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(M1) Governance
Contractor Assurance


Management System Owner:  Chief Operating Officer

Revision Number:    2.5          Date:   October 1, 2019

1.0   Purpose

The Fermilab Governance Management System (M01) provides the framework for policies, procedures, and standards describing how Fermi Research Alliance, LLC (FRA) does business in order to provide assurance to key stakeholders.

The Governance Management System is the basis of the Prime-Contract-required Contractor Assurance System (CAS). This Management System governs the CAS program under the Prime Contract including work at the Fermilab site in Batavia, Illinois, and the DOE-leased areas in Lead, South Dakota.


2.0   Roles and Responsibilities

Title Responsibilities
Members of FRA, LLC
  • Owners of the LLC with interest shared between the University of Chicago and the Universities Research Association, Inc.
  • The corporate-parent Members of FRA, LLC are responsible for Contractor Assurance and Prime-Contract performance.
Laboratory Director
  • Serves as President of FRA; appointed by the Board. Accountable for Line-Management execution of work and Management System Owner assurance.
Chief Operating Officer
  • Oversees line-organization execution of work.
  • Drive operational-excellence initiative across the organization.
  • Oversees the Contractor Assurance System, which crosscuts all the lab's line organizations, and provides a meaningful summary of compliance to the FRA Board and the Department of Energy.
  • Holds Management Systems Owners accountable
Internal Audit
  • Serves as an independent and objective resource for conducting audits and providing guidance regarding internal controls.

FNAL General Counsel

  • Oversees the business ethics and compliance programs of the laboratory.
  • Responsible for monitoring deliverables required under the Prime Contract.
  • Responsible for facilitating the Prime Contract modification process.

​Head, Quality Assurance

  • Responsible for setting standards for Management System continuous improvement and Assessment Planning.
​Management System Owners
  • ​Accountable for defining and overseeing Management Systems that set expectations for work across line organization per Prime Contract requirements and other considerations.
  • Responsible for providing reasonable assurance work in line organizations are being executed per MS policies, procedures, and standards; this provision is based on data derived fro regular assessments.
  • Support a commitment to continuous improvement.
Line Management
  • Responsible for executing work according to Management System policies, procedures, and standards.
​Assurance Council
  • Responsible for overseeing the maintenance and continuous improvement of the Fermilab Contractor Assurance System.


3.0   Primary Requirements

3.1   M&O Contract

  • DOE Prime Contract No. DE-AC02-07CH11359 for the Management and Operation of the Fermi National Accelerator Laboratory (Fermilab)
  • Fermilab Performance Evaluation and Measurement Plan (PEMP)
  • All DOE orders, regulations, and statutes inherent in the M&O contract and applicable U.S. laws and regulations.

 3.2   Fermilab Performance Evaluation and Measurement Plan (PEMP)

  • Objective 4.1 – Leadership and stewardship of the Laboratory
  • Objective 4.2 – Management and Operation of the Laboratory
  • Objective 6.4, Part 1 – Provide efficient, effective, and responsive contractor assurance system

3.3    Other Required DOE Orders and Instructions

  • Annual Lab Plan

4.0   Management System Description

Fermi Research Alliance, LLC is the operator of Fermi National Accelerator Laboratory (Fermilab) on behalf of the U.S. Department of Energy under a management and operating (M&O) contract.. FRA has developed a Contractor Assurance System (CAS). The system provides reasonable assurance that objectives of the Management Systems are being accomplished and that the systems and controls are effective and efficient.

The model for laboratory success includes mission performance, compliance with requirements, and reasonable assurance about both. 

4.1   Definitions and Responsibilities

FRA organizes its mission according to lab line-management activities designed to achieve Laboratory Goals and Objectives specified in the Annual Lab Plan (the "what" of the lab mission) according to the requirements in the Prime Contract and other applicable rules and regulations (the "how" of the lab mission).  The latter is governed by the CAS program.

The Laboratory Director is responsible for both dimensions and delegates day-to-day management of the CAS to the Chief Operating Officer.  Operation of the CAS consists of several major components with clear, documented descriptions of activities.  The Operations and Finance Committee of the FRA Board of Directors has oversight of the CAS program. 

In addition to other duties, the Chief Operating Officer (COO) is accountable for line management performance and progress against laboratory goals and objectives.

Generally, a Management System (MS) is the method in which an organization manages the inter-related parts of its business in order to achieve its objectives. At Fermilab, there are fourteen management systems organized by related requirements in the FRA Management & Operating (M&O) Prime Contract which prescribe "how" the laboratory should execute its mission.

Management System Owners (MSO) are appointed owners of the management systems who are responsible for ensuring FNAL policies and procedures related to their managements systems are developed, implemented, monitored, maintained, evaluated, and improved; as such they apply across the laboratory. MSOs are responsible for the day-to-day oversight and management of the defined management systems. Their primary focus is ensuring that all elements of each management system are applied as appropriate across the laboratory in support of the mission as defined by the Annual Lab Plan.  Assessment reports are reviewed for breadth, depth and consistency, and feedback is provided to the line organizations.

The purpose of the Assurance Council (AC) is to serve as a forum to evaluate, monitor, and improve compliance with the Prime Contract Clause H.13 – Contractor Assurance System (CAS) requirements. The AC shall provide reasonable assurance to the Laboratory Director that the objectives of the CAS are accomplished, risks to achieving compliance to the H.13 clause are identified and mitigated, and the systems and internal controls are effective and efficient.

FRA Internal Audit provides independent checks and assessments of FRA's management systems using an independent team of professional, credentialed auditors.

The CAS is designed to provide assurance of the execution of work per Management System requirements at Fermilab sites including Batavia, Illinois, and Lead, South Dakota.

4.2   Framework for Policies, Procedures, and Standards

MSOs are responsible for defining policies, procedures, and standards for how work is to be executed by the line organizations according to requirements in the Prime Contract and other applicable rules and regulations.


The Governance MS will specify, oversee, and support a common approach. 


Policies shall follow a standard format, shall be reviewed at set intervals, and shall be approved following a standard process with visible demarcation of approval date and approving authorities. Policies shall be accessible to laboratory staff. Line organizations may develop processes and procedures to implement the policies set by Management Systems.

4.3   Provision of Assurance


Management Systems are required to provide reasonable assurance to the Laboratory Director; FRA, LLC.; and other key stakeholders that the objectives of the management systems are being accomplished and the systems and controls will be effective and efficient.  These assurances shall be provided in the form of scorecards updated quarterly that sample across the laboratory organization.  The grading criteria will be regularly reviewed by the Assurance Council.  The scorecards shall be shared with the DOE Fermi Site Office and the FRA corporate-parents at designated meetings of the Assurance Council. 

The MSOs are responsible for measuring and reporting on "How well are we complying with the MS?" across the laboratory on a quarterly basis using a visible, defined set of criteria. This is a critical aspect of CAS performance.

The Governance Management System provides assurance (via its scorecard) that the Management Systems are designed and implemented consistent with these intentions.  Its scorecards are updated quarterly.

4.4   Continous Improvement


One of FRA's governing principles is a commitment to continuous improvement.  As such, the CAS program as well as each of its management systems shall evolve each year to address new work, new requirements, and new expectations of performance. 

One aspect of this commitment is a periodic measure of, "Does the lab have the right set of policies and procedures in place to comply with the Prime Contract and other applicable rules and regulations?" in addition to measuring "Is the MS effective at measuring compliance across the laboratory organization?"

To meet these expectations, the MSOs are responsible for defining rolling, three-year assessment plans addressing key elements of (such as high-risk areas or the entire MS).  There shall be at least one assessment each year and an independent, external assessment at least every three years.

Improvement actions shall be tracked through Fermilab's Issues Management System ( iTrack) and visible.


4.5   Maintaining the CAS Program


The Governance Management System works with the Laboratory Director and other FRA leadership to periodically refresh Management System Owner assignments as an element of the principal commitment to "leadership circulation."

This management system also monitors the design and implementation of the CAS program and, in consultation with the appropriate stakeholders, make proposals to the DOE Contracting Officer about updates and adjustments. 

As the foundation for CAS, the Governance Management System manages and oversees changes to the CAS program and/or its Management Systems based on updates to the Prime Contract.  A formal supporting procedure is included in the MS.  In short, the DOE Contracting Officer or the National Laboratory Directors' Council (NLDC) notifies the Laboratory that certain Contract changes are being considered.  With support from the Laboratory's Office of General Counsel, these proposals are circulated to Laboratory subject matter experts.  Comments are collected and fed back to the CO or the Directives Review Board.  The Governance MSO advises the Laboratory Director on considering formally-proposed Contract changes.  Once changes are incorporated into the FRA Prime Contract, the changes are circulated to the relevant Management Systems to either update policies or revise procedures.  The Assurance Council advises on whether changes need to be explicitly communicated to line management.

Based on Prime Contract modifications, MS performance data, and/or other considerations, the Governance MSO is responsible for adjusting the CAS program and its Management Systems in coordination with the Laboratory Director / FRA President and the DOE Fermi Site Office.

5.0   Policies

6.0   Key Processes, Procedures, and Manuals (and Key Interfaces)

The Governance Management System oversees several critical processes and procedures for the Laboratory that transcend over MSs.  

6.1   Planning


The Governance Management System is maintained by the Office of the Chief Operating Officer.  It is reviewed annually by the Office as well as subject to internal and external reviews.  The Quality Section provides an independent and high-level view of opportunities for improvement.

Using data from MS Scorecards, MS Assessments, and the Assurance Council as well as other inputs, this Management System is responsible for developing annual plans for stewardship of the CAS program.  These plans shall be available to FRA leadership and the relevant Committee(s) of the FRA Board of Directors in addition to being presented to the DOE Fermi Site Office on an informational basis.

6.2   Document Control

The Directorate document database (Directorate DocDB) has been set up and is used as a repository for laboratory-level policies and procedures in lieu of other document repositories (i.e. Division and Section DocDB databases, FermiPoint sites, protected servers, etc.). URL

Management Systems and the CAS Program Description are stored on the CAS website at URL

Policies are located on the Fermilab internal website at a top-navigation link pointing to URL This website links directly to lab policies and also points to the detailed procedures and comprehensive manuals.

6.3   Access Control

The Governance Management System owns the Policy on controlling access to government provided resources overseen by FRA.  These accesses include physical, on-site access and remote, computing access to either Batavia, IL, or Lead, SD resources.    

A policy with supporting procedures outlines the MS approach to receiving, evaluating, and/or approving access requests.  These policies and procedures consider DOE requirements across the board and are evolving.

While line management responsibility for these functions rests with the Office of the Director (focusing on international) and the Global Services Offices (focusing on Users), assurance about laboratory performance against these requirements may be distributed across several Management Systems particularly the Physical Security & Emergency MS.

6.4   International Engagement

Fermilab's mission requires substantive and detailed engagement with International Partners pertaining to substantive and significant contributions.  These engagements proceed according to policies and procedures within the Governance Management System because of their importance and cross-cutting nature.

A policy framework on international engagements has been formulated and reviewed and approved not only by the DOE Fermi Site Office and the DOE Office of High-Energy Physics, but also the DOE Office of Science.  This framework specifies the ground rules for all interactions.  The Governance Management System provides assurance about laboratory compliance with these high-level policies while detailed, laboratory-level, bilateral agreements are part of the Partnerships Management System.

6.5   Business Ethics, Legal Compliance, and Associated Matters

The Governance MS is responsible for the framework for laboratory compliance with legal services, business ethics, and business compliance requirements of the Prime Contract and other applicable rules and regulation.  In term of line management, the Office of General Counsel (OGC) supports these elements. 

Enterprise legal risks are identified through the Laboratory's Enterprise Risk Management activities, with mitigations and risk responses that also tie into the legal policy, processes, and training activities.  Additional legal risks are identified on a continuing basis, with mitigation plans and responses developed as needed.

The OGC also mitigates and manages risk through assessment of Laboratory insurance needs and availability, and the procurement and management of appropriate insurance programs and consulting services.

The OGC owns policies and procedures relating to legal issues and has input into others.  The OGC has specific ownership of the Code of Business Ethics and Conduct Program and related procedures, processes and training.  The OGC publicizes the Code of Business Ethics and Conduct Program through the website, administers the "Ask the Ethicist" program, and conducts training on Code of Business Ethics and Conduct Program issues.  The OGC also distributes reminders on various issues such as reporting fraud, waste, and abuse and conflict of interest issues. 

For policies and procedures owned by other MSOs, the OGC provides input and advice on development, implementation, and enforcement. The OGC reviews all new Laboratory policies.  The OGC works to ensure that the Laboratory overall has appropriate policies and procedures through the following types of activities, which are ongoing and dynamic:

The OGC maintains several logs to manage legal matters: (1) a general action log; (2) P.O./Procurement review log; and (3) a log relating to reviews for the Fermilab Office of Partnerships and Technology Transfer.

Litigation management is governed by 10 CFR 719,Part II, Section I, Clause I.112 of the M&O Contract, and the FRA Legal Management Plan, each of which include requirements for outside counsel retentions, engagement letters, staffing and resource plans, and billing.  In addition, DOE Acquisition Letter 2014-03 and FAR 31.205-47 as modified by DEAR govern allowability of costs and settlements on litigation (and pre-litigation) matters.  The OGC is developing a custom set of T&Cs for legal services agreements, a "Doing Business with the OGC" manual to provide guidance to outside counsel on particular requirements for working with Fermilab and complying with 10 CFR 719, and a Fermilab Litigation Response Plan.

In accordance with the M&O Contract and DOE requirements, the OGC reports to and seeks approval as required by DOE (the Fermi Site Office or DOE-Office of Science and Integrated Service Center, Office of Chief Counsel) on retention of counsel, staffing and resource management, and resolution for "significant matters."

7.0   Approach to Collaboration and Communication


The Governance Management System is the foundation of CAS and thereby oversees the other management systems which specify how FRA performs work in accordance to the Prime Contract requirements.  M01 is responsible for regular and systematic communication with FRA, LLC, DOE-HEP; DOE-FSO; and other stakeholders for regular updates and queries about activities.  The Director’s Office oversees biweekly conference calls between Fermilab management and HEP staff; supports monthly communication among lab leadership, HEP staff, and FSO staff about project performance, and escalates key contractor assurance issues to the Fermilab Enterprise Risk Management Board as well as DOE-FSO/HEP as appropriate.

8.0   Contractor Assurance Requirements

8.1   Metrics and Key Performance Indicators (KPIs)

The Governance Management System sponsors key elements of FermiDash, a technology platform that integrates performance metrics from each of the Management Systems and makes them visible online.  Each Management System, with guidance from the M08 Quality Management System, is responsible for creating and maintaining relevant assurance metrics.

Assurance measures are used to demonstrate sustained and improved performance relative to defined outcome measures and targets. Leading indicators are used, where possible, to monitor performance. Performance measures are aligned with strategic goals and periodic reporting of status against metrics is provided to key stakeholders.

At present, the metrics for assuring effective performance of the Governance Management System are:

a. Scorecard across the lab (by divisions/sections/projects) for each Management System's implementation of the four functions (policies & procedures, provision of assurance, assessment plans and progress, continuous improvement);

b. MS progress on assessment plans; and

c. Issues management status by MS.

These are reported on a regular basis to the Assurance Council, lab leadership, and the Operations and Finance Committee of the FRA Board of Directors.

 8.2   Assessments

Fermilab uses a combination of Management Assessment and Independent Assessments to ensure the requirements and controls applicable to the laboratory are satisfied.  The following list provides best practice options for Management Systems to conduct assessments.

  • Benchmarking: This practice consults with best-practice, peer-group organizations and compares FRA practice and procedures to the approach undertaken elsewhere.  It can reveal gaps, opportunities for improvement, and areas of strength.
  • Management Assessments (also referred to as self-assessments):  Management Assessments at Fermilab are conducted by, or under the direction of, Fermilab managers at all levels including Management System Owners, to identify and correct problems that hinder their organizations from achieving their objectives or to identify opportunities for improvement. Management Assessments are performed by an organization on its own processes and programs.
  • Independent Assessments: Independent Assessments at Fermilab are conducted by external or internal parties independent from work or process being evaluated. These assessment activities include : audits, surveillances, verification and validation reviews, gap analyses, or inspections. p. The Fermilab Board may participate by convening assessments or suggesting external experts to participate in such assessments

8.3   Performance Management and Issues Management

The Governance Management System is responsible for its own performance.  Based on reviews and other direction, actions to enhance the performance or structure of the system are registered in the iTrack issues management system.

8.3.1   Performance Management


The Governance Management provides the framework for overall assurance about laboratory compliance and performance. Certain elements provide assurance about the effectiveness of this management system.

As noted above, the key elements of the assurance framework are the Board of Directors and its Committees, various external advisory groups and internal committees, and a system of assessments. Key performance metrics are used to provide assurance and an issues management system (with progress indicators) is used to provide assurance about continuous self-improvement.

Awareness and oversight of this Management System's performance is provided to the MSO through additional tools.

  • DOE formal feedback such as in the mid-year and end-of-year PEMP grades, Independent Project Reviews by the DOE Office of Project Assessment, or other DOE-led reviews;
  • DOE informal feedback such as weekly meetings with the site office and the program office;
  • Assurance Council meets monthly to not only discuss maturity and challenges to each Management System but also to identify new engagements and route them to the relevant Management System Owners for SWOT analysis and recommendations to Laboratory leadership; and
  • Committees of the Board of Directors which regularly examine Laboratory performance and systems and challenge internal assumptions.

8.3.2   Issues Management

Issues management is utilized to ensure that significant items requiring the laboratory leadership's involvement and/or commitment on resources, problems, trends, and issues are identified, documented, analyzed, and prioritized to promote effective resolution in a timely manner. Issues management applies to issues identified through contractual obligations, corrective actions, assessments, lessons learned, and worker feedback, as well as injury, incident, and event (mishap) reporting which tend to be of major consequence, need lab-wide attention, and/or need senior management involvement. For more information, see M08, Quality Management System.

8.4   Lessons Learned

As part of the CAS program, the Governance Management System participates in the Fermilab Lessons Learned Program.  Specifically, this MS looks for opportunities to learn from incidents and situations at other laboratories in concert with M08 Quality Management System.

8.5   Risk Management

The Laboratory has established a Risk Management program using a graded approach to provide assurance regarding the mitigation of risk.  Three domains of risk are managed: Enterprise, Operational, and Project.  M03 Planning and Performance Management. The Enterprise Risk Registry is updated annually through a series of consultations and a senior management workshop.  The Enterprise Risk Management Board meets monthly to maintain the ERR and make recommendations to laboratory leadership regarding mitigations.  Out briefs are provided to the program and site offices after each meeting, typically via teleconference.   An Operational Risk Registry (ORR) is used to identify and manage risks associated with operational commitments.  Finally, each major capital asset construction project maintains its own registry of Project Risks as part of the DOE, project-management framework.

Risks/assessments monitored by:

  • Self-Assessment Program
  • iTrack Procedures and Risk Assignment
  • Corrective Action Plans – in iTrack
  • Effectiveness Reviews – in iTrack

9.0   Required Reports and Records

9.1   Required Records

M01-directed changes to the CAS Program are required to be shared and discussed with the DOE Fermi Site Office.

9.2   Required Reports

Governance MS performance reports are collected and shared with lab leadership, DOE Fermi Site Office, and the relevant Committee(s) of the FRA Board of Directors.

10.0   Extension of Management System to SDSTA (SURF)

This section formally captures the extension of the management system to Fermilab activities and roles at Sanford Underground Research Facility (SURF).

FRA is heavily involved with the South Dakota Science and Technology Authority (SDSTA) and the Sanford Underground Research Facility (SURF) which it owns and operates. The Governance Management System has been modified to address these engagements with the creation of five elements.

      1. A jointly developed and executed Memorandum of Understanding between FRA and SDSTA from June 2018. This document articulates and records the common mission of the two organizations and identifies the basic framework for cooperation and shared progress. It is on record in M12 Partnerships Management System.
      2. DOE executed a land-lease agreement with SDSTA for some surface space and a set of massive underground chambers. FRA acts as the leasee's representative for the land lease and all normal DOE requirements apply inside of this leased area. This tool allows Fermilab to have the identical control of work, personnel, and representations as it does in Batavia.
      3. The creation of a new organizational unit (the South Dakota Services Division, or SDSD) with an executive leader which provides full-time presence, oversight, and integration of all FRA activities at SURF and serves as the primary conduit for interactions between SDSTA and FRA. The SDSD was created in mid-2018 and have brought centrality, focus, and accountability to the work between FRA and SDSTA.
      4. Specific tasks or activities to be executed by SDSTA are presently captured in distinct and individually negotiated Subcontracts and Agreements. These legally-binding documents address statements of work, exchange of payments, access rights, and so on. Efforts have been made to consolidate, systematize, and simplify the set of agreements.
      5. Fermilab Plan for Governance, Assurance, and Operations in South Dakota. This plan was developed in early 2018 and outlines the operations and assurance models, functional requirements, and specific responsibilities of laboratory organizational units and Management Systems in supporting FRA work at SURF through SDSD. It is available in the LBNF/DUNE DocDB.

11.0   Additional References

Annual (Rev FY) Laboratory Plan for Fermilab

DOE Performance Evaluation and Measurement Plan (PEMP) for FRA (Rev FY)

CAS Program Description (Rev Sep 2019)

12.0   Acronyms and Terms

CASContractor Assurance System
DOEDepartment of Energy
DOE-SCDOE - Office of Science
DOE-OHEPDOE – Office of High Energy Physics
DOE-FSODOE - Fermi Site Office
MSOManagement SystemOwner
PEMP  Performance Evaluation Measurement Plan



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