ongoing basis using the process described in Work Process A. The terms “shall,” “must,” “should,” and “may” in EHS documents are used to differentiate between requirements and recommendations as described in Work Process B.

Source Requirements (regulations and standards required by Contract 31) and Other Driving Requirements (regulations and standards required by a regulatory agency, but not specifically required by Contract 31) are reviewed and updated by program managers as part of periodic policy and program reviews.

Policy and technical program implementation, review, continuous improvement, and change are aligned with ISM guidelines and the Laboratory’s Requirements Management (RM) and Document Management policies. The ES&H technical program areas are defined by DOE Contract 31, the ES&H Standards Set (Appendix I of Contract 31), and applicable federal, state, and local regulations.

1.7 Subcontractor Flow Down of Safety and Health Requirements

Subcontractors, including service providers, provide a variety of on-site services at Berkeley Lab, 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 Injury and Illness Prevention/Worker Safety and Health Program (IIPP/WSHP) to protect workers who are employed at a DOE facility. It also requires Berkeley Lab to flow down its requirements to subcontractors. Procurement guidelines delineate IIPP/WSHP requirements for subcontractors, including construction and general service subcontractors. For specific information about Berkeley Lab’s construction safety program for subcontractors, refer to ES&H Manual Chapter 10, Construction Health and Safety, and ES&H Manual Chapter 31, sJHA Process—Subcontractor Job Hazards Analysis.

1.8 Workers’ ES&H Rights and Responsibilities

Berkeley Lab defines workers’ rights to participate in ES&H activities and to have access to ES&H records and information. This section defines these rights and describes workers’ responsibilities for understanding and following ES&H requirements.

Specific worker rights are guaranteed by federal law in the DOE Worker Safety and Health Program rule, 10 CFR 851. These rights are implemented through the ES&H Manual and other safety documents.

Workers at Berkeley Lab have the right, without reprisal, to:
1. Participate in activities related to ES&H Programs, including exercising all workers’ rights, listed in paragraph 2.a through 2.h below, on official time
2. Be notified when monitoring results indicate they have been overexposed to hazardous materials
3. Observe the exposure monitoring or measurement of hazardous agents, and be provided with the results of their own exposure monitoring
4. Express their concerns related to worker safety and health
5. Decline to perform an assigned task because of a reasonable belief that the task poses an imminent risk of serious physical harm or death, coupled with a reasonable belief that there is insufficient time to seek effective redress through normal hazard reporting and abatement procedures
6. Stop work if there is an imminently dangerous condition
Workers have the right to have access to:
1. Department of Energy (DOE) safety and health publications
2. Berkeley Lab’s Injury and Illness Prevention/Worker Safety and Health Program (IIP/WSHP) and the ISM Plan
3. Safety and health standards, controls, and procedures applicable to Berkeley Lab as identified in such documents as the ES&H Manual, including the Chemical Hygiene and Safety Plan
4. DOE’s Job Safety and Health poster that informs workers of their rights and responsibilities
5. Results of inspections and accident investigations
6. Limited information on any record-keeping log (Cal/OSHA Form 300), subject to Freedom of Information Act requirements and restrictions
7. DOE Form 5484.3 (the DOE equivalent of Cal/OSHA Form 301, Injury and Illness Incident Report) that contains the employee’s name as the injured or ill worker
8. A worker representative authorized to accompany the DOE Director or authorized representative during the physical inspection of the workplace for the purpose of aiding any 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.
Every worker at Berkeley Lab is responsible for:
1. Ensuring their own safety and for promoting a safe and healthful workplace and community
2. Following ES&H-related work instructions. If work instructions cannot be followed safely as presented, or if they present a new hazard, workers must notify the appropriate individuals and assist, as appropriate, with modifying the work instructions.
3. Understanding and participating in the Berkeley Lab ES&H goal of performing all work safely and in a manner that strives to protect employees, affiliates, visitors, subcontractors, the public, and the environment from hazards
4. Collaborating with other workers to determine the best way to achieve the ES&H goal in conformance with Berkeley Lab requirements
5. Using appropriate resources at their disposal
6. Asking for any help necessary (such as assistance from technical, administrative, or craft services) to ensure a safe work environment and reduce environmental impact while performing their broader set of job responsibilities
7. Bringing existing or previously unrecognized hazardous conditions and opportunities for improvement to the attention of their immediate supervisor
8. Notifying their work supervisor immediately and obtaining appropriate transportation to Health Services if they are injured or becomes ill as a result of a work-related activity or an accident

1.9 Employee ES&H Concerns Reporting Policy

Berkeley Lab defines workers’ rights to express concerns related to worker safety and health.

General Safety Concerns

Workers have the right to express their concerns related to worker safety and health. Federal law prohibits Berkeley Lab from making reprisals against workers who raise safety concerns.
Workers or former workers are encouraged to file an environment, safety, and health (ES&H) concern with their immediate supervisors.
1. If the immediate supervisor is unable to resolve the concern, workers may take their ES&H concerns to higher-level managers, the Environment, Health and Safety (EHS) Division Director, or the local U.S. Department of Energy (DOE) office.
Berkeley Lab has established the Safety Concerns webpage for workers to report, without reprisal, job-related injuries, illnesses, fatalities, incidents, and hazards, and to recommend ways to control those hazards. The Berkeley Lab Employee Concerns Program website also has information regarding the whistleblower policy, and provides a number of 24-hour hotlines of potential use to Berkeley Lab employees.
1. Berkeley Lab workers have access to UC whistleblower procedures, which provide a process for reporting events and hazards. Concerns may be submitted by calling the UC Employee Hotline at (800) 403-4744. This toll-free number is available 24 hours per day, seven days a week, and is operated by a third-party vendor for confidentiality and anonymity.
2. Under 10 CFR 708, employees may also file concerns (not limited to ES&H) with the DOE Chicago Office Employee Concerns Program Manager’s 24-hour hotline at (800) 701-9966. Employees of DOE contractors have the right to file confidential complaints with the local DOE office within 60 days regarding safety and health issues or reprisals. Workers may file a concern with the DOE Employee ES&H Concerns Program.

Differing Professional Opinions for Technical Issues Relating to ES&H Concerns

The DOE has a Differing Professional Opinion (DPO) process for workers to raise technical concerns related to ES&H issues that cannot be resolved using routine processes. The DPO process — which addresses ES&H technical issues — may be used by all personnel who work at Berkeley Lab. If the immediate supervisor is unable to resolve the issue, workers may take their ES&H issue to higher-level managers, the EHS Division Director, or the local DOE office. The DPO process should not be used as the first step to report concerns.
The objectives of the DPO process are to:
1. Encourage workers to raise ES&H technical concerns and to use the DPO process when routine work processes fail to resolve ES&H technical concerns.
2. Provide reasonable time and resources for workers to use the DPO process.
3. Protect workers from reprisal or retaliation for reporting DPOs.
Use this link to access the DOE DPO process.

1.10 Roles and Responsibilities

Every person working in a Berkeley Lab workplace must be familiar with and implement the Berkeley Lab safety standards that are applicable to them. Clear, unambiguous lines of authority and responsibility for ensuring safety must be established at all organizational levels.

The principal roles and responsibilities of the various stakeholders in the ISM system are listed in the table below.

Role	Responsibility
Area Safety Leaders	Area safety leaders are coordinators and not are generally not part of Safety Line Management. An area safety leader is an individual assigned by the division controlling a technical area to oversee coordination of safety issues within the area. The area safety leader may also be a manager, supervisor, or work lead. They are usually designated when multiple organizations do work within the technical area. Area safety leaders must: Coordinate with supervisors, managers, and work leads who work in the technical area to ensure that the hazards associated with their operations are identified and communicated to all occupants Ensure that hazards associated with their areas are posted
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, and assist with the implementation of protective actions Ensure the coordination of construction and maintenance activities within their buildings Oversee the space management of their respective buildings Act as the liaison with visitors and regulatory agencies visiting their respective buildings
Business Guests and Visitors / Sponsors	Sponsors of business guests and visitors must: Ensure that business guests and visitors are provided a safe environment while visiting Berkeley Lab Provide clear instructions to business guests and visitors as to what they may do and where they may go Business guests and visitors must: Follow instructions given by their sponsor Obey all safety instructions given to them by any Berkeley Lab worker
Chief Operating Officer / Associate Laboratory Director for Operations / Chief Operating Officer	Is responsible for ES&H policy making and implementation and the daily operation of the ES&H program Delegates responsibility for developing and publishing Berkeley Lab ES&H policy and developing and operating effective service and support programs to ensure that Berkeley Lab 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 EHS Division Director and their staff Manages appeals for denials of variances on Berkeley Lab policy and requests for variances from DOE orders and regulations
Division Directors	Ensure that Berkeley Lab ES&H policies are fully implemented within their divisions. They are also responsible for adhering to the principles of Berkeley Lab ISMS Management Plan. Ensure that their division employee performance assessment process is used to hold each employee accountable for their respective ES&H obligations, responsibilities, and performance Develop and implement a Division ISM Implementation Plan tailored to the work and hazards found in their divisions Investigate the circumstances surrounding situations identified as imminent dangers and ensures that appropriate corrective actions and Lessons Learned are developed, implemented, and disseminated Ensure dissemination of ES&H directives and information to their staff Ensure that their divisions provide sufficient resources for division ES&H efforts Advise the Directorate on ES&H policy implementation Ensure that, within their divisions, clear roles and responsibilities for compliance with all applicable ES&H policies are defined Establish and implement an ES&H self-assessment program in accordance with Berkeley Lab policies Establish committees, as needed, to consider ES&H problems and recommend solutions to Safety Line Management and/or designated safety representatives Ensure that their divisions’ research projects, work locations, and unique work activities are evaluated for potential hazards, and that safety controls are specified and implemented using the appropriate institutional hazard and work authorization systems (including, but not limited to Chemical Management System, Work Planning and Control – Activity Manager, the Laser Database, etc.)
Division Safety Coordinators (DSC)	Report directly to their Senior division management and is responsible for administering the division’s ES&H program Support division line managers or work leads in the execution of their safety responsibilities and 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 Management Plan (PMP) input to the division director on the safety performance of division staff Serve as members of the institutional Division Safety Coordinator Committee and serve on division and/or area safety committees Help develop and implement division-specific safety training if needed Consult and coordinate with EHS Division staff and other resources as needed. The EHS Division provides DSCs with technical guidance on the interpretation and application of ES&H policies, procedures, and programs. Are familiar with division staff, facilities, work activities, and potential hazards Serve as the division point-of-contact for the Environment, Safety & Health ES&H Standards Set (Appendix I of Contract 31) for Berkeley Lab. Perform ongoing reviews of work with division staff to identify hazards that may require inclusion of new standards in the ES&H Standards Set (Appendix I of Contract 31) for Berkeley Lab. Serve as members of, or chairs, the Division Safety Coordinators’ Committee, and attends this and other meetings as necessary Assure that institutional ES&H programs and processes are implemented. This includes but is not limited to: Division ISM Plan ES&H training Incident reporting and investigation Corrective action tracking (CATS) Occurrence Reporting and 10 CFR 851 reporting Walkaround inspection/surveys Work authorizations (Work Planning and Control or equivalent) Divisional ergonomics reviews and support Coordination and management of required safety documentation Utilize institutional ES&H databases to support operations, including but not limited to: Chemical Management System (CMS) Corrective Action Tracking System (CATS) Occurrence Reporting and 10 CFR 851 reporting Laser Inventory Database Satellite Accumulation Area (SAA) / Waste Accumulation Area (WAA) records Ergonomic evaluations via ergoeval.lbl.gov Incident investigation and reporting (CHESS) Lessons Learned and Best Practices database A comprehensive table of ES&H databases is provided here. Manage the safety-related corrective action process for the division. This includes ensuring that the appropriate CATS item is assigned to the correct individual, addressed and corrected as scheduled, and closed in the system. In collaboration with line managers and work leads, assess the adequacy of hazard controls through periodic frequent surveys and monitoring of work activities as defined by the division’s ISM Plan, and facilitate the implementation of appropriate hazard controls Serve as a conduit for feedback on how safety is implemented (including division point-of-contact for Lessons Learned) Manage the annual division self-assessment by participating in the development of objectives, training and leading assessment teams, writing and coordinating the approval of the annual assessment report, and ensuring that findings are entered into CATS and closed on schedule Serve as the division point-of-contact for ES&H audits and/or surveys originating outside the division Support the investigation of incidents, including injuries, accidents, and other safety and environmental incidents
EHS Division Director	Develops, maintains, publishes, and supports the implementation of the Berkeley Lab ES&H policy and procedures as described in the ES&H Manual and other supporting documents Develops and operates effective service, support, and compliance programs that provide line management with the information and support needed to work safely With the Office of Institutional Assurance and Integrity (OIAI), conducts ES&H assurance activities to ensure the effective implementation of ES&H policies and programs and the safe performance of work activities Delegates 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 Stops unsafe work activities in the absence of cognizant line management or work leads May ask that a request for a variance be studied by the Safety Advisory Committee (SAC) and its appropriate subcommittees Approves or denies in writing requests for variances
EHS Division ALD Liaisons	EHS Division Liaisons are designated for each Associate Laboratory Directorate (ALD). EHS Division Liaisons provide a convenient, single EHS point of contact between a customer division and the EHS Division and function as troubleshooters and problem-resolution facilitators. This relationship does not preclude any Berkeley Lab employee from directly approaching an EHS professional or subject matter expert to address a particular issue or need. The EHS Division Liaison: Serves as the designated EHS point of contact to ALDs Requests that the appropriate technical support be provided to implement and interpret Berkeley Lab ES&H policies Understands the assigned customer division’s work activities, personnel, and associated hazards, and assists in hazard identification and the development of controls appropriate to the hazard and work being performed Provides consultation to allow for resolution and closeout of the customer division’s ES&H issues or concerns Develops and/or leads cross-functional EHS teams when necessary to assess complex operations and equipment Participates in a customer division’s self-assessment as requested and in other ES&H assessments, as required Coordinates EHS review of formal authorizations (e.g., Work Planning and Control Level 3 Activity reviews), which involves coordinating activity review and sign-off with appropriate subject matter experts (SMEs) and customers Participates in incident reviews of illnesses, injuries, accidents, and other safety and environmental incidents, as requested by the incident investigation manager In relation to assigned divisions or facilities, and in collaboration with their respective Division Safety Coordinator (DSC), supports, as requested, the elements of the ES&H program. Examples include: Division ISM Plan: Provides supporting technical information Training records: Monitors training completion status, and helps ensure that technical assistance is provided in the development of division-specific training Corrective Action Tracking System (CATS): Closes out ES&H-related items Walkaround survey inspection reports: Provides technical interpretation Chemical Management System (CMS): Provides technical guidance and coordinates support Occurrence Reporting and 10 CFR 851 reporting: Serves as a technical resource Laser Inventory Database: Serves as a technical resource, and monitors status SAA/WAA issues: Assists with compliance Ergonomic safety: Serves as a technical resource or consults with a Berkeley Lab ergonomist.
EHS Division Requirements Management (RM) Program Coordinator	Serves as editor of the Berkeley Lab Environment, Safety & Health Manual Represents the EHS Division on the institutional Requirements Management Committee (RMC) Must have and apply experience and breadth of knowledge of requirements, policy, and specific functional operation in their respective areas of expertise Must have and apply good working knowledge and experience of general Berkeley Lab Laboratory operations Must be trained on Berkeley Lab RM and document management processes Is the communications conduit between the EHS Division and RMC for Division policy-related efforts, whether initiated by the Division or by other functions Has authority (as delegated by their Senior Line Manager) to accept RMC actions or assignments on behalf of their respective functional area Communicates actions and assignments to respective Senior Line Manager on regular basis Attends and participates at RMC meetings. May designate an alternate if unable to attend. Applies skills and experience in risk analysis and problem solving techniques May be assigned to other RM roles (working group, Policy Area Manager, functional document control administration). [Note: assignment to multiple roles is not recommended, though in the short term is recognized as necessary.]
Environment, Health and Safety (EHS) Division	Provides professional and technical expertise, follow-up services, and integrated ES&H policy to the Laboratory’s research and support programs to protect workers, the public, and the environment Supports and serves as a partner with line management as it meets direct responsibilities to ensure that protection of workers, the public, and the environment is integrated into the primary research and support functions of each division or unit Supports and provides expertise directly to each Laboratory worker who seeks ES&H advice and help or who voices a concern
Laboratory Director	Has the ultimate responsibility for safety at Berkeley Lab and, in particular, for the establishment and administration of ES&H policies Ensures that environment, health, and safety policies meet the applicable requirements of the U.S. Department of Energy (DOE) and other governmental agencies, as applicable Is responsible for the implementation of the ISM Plan Carries out the ES&H policy under the terms of Contract 31 (between the University of California and DOE) Delegates, in their absence, overall ES&H responsibility to senior Berkeley Lab management in the normal chain of command Delegates responsibility for ES&H policy making and implementation and daily operation of the ES&H program to the Associate Laboratory Director for Operations / Chief Operating Officer
Office of Institutional Assurance and Integrity (OIAI)	Manages the Institutional Assessment Process Provides support to the EHS Division Director in ES&H program technical assurance and DOE Contract 31, Appendix B Self-Assessments (see the Organizational Self-Assessment Policy in the RPM) In consultation with the EHS Division Director, analyzes the results of all self-assessment reports to improve the effectiveness of the technical and management aspects of Laboratory formal ES&H programs
OIAI Requirements Management Program Manager (RM PM)	Manages the Berkeley Lab requirements management and institutional document management processes. Is the main driver and champion of these processes. Has author, review, and recommendation responsibilities for quality and completeness of RM process and institutional document management process documentation. Serves as the Berkeley Lab contact point on requirements and institutional document management-related matters. Is the focal point for receipt of new or modified requirements accepted into Contract 31 or mandated by applicable federal, state, or local laws, standards or regulations. Notifies Requirements Management Committee (RMC) of such matters. Chair is a member of the RMC Leads RMC and other cross-functional teams in solving problems using risk based-analysis techniques Works with RMC members and the RMC chair as required to meet the RMC’s and RMC members’ responsibilities within the framework of the RM process Applies broad knowledge of operations functions to: Assess the quality, accuracy, efficiency and effectiveness of recommendations generated by the RMC and the working groups Seek resolution of issues or conflicts related to Laboratory policy or document matters at the lowest levels possible Oversees management of Berkeley Lab’s Requirements and Policies Manual (RPM)policy manual Maintains the Requirements Management (RM) database for tracking requirements, their associated policy areas (PA), owners, records of implementing mechanisms, and their flow-down to implementing documents Maintains accuracy and currency of the RM tracking system Has review and approval responsibility for quality and completeness of requirement, policy, and document metadata.
Requirements Management Committee (RMC)	The RMC is an institutional committee chartered by the ALDO/COO. It reviews and oversees disposition of Requirements Review Cases related to requirements, Laboratory policies, and, on a case-by-case basis, Laboratory implementing documents. It is responsible for overseeing the Requirements Management (RM) process to ensure that: Each requirements review case related to an institutional requirement is logged into the RM database Each review case has at least one record of decision (ROD) and an analysis that supports the decision, both of which must be filed in the RM database For those cases that result in change to policy or its related supporting documents, a ROD on whether an implementation plan is needed is filed in the RM database (along with the implementation plan, if deemed necessary) Flow-down from requirement into implementing documents is demonstrated and managed The RMC applies cross-functional knowledge on requirements matters and: Assesses the Laboratory- wide impacts of new or changed requirements and adopts a holistic response Reviews and recommends best qualified team members to address requirements analyses, implementation mechanisms and plans, policy and procedure documents: Such team members include Policy Area Managers (PAM), working group (WG) members, and subject matter experts (SME) Ensures teams are cross-functionally represented Recommends collaboration with other Laboratory standing committees whenever possible Reviews and applies cross-functional knowledge and judgment on WG, PAM, SME work products (analyses, implementation plans, policies): Ensures analyses and plans lead to practical implementation (taking into consideration cost, breadth of impact, simplicity, etc.) Ensures risk analysis and problem solving techniques and best practices have been applied Advises responsible Senior Line Manager on WG, PAM, and SME work products Drives for process simplicity. Seeks resolution and decision-making at the lowest levels possible. Reviews processes at least annually and makes improvements for efficiency and effectiveness. Reviews communications plan to ensure effectiveness and thoroughness Champions RM and institutional document management processes
Safety Advisory Committee (SAC)	The SAC is an interface between the research and operations divisions of Berkeley Lab, as well as between the ES&H technical programs (mainly in the EHS Division) and assurance and assessment activities of the Office of Institutional Assurance and Integrity (OIAI), see RPM, Policy Area – Quality Assurance. To effectively execute this role, the SAC has direct access to Berkeley Lab Leadership. Its responsibilities include: Making recommendations to the EHS Division Director on the development and implementation of ES&H policy, guidelines, codes, and regulatory interpretation Conducting reviews of special safety problems and providing recommendations for possible solutions to the Laboratory Director, Associate Laboratory Director for Operations (ALDO) / Chief Operating Officer (COO), and the EHS Division Director, as requested Providing advice and counsel to the ALDO/COO by reviewing appeals from the Laboratory divisions when any division and the EHS Division do not agree on the interpretation or application of criteria, rules, or procedures. Such advice and counsel may include options for a resolution. The SAC has established permanent subcommittees to assist in the review of ES&H issues and concerns and the development of recommendations for institutional implementation. These subcommittees report to the SAC and cover the following areas: Radiation Safety Laser Safety Chemical Safety Laboratory Safe Practices Electrical Safety Safety Culture Traffic and Pedestrian Safety Safeguards and Security Division Safety Coordinators To properly execute its responsibilities under its charter, the SAC Chair may set up additional subcommittees made up of subject matter experts to address specific health and safety matters. Such subcommittees may become long-standing expert subcommittees or may be of short duration depending upon technical support requirements.
Supervisors and Managers	In addition to their individual responsibilities as workers, Supervisors and Managers: 1. Must protect their staff, other workers, the public, and the environment Ensure that staff members under their supervision are properly trained in emergency procedures Provide sufficient resources (staff, time, training, equipment, and funding) for all applicable safety responsibilities 2. Must integrate ES&H into all work activities Ensure that all staff under their supervision complete all applicable work authorization documents (e.g., Work Planning and Control or equivalent process) relevant to their work, activities, and operations Review and revise applicable work authorizations (e.g., Work Planning and Control or equivalent process)(i.e., WPC Activities) annually or whenever the scope of work changes or hazards change. Ensure that the required controls and formal training are completed and implemented before unescorted work begins Verify that worker competence and on-the-job training are commensurate with work assignments before allowing unescorted work to proceed Monitor work activities on a regular basis and take action to enforce safety rules Ensure that all materials and equipment — regardless of origin — used or applied in performance of Berkeley Lab work are used, maintained, and serviced in a manner that ensures the protection of the environment, safety, and health 3. Must actively communicate ES&H and Integrated Safety Management issues Know the federal regulation for workers’ rights to a safe and healthful workplace (10 CFR 851) Promptly report all significant accidents, injuries, near-misses, and significant mishaps in accordance with the requirements of the Occurrence Reporting Program of the ES&H Manual. Ensure that their staff members report occupational injuries and illnesses to Health Services at the earliest opportunity. Investigate all significant accidents and take actions to prevent recurrence Ensure that safety deficiencies are entered into the Corrective Action Tracking System (CATS) and corrected in a timely manner. See LBL’s Issues Management Program Manual, Section 7.1. Promptly respond to applicable reports of incidents and recommendations for ES&H improvements Inform their workers of the command chain for Safety Line Management up to the Laboratory Director Communicate pertinent safety issues and applicable Lessons Learned in staff meetings and/or through other mechanisms Coordinate and periodically meet with area safety leaders in their respective technical area work spaces to ensure that the hazards associated with their operations are identified and communicated 4. Must recognize language and cultural barriers Must ensure that all individuals for whom they are responsible comprehend the ES&H hazards to which they are exposed and the protective measures available Methods for learning ES&H hazards include, but are not limited to, standardized training or explanations through a translator, oral or written instructions, or demonstrations of procedures. Develop a tailored approach to ensure that the individual understands ES&H hazards and the responsibilities related to performing work safely at Berkeley Lab. 5. Additional supervisor/ and line manager responsibilities when using work leads Must determine the need for using work leads under their areas of supervision If needed, must assign workers to work leads with the cognizance of the work leads and the permission of the work leads’ supervisors(s) Must ensure that work leads under their supervision understand their roles and responsibilities Provide their work leads with sufficient resources (staff, time, training, equipment, and funding) to fulfill all assigned safety responsibilities Cannot delegate responsibilities to a work lead for work activities for which that person has no oversight or knowledge
Workers (Employees and Affiliates)	1. Must protect themselves, other workers, the public, and the environment Conduct their work activities safely and in an environmentally sound manner Maintain currency in required safety training Comply with the conditions stated in applicable Work Planning and Control activities Know how to respond to emergencies and incidents Immediately stop any activities, including the activities of others, that pose an imminent danger to personnel or the environment, and report these activities to their supervisors or work leads (i.e., implement the Stop Work Policy – Work Process E) 2. Must integrate ES&H into all work activities Participate in activity-based hazard analysis processes related to their work Develop an awareness of these hazards, and protect others in the area Obtain authorization from their work leads or supervisors to perform work using approved Berkeley Lab work authorization methods (e.g. Work Planning and Control or equivalent processes) Obtain training to safely perform potentially hazardous tasks and to recognize the associated hazards, and only work when appropriate safety controls and procedures are in place Have access to Berkeley Lab ES&H program documents (including the ES&H Manual), DOE ES&H publications, Cal/OSHA Form 300 (a record-keeping log), and exposure assessments and investigation reports for incidents in which they are involved Minimize the volume and toxicity of Berkeley Lab-generated waste and maintain chemical inventories as low as reasonably achievable Be accountable to Berkeley Lab for willful disregard of ES&H procedures 3. Must actively communicate ES&H and Integrated Safety Management issues Notify their supervisors or work leads if they feel unqualified or insufficiently trained to do the task at hand or have any questions about performing tasks safely Report unsafe activities, unsafe or potentially unsafe conditions, safety violations, and near-hits to Safety Line Management and/or designated safety representatives Notify their Safety Line Management about conditions that may develop into unsafe situations Raise concerns, send suggestions, and report ES&H issues to Safety Line Management, designated safety representatives, EHS staff, or DOE without fear of reprisal Report work-related, occupationally-incurred injuries and illnesses to their supervisors or work leads and Health Services at the first opportunity Participate in incident investigations as requested by Safety Line Management and/or designated safety representatives
Work Leads	Individuals delegated to perform select safety responsibilities by their supervisors and managers. Work leads are expected to apply these responsibilities under their Supervisors or Managers authority to perform these specific assignments. Work leads may decline to accept safety responsibilities with the permission of their supervisor.

1.11 Definitions

NOTE: Some functions and definitions overlap, depending on the specific situation.

Term	Definition
Affiliate	Non-Laboratory employees engaged in on-site Laboratory activities. Affiliates are subject to training in safety and other subjects. They are also issued a Berkeley Lab identification badge. Affiliates may receive system accounts, research access to facilities, and a per diem allowance for housing and living expenses. Examples: facility users, scientific collaborators, students.
ALDO	Associate Laboratory Director for Operations
Area	An entity that is separately listed in the Berkeley Lab Space Database maintained by Facilities Division and assigned to a division for programmatic use. Areas may be further described by their functional use (e.g., laboratories, shops, offices, conference rooms).
Area Safety Leader	The individual assigned by the division controlling the technical area to oversee coordination of safety issues within the area
Berkeley Lab	Abbreviated designation used to denote LBNL or the Lawrence Berkeley National Laboratory
CHESS	Comprehensive Health Environment Safety System
Contract 31	U.S. Department of Energy Contract No. DE-AC02-05CH11231, also referred to as the UC-DOE Prime Contract or Contract 31. The Contract describes the terms for UC’s management of Berkeley Lab. The Contract includes a statement of work (SOW) for the science missions, and details the requirements for managing the operations and business of Berkeley Lab.
COO	Berkeley Lab’s Chief Operating Officer
EHS	Environment, Health and Safety Division
Employee	An individual who is hired by to provide services on a regular basis in exchange for compensation
ES&H	Environment, Safety & Health; the discipline, generally interchangeable with “safety”
ES&H Coordinating Committee	The ES&H Coordinating Committee is formed when a Significance Level A program or project is ready for the Berkeley Lab Director review. The purpose of the ES&H Coordinating Committee is to advise the Berkeley Lab of the readiness and effects of implementing the program. The EHS Division Director identifies and contacts the most affected division directors and other senior Berkeley Lab management personnel to serve on the Committee. The SME provides a briefing to the members of the Committee to ensure that they are ready to advise the Berkeley Lab Director on the new policy or program.
Faculty scientist	Faculty scientists hold dual appointments at Berkeley Lab and an academic institution (usually UC Berkeley). When they perform work at or for Berkeley Lab, they are staff members. Work includes being a HEERA supervisor, matrix supervisor, or work lead for one or more workers. See Supervisory Employees in the RPM Glossary.
HEERA	Higher Education Employer-Employee Relations
Host	A host provides oversight to users at user facilities. A host has ultimate responsibility for safety at an assigned scientific station and ensures that all users receive proper training and oversight. A host may be a matrix supervisor, HEERA supervisor, or a work lead.
ISM / ISMS	Integrated Safety Management. Also referred to ISMS, or Integrated Safety Management System
Key personnel	This is a Contract 31 term that includes the Berkeley Lab Director, deputy directors, associate laboratory directors, Chief Financial Officer, Berkeley Lab Counsel, Director of EHS Division, Director of the Facilities Division, and the Director of the Office of Institutional Assurance.
Line Manager, Line Management	Managers are individuals responsible for formulating and administering policies and programs of Berkeley Lab; 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 Berkeley Lab starts at the top with the Berkeley Lab 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.
Matrixed Employee	A person from one division (the home division) who provide special technical expertise for another division (the host division)
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 affiliates 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 affiliates and visitors of Berkeley Lab. A Matrix Supervisor partners with the HEERA Supervisor on matters of staffing, performance review, work direction, and evaluation.
Mentor	A mentor is a work lead for a student or Berkeley Lab employee. Mentors do not need to be line managers, HEERA-designated supervisors, or Berkeley Lab employees.
OIAI	Office of Institutional Assurance and Integrity.
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, procurement and oversight of 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.
Requirements review case	An instance or a question related to a requirement that has been logged into the Requirements Management database for disposition by the RM Committee
RM	Requirements Management
RMC	Requirements Management Committee: an institutional committee
RPM	Berkeley Lab Requirements and Policy Manual, PUB-201
safety	Safety is used generically to cover all aspects of Environment, Safety & Health (ES&H) including regulatory requirements and is interchangeable with ES&H.
Safety Line Management	The management chain of command that carries out the Laboratory Director’s ES&H concerns for safety. The unbroken linear safety management chain linking the Berkeley Lab 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.
Staff	Anyone who works at Berkeley Lab and has been issued a current Berkeley Lab badge
Student or student intern	Students or student interns often work at Berkeley Lab in different positions. Students can be employees or affiliates. Students are part of the Safety Line Management, no matter what their positions. Types of students employed at Berkeley Lab are: Interns: A special class of students who work at the Berkeley Lab for education purposes Graduate Student Research Assistants (GSRAs): Registered graduate students of the University of California (UC) Student Assistants: Hired for variable-time or fixed-percent-time work schedules. These students can be high school, undergraduate, or graduate students from any institution.
Subcontractor	An individual worker or company hired by Berkeley Lab to perform a specific task that supports new or continuing of Berkeley Lab operations as part of an overall project
Subject Matter Expert (SME)	An SME has been designated by the group leader to provide technical direction to the Berkeley Lab population in a specific area. The SME is responsible for all technical questions in their assigned area(s).
Supervisor (HEERA)	Supervisory employees are defined by the Higher Education Employer-Employee Relations Act (HEERA) as “any individual, regardless of the job description or title, having authority in the interest of the employer to hire, transfer, suspend, lay off, recall, promote, discharge, assign, reward or discipline other employees, or responsibility to direct them, or to adjust their grievances, or to effectively recommend such action, if, in connection with the foregoing, the exercise of such authority is not of a merely routine or clerical nature, but requires the use of independent judgment. Employees whose duties are substantially similar to those of their subordinates shall not be considered to be supervisory employees.”
Technical Area	Technical areas generally include laboratories, shops, workrooms, and similar areas. Offices, conference rooms, food preparation, and consumption areas such as the cafeteria, kitchenettes, and break rooms are generally not considered technical areas.
User	A subset of employees or affiliates who come to Berkeley Lab as users at one or more of its various user facilities. They may be Berkeley Lab 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 Berkeley Lab safety requirements. They work under the auspices of a Berkeley Lab host.
Visitors	Individuals who are visiting the Laboratory for typically one week or less and are not engaged in Laboratory research or use of Laboratory facilities. Examples of visitors are meeting attendees or speakers, participants in scientific discussions, tour groups, and interviewees.
Work	Work is defined broadly to include all Berkeley Lab activities undertaken by staff independent of sponsor, program, or location of activities.
Worker	Defined broadly to include anyone who performs work at or for the Laboratory. Individuals who work at the Laboratory, including but not limited to employees, affiliates, and contractors
Work lead	A work lead is anyone who directs, trains, or oversees the work and activities of one or more workers. Work leads provide instruction on working safely and the precautions necessary to use equipment and facilities safely and effectively. Work leads do not need to be line managers, HEERA-designated supervisors, or Berkeley Lab employees.
Work Planning and Control (WP&C)	Berkeley Lab’s system for authorization of work activities.

1.12 Required Work Processes

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

The EHS Division adheres to the following institutional policies relating to Requirements Management:

This process includes identifying the Subject Matter Expert (SME) for a particular requirement, analyzing meanings and impacts of a new or changed requirement, and then setting forth applicable implementation mechanisms for the requirement to ensure flow-down to the workforce. Additionally, user input and management’s review and approval are key elements of the process. Implementing mechanisms include, but are not limited to: documents, training programs, communication, and definitions of roles and responsibilities. All institutional documents are subject to the Laboratory’s Managing Institutional Documents Process and Document Management Policy. The Document Management Policy applies a “graded” rating for documents: major, minor, editorial. All major changes to institutional policies must be reviewed by the Laboratory Requirements Management Committee (RMC). Minor changes to institutional policies must be reviewed by the EHS Requirements Management (RM) Representative. However, if cross-functional actions are needed, the EHS RM Representative can recommend an RMC review. Additionally, the EHS RM Representative must review major and minor changes to institutional non-policy documents and can recommend an RMC review if cross-functional activity is involved.

EHS SMEs and their managers follow the steps below for developing or revising ES&H policies and programs:

SME receives a new or modified ES&H requirements, such as a:
1. Regulation
2. DOE order
3. Contractual requirement
SME prepares a preliminary analysis comparing the new requirements to existing requirements (gap analysis).
SME analyzes the proposed new or changed requirement and policy/program changes and determines the significance rating using the Berkeley Lab Analyzing Requirements and Determining Significance Rating from Impact and Risk Analysis Procedure.
EHS RM Representative reviews the proposed change and significance rating to ensure they are properly aligned.
Based on the significance rating, the SME and department manager:
1. Determine whether a working group is required
2. Draft an Implementation Plan using guidance from Developing, Reviewing, Approving an Implementation Plan and the Implementation Plan Form
EHS RM Representative reviews the Implementation Plan to ensure it includes applicable program elements.
SME documents the plan on the Implementation Plan Form. Applicable elements of an Implementation Plan are based on the significance rating and may include:
1. Review and refinement of the gap analysis
2. User input/establishing a working group
3. Benchmarking
4. Alpha, beta, or pilot testing
5. Cost/benefit analysis
6. Alternative and preferred approach analysis
7. Communication plan
SME, and working group if appropriate, drafts the new or changed policy and/or program.
SME presents the preferred approach supported by the Implementation Plan to the approving manager and, at management’s discretion, the Laboratory Counsel and/or the Safety Advisory Committee (SAC) or subcommittee.
SME, and working group if appropriate, finalizes the new or changed policy, program, and/or procedure based on the input of the approving manager, line management, the Laboratory Counsel, SAC, RMC (for policies), and/or subcommittee input.
Approving manager approves the new or changed policy and/or program. Approving manager may be EHS Division Line Management, the Chief Operating Officer, or the Laboratory Director depending on the significance rating.
SME implements the new or changed policy and/or program following the Implementation Plan, and communicates the new requirements to affected populations.
SME submits all documentation to be filed to the EHS RM Representative.
After the new or changed policy and/or program is implemented, the SME evaluates it through the Technical Assurance Program and, as necessary, gathers user feedback to identify potential improvements.

Process for Urgent Compensatory Situations

Occasionally, there may be a need to quickly implement a requirement- or policy-related change. Such “stop work” or “stop practice” mandates must have at least EHS Division Director authority. These high-urgency situations are still subject to completion of the applicable elements of the Requirements Management process. However, the Requirements Management elements may be worked on in parallel or in a different sequence. EHS, through assigned SMEs, is expected to drive completion. Because the matter is urgent, emphasis on communication is likely needed. The following is an example of re-ordering the RM process for a highly urgent situation:

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

Work Process B. The Use of “Shall,” “Must,” “Should,” and “May” in EHS Documents

EHS uses “shall,” “must,” “should,” and “may” statements in the following manner to convey requirements and best practices:

“Shall” statements implement applicable regulation requirements, Department of Energy (DOE) orders, or Berkeley Lab contractual requirements. Exemption can only be granted by the DOE. Berkeley Lab documentation distinguishes external requirements by either using direct quotes or clearly identifying the source of the requirements.
“Must” statements implement Berkeley Lab policy. Exemption could be granted by the EHS group manager supervising the program manager or SME or higher EHS management.
“Should” statements implement recommendations, best practices or safest methods at the time the implementing document was developed. Exemption can be granted by line management.
“May” statements are generally used in statements that implement a “shall,” “must,” or “should” but have the additional option for further action or steps. It is also used to indicate allowable alternatives.

Work Process C. EHS Safety Evaluations of Used, Gifted, Loaned, Borrowed, or User-Owned Equipment

Each division is responsible for ensuring that used equipment – whether brought to Berkeley Lab as a donation, or prepared to be transferred elsewhere within or outside Berkeley Lab – is inspected prior to acceptance or transfer to determine whether it is safe for further use. This evaluation must be documented. Contaminated, unguarded, electrically incompatible, damaged, or otherwise questionably safe equipment must be evaluated by qualified subject matter experts (SMEs) before the equipment is deemed safe to be placed into service. The EHS Division will provide the qualified SMEs to perform the evaluations. A list of EHS SMEs can be found at the EHS Subject Matter Contacts Web page.

Work Process D. Working Alone Policy

The Working Alone Policy restricts work conducted during the course and scope of Berkeley Lab business in cases where a plausible failure of hazard controls could result in an injury or exposure that would render an individual unable to take appropriate emergency actions. Examples include the following:

An individual may be splashed with a corrosive chemical that blinds him or her (volume used and concentration, etc., should be considered).
An individual may be exposed to a chemical or trauma that impairs consciousness.
An individual may be set on fire.
An individual may receive a severe electrical shock or arc-flash injury.
An individual may fall from an elevation above six feet.
An individual may become trapped in or by moving machinery.
An individual may be injured by a powered cutting tool.

Workers at Berkeley Lab are not allowed to work alone when the mitigated hazards associated with their work could incapacitate them such that they could not “self-rescue” or activate emergency services.

The Working Alone Policy is implemented through the Work Planning and Control (WPC) process at the division level.

Each division must assess its work activities and find those in which the severity of mitigated hazards may prevent workers from self-rescuing or activating emergency services in the event of an accident.
Authorizations for the identified work activities must place restrictions on working alone.
During the work authorization development and review process, authors and reviewers determine whether and when a working alone restriction is necessary and include it in the controls listed in a WPC Activity or other work authorization document.
This working alone restriction then flows down to individual workers through their WPC Activities or other authorizations.
For construction activities, the policy is implemented through the construction safety review process; for non-construction subcontractors, it is implemented through the Subcontractor Job Hazards Analysis and Work Authorization process.
The policy does not address activities “commonly performed by the general public” that include hazards commonly accepted by the public, the control of which requires little or no specialized guidance or training. These activities include walking or driving while alone and the consequences of personal medical conditions that may arise while at work.

Work Process E. Stop Work Policy

This work process describes stopping work activities considered to be an imminent danger. An “imminent danger” is defined as any condition or practice that could reasonably be expected to cause substantial harm to the health and safety of employees or the public, or to the environment. This policy applies to all activities conducted at Lawrence Berkeley National Laboratory (Berkeley Lab) and to all off-site facilities operated by Laboratory personnel.

All Berkeley Lab employees, affiliates, and contractors are responsible for stopping work activities considered to be an imminent danger. This policy applies to all activities conducted at Berkeley Lab 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 substantial harm to the health and safety of employees or the public, or to the environment.

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

Alert the affected worker(s) engaged in the unsafe work creating an imminent-danger condition and request that the work be stopped.
Call ext. 6999 to report the incident. Environment, Health, and Safety (EHS) Division staff will investigate it.
Notify the immediate supervisor and/or responsible division/department manager (if known).

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

Resumption of work will not proceed until after the condition has been evaluated and the appropriate remedial actions have been taken.

Work Process F. Requesting a Variance from Berkeley Lab Safety Policy

In the rare case that an ES&H policy prevents a work activity from being performed, even though it may be demonstrated that it can be performed in a safe and healthful manner, a variance from the policy must be requested by Line Management. Variance requests are reviewed on a case-by-case basis. If a variance is not authorized, an alternate means of compliance within requirements is developed.

Circumstances may occasionally arise where an ES&H policy and/or other ES&H Manual requirement may:

prevent work from being conducted safely, or
prevent a work activity from being performed, even though it may be demonstrated that it can be performed in a safe and healthful manner.

If it is necessary to perform this work, each circumstance must be brought to the attention of the EHS Division in the form of a request for variance, as identified below. Each request will be reviewed on a case-by-case basis.

Principal investigators and/or other Berkeley Lab employees who have concurrence from his/her cognizant division director or independent department head may request in writing a variance from a Laboratory ES&H policy. Requests for variances go to the EHS 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

Employees denied variance requests may make an appeal to the Deputy Director for Operations, whose decisions are final. If a variance is not authorized, an alternate means of compliance within requirements is developed.

1.13 Source Requirements Documents

Contract 31, I.131, DEAR 970.5223-1, Integration of Environment, Safety, and Health into Work Planning and Execution (Dec 2000)
Contract 31, I.123, DEAR Clause 970.5204-2 Laws, Regulations and DOE Directives (Dec 2000)
Contract 31, Appendix I, Environment, Safety and Health Standards for LBNL
Applicable standards listed in Appendix G of the Contract between DOE and the University of California (copies available from the EHS Division)
LBNL Integrated Environment, Safety & Health Management Plan, PUB-3140
LBNL Operating and Quality Management Plan, PUB-3111
LBNL ES&H Manual
LBNL Requirements and Policy Manual (RPM), PUB-201
DOE Policy 450.4, Safety Management System Policy
DOE Order 450.1A, Environmental Protection Program
Requirements Management Policy, 04.04.001.000
Document Management Policy, 10.06.001.000
Requirements Management Process, 04.04.001.003

1.14 Reference Documents

Berkeley Lab Environment, Safety & Health (ES&H) Manual (formerly the PUB-3000)
Worker Health and Safety Plan (PUB-3851)
Issues Management Program Manual (PUB-5519)
Biological Safety Program Manual
Radiation Protection Program
Environmental Management System
Waste Management Plans
Work Processes supporting the overall EHS Core Program

Other References and Best Management Practices

Document Number	Title
04.04.001.000	Requirements Management Policy
04.04.001.003	LBNL Requirements Management Process Description
04.04.001.101	Procedure: Analyzing Requirements and Determining Risks and Impacts
04.04.001.102	Procedure: Developing, Reviewing, Approving an Implementation Plan
04.04.001.103	Procedure: Parsing Requirements
04.04.001.202	Form: LBNL Implementation Plan Template
04.04.001.201	Form: Analyzing Requirements and Determining Risks and Impacts
04.04.001.203	Form: Parsing Requirements
10.06.001.102	Procedure: Developing, Reviewing, Approving Institutional Policy Documents

Where to find out more:

PUB-3140, Integrated Environment, Safety & Health Management Plan
PUB-3851, Injury and Illness Prevention/Worker Safety and Health Program
LBNL Hazard Management System (HMS)
ES&H Manual, Exposure Assessment
ES&H Manual, Work Planning and Control Program
ES&H Manual, Construction Health & Safety
Construction Subcontractor Resource Website
Subcontractor Job Hazards Analysis (for non-construction vendors)
Issues Management Program Manual (PUB 5519)