TITLE:	ES&H Manual
DOCUMENT ID:	3310 Appendix T1 Operational Safety Procedure (OSP) and Temporary Operational Safety Procedure (TOSP) Procedure

1.0 Purpose

This appendix outlines the process steps used to: develop, submit, review, approve, document, implement, close-out, and renew or revise an Operational Safety Procedure (OSP) or Temporary Operational Safety Procedure (TOSP).

2.0 Scope

An OSP is developed when work activities:

· Cannot be conducted in a manner consistent with ES&H Manual requirements as written;

· Introduce a new/previously unrecognized hazard issue.

· Have an unmitigated Risk Code (RC) of 3 or 4, as determined by a Task Hazard Analysis (THA), when Standard Protecting Measures are unable to reduce the hazard to RC <3.

TOSPs are developed identical to OSPs except they are valid for three months or less.

3.0 Responsibility

NOTE: Management authority may be delegated at the discretion of the responsible manager.

3.1 Document Owner – The individual responsible for the OSP’s implementation.

· Is a Jefferson Lab employee.

· Develop the OSP. This includes but is not limited to:

o Define the Scope of Work

o Analyze the Hazards

o Develop the Procedure

· Initiate the OSP Review.

· Implement the OSP’s requirements:

o Post the OSP in-or-around the effected area.

o Ensure affected personnel are aware of the procedure.

o Ensure that those who need to follow the procedure are trained and a list is maintained of those individuals.

o Verify the effectiveness of the procedures by job walk-throughs and procedure review.

· Review and update the OSPs prior to expiration and whenever there is a change that affects the work activity (e.g., work group reorganization or equipment upgrade).

3.2 Subject Matter Experts (SME) (see ES&H Manual Chapter 2410 Appendix T1 Hazard Issues List)

· Support the development of OSPs to ensure hazard mitigation techniques are adequate prior to review.

· Ensure all hazards have been identified and include additional reviewers as required.

3.3 Division Safety Officers (DSO)

· Review and, if appropriate, approve all OSPs involving areas or individuals under your authority, or justify need for revision/re-submittal.

· Verify the unmitigated and mitigated RCs assigned using the associated THA.

· If appropriate, personally inspect the relevant area with the document owner and the supervisor prior to approval.

· Ensure all hazards have been identified and include additional reviewers as required.

3.4 Supervisor

· Review and, if appropriate, approve OSPs involving areas or individuals under your authority, or justify need for revision/re-submittal.

· Ensure all hazard issues associated with the work have been addressed.

3.5 Safety Warden

· Review and, if appropriate, approve OSPs involving areas under your authority, or justify need for revision/re-submittal.

· Ensure mitigation is adequate and appropriate for the area.

3.6 ESH&Q Document Control

· Record the serial number, author, appropriate expiration date, and content in the Jefferson Lab authorized electronic filing system.

· Maintain a record of all active and expired OSPs.

· Ensure electronic files are accessible and current.

· Initiate ES&H Manual Chapter 1300 Content Review Process for activities that cannot be conducted in a manner consistent with ES&H manual requirements as written; or introduce a new/anticipated/previously unrecognized hazard.

4.0 Process Steps

4.1 OSP Development

OSPs communicate the safe work practices used to mitigate hazard issues documented within a THA.

4.1.1 Define the Scope of Work

Refer to the associated THA and use ES&H Manual Chapter 2410 Appendix T1 Hazard Issues List to help identify hazard issues needing mitigation.

Step 1: Summary:

Provide the following (in accordance with the associated THA):

· Title: Summarize the process for which the OSP will apply. · Location: List all areas which the OSP will affect. · Type: Determine the duration: o OSP – valid for up to three years o TOSP – valid for up to three months · Risk Classification: Use the associated THA to determine the Risk Code classifications, both mitigated and unmitigated. · Document Owner(s): The individual(s) responsible for implementing the OSP’s requirements. (Note: The first “Document Owner” designated is considered the “Primary Owner” and must be an employee of Jefferson Lab.) · Date: When the procedure form was completed.

The associated THA is submitted, as an attachment, for final review and approval.

Step 2: Document History:

If you are revising a current OSP, you may reference the existing document at this time.

· Revision – Provide the revision number of this document. · Reason for Revision – brief description of changes made. · Serial Number of Superseded Document – provided so comparisons can be made between the two documents.

4.1.2 Analyze the Hazards

Review lessons learned/problems from similar jobs. Identify all work groups that may be affected by the process steps or whose support is needed to complete the work. Include this input when developing the procedure.

Step 1: Purpose of the Procedure

Summarize the procedure’s objective(s).

Step 2: Scope

Outline the limits of the procedure, its range, extent, and capacity.

Step 3: Description of the facility

Include floor plans and layout of a typical experiment or operation, as needed.

Step 4: Authority and Responsibility:

· Who has the authority to implement/terminate the operation?

· Who is responsible for the key tasks?

· Who analyzes the special or unusual hazards?

· What are the training requirements:

IF	THEN
Jefferson Lab Sponsored	List skill number, title, and owner/contact information. (See http://www.jlab.org/div_dept/train/poc.pdf)
Off-Site Vendor	List course title and vendor contact information.

Step 5: Personal and Environmental Hazard Controls include:

· Shielding

· Interlocks

· Monitoring systems

· Ventilation

· Others as necessary

Step 6: List of Safety Equipment – List all required.

· Personal protective equipment (See ES&H Manual Chapter 6620 Personal Protective Equipment Program)

· Special tools

4.1.3 Develop the Procedure

This section provides the proposed mitigation measures for the identified hazards. It may include, but not be limited to, the following:

Step 1: Associated Administrative Controls

List the routine controls (those that require action on the part of an individual) in the effected area(s), which are currently in-place.

Step 2: Operating Guidelines

Include any operating manuals, guidance, or parameters that are required.

Step 3: Notification of effected personnel (Who, How, and When)

Notification options include: Verbal, postings, telephone, paging, etc.

Determine when notification is to occur: e.g.: every time the procedure is implemented? Only on the commencement date?

Step 4: List the Steps Required to Execute the Procedure

List the procedure’s process steps from start to finish.

Step 5: Back Out Procedure(s)

Provide the steps necessary to restore the equipment/area to a safe level upon conclusion of the operation.

Step 6: Special Environmental Control Requirements:

· Environmental Impacts – See ES&H Manual Chapter 8012 Appendix T1 Environmental Review Procedure for Projects/Activities/Experiments

· Abatement Steps – e.g.: Secondary containment, special packaging or shipping requirements.

Step 7: Unusual/Emergency Procedures:

Consider reasonable possibilities and determine how to reduce the possible effects. For example:

· Lost of power

· Spill or other chemical release

· Fire

Step 8: Instrument Calibration Requirements

In accordance with Jefferson Lab’s Quality Assurance Plan – Measurement & Test Equipment Control and Calibration Procedure outline the calibration process for instruments as applicable. For example:

· Safety system/device recertification

· RF probe calibration

Step 9: Inspection Schedule

If needed.

Step 10: References/Associated Documentation

As relevant or useful.

Step 11: List of Records Generated

Provide documents title, location, generation, and review periods.

NOTE: Save the completed OSP form to a local file. You will need to submit the completed form into the database for review.

4.2 Submit for Review

Upon completion of the draft procedure the OSP form is submitted by the Document Owner for electronic signatures.

4.2.1 Identify the OSP Requiring Review/Approval

· Type: Click as appropriate: o OSP – valid up to three years; o TOSP – valid for up to three months. · Serial Number: Upon final approval the program will automatically assign a number based on Document Owner’s division, year generated, and total number of documents generated thus far. · Issue Date: The program will automatically fill in the issue date upon final approval. · Expiration Date: Use the pull down menu to determine the desired duration of the procedure. (The form will then display an approximate expiration date based the duration selected. The actual date will be determined upon final approval.)

(The following are identical to the applicable OSP procedure form (See 4.1.1 Define the Scope of Work above))

· Title: Summarize the process for which the OSP applies.

· Location: List all area which the OSP will affect.

· Risk Classification: Determined by the THA. (The applicable THA is required to be included as an attachment for final review and approval.)

· Reason: You must select one. (See “If-Then Table” below to determine appropriate “Required Review” criteria.)

IF Work Activities are:	THEN OSP is Required to be Reviewed by:
Unable to comply with ES&H Manual requirements as written	· Associate Director – ESH&Q (Automatic) · Supplemental Technical Validations – Hazard Issue/Subject Matter Expert(s) · Others as deemed appropriate
New/previously unrecognized Hazard Issue	· Associate Director – ESH&Q (Automatic) · Others as deemed appropriate
Determined to have an unmitigated Risk Code of 3 or 4	· Supplemental Technical Validations – Hazard Issue/Subject Matter Expert(s)
Not Applicable (This option is only available if Unmitigated Risk Code is <2.)	· Others per Document Owner’s determination

· Document Owner(s): The individual(s) responsible for implementing the OSP’s requirements. (Note: The first “Document Owner” designated is considered the “Primary Owner” and must be an employee of Jefferson Lab. You will be given the option to include as many as you would like.)

4.2.2 Supplemental Technical Validations

Jefferson Lab has identified Subject Matter Experts (SME) for recognized hazard issues. These individuals are responsible for determining the efficiency of proposed mitigation measures and appropriateness of the controls outlined. Additional reviews are necessary when compliance with ES&H Manual requirements is jeopardized or unavailable. The OSP Review Program assigns responsibilities automatically in accordance with Jefferson Lab’s criteria.

Document Owners are also given the option to designate others per department procedures, as long as the above minimum requirements are met.

SMEs are responsible for performing due diligence (including consulting with others, when necessary) prior to making their determination.

· Identify the Hazard Issues

Ensure your document receives an authorized review:

	Step 1: Select the hazard issue(s) having RC>3 without mitigation. (Recognized hazard issues are determined within the THA.) Step 2: Click the form’s “Save” button.
	Step 3: Other Hazards – IF your designated Risk Code is <2, or you have additional issues you would like reviewed, THEN the program provides a blank in which you may designate the hazard and select an individual you would like for review.
	NOTE: Every time you click the “Save” button the form will provide a blank in which you can denote an “Other Hazard” and select an appropriate reviewer. You may choose to leave this blank, or include as many additional reviewers as necessary.

4.2.3 Document History

IF this document is a revision to an existing document, THEN you may denote its history in this section. (See 4.1.1 Define the Scope of Work, Step 2 Document History, above.)

4.2.4 Attachments

At least two attachments are required: The THA and the OSP form.

Other documents may be attached at the discretion of the Document Owner.

	· Click the “Save” button before adding any attachments.
	NOTE: Any typical Word or Adobe software formats may be attached.
	· Click the “Browse” button to select your OSP Procedure document. · Click the “Browse” button to select your THA document.
	NOTE: The “Delete Selected Attachment” button only works for the “Additional Files” line. Before you save, make sure your OSP and THA are correct.
	IF you would like to attach an additional document(s) you may do so in the “Additional File(s)” blank.
	· Click the “Save Attachments” Button.
	NOTE: Every time you click the “Save Attachments” button the program will provide a blank in which you can denote an additional file. You may choose to leave this blank, or include as many additional files as necessary.

4.2.5 Submit

The program will automatically notify required and requested reviewers via e-mail.

· Click the “Submit” button.

IF, at this time, you would like to add any additional reviewers, not associated with a particular hazard, a blank is provided.

	· Type the name of the individual and the reason for the request. · Click the “Add Another Signature” button. DO NOT CLICK THE SUBMIT BUTTON. The program will automatically notify the additional reviewer(s).
	NOTE: Every time you click the “Add Another Signature” button the system will provide you an additional blank for your convenience. You do not have to use it.

4.3 Review

OSPs are reviewed by appropriate SMEs depending on the recognized hazard issue(s); and may be reviewed by others per department procedures or preferences. Upon submittal, the program contacts the designated reviewers via E-mail and informs them that a document needs their review.

Subject: Signature needed for OSP Form XYZ-##-###

Reviewers are then provided with a link to the appropriate Page.

Reviewers:

· Open the link provided within the e-mail.

· Open the attached document(s) for review.

IF the OSP outlined is	THEN Reviewer does the following	AND THEN
Acceptable	Click the “Approve” button next to your name on the electronic form. You will receive notification if there is any further action required.
Unacceptable	Click the “Reject” button next to your name on the electronic form. You will receive a Blank to enter a reason for the rejection. (This is a requirement, not an option.)	The Document Owner receives a notification of the rejection, at which time they take the appropriate steps to rectify the situation.

Once all reviewers have “accepted” the document it goes for final approval.

4.4 Approve

All OSPs are reviewed and, if acceptable, approved by:

· Responsible DSO(s)

· Responsible Supervisor(s)

· Area Safety Warden(s)

· Others as deemed appropriate, up to and including the Laboratory Director.

Upon completion of all hazard reviews, the program contacts the appropriate Approvers via E-mail and informs them that a document needs their approval.

Subject: Signature needed for OSP Form XYZ-##-###

Approvers are then provided with a link to the appropriate Page.

Approvers:

· Open the link provided within the e-mail.

· Open the attached document(s) for review.

IF the OSP outlined is	THEN Approver does the following:	AND THEN
Acceptable	Click the “Approve” button next to your name on the electronic form. You will receive notification if there is any further action required.
Unacceptable	Click the “Reject” button next to your name on the electronic form. You will receive a Blank to enter a reason for the rejection. (This is a requirement, not an option.)	The Document Owner receives a notification of the rejection, at which time they take the appropriate steps to rectify the situation.

NOTE: Authorized/Trained Individuals Signature Page

Upon successful completion of the Review/Approval Process the program provides the final OSP document an Authorized/Trained Individuals Signature Page. Individuals, who are authorized to perform the process steps listed, attest by signature that they have read the document and are appropriately trained to perform the process as described. (See Section 4.6 Implement below.)

4.5 Document

Upon final approval, the program automatically sends the document’s URL to the Document Owner(s) via E-mail. Documents may then be printed in .pdf format.

Active and archived OSPs are available for review at:

http://www.jlab.org/ehs/workcontrol.html

4.6 Implement

Individuals involved in the work covered by the OSP are required to read and sign the document prior to performing the work. By doing so, they agree to abide by its requirements. Only those individuals who have read and signed the document are considered authorized to perform the work activities described.

Active OSPs, including the list of Authorized/Trained Individuals, are posted in the area of the defined activity.

If the procedure is used infrequently, refresher training schedule at regular intervals.

4.7 Close Out

Prior to expiration the Document Owner and Responsible DSO receive a notification E-mail. At that time the document may be renewed (see below), or allowed to expire.

Hard copies of expired documents are to be returned to ESH&Q Document Control.

On-line versions are categorized as such with an “Expired” watermark in the on-line database.

Any Lessons Learned from OSPs are to be submitted to your Lessons Learned Coordinator.

4.8 Renew/Revise

Renewal of an existing OSP or TOSP within its three year, or month, term is handled in the same manner as the creation of a new one. If the current document expires during the renewal process, work under the document terminates until a current version is approved.

If an expired OSP/TOSP’s content is reviewed by effected parties and found to be current and appropriate, the document need not be re-written, however a new Review and Approval is initiated. The same rigor of review and approval applies as if the document had been written as new.

5.0 Revision Summary

Revision 2.1 – 02/19/13 – Updated OSP button link to clarify OSP submissions for electronic signatures per HFanning.

Revision 2 – 09/15/12 - Reformatted to incorporate electronic review processes.

Revision 1 – 12/01/11 – Added reasoning for why an OSP is written and appropriate review requirements.

Revision 0 - 10/05/09 – Updated to reflect current laboratory operations

ISSUING AUTHORITY	TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	REVIEW REQUIRED DATE	REV.	Page 7 of 17
ESH&Q Division	Harry Fanning	12/01/11	12/01/14	2.1

This document is controlled as an on line file. It may be printed but the print copy is not a controlled document. It is the user’s responsibility to ensure that the document is the same revision as the current on line file. This copy was printed on 2/19/2013.