Program Review, Workplace Inspections, Hazards Analysis And Abatement
This document provides guidance information and suggested
procedures for performing program review, workplace inspections,
hazards analysis, and abatement, successfully at DOE Federal
Hazards can be identified using many methods, including hazard
analyses (e.g., job safety analysis and comprehensive safety
and health surveys), accident investigations, routine self-assessment,
and inspections. This chapter touches on all these methods.
Hazard identification and analysis can be formal or informal.
Frequently, hazard identification is more effective when performed
informally by supervisory and non-supervisory employees during
the course of daily work activities, with appropriate technical
assistance from safety and health professionals. The worker
should be the person most likely to recognize potential hazards.
Formal hazard analyses can include job safety analysis (JSA),
nuclear safety analysis, process hazard analysis, comprehensive
safety and health surveys, and investigation of employee suggestions
Job Safety Analysis
Job Safety Analyses (JSAs) are step-by-step analyses of each job component and existing or potential hazards. They should be performed by supervisors and workers and supplemented by the safety and health staff. JSAs should be performed initially for all operations and then revised as operations change.
JSAs are the most basic and widely used tool to identify job and task hazards and prevent accidents before they occur. JSAs can satisfy a large portion of the hazard identification tasks at a facility. These analyses are appropriate for dynamic activities and tasks, such as construction projects, however, static work environments are also appropriate for using JSAs: - during the planning stage for new operations and procedures - prior to implementation of changes to existing operations - for existing operations and procedures that have resulted near misses and - for existing operations and procedures that have not been the past or when there is no recent hazard analysis.
Quick completion time and limited resource allocation make
JSAs a very adaptable and widely used hazard identification
technique. A JSA is performed by breaking down a job into
its component steps and then examining each job component
to determine hazard and accident causes or those that may
potentially occur. Reviewing the job steps and hazards while
the employee performs the job will ensure that a comprehensive
and accurate list of hazards is identified and documented.
Consideration must be given to job mobility, area of performance,
ongoing operations in surrounding areas, and specific hazards
in the area, relative age of the workforce and job experience,
applicable safety and health rules, and recognition of abnormal
or unforeseen problems.
JSAs benefit new employees by providing a basis for them
to perform their jobs. Likewise, experienced employees also
benefit by undergoing safety awareness "reality check"
on their job.
Following are the steps that comprise the JSA process:
- Develop a list of all the jobs at your facility; group
the jobs (e.g., job title or function).
- Prioritize the job risks based on occurrence severity
and probability. Make a high-risk job list.
- Conduct an initial JSA on the highest-priority job.
- Determine which methods should be used for the JSA (e.g.,
discussions with employees, direct observation of work by
safety and health professionals, videotaping, or a combination
- Select an employee to assist in conducting the JSA.
- Dissect and define each task involved with the job.
- Perform the JSA and complete a JSA worksheet for each
- Evaluate the JSA worksheet and develop solutions to reduce
or eliminate discovered hazards.
- Review the JSA with the employee.
Write or modify procedures to accomplish the task. When a
JSA is completed, it should be reviewed by a qualified person
who was not part of the process and with the involved employee.
Detailed information about conducting JSAs can be found in
DOE 76-45/19 SSDC-19, "Job Safety Analysis," and
DOL, Mine Safety and Health Administration Safety Manual No.
5, "Job Safety Analysis."
Analysis during Design and Development
Hazards that are identified during the design phase of new
facilities and facility modifications should be eliminated
or controlled through design or procedure changes.
This also applies to hazards identified during the development
or modification of procedures. The controls implemented should
be commensurate with the identified risk levels.
Hazards that pose a serious threat to employee safety and
health should be either completely eliminated or effectively
Proposed design or procedure modifications that are intended
to eliminate or control hazards should be reviewed by OSH
professionals to ensure that the change adequately addresses
the hazard and does not introduce new workplace hazards. Alternative
control measures should be evaluated to determine risk reductions
provided by each measure and to identify the most effective
practical control for the hazard.
When engineering controls do not reduce the associated risk
to acceptable levels, they may be supplemented with work practices
and administrative controls. Where necessary, these controls
may be further supplemented with appropriate PPE.
Analysis of Equipment, Products, and Services
Hazards should also be addressed when selecting or purchasing
equipment, products, and services. Provisions should be made
for evaluating pre-engineered or "off-the-shelf"
equipment prior to selection and purchase.
This evaluation should focus on whether the worker can perform
required tasks with the equipment or procured material without
endangering the health and safety of workers, considering
existing facility and operational constraints.
Evaluation methods may include:
- Review of equipment or material specifications.
- Observations of equipment or material demonstrations.
- Analyses of change.
- Analyses of operational hazards.
- Analyses of ergonomic/human factors.
- Quality assurance checks for suspect or counterfeit parts
for critical safety-related components.
Considerations to be taken into account when reviewing equipment
- Health hazards
- Operating noise
- Temperature levels
- Point-of-operation guards
- Lockout provisions
- Presence of hazardous material
- Training requirements for safe operation
- Ergonomic design, worker/machine interface
- Maintenance requirements
- Availability and practicality of "add-on" (post-purchase)
- Existing facility and operational constraints (e.g.,
floor loading, hazards from adjacent operations, congested
After installation of complex or potentially hazardous equipment,
a pre-startup evaluation should be conducted by affected workers,
supervisors, and OSH professionals to verify safe conditions
and identify any previously unforeseen hazards.
USING THE INFORMATION
Collecting information about existing and potential hazards
is only the first step in the hazard identification process.
Once hazards have been identified, the associated data must
be evaluated to assess exposure potential and determine whether
there are certain trends that should be addressed.
Usually, a wealth of data is available from various resources
(injury/illness reports, inspection findings, accident investigation
reports, employee concerns, workers compensation data, etc.).
It is important to maintain hazard information in such a way
that the data can be tracked and trended to determine the
root causes of safety and health problems.
For example, if several workers at the same site suffer similar
injuries during a given period, can these injuries are tracked
back to a common cause (faulty equipment, inadequate training,
poor work practices, etc.)?
Many facilities have formal corrective action tracking systems
that employ computer databases to record and manipulate data
about existing hazards, root causes, abatement activities,
Information from these databases can be used as performance
indicators to demonstrate the success of the facility's hazard
abatement program. Hazard analysis processes do not need to
be formal, but it is essential that you have some means of
evaluating hazard information.
Your goal should be to go beyond determining what hazards
exist and get to the "bottom line" of why they exist.
To assist in data management, DOE maintains the Computerized
Accident and Incident Reporting System (CAIRS). The CAIRS
accident and incident information is issued in summary reports
entitled, Occupational Injury and Property Damage Summary.
The quarterly reports are the "rolled-up" performance
statistics of injuries, illnesses, and property damage recorded
by DOE and its contractors during a 3-month period throughout
The data recorded by DOE are compared with relevant statistics
from businesses in private industry performing similar activities.
Ad hoc queries can also be made to tailor analyses to specific
Accident investigations are conducted to uncover hazards that
were either missed during earlier inspections or are present
because of inadequate controls. Another objective is to identify
the causal factors associated with the accident, so that both
the hazards and the causal factors can be controlled and future
occurrences prevented. The process concludes with the issuance
of a final report with recommendations for corrective action
and follow-up to ensure closure.
The essential elements of an accident investigation follow:
- Establishing effective investigation and communication
- Selecting knowledgeable impartial experts who ideally
should include one individual from another area with similar
- Collecting and preserving physical evidence prior to
its being moved.
- Interviewing initially the eyewitnesses at the accident
- Determining and documenting the facts.
- Determining the causal factors by analysis.
- Developing recommendations (actions needed to prevent
- Following-up to ensure closure.
The accident investigation should fully cover and explain
the technical elements of the causal sequences and should
also describe the management system that should have, or could
have, prevented the occurrence. Where feasible, the response
to the interviews should be documented and included as backup.
The basic questions to be answered during the interview are
who, what, when, where, why, and how.
Facts must be clearly distinguished from opinions, other
expectations, or the investigators. The latter can be included
in the report's findings and recommendations for corrective
action. Remember the goal of an accident investigation is
to improve an organization's ability to maintain a safe workplace,
not to place individual blame.
Supervisors and others who investigate accidents should be
responsible for clearly documenting the causes uncovered during
the investigation. Supervisors should be careful to avoid
the tendency to lay sole blame on an injured employee. In
most cases where human error is involved, there is often a
managerial deficiency involving procedures, training, or staffing
Even if the injured worker openly blames him- or herself,
the accident investigator must not be satisfied that all contributing
causes have been identified. For more information about accident
investigations, see DOE Order 225.1 and DOE Form 5483.3.
DOE Federal facilities are responsible for periodically evaluating
the management systems that support their safety and health
programs. For DOE elements, the self-assessment process should
include analyses of the effectiveness of safety and health
policies, programs, and procedures and the efficiency of processes
and functions that sustain these programs.
Self-assessment activities should be integrated both vertically
and horizontally within the line organization to ensure a
comprehensive top-to-bottom self-assessment process.
Self-assessment, at its most basic, can be as simple as "walking
your spaces." Workers and supervisors can police their
own work areas, periodically conducting informal safety inspections,
and noting hazardous work conditions or activities.
Checklists are helpful to focus attention to particular areas
(e.g., electrical hazards, fire exits and extinguishers, ladders,
and walking/working surfaces).
The two most important considerations are to be vigilant
about performing these walk-throughs and ensure that any noted
deficiencies are acted upon.
Inspectors must be competent to identify and recommend abatement
techniques for potential workplace hazards. Industrial area
inspections should be accomplished by safety and health professionals
with training and experience in recognizing hazards in the
types of work spaces to be inspected.
Inspections of less complex hazards may be conducted by individuals
with documented training and experience in identifying the
types of hazards that will be encountered in such environments.
This provides an opportunity for supervisors to walk their
Inspectors should be provided with the necessary PPE and
monitoring/test equipment for the work environment being inspected.
Inspectors need the necessary security clearance and documentation
to allow them unimpeded access to all work sites.
TYPES OF INSPECTIONS
There are many types of inspections and inspection activities
that can improve employee safety and health in the workplace.
They range from inspections by supervisors and employees in
their work areas to ensure that equipment and work areas are
safe to a more formal external look at the work environment.
Formal or annual inspections are supplemented by informal
identification of deficiencies by professionals when they
are in the work area for other reasons. The deficiencies should
be handled in the same manner as those identified during the
formal inspection activities.
Inspections should be targeted toward high-risk and problem
areas. All work areas should be formally inspected at least
annually. Frequency should be sufficient to identify and abate
The objective of the inspection program is to improve employee
working conditions through systematic identification and abatement
of hazards. Hazards may not relate directly to a violation
of a safety and health standard.
Inspections are required to validate employee concerns of
alleged unsafe or unhealthful working conditions. These conditions
must be inspected within 24 hours for imminent danger situations,
within 3 days for potentially serious allegations, and within
20 days for all other conditions.
A computer-based inspection management system can be helpful
in scheduling inspections, tracking abatements, tracking inspection
results, and targeting inspection activities in high-risk
or identified problem areas.
CONDUCTING WORKPLACE INSPECTIONS/PROGRAM ASSESSMENTS
It is crucial that the inspection process be viewed as a beneficial
activity. Workplace Inspections/Program Assessments must be
a common-sense, practical application of standards and work
practices that will eliminate physical hazards from the workplace.
Prior to any inspection, the inspectors should review the
following items to identify areas that should receive special
emphasis or be targeted for inspection.
- Previous inspection trends
- Injury/illness records
- Employee complaint files
- Facility modification/alteration records
- work process or procedure changes
- Equipment needed for the inspection
Inspection checklist(s) should serve as memory joggers to
ensure a thorough inspection. They should be small (fit in
your pocket), short, and to the point. Checklists may include
suggested sample size, areas by types of operations requiring
special attention, records to be received, reminders of interviews
to conduct, or special programs to be conducted.
They are not a substitute for thoroughness and professional
knowledge. To ensure adequacy of inspection coverage, they are a
useful inspection tool. They should not be used to limit the scope
of the inspection. In the section titled Closeout, replace last
bullet with Confront controversial issues that will be raised in
the final report.
Checklists should be developed by the inspector to fit the
inspector's individual style and should be reviewed and revised
frequently. Functional Area inspection checklists may require
more detailed requirements than an equipment or facility inspection
checklist. View an example FEOSH
Office Inspection Checklist
Prior to entering a work area to perform an inspection, the
inspector should introduce himself/herself to the person in
charge. The inspector should give the manager sufficient time
to assemble the personnel he or she wishes to be present at
the opening conference, including employee representative(s)
as well as other supervisors, employees, collateral duty safety
or health personnel, etc.
Once everyone is assembled, the inspector should explain
the purpose of the inspection, set the tone for the inspection
(non-adversarial), and determine special requirements (e.g.,
protective equipment or security restrictions, the mechanics
of the report, posting, and abatement procedures).
If employees are represented by an authorized representative,
that individual should participate in the inspection. If there
is no representative, the inspector should consult with two
or more employees in each visited work area.
Work Environment Monitoring
If the inspector is not an industrial hygienist and notes
an area that requires sampling to validate working conditions,
the relevant facts should be recorded; and a referral should
be made to an industrial hygienist for professional follow-up
When possible, a team (e.g., safety, industrial hygiene,
fire protection, radiation safety, etc.) approach should be
used in performing the inspections. This will ensure more
thorough coverage of facilities in a single inspection.
Inspecting Familiar Facilities
Start at one end of the facility and proceed methodically
through each work area, storage area, and transition space.
It is important that the inspector be methodical to ensure
that familiarity does not lead to complacency. A mental grid
pattern should be used to ensure full coverage, for example,
starting in the upper left rear corner of the room, moving
top-to-bottom-to-top, progressing left to right, and moving
toward the front of the room. This is sometimes referred to
as the stop and look method. It is much more effective than
randomly looking around the room. Look over, under, behind,
and in all areas.
Inspecting Unfamiliar Facilities
Obtain a floor plan of the facility and request a quick familiarization
tour. No inspecting should be done during the tour. The inspector
should note areas of most/least concern and utilize this information
to plan and pace the detailed inspection. Then proceed to
inspect as described for familiar facilities.
Inspecting Functional Areas
This type of inspection can be very beneficial in determining
the effectiveness and degree of compliance with the requirements
for regulated functional areas such as confined space, lockout
tagout, laboratory safety, respiratory protection, exposure
The common denominator for these programs is that they all
require the employer to develop a written implemented program.
Inspections of these areas should include the opening and
closing conference and the other attributes of a typical compliance
They differ in the following aspects:
- First, the inspector will grade the written program against
the requirements and then grade the implementation against
the written program.
- The inspection may encompass numerous facilities, programs,
and management or employee representatives; a consolidated
opening and closing conference may be beneficial.
- Because of documentation to be reviewed, personnel to
be interviewed, and geographical areas to be covered, the
inspection will normally take longer.
- A text report style may be more beneficial than traditional
- Many of the internal evaluation criteria can and should
be applied to these types of inspections.
The inspector should take notes on both the positive and
negative items noted during the inspection. All notes should
be openly discussed with management and employee representatives
who accompany the inspector.
Taking pictures of both good and bad practices can be beneficial
in providing feedback to supervisors and employees on hazard
To better evaluate and trend inspection results, it is helpful
to record the number of items checked versus the number of
items found deficient. For example, "ten exit doors checked
and eight were propped open" or "ten fire extinguishers
checked and only one needed a 30-day inspection."
If the inspector discovers a condition that could cause immediate
death or physical harm, the inspector informs the person in
charge to shut down the part of the operation causing the
exposure or removes the personnel until the hazard is abated.
At the conclusion of the inspection, the inspector discusses
the preliminary results of the inspection with management
and employee representatives. This includes both positive
and negative findings and the relative seriousness of the
deficiencies. Official report and deficiency abatement timeframes
and procedures should be determined, and violation posting
requirements should be reviewed.
There should be no surprises at this point and no disagreement
with the findings. The following tips and questions are provided
to help the closeout conference proceed smoothly and effectively.
- Be prepared to face high-level, highly specialized people.
- Consider taking your own backup personnel in controversial
- Keep communications clear and concise.
- Control your emotions.
- Keep matters in perspective.
- Proceed from "good" to "bad" in the
- Confront controversial issues that will be raised in
the final report.
The inspectors should make notes on any items brought to
their attention by management or employee representatives
during their closeout briefing, such as additional facts,
disagreement resolutions, and conditions beyond control of
the inspected individuals.
FEOSH PROGRAM ASSESSMENT
Example Plan for Conducting a Detailed FEOSH Program Assessment
The objective of this assessment is to evaluate the level
of formality and depth of the FEOSH Program implementation
of management systems, industrial hygiene, health physics,
and general worker safety programs.
The reviewers will concentrate on performing a top level
safety management systems review, and conducting vertical
slice reviews down through several technical areas of the
These technical slice reviews may include: health physics;
laboratory chemical hygiene; hazard communication; employee
training; qualifications; compliance with ACGIH Threshold
Limit Values (TLVs); work control procedures; personnel exposure
monitoring; electrical safety; emergency preparedness; medical
surveillance; respiratory protection; hearing conservation;
confined space; beryllium and, ergonomics programs.
Program Documentation and Record Review
A review will be conducted of the manuals of practice and
selected records that define the procedures and interactions
required for worker safety, industrial hygiene, and health
physics program at the facility or activity level. The review
will also consider the adequacy of the sites documents to
meet the criteria noted below, and to determine that the worker
safety, industrial hygiene, and health physics programs are
effectively integrated into the facility or activity procedures.
A review will be conducted of any lessons learned, occurrence
reports, OSHA 300 logs that may provide an opportunity to
determine if lessons learned have been effectively used, and
corrective actions implemented, within the worker safety,
industrial hygiene, and health physics area.
A review will be conducted of the training records of personnel
in the industrial safety, industrial hygiene, and health physics
area to determine that they meet competency standards.
Document reviews will be conducted prior to the assessors
arriving on-site, to the extent possible.
The following documents are requested for review: (Note:
these documents should be reviewed prior to the first week
of the on-site FEOSH program review.)
- Site FEOSH Program Manual: (List document name and numbers)
- OSHA 300 Log for the past and current year.
- CAIRS and ORPS data report associated with Federal employees
for the past and current year.
- Job Safety Analysis (JSA) Numbers: (List document name
- Technical FEOSH (IH, HP, and Safety) Procedure Numbers:
(List document name and numbers)
- Administrative Procedures: Examples of Training and Qualification
Standards, Employee Complaints Process Documentation, (List
document name and numbers)
Interviews, Workplace Walk around, and Technical Program
Interviews will be conducted of personnel and responsible
managers in the FEOSH, industrial hygiene, safety, and health
physics areas assigned. Interviews will be conducted of line
managers to assess the establishment of clear roles, responsibilities,
and the level of understanding of worker safety, health priorities,
needs, and objectives.
It is desirable that individuals performing the following
functions be available for interviews.
- Senior Site/Facility Manager. (Federal employee)
- Facility Safety and Health Program Representatives. (Federal
- FEOSH Program Manager. (Federal employee)
- Support - Industrial Hygienist, Health Physics, and Safety
Engineer. (May be contractor supported)
- Medical Program Director (May be contractor supported)
- CAIRS/ORPS Reporting Coordinator. (Federal employee)
- In briefing with key site/facility staff.
- General familiarization tour of Federal facilities with
emphasis on noting operations and work activities preformed
in specific areas, and key contact persons.
- In-depth, specific walk-around of areas to observe work
process, controls, and procedures. This may include visits
beyond Federal office areas to include a sampling of operations,
production, and laboratory facilities, which are occupied
or frequently visited by Federal personnel.
Technical Program Review
Day 3 and 4
- In depth, vertical slice, interviews, and technical reviews
of implementation of the following programs:
- Hazard Communication Program
- Office Safety and Health Program
- General FEOSH Training Program
- Occupant Emergency Preparedness
- General Safety, Workplace Inspection, and Use of Personal
Protective Equipment Program Elements.
- Federal Employee Medical and Exposure Monitoring Program
- An out-briefing of the preliminary findings and recommendations
will be given to interested Federal managers and staff.
Inspection reports provide management with a summary of results,
undesirable and noteworthy trends, and a risk assessment associated
with each hazard. The report should transmit notices of unsafe
or unhealthful working conditions.
Notice of Unsafe or Unhealthful Working Conditions
An inspection form can be used effectively for such notices;
it provides uniform recording of information, captures pertinent
corrective action/abatement data, and can be used to post
the violation notice.
Notices should be issued formally 15 days after the safety
condition inspections and no later than 30 days for health
condition inspections. The notices should be posted at the
infraction site for 3 days or until abated.
Notices of unsafe or unhealthful working conditions should
be mailed to the facility or workplace official and the employee
representative. Safety and health committees, if they exist,
should be provided with a copy.
EMPLOYEE CONCERN REPORTS
Providing employees with a mechanism to report safety and
health concerns quickly and easily is an excellent way to
gather information on actual or potential worker hazards.
Employees are encouraged to inform supervisors of any safety
and health concern; however, employees may go to higher management
or OSHA with the safety and health concern.
Employee concerns should be documented in writing either by
the person making the complaint or the person receiving the
report. Employees submitting the concern may request anonymity.
Individual case files should be established for each concern.
File coding will ensure that the identity of the individual
Responding to Concerns
In addition to the recordkeeping and reporting requirements
associated with the OSHA and OWCP forms, Federal agencies,
under 29 CFR Part 1960.28, "Employee Reports of Unsafe
or Unhealthful Working Conditions," must also maintain
a log of all existing reports or potential unsafe or unhealthful
work conditions at each establishment. A copy of each report
alleging an unsafe or unhealthful work condition must be sent
to the appropriate site safety and health committee.
In addition, a sequentially numbered case file, coded for
identification, is assigned to each report alleging an unsafe
and unhealthful working condition. Furthermore, the agency's
response to the situation must be documented. Each log should
contain the following information: date, time, code/file number,
location of condition, brief description of the condition,
classification (serious, non-serious, imminent danger), and
date and nature of action taken.
An employee submitting an unsafe or unhealthful condition
report should be notified in writing within 15 days if the
agency determines that a hazard does not exist and an inspection
will not be conducted. In addition, a copy of this notice
must be sent to the appropriate certified safety and health
DOE Elements must inspect allegations of imminent danger
within 24 hours. They must inspect potentially serious conditions
within 3 working days and other-than-serious allegations within
If, after notifying the safety and health committee, the
hazardous condition can be abated immediately, no inspection
For assistance with your program contact:
David M. Smith, Manager
Federal Employee Occupational Safety and Health
U.S. Department of Energy
Office of Health, Safety and Security
1000 Independence Ave S.W.
Washington D.C. 20585
||Federal Employee Occupational Safety and Health (FEOSH) Program |
U.S. Department of Energy,
Office of Health, Safety and Security (HSS)
1000 Independence Avenue, SW Washington, D.C. 20585-1290
FEOSH Program Manager: Carlos Coffman, HS-23, (301)903-6493 or Carlos Coffman