Attachment_6_DSRM_Safety_and_Occupational_Health_Program_Evaluation_Guide_(May_2013).pdf

U.S. Department of the Interior Indian Affairs Office of Facilities, Environmental and Cultural Resources Division of Safety and Risk Management

Safety and Occupational Health Program Evaluation Guide

May 2013

TABLE OF CONTENTS

Introduction

Component 1: Leadership and Management

(i) Management Commitment, Involvement and Communication

(ii) Responsibility and Accountability

(iii) Financial Resources

(iv) Personnel Resources (Size and Technical Skills of Staff)

(v) Policy

(vi) Program Promotion and Recognition

Component 2: Employee Involvement

(i) Safety Committees and Councils

(ii) Program Involvement

Component 3: Hazard Recognition and Prevention

(i) Inspection, Identification and Prioritization of Deficiencies

(ii) Hazard Control and Abatement

(iii) Reports of Unsafe and Unhealthful Conditions

(iv) Process/Operational Hazard Analysis, Management of Change

Component 4: Evaluation and Analysis

(i) Program Evaluation and Assessment

(ii) Accident Analysis and Prevention

(iii) Data Analysis. Performance Metrics, Management Review/Follow-up

Component 5: Training and Awareness

(i) Mandatory SOH Training

(ii) Training for SOH Professionals (iii)Training for Collateral Duty Safety Officers and Safety Committee Members

(iv) Promotion and Awareness Programs

Component 6: Program Implementation and Operation

(i) Accident Reporting and Investigation

(ii) Industrial Hygiene and Occupational Medicine

(iii) Fire Protection and Prevention

(iv) Occupant Emergency Planning

(v) Motor Vehicles and Motorized Equipment

(vi) Contractor Safety

(vii) Procurement and Design Review

(viii) Specialized Programs and High Hazard Operations

Introduction

This Guide has been prepared to help users complete the Indian Affairs (IA) Safety and Occupational

Health (SOH) Program Evaluation Tool. Whereas the Tool provides the framework and scoring criteria to be used to evaluate an IA organization (includes Bureau of Indian Affairs, Bureau of Indian

Education, and Office of the Assistant Secretary – Indian Affairs) with respect to each of 27 specific

SOH program Elements within six broad Components, this Guide is intended to provide the users with additional insight into the types of considerations that are important during the inquiry and the evaluation processes. Overall, it is the goal of this Guide to help evaluators apply the Tool to the many diverse organizations within the IA by providing additional explanatory information, example interview questions, ideas for determining how criteria should be applied to a specific workplace, and considerations for assigning meaningful ratings for the various program Elements.

As indicated in the “Instructions for Users” section of the Tool, different organizations and workplaces may require varying approaches to the SOH evaluation as well as emphasis on different programmatic

Elements, lines of inquiry, or documents. For example, an organization or workplace with where high hazard activities are frequently performed requires a greater degree of confidence that the SOH program is effective than those that have few potential hazards. Similarly, an organization that relies heavily of contractors might require an emphasis on different programmatic Elements than one that does not. The SOH programs of these organizations can and should ‘look different’ from the perspective of the evaluator and it is a goal of this Guide to provide insight into what is necessary and sufficient with respect to the challenges faced by each organization’s SOH program. However, while the emphasis on a particular evaluation Element may differ from one Region/Office to another, each

Element should never-the-less be a part of any organization’s SOH program in order to demonstrate conformance with the IA’s SOH policies, applicable standards and regulations. That is, while what is considered an “effective program” may differ depending on the needs of the different organizations, the evaluator must look at each element and determine to what extent it meets the organizational needs identified. This Guide is intended to assist with these considerations.

This Guide is organized into the following sections:

Component: General introductory information is provided for each of the six Components.

Components are the overall groupings or categories which are comprised of a certain number of the 27 evaluation Elements. The Elements within a Component are related by common programmatic objectives. For example, the first Component, “Leadership and Management”, provides explanatory information relating to the Elements, i.e., “Management Commitment, Involvement and

Communication”, “Responsibility and Accountability”, “Financial Resources”, “Personnel Resources”, “Policy”, and “Program Promotion and Recognition”.

Element: Introductory information is provided for each element. This information summarizes and reinforces key considerations for the evaluator, as further detailed later in the various descriptive sections for that Element.

Inquiry and Evaluation Considerations: For each Element, the Handbook provides useful information that is intended to help the evaluator further understand the nature of the programmatic requirements and suggestions for how to go about determining their status within the organization being evaluated.

Information relates directly to the Tool’s SOH Program Evaluation Criteria form which must be completed by the evaluator. Included are sections for:

“Documents and Records Review”: Provides examples of the sorts of documents and records to be solicited from the organization and reviewed by the evaluators.

“Potential Interviewees”: Lists examples of various positions in the organization that would likely provide good information related to the specific Element being evaluated.

“Potential Interview Questions”: Provides example questions to discuss with the

Interviewees.

“Observations”: Identifies the types of physical observations that may help reflect the status of organization with respect to the Element in question. The evaluator should be on the lookout for these types of conditions or activities over the course of the evaluation.

“References”: Provides a listing of key resources and references with which the evaluator should be familiar.

“Ranking Criteria for this Element”: Provides suggestions for determining a quantitative ‘score’ for the various criteria indicated on the SOH Program Evaluation

Criteria form. Considerations are given which help the evaluator decide the status of organization’s SOH program with respect to rankings of “Outstanding”, “Exceeds”, “Mostly Met”, “Partially Met”, and “Not Present”.

SOH Program Evaluation Criteria Form: This form is from the Indian Affairs’ SOH Program

Evaluation Tool. The respective form for each of the Elements has been provided for reference. The completion of these forms in an accurate, consistent, and meaningful way is a primary goal of the SOH evaluation. The information on these forms serves to identify SOH program strengths and weaknesses and helps IA decision-makers determine where to focus finite resources to ensure a safe and healthy workplace.

This Guide is simply intended to be guidance. It is up to the evaluator to decide the best approach for conducting the evaluation at hand and identifying and using any information in this Guide that might be helpful.

Component 1: Leadership and Management 3

Component 1: Leadership and Management

Public Law 91-596 requires the Secretary as well as the head of each region and office to furnish their employees with places of employment that are free from recognized hazards that are causing or could cause death or serious physical harm. This is a requirement that has been reinterpreted over time to include protecting employees from all workplace hazards that could cause them harm or disrupt the continuity of operations, not just those that are serious. Most Indian Affairs (IA) senior leaders value employee SOH; however, they are faced with a number of challenges on a daily basis and can tend to focus on issues rather than outcomes. SOH hazards and concerns can be less obvious to senior managers because they may stem from longstanding workplace practices or conditions or do not tend to be issues requiring their immediate attention. This makes it easier for senior management to defer actions and assume SOH needs are being met, at least for the present.

However, only senior managers can ensure that safety becomes and is maintained as an organizational value and part of the Region/Office’s culture. Therefore, ongoing senior management engagement in the SOH program is really crucial for long-term success. Senior managers should also define the expected level of participation of managers and supervisors at other levels in the organization.

Senior management’s core beliefs about SOH are transferred through their policies, procedures, and oversight to the organization as a whole. Through delegation, Safety Managers are responsible for helping implement senior management’s SOH policies and procedures and running day-to-day program activities. With the proper authorities, Safety Managers can assume ‘on-the ground’ roles that senior leadership is unlikely to fulfill and which are fundamental to advancing organizational objectives. Overall, successful SOH programs rely on effective leadership and management and require a consistent, reinforcing commitment by senior management and Safety Managers in order to:

Visibly support the program and lead by example;

Reinforce safety in their presentations, meetings, and briefings;

Adopt the correct program indicators and milestones for measuring SOH program performance;

Provide adequate support and funding to their SOH program;

Hold their subordinate managers accountable for employee SOH; and

Ensure that SOH processes are fully integrated into the Region/Office’s core business functions.

The best SOH programs successfully integrate sound SOH policies and practices into all workplace activities, supervision, and management. The Region/Office SOH program will be less successful if it is managed independent from the management of routine business. Senior managers should establish a template that incorporates SOH management systems into the Region/Office management process at all levels of the organization. Safety should be treated just like any other important part of the

Region/Office’s business and should be incorporated into the performance measurement process as well.

Component 1: Leadership and Management 4

(i) Management Commitment, Involvement and Communication

Senior leadership must be committed to, and visibly support, the Safety and Occupational Health (SOH) program in order for it to succeed. They must also provide the motivating force that ensures an effective program and communicate the importance of occupational SOH to all. If a cultural shift is necessary to institute or maintain the SOH program, then it is essential that support, commitment, and communication be consistently provided from the very top to everyone in the organization including all levels of management, employees and their union representatives.

Individual program manager involvement is instrumental to the success of the program; however, managers often have varying levels of commitment to employee occupational SOH. For the less-than-enthusiastic manger, safety can seem like just another in a long list of tasks, or worse, a burden.

Employee occupational SOH programs can be less than successful under this kind of leadership.

These managers may need additional oversight, management systems, or technical support to carry out their occupational SOH responsibilities and institute SOH as a core value in their organization.

(1) Documents and Records Review:

(a) SOH policy documents issued by region and regional managers to provide insight into the level of management commitment to the program and the level of program implementation.

(b) Program goal documents, such as POWER goals, provide insight into the level of management’s involvement in the program and how well goals are communicated.

(c) SOH performance elements to demonstrate the level of development the SOH program has undergone.

(d) SOH awards programs to indicate the level at which management recognizes and rewards positive performance.

(e) Voluntary Protection Plan (VPP) applications to include information about the program, how it is implemented and managed. VPP applications are also good indicators of management commitment to the program and indicate places with strong employee participation.

(f) Records promoting the SOH program to include the Region/Office Director’s annual commitment statement and any other documents created by supervisors or managers.

(g) Injury and illness records, including OSHA 301/300 records and other statistical information collected by the Region/Office and to provide indicators of program performance.

(h) Workers’ compensation cost information and return-to-work programs that show how well injured workers are restored to employment provide an indication of the vitality of the program.

Coordination with the safety staff is a good indicator of management’s support of injury prevention by using all information streams in their injury prevention efforts.

(i) Senior managers and safety committee members’ SOH training and education records to show whether the required training has been provided in a timely manner. The quality of the record kept will also indicate managements’ emphasis on safety training generally

(j) “Tool box” safety briefings minutes provide records of SOH briefings given by the

Region/Office at any level in their organizations. These will indicate strong and weak areas of

SOH program implementation.

(2) Potential Interviewees:

Component 1: Leadership and Management 5

(a) Regional/Office Director will offer an opportunity to learn how involved/committed the head of the organization is to employee SOH.

(b) Mid and higher level managers will be able to discuss the program’s implementation in the areas they are responsible for. They should also be able to discuss accident trends, overall inspection results, and employee participation opportunities.

(c) Supervisors should be able to clearly articulate their SOH responsibilities, policy guidance they have received from above, and how they handle the day-to-day operation of the program.

(d) Employees should be able to explain Region/Office policies and how they are communicated.

(e) Personnel assigned to implement and maintain SOH program should be able to discuss the origin of organizational policies, their dissemination and implementation. They should also be able to discuss the success and failure of various policies promulgated by the Region/Office.

(3) Potential Interview Questions:

(a) When did management last participate in the SOH program?

(b) Are SOH issues regularly included on the agendas of management and operational meetings?

(c) Does management follow all safety rules?

(d) Does management give visible support to the SOH efforts of others?

(e) Do managers participate in the significant aspects of the SOH program (i.e., site inspections, accident reviews, and program evaluations)?

(f) Do managers have SOH incorporated into their performance reviews?

(g) Are workplaces free of recognized hazards?

(h) Do employees follow the SOH rules of the Region/Office?

(i) Do employees use safety equipment provided by the Region/Office?

(j) Are supervisors held accountable for the SOH of their employees?

(k) Have managers established and communicated SOH goals and expectations?

(l) Does the Region/Office timely submit the required supporting material for the annual report to

OSHA?

(m) Does the Region/Office conduct self evaluations of their SOH program?

(4) Observations:

(a) SOH posters, posted memos and policy statements. Posters, policy statements and important

SOH memos should be clearly posted in a location accessible to all employees. They should be current, up to date, and, when required, signed by the appropriate authority. Employees working in the area should be able to tell the evaluator where these documents are located.

(b) Knowledge of POWER and Region/Office’s performance. At a minimum, all managers should be aware of the POWER initiative. In order to manage their SOH responsibilities effectively, supervisors should also have knowledge of POWER, and use the statistical information to improve performance

(c) SOH awards. The Region/Office should have some sort of awards program to recognize and encourage positive behavior. Conversely, there should be some sort of program to manage negative behavior as well.

(d) Attitude. Attitude, combined with performance statistics are good indicators of the level of management support and SOH program implementation in the organization.

Component 1: Leadership and Management 6

(5) References:

Public Law 91-596, Section 19(a) It shall be the responsibility of the head of each Federal agency to establish and maintain an effective and comprehensive SOH program which is consistent with the standards promulgated under section 6.

Executive Order 12196 -The head of each agency shall operate a SOH program in accordance with the requirements of this order and basic program elements promulgated by the Secretary.

29 CFR 1960.11 Each agency head shall ensure that any performance evaluation of any management official in charge of an establishment, any supervisory employee, or other appropriate management official, measures that employee's performance in meeting requirements of the agency

SOH program, consistent with the employee's assigned responsibilities and authority, and taking into consideration any applicable regulations of the Office of Personnel Management or other appropriate authority. The recognition of superior performance in discharging SOH responsibilities by an individual or group should be encouraged and noted.

29 CFR 1960.9 Employees who exercise supervisory functions shall, to the extent of their authority, furnish employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm. They shall also comply with the SOH standards applicable to their agency and with all rules, regulations and orders issued by the head of the agency with respect to the agency SOH program.

29 CFR 1960.10(a) Each employee shall comply with the standards, rules, regulations and orders issued by his/her agency in accordance with section 19 of the Act, Executive Order 12196, and this part which are applicable to his/her own actions and conduct.

29 CFR 1960.10(b) Employees shall use safety equipment, personal protective equipment, and other devices and procedures provided or directed by the agency and necessary for their protection.

29 CFR 1960.71(a) The Act and E.O. 12196 require all Federal agency heads to submit to the

Secretary an annual report on their agency's SOH program, containing such information as the

Secretary prescribes.

29 CFR 1960.71(a)(1) Each agency must submit to the Secretary by January 1 of each year a report describing the agency's SOH program of the previous fiscal year and objectives for the current fiscal year. The report shall include a summary of the agency's self- evaluation findings as required by § 1960.78(b).

(6) Ranking Criteria for this Element:

(a) Outstanding. SOH issues are regularly included on agendas of management operations meetings. Region/Office management clearly demonstrates—by involvement, support, and example—the primary importance of SOH for everyone at their worksites. Performance is consistent and sustained or has improved over time. The region has a viable workers’ compensation program. If the evaluation of this element indicates this is the case, rate this element as a 5.

Component 1: Leadership and Management 7

(b) Exceeds. Management participates in significant aspects of the SOH program, such as site inspections, incident reviews, and program reviews. Managers monitor the workers’ compensation program and use the information to better manage their SOH performance.

Management practices gain and maintain support for the occupational SOH program at all levels within the region. Incentive programs may be present. If the evaluation of this element indicates this is the case, rate this element as a 4.

(c) Met. Management follows appropriate SOH rules, and gives visible support to the SOH efforts of others. Managers and supervisors are held accountable for the SOH of their employees. If the evaluation of this element indicates this is the case, rate this element as a 3.

(d) Partially Met. Management sets and communicates SOH policy and goals, but remains detached from all other SOH efforts. If the evaluation of this element indicates this is the case, rate this element as a 2.

(e) Not Present. Management demonstrates no policy, goals, objectives, or interest in SOH issues at this worksite. If the evaluation of this element indicates this is the case, rate this element as a 1.

Component 1: Leadership and Management 8

SAFETY AND OCCUPATIONAL HEALTH PROGRAM EVALUATION CRITERIA

Safety and Occupational Health (SOH) Component: 1. Leadership and Management

Assessed Element: (i) Commitment, Involvement and Communication

SOH Section Goal(s): Leadership and management demonstrate visible support, commitment and provide a motivating force for an effective SOH program.

Leadership and management communicate SOH values throughout the Region.

Recommended Performance Metric(s): Safety topics at senior management meetings. Current SOH policy. Effective communication tools.

Interviewees: Regional Director, Agency Superintendents, Supervisors, Employees and SOH staff

Documents/Records: Documented processes that a Region has implemented in furthering its SOH program. Specific records used to evaluate conformance to

SOH regulations, mandates, DOI/IA goals and the Region’s SOH program and its effectiveness.

Observations Workplaces where physical inspections of facilities may occur but also operations where safe and efficient or unsafe and inefficient activities can be witnessed.

-SMIS Injury/Illness records/analysis -SOH policy documents -POWER goal documents -SOH performance elements

-SOH awards programs -POWER records -Workers’ comp. cost information and return-to-work programs

-Senior managers/safety committee members training and education records -“Tool Box” safety briefings minutes

-VPP applications - Records promoting the SOH program

Processes/Evaluation Criteria: (Rank 1-5)

1. Does management participate in the program? _____

2. Are SOH issues regularly included on agendas of management and operational meetings? _____

3. Does management follow all SOH rules? _____

4. Do leaders and managers give visible support to the SOH efforts of others? _____

5. Does management participate in significant aspects of the SOH program, such as site inspections, accidents, program reviews? _____

6. Is SOH a performance standard for managers and supervisors? _____

7. Are managers and supervisors held accountable for the safety and occupational health of their employees? _____ How?

8. Has management established and communicated SOH goals/objectives? _____

SOH Section Ranking ____

5-Outstanding

4-Exceeds

3-Met

2-Partially Met

1-Not Present

Component 1: Leadership and Management 9

(ii) Responsibility and Accountability

Leadership of the Region/Office must communicate and demonstrate that Safety and Occupational

Health (SOH) is the responsibility of everyone from senior management to hourly employees and that everyone will be held accountable for effectively meeting the SOH needs of their organization. Senior management must be responsible for designating an appropriate level of authority to line managers and other subordinates to implement the SOH program and provide adequate implementation tools and resources. Managers and supervisors must implement senior management’s policies and hold staff accountable to program objectives for a safe and healthful work environment.

Organizations with sound SOH programs reflect an ingrained safety culture where responsibilities are not overly concentrated on the SOH staff but are integrated across the entire organizational structure.

Regions/Offices must be able to show that responsibilities for SOH are clearly communicated to and understood by managers, supervisors, employees, contractors, vendors, etc. Every employee should be able to describe his/her role within the SOH program and understand the benefits derived from fulfilling these responsibilities as well as the adverse impacts that may result when such responsibilities are not met.

(a) Documents designating various positions with SOH duties and responsibilities. These should reflect the written programs, goals, objectives, etc. of the Region/Office.

(b) SOH related programs, manuals and management systems - These include the written SOH standard operating procedures, “vision statements”, ISO policies (if applicable), etc.

(c) Qualifications required for SOH staff.

(d) Organizational chart, budgets and job descriptions that show how authority and responsibility is distributed in the Region/Office.

(e) Performance evaluations showing specific SOH criteria for all line managers, supervisors and hourly employees.

(f) Training records of managers, supervisors, and SOH staff and committee.

(g) SOH-related excerpts from executive meeting minutes.

(h) SOH Committee meeting minutes.

(i) Performance metrics and reports showing measures of progress towards SOH objectives.

(a) Managers should be able to discuss how authorities and responsibilities are integrated into position descriptions. They should also be able to identify how SOH performance impacts decisions made about compensation, career advancement, and performance ratings.

(b) Supervisors should be able to convey how responsibilities for SOH are applied on a daily basis in their assigned area. Supervisors can explain how SOH responsibilities are taken into consideration during performance evaluations.

(c) SOH staff should be able to discuss from a very practical standpoint how SOH-related authorities and responsibilities are integrated throughout the organization and how objective, meaningful criteria are applied to performance evaluations.

Component 1: Leadership and Management 10

(d) Employees should be able to discuss their roles, responsibilities, and authorities when it comes to SOH in their given area and how they are motivated to achieve positive results and held accountable through evaluations and work reviews.

(a) What are your responsibilities for ensuring safe and healthful working conditions in your area?

How are you evaluated and held accountable?

(b) What methods are used to provide positive/negative reinforcement dealing with safety rules and work practices?

(c) What orientation and training have you received regarding your responsibilities for SOH in your work area? Is it effective? Do you have authorities commensurate with your responsibilities?

(d) Does the region provide adequate budgets and staffs to implement the SOH program at all operational levels?

(e) Do managers and supervisors have the responsibility to plan for necessary SOH staff, equipment, materials, and training? Do they have the authority to implement their plans and secure the necessary funds and resources?

(f) Does region management assign overall responsibility for implementing site SOH programs to line managers?

(g) Do line managers have authority to direct abatement of hazards that can be corrected without major capital expenditure?

(h) Do management representatives have some expertise in hazard recognition and applicable

OSHA requirements?

(a) SOH posters, posted memos and policy statements. Posters, policy statements and important

SOH memos should be clearly posted in a location accessible to all employees. They should be current, up to date, and, when required, signed by the appropriate authority. Employees working in the area should be able to tell the evaluator where these documents are located and how SOH responsibilities are part of their work.

(b) SOH awards. The Region/Office should have some sort of awards program to recognize and encourage positive behavior. Conversely, there should be some sort of program to manage negative behavior as well.

(c) Attitude. Attitude, combined with performance statistics are good indicators of the level of management support and SOH program implementation in the organization.

Executive Order 12196 - The head of each agency shall operate a SOH program in accordance

29 CFR 1960.8(a) The head of each agency shall furnish to each employee employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm.

29 CFR 1960.8(b) The head of each agency shall comply with the SOH Administration standards applicable to the agency.

Component 1: Leadership and Management 11

29 CFR 1960.8(c) The head of each agency shall develop, implement, and evaluate a SOH program in accordance with the requirements of section 19 of the Act, Executive Order 12196, and the basic program elements prescribed in this part, or approved alternate program elements.

29 CFR 1960.8(d) The head of each agency shall acquire, maintain, and require the use of approved personal protective equipment, approved safety equipment, and other devices necessary to protect employees.

29 CFR 1960.8(e) In order to provide essential specialized expertise, agency heads shall authorize

SOH personnel to utilize such expertise from whatever source available, including but not limited to other agencies, professional groups, consultants, universities, labor organizations, and SOH committees.

29 CFR 1960.9 Employees who exercise supervisory functions shall, to the extent of their authority, furnish employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm. They shall also comply with the SOH standards applicable to their agency and with all rules, regulations and orders issued by the head of the agency with respect to the agency SOH program.

29 CFR 1960.10(a) Each employee shall comply with the standards, rules, regulations and orders issued by his/her agency in accordance with section 19 of the Act, Executive Order 12196, and this part which are applicable to his/her own actions and conduct.

29 CFR 1960.10(b) Employees shall use safety equipment, personal protective equipment, and other devices and procedures provided or directed by the agency and necessary for their protection.

29 CFR 1960.10(c) Employees shall have the right to report unsafe and unhealthful working conditions to appropriate officials.

29 CFR 1960.10(d) Employees shall be authorized official time to participate in the activities provided for in section 19 of the Act, Executive Order 12196, this part, and the agency SOH program.

OSHA Instruction FAP 2.1B June 19 1989 - Instructions for evaluation of Federal agency SOH programs.

(6) Rating Criteria for this Element:

(a) Outstanding. Responsibility for SOH is clearly defined by top management and has been communicated in writing to all employees. A culture of safety is valued and evident throughout all levels of the organization. All employees are actively engaged in fostering a safe workplace for themselves and their coworkers and take personal responsibility and initiative. Managers and supervisors are delegated with appropriate levels of authorities commensurate with their responsibilities. Adequate funds and resources are provided to ensure an effective SOH program. All employees are provided orientation/training in their SOH roles and responsibilities within 45 days of employment. There is documented evidence that

Component 1: Leadership and Management 12 managers, supervisors, and employees are held accountable for SOH through a fair, consistent and unambiguous performance evaluation system. There is an award system in place. Safety goals and objectives are included in all performance evaluations. If the evaluation of this element indicates this is the case, rate this element as a 5.

(b) Exceeds. Responsibility for SOH is defined by top management and has been communicated in writing to all employees. A culture of safety is valued and evident throughout the majority of the organization. Most employees are actively engaged in fostering a safe workplace and take personal responsibility and initiative. Managers and supervisors are delegated with appropriate levels of authorities commensurate with their responsibilities. Adequate funds and resources are provided. All employees are provided orientation/training in their SOH roles and responsibilities. Managers, supervisors, and employees are held accountable for the effectiveness of the SOH program. Safety goals and objectives are included in most performance evaluations. If the evaluation of this element indicates this is the case, rate this element as a 4.

(c) Met. Responsibility for SOH is defined by top management and has been effectively communicated, albeit not always in writing. A culture of safety is valued and embraced by the majority of the organization. Managers and supervisors have the responsibility to ensure an effective SOH program but do not always have the adequate authority or funding/resources to implement desired improvements in a timely manner. Most employees are eventually trained in their SOH responsibilities but this is not always a priority. Most managers, supervisors, and workers know what SOH performance is expected of them, and they understand how the system of incentives and adverse consequences affects them and their performance ratings. If the evaluation of this element indicates this is the case, rate this element as a 3.

(d) Partially Met. Responsibility for SOH is defined by top management but is not widely shared with employees. Managers and supervisors often do not have the responsibility, authority, or adequate resources to ensure an effective SOH program. Employee orientation on SOH responsibilities is not a priority. Many employees lack understanding of personal responsibility for keeping themselves, coworkers, and equipment free from mishaps. There is little, if any, incentive for employees or the organization as a whole to meet SOH performance standards. A safety culture is not being fostered. Many managers, supervisors, and workers do not know what SOH performance is expected of them, and they lack an understanding of the system or rewards and corrections associated with evaluation of performance. Safety goals and objectives are not consistently addressed in performance evaluations. In general, the management systems for SOH-related responsibilities and accountabilities are not well defined, established, or implemented. If the evaluation of this element indicates this is the case, rate this element as a 2.

(e) Not Present. Responsibility for SOH is not well defined by top management. Managers, supervisors, and workers do not know what SOH performance is expected of them. SOH responsibility is not spread throughout the organization. There is no documented evidence that mangers, supervisors, and employees (hourly) are held accountable for SOH. There are no rewards in place if performance standards are met. Safety goals and objectives are not included in performance evaluations. If the evaluation of this element indicates this is the case, rate this element as a 1.

Component 1: Leadership and Management 13

Safety and Occupational Health (SOH) Component: 1. Leadership and Management

Assessed Element: (ii) Responsibility and Accountability

SOH Section Goal: Top management shall provide leadership and assume overall responsibilities for: (a) Implementing, maintaining, and monitoring performance of the Safety and Occupational Health Management System (SOHMS); (b) Providing appropriate financial, human, and organizational resources to plan, implement, operate, check, correct, and review the SOHMS; (c) Defining roles, assigning responsibilities, establishing accountability, and delegating authority to implement an effective SOHMS for continual improvement; and (d) Integrating the SOHMS into the organization’s other business systems and processes. Employees shall assume responsibility for aspects of health and safety over which they have control, including adherence to the organization’s health and safety rules and requirements.

Recommended Performance Metric(s): Written policies are in place and implemented

Interviewees: Regional Director, Agency Superintendents, Supervisors, Employees and SOH staff

Documents/Records: Documented processes that a Region has implemented in furthering its SOH program. Specific records used to evaluate conformance.

Observations Workplaces where physical inspections of facilities may occur but also operations where safe and efficient or unsafe and inefficient activities can be witnessed.

-Documents designating various positions with S&H duties and responsibilities -SOH program/ manual -Qualifications for SOH staff

-Organization chart, budgets, and job descriptions -Manager, Supervisor, SOH staff and Committee training records

-SOH excerpts from executive meeting minutes, -SOH committee meetings minutes

-Meetings -Verification of S&H authority at appropriate levels

Processes/Evaluation Criteria: (Rank 1-5)

1. Has the Director selected a Safety and Occupational Health Manager with sufficient authority and responsibility to represent the Region interest and support of the SOH program? _____

2. Do Regional SOH staff report directly to, or have appropriate access to, the Director, in order to carry out the responsibilities under this part? _____

3. Does the Region provide adequate budget and staff to implement the occupational SOH program at all operational levels? _____

4. Are managers and supervisors delegated at each appropriate level with sufficient authority and responsibility to plan for and assure funds for necessary SOH staff, equipment, materials, and training required to ensure an effective occupational SOH program? _____

5. Does Regional management assign overall responsibility for implementing site SOH programs to line managers? _____

6. Do line managers have authority to direct abatement of hazards that can be corrected without major capital expenditure?

7. Do management representatives have some expertise in hazard recognition and applicable OSHA requirements? _____

8. Does the organizational structure facilitate open communication across their organization and especially between managers and safety staffs in the field and at their national office? _____

SOH Section Ranking ____

5-Outstanding

4-Exceeds

3-Met

Component 1: Leadership and Management 14

(iii) Financial Resources

Commitment to a fully-functioning Safety and Occupational Health (SOH) program requires that management adequately fund the program with financial and capital equipment resources. Funds are necessary for sufficient staffing, space, equipment, training, and special contingencies (emergencies, etc.). Without adequate financial resources, staff cannot perform their tasks responsibly and the SOH program cannot be administered effectively. The organization’s budget and capital expenditures plan must reflect input from SOH personnel.

(1) Documents and Records Review:

(a) Documented budgeting processes that a region has implemented to identify SOH program needs and commensurate costs.

(b) Records which reflect the effectiveness of the existing SOH program (e.g., evaluations of conformance to IA’s SOH regulations, mandates, and goals) and identify problem areas which may stem from a lack of financial resources (e.g., root cause investigations pointing to lack of resources as a cause of a mishap).

(c) Budget and expense reports; Green Book submittals; and abatement costs.

(d) Where capital expenditures are not adequate due to budget constraints, documented evidence that bona fide attempts have been made to improve the capital expenditure budget in order to improve SOH relating to conditions and equipment.

(e) Reports of backlogs in preventative maintenance or hazard correction activities due to lack of resources.

(a) Managers should be able to discuss the specifics of their available financial resources, how they are allocated, budget consistency from year to year, and the rationale behind any significant SOH budget increases/decreases and how such changes affected SOH effectiveness.

(b) Supervisors should be able to discuss how resources are used to administer the program.

(c) SOH staff should be able to provide details about their role in implementing the program as well as the adequacy of resources (past, present and future).

(d) Employees should be able to explain how they are provided the opportunity to provide input with regards to the budget, PPE, etc., and whether it appears that adequate financial resources are brought to bear for the SOH program.

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(a) Does the Secretary/Director ensure that the agency budget submission includes appropriate funds for effective implementation and administration of the agency’s SOH program?

(b) For Supervisors, has upper management consistently provided adequate funding for SOH programs?

(c) Do line managers have authority to order/purchase SOH equipment?

(d) Are safety supplies provided/available when they are needed, e.g. personal protective equipment?

(e) Describe the adequacy of the financial resources and capital expenditures for SOH. Are special and emergency needs anticipated and addressed in the SOH budget?

(a) Investigators should make a physical inspection of areas, operations and facilities where workplace activities/conditions can be witnessed. Emphasis should be placed on observing

SOH equipment supply areas (first aid areas, PPE, etc.) to determine if adequate resources appear to be available.

29 CFR 1960.7(a) The head of each agency shall ensure that the agency budget submission includes appropriate financial and other resources to effectively implement and administer the agency's SOH program.

29 CFR 1960.7(b) The Designated Agency SOH Official, management officials in charge of each establishment, SOH officials at all appropriate levels, and other management officials shall be responsible for planning, requesting resources, implementing, and evaluating the SOH program budget in accordance with the regulations of the Office of Management and Budget Circular A-11

(sections 13.2(f) and 13.5(f) and other relevant documents.

29 CFR 1960.7(c) Appropriate resources for an agency's SOH program shall include, but not be limited to:

1960.7(c)(1) Sufficient personnel to implement and administer the program at all levels, including necessary administrative costs such as training, travel, and personal protective equipment;

1960.7(c)(2) Abatement of unsafe or unhealthful working conditions related to agency operations or facilities;

1960.7(c)(3) SOH sampling, testing, and diagnostic and analytical tools and

1960.7(c)(4) Any necessary contracts to identify, analyze, or evaluate unsafe or unhealthful working conditions and operations;

1960.7(c)(5) Program promotional costs such as publications, posters, or films; and

1960.7(c)(6) Technical information, documents, books, standards, codes, periodicals, and publications.

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(a) Outstanding. Management provides resources to all responsible parties so that assigned responsibilities can be met. Financial records reflect liberal funding for the SOH programs and allows for fluctuations in need and contingencies. There is an effective process in place and employees are aware of the process for acquiring necessary equipment and supplies. Repairs and maintenance related to safety are fully funded and completed on time indicating fully sufficient resources. If the evaluation of this element indicates this is the case, rate this element as a 5.

(b) Exceeds. Management provides resources to responsible parties so that assigned responsibilities can be met. Financial records reflect adequate funding for SOH programs. Employees are aware of the process for acquiring necessary equipment and supplies. Repairs and maintenance related to safety are adequately funded. If the evaluation of this element indicates this is the case, rate this element as a 4.

(c) Met. Management provides resources to responsible parties so that assigned responsibilities can be met. Financial records reflect adequate funding for SOH programs but some delays or inadequacies in obtaining resources have been reported. Most, but not all, employees are aware of the process for acquiring necessary equipment and supplies. Repairs and maintenance related to safety are generally funded without delay. If the evaluation of this element indicates this is the case, rate this element as a 3.

(d) Partially Met. Management provides resources to responsible parties so that most but not all assigned responsibilities can be met. Financial records reflect some funding for SOH programs but resources/funding fluctuate and are often difficult to obtain in a timely manner. Few employees are aware of the process for acquiring necessary equipment and supplies. Repairs and maintenance are sometimes deferred due to funding issues. If the evaluation of this element indicates this is the case, rate this element as a 2.

(e) Not Present. Management does not appear to provide adequate resources to responsible parties, so that assigned responsibilities can be met. Financial records reflect inadequate funding for

SOH programs. SOH budgets fluctuate significantly over time without good risk-based rationale. Employees are not aware of the process for acquiring necessary equipment and supplies. Repairs and maintenance are often deferred due to funding issues. If the evaluation of this element indicates this is the case, rate this element as a 1.

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Assessed Element: (iii) Financial Resources

SOH Section Goal(s): Employee SOH is adequately resourced.

Recommended Performance Metric(s): SOH input in budget formulation; Adequacy of resources to implement and administer the program

Interviewees: Regional Directors, Agency Superintendents, Supervisors, Employees and SOH staff

Documents/Records: Documented processes that a Region has implemented in furthering its SOH program. Specific records used to evaluate conformance to

SOH regulations, mandates, DOI/IA goals and the Region’s SOH program and its effectiveness.

Observations Workplaces where physical inspections of facilities may occur but also operations where safe and efficient or unsafe and inefficient activities can be witnessed; -Budget and Expense Reports; Green Book Submittals; Abatement Costs

1. Does the Director ensure that the Regional budget submission includes appropriate funds for effective implement and to administer the region’s occupational

SOH program? _____

2. Does the final budget actually reflect program requirements? _____

3. Do line managers have authority to order/purchase SOH equipment? _____

4. Are safety offices provided the resources goods and services (i.e., SOH sampling, testing, and diagnostic and analytical tools and equipment, including laboratory analyses, etc.) _____

4-Exceeds

3-Met

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(iv) Personnel Resources (Size and Technical Skills of Staff)

Management must commit to assembling and maintaining adequate personnel resources for workplace

Safety and Occupational Health (SOH). Personnel must be readily available in sufficient numbers and have the requisite skills, training, and authorities to accomplish assigned responsibilities and to perform necessary tasks commensurate with the hazards potentially present in the workplace. A SOH staff may need to be periodically supplemented with temporary/part time resources such as certified safety professionals (CSP), certified industrial hygienists (CIH), licensed health care professionals, consultants, and other subject matter experts, as needed.

(a) Budgets and other records that reflect the personnel resources utilized to fulfill SOH requirements currently and in the past.

(b) Evidence that personnel assigned with the responsibility for ensuring a safe and healthful workplace have full authority to shut down operations or equipment and order maintenance when necessary, are adequate in numbers and coverage, and are properly credentialed and/or trained to carry out assigned responsibilities. Such records may include organizational charts, position descriptions, employee manuals, training records, and position recruitment postings/records.

(c) Records that show SOH staff have adequate equipment and technical resources to carry out their responsibilities. Such records might include safety equipment inventories, technical journal subscriptions, etc.).

(d) Evidence SOH resources have been in place and working effectively for a significant period of time (i.e., at least one year).

(a) Managers should be able to discuss the policies, guidelines, and rationale related to staffing

SOH personnel based on the workplace facilities, operations, hazards, conditions at hand, and

SOH-related requirements.

(b) Supervisors should be able to clearly articulate the staffing requirements and whether sufficient trained and credentialed SOH personnel are available.

(c) SOH staff should be able to provide their assessment of how effective they are in implementing

SOH policies and whether staffing levels are adequate to meet the needs of the agency or region (i.e., employees, contractors, visitors, and public).

(d) Employees should be able to discuss how well the SOH staff meets the needs of their workplace, whether SOH staff, equipment and other resources are available in a timely manner to address their concerns, how frequently SOH inspections are performed, and how timely and effectively identified hazards are corrected.

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(a) Has senior management provided adequate personnel resources for the SOH program?

(b) Is supplemental technical support or resources ever needed? If so, is this support readily available?

(c)…