Program Review, Workplace Inspections, Hazards Analysis And Abatement

INTRODUCTION

This document provides guidance information and suggested procedures for performing program review, workplace inspections, hazards analysis, and abatement, successfully at DOE Federal employee worksites.

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 ANALYSES

Informal

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

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 or complaints.

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 of methods).
• 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 job.
• 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 controlled.

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 specifications include:

• 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) safety equipment
• Existing facility and operational constraints (e.g., floor loading, hazards from adjacent operations, congested workplaces, etc.)

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, and schedules.

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.

CAIRS Database

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 Complex.

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 sites.


ACCIDENT INVESTIGATIONS

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 procedures.
• Selecting knowledgeable impartial experts who ideally should include one individual from another area with similar operations.
• Collecting and preserving physical evidence prior to its being moved.
• Interviewing initially the eyewitnesses at the accident scene.
• Determining and documenting the facts.
• Determining the causal factors by analysis.
• Developing recommendations (actions needed to prevent recurrence).
• 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 levels.

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.


SELF-ASSESSMENTS

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.

Daily Walkthroughs

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

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 spaces.

Equipment

Inspectors should be provided with the necessary PPE and monitoring/test equipment for the work environment being inspected.

Security Clearance

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.

Compliance Inspections

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 hazardous conditions.

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.

Employee Concerns

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.

Tracking Program

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.

Preparation

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

Checklist

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

Introduction

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).

Employee Representative

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 and/or monitoring.

Inspection Teams

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 records, etc.

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 inspection.

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 violation tickets.
• Many of the internal evaluation criteria can and should be applied to these types of inspections.
  

Recording Results

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 recognition.

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."

Imminent Danger

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.

Closeout

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.

• Be prepared to face high-level, highly specialized people.
• Consider taking your own backup personnel in controversial situations.
• Keep communications clear and concise.
• Control your emotions.
• Keep matters in perspective.
• Proceed from "good" to "bad" in the presentation.
• 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

Objectives

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 program.

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 and numbers)
• 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 Reviews

Interviews

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.

Day 1

• Senior Site/Facility Manager. (Federal employee)
• Facility Safety and Health Program Representatives. (Federal employee)
• FEOSH Program Manager. (Federal employee)
• Support - Industrial Hygienist, Health Physics, and Safety Engineer. (May be contractor supported)

Day 2

• Medical Program Director (May be contractor supported)
• CAIRS/ORPS Reporting Coordinator. (Federal employee)

Walk around

Day 1

• 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.

Day 2

• 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

Out briefing

Day 5

• An out-briefing of the preliminary findings and recommendations will be given to interested Federal managers and staff.
  
  

INSPECTION REPORTS

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 is protected.

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 committee.

Inspection Requirements

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 20 days.

If, after notifying the safety and health committee, the hazardous condition can be abated immediately, no inspection is necessary.

TECHNICAL ASSISTANCE

For assistance with your program contact:

David M. Smith, Manager
Federal Employee Occupational Safety and Health Program
U.S. Department of Energy
Office of Health, Safety and Security
HS-23-270CC
1000 Independence Ave S.W.
Washington D.C. 20585
(301) 903-4669
David.Smith@hq.doe.gov

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