TITLE:

ES&H Manual

 

DOCUMENT ID:

3310 Appendix T1

Operational Safety Procedure (OSP) and

Temporary Operational Safety Procedure (TOSP) – Instructions

 

 

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.

·       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.  OSPs are effective for up to three years.

 

3.0          Responsibilities

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

 

3.1            Document OwnerThe 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 and obtain required signatures for implementation.

·       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 have read and signed the OSP and a list of those individuals is maintained.

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

·       Review and update the OSP whenever a process or task within the OSP changes (i.e., scope creep).  This applies especially whenever there is a change that affects the work activity (e.g., work group reorganization or equipment upgrade).

 

3.2            Subject Matter Expert (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/approval. 

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

 

3.3            Division Safety Officer (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. 

·       Ensure required training for those who need to follow the procedure is current.

 

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.

 

3.7            Workers

·       Review and, if appropriate, sign the OSP, especially if working in effected area.

·       Work the plan as described in the OSP.  If change in OSP is required, notify Supervisor and Document Owner.

 

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       Develop the THA

Develop the THA as instructed in ES&H Manual 3210 Appendix T1 Work Planning, Control, and Authorization Procedure and utilize ES&H Manual Chapter 2410 Appendix T1 Hazard Issues List to help identify hazard issues needing mitigation.

 

 

4.1.2       Define the Scope of Work

Refer to the developed THA to help define the OSP’s scope of work.

 

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 before mitigation and after mitigation.

·     Owning Organization: Division or Department   

·     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. 

 

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

 

Step 2:          Text Box: Optional 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.

 

 

4.1.3       Analyze the Hazards

Review lessons learned/problems from similar jobs.  Identify all work groups that may affect or be affected by the process steps or whose support is needed to complete the work.  Include their input when developing the procedure.  Walk the job site to identify any additional hazard(s) not accounted for in the THA.

 

Step 1:          Purpose of the Procedure  

Describe in detail the reason for the procedure (what is being done and why).

 

Step 2:          Scope

Outline the limits of the procedure, its range, extent, and capacity.  Include all operations, people, groups, and/or areas that the procedure will affect.

 

Step 3:          Description of the facility

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

 

Step 4:          Authority and Responsibility: 

Step 4.1   Who has the authority to implement/terminate the operation?  (e.g., Supervisor, etc.)

Step 4.2   Who is responsible for the key tasks? (e.g., Safety Warden, Operations, etc.)

Step 4.3   Who analyzes the special or unusual hazards? (See ES&H Manual Chapter 3210 Appendix T1 Work Planning, Control, and Authorization Procedure.)

Step 4.4   What are the training requirements? (Do I have all the right people and do they need to be trained?) List all training required to access area and perform task(s):

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:

Step 5.1   Shielding – Consider any barriers of protection between the operator and the hazard such as radiation shielding blocks, splash guards, etc.

Step 5.2   Interlocks – List any and all interlocks which safe out the process or remove hazards when triggered.

Step 5.3   Monitoring systems – Consider any monitoring systems like Air Quality Samplers, Radiation Monitoring, etc.

Step 5.4   Ventilation – Consider if there is any ventilation built in which will improve air flow in the area in question.  Describe air exchange rates (if available) which could remove/reduce hazards.

Step 5.5   Others as necessary – Consider any other personal or environmental hazard controls not listed above.

 

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

Step 6.1   Personal protective equipment (See ES&H Manual Chapter 6620 Personal Protective Equipment Program)

Step 6.2   Special tools 

 

 

4.1.4       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 affected 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 affected personnel (Who, How, and When)

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

 

Determine who needs to be notified and 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 back out operation.

 

Step 6:          Special Environmental Control Requirements:

Step 6.1   Environmental Impacts – See ES&H Manual Chapter 8012 Appendix T1 Environmental Review Procedure for Projects/Activities/Experiments.

Step 6.2   Abatement Steps – Secondary containment, special packaging or shipping requirements.  (For example, for oil spills see ES&H Manual Chapter 8030 Appendix T5 Oil-Spill Prevention, Control, and Countermeasures.)

 

Step 7:          Unusual/Emergency Procedures:

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

·       Loss 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

How often does it need to be inspected (if needed)?

 

Step 10:       References/Associated Documentation

Include any and all references as relevant or useful to perform task(s) and list what documentation is needed.

 

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 electronic signatures after review.

 

 

4.2            Submit Draft Procedure for Initial Review

Prior to submitting procedure for Final Review and Approval, it is recommended that you submit the OSP and THA to appropriate SMEs and authorizers for initial review to assist in completion of the final draft procedure. 

 

Step 1:          Follow the process steps in 4.3 Submit for Electronic Signature and SAVE the Cover Page – DO NOT submit for signatures.

 

Step 2:          The Cover Page can assist the document owner in selecting the correct SMEs and authorizers for initial review.  Upon saving the Cover Page, click “List Required Reviews and Approvals”:

 

Step 3:          Scroll to top of page for distribution list:

 

Step 4:          Ensure that comments are incorporated as applicable into the final draft procedure and submit for electronic signatures.

 

 

4.3            Submit for Electronic Signatures

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

 

4.3.1       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.  (Copy the title directly from the OSP/THA to maintain consistency and reduce confusion.)

·       Location:  Click the magnifying glass to reveal a pull down list of buildings and areas.  Click on all areas which the OSP will affect.  (Delete the areas that are not applicable.)  

·       Location Details: List any specific location detail that may be applicable. (Example: Northeast corner)

·       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.)

 

·       Owning Organization: The Division/ Department/Organization responsible for implementing or otherwise enforcing the subject material.

·       Document Owner(s): The individual(s) responsible for the OSP’s requirements. (Note: The first “Document Owner” designated is the “Primary Owner” and must be an employee of Jefferson Lab.  The option is then given to include as many other responsible individuals as you would like.) (There is an “auto-complete” function where typing the name will auto-populate a list of names from which to select.)

 

 

4.3.2       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).  (Recognized hazard issues requiring review, especially those with RC>3 before mitigation, are determined within the THA.)

 

 

 

 

Step 2:       Click the form’s “Save” button.

 

 

 

Step 3:        Text Box: Optional Other HazardsIF you have additional issues you would like reviewed, THEN designate the hazard and select an individual you would like for review. (There is an “auto-complete” function where typing the name will auto-populate a list of names from which to select.)

 

NOTE:  Every time you click the “Save” button the form will provide a blank in which you can denote “Other Hazard” and select an appropriate reviewer.  You may choose to leave this blank, or include as many additional reviewers as necessary.

 

 

4.3.3       Text Box: Optional 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.)

 

 

 

4.3.4       Attachments

The THA and the OSP form are required attachments.  Other documents may be attached at the discretion of the Document Owner.

 

·       Save: Click the “Save” button before adding any attachments.

·       Comments for reviewers/approvers: Add any additional comments that may be relevant to reviewers.

·       List Required Reviewers and Approvals: Click if you would like to preview a list of those who are required to review and approve your document.

 

NOTE:  Only Adobe (.pdf) documents must be attached.  Word documents can be saved to the PDF format by using the “Save As” function within Microsoft Word and selecting “PDF” in the pull down menu.

 

 

·       Click the “Browse” button to select your OSP Procedure document. 

·       Click the “Browse” button to select your THA document. 

·       IF you would like to attach additional documents you may do so in “Additional File(s)”.  Click the “Browse” button to select your document.  Click the “Save Attachments” Button.

 

 

·       Text Box: Optional To replace an already attached OSP Procedure, click “Browse” and select the correct document.

·       Text Box: Optional To replace an already attached THA, click “Browse” and select the correct document.

·       Text Box: Optional To delete already attached “Additional File(s)”, select box for appropriate document(s) and click “Delete Selected Attachments”.

 

NOTE: The “Delete Selected Attachment” button only works for the “Additional Files”.  Before you save, make sure your OSP and THA are correct.

 

 

4.3.5       Submit

Upon completion of the final draft and cover page, the OSP is ready for submittal of electronic signatures.  The program will automatically notify required and requested reviewers via e-mail.

·       Click the “Submit” button.

 

 

Text Box: Optional 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 an additional blank.  You do not have to use it.

 

 

4.4            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

Contact Document Owner to discuss before rejecting.

 

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.

 

 

4.5            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

Contact Document Owner to discuss before rejecting.

 

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 4.7 Implement below.)

 

 

4.6            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

 

 

4.7            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.

 

 

4.8            Revise

An OSP must be revised and submitted for approval if there is a newly identified hazard(s), any change in the procedure, or if a current OSP does not accurately describe the procedure.  Editorial changes for clarification to the procedure can be made and does not require additional submission for review and approval. 

 

When there is time dilation (i.e., circumstances change the order of the procedure, or there is a delay in schedule), review work to ensure OSP includes all hazards and, if necessary, revise the OSP. 

 

If an unaccounted hazard is found while working, stop work if a safety issue arises (see ES&H Manual Chapter 3330 Stop Work and Re-Start for Safety Program).

 

To revise a current OSP, follow the process steps outlined in this document and ensure all information is accurate.  Be sure to reference the existing document in “Document History”.

 

 

4.9            Close Out

Prior to expiration the Document Owner and Responsible DSO will receive a notification E-mail.  At that time the document may be renewed (see below), or allowed to expire (no action is necessary).

 

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.

 

 

4.10         Renew

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 2.4  02/18/14  Editorial changes made to align with electronic OSP form; added 3.7 Workers, 4.1.1 Develop THA, 4.2 Submit Draft Procedure for Initial Review, and 4.8 Revise; updated screen shots; clarified process steps with detailed instructions and examples; included multiple work groups and walk down of job in 4.1.3; per HFanning.

Revision 2.3  11/27/13  Editorial changes made to 4.2.1 to reflect upgraded “Location” selection function in electronic OSP form.

Revision 2.2  10/22/13  Clarified procedure; added ability to determine owning division/organization,  a “comments” box, and the ability to preview required reviewers and approvers prior to distribution.

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

Revision 2.0  09/15/12  Reformatted to incorporate electronic review processes.

Revision 1.0  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.

ESH&Q Division

Harry Fanning

12/01/11

12/01/14

2.4

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 2/18/2014.