DOE Independent Validation Team Review of LBNL Corrective Action Plan On site Closeout

1. DOE Independent Validation Team Review of LBNL Corrective Action PlanOn site Closeout Paul Kruger, Team Leader June 28, 2006

2. Validation Team • Chartered by the SC Chief Operating Officer (COO) and Berkeley Site Office (BSO) Manager • Team members: • Paul Kruger, PNSO Manager (Team Leader) • Roger Christensen, PNSO (Deputy Team Leader) • Earl Carnes, EH • Hattie Carwell, BSO • Carol Ingram, BSO • Larry Kelly, ORO • Ted Pietrok, PNSO

3. Review Purpose • Provide BSO Site Manager with evaluation of the adequacy of the LBNL development process for corrective actions in response to the LBNL Peer Review • To that end, the team made no assessments nor performed any evaluations regarding the adequacy of the LBNL ISMS

4. Review Approach • A formal Validation Team Review Plan was developed and approved • The Team reviewed relevant documentation, including: • Peer Review Report • Validation Team Member Trip Report • LBNL Corrective Action Plan (CAP) • Root Cause and Extent of Condition Documentation • CAP process and CAP was reviewed against DOE Corrective Action Program expectations and criteria • Purpose of Team visit to LBNL was to gain additional insights regarding CAP development process and content of the CAP as well as to provide initial feedback (not a performance review)

5. Conclusions • Noteworthy Areas • Lab leadership commitment to safety improvement • UC initiation of independent Peer Review • Use of root cause analysis and training of staff in root cause technique • Involvement of line management in defining the problems and developing the corrective actions • Collaboration with safety leader in industry (e.g. Intel)

6. Conclusions (cont) • Areas for Improvement • The CAP does not provide clarity regarding how the 97 actions will integrate and contribute to specific improvements of Laboratory systems: • no tie to Quality systems and processes • some of the root causes are not clear • some root causes do not appear to be adequately addressed by corrective actions. • The CAP does not include discussion of the prioritization logic for implementing corrective actions

7. Conclusions (cont) • Areas for Improvement (cont) • The change control process does not appear to address active management of the set of corrective actions to achieve the ultimate desired outcomes • The individual outcomes for corrective actions are not specifically stated in measurable terms • The overall desired outcome is not clear

8. Phase 0 Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Six Phases of Safety Excellence What is Safety? Keep us out of jail/Don’t shut us down Accidents cost too much EHS is a top priority EHS is a value EHS is instinctive LBNL Culture Focus Self Assessment – Data Focus Discipline/Compliance Focus EHS Performance Chart Origin: Intel presentation to LBNL on March 27, 2006

9. Supporting Concerns • Emphasis on “certified” self assessment program contrasts with data that demonstrates self assessment was less than effective • Appropriate benchmarks have not been identified considering the highest vulnerable population of temporary grad students, post docs and guests • A cohesive strategy to address the variety of lab workforce groups is not clearly articulated • No clearly identified organizational competence for analyzing and acting promptly to operational data • It is not evident that the lab operates from the perspective of “proving it is safe” versus “proving it is unsafe” and is thus vulnerable to normalization of deviation

10. Summary • LBNL is in an early phase of building safety excellence • Keys to reaching next phase: • Strengthened Systematic and integrated work planning and control processes • Open and honest reporting of incidents (reporting culture) • Proactive investigation of events and analysis of event data • Line accountability for safety • Continued Management commitment and example • Robust self assessment program to include system effectiveness evaluation • Effective “lessons learned” program that aids feedback and continuous improvement

11. Recommendations • The LBNL CAP can be accepted as a reasonable starting point if: • BSO sets the expectations for safety excellence • BSO works closely with LBNL to improve the clarity of corrective actions and develop appropriate metrics to evaluate success • BSO performs oversight to ensure that expectations are being met

12. Recommendations (cont) • To better understand the opportunities for systems improvement, BSO & LBNL should consider performing rigorous self and external assessments of ISMS to ensure systematic approaches are in place

13. Path Forward • A draft Review Report will be provided by the Teamto the BSO Manager within 3 weeks • BSO will be responsible for monitoring and reporting status of corrective actions, validation of completion, and follow-on effectiveness reviews

14. BACKUP SLIDES

15. Review Criteria • Issues management system is in place • Proper investigation and understanding of deficiencies is demonstrated • Root causes and causal factors are identified • Corrective actions are concise, executable and have clear outcomes • Interim/Compensatory actions are identified where appropriate • Corrective actions include participation by line organizations • Completion dates are clearly established, reasonable, and achievable • A systematic process for tracking and reporting actions is identified • Mechanisms for independent validation/effectiveness review are identified • CAP is approved and supported by senior management