DOE-HDBK-3027-99, Integrated Safety Management Systems (ISMS) Verification Team Leader's Handbook
Functional areas: ISMS, Verification Review, Criteria and Review Approach Documents, Review Plan
The ISMS Verification Team Leader's handbook has been developed to provide guidance to the ISMS verification Team Leader and the verification team. The Team Leader has a significant responsibility to ensure that the ISMS presented for review conforms to DOE regulations. Another purpose for this handbook is to provide recommended actions and procedures to help develop the skills and understanding necessary for effective membership on a verification team.
Document text
Text extracted from the attached file. Refer to the original document for the authoritative version.
Section 1
TS
NOT MEASUREMENT
SENSITIVE
DOE-HDBK-3027-99
June 1999
DOE HANDBOOK
INTEGRATED SAFETY MANAGEMENT
SYSTEMS (ISMS) VERIFICATION
TEAM LEADER'S HANDBOOK
U.S. Department of Energy AREA SAFT
Washington, D.C. 20585
DISTRIBUTION STATEMENT A. Approved for public release; distribution is unlimited.
This document has been reproduced from the best available copy.
Available to DOE and DOE contractors from ES&H Technical Information Services,
U.S. Department of Energy, (800) 473-4375, fax: (301) 903-9823.
Available to the public from the U.S. Department of Commerce, Technology
Administration, National Technical Information Service, Springfield, VA 22161;
(703) 605-6000.
DOE-HDBK-3027-99
iii
INTEGRATED SAFETY MANAGEMENT SYSTEMS (ISMS) VERIFICATION
TEAM LEADER’S HANDBOOK
FOREWORD
This ISMS Verification Team Leader’s handbook has been developed to provide guidance to the
ISMS verification Team Leader and the verification team. The Team Leader has a significant
responsibility to ensure that the ISMS presented for review conforms to DOE regulations,
directives, policy, and guidance for the establishment of safety management programs across the
complex. This responsibility must be filled in conformance with the direction of the Approval
Authority, normally the DOE Operations Office Manager. In addition, this handbook also
provides information useful in developing personnel to conduct verification reviews and to assist
organizations in preparing for such reviews. This handbook supplements and is consistent with
the Integrated Safety System Management Guide (DOE G 450.4-1).
Another purpose for this handbook is to provide recommended actions and procedures to help
develop the skills and understanding necessary for effective membership on a verification team.
The handbook provides recommended training, experience, and skills that are important
components to ensure that individual team members are prepared to effectively participate in the
verification. The handbook also provides useful information for those individuals who are
preparing for a verification.
An ISMS verification involves considerable investment in time and resources requiring a carefully
devised review plan, a dedicated and well trained team, and good coordination with the
contractor and Department of Energy (DOE) office for which the ISMS pertains. ISMS
verifications are similar to Operational Readiness Reviews (ORRs) in that Criteria and Review
Approach Documents (CRAD) define criteria to be met that satisfies the objective through
interviews, record reviews, and activities to be observed. However, an ISMS verification is more
wide ranging, requires more preparation and training, and is more subjective than an ORR. All
ISMS verifications need a tailored Review Plan, including CRADs, for the organization being
reviewed.
This handbook provides guidance for the Team Leader and the team in conducting ISMS
verifications. This guidance complements the requirements found in the following:
C DEAR 970.5204;
C DOE P 450.4, SAFETY MANAGEMENT POLICY;
C DOE G 450.4-1, INTEGRATED SAFETY MANAGEMENT GUIDE ;
C DOE P 450.5, LINE MANAGEMENT, SAFETY, AND HEALTH OVERSIGHT;
C DOE P 450.6, SECRETARIAL POLICY STATEMENT, ENVIRONMENT, SAFETY,
AND HEALTH; and
C DOE M 411.1, MANUAL OF SAFETY MANAGEMENT FUNCTIONS,
RESPONSIBILITIES, AND AUTHORITIES (FRAM).
DOE-HDBK-3027-99
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This is Revision 1 of this handbook. A subsequent revision will be issued in about one year and
will reflect additional lessons learned from ISMS verifications.
Section 2
This Department of Energy handbook is approved for use by all DOE components and their
contractors. Beneficial comments (recommendations, additions, deletions) and any pertinent data
that may improve this document should be sent to: Jim Winter, DP-45, US DOE, 19901
Germantown RD., Germantown, MD 20874-1290 by letter or by using the Document
Improvement Proposal (DOE F 1300.3) attached at the end of this document.
DOE-HDBK-3027-99
v
TABLE OF CONTENTS
PARAGRAPH PAGE
1.0 PURPOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2.0 SCOPE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3.0 APPLICABLE DOCUMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.1 DOE Policy and Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.2 Federal Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4.0 DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
5.0 GENERAL GUIDANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
5.1 Purpose of ISMS Verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
5.2 The Phase I Verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
5.3 The Phase II Verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
5.4 Combined Phase I and Phase II Verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
5.5 Training, Advising, and Mentoring of DOE Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
5.5.1 Team Leaders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
5.5.2 Team Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
6.0 DETAILED GUIDANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
6.1 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
6.1.1 ISMS Verification Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
6.2 Roles and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
6.2.1 Field Element Managers (FEM) or Approval Authorit y . . . . . . . . . . . . . . . . 14
6.2.2 Site Operating Contracto r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
6.2.3 ISMS Verification Team Leader . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
6.2.4 ISMS Verification Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
6.3 Conducting the ISMS Verificatio n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
6.3.1 Appointing the Team Leade r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
6.3.2 Team Leader Considerations for ISMS Verification Preparation s . . . . . . . . 16
Section 3
6.3.2.1 Determining the Interface with the Approval Authorit y . . . . . . . . . 16
6.3.2.2 Selecting and Training the Team . . . . . . . . . . . . . . . . . . . . . . . . . . 17
6.3.2.3 Establishing Effective Contractor Interfaces . . . . . . . . . . . . . . . . . 18
6.3.2.4 Concepts for developing the Review Pla n . . . . . . . . . . . . . . . . . . . 18
6.3.3 ISMS Phase I Verification Specifics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
6.3.4 ISMS Phase II Verification Specifics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
6.3.5 ISMS Combined Phase I and Phase II Verification Specifics . . . . . . . . . . . . 23
6.4 The Report of the ISMS Verificatio n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
6.4.1 Specifics of the ISMS Verification Report . . . . . . . . . . . . . . . . . . . . . . . . . . 25
6.4.2 Other Report Consideration s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
DOE-HDBK-3027-99
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Appendix 1 Core Expectations for ISMS Verifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1-1
Appendix 2 Criteria and Review Approach Template
for Phase I ISMS Verifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-2-1
Appendix 3 Criteria and Review Approach Template
for Phase II ISMS Verifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-3-1
Appendix 4 Sample Approval Authority
Letter of Appointment to the Team Leader . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-4-1
Appendix 5 Phase I, Phase II and Combined Phase I/II Verification Lessons Learned . . . . . . A-5-1
Appendix 6 Sample Team Member Qualification Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-6-1
Appendix 7 Writer's Guide for ISMS Verifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-7-1
DOE-HDBK-3027-99
1
INTEGRATED SAFETY MANAGEMENT SYSTEMS (ISMS) VERIFICATION
TEAM LEADER'S HANDBOOK
1.0 PURPOSE
The primary purpose of this handbook is to provide guidance to the ISMS verification Team
Leader and the verification team in conducting ISMS verifications. The handbook describes
methods and approaches for the review of the ISMS documentation (Phase I) and ISMS
implementation (Phase II) and provides information useful to the Team Leader in preparing the
review plan, selecting and training the team, coordinating the conduct of the verification, and
documenting the results. The process and techniques described are based on the results of several
pilot ISMS verifications that have been conducted across the DOE complex. A secondary
purpose of this handbook is to provide information useful in developing DOE personnel to
conduct these reviews. Specifically, this handbook describes methods and approaches to:
a. Develop the scope of the Phase I and Phase II review processes to be consistent with the
history, hazards, and complexity of the site, facility, or activity.
b. Develop procedures for the conduct of the Phase I review, validating that the ISMS
documentation satisfies the DEAR clause as amplified in DOE Policies 450.4, 450.5, 450.6
and associated guidance and that DOE can effectively execute responsibilities as described in
the Functions, Responsibilities, and Authorities Manual (FRAM).
Section 4
c. Develop procedures for the conduct of the Phase II review, validating that the description
approved by the Approval Authority, following or concurrent with the Phase I review, has
been implemented.
d. Describe a methodology by which the DOE ISMS verification teams will be advised, trained,
and/or mentored to conduct subsequent ISMS verifications.
This handbook provides proven methods and approaches for verifying that commitments related
to the DEAR, the FRAM, and associated amplifying guidance are in place and implemented in
nuclear and high risk facilities. This handbook also contains useful guidance to line managers
when preparing for a review of ISMS for radiological facilities, non-nuclear, or non-Defense
Programs facilities. DOE line managers are encouraged to tailor the procedures described in this
handbook for ISMS verifications for low risk facilities.
1.1 Organization of the Team Leader's Handbook
This handbook provides detailed guidance for ISMS verification Team Leaders and team
members in the conduct of ISMS verifications. The handbook should be useful to the ISMS
Approval Authority and to contractors preparing their ISMS for review and implementation and
should be of benefit in developing local DOE personnel to perform ISMS verifications.
Scope: This section discusses the relationship of this handbook to the Department of Energy
Acquisition Regulation (DEAR) and the FRAM, and provides a general overview of the ISMS
verification process.
DOE-HDBK-3027-99
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Applicable Documents: This section lists references directly applicable to the methods and
processes described in the handbook.
Definitions: This section supplements the Glossary of Appendix A of Volume II of the ISMS
Guide, DOE 450.4-1, and provides the meaning of the terms and statements used in the
handbook. The description or definition of the terms have been expanded to be specific to the
intended meaning in this handbook. The usage in the handbook is consistent with the usage in
other DOE documents.
General Guidance: This section provides a summary of the actions, responsibilities, decisions,
and documents associated with ISMS verifications. Recognizing that each site, facility, or
activity will have an ISMS unique to its specific needs, this section provides the general sequence
of review actions to be followed. The section also contains general information on the
expectations for the ISMS verification.
Detailed Guidance: This section describes suggested methods and techniques which the Team
Leader and the team should consider when preparing for and conducting ISMS verifications.
Appendices: The appendices contain detailed information useful to the ISMS verification Team
Leader and individual ISMS verification team members or line managers to help them in the
preparation for the review process.
X Appendix 1 contains a list of Core Expectations for the review.
X Appendix 2 contains a Criteria and Review Approach Document (CRAD) template for the
Phase I ISMS verification.
X Appendix 3 contains a Criteria and Review Approach Document (CRAD) template for the
Phase II ISMS verification.
X Appendix 4 contains a sample Approval Authority Letter of Appointment to the Team
Leader.
X Appendix 5 contains Lessons Learned from the first ISMS pilot verifications.
X Appendix 6 contains a sample format for the documentation of team member qualifications.
X Appendix 7 contains a Writer's Guide which provides assistance in documenting the ISMS
verification and preparing the final report.
Section 5
2.0 SCOPE
DOE M 411.1, MANUAL OF SAFETY MANAGEMENT FUNCTIONS (LEVEL I FRAM), is
the DOE directive that assigns responsibilities to approve safety management system descriptions
and revisions to the Head of the Contracting Activity. The Functions, Responsibilities, and
Authorities document (Level II FRAM) assigns flow down requirements to the Principal
Secretarial Officer (PSO) and field elements. Responsibilities as Head of the Contracting Activity
DOE-HDBK-3027-99
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are normally assigned to the Manager of the cognizant DOE Operations Office who is generally
known as the Approval Authority. As described in the FRAM, the documentation of the ISMS
and the description of how ISMS will be integrated into work practices must be submitted to the
Approval Authority for review. Per FRAM 9.2.2.6, the Approval Authority must decide whether
the ISMS Description should be reviewed by a team, and, if a team is needed, select the Team
Leader. The review process is called "verification" and is required in FRAM 9.5.2. General
guidance for conducting ISMS verifications is found in Appendix E of Volume II of the ISMS
Guide, DOE G 450.4-1. This handbook supplements this guidance and provides additional
information useful to the Team Leader and the team assigned to conduct ISMS verifications.
3.0 APPLICABLE DOCUMENTS
3.1 DOE Policy and Guidance
a. DOE Policy 450.4, SAFETY MANAGEMENT POLICY
b. DOE Policy 450.5, LINE MANAGEMENT, SAFETY, AND HEALTH
OVERSIGHT
c. DOE Policy 450.6, SECRETARIAL POLICY STATEMENT, ENVIRONMENT,
SAFETY, AND HEALTH
d. DOE Guide 450.4-1, INTEGRATED SAFETY MANAGEMENT GUIDE
e. DOE M 411.1-1, MANUAL OF SAFETY MANAGEMENT FUNCTIONS
(LEVEL I FRAM)
3.2 Federal Regulations
a. 48 CFR 970 (DOE Acquisition Regulations) -DEAR
b. 10 CFR 830.120, Quality Assurance
4.0 DEFINITIONS
This section supplements the Glossary of Appendix A, Volume II, of DOE G 450.4-1,
INTEGRATED SAFETY MANAGEMENT SYSTEM GUIDE, for the purposes of
standardizing terms used in the ISMS verification process. Where the definition is verbatim to
DOE G 450.4-1, it is annotated by brackets.
Approval Authority: The senior DOE Line Manager responsible for the approval of the
documented Integrated Safety Management System Descriptions, usually the Manager of the
Operations Office. Head of the Contracting Activity (HCA) has also been used with a similar
meaning.
Core Technical Group (CTG): The CTG maintains a system and process to share Federal
technical resources within DOE and across organizational lines. A database is maintained by
DOE-HDBK-3027-99
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technical specialty area to assist customers in identifying the best individuals or mixes of expertise
needed to support the customer's projects. [DOE G 450.4-1]
Head of the Contracting Activity (HCA): Head of a DOE element who has been delegated
authority by the Deputy Assistant Secretary for Procurement and Assistance Management to (1)
award and administer contracts, sales contracts, and/or financial assistance instruments; (2)
appoint contracting officers; and (3) exercise the overall responsibility or managing the
contracting activity. [DOE G 450.4-1]
Integrated Safety Management System: A Safety Management System (SMS) systematically
integrates safety into management and work practices at all levels as required by DOE P 450.4,
SAFETY MANAGEMENT SYSTEM POLICY, and the other related Policies: DOE P 450.5
and DOE P 450.6. [DOE G 450.4-1]
Section 6
Letter of Appointment: The Approval Authority's written designation of a Team Leader,
selected from the approved team leader list. This letter directs the Team Leader to select and
form a team to conduct an ISMS verification at a site, facility, or activity. The letter outlines the
scope of the verification effort, the tentative dates of the verification, and any special instructions
to the Team Leader.
Line Management: Any management level within the line organization, including contractor
management, that is responsible and accountable for directing and conducting work. [DOE G
450.4-1]
Phase I ISMS Review: A review of the documentation as submitted to the Approval Authority
by the contractor. This review is not only a review of the ISMS Description documentation, but
is also a review of the procedures, policies, and manuals of practice used to implement safety
management. The review evaluates how these procedures, policies, and manuals of practice
have been implemented at the upper levels of management and includes detailed discussions with
key management personnel who are assigned, or will be assigned safety management
responsibilities.
Phase II ISMS Review: A review to determine that the ISMS, as approved by the HCA,
satisfactorily implemented at the site, facility, or activity. The review is normally accomplished by
sampling at various facilities or activities to determine that the safety management system
outlined in the ISMS Description is in fact being effectively carried out.
Qualified Team Leader: A person selected from a list of Senior Technical Safety Managers
who has been approved by the Director, Safety Management Implementation Team. Additional
Team Leaders may be added to the Approved Team Leader List after the member has
successfully served on at least one team and was recommended by an Approved Team Leader.
Qualified Team Member: A person selected by the Team Leader with appropriate technical or
managerial skills and assessment experience, as required, to conduct the review. The ISMS
verification membership list of qualified DOE team members can be supplemented by experienced
contractor personnel who have successfully participated in, and qualified for, other DOE
assessments such as Operational Readiness Reviews (ORRs). A list of qualified team members
will be maintained by the CTG.
DOE-HDBK-3027-99
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ISMS Verification Review Plan (RP): The plan developed by the Team Leader to conduct the
ISMS verification.
Work: Process of performing a defined task or activity; for example, research and development,
operations, maintenance and repair, administration, software development and use, inspection,
safeguards and security, data collection, and analysis. [DOE G 450.4-1]
Work Authorization: The process used by line management to permit a task or activity to be
initiated as planned, having determined that it can be performed safely. [DOE G 450.4-1]
Work for Others: The performance of work for non-DOE entities by DOE/contractor personnel
and/or the use of DOE facilities that is not directly funded by DOE appropriation. [DOE G
450.4-1]
Work Planning: The process of planning a defined task or activity. Addressing safety as an
integral part of work planning includes execution of the safety-related functions in preparation for
performance of a scope of work. These functions include (1) definition of the scope of work; (2)
formal analysis of the hazards bringing to bear in an integrated manner specialists in both ES&H
and engineering, depending on specific hazards identified; (3) identification of resulting safety
controls including safety structures, systems and components, and other safety-related
commitments to address the hazards; and (4) approval of the safety controls. [DOE G 450.4-1]
Section 7
Worker(s): Those individuals involved in tasks directly related to the safe accomplishment of
work, which is consistent with the in-place ISMS. Such tasks include a scope of work from the
inception of mission/design through accomplishment of the work and lessons learned. Workers
could include for example: craftsmen, operators, planners, designers, safety professionals,
responsible supervisors, and managers (in some cases). These examples serve only as a guide to
the possible breadth of "workers" in a given task and are not meant as a minimum or maximum
complement of any ISMS verification team.
5.0 GENERAL GUIDANCE
5.1 Purpose of ISMS Verification
The primary purpose of the ISMS verification is to review the adequacy of the contractor’s ISMS
and its implementation in order to provide a recommendation to the Approval Authority. A
secondary purpose is to evaluate the role of DOE in the implementation and oversight of the
contractor’s ISMS. ISMS verifications are more subjective and wide ranging than other DOE
reviews such as ORRs and oversight activities. By its very nature, this is a subjective review
requiring mature leadership. There are many ways to satisfy ISMS requirements and good
judgment and practical experience are often needed to identify the real issues and concerns.
The ISMS verification activities should be well planned and coordinated by an approved Team
Leader. The Team Leader should carefully plan the review process and select and assemble a
dedicated team of safety management professionals. Dedicated is used here to mean that during
the period for the review, the team member will devote his/her time exclusively to the verification
review as opposed to his/her normal duties. The PSO or HCA may assist the Team Leader in
DOE-HDBK-3027-99
6
assembling the dedicated team of safety professionals by placing high priority on the effort. This
may ensure that the selected team members are made available for the duration of the verification.
As more experience is gained in ISMS verifications, it is envisioned that each DOE site should be
able to conduct these reviews, when appropriate, using their own qualified staff. A goal of this
handbook is to provide information useful in developing personnel to conduct these reviews. In
all cases, the review should be well coordinated and documented and should confirm the
capability of DOE and the contractor to implement all aspects of the ISMS as required in DOE
policies, the DEAR, and the FRAM. The role of DOE in the success of the ISMS implemented
by the contractor is a major one that cannot be overstated.
It is Departmental policy (DOE P 450.4, 450.5, and 450.6) that safety management systems are
integrated into management, operations, and work practices at all levels of the Department's
facilities. In simple and straightforward terms, the department will "do work safely." These
concepts are embodied as requirements in the DEAR clause of 48 CFR 970, the FRAM, and as
amplified by DOE policies as noted above and in DOE G 450.4-1. The Department is committed
to achieving an integrated safety management system for all its activities as appropriate. This
handbook provides an acceptable process for the review and approval of the ISMS Description
plus approaches and methodologies for evaluation of the implementation of these agreements in
site and facility operations.
Section 8
According to the DEAR Clause, "Guidance on the preparation, content, review, and approval of
the system will be provided by the contracting officer." The “system” being described is the
Integrated Safety Management System (ISMS) and the means by which the ISMS is normally
presented to DOE for review and approval is for the contractor to prepare an ISMS Description.
Experience has shown that the Contracting Officer's guidance is best developed through a process
that includes consultation with the contractor. So, it may evolve somewhat as the actual ISMS is
being developed. It is, therefore, important that the ISMS Description be maintained under a
configuration and change control process. The Contracting Officer's guidance to the contractor
will be used by the ISMS verification team as one of the principle elements against which the
ISMS is reviewed.
For the ISMS to be effective, contractor and DOE field organizations must integrate the
contractor’s ISMS with DOE requirements outlined in DOE M 411.1-1, MANUAL OF
SAFETY MANAGEMENT FUNCTIONS (FRAM). At the Field Element level these
requirements are promulgated in lower tiered Functions, Responsibilities, and Authorities (FRA)
documents. The FRAM/FRA documents highlight many important DOE functions necessary for
the development and implementation of an ISMS. These DOE functions will also be reviewed
during ISMS verifications. DOE elements essential to the development and implementation of
ISMS are discussed in detail in Volume I, Chapter III of DOE G 450.4-1, ISMS GUIDE.
5.2 The Phase I Verification
The following sections broadly describe the activities, decisions, and sequence of events
necessary to provide the Approval Authority with a recommendation for the approval of the
ISMS Description for a given site, facility, or activity. The Phase I verification process is
outlined by a flow chart, which is included as Figure 1 of this handbook.
DOE-HDBK-3027-99
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Phase I is a review of the Description of the Integrated Safety Management System developed by
the contractor in response to formal direction provided by the Approval Authority in accordance
with the ISM DEAR clause. To be successful, Phase I should not just be an administrative
review of the ISMS Description, but should also be a review for adequacy of the procedures,
policies, and manuals of practice used to implement safety management. The review should
evaluate whether the procedures, policies, and manuals of practice adequately address the
functions and the principles of the ISMS Description prepared by the contractor. Implementation
of these procedures, policies, and, manuals of practice at the upper levels of management should
be evaluated by detailed discussions with key management personnel who are assigned, or will be
assigned, safety management responsibilities. The primary goal of the Phase I review is to
provide a recommendation to the Approval Authority as to whether the ISMS documentation
should be approved. This handbook is intended to be used as a tool to help in determining the
adequacy of the submitted documentation.
The ISMS verification should be a well structured review process and should be conducted by a
review team of qualified team members led by a Team Leader who is selected from a list of
approved team leaders. The ISMS verification team members are selected by the Team Leader
who prepares and trains the team. The team will prepare a Review Plan (RP), conduct the
review, and provide a report of the review to the Approval Authority. This report will include a
recommendation for approval, or identify the actions required for approval to be recommend.
Section 9
5.3 The Phase II Verification
The following section broadly describes the activities, decisions, and sequence of events to help
the Approval Authority in determining the adequate implementation of the ISMS at a site, facility,
or activity. The Phase II ISMS verification process is outlined by a flow chart included as Figure
2 of this handbook.
The purpose of Phase II is to verify that the contractor’s ISMS submitted to and approved by the
Approval Authority is in-place at the site, facility, or activity. The Phase II review is developed,
prepared, and conducted by a team of safety management professionals. Like the Phase I
verification, the Team Leader is selected by the Approval Authority from a list of approved Team
Leaders. The team members are selected by the Team Leader who leads the preparations and
training of the Team Members. The team then prepares a Review Plan (RP), conducts the
review, and provides a report of the review to the Approval Authority. For continuity, team
members from the Phase I verification should be used for Phase II to evaluate the response to
Phase I issues.
5.4 Combined Phase I and Phase II Verification
At some sites, facilities, and activities the status of implementation of the ISMS has been viewed
by the contractor and the DOE HCA as mature. Thus, it was the view of the contractor and the
HCA that verification of implementation (Phase II verification) could be conducted at the same
time as the verification of the adequacy of the ISMS Description (Phase I verification).
Experience gained as a result of conducting a combined Phase I and Phase II review has provided
several lessons learned:
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X Management and successful completion of a combined review is difficult, but can be
accomplished.
X A combined review takes less total time and can result in a reduced impact on the site,
although a combined verification is more demanding on the team and those organizations
being verified.
X If the site, facility, activity has truly achieved a mature ISMS implementation, the benefits
of a combined verification outweigh the difficulty.
X The verification team should include several team members in each functional area with
previous ISMS Verification experience.
X A sub-team leader who has previous ISMS verification experience should be assigned to
each verification Functional Area
X Contractor and DOE efforts to fully and effectively prepare for and support the
verification effort must be assured before making a commitment to a combined
verification.
To be successful, the conduct of a combined verification must be carefully planned, by the
verification Team and by the contractor and DOE. Figures 1 and 2 portray the Phase I and Phase
II planning considerations as well as the dependency of Phase II aspects upon Phase I. The
presentations to the team must provide information on both the policies and procedures
(implementation mechanisms) that implement the ISMS Description as well as the work site's
implementation of those mechanisms. The members of the verification team focusing on the
Phase II portion of the review must understand the implementing mechanisms prior to focusing
on the Phase II aspects. One section of Appendix 5, Lessons Learned, discusses a combined
verification in detail.
Experience has also shown that a combined verification may not be successful when there are
gaps in the implementing policies and procedures. Similarly, the combined verification may not
be meaningful if the implementation has only progressed at a few pilot facilities.
Section 10
Careful review and candid judgement is required when making the decision whether to conduct a
combined verification. If the conditions are met for a successful combined verification, it is
recommended that a combined verification be conducted. The overall savings of time, effort, and
distractions at the site will be worth the extra effort associated with the combined verification.
5.5 Training, Advising, and Mentoring of DOE Staff
The following sections describe the principles and methodologies for the development of staff
capabilities to integrate ISMS throughout the DOE complex.
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5.5.1 Team Leaders
ISMS verification Team Leaders were initially designated by an Under Secretary memorandum
dated February 21, 1997. These Team Leaders were selected for their technical competence and
experience in similar evaluation processes. The process for developing Team Leaders includes
efforts to provide on-the-job training by recognized safety management professionals. The
Approval Authority, with the Team Leader, may designate potential Team Leaders from his or
her staff or other DOE organizations. These potential candidates accompany the Team Leader
during the preparation for, and conduct of, an ISMS verification. Assignment as a sub-team
leader should be considered to provide the candidate with experience in coordinating the
verification activities of a small team. During the verification , the Team Leader evaluates the
candidate's grasp of the overall verification process. Upon the completion of the verification, the
Team Leader provides a recommendation to the Approval Authority regarding the suitability of
this individual to act as a Team Leader for future reviews. This favorable recommendation is
provided to the Director, Safety Management Implementation Team, who provides the final
designation of the individual as a Team Leader. This certification is also included in the CTG
database.
5.5.2 Team Members
Team members will be selected and qualified by the Team Leader. There are several
considerations that the Team Leader should use to choose qualified team members. Each team
member should have expertise in functional areas related to the verification. Also, sufficient site
experience should be resident in sub-teams to have familiarity and understanding of site programs.
A combination of local and federal employees and team training is needed. Finally, experience in
the conduct of ISMS verifications or similar assessments is necessary for a qualified team.
The team as a whole will have the collective technical expertise to conduct the verification by
effectively sampling the ISMS for the given site, facility, or activity. A methodology similar to
the development and qualification of Team Leaders will be used to prepare the DOE staff to serve
as team members. The Approval Authority may designate members of his or her staff to
participate with qualified team members in the ISMS verification. Upon completion of the
review, the currently qualified team members will make a recommendation to the Team Leader
regarding the suitability of the individual to participate independently as a team member on future
reviews. The Team Leader recommends the individual as a team member to the Approval
Authority and provides the individual’s name for input into the CTG Database for the functional
area expertise demonstrated so that he or she can be made available for future reviews.
Section 11
There are many ways to establish successful safety management programs and there are many
different methodologies which can be proposed to meet the functions and principles of ISMS. In
order for the verification to be successful, the team must have a good understanding of ISMS
principles, the processes and mechanisms the contractor proposes to meet the requirements
specified in DOE P 450.4, 450.5, 450.6 and the DEAR. In addition, it is important that the team
understand the ISMS interface requirements for DOE as specified in the FRAM. Training for the
ISMS verification team members in preparation for the verification is a critical step toward a
successful review. Due to the unique nature of each ISMS, some training is generally necessary
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before each review, without regard to the previous experience of the team members. The
following subjects are recommended for training as a minimum:
X ISMS Training (ISMS Executive Level Course or equivalent)
X Discussion of the review plan including the methodology used to develop it.
X Discussion of ISMS verification process including the goals, scope, methods, and
processes for a Phase I and a Phase II verification.
X Review and understanding of the FRAM as implemented at the Field Element Manager
level.
X Presentation of the ISMS Description. This review should be presented by contractor
personnel who are familiar with the concepts and methodologies used in the development
of the ISMS.
X Presentations by line managers (contractor and DOE) to describe the manner in which the
ISMS is or will be carried out in their areas of responsibility and how requirements flow
down through their respective organization. Through these presentations, the team will
get a better understanding of the methodologies and strategies that the contractor plans to
use to establish the ISMS. The team will also receive some insight on how the DOE
ISMS interface responsibilities are being met.
X Discussion of verification skills and processes such as interview techniques, field
assessment techniques, and report writing. The training should make clear that the
verification is not an ORR. The review is evaluating the functions and principles of ISM,
not the conduct of work.
6.0 DETAILED GUIDANCE
6.1 Purpose
The primary purpose of this handbook is to provide advice and guidance to ISMS verification
Team Leaders so that they can effectively carry out their responsibilities to coordinate the efforts
of the ISMS verification team in the conduct of reviews of the contractor’s ISMS. A secondary
purpose of this handbook is to provide information useful to the Approval Authority, the ISMS
team members, DOE staff, and the contractor and his staff in the preparations for, and the
conduct of, ISMS verifications. This handbook provides proven approaches and methodologies
for the review of the ISMS Descriptions provided by contractors. It also provides proven
approaches and methodologies for evaluating the implementation of these agreements.
6.1.1 ISMS Verification Techniques
Generic core expectations for the implementation of each of the ISMS core functions and guiding
principles are thoroughly discussed in Appendix E of Volume II of the ISMS GUIDE, DOE G
450.4-1 and are included in Appendix 1 of this handbook for reference. Each ISMS verification
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Section 12
team will develop acceptance criteria for each applicable core expectation along with review
approaches to permit an assessment of the expectations. These tailored review approaches will
be unique to the site, facility, or activity. When they are evaluated as effective, it should be
possible to conclude that the core expectations have been met. The techniques used by the
verification teams will differ; however, it has been shown that a carefully selected sampling of
records, interviews with responsible personnel, and observations of work and operations is
sufficient to evaluate the status of ISMS.
Templates of Criteria and Review Approach Documents (CRADs) have been developed for both
phases of ISMS verifications and are included in Appendices 2 and 3. They serve as a frame of
reference from which a tailored set of CRADs may be developed to fit the particular needs of the
specific ISMS to be reviewed.
The ISMS verification Review Plan (RP) should define how the review will be structured.
Experience shows that the review is best conducted using CRADs grouped along functional
areas. By establishing these groupings, personnel can be assigned responsibilities in designated
review areas in which they have the required expertise. This also is an effective way to distribute
report writing responsibilities and contributes to the overall efficiency of reaching an overall
conclusion. The functional areas most frequently used and found to be effective include:
Phase I
+ Business, Budget, and Contracts (BBC)
+ Hazards Identification and Standards Selection (HAZ)
+ Management (MG)
+ Department of Energy (DOE)
Phase II
+ Hazards Identification and Standards Selection (HAZ)
+ Management (MG)
+ DOE ISMS Implementation (DOE)
+ Operations (OP)
+ Subject Matter Expert (SME)
It has been necessary to include SMEs to ensure that specific safety management functions are
effectively addressed. It is highly recommended that all Phase II verifications include an SME for
Maintenance and Work Control since these are basic functions of all ISM systems. SMEs to be
considered may include experts in the following disciplines:
+ Criticality Safety
+ Fire Protection
+ Industrial Hygiene and Safety
+ Radiation Protection
+ Security
+ Training and Qualification
+ Maintenance and Work Control
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+ Quality Assurance
+ Configuration Management
+ Environmental Compliance (including pollution prevention/waste minimization)
The selection of the appropriate SMEs should be tailored to the site, facility, or activity and the
SME composition should be determined by the Team Leader based on the size, complexity, and
state of maturity of the safety management programs. It is important to select SMEs who have
expertise in the functional area of interest and understand implementation of ISMS at the floor
level.
6.2 Roles and Responsibilities
The DOE M 411.1-1, MANUAL OF SAFETY MANAGEMENT FUNCTIONS,
RESPONSIBILITIES AND AUTHORITIES (FRAM) defines the overall ISMS roles and
responsibilities for personnel within the DOE. The DOE ISMS GUIDE, DOE 450.4-1 Volume I,
Chapter III, Sections 2 and 3 discuss expectations for DOE and contractor ISMS development
and implementation. The documents described can provide a focus to the verification and are
important to the development of a site, facility, or activity specific review plan.
6.2.1 Field Element Managers (FEM) or Approval Authority
Section 13
The FEM is directly responsible for day-to-day control of activities at a site. The FEM directs,
plans, and monitors the field element’s safety management activities. The following specific roles
and responsibilities defined by the FRAM and the DEAR apply to the ISMS verifications:
a. Provide the contractor guidance on the preparation, content, review and approval of the
safety management system. Dates for submittal, discussions, and revisions to the System
will be established by the Contracting Officer. DEAR 970.5204-2(e)
b. Ensure that contracts establish clear expectations and work performance measures and to
ensure the contracts define the action necessary to meet site mission and safety
expectations. FRAM 9.2.2.4
c. Determine the need for the team to review the safety management description. If a team
is needed, the HCA selects members of the review team for specific applications and the
team leader from the approved List of senior technical managers approved by the Deputy
Secretary. FRAM 9.2.2.6
d. Ensure that the safety management system adequately prioritizes work to ensure that,
when implemented, mission and safety expectations for the site are met within available
budget and resources. FRAM 9.2.4
e. Review and support development of expected performance objectives and related CSO
goals and priorities. FRAM 9.2.4
f. Ensure that the ISMS is properly implemented. FRAM 9.5.2
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6.2.2 Site Operating Contractor
This is the business entity with whom the Approval Authority has established a contract in
accordance with the DEAR to operate a particular site or facility. The contract will require
development of an ISMS that will define the requirements by which the site, facility, or activity is
to be operated. The following specific roles and responsibilities should be applied to the Site
Operating Contractor as they relate to the ISMS verification process:
a. Develop a plan for an ISMS verification according to the direction provided by the
Approval Authority.
b. Prepare and submit the elements of the ISMS following the schedule specified by the
Approval Authority.
c. Support the conduct of the ISMS verification.
d. Place all elements of the ISMS into effect to ensure that work is done safely and in
accordance with the ISMS as approved by the Approval Authority.
6.2.3 ISMS Verification Team Leader
The Approval Authority selects the Team Leader per FRAM 9.2.2.6. The following specific
roles and responsibilities are recommended for assignment to the Team Leader:
a. Select, prepare, and train team members to serve on the verification team.
b. Prepare, with support of the team members, the Review Plan (RP) for the verification.
The RP should reflect the scope and requirements identified in the letter from the
Approval Authority appointing the Team Leader.
c. Manage the team in the conduct of the verification review in accordance with the RP.
d. Oversee preparation of the verification report including appropriate recommendations to
the Approval Authority.
e. Carry out other related activities as directed by the Approval Authority in support of
review and implementation of the ISMS.
6.2.4 ISMS Verification Team
The verification team is selected by the Team Leader and/or Approval Authority. It consists of
federal safety management professionals from DOE line management and contractor or
laboratory personnel, where needed or appropriate. Team qualification will be directed and
approved by the Team Leader. Duties and responsibilities include the following:
Section 14
a. The team members assist the Team Leader in the preparation of the Review Plan.
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b. The team members take actions required to achieve the qualification to perform the
review as specified by the Team Leader.
c. The team members will conduct the assigned portion of the verification following the
Review Plan under the supervision of the Team Leader.
d. The team members will support the preparation of the report and the recommendations to
the Approval Authority as required by the Team Leader.
6.3 Conducting the ISMS Verification
6.3.1 Appointing the Team Leader
The Approval Authority will appoint the Team Leader for the ISMS verification from a list of
Senior Technical Safety Managers approved by the Director, Safety Management Implementation
Team. Within the Letter of Appointment, the Approval Authority should define the scope,
expectations, and desires for the ISMS verification. Since the ISMS verification may be
conducted in two phases, defining the expectations for each phase of the ISMS verification in a
separate letter is appropriate. The quality of the review and the degree to which it is successful is
significantly influenced by the level of detail and specificity with which the expectations for the
review are defined by the Approval Authority. A sample format for an Approval Authority Letter
of Appointment is included as Appendix 4.
6.3.2 Team Leader Considerations for ISMS Verification Preparations
In preparing to conduct ISMS verifications, the Team Leader must make several decisions shortly
after he/she is designated. There are a number of key areas to address. Significant among these
are establishing the relationship and determining the requirements of the Approval Authority,
selecting and training the team, establishing relationships with the contractor, and developing the
basis or approach on which to prepare the review plan. The following is a discussion of some of
the more critical decisions that the Team Leader should make soon after being designated to set
the stage for a successful verification. The Lessons Learned provided in Appendix 5 should be
consulted to assist in developing possible approaches to making these decisions. The Lessons
Learned provide, in detail, an historical record of several pilot ISMS verifications and should give
some insight into possible ways to address key questions.
6.3.2.1 Determining the Interface with the Approval Authority
It is important to establish an effective relationship with the Approval Authority. The Team
Leader should gain a good understanding of the scope and expectations for the review and should
establish the mechanisms with which he/she will update the Approval Authority on the status of
review preparations. Items such as the sequence of the review(s) (Phase I, Phase II, Combined
Phase I/II decisions), establishment of the schedule, dedicated team member selection,
establishment of contractor interfaces, and development and approval of the review plan are
subjects for which the Team Leader and the Approval Authority should have complete
agreement. It is also important that the Approval Authority support and assist the Team Leader
in gaining the dedicated resources necessary to ensure that the verification is successfully
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Section 15
completed. It is also important that the Approval Authority support and assist the Team Leader
in gaining the dedicated resources necessary to ensure that the verification is successfully
completed. As the verification proceeds, it is important to establish what briefings and status
reports are desired. This is particularly important for any ISMS issues affecting the DOE staff, as
the Approval Authority is normally responsible for directing action for any improvements
required. The Team Leader must not lose sight of the fact that he/she is ultimately responsible
for providing a recommendation to the Approval Authority as to the acceptability of the ISMS
Description and implementation.
6.3.2.2 Selecting and Training the Team
Selecting the team is one of the most important steps of preparing for an ISMS verification. As
discussed earlier, ISMS verifications are more wide ranging and subjective than other DOE
reviews such as ORRs, oversight assessments, and compliance audits. The team should develop a
broader approach to the review than would normally be required in these or similar review
processes. There are many ways to establish ISMS and the evaluation of the ISMS proposed
must be conducted with an open mind. Just because the ISMS proposed does not exactly
conform to a team member’s past experience does not necessarily mean the ISMS will not work.
Good judgement and some good practical experience are needed to determine whether the
described ISMS provides appropriate and sufficient integration. The ISMS verification is by
nature more complex than other review processes. Issues and concerns developed in one
functional area may have significant consequences in other areas. There has to be unusually good
communications between the team and the site during the review to ensure the correct
perspective of an issue is understood. Team members must be good communicators and
information must be freely shared among the team, the affected contractor, and the DOE staff.
Often this information must be provided quickly so that an issue may be identified early in the
review. The Team Leader should ensure that a system, such as a daily team status meeting (with
selected contractor and DOE staff attending), is planned into the schedule. Team members
should have a proven ability to express their thoughts well both verbally and in writing.
Team members should be fully dedicated to conducting the ISMS verification. This is sometimes
difficult because ISMS verifications can be quite lengthy. There are always pressures for persons
at a site to continue to pursue their regularly assigned duties to the detriment of their temporary
review assignment. If team members lack the full dedication required, either in the time spent or
in personal commitments, the quality of the effort will suffer. In some cases, the Team Leader
may be forced into doing some of the specific team member’s assignments just to get the ISMS
verification completed. This obviously detracts from the capability of the Team Leader to
effectively supervise the effort. There should be an understanding between the Approval
Authority and the Team Leader concerning the need for commitment from the team. If a team
member is selected and cannot dedicate the required time, a replacement should be obtained.
Section 16
The Team Leader should have a good understanding of the history of the status of the safety
management programs at the affected site, facility, or activity. This understanding is a key factor
in tailoring the review approach. Selection of Subject Matter Experts (SMEs) for the team
should be based on the Team Leader’s understanding of that history. Disciplines that have a
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history of poor performance or problems should normally dictate an assignment of an SME to the
team. Other disciplines that have a good record of performance would not necessarily require an
SME.
The question of how the team will be organized should also be considered by the Team Leader in
selecting the team. If the review is particularly complex and the size of the site, facility, or
activity is large, it may be important to identify sub-team leaders. Also, if team members are
inexperienced in ISMS verifications, it may be desirable to have an experienced sub-team leader
to act as a mentor and to provide assistance to the individual team members. These individuals
should be persons the Team Leader can count on to coordinate and administer the review to
lessen the burden on his/her duties. A Senior Advisor is recommended but not required as a
knowledgeable resource to the Team Leader for identification of Noteworthy Practices,
Opportunities for Improvement, and related summarization and conclusions during the
verification.
Considerations should be given to the need to train the team. If there are a number of team
members who have conducted ISMS verifications and have recent audit/assessment experience at
the site, then the training needs may be reduced. If it is not possible to get experienced persons,
then a more comprehensive training process will be required. The Team Leader needs to be
prepared to justify the technical competence of each individual member for his/her area of
expertise and the credentials of the team as a whole. Technical credentials and assessment
experience are appropriate considerations. Appendix 6 is a sample form used to document a team
member’s training and qualification.
6.3.2.3 Establishing Effective Contractor Interfaces
The conduct of ISMS verifications requires a significant amount of coordination with the
contractor’s and local DOE staffs. It is the contractor’s responsibility to present and explain his
ISMS, and it has been found to be productive for the contractor to conduct formal presentations
to the team on the ISMS. For this presentation to be effective, the Team Leader should provide
the contractor with the type and scale of magnitude necessary. Examples of schedules of
presentations provided during Phase I and Phase II verifications are provided in Appendix 5,
Lessons Learned. A dedicated contractor point of contact (POC) for the ISMS verification has
been valuable. This POC has normally been a member of the contractor’s management staff who
has been involved in developing the ISMS. As the ISMS verification preparations reach closure,
there are a multitude of details that will require close coordination between the Team Leader and
the POC. Details such as establishing the briefing schedule and format, developing the list of
personnel to be interviewed by the team, establishing a library of manuals of practice and records
available for the team, and selecting activities for observation are examples of some of the details
of the verification that will require close coordination to ensure these activities occur efficiently.
Since a portion of the verification will involve a review of DOE, it is also just as important to
have a DOE POC designated who performs similar functions.
Section 17
6.3.2.4 Concepts for developing the Review Plan
The Team Leader must be able to present to the team his/her expectations on the format of the
final report. The reviewers must understand the format required in order to effectively plan their
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review. This guidance is essential in the development of the Review Plan (RP). The RP, if
prepared correctly, provides guidance and direction to the team so that they have a clear goal for
accomplishing the review. The RP provides the contractor and DOE staff with an outline of
exactly what is expected for the review. Thus they can be better prepared to provide the team
with the information necessary to determine the adequacy of the ISMS.
The development of the Criteria and Review Approach Documents (CRADs) should be one of
the first tasks conducted in preparing for the verification review. The Team Leader should
suggest the functional areas to be specified in tailoring the CRADs. Appendices 2 and 3 of this
handbook provide templates to assist in preparing the CRADs. CRADs should be tailored to
address the site, facility, or activity being reviewed. One of the first team projects is to develop
the CRADs. This is a key step. By involving the team in the development of the CRADs, the
team develops a sense of ownership. The contractor and the DOE staff should be included in the
writing of the CRAD. At the end of this effort, if it is conducted rigorously, the team will clearly
understand what it is that they must do to satisfy their CRADs, and the inspected contractor and
DOE staff will understand the scope of the review for which they are to be held responsible.
Experience has shown that when this process has been effectively conducted, an effective
verification has resulted. When this process has not been conducted so that the team members,
contractor, and DOE staff have been involved, the ISMS verification has proceeded in a chaotic
fashion.
The Team Leader must carefully craft the Review Plan so that the information gained will lead to
a recommendation to the Approval Authority as to the acceptability of the ISMS. This result is
usually required to be documented in a report. As part of the ISMS verification preparation
process, the Team Leader must carefully consider what format he/she will use for the report. The
input of the team and sub-team leaders, if assigned, should be crafted to efficiently support the
report format. The manner of identifying issues and concerns should be understood by the team
and there should be agreement that those determinations will support the needs of the Approval
Authority.
The following outline provides a suggested format for the Review Plan.
1.0 Introduction/Background : Describes the site, facility, or activity that will be reviewed.
This section provides background information concerning the basic process, hazards, and
issues associated with the activity to be reviewed.
2.0 Purpose: Describes the reasons why the review will be conducted and provides the basic
rationale for the defined scope of the review.
3.0 Scope: Defines the physical and administrative boundaries of the site, facility, or activity
and justifies those defined boundaries and support functions for review. This section of the
Review Plan should describe the approved scope as identified by the Approval Authority. It
should define the major objectives of the review. These objectives define the disciplines or
areas which are selected for review and define the approach and guidelines for the reviewer.
Section 18
4.0 Prerequisites: Summarizes prerequisites specified by the Approval Authority. The use of
defined prerequisites has proven beneficial both in the preparation and conduct for the review.
DOE-HDBK-3027-99
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It is not the responsibility of the team to develop the prerequisites but they must understand
them as they reflect the expectations of the Approval Authority. Appendix 4 provides
examples of prerequisites that have proven to be effective.
5.0 Overall Approach: Defines a generic approach by which the review will be conducted,
and provides an introduction to the verification. The Criteria and Review Approach
Documents (CRADs) will be defined by the processes described in this section.
6.0 Preparations: Describes any preparations, including team pre-review site visits,
document reviews, etc., that will be undertaken prior to the on-site review. A discussion of
qualifications and training considerations for team members should appear here.
7.0 Process: Describes the criteria and review approaches that will be used to review the
ISMS. These CRAD should be developed in a format to include the following items:
A. Objective - Identification of the expectation which will be verified as having been
achieved.
B. Criteria - The specifics by which the objectives will be measured, which may include
Approval Authority direction in Phase I, and regulatory requirements.
C. Review Approach - What combination of review of documentation, interviews of
personnel, walkdown of systems, and observations that will be conducted to derive
objective evidence by which the team will measure the defined criteria of the particular
objective or sub-objective.
8.0 Administration: Describes the mechanism for meetings, correspondence,
communications, team structure, etc. of the review. The team composition and organization,
interface requirements, any oversight groups, and DOE organizations to be involved in the
review should be discussed in this section.
9.0 Reporting and Resolutions : Details the methods for preparation and completion of items
identified by the Approval Authority as deliverables at the conclusion of the review.
10.0 Schedule: Presents the proposed schedule for any preparation, pre-review site visits,
on-site review, conduct of review, report preparation, and closeout.
11.0 Appendices: Includes the check lists or other specific evaluation and review documents
which are to be used by the Team Members to conduct the individual assessments. They may
also include reporting forms, writing guides, and other sections appropriate to stand alone in
an appendix. The appendices of this handbook contain information and examples that may be
useful during development of the appendices.
6.3.3 ISMS Phase I Verification Specifics
The primary purpose of the Phase I review is to provide the Approval Authority with a
recommendation for approval of the ISMS Description, showing that the requirements of 48 CFR
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Section 19
970 (DEAR) are met. A secondary purpose of the review is to evaluate the role of DOE in
support of the contractor’s ISMS. For the most part, this is an administrative review of the ISMS
Description and a review of the line management processes that will be used to implement the
ISMS. However, to be successful, the Phase I review should not just be an administrative review
of the ISMS documentation but should also be a review of the procedures, policies, and manuals
of practice used to implement safety management. The team should seek an understanding of
how management integrates the documentation's processes to "perform work safely." It is
anticipated that the Approval Authority will require that a high hazard and high activity site,
facility, or activity will be required to undergo a more rigorous and in-depth ISMS review than
one of a lesser hazard. The CRADs detailed in Appendix 2 of this handbook are provided as a
template to assist in the preparation of a tailored review approach for the appropriate site,
facility, or activity. These approaches, developed by the Team Leader with assistance from the
team, should be included in the RP.
An important consideration in planning and conducting the review is to verify the adequacy of
the "integration" which the ISMS Description provides. Integration must be evident from the
DOE direction concerning programs and mission through the site or corporate level direction to
the intermediate level, the facility, and finally to the individual work or process action level. For
example, work at the activity level should be consistent with budget commitments and
agreements between DOE and the contractor. Similarly, work control hazard analysis procedures
at the worker level should be consistent with the corporate or site level descriptions. There
should also be integration across functional areas. Each functional area (criticality, environmental
protection, worker protection, etc.) must be integrated with other safety functions such that all
relevant safety functions are addressed.
The core functions of safety management should be addressed in a manner that is consistent with
the appropriate guiding principles. Take for example, line management responsibility for safety in
the core function of analyzing hazards. The roles and responsibilities ensuring that line
management responsibility for safety when analyzing hazards must be clearly defined. Similarly,
the other individual core functions should be integrated so that the decisions and information
from one function to an adjacent function is fully and consistently used. For example, the work
controls that are in place for a specific maintenance action must be consistent with the hazards
that were analyzed for that maintenance action. The ISMS Description must provide for this
integration and the Review Plan should require evaluation of the effectiveness of integration
concepts.
6.3.4 ISMS Phase II Verification Specifics
The purpose of the Phase II review is to provide the Approval Authority with an assessment of
the status of the ISMS implementation for a given contractor site, facility, or activity. It is
essential that the Phase I review be completed prior to the Phase II review except in those case
where the Phase I and Phase II reviews are combined. The review methodology at this point
should concentrate on the implementation of documentation, that is the manuals of practice or
mechanisms used. Appendix 3 of this handbook contains a template of CRADs that can be used
to develop a tailored review approach for a specific site, facility, or activity. CRADs should
reflect the known conditions of the facility or activity as well as the work that is conducted. The
Review Plan should be designed to take advantage of past reviews and assessments.
Section 20
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The focus of Phase II verification is the implementation of integrated processes for accomplishing
work safely. The documentation of other reviews can be enlightening and reduce the verification
effort. It is an evaluation based on performance of the adequacy of the implementation of the
ISMS. All available information such as previous ORRs, ISMS verifications, EH site
assessments, etc. should be used. It should also include an assessment of facility level
performance.
The Phase II verification is more focused on the planning and control of work including feedback
and improvement. Through the evaluation of work planning, control, and feedback and
improvement, it is possible to evaluate the effectiveness of the implementation of the ISMS
Description. Two different aspects are addressed and evaluated.
(1) Are the practices and mechanisms that are observed relevant to accomplishment of work,
and do they follow and comply with the mechanisms that are discussed in the ISMS
Description?
(2) Do the practices and mechanisms observed during the conduct of actual work meet the
functions and principles of Integrated Safety Management?
The Phase II evaluation is conducted by focusing on the management, operations, and Subject
Matter Expert (SME) areas. Implementation of the Authorization Basis or Authorization
Agreement is evaluated. Practices for definition of individual work (maintenance, processes,
experiments, or construction projects), identification of the hazards associated with the work,
development and implementation of the controls, authorization and control of the actual work,
and feedback and improvement processes are evaluated. The Phase II verification also includes
an evaluation of the status of implementation of the DOE commitments to Integrated Safety
Management. Through this evaluation from the perspective of line management, SMEs, and
DOE, the status of implementation of ISM can be determined.
It is important to recognize that the ISMS Phase II verification is not an ORR that determines the
readiness to conduct work safely. The Phase II verification focus is on the implementation of the
processes through which work is planned and managed to ensure that it is conducted safely. The
Phase II verification is an evaluation as to whether the functions and principles described in the
DOE Policy 450.4 have been effectively translated into policies and procedures and whether
those policies and procedures have been effectively implemented within the workplace.
While the Phase I verification consists primarily of documentation reviews and management
interviews, the Phase II verification is primarily a performance-based review of the functioning
ISMS. This should be clearly reflected in the RP used to guide the Team. The site, facility, or
activity procedures and policies that implement the Phase I requirements should be reviewed to
validate the flowdown of requirements. Personnel in the operations and support organizations
should be evaluated to determine their understanding of these requirements in all appropriate
aspects of operations. Most importantly, the review should include the observation of program
mission operations as a demonstration of the integration of all aspects of the ISMS.
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6.3.5 ISMS Combined Phase I and Phase II Verification Specifics
Section 21
As discussed in Section 5.4, a combined verification should be conducted only when it is clear
that the site had achieved a mature implementation of the ISMS. The ISMS should also be
consistent with the system description that was submitted to the HCA for approval. It is possible
to conduct a combined verification when the implementation is not complete or mature in some
known areas but which is complete and mature in a majority of the areas. A combined
verification should not be attempted when all of the mechanisms for implementation of the ISMS
Description have not been developed or have not been implemented.
The ISMS verification team for a combined verification should contain members with previous
ISMS verification experience as well as a good understanding of the site and the work that is
conducted at the site. Experience with the site and the work conducted there is particularly
important for the members of the operations and SME sub-teams and some members of the
management sub-team. Each sub-team should have an experienced sub-team leader for a
combined verification.
For a combined verification, it is recommended the team and review be divided into the following
Functional Areas:
+ Business, Budget, and Contracts (Phase I)
+ Hazards Identification and Standards Selection (Phase I & II)
+ Department of Energy (Phase I & II)
+ Management (Phase I & II)
+ Operations and Implementation (Phase II)
+ Subject Matter Experts (Phase II)
The bulk of the Phase II portion of the verification is assigned to the Operations and
Implementation and Subject Matter Expert sub-teams. Some portion of the DOE and
Management assessment activities are also focused on implementation of the ISMS, although
more of their effort is focused on the Phase I aspect of the verification.
A major challenge to a successful combined verification is development of an effective and
efficient Review Plan. The Review Plan must be developed with a detailed understanding of the
site, facility, or activity. The draft or preliminary plan is normally developed by the Team Leader
or an individual who has been tasked by the Team Leader to prepare the draft Review Plan. The
draft is then further tailored by the individual team members. The development of the draft
Review Plan must occur with full and detailed knowledge of the site, facility, or activity, its
history including recent ORRs and other verifications and with an understanding of the work that
is accomplished, and an understanding of the procedures and processes that are utilized. The
verification must build from the history of the site, facility, or activity and look at the work
involved. The success of the verification will depend in large measure on the effectiveness of the
Review Plan. The draft CRADs for both a Phase I verification and a Phase II verification should
be included in the Review Plan. The CRADs must be tailored to reflect the work, the unique
aspects, and the history of the site, facility, or activity. The CRADs should also be tailored to
remove overlap and redundancy that exists with the CRADs that are designed for stand alone
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Phase I and Phase II verifications. It is not a trivial exercise to get the Review Plan right. It is
one of the most important challenges of the entire combined verification process.
Section 22
The conduct of the review must be carefully planned. For the Review Plan to be effectively
utilized, it is necessary that the team determine the status of development of the implementing
mechanisms before evaluating the implementation of those mechanisms at the work place. The
quality and content of the presentations made to the team by the contractor and DOE is key to
success in this important aspect of the verification process. The discussion of the content and
agenda for the presentations provided in Appendix 5 should be carefully considered as the
presentations for a combined verification are being planned.
Another challenge to the combined verification is the final report. The report must clearly define
the recommendation as to whether the ISMS Description should be approved or what changes to
the Description are considered to be necessary. In addition, the report must discuss the status of
implementation of the mechanisms, including a discussion of a recommended path forward to
verify corrective actions or conduct additional verifications, if required. Experience indicates that
the entire verification should be included in a single report. The interrelationships between the
Phase I aspects of the verification and the Phase II aspects are too tightly intertwined to
effectively separate the report of each phase.
Another challenge associated with the report is the decision as to how it should be structured.
Several choices are possible. It could be structured by functional areas or by CRAD. It could
also be structured by the functions and principles of Integrated Safety Management. It could also
be structured with a Phase I and Phase II focus. The choice of how the report is to be focused
and structured must be made before the start of the verification and integrated into the Review
Plan. The Team Leader should review past reports for information and for guidance. The
Approval Authority Letter of Appointment to the Team Leader should also provide insight into
the expectations and the desires of the AA as to the content and the format of the report. The
ability of the team to successful complete the verification including issuing a report, will depend
on the prior planning and decisions associated with the format, focus, and content of the report.
If the conditions at the site, facility, or activity are right, a combined review should be considered.
It will save time and resources for the site and for the verification team. It will challenge the
planning and management skills of the Team as well as the site. It will, however be worth the
effort.
6.4 The Report of the ISMS Verification
The report of the ISMS verification should be the basis by which the Approval Authority will
determine the results of the Phase I or Phase II reviews for the site, facility, or activity. The
report should be sufficiently detailed to allow a knowledgeable reader an understanding of the
verification process. The report should contain a conclusion and recommendation by the Team as
to whether the Phase I or Phase II results meet the direction for that site, facility, or activity. The
report process should have a provision for the team members to provide dissenting opinions or
individual observations not reflected by the team as a whole. In that the report is the record of
the review, it is as important as the review itself.
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6.4.1 Specifics of the ISMS Verification Report
Section 23
A suggested format, derived from an ISMS Verification Final Report, is discussed in detail in
Appendix 7, the Writer's Guide.
6.4.2 Other Report Considerations
Additional considerations may include:
a. the ISMS Review Plan;
b. how the plan was followed;
c. deviations from the plan; and
d. whether findings and observations are traceable and related to specific objectives.
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Appendix 1
Core Expectations for ISMS Verifications
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INTEGRATED SAFETY MANAGEMENT SYSTEM VERIFICATION
CORE EXPECTATIONS
The following core expectations were developed from the requirements of the DOE policies, the
requirements of the DEAR, FRAM, and the fundamental attributes that support the
implementation of ISMS. These core expectations have been developed to provide a reference or
starting point which can serve as the basis for developing the Criteria and Review Approach
Documents (CRADs). The CRADS are tailored to support the verification efforts at the
particular site, facility, or activity. The following core expectations are annotated as being
applicable to Phase I or Phase II. The Phase I core expectations are used to evaluate the
adequacy of the safety management documentation and the establishment of these programs at
the site or corporate level. The Phase II core expectations are used to evaluate the status of
implementation at the facility or activity. There is a complete discussion of the ISMS core
expectations in Volume II Appendix E of the ISMS Guide, DOE G 450.4-1. The core
expectations are reiterated here for ease of reference.
Phase I ISMS Core Expectations
Nine core expectations are recommended for conducting the Phase I review. To be fully
effective, the Phase I review should evaluate whether safety management programs and
institutional processes have been implemented at the site or corporate level.
1. The ISMS documentation is consistent with DOE P 450.4, the DEAR, and the guidance
provided to the contractor by the Approval Authority. (CE I-1)
2. DOE and the contractor effectively translate mission into work, set expectations, provide
for integration, and prioritize and allocate resources. (CE I-2)
3. An ISMS should include methods for identifying, analyzing, and categorizing hazards.
(CE I-3)
4. The ISMS should include methods for establishing and maintaining an agreed-upon set of
safety standards before work is performed. (CE I-4)
5. Contractor policies, procedures, and documents are established and are adequate for the
work or process to be performed safely. (CE I-5)
6. The ISMS should be continuously improved through an assessment and feedback process,
which should be established at each level of work and at every stage in the work process.
(CE I-6)
7. The ISMS should establish that at every level of control, line management must be
responsible for safety. Clear and unambiguous roles and responsibilities should be defined
and maintained at all levels within the organization. (CE I-7)
8. The ISMS should ensure that personnel are competent commensurate with their
responsibility for safety. (CE I-8)
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9. The DOE Approval Authority should have a set of processes that interface efficiently and
effectively with the contractor organization. (CE I-9)
Phase II Core Expectations
Section 24
The following eight core expectations should be considered during a Phase II assessment of
ISMS implementation following the approval of the ISMS Description. This assumes that the
Approval Authority has formally approved the ISMS Description or has approved it with
comments. This acknowledges that contractor ISMS programs are satisfactory at the corporate
or site level. Any comments that affect the adequacy of the safety management programs should
be resolved and incorporated before the Phase II review occurs.
1. An integrated process has been established and is utilized to identify and prioritize specific
mission discrete tasks, mission process operations, modifications and work items. (CE II-
1)
2. The full spectrum of hazards associated with the Scope of Work is identified, analyzed,
and categorized. Those individuals responsible for the analysis of the environmental,
health and safety, and worker protection hazards are integrated with those personnel
assigned to analyze the processes. (CE II-2)
3. An integrated process has been established and is utilized to develop controls that mitigate
the identified hazards present within a facility or activity. The set of controls ensure
adequate protection of the public, worker, and the environment and are established as
agreed upon by DOE. These mechanisms provide integration, which merge together at
the workplace. (CE II-3)
4. An integrated process has been established and is utilized to effectively plan, authorize
and execute the identified work for the facility or activity. Both workers and management
demonstrate a commitment to ISMS. These mechanisms demonstrate effective
integration. (CE II-4)
5. A process has been established and is utilized which ensures that mechanisms are in place
to ensure continuous improvements are implemented through an assessment and feedback
process, which functions at each level of work and at every stage in the work process.
(CE II-5)
6. Clear and unambiguous roles and responsibilities are defined and maintained at all levels
within the facility or activity. Facility or activity line managers are responsible and
accountable for safety. Facility or activity personnel are competent commensurate with
their responsibility for safety. (CE II-6)
7. DOE ISMS procedures and mechanisms should ensure that work is formally and
appropriately authorized and performed safely. DOE line managers should be involved in
the review of safety issues and concerns and should have an active role in authorizing and
approving work and operations. (CE II-7)
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8. DOE ISMS procedures and mechanisms ensure that hazards are analyzed, controls are
developed, and that feedback and improvement programs are in place and effective. DOE
line managers are using these processes effectively, consistent with FRAM and FRA
requirements. (CE II-8)
Core Expectations for Combined Phase I and II ISMS Verifications
If the Approval Authority elects to combine the ISMS Phase I and II verifications, use of all
Phase I and II core expectations with some combinations to account for efficiency is appropriate.
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Appendix 2
Criteria and Review Approach Template
for Phase I ISMS Verifications
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Criteria and Review Approach Template for Phase I ISMS Verifications
Section 25
The following set of criteria and review approach documents (CRADs) provide a template for
developing a tailored approach for conducting a Phase I ISMS verification of an ISMS
Description. As discussed in Volume 2, Appendix E of DOE G 450.4-1, ISMS Guide, this review
is an assessment of the adequacy of the ISMS documentation as submitted to the Approval
Authority by the contractor. To be successful, Phase I is not just an administrative review of the
ISMS documentation, but is also a review of the procedures, policies, and manuals of practice
used to implement safety management. The review evaluates how these procedures, policies, and
manuals of practice have been implemented at the upper levels of management and includes
detailed discussions with key management personnel who are assigned, or will be assigned, safety
management responsibilities. The primary goal for the review is to provide a recommendation to
the approval authority as to whether the ISMS documentation should be approved. To reach that
conclusion, it is necessary to develop a complete understanding of the safety management
programs and to determine that, when implemented, they will satisfy DOE requirements for ISMS
and adequately manage the work safely. The review also includes an assessment of the adequacy
of the local DOE office responsibilities as they relate to ISMS interface functions, responsibilities,
and authorities.
Each CRAD objective includes a reference to the specific ISMS Core Expectation (CE) it
addresses. The referenced CE as delineated in DOE G 450.4-1, ISMS Guide, and Appendix 1 of
this handbook is included in parenthesis after the statement of the objective.
The full scope of the review of DOE responsibilities to support the development of ISMS is
contained in the Business, Budget and Contracts (BBC), Hazards Identification and Standard
Selection (HAZ), and DOE CRADs. These review approaches involve the review of DOE
programs and policies, interviews with DOE managers, and selected observations of DOE
interactions with the contractor. In preparation of the tailored CRADs for the DOE review, the
applicable DOE FRAM/FRA documents should be reviewed to determine the extent of the
review approaches. The policy does not specifically require a verification of DOE performance.
It is recommended that the Team Leader negotiate the inclusion of DOE in their verification.
Integrated Safety Management policy requirements are applicable to subcontractors as well as the
Management and Operation (M&O) or Management and Integration (M&I) contractors. This
applies to M&O/M&I subcontractors and any contractors working for DOE, if applicable. The
DEAR clause specifies that the subcontractors be required to either develop an individual ISMS
Description or to meet the requirements of the M&O/M&I ISMS Description. Therefore, it is
necessary that the ISMS verification include subcontractors and that as appropriate their ISMS
Description be evaluated utilizing the same core expectations. The CRADs should be
appropriately tailored to include the subcontractors.
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BUSINESS, BUDGET, AND CONTRACTS (BBC)
OBJECTIVE
BBC.1 DOE and contractor procedures ensure that missions are translated into work,
expectations are set, tasks are identified and prioritized, and resources are allocated. (CE I-2, CE
I-6, CE I-7, CE I-9)
Criteria
1. DOE guidance for translating mission into work includes delineating its plan of work.
This means the scope, schedule, and funding allocations for each fiscal year. (FRAM 9.2.1)
Section 26
2. DOE guidance for setting expectations for the contractor is established through contracts
and regulations. These contracts and regulations provide guidance on expected performance,
set goals and priorities, and allocate resources. (FRAM 9.2.2)
3. DOE roles and responsibilities are clearly delineated to ensure a satisfactory level of safety,
accountability, and authority to define the scope of work. (FRAM 9.2.2)
4. DOE procedures ensure that the contractor adequately prioritizes work so that, when the
ISMS is implemented, mission and safety expectations are met within available budget and
resources. DOE procedures require that performance objectives and related goals and
priorities are reviewed and approved. (FRAM 9.2.4)
5. Contractor procedures translate mission expectations from DOE into tasks that permit
identification of resource requirements, relative prioritization, and performance measures that
are established consistent with DOE requirements (DEAR 970.5204-2, DOE P 450.5).
6. DOE and contractor procedures provide for DOE approval of proposed tasks and
prioritization. Work planning procedures provide for feedback and continuous improvement.
7. DOE and contractor procedures provide for change control of approved tasks,
prioritization, and identification of resources.
8. Contractor procedures provide for flowdown of DEAR 970.5204-2, “Integration of
Environment, Safety and Health into Work Planning and Execution,” requirements into
subcontracts involving complex or hazardous work.
Approach
Record Review: Review the FRAM/FRA and DOE implementing procedures. Determine if
there is adequate guidance for DOE involvement in the clear definition of the scope of work.
Determine if the mechanisms for translation of the missions and policies from higher authority
are appropriate, if a mechanism for assigning priorities has been established, and if
performance objectives are reviewed and approved. Determine if the roles and responsibilities
for DOE personnel are adequate to support the corporate/site mission. Verify that DOE line
management and staff personnel roles, responsibilities, and authorities are appropriate to
support ISMS. Review personnel position descriptions, selection criteria, training programs
and training records to determine if the staff competency is adequate. Review mission
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prioritization procedures to determine if tailoring of resources is appropriate. Verify that the
budget process allows adequate resources for standards selection, hazard controls, and work
authorization processes to support work planning and scope definition.
Review corporate/site manuals of practice that describe the budget and planning process and
those documents that identify mission requirements, the approval of contractor plans, and
those that address the assignment of budget priorities. Review corporate/site procedures for
formally documenting change control procedures. Review how safety requirements are
included in subcontracts as well as the flowdown of the DEAR clause into subcontracts for
hazardous work.
Select several mission tasks from the DOE programs and planning documents and track the
tasks through the process to evaluate how the above criteria are met. Review future year
planning and current year authorized work. Select several current year authorizations and
track change control. Select several DOE and contractor subcontracts and review for
incorporation of the ISM DEAR clauses.
Section 27
Interviews: Interview DOE and contractor personnel responsible for management of the
budget process. Interview line managers responsible for Headquarters directed mission
accomplishment. Interview the ES&H manager to determine how the process for integration
of safety into mission tasks is accomplished. Interview managers at selected corporate/site
level to determine their understanding and implementation of the defined process for
translation of mission into work authorization. Interview selected ES&H professionals and
line managers to determine how safety is incorporated into the budget plans and
authorization. Interview DOE and contractor procurement personnel regarding subcontract
flowdown requirements.
Observations: If possible, observe actual budgetary discussions (including meetings involving
the development of the outyear planning documents) within and between DOE and the
contractor.
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OBJECTIVE
BBC.2 DOE and contractor budgeting and resource assignment procedures include a process to
ensure the application of balanced priorities. Resources are allocated to address safety,
programmatic, and operational considerations. Protecting the public, workers, and environment
is a priority whenever activities are planned and performed. (CE I-2, CE I-7)
Criteria
1. The prioritization and allocation process clearly addresses both ES&H and programmatic
needs. The process involves line management input and approval of the results.
2. Priorities include commitments and agreements to DOE as well as stakeholders.
3. Contractor procedures provide resources to adequately analyze hazards associated with
the work being planned.
4. Contractor procedures for allocating resources include provisions for implementation of
hazard controls for tasks being funded.
5. Resource allocations reflect the tailored hazard controls.
6. The incentive and performance fee structure promote balanced priorities.
7. DOE procedures for defining the scope of work ensure balanced priorities. (FRAM 9.2.3)
Approach
Record Review: Review corporate/site manuals of practice that describe the budget and
planning process and those documents that address the assignment of budget priority as well
as the procedures for their development. Review DOE procedures that identify mission
requirements, balancing of resource allocations, and approval of contractor plans in the work
authorization documents.
.
Select several mission tasks from the DOE requirements and outyear planning documents to
determine if they adequately address the assignment of resources with balanced priorities.
Select several current year authorizations and review selected funded tasks at the individual
task level to verify balanced priorities.
Interviews: Interview responsible DOE and contractor personnel who manage the budget
process to determine their understanding of the priority for assigning resources. Interview
line managers responsible for DOE mission accomplishment. Interview the ES&H manager
to determine the process used for integration of safety into mission tasks. Interview selected
managers at each level of corporate/site organizations to determine their understanding of the
allocation of resources with appropriate priority.
Observations: If possible, observe actual budgetary discussions (including meetings involving
the development of the outyear planning documents) within and between DOE and the
contractor.
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Section 28
OBJECTIVE
BBC.3 The contractor procedures and practices ensure that personnel who define the scope of
work and allocate resources have competence that is commensurate with the assigned
responsibilities. (CE I-8)
Criteria
1. Contractor procedures ensure that the personnel including line management who define,
prioritize, and approve the scope of work and allocate resources have competence that is
commensurate with the assigned responsibilities.
2. Personnel who actually participate in definition of the scope of work and allocate
resources demonstrate competence to prioritize and approve work with tailored hazard
controls.
Approach
Record Review: Review organizational documentation to determine the personnel positions
with responsibility associated with this objective. Review the position description for those
positions. Review the personnel records that identify the individual qualifications that meet
the elements of the position descriptions. Review any training or qualification material
including corporate/site manuals that support gaining or verifying competence to fill the
positions.
Interviews: Interview selected individuals and managers whose responsibilities include
defining the scope of work and allocation of resources to determine competence in
prioritizing and approving work with tailored hazard controls.
Observations: None.
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DEPARTMENT OF ENERGY (DOE)
NOTE: The team should negotiate with the Operations Office Manager to include the review of
DOE performance in the verification.
OBJECTIVE
DOE.1 DOE has established processes that interface efficiently and effectively with the
contractor’s organization to ensure that work is performed safely. (CE I-7, CE I-8, CE I-9)
Criteria
1. DOE line management responsibility for safety includes responsibility to ensure that work
is performed within the approved controls.
2. DOE has established clear roles and responsibilities to ensure that work is performed
within controls.
3. DOE procedures ensure that personnel who review or oversee the performance of work
have competence commensurate with the responsibilities to which they are assigned.
4. DOE procedures ensure that priorities are balanced so that work is performed within
controls.
5. DOE procedures require work readiness be properly verified and authorized before work
commences.
Approach
Record Review: Review the FRAM/FRA and DOE implementing procedures for effective
interface with the contractor. Determine if there is adequate guidance for the authorization
and oversight of work by DOE. Verify that those authorized to perform these functions have
clear roles and responsibilities. Determine if the chain of command is clearly described.
Verify that the Facility Representative (FR) program is tailored to match the work.
Determine if oversight is balanced with risk and the priority of the mission being performed.
Interviews: Discuss work authorization and performance activities with the DOE and
contractor personnel and determine if there are adequate mechanisms to ensure that work is
properly authorized at all levels. Determine if work safety is perceived as an integral part of
work authorization methods and issue resolution. Discuss the systematic oversight of work
with DOE and contractor personnel. Determine if oversight is adequate or excessive.
Discuss the FR program with the FRs and with contractor personnel to determine if it is
effective.
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Section 29
OBJECTIVE
DOE.2 DOE has established processes that interface efficiently and effectively with the
contractor’s organization to provide feedback and continuous improvement. Feedback
information on the adequacy of controls is gathered, opportunities for improving the definition
and planning of work are identified and implemented, line and independent oversight is
conducted, and, if necessary, regulatory enforcement actions occur. (CE I-6, CE I-7, CE I-8, CE
I-9)
Criteria
1. DOE procedures describe clear roles and responsibilities to provide feedback and
continuous improvement.
2. DOE procedures ensure that competence is commensurate with the responsibilities to
provide feedback and continuous improvement.
3. DOE procedures ensure that feedback is provided and continuous improvement results in
the identification of safety standards and requirements.
4. DOE procedures ensure that feedback is provided and continuous improvement results in
the tailored hazard controls of the work being performed.
5. DOE procedures promote the continuous improvement and efficiency of operations. DOE
priorities are balance and corrective actions are developed, implemented, and tracked in order
to profit from prior experience and the lessons learned.
6. DOE procedures provide line oversight of the contractor’s self-assessment programs.
Approach
Record Review: Review the FRAM/FRA and DOE implementing procedures to determine
how the feedback program functions. Verify that there is DOE line management involvement.
Determine that the roles and responsibilities for these programs are clear. Review DOE
training requirements and records to ensure that personnel are trained to perform feedback
functions and participate in the continuous improvement process. Verify that balanced
priorities and tailored approaches are used to conserve and maximize use of resources.
Review the procedures for issue management and determine if this system enhances the
improvement process. Review the procedures established to provide line oversight of the
contractor’s self-assessment programs. Review the process established to ensure lessons
learned are incorporated into the feedback system. Determine if the lessons learned between
the federal safety offices and offices of similar functions are appropriately integrated and
shared.
Interviews: Discuss the feedback and continuous improvement process with DOE personnel.
Verify that safety is integrated into this process and that DOE efforts in this area are important to
safety. Determine if process improvement includes efforts to reduce unnecessary safety
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requirements and improve efficiency. Evaluate the status of establishing line oversight of the
contractor’s self-assessment programs. Determine if personnel believe that safety activities are
tailored to the risk and the priority of the work being performed.
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HAZARDS IDENTIFICATION AND STANDARD SELECTION (HAZ)
OBJECTIVE
HAZ.1 Hazards associated with the work are identified, analyzed, and categorized. (CE I-3,
CE I-9)
Criteria
1. Contractor and DOE procedures require identification, analysis, and categorization of all
hazards associated with the site. Contractor ISMS procedures for analysis of hazards reflect
accepted rigor and methodology. The resulting hazards are utilized in selection of standards
included in the contract as List A/List B.
Section 30
2. Contractor procedures require identification, analysis, and categorization of all hazards
associated with facilities or activities. Hazards that are considered include nuclear, chemical,
industrial or others applicable to the work being considered. Contractor procedures for
analysis of hazards reflect accepted rigor and methodology.
Approach
Record Review: Review the contractor’s procedures for identifying, analyzing, and
categorizing hazards at both the site as well as the facility level. Review DOE procedures for
authorizing operations to ensure that adequate provisions are included so that hazards are
properly identified and analyzed. Determine that these procedures are adequate to address
the hazards associated with the work and operations.
Review the approved or proposed hazard analysis documentation for selected facilities and
activities to verify consistency and compliance with contractor procedures and mechanisms as
well as compliance with DOE review and approval mechanisms.
Personnel Interviews: Interview corporate/site personnel responsible for identification,
analysis, and categorization of hazards to assess their understanding of the procedures and the
underlying principles and requirements. Interview DOE personnel responsible for the
oversight of the hazards analyses processes to determine that an effective interface with the
contractor has been established.
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OBJECTIVE
HAZ.2 Applicable standards and requirements are identified and agreed upon. (CE I-4, CE I-9)
Criteria
1. Contractor procedures utilize acceptable methodologies to identify adequate hazard
control standards at both the site or corporate level and at the facility level to protect the
public, worker, and environment. Controls at the corporate level appear in the contract while
those at the facility level are reflected in the authorization basis documentation.
2. Contractor procedures ensure controls are tailored to the hazards associated with the
work or operations to be authorized.
3. Contractor procedures ensure the identified controls, standards, and requirements are
agreed upon and approved prior to the commencement of the operations or work being
authorized.
4. Contractor procedures utilize accepted and structured methods and processes to identify,
select, gain approval for, periodically review, and maintain safety standards and requirements.
5. DOE procedures specify an appropriate review and approval process for the hazard
controls and safety standards and requirements.
6. DOE contracting procedures require that the requirements of applicable Federal, State,
and local regulations (List A) and the requirements of Department of Energy directives (List
B) are appended to the contract.
7. Contractor and DOE procedures define the processes for the development, approval, and
maintenance of documentation addressing the establishment of authorization protocols and
authorization agreements.
Approach
Record Review: Review contractor procedures for identification and designation of standards
that become contract requirements and assess their adequacy. Review contractor procedures
for identification and designation of standards that are incorporated into facility authorization
basis documentation and assess their adequacy. Review DOE procedures established to
review and approve standards submitted by the contractor for approval. Review the approach
to tailoring the selection of standards and requirements to the identified hazards and
maintenance of an appropriate set of standards over time. Review the procedures established
to ensure that the appropriate requirements are included in the contract as specified in List A
or List B. Review the processes established to develop, approve, and maintain authorization
protocols and authorization agreements as applicable.
Section 31
Interviews: Interview contractor site/corporate and DOE personnel responsible for selection
and approval of standards. Determine the understanding and compliance with the procedures
for identification, tailoring, review, submittal, approval, and maintenance of the set of
standards.
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Observations: Observe DOE and contractor activities involving the preparation, review,
approval and/or maintenance of the selected set of standards and requirements; or observe
DOE and contractor activities that are scheduled to develop, approve, or maintain
authorization protocols and authorization agreements as applicable.
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OBJECTIVE
HAZ.3 Contractor procedures ensure that contractor personnel responsible for analyzing the
hazards and developing, reviewing, or implementing the controls, have competence that is
commensurate with their responsibilities. DOE roles and responsibilities are clearly defined to
ensure appropriate oversight and review of the analysis of hazards and the identification of
controls. Personnel shall posses the experience, knowledge, skills, and abilities that are necessary
to discharge their responsibilities. (CE I-7, CE I-8, CE I-9)
Criteria
1. Contractor procedures have clearly defined roles and responsibilities for personnel
assigned to oversee, review, approve the analysis of hazards, and establish controls associated
with facilities and activities.
2. Contractor procedures require that personnel responsible for analyzing hazards and
identification of adequate controls have competence that is commensurate with their
responsibilities.
3. DOE procedures have clearly defined roles and responsibilities for personnel assigned to
oversee, review, and approve the analysis of hazards and controls associated with facilities
and activities.
4. DOE procedures require that personnel responsible for approving hazards analyses and
controls have competence commensurate with their responsibilities.
Approach
Record Review: Review contractor organization documentation to identify personnel
including all levels of management to whom this objective applies. Review the position
descriptions for those personnel to determine the required competencies. Review
corporate/site training manuals and qualification and competency procedures. Review
selected training and qualification records for those personnel identified above to determine
how the required competency has been gained, retained, and validated.
Review DOE FRAM/FRA or other implementing procedures that identify the roles and
responsibilities for personnel who conduct oversight and review of the hazard analyses and
the establishment controls. Verify that DOE line management and staff personnel’s roles,
responsibilities, and authorities are appropriate. Review selected qualification program
records.
Interviews: Interview selected contractor individuals to verify their understanding of the
required competencies and the degree to which they meet them.
Interview selected DOE personnel to determine their understanding of the assigned
responsibilities and determine that they are competent to meet these requirements.
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MANAGEMENT (MG)
OBJECTIVE
MG.1 The ISMS Description is consistent and responsive to DOE Policies 450.4, 450.5, and
450.6; the DEAR; and the direction to the contractor from the Approval Authority. The
contractor policies and procedures ensure that the ISMS Description is maintained, implemented,
and that implementation mechanisms result in integrated safety management. (CE I-1)
Section 32
Criteria
1. The ISMS Description is consistent and responsive to DOE Policies 450.4, 450.5, and
450.6; the DEAR; and the direction to the contractor from the Approval Authority.
2. The contractor has mechanisms in place to direct, monitor, and verify the integrated
implementation of the ISMS as described in the ISMS Description. Implementation and
integration expectations and mechanisms are evident throughout all corporate/site
organizational functions.
3. The contractor has assigned responsibilities and established mechanisms to ensure that the
ISMS Description is maintained current and that the annual update information is prepared
and submitted.
4. The contractor has established a process that establishes, documents, and implements
safety performance objectives, performance measures, and commitments in response to DOE
program and budget execution guidance. The ISMS describes how system effectiveness will
be measured.
Approach
Record Review: Review the ISMS Description and the direction concerning the guidance on
the preparation, content, review and approval of the ISMS. Review corporate/site
procedures for the implementation review, and maintenance of the ISMS Description and
associated items, including provisions for the annual review and update to DOE. Review
charters and “output documentation” from any ISMS coordinating committees. Review
contractor assessment activities incident to determination of the adequacy of implementation
of ISMS. Review implementation planning efforts and any “gap analysis” reports, which may
have been developed. Review the process established to measure the effectiveness of the
ISMS to ensure that the methods support the establishment, documentation, and
implementation of safety performance objectives that support DOE program and budget
execution guidance.
Interviews: Interview contractor managers who are responsible for the development and
maintenance of the ISMS Description. Interview contractor line managers who are or will be
responsible for administering the mechanisms of the ISMS. Interview chairman and key
members of any ISMS coordinating committees, if established.
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OBJECTIVE
MG.2 Contractor roles and responsibilities are clearly defined to ensure satisfactory safety,
accountability and authority. Line management is responsible for safety. Competence is
commensurate with responsibilities. (CE I-7, CE I-8)
Criteria
1. Contractor ISMS defines clear roles and responsibilities of all personnel to ensure that
safety is maintained at all levels. ISMS procedures and implementing mechanisms specify that
line management is responsible for safety.
2. Contractor procedures identify line management as responsible for ensuring that the
implementation of hazard controls is adequate to ensure that work is planned and approved
and conducted safely. Procedures require that line managers are responsible for the
verification of adequate implementation of controls to mitigate hazards prior to authorizing
work to commence.
3. Contractor procedures identify line management as responsible for ensuring that hazard
controls remain in effect so long as hazards are present.
4. Contractor procedures ensure that personnel who supervise work have competence
commensurate with the responsibilities.
Section 33
Approach
Record Review: Review corporate/site manuals of practice that define roles and
responsibilities of personnel responsible for safety. Review position descriptions and other
documentation that describes the roles and responsibilities related to ensuring safety is
maintained when developing the definition of the scope of work. The review should consider
personnel in both line management and staff positions and should evaluate whether line
managers are responsible for safety.
Interviews: Interview selected personnel at all levels of management who are identified by the
record review above. Verify their understanding and commitment to ensuring safety during
the processes of defining the scope of work.
Observations: Observe scheduled activities that demonstrate the planning and approval
activities prior to authorizing work to assess that clear roles and responsibilities are
established and that line management is responsible for safety. Activities such as weekly
planning meetings, plans of the day, or site/corporate safety meetings are typical meetings,
which may provide good examples of the safety decision making process.
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OBJECTIVE
MG.3 Feedback information on the effectiveness of the ISMS is gathered, opportunities for
improvement are identified and implemented, line and independent oversight is conducted, and, if
necessary, regulatory enforcement actions occur. (CE I-6, CE I-7, CE I-8)
Criteria
1. Contractor procedures describe clear roles and responsibilities to provide feedback and
continuous improvement including line management responsibility for safety.
2. Contractor procedures ensure that competence is commensurate with the responsibilities
to provide feedback and continuous improvement.
3. Contractor procedures ensure that priorities are balanced to ensure feedback is provided
and continuous improvement results.
4. Contractor procedures require line and independent oversight or assessment activities at
all levels. Oversight and assessment activities verify that work is performed within agreed
upon controls.
5. Contractor procedures ensure oversight or assessment results are managed to ensure
lessons are learned and applied; that issues are identified and managed to resolution; that
fundamental causes are determined and effective corrective action plans are developed and
implemented.
6. Contractor procedures ensure that performance measures or indicators and performance
objectives are developed in coordination with DOE as required. Contractor procedures
require effective management and use of performance measures and objectives to ascertain
the status of the ISMS.
7. Contractor procedures provide for regulatory compliance and enforcement as required by
rules, laws, and permits such as PAAA, NEPA, RCRA, CERCLA, etc.
Approach
Record Review: Review corporate/site manuals of practice to determine that the procedures,
processes and requirements that meet this objective are effective. The review should include
determining compliance with regulations in accordance with laws, rules, and permits.
Review the results and schedules of self and independent assessments. Review procedures for
scheduling and tracking routine assessments. Track issues identified during assessments to
completion. Assess the effectiveness of the assessment and feedback process to achieve
process improvement.
Review the issues management program for adequacy, effectiveness, and support for process
improvement.
Section 34
Review the performance measures or indicators and performance objectives. Ensure that a
process has been established to measure the performance of the ISMS. Review the process
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for development of the performance indicators including how the development and change is
coordinated with DOE.
Interviews: Interview selected managers to determine the adequacy and effectiveness of the
assessment activities. Interview contractor assessment managers to determine the adequacy
and effectiveness of the contractor’s oversight program, as well as other compliance or
independent assessment programs that may be established.
Observation: If possible, observe senior management assessments or self assessment
activities, including documentation and post activity briefing of results. Observe a critique or
management review including development of lessons learned and determination of root
causes.
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OBJECTIVE
MG.4 Contractor procedures provide a method to ensure that controls are implemented during
preparation for the initiation of work at each level. The procedures ensure that adequate controls
are identified to mitigate the identified hazards and the controls are effectively implemented.
Contractor procedures provide assurance that controls will remain in affect so long as the
hazards are present. (CE I-5, CE I-7, CE I-8)
NOTE: This objective will evaluate both the line management practices and mechanisms, as well
as the practices and mechanisms associated with the selected individual disciplines such as
maintenance, radiological controls, industrial safety, criticality safety, etc.
Criteria
1. Contractor procedures for individual processes or maintenance actions ensure that
controls are implemented prior to commencing work and that these controls remain in affect
so long as the hazard is present.
2. Contractor procedures for individual disciplines ensure that individual processes or
maintenance actions include adequate controls associated with the individual discipline prior
to commencing work and that the controls remain in affect so long as the hazard is present.
3. Contractor procedures provide mechanisms or processes for gaining authorization to
conduct operations or perform work.
4. Contractor mechanisms for the control of work specify that line management is
responsible for safety.
5. Contractor personnel who plan, control, and conduct work are required to have
competence commensurate with the assigned responsibilities.
Approach
Record Review: Review contractor manuals of practice that define requirements to verify
controls are in place prior to performing work and that these controls remain in place as long
as the hazards are present. Review the processes for authorizing the commencement of work
to ensure that managers are responsible for safety. Review the contractor’s training and
qualification process to ensure that personnel who plan, control, and conduct the work are
competent. Review procedures for selected disciplines to ensure consistency and adequacy.
Interviews: Interview line and support personnel responsible for implementation of
requirements to control work. Through interviews, assess their understanding, support, and
implementation of the control of work within the approved controls.
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Appendix 3
Criteria and Review Approach Template
for Phase II ISMS Verifications
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Section 35
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Criteria and Review Approach Template for Phase II ISMS Verifications
The following set of criteria and review approach documents (CRADs) provide a template for
developing a tailored approach for conducting a Phase II ISMS verification of the implementation
of ISMS within a facility or activity. The CRADS have been developed to provide a tool to
enable the verification team to tailor a review based on evaluating the five functions of ISMS as
implemented at the facility or activity. They support the expectations and attributes of ISMS
described in Volume I, Chapter III of the ISMS GUIDE, DOE G 450.4-1.
All CRADs apply to each facility or activity to be reviewed. The Phase I ISMS verification
report should be carefully reviewed prior to preparing the Phase II ISMS CRADs to ensure the
recommended areas from the Phase I verification are included in the Phase II review. Team
composition and review duration should be tailored to the specific facility or activity. Experience
has shown that to successfully conduct a Phase II verification at a nuclear facility requires a team
of 6-8 personnel The review can be completed in one week. A second week following the on
site verification is generally required to analyze the results and write the report.
Each CRAD objective includes a reference to the specific ISMS Core Expectation (CE) it
addresses. The referenced CE as delineated in DOE G 450.4-1, ISMS GUIDE, and Appendix 1
of this handbook is included in parenthesis after the statement of the objective.
The CRADs have been divided and numbered to support a review that has Functional Areas of
Hazard Identification and Standard Selection (HAZ), Management (MG), Operations (OP),
Subject Matter Experts (SME), and Department of Energy Implementation (DOE).
In preparation of the tailored CRADs for the DOE review, the applicable DOE FRAM/FRA
documents should be reviewed to determine the extent of the review approaches.
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DOE ISMS IMPLEMENTATION
NOTE: The Team Leader should negotiate with the Approval Authority to include a review of
the effectiveness of DOE in their role in ISMS.
OBJECTIVE
DOE.1 DOE procedures and mechanisms should ensure that work is formally and appropriately
authorized, and performed safely. DOE line managers should be involved in the review of safety
issues and concerns and should have an active role in authorizing and approving work and
operations. (CE II-7)
CRITERIA:
1. DOE procedures and/or mechanisms are in place that establish a process for confirming
readiness and authorizing operations. (FRAM 9.5.1 and 9.5.2)
2. DOE procedures and/or mechanisms ensure that the safety management system is properly
implemented and line management oversight of the contractor’s worker, public, environment,
and facility protection programs is performed. (FRAM 9.5.2)
3. DOE procedures and/or mechanisms require day-to-day operational oversight of
contractor activities through Facility Representatives. (FRAM 9.5.2)
4. DOE procedures and/or mechanisms ensure the implementation of quality assurance
programs and ensure that contractors implement quality assurance programs. (FRAM 9.5.3)
APPROACH:
Section 36
Record Review: Review the FRAM/FRA and DOE implementing guidance to determine that
the process for the authorization and oversight of work is adequate. Verify that those DOE
personnel assigned to perform these functions have clear roles and responsibilities. Determine
if the oversight policy is balanced with risk and priority of mission. Review the quality
assurance program established by DOE and the interactions of that program with the
contractors quality assurance program. Verify DOE programs hold line management
responsible for safety and contain clear roles and responsibilities.
Interviews: Discuss work authorization and performance activities with DOE and contractor
personnel to determine if there are adequate mechanisms to ensure that work is properly
authorized at all levels. Determine if worker safety is perceived as an integral part of the
work authorization process and that workers are involved in issue resolution if appropriate.
Discuss the oversight programs with DOE and contractor personnel. Discuss the Facility
Representative (FR) programs with facility representatives and contractor personnel to
determine if the FR program is effective. Discuss oversight programs with DOE staff who
perform ES&H management and supervision assignments. During interviews, verify
understanding of line management responsibility for safety and understanding of clear roles
and responsibilities.
Observations: Observe selected facility representative and DOE staff oversight activities
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OBJECTIVE
DOE.2 DOE procedures and mechanisms ensure that hazards are analyzed, controls are
developed, and that feedback and improvement programs are in place and effective. DOE line
managers are using these processes effectively, consistent with FRAM and FRA requirements.
(CE II-8)
CRITERIA:
1. DOE processes and/or mechanisms are in place to ensure that the contractor’s hazard
analysis covers the hazards associated with the work and is sufficient for selecting standards.
(FRAM 9.3.1)
2. DOE procedures and/or mechanisms are in place in which DOE directs the contractor to
propose facility or activity-specific standards tailored to the work and the hazards. DOE
procedures require that appropriate safety requirements in necessary functional areas are
included in contracts. (FRAM 9.4.1)
3. DOE procedures and/or mechanisms are in place that direct DOE line manager oversight
to ensure that implementation of hazards mitigation programs and controls are established.
(FRAM 9.4.2)
4. DOE procedures and/or mechanisms are in place that direct the preparation of the
authorization basis documentation and oversee the implementation by the contractor.
Procedures for development, review, approval, maintenance, and utilization of Authorization
Agreements are implemented. (FRAM 9.4.3)
5. DOE procedures and/or mechanisms require that contractors develop a lessons- learned
program and monitor its implementation. A process is established for reviewing occurrence
reports and approving proposed corrective action reports. A DOE process is established and
effectively implemented to continuously improve efficiency and quality of operations.
Corrective actions are developed, implemented, and tracked in order to profit from prior
experience and the lessons learned. DOE provides effective line oversight of the contractor’s
self-assessment programs. (FRAM 9.6.2)
Section 37
APPROACH:
Record Review: Review the FRAM/FRA and DOE implementing guidance to determine that
a process for ensuring that effective interfaces with the contractor’s ISMS has been
established. Review DOE procedures for ensuring that adequate provisions are included for
verification that hazards are properly identified, analyzed, and categorized. Review the
approved and in process hazards analysis documentation to verify that contractor procedures
and mechanisms have been properly reviewed and approved. Review DOE procedures that
specify the process to be followed for the review and approval of standards and hazard
controls. Ascertain that DOE has approved the process used by the contractor to tailor the
selection of standards and requirements.
Review the process used for the review, approval, and implementation of authorization basis
documentation including authorization protocols and agreements. Review the DOE process
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established to provide line oversight of the contractor’s self-assessment programs. Review
DOE guidance to the contractor concerning the establishment of a lessons learned program.
Determine if the lessons learned between federal safety offices and offices of similar functions
are appropriately integrated and shared. Evaluate the DOE issues management and tracking
system to ensure that there is an adequate system in place.
Interviews: Interview selected DOE personnel responsible for the review and approval of the
results of the contractor’s identification, analysis, and categorization of hazards to assess their
understanding of the procedures and the underlying principles and requirements. Interview
DOE personnel responsible for the review and approval of the standard selection process
including the approval of the authorization protocols and agreements. Interview DOE
personnel responsible for administering the issues management program and those DOE line
managers who provide oversight of the contractor’s self-assessment programs.
Observations: Observe the programs, processes, and mechanisms identified in practice.
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HAZARD IDENTIFICATION AND STANDARD SELECTION (HAZ)
NOTE: The primary focus of this section of the review is the identification of hazards and
development, review, and approval of Authorization Basis documentation at the facility level.
Controls for individual work items or activities will be evaluated by the Operations and Subject
Matter Expert functional area.
OBJECTIVE
HAZ.1 The full spectrum of hazards associated with the Scope of Work is identified, analyzed,
and categorized. Those individuals responsible for the analysis of the environmental, health and
safety, and worker protection hazards are integrated with personnel assigned to analyze the
processes. (CE II-2)
CRITERIA:
1. Procedures and/or mechanisms are in place and utilized by personnel to ensure hazards
associated with the work throughout the facility have been identified and analyzed. The
resulting documentation is defined, complete, and meets DOE expectations. The execution of
these mechanisms ensure personnel responsible for the analysis of environmental, health and
safety concerns are integrated with those assigned to analyze the hazards for the facility or
activity. These mechanisms ensure direction and approval from line management and
integration of the requirements.
Section 38
2. Procedures and/or mechanisms are in place and utilized by personnel that describe the
interfaces, roles and responsibilities of those personnel who identify and analyze the hazards
of the scope of work. Personnel assigned to accomplish those roles are competent to execute
those responsibilities.
APPROACH:
Record Review: Review the documents that govern the conduct, review, and approval of
facility or activity hazard analysis and documentation such as Process Hazards Analysis
(PHA), Preliminary Hazards Review (PHR), Preliminary Safety Analysis Report (PSAR), job
hazards analysis (JHA), and Work Control Permits (WCP). Verify that these records
conform to the hazard analysis requirements. Coordinate the review of work related
documents such as Job Hazard Analysis (JHAs), and WCPs with the OP and SME functional
area reviewers.
Interviews: Interview personnel responsible for the identification and analysis of work
hazards. In nuclear facilities, for example, this should include personnel responsible for USQ
determination, lock and tag preparation, procedure technical reviews, etc.
Observations: If possible, observe the actual preparation and field implementation of the
analysis of hazards. In nuclear facilities, this should include an Unreviewed Safety Question
Determination (USQD), preparation of a JHA, SAR/TSR, or Criticality Safety Evaluation,
etc.
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OBJECTIVE
HAZ.2 An integrated process has been established and is utilized to develop controls that
mitigate the identified hazards present within a facility or activity. The set of controls ensure
adequate protection of the public, worker, and the environment and are established as agreed
upon by DOE. These mechanisms demonstrate integration, which merge together at the
workplace. (CE II-3)
CRITERIA:
1. Procedures and/or mechanisms are in place to develop, review, approve and maintain
current all elements of the facility Authorization Basis Documentation with an integrated
workforce.
2. Procedures and/or mechanisms that identify and implement appropriate controls for
hazards mitigation within the facility or activity are developed and utilized by workers (see
Section 4 for definition) and approved by line managers. These procedures/mechanisms
reflect the set of safety requirements agreed to by DOE.
3. Standards and requirements are appropriately tailored to the hazards.
4. Procedures and/or mechanisms are in place to develop, maintain, and utilize Authorization
Agreements.
5. Procedures and/or mechanisms are in place to effectively and accurately implement all
aspects of the Authorization Basis.
APPROACH:
Record Review: Review a sample of hazard control documents to verify safety controls are
provided for the hazards identified and that the control strategy encompasses a hierarchy of
1) hazard elimination, 2) engineering controls, 3) administrative controls, and 4) personnel
protective equipment. Typical documents include Authorization Agreements (AAs), Safety
Analysis Reports (SARs), Technical Safety Requirements (TSRs), Health and Safety Plans
(HASPs), Radiological Work Permits (RWPs), operating procedures, etc. Review
procedures and mechanisms to ensure accurate and effective implementation of Authorization
Basis documentation. Sample actual implementing documentation. Coordinate the review of
work related documents such as RWPs and operating procedures with the OP and SME
functional area reviewers.
Section 39
Interviews: Interview personnel responsible for developing and implementing hazard controls
and/or Authorization Basis Documentation at the facility level. This should include personnel
such as those responsible for SAR/TSR preparations and implementation, ALARA review
requirements, Process Hazard Analysis activities, etc.
Observations: Observe the actual processes development, review, approval, and
implementation of SAR/TSR, AA, and other Authorization Basis Documents as available.
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MANAGEMENT (MG)
OBJECTIVE
MG.1 An integrated process has been established and is utilized to identify and prioritize specific
mission discrete tasks, mission process operations, modifications and work items. (CE II-1)
CRITERIA:
1. Procedures and/or mechanisms that require line management to identify and prioritize
mission-related tasks and processes, modifications, and work items are in place and utilized by
personnel.
2. Procedures and/or mechanisms are in place and utilized by personnel that define the roles
and responsibilities for the identification and prioritization of mission-related tasks and
processes, facility or process modification, and other related work items. Personnel assigned
to the roles are competent to execute these responsibilities.
3. Procedures and/or mechanisms are in place and utilized by personnel that ensure identified
work (i.e.,mission-related tasks and process, processes or facility modification, maintenance
work, etc.) can be accomplished within the standards and requirements identified for the
facility.
APPROACH:
Record Review: Review the facility or activity long-range planning documentation. This
should include such items as: summary schedules, plan of the week, long-range maintenance
schedules, modification schedule, etc. Review the procedures and mechanisms that line
managers utilize to identify and prioritize mission-related tasks and processes, modifications,
and work items.
Review organizational documentation to determine the personnel positions with responsibility
associated with this objective. Review the position description for those positions. Review
the personnel records that identify the individual qualifications that meet the elements of the
position descriptions.
Review any training or qualification material including in training and qualification manuals
that support gaining or verifying competence to fill the positions.
Review the procedures and/or mechanisms that are utilized by the facility or activity to ensure
that identified work is accomplished in accordance with established standards and
requirements.
Interviews: Interview management personnel responsible for the identification and
prioritization of work. This should include personnel such as those responsible for long-range
planning documentation, schedule preparation, etc.
Observations: Observe work definition and planning activities such as plan of the week
meetings, long-range scheduling meetings, etc.
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OBJECTIVE
MG.2 Clear and unambiguous roles and responsibilities are defined and maintained at all levels
within the facility or activity. Managers at all levels demonstrate a commitment to ISMS through
policies, procedures, and their participation in the process. Facility or activity line managers are
responsible and accountable for safety. Facility or activity personnel are competent
commensurate with their responsibility for safety. (CE II-6)
Section 40
CRITERIA:
1. Procedures and/or mechanisms are in place that define clear roles and responsibilities
within the facility or activity to ensure that safety is maintained at all levels.
2. Facility or activity procedures specify that line management is responsible for safety.
3. Procedures and/or mechanisms are in place that ensure that personnel who supervise work
have competence commensurate with their responsibilities.
4. Procedures and/or mechanisms are in place that ensure that personnel performing work are
competent to safely perform their work assignments.
APPROACH:
Record Review: Review facility or activity manuals of practice that define roles and
responsibilities of personnel responsible for safety. Review position descriptions and other
documentation that describe roles and responsibilities related to ensuring safety is maintained.
The review should consider personnel in line management and staff positions and should
evaluate whether line managers are responsible for safety. Review the procedures established
to ensure that managers and the work force is competent to safely perform work. Review the
records of qualification and certification as applicable.
Interviews: Interview selected personnel at all levels of facility or activity management who
are identified by the record review above. Verify their understanding and commitment to
ensuring that safety is maintained for all work at the facility or activity. Interview a selected
number of supervisors and workers (see definition) to determine their understanding of
competency requirements and their commitment to performing work safely.
Observations: Observe scheduled activities that demonstrate that clear roles and
responsibilities are established and understood, that line managers are actively involved with
decisions affecting safety, and that managers and workers are competent to perform their
duties. Activities such as weekly planning meetings, plans of the day, event critiques, safety
training, and safety meetings are typical events that may provide good examples of the safety
training and decision making process.
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OBJECTIVE
MG.3 An integrated process has been established that ensures that mechanisms are in place to
ensure continuous improvements are implemented through an assessment and feedback process,
which functions at each level of work and at every stage in the work process. (CE II-5)
CRITERIA:
1. Procedures and/or mechanisms are in place and utilized by personnel to collect feedback
information such as self assessment, monitoring against performance objectives, occurrence
reporting, and routine observation. Personnel assigned these roles are competent to execute
these responsibilities.
2. Procedures are in place that develop feedback and improvement information opportunities
at the site and facility levels as well as the individual maintenance or activity level. The
information that is developed at the individual maintenance or activity level is utilized to
provide feedback and improvement during future similar or related activities.
3. Procedures and/or mechanisms are in place and utilized by managers to identify
improvement opportunities. Evaluation and analysis mechanisms should include processes for
translating operational information into improvement processes and appropriate lessons
learned.
4. Procedures and/or mechanisms are in place and utilized by managers to consider and
resolve recommendations for improvement, including worker suggestions.
Section 41
5. Procedures and/or mechanisms are in place, which include a process for oversight that
ensures that regulatory compliance is maintained.
APPROACH:
Record Review: Review the performance monitoring documentation for the feedback and
continuous improvement process. This should include such documents as occurrence reports,
shift orders, deficiency reports, post-job reviews, safety observer reports, employee concerns
programs, and reports of self assessments. Review procedures for work to determine that
adequate feedback and improvement mechanisms are in place at the individual maintenance or
activity level. Review actual data from these processes to evaluate the effectiveness of the
implementation of these mechanisms.
Interviews: Interview personnel responsible for administering the feedback and continuous
improvement progress. This should include personnel such as those responsible for
occurrence reporting, lessons learned preparation, shift orders preparation, worker concerns
program, self assessment, and oversight. Interview personnel responsible for capturing and
utilizing feedback and improvement information during individual maintenance or other work
activities.
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Observations: Observe development and utilization of feedback and continuous improvement
activities. This should include such things as conducting post-job critiques, monitored
evolutions, post ALARA reviews, conducting a self-assessment or independent assessments,
etc.
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OPERATIONS (OP)
OBJECTIVE
OP.1 An integrated process has been established and is utilized to effectively plan, authorize and
execute the identified work for the facility or activity. (CE II-4)
CRITERIA:
1. Procedures and/or mechanisms are in place to ensure that work planning is integrated at
the individual maintenance or activity level fully analyzes hazards and develops appropriate
controls.
2. Procedures and/or mechanisms are in place which ensure that there is a process used to
confirm that the facility or activity and the operational work force are in an adequate state of
readiness prior to authorizing the performance of the work.
3. Procedures and/or mechanisms are in place which ensure that there is a process used to
gain authorization to conduct operations.
4. Procedures and/or mechanisms are in place which ensure that safety requirements are
integrated into work performance.
5. Procedures and/or mechanisms are in place which ensure that adequate performance
measures and indicators, including safety performance measures are established for the work.
6. Workers (see definition) actively participate in the work planning process.
7. Procedures and/or mechanisms demonstrate effective integration of safety management.
APPROACH:
Record Review: Review documents and/or mechanisms that govern the process for planning,
authorizing, and conducting work with emphasis on the individual maintenance or activity
level. Evaluate the adequacy of the division of responsibilities, worker involvement, and
work authorization process. Review the performance measures and performance indicators
established to determine that these tools provide information that is truly a direct indicator of
how safely the work is being performed. Review the mechanisms used to prepare
authorization agreements and protocols. Review these documents to determine if they are
adequate, that they demonstrate effective integration, and that proper procedures were
followed to prepare, review, and approve them.
Section 42
Interviews: Interview personnel responsible for authorizing, performing, and measuring the
performance of the work. This should include personnel such as those responsible for
preparing and maintaining documents such as the Plan of the Day (POD), equipment status
files, pre-job briefings, and the conduct of facility or activity operations. Interview personnel
responsible for development of maintenance or individual activity procedures and controls.
Verify adequate worker involvement at each step of the process.
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Observations: Observe the actual authorization and performance of work activities. This
should include such items as pre-job briefings, authorization by the managers to proceed,
command and control of the work, review of safety requirements, etc. Observe work hazard
identification activities. This should include such things as validation of procedures,
procedure tracking, compensatory measures determination, etc.
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SUBJECT MATTER EXPERT INTERACTIONS
The following CRAD should be adapted as required and utilized by subject matter experts (SME)
to assess whether the core functions and guiding principles of ISMS are met for the control of
work within the specified discipline. Specific disciplines that have proven useful in past
verifications include:
C Criticality Safety
C Fire Protection
C Industrial Hygiene and Safety
C Radiation Protection
C Security
C Training and Qualification
C Maintenance and Work Control
C Quality Assurance
C Configuration Management
C Environmental Compliance (including pollution prevention/waste minimization)
The evaluation of the maintenance and work control should be considered in every verification
since this discipline normally demonstrates the essence of safely conducting work.
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SUBJECT MATTER EXPERTS
OBJECTIVE
SME.1 Within the individual subject area the planning of work includes an integrated analysis of
hazards and development and specification of necessary controls. There is an adequate process
for the authorization and control of work and a process for identifying opportunities for feedback
and continuous improvement. Within the individual subject area, line managers are responsible
for safety; clear roles and responsibilities have been established; and there is a satisfactory level of
competence. (CE II-2, CE II-3, CE II-4, CE II-5, CE II-6)
CRITERIA:
1. Procedures and/or mechanisms for the individual subject area require adequate planning of
individual work items to ensure that hazards are analyzed and controls are identified.
2. Procedures and/or mechanisms for the individual subject area contain clear roles and
responsibilities. The individual subject area is effectively integrated with line support
managers to ensure that line managers are responsible for safety.
3. Procedures and/or mechanisms for the individual subject area require controls to be
implemented, that these controls are effectively integrated, and readiness is confirmed prior to
performing work.
4. Procedures and/or mechanisms for the individual subject area require that personnel who
are assigned to the subject area have a satisfactory level of competence.
5. Procedures and/or mechanisms for the individual subject area require that within the
subject area feedback and continuous improvement results.
Section 43
APPROACH:
Record Review: Review the manuals of practice and selected records that define the
procedures and interactions required for the subject area at the facility or activity. Assess the
adequacy of the documents to meet the criteria above and determine that the individual
subject area is effectively integrated into the facility or activity procedures. Review any
lessons learned that provide an opportunity to assess that lessons learned have been
effectively used within the subject area. Review training records of personnel in the subject
area to determine that they meet competency standards.
Interviews: Interview personnel and responsible managers in the subject area assigned.
Interview line managers to assess the establishment of clear roles and responsibilities and the
understanding of the support provided to line managers. Interview personnel assigned to the
subject area to assess the level of competence.
Observations: Observe events such as the development of a procedure, development of a
hazards analysis such as a radiological work permit or job hazard analysis, or the approval
process for an individual work item, which includes interactions with personnel of the subject
area.
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Appendix 4
Sample Approval Authority
Letter of Appointment to the Team Leader
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INTENTIONALLY BLANK
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Approval Authority Expectations and Scope for the Review
The Approval Authority should discuss the expectations for the ISMS verification in the
appointing letter to the Team Leader. The discussion should define both the expectations of the
Approval Authority and the scope of the review. With a thorough description of the
assumptions, limitations, and the scope of the review, the probability the review will meet the
expectations of the Approval Authority is increased. The following subjects or information
should be considered for inclusion with the appointing letter:
a. A description of the activity to which the ISMS verification applies, or to which the
review is to be limited. This might include an entire site, one or more specific facilities, or
an activity within a facility.
b. A discussion of the background and historical perspective of the ISMS at the site or
facility in question. The discussion should include the maturity of the ISMS and the
adequacy of the existing ISMS and the status of implementation. In some cases, the
ISMS may be very mature and implementation thought to be complete. In other cases,
the ISMS may be newly developed and not yet implemented, as for a new facility that is
not yet completed. This background and historical perspective will help in defining the
scope of the ISMS verification.
c. Whether the review is to be a Phase I or Phase II or a combined Phase I and II, and
whether it is expected that the review will occur in segments.
d. A definition of the scope or focus of the review. For a Phase I review, the scope could be
limited to an ISMS that is developed but not yet implemented. Or, the review could
involve a review of facilities that have a mature safety management system already in
place, that has been routinely evaluated by readiness and operational reviews. In the
second case, the scope of the review could be limited to responses to issues identified in
previous reviews and to changes since the previous reviews. However, an ISMS review
should never simply be a validation of a plan for a future ISMS. That is, the verification
must review the ISMS Description and implementing program requirement documents.
Similarly, a Phase II review might include all aspects of an implemented ISMS, or only
those areas that were not considered in a recent independent review such as an ORR or an
EH Assessment.
Section 44
e. The information provided by the Approval Authority to the contractor that specifies the
dates for submittal, discussion, and reviews of the system and the guidance on
preparation, content, review, and approval of the system. This information could be in the
form of an attachment or a reference.
f. If the verification is to be a Phase II review, the report from the Phase I review and the
direction from the Approval Authority to the contractor concerning implementation of the
ISMS should be discussed or attached.
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g. The Approval Authority should specify the deliverables of the review. The letter may
specify a report documenting the process and the results, or only a summary of the results.
Either should require a recommendation for future action.
h. The prerequisite conditions that the Approval Authority considers necessary before the
verification may commence. The prerequisites should be specific and measurable to
minimize any confusion as to what is expected. Effective prerequisites which have been
used in past verifications include:
For Phase I Verifications
C The ISMS Description has been formally submitted
C Corporate/Site manuals of practice supporting the ISMS Description are
available for review
C Authorization Agreements (draft/approved) are available for review
C ISMS Verification Team Leader has been appointed, team has been designated
and trained, and ISMS Verification Review Plan has been approved and
promulgated
For Phase II Verifications
C The ISMS as described in the approved ISMS Description has been
implemented
C ISMS Verification Team Leader has been appointed, team has been designated
and trained, and ISMS Verification Review Plan has been approved and
promulgated
i. There should be a discussion of previous reviews that could affect the scope of the
verification. Examples of reviews that may affect the scope of a review include a previous
ORR, a SAR review and associated SER, or the implementation of Work Smart
Standards or Enhanced Work Planning programs. The Approval Authority should define
the amount of consideration to be given to each of these previous reviews or assessments.
j. The estimated date or commitment for the verification with recognition that the review
will not be started until the prerequisites have been achieved.
k. Any additional information useful to the designated Team Leader for meeting the
expectations of the Approval Authority.
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Sample Letter of Appointment to the Team Leader
The following sample letter provides an example and discussions of elements of the letter of
appointment. It illustrates a way in which the Approval Authority could pass the expectations for
the ISMS verification to the Team Leader. For this example, a fictitious site, XYZ, is used. For
purposes of demonstrating as many options as possible, the site contains many different types of
conditions and hazards. Each Approval Authority should prepare the Appointing Letter to
address the particular situation that exists at the site, facility, or activity for which the verification
is intended.
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SAMPLE
AA ORGANIZATION LETTERHEAD
Date
FROM: Approval Authority (Name or title as appropriate)
TO: Selected Team Leader by name and position
In accordance with the requirements of the DEAR, the FRAM [ specify FRA document], and the
associated contract for operation of Site XYZ [ specify the site or facility] you are selected to be
the Team Leader for the Phase II ISMS verification. [ specify the phase or phases for which this
designation applies]
Section 45
1.0 Description of Facility/Activity: The review will verify the implementation of the ISMS for
operation of all facilities and activities within Site XYZ (XYZ).
2.0 Background and History: The maturity of the ISMS vary among the individual facilities at
XYZ. The contractor's ISMS Description, that was submitted and approved, indicated that four
of the facilities will continue to use the existing SARs, two will use existing BIOs, and the final
two will operate according to an approved set of standards (Work Smart Standards). All
facilities and activities have approved Authorization Agreements. The contractor's ISMS
Description identifies that the site integrated budget and schedule process and the sitewide
maintenance, radiological controls, and emergency management programs will be utilized at all
facilities and activities. The contractor's ISMS Description was approved following the Phase I
ISMS verification. The ISMS Description, as well as the Phase I ISMS verification report and
recommendations, are included as enclosures to this letter.
3.0 Phase II ISMS Verification: You are appointed as the Team Leader for the Phase II ISMS
verification for XYZ. The scope and special considerations of the review are discussed below.
4.0 SCOPE and Special Considerations for the Phase II ISMS Verification: The purpose of
this review is to verify satisfactory implementation of the ISMS Description that was submitted
by the contractor and approved as a result of the Phase I ISMS verification. Many aspects of
XYZ's ISMS are mature and have been the subject of previous implementation reviews. These
reviews should not be repeated as previously identified deficiencies of those reviews should have
been adequately resolved. Several internal programs (e.g., maintenance, environmental
compliance, and calibration control) are mature and have been determined to be satisfactory by
previous independent reviews. These programs are included within this review only to the degree
necessary to ensure ISMS has been expanded into the new facilities at XYZ. The following
specific guidance is provided:
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Facility: Special considerations for review:
XYZ 1 XYZ 1 continues to operate in accordance with an approved SAR. Satisfactory readiness
to conduct operations was verified by an ORR two years ago. Operations since startup
have been satisfactory.
The scope of the review should be limited to evaluating corrective actions for ORR
findings and the adequacy of the self-assessment program specified in ISMS.
XYZ 2 XYZ 2 continues to operate with an approved BIO. Operations at XYZ 2 were
independently evaluated within one year. Periodic EH assessments indicate weakness in
the radiological controls program. Several recent occurrences raise questions about the
adequacy of radiological controls.
The scope of the review should be limited to evaluating corrective actions for the EH
assessment, verifying the adequacy of the self-assessment program, and a reviewing
the radiological controls program within XYZ 2.
XYZ 3 XYZ 3 is in the final stage of construction. A SAR is being prepared. Readiness to
commence operations will be verified by an ORR in the next fiscal year. Construction
safety programs are in accordance with OSHA requirements and project management
programs are in accordance with DOE Order 4700.1, as specified in the ISMS.
Section 46
Verifying satisfactory implementation of Construction Safety and project
management programs are within the scope of this review. The contractor's self
assessment program should also be evaluated to determine whether it is consistent
with the ISMS.
XYZ 4 All program work within XYZ 4 has been completed. The facility is scheduled for D&D
in two fiscal years. Some spaces within XYZ 4 are in use as office and storage space.
One vault is used to store low level mixed radiological waste in accordance with a site
RCRA Part B permit. A recent sitewide RCRA compliance inspection verified the
implementation of the RCRA permit was satisfactory. Due to the limited inventory of
material, XYZ 4 is a radiological facility. Previous facility representative reports indicate
that radiological controls may be deficient.
The scope of the review should be limited to the fire protection aspects of
housekeeping as well as adequacy of radiological controls within the storage areas.
The self assessment program established by the part time Facility Manager should also
be evaluated.
XYZ 5 XYZ 5 is a low hazard, non-nuclear facility with limited chemical hazards and is being
operated by a sub contractor. All work is controlled in accordance with OSHA
requirements. Your verification efforts should include a review of the responses to a
recent review by my OSHA compliance office and the implementation of ISMS by the sub
contractor.
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XYZ 6 The same as XYZ 2 except that radiological controls are satisfactory. Your review need
not go beyond a general review of radiological controls.
XYZ 7 The same as XYZ 4 except that the RCRA compliance inspection identified several areas
of concern. The scope of the verification for XYZ 7 should therefore, include a follow up
of the issues identified during the RCRA inspection.
XYZ 8 XYZ 8 is a new facility that will be starting operations within one month. It is a Hazard
Category 2 facility. An ORR will be conducted to authorize the start of operations.
Therefore, only those aspects of the ISMS for XYZ 8 that are outside of the scope of
the ORR should be included. These include programmatic and budgetary control
procedures that were identified in the ISMS.
The following special considerations apply to the Phase II ISMS verification for the infrastructure
programs, which are described as follows:
Maintenance: The ISMS Description indicates that the site maintenance program is mature and
will be continued across XYZ. A recent Headquarters' Maintenance evaluation determined the
program was satisfactory. Therefore, the verification need not include a review of the
maintenance program except for XYZ 4.
Emergency Preparedness : Same as Maintenance.
Radiological Controls: Recent staff assessments, as well as the contractor's self assessments and
recent occurrence reports, raise questions as to the adequacy of the radiological controls program
at XYZ. Consequently, the scope of this Phase II ISMS verification should include a thorough
review of the radiological controls program at XYZ as well as the implementation of radiological
controls procedures within each facility at XYZ.
DOE Implementation of ISMS: The scope of your review should include verifying that the ISMS
responsibilities for my staff have been implemented. These responsibilities are defined in the
Manual of Safety Management Functions, Requirements, and Authorities (FRA).
The review should be limited to the implementation aspects of the XYZ ISMS including:
Section 47
C preparation and approval of mission assignments and program guidance,
C allocation of adequate resources to support the mission and safety responsibilities,
C approval of hazards analysis and identified controls,
C adequacy of guidance provided to staff regarding the safety management system, and
C participation of staff in feedback and improvement mechanisms including verifying
contractor performance and evaluating the performance of the ISMS.
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5.0 Phase II ISMS Verification Letter of Appointment: You should prepare an ISMS
verification review plan for my approval, select and train the team, and confirm readiness to
conduct the verification. The following documents to assist you in the determination of the scope
of your review are attached: the contractor's ISMS Description; the Report of the Phase I ISMS
verification with recommendations; and direction to the contractor concerning implementation of
the ISMS.
6.0 Desired Deliverables from the review: The Phase II ISMS verification team should
document the review with a report written in accordance with the guidance of Appendix 7 to the
ISMS verification Process Team Leader’s Handbook. The report should include any
recommended actions that the team considers necessary or desirable to ensure work is done
safely.
7.0 Prerequisites for Phase II ISMS Verification: The ORR for XYZ 8 must be completed.
In addition, the conditions discussed in my letter that approved the contractor's ISMS Description
concerning implementation of new or modified programs must be met. The contractor will
provide written confirmation when the conditions discussed in the ISMS approval letter have
been met.
8.0 Reviews that reduce the scope of the Phase II ISMS Verification: The following reviews
should be considered as indicated to reduce or modify the scope of the verification for XYZ:
1. At Headquarter's direction, a sitewide evaluation of the maintenance program was
completed six months ago. Few deficiencies were noted and the program was determined
to be in compliance with ISMS. The sitewide maintenance program should be excluded
from the scope of your review except as noted above.
2. The areas that were reviewed during the ORRs at XYZ 1 and XYZ 8 should not be
repeated. Satisfactory resolution of ORR findings should be evaluated. For XYZ 1, the
contractor self assessment program, as well as the assessment program by the assigned
Facility Representative should be evaluated.
3. The sitewide RCRA Compliance inspection determined that conditions were in
accordance with the applicable CFR and the Permit. This area should not be included in
the review beyond an assessment of the adequacy of the management of the issues
identified by the review.
4. EH completed an assessment of XYZ 2 and XYZ 6 nine months ago. Areas that were
evaluated by that review should not be repeated in the Phase II ISMS verification beyond
a verification of the adequacy of the contractor's management of the issues, which were
raised by the EH assessment.
9.0 Estimated date for Commencement: The Phase II ISMS verification should commence as
soon as possible following the ORR of XYZ 8 and following the contractor's verification that the
implementation of the ISMS has been completed.
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Section 48
10.0 Point of contact: The point of contact for the Phase II ISMS verification is J. S. Jones
[name of point of contact]. Copies of all the documentation and reports discussed above are
available and will provide additional information to assist you in determining the details of the
specific scope of the verification at each facility within XYZ. Copies of recent occurrence
reports applicable to each XYZ facility are also available through J. S. Jones. Review that
documentation prior to or during the development of your Review Plan.
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Appendix 5
Phase I, Phase II and Combined Phase I/II Verification
Lessons Learned
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INTENTIONALLY BLANK
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LESSONS LEARNED
These lessons learned were developed during several pilot ISMS verifications, which were
conducted in 1997 and 1998. It should be recognized that some of these lessons may not be
directly applicable to ISMS verifications at all locations. Most of the lessons are of a general
nature however, and are expected to be of benefit across the complex as ISMS verifications are
planned and conducted. Lessons Learned are normally included in all reports of ISMS
verifications. These reports can be reviewed on the ISMS home page (http://tis-
nt.eh.doe.gov/ism).
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PHASE I LESSONS LEARNED
1. Team. The team assembled for the Savannah River Site (SRS) Phase I verification consisted
of DOE-HQ, DOE-SR, and contractor personnel who conducted the review over a four week
period. Most of the team members had recent ORR experience at SRS and were familiar with
site programs in the functional areas assigned. This team composition was adequate for a site-
wide review of this magnitude. A team with lesser experience would not be able to conduct an
effective evaluation in a similar time frame. Continuity of the team through the Phase I review
process is essential.
The following team member experience is considered beneficial in conducting ISMS verifications:
expertise in a functional area; site experience (especially familiarity and understanding of site
programs); assessment experience (Assessment, Audits, ORRs); ISMS training (knowledge of
ISMS Policy, Guide, and Verification Team Leader’s Handbook). The verification team will lack
breadth and the review will be of reduced value if the members lack a conceptual understanding
of ISMS. The ISMS training builds on the basic, conceptual understanding of ISMS that each
team member must bring to the team. The ISMS training will not ensure an adequate
understanding unless the individual team members have already reviewed the policy, FRAM, the
DEAR, and the ISMS Guide to gain an appreciation for the principles and functions of ISMS.
2. Tailoring and Functional Areas Selected for Review. Five functional areas were
established for the review. These areas were Business, Budget, and Contracts (BBC), Hazards
Identification and Standards Selection (HAZ), Management (MG), Operations and
Implementation (OI), and DOE Savannah River Site Office (DOE-SR).
Section 49
These functional areas were selected for a logical grouping of experts for the review. The
Operations and Implementation functional area was further augmented by four Subject Matter
Expert (SME) areas. Areas of SME expertise included maintenance and work control, industrial
safety/industrial hygiene, training, and radiological controls. Additional SME areas considered
but not addressed included quality assurance, criticality safety engineering, configuration
management, and environmental compliance. These areas were not sampled. This tailored
approach eliminated some potential review areas, however, these areas were not expected to
show weaknesses in the establishment of ISMS at the site. The functional areas appeared to be a
good selection and permitted a comprehensive sampling of the safety functions and guiding
principles of ISMS. Subsequent reviews have revealed that functional areas of BBC, HAZ, MG,
and DOE are generally sufficient for a Phase I verification. SME evaluations have generally been
performed in Phase II.
3. Criteria and Review Approach Document (CRAD) Development. The CRADs developed
for this verification were developed in a format similar to CRADs used for Operational Readiness
Reviews (ORRs). These CRADs permitted a thorough review of the ISMS Description. It
should be noted that the CRADs used in subsequent verifications must be individually tailored for
the site, facility, or activity.
4. Review Sequence. A four week period was established to prepare the team, conduct the
review, and prepare the report. An initial site visit by the Team Leader was conducted well
before the start of the review to meet site personnel responsible for ISMS and discuss the conduct
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of the review. Two weeks, outside of the normal review activities, were scheduled to review
operations to assist in the preparation of a recommendation to the Approval Authority concerning
Phase II activities at eleven identified priority facilities.
a. Week One/Initial Site Orientation and Team Preparations . An initial three day site visit
was used to train the team, to explain the verification methodology, and to develop the
CRADs to be used for the review. The Team Leader presented a “straw man” as a starting
point for the team. This pre-visit was also an opportunity for the team to meet the WSRC
management personnel responsible for developing the Description. The ISMS Executive
Course, developed at DOE Headquarters, was presented for the team training.
b. Week Two/ISMS Briefings and Final Preparations. A second one week period at the site
was scheduled to permit the WSRC and DOE-SR management to present an overview of the
Plan to the team. WSRC presented three and one-half days of briefings on topics relating to
the manner in which the five safety functions were addressed in the WSRC ISMS Description
and provided two facility examples of the implementation strategy. DOE-SR personnel
presented a half day session on topics germane to the DOE oversight of ISMS programs. An
outline of the schedule used for these briefings is included at the end of the Phase I Lessons
Learned. Following the four days of briefings, team members developed a list of personnel to
be interviewed and records to be reviewed. This process was effective in preparing the team
and the WSRC and DOE-SR personnel and in establishing the expectations for the review.
The following lessons learned are pertinent to the team briefing and final preparations:
Section 50
C The briefings by the contractor provide the verification team members with
information concerning the processes in place and should be made a part of every
verification effort. These briefings should be comprehensive to convince the team that
the ISMS is well understood and the efforts are integrated. (See "Content of the
Presentation" below.)
C Good communications between the team and the contractor and DOE are required so
that the presentations provide information useful to the team.
C Briefings provided for review should include information on the site's organization,
points of contact, and pertinent programs and documents.
C Guidance from the Team Leader should be provided sufficiently well in advance of the
briefings to ensure the content and format of this material is correct. See paragraph
4.b. (1) below for suggested guidance regarding content of the briefings.
C Allow sufficient time between the briefing, final preparations phase, and
commencement of the review process to permit the contractor to make all the
necessary preparations such as developing the interview schedule, assembling
documents for the team, and briefing site personnel on expectations. The one week
period allowed in this review was not sufficient. A two-week interval for this effort
would provide enough time for the contractor to develop the schedule and submit it to
the Team Leader for approval prior to the team arriving on site.
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C A presentation on the Management Systems, Programs, and processes used by the
DOE Operations Office to execute its roles and responsibilities for the ISMS functions
should be provided to the team.
(1) Content of the Presentation. The following guidance is provided for consideration in
developing and preparing for the presentation portion of the review. This information has
proven beneficial as the team enters into discussions with the contractor regarding the ISMS
and helps the team and the contractor to "hone in" on the significant issues during the
presentations and subsequent discussions of the program. It would be beneficial for the Team
Leader to provide the following information, edited as necessary, to the contractor. The
earlier in the verification process that it is provided, the greater the opportunity for productive
discussions during the presentations.
a) A description of the ISMS from the perspective of senior Contractor and DOE
leadership. Address what benefits, if any, are being achieved? How "Line
Management" executes their responsibility and what mechanisms Senior Management
uses to keep the program on track. Some discussions of the organizational roles and
responsibilities should be included.
b) An overview of the ISMS, and identification of the processes that are used to execute
the programs. This presentation should identify those guiding principles that are
useful in the execution of those processes.
c) Discussion of the process utilized for development of requirements such as Lists A
and List B, SRIDs or Work Smart Standards (WSS) and the methods to manage,
control, and verify the flowdown of those standards to actual work requirements. The
discussion should include the seamless vertical integration of the requirements from
the highest level to the most specific aspect of control of individual work items.
d) Following the overview, a more detailed look at each functional area should be
provided. Key principles identified for each function should be as described below.
Section 51
1. Define Scope.
C Discussion of the budget process.
C Definition of the work.
C Detailed presentation on process of how resources are identified and
represented.
C How tradeoffs for resources are executed at site level.
C How shortages are distributed in respect to the safety resources
C Tools (mechanisms and processes) used in each area.
2. Analyze hazards, identify controls and implement controls . Demonstrate what
process is used to execute these functions within nuclear, public, and worker
safety concerns. Demonstrate who is responsible and how the interface
between Nuclear Safety, Worker Safety, Industrial Hygiene, Radiation Control
Safety is executed. Demonstrate the process used for standards development
and change to the required standards. Demonstrate how the hazard controls,
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once identified, are put into place and how they are assessed to remain in
place.
3. Perform work. Demonstrate how the management system determines work is
ready to be preformed and how this work is monitored for safety during the
execution. What are the key control mechanisms that management uses to
ensure only properly reviewed work is accomplished?
4. Feedback. Describe how the feedback process works. Management self-
assessments, independent assessments, performance indicators, evaluations of
issues, and corrective action plans are processes that need to be described.
e) DOE line managers should present the mechanisms and processes that they use to
assist in the integration and oversight of the execution of the ISMS. The DOE
input into the Define Scope of Work from the macro (site, budget) level to the
micro (high risk maintenance on safety or process equipment) level and input
and/or approval on the hazards and control of hazards may be better integrated
into the contractor mechanism and process or it can be provided separately. DOE
processes for input and approval requirements for readiness to perform work,
processes for monitoring the work, and processes for feedback may be presented
separately or in conjunction with the contractor functional areas. A discussion of
the organization and the responsibilities as defined in the level II FRA should be
included.
f) Once these program processes have been described, the presentation should
provide an example of activity in two or three existing organizational structures at
the site that demonstrate the execution of those described processes. The example
may be a work item that includes several work activities or may be a major work
activity. The responsible organizations should describe how resources were
obtained, how the hazards were analyzed and controls were installed, how
readiness to conduct the activity was verified. It should also include how the
work was monitored and feedback was obtained. Of particular interest, is the
integration of the safety controls, for example, criticality safety, radiation controls,
and the risk trade off. These examples should demonstrate how the sub-tier
organization executes the processes and mechanisms that are described by
programmatic presentations.
g) Any principal, function, or mechanism that is thought to be useful, necessary, or
laudable to the ISMS should be presented to the team.
h) Future activities - What activities at the site will tell management about how well
the integration of safety is being accomplished. What is the forcing function to
cause integration improvement? What is the feedback and improvement
mechanism for ISM?
Section 52
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(2) General Considerations for the Presentations
a) Line Management involvement should be emphasized.
b) Areas should be presented by personnel responsible for execution.
c) The goal is to provide the mechanism, processes, and controls that management
uses to provide integrated safety management. Safety statistics on their own are
not useful to demonstrate those processes and controls. (Those statistics may be
the result of no work or layering of requirements that prevent useful work.)
d) Contractor presentations should allow for coordinated presentation of DOE
information as well. For instance, DOE involvement in the budget process may be
easily demonstrated in conjunction with the contractor rather than two separate
presentations of the material related to that topic.
e) The environment in which the presentation is conducted is important.
Presentations will be given over a period of several days. Allow the team space to
spread out notes, handouts, and references. You will provide a lot of paper,
provide space for the team to use it.
f) Make clear the difference between what is the enforced practice and new idea
testing. If the new idea will solve a deficiency in the system, then demonstrate
how the new idea (if it works) will be accepted and implemented into an
enforceable process.
g) Presentations should go to the level of detail that would convince the team that the
specific aspect of the ISMS presented is being executed in such a fashion that
further review is unnecessary.
c. Week Three/Review Process Activities . A one week period was established to
conduct the review. The review consisted of interviews, document reviews, and
observations (primarily attendance at site coordinating meetings when possible). The one
week review period was sufficient. The team was dispatched to various parts of the site
to conduct the interviews rather than having the interviewees report to a central location.
This worked well; however, most of the team had previous site experience. A team with
little site experience might be better served by establishing a central location for
interviews. Approximately 90 interviews of corporate, division, and facility level mangers
were conducted. The following lessons learned as they affect the review process are
provided:
A central Point of Contact (POC) was provided by the contractor for this review. The
involvement and effectiveness of the POC were key factors in ensuring all coordinating
functions were accomplished as requested and in a timely manner. Coordination of
interviews was a major effort. The POC’s efforts in scheduling and rescheduling
interviews were important to ensure that the necessary interviews were completed.
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C Some interviews were scheduled with multiple team members attending. This
sometimes intimidates the interviewee, but time constraints may make this
unavoidable. When possible, this practice should be avoided. The Team Leader
should insist that one team member be the interviewer. That person can collect data
for other team members as required.
C Should it be necessary for more than one team member to be involved in an interview,
team members should agree on an approach to follow prior to starting the interview.
C In the team preparation phase, team members should be briefed on proper interview
technique. For ISMS verification efforts it is important to identify the purpose of the
interview at the beginning of the interview session.
Section 53
C Do not plan interviews for the first day of the review. It is better to start the first day
of the review with the team dedicated to reviewing records. This permitted the
interview schedule to be reviewed by the team and adjusted if necessary. The team
can be more focused after reviewing the records.
C Consider assigning pagers to team members so that they may be notified promptly of
interview schedule changes.
C The contractor should provide advance information to their employees on the purpose
and expectations of ISMS. This will assist them in preparing for the interview and
review process.
C The records of program implementation should be collected and available to the team
in a central or designated location at the start of the review.
d. Facility Reviews in support of Providing a Phase II Recommendation . The Approval
Authority (Field Office Manager at SRS) directed that the Phase I activities include a review of
eleven priority facilities to provide a recommendation for an approach to be used to conduct
Phase II verifications. During a two week period outside of the Phase I review schedule,
personnel from the team conducted a two-day review of each of the eleven priority facilities. The
review included a table top presentation of the status of ISMS programs given by facility
management, a review of records (e.g., Operational Readiness Reviews, Facility Evaluation
Board Reports, EH Oversight Reports, Occurrences and pertinent facility documentation), and a
facility walkdown. The facility walkdown was conducted to provide an assessment of facility
operating and material conditions. The results of these reviews were presented to the team
during the review and formed the basis for recommended actions in Phase II. Where facilities had
recently undergone ORRs and extensive oversight, and had demonstrated safe operations,
recommendations were appropriately tailored and credit for these evaluations was given as
meeting Phase II goals. This process is considered to be effective in providing a tailored
approach to assessing actions required to meet ISMS criteria for Phase II.
(4) Week Four/Report writing and Briefings. A one week period was used to prepare the
report and to brief contractor and DOE management on the results of the review. For a site-wide
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verification, one week is considered adequate. This period is considered essential to ensure a
quality report is prepared on site before the team is released.
(5) Report. A report similar in form to an ORR Report was drafted to document the team
findings. No Form Deficiency Forms (Form 2) were used. Issues, where identified, were
highlighted in the Assessment Form. Only Assessment Forms (Form 1) were used. This worked
well. Categorizing problems in the form of “Issues,” “Concerns,” and “Observations” may be
useful.
(6) General Recommendations
a. The establishment of a site-wide ISMS Description provides the optimum opportunity for
an ISMS verification team to fully evaluate an ISMS baseline. Where it is possible to conduct
ISMS reviews on a site-wide basis, this option should be exercised. Other approaches
(facility or activity reviews) while not restricted by policy, may be more difficult to administer
and evaluate and less efficient.
Section 54
b. The ISMS verification is normally conducted in two phases. Phase I involves a review of
the ISMS Description including enabling documents and processes. Phase II involves the
acceptability of the ISMS implementation. A review of the documentation without
consideration of the implementation process is not a totally worthwhile exercise. It is
considered necessary that a review of any ISMS Description include the implementation of
that ISMS at least at the corporate or division level.
c. When tasked to conduct a two-phase review, it is important to ensure that issues affecting
implementation are appropriately relegated to Phase II. It is appropriate to provide
implementation issues to the contractor informally; however, these issues should not be made
a part of Phase I. At SRS, the ISMS was reported as implemented. During the Phase I
Review, implementation issues were routinely developed and required some rethinking to
categorize them correctly.
d. The contractor should develop and provide the ISMS verification team with key
summarized information that assists in the evaluation of the core functions and guiding
principles. Examples are:
C calendars of ISMS related events and work evolutions
C a key document locator reference
C site maps and facility layouts
C ISMS mechanism/process flow diagrams and descriptions
C organization charts, phone/fax/e-mail lists
C key roles and responsibilities at each level of the organization
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C identification rosters of key ISMS personnel
e. The ISMS verification team members should be provided individual word processing
computer disks with assessment form templates at the beginning of the review. An example
of a completed assessment form should be provided to each ISMS verification team member
to show the expected level of detail required by the Team Leader.
f. Scheduling of ISMS verification team activities should include an allowance of time for
interaction between the team members to discuss common findings, coordinate lines of
inquiry, and coordinate the flow of information.
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Example Outline of Phase I Briefings to an ISMS Verification Team
Westinghouse Savannah River Site (WSRC) ISMS Verification Overview Agenda
Duration Topic Presenter
Day 1
1100-1115 Introduction Manager, Savannah River
Operations Office (DOE-SR)
1115-1215 WSRC/ISMS Overview
Organization Roles and
Responsibilities
Executive Vice President and
General Manager WSRC
1300-1350 Planning and Budget/Annual
Operating Plan (AOP)
Site Programs/Integration
Managers (WSRC and DOE-
SR)
1400-1430 Hazard Identification/Manual
11Q
Safety Management
Programs Manager
1430-1500 Safety Analysis Overview Engineering/Nuclear Safety
Manager
1510-1600 Standard Selection-S/RID,
WSS
Regulatory Compliance
Manager
1600-1630 WSRC Procedures
Management System
Standards Department
Manager
1630-1700 Disciplined Operations/
Manuals 2S, 1Y, 4B, and E7
Operations Division Deputy
Manager
Day 2
0815-0845 Worker Safety Processes Occupational Safety and
Health Manager
0845-0915 RADCON operations RADCON Manager
0940-1045 Assessment processes
Self Assessment Integrated Safety
Management Manager
Readiness
Assessments/Independent
Oversight
Head Facility Evaluation
Board (FEB)
1100-1130 Management Evaluations Safety Management
Programs Manager
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1230-1300 Metrics/Performance
Indicators
Industrial Safety Manager
1300-1400 Division Level Planning and
Budgeting
Section 55
Operations Division Deputy
Manager (WSRC)/ Assistant
Manager (DOE-SR)
Day 3
0815-0915 Facility ISMS Discussion-
RBOF (organization,
mission, roles &
responsibilities, hazards,
standards, implementation-
CONOPS, ENG, & Maint)
Facility Operations Manager
0930-1100 RBOF (contd)-facility
assessment/oversight, facility
management evaluation,
vertical integration)
Facility Operations Manager
1200-1600 DOE-SR DOE-SR
Day 4
0815-0915 Facility ISMS Discussion-
Tritium (organization,
mission, roles &
responsibilities, hazards,
standards, implementation-
CONOPS, ENG, & Maint)
Tritium Engineering Manager
0930-1015 Tritium (contd)--facility
assessment/oversight, facility
management evaluation,
vertical integration)
Tritium Engineering Manager
1030-1200 Facility Panel Question and
Answer
1300-1600 Question/Answer Session-
General Lists, Documents for
review, interview schedule,
operations to be witnessed at
Corporate/Division level
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PHASE II LESSONS LEARNED
The following lessons learned were developed during the conduct of a Phase II verification of the
contractor’s ISMS implementation at FB-Line at the Savannah River Site. These lessons learned
apply specifically to this facility and may not be directly applicable to Phase II ISMS verifications
at other locations.
1. Team Size. A 13-member team was assembled for this verification. The team consisted of
DOE-HQ, DOE-SR, and independent contractor personnel who conducted the review over a four
day period. Most of the team members had recent ORR experience at SRS or were familiar with
site programs in the functional areas assigned. This team composition was adequate for a facility
level review of this magnitude. As in the Phase I review, the following team member experience
is considered beneficial in conducting ISMS verifications:
C Expertise in a functional area
C Site experience (especially familiarity and understanding of site programs)
C Assessment experience (Assessment/Audits/ORRs)
C ISMS training (Knowledge of ISMS Policy, Guide, and Verification Team Leader's
Handbook)
2. Functional Areas Selected for Review. The purpose of the review was to evaluate the
facility management’s ability to identify and control work, to conform to the processes for control
of operations and maintenance, and to learn from the effort. Five functional areas were
established for the review. These areas were selected:
C Define the Scope of the Work
C Feedback and Continuous Improvement
C Operations (including analyzing hazards, identify and establish controls, and perform
work)
C Maintenance (including analyzing hazards, identify and establish controls, and perform
work)
C DOE Savannah River Site Office
These functional areas were selected so that personnel having expertise in these areas could be
assigned to a logical grouping of effort for the review. The Operations and Maintenance
functional areas are the two areas used at this facility that provide a practical review approach to
determine the effectiveness of the implementation of integrated safety management. Three SMEs
were selected to provide expertise to the operations and maintenance functional areas of the
review. Two SMEs provided expertise in the areas of radiological controls and industrial
hygiene. A third SME provided expertise in the areas of criticality safety and the authorization
safety basis. The functional areas appeared to be a good selection and permitted an adequate
review of the safety functions of ISMS. Similar functional areas are recommended for Phase II
ISMS verification reviews of a nuclear facility.
Section 56
3. Criteria and Review Approach Document (CRAD) Development. The CRADs developed
for Phase II verification were developed in a format similar to CRADs used during Operational
Readiness Reviews (ORRs) and were written to address the five core safety functions. They
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were prepared so that each team member was responsible for an individual CRAD. This worked
well from the standpoint of report preparation, however, some of the team member’s findings
overlapped other functional areas. This required the use of cross references between some
CRADs. When aligning the CRADs to address the five sore safety functions, it is important to
ensure that the CRADs also adequately address the seven principles of ISMS. A technique to
accomplish this is to include specific criteria to address the principles within each CRAD. This
technique is used in the CRAD template for Phase II ISMS verifications contained in Appendix 3
of this handbook. CRADs must be individually tailored for the facility or activity reviewed.
4. Review Sequence. An initial two day team visit to the facility was conducted a week and a
half prior to the start of the review. The actual review occurred in four days, with three days
following used to prepare the report and brief contractor and DOE management.
a. Initial Team Visit. The purpose of this two day visit was to perform required team
indoctrination and training, to meet facility personnel responsible for the management of the
facility, and to discuss the conduct of the review with the facility. The two day time frame
allotted for this was marginal. Three days may be required to effectively plan for this review.
During this visit, the proposed CRADs were provided to the facility for their review and
agreements were reached on records to be reviewed, personnel to be interviewed, and
activities to be observed. The thoroughness of these preparations, as in an ORR, determines
the successful execution of the review. Should the team be composed of site personnel
exclusively, this visit may be shortened; however, it is important to assemble the team as a
group for meetings with the facility personnel. It is important to ensure the team members are
sufficiently indoctrinated that the review is not an operational assessment, but rather is a
review of the implementation of an ISMS program. As such, it is essential that team members
understand that they are to review processes such as the implementation of control systems
and the interactions among interface organizations at the facility. They should be cautioned
not to pursue deficiencies as would be appropriate during an audit. As discussed below, it is
suggested that the initial team visit precede the actual review by at least two weeks to permit
the facility to adequately prepare for the review.
b. Verification. The first day of the review consisted of presentations from the facility
concerning the process to implement ISMS. This briefing should be consistent with the
approved ISMS Description. There was also a companion briefing provided by DOE
managers with oversight responsibilities for the facility. Both the contractor and DOE were
requested to format their briefings to address the individual core safety functions of ISMS.
An outline of the schedule used for these briefings is included at the end of the Phase II
Lessons Learned. Record reviews followed these briefings. Interviews with facility and DOE
personnel were scheduled after the record reviews to permit the team to familiarize
themselves with the material presented by the facility personnel. Observations were scheduled
as time permitted and as occurring in accordance with the facility schedule.
Section 57
(1). For this review it was specified that the interviews should not start for at least a
day following the facility presentations. This is important to ensure that the facility
has an opportunity to present their ISMS and to ensure that the verification team is
focused on issues identified from the briefings. This schedule worked well.
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(2). A useful technique to enable the team to understand the approach to ISMS, is to
ask the facility managers to explain in their presentations what has changed in the
administration of the facility to support ISMS implementation. Further discussions on
the effectiveness of the results of the efforts of continuous feedback and the
effectiveness of determining root causes for problems are also useful. Reference to
any gap analysis which may have been developed during implementation is helpful.
(3). The facility should allow sufficient time to prepare for the review. It is important
that the presentations at the beginning of the review be well prepared. FB-Line did
this well. Their success can be attributed to conducting several briefing dry runs with
site personnel knowledgeable of ISMS. FB-Line personnel still felt they had
insufficient time to get ready. Site ISMS knowledgeable personnel should assist the
facility in ensuring that key site ISMS issues are understood at the facility level prior
to the Phase II verification. The facility suggested that two weeks be allowed to
prepare for the visit following the initial team visit. This appears to be reasonable.
(4). The schedule followed for this review was intense with a lot to be accomplished
in a short time. The facility had difficulty supporting the record reviews, interviews,
and observations in conjunction with normal operations. Requirements for stationing
Senior Supervisory Watches and demonstrating a newly established facility process
caused difficulties in supporting the interview schedule. While this review is not an
ORR, a review of ISMS implementation will involve the majority of facility
operations, maintenance, and support personnel. It should be recognized by the team
and the facility that the verification will significantly impact the normal routine.
5. Report. A report similar in form to an ORR Report was drafted to document the team
findings. Form 1s (Assessment Forms ) were utilized to provide results from the record reviews,
interviews, and observations. No Form 2s (Deficiency Forms) were used. Issues, where
identified, were listed in the Form 1s. The Executive Summary selected the more important
issues identified as "Noteworthy Practices" or "Opportunities for Improvement."
6. General Recommendations
a. This Phase II verification did not develop issues that were significantly different from those
identified in the Phase I review. This may be indicative of the mature safety management
infrastructure that exists at SRS. In cases where the infrastructure is less mature or just being
established, this may not always be the expected result. For verifications following the review
of a site ISMS Description, where a mature infrastructure is in place, it may be possible to
conduct the Phase II verification using established site/DOE Operations Office evaluations in
conjunction with routinely scheduled evaluations. The Facility Evaluation Board (FEB) at
SRS, which is a formally established and effective evaluation process, could conduct this
review with local DOE oversight. It would be necessary for some external review of the local
DOE office ISMS in conjunction with the facility review. This external review should only
involve one or two persons to evaluate the local DOE functions.
b. The review phase for this verification wa