Management System Owner:  Chief Safety Officer

Revision Number:   4.5          Date:   June 15, 2020

1.0   Purpose

The purpose of the Environment, Safety and Health management system is to ensure compliance with the Contract; improve Fermilab's ability to meet or exceed the customer's ES&H expectations; and protect the public, the worker, and the environment through a set of elements that Fermilab uses to plan, direct, control, and coordinate activities that directly and indirectly support the scientific mission. The management system describes  how ES&H policies, objectives, processes, and procedures are established, implemented, monitored, and achieved, thereby enabling the scientific mission.

2.0   Roles and Responsibilities


Title Responsibilities
Chief Safety Officer
  • Owns the ES&H Management System.
  • Establishes and maintains ES&H policies, programs, and procedures.
  • Assesses line organizations for compliance.
  • Seeks and implements improvements.
Fermilab ES&H Committee - Subcommittees & Working Groups
  • Monitor, update (with management system owner concurrence), review, and improve the ES&H Management System policies and processes in their area of expertise.
Chief Laboratory Officers, D/S Heads, and Project Directors/Managers
  • Implement all ES&H policies and procedures pertinent to activities being performed in their organizations and hold managers and employees accountable for performance.
Division Safety Officers
  • Assist in implementation in their line organizations as subject matter experts.
All Employees, Users, Visitors, Contractors and Guests
  • Ensures compliance to all ES&H policies and procedures pertinent to activities being performed or that are carried out under that person's supervision. This is a line management function carried out through each individual's management chain.

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)
  • Contract deliverables are monitored by an automatic tracking system to ensure obligations are delivered on time.  The responsible ES&H department manages and provides the technical information to meet the contract expectations. 

3.2   Fermilab Performance Evaluation and Measurement Plan (PEMP)

  • Goal 5.0: Sustain Excellence and Enhance Effectiveness of Integrated Safety, Heath, and Environmental Protection;
  • Goal 8.0: Sustain and Enhance the Effectiveness of Integrated Safeguards and Security Management (ISSM) and Emergency Management Systems
  • PEMP Objectives for ES&H are monitored through quarterly reports submitted by each department to the Chief Safety Officer.  PEMP Notable Outcomes are monitored and managed through iTrack. 

3.3   Other Required DOE Orders and Instructions

  • Fermilab Environment, Safety, and Health Manual (FESHM) Chapter for the Fermilab Work Smart Set
  • Fermilab has adopted the Necessary and Sufficient (N&S) Process for determining the Work Smart Set of Standards (WSS) to determine the appropriate ES&H standards to ensure the safe and environmentally responsible operations of the laboratory. These standards, when properly implemented, provide adequate assurance that the public, workers, and environment are protected from adverse consequences. Applicable DOE standards covered by Fermilab's Work Smart Set are located on the Office of General Counsel webpage, DOE Directives and Current Appendix I
  • DOE Order 231.1B Environment, Safety & Health Reporting

3.4   FRA Contract Mapping to Management Systems

4.0   Management System Description

Implementation of this Management System occurs through oversight, assessment, and evaluation of employee, scientist/user and subcontractor performance; reporting of ES&H performance data; and striving for continuous improvement in all ES&H areas. Overall documentation for implementing/assuring an effective system operation is contained in the Fermilab ES&H Manual which includes the Fermilab Radiological Control Manual.  Fermilab's ES&H Management system strives to systematically integrate safety into management and work practices at all levels so that missions are accomplished while protecting the public, the worker, and the environment. This is to be accomplished through effective integration of safety management into all facets of work planning and execution.

  • Line management is directly responsible for the protection of the public, workers and the environment
  • Clear lines of authority and responsiblity for ensuring safety are established and maintained at all organizational levels
  • Personnel possess the experience, knowledge, skills and abilities that are necessary to discharge their responsiblities
  • Resources are effectively allocated to address safety, programmatic, and operational considerations. Protecting the workers, the public and the environments is a priority whenever activities are planned and performed
  • Before work is performed, the associated hazards are evaluated and an agreed-upon set of safety standards and requirements is established which, if properly implemented, will provide adequate assurance that the workers, the public and the environment are protected from adverse consequences
  • Administrative and engineering controls to prevent and mitigate hazards are tailored to the work being performed and associated hazards
  • The conditions and requirements to be satisfied for operations to be initiated and conducted are clearly established and agreed upon
  • Walkthroughs, inspections, and assessments ensure verification that safe work practices and controls are implemented effectively, and any deficiencies are found and corrected appropriately to prevent incidents
  • SHAPE is the process by which Integrated Safety Management principles are implemented across the laboratory for all work performed.
    • Scope of Work - Identification of the scope of work, including what, where, who, when, how and why.
    • Hazards & Controls - Identification of hazards, mitigations and controls including engineered controls, development of SOPS, HAs, Permits, Checklists, Travelers, and identification of training and PPE.
    • Authorize Work - Obtain appropriate reviews and approvals to conduct work, including reviews by subject matter experts, workers, and approvals from authorizing supervisors.
    • Perform Work - Work is executed within the controls identified, and reevaluated if conditions change.
    • Evaluate - Work is evaluated when completed to identify lessons learned and continual improvement opportunities.


Operation is accomplished substantially through the ES&H Section and the Fermilab ES&H Committee (FESHCom).  Chairpersons of the Subcommittees and Working Groups formally report to FESHCom on a regular basis.  The FESHCom is Chaired by the Laboratory Director and attended by senior management, including the Chief Safety Officer. The subcommittees and working groups, along with working relationships between line management personnel and the ES&H Section ensure the implementation, operation and integration of ES&H processes at the lab. Division Safety Officers serve as the liaison to each Fermilab organization providing guidance and assure management system implementation.

Information on the FESHCom, the subcommittees, and working groups is shown on the FESHCom webpage. Their primary responsibilities are to manage their areas of expertise, assure code and standard updates are vetted and adopted where appropriate, update their respective FESHM Chapters and training, watch for/discuss issues and lessons learned, look for improvements (lab wide consistency, best practices discussions) and to communicate to the Lab Director and Chief Safety Officer issues/actions at FESHCom meetings or through e-mails/phone calls.

Fermilab's ES&H Management System is compliant to both the OHSAS 18001 Standard and the ISO 14001 Standard.

4.1   Environmental Protection

Fermilab's Environmental Management System (EMS) is an integrated system of managing activities, training and communication to achieve environmental protection objectives. The EMS describes the Laboratory's program for execution and evaluation of programs for protecting the environment, assuring compliance with applicable environmental regulations and standards and avoiding adverse environmental impacts through an effort of continual improvement.

Fermilab's policy for environmental protection is described in the Environmental Policy. The policy identifies the major goals under which the Laboratory's efforts are directed to meet the EMS program objective.

The FESHM 8000 Environmental chapter series describes certain key program elements under this management system.

4.1.1   Environmental Management System

Fermilab's EMS is detailed in the FESHM chapter titled Environmental Protection Program. This chapter defines the roles and responsibilities for EMS implementation.

A number of environmental permits are in place to minimize the operational impact to the environment. They include: 

  • Registration of Smaller Sources (air emissions registration approved by the Illinois Environmental Protection Agency (IEPA))
  • National Pollution Discharge Elimination System (NPDES) permits including Storm Water Pollution Prevention Plans – permits include: general, pretreatment, construction and pesticide application (issued by IEPA for the protection of surface water)
  • Resource Conservation and Recovery Act (RCRA) Part B permit (issued by the United States Environmental Protection Agency for the management of hazardous waste)
  • Others (such as nuisance wildlife control, dam permit, wetland mitigation, open burn, pretreatment)

4.1.2   Waste Management

Several chapters outline Fermilab's waste management policy. These chapters address the management of waste from multiple perspectives – minimization of waste and maximization of recycling to procedures for characterizing and handling special, universal or hazardous waste.

The FESHM chapter Decontamination and Decommissioning Documentation outlines the policy to ensure that hazardous materials are identified prior to the demolition of a facility.

4.1.3   Surface Water Protection

Fermilab's NPDES permit and surveillance monitoring program is the primary protection for Waters of the United States. Monthly water samples are taken and analyzed for pollutants (pH, temperature, tritium and in some locations, chlorine).

 4.1.4   Ground Water Protection

Fermilab's Ground Water Protection Plan (GWPP) details the policy for protecting groundwater.  It defines a network of groundwater monitoring wells that are used to track water gradients and some are sampled for pollutants associated with Solid Waste Management Units.  In addition, the FESHM chapter Groundwater Protection - Excavations and Wells establishes guidelines for the installation or abandonment of monitoring wells.

4.1.5   Air Protection

The FESHM chapter Air Emissions Control Program defines the guidelines for regulatory compliance with regard to the Clean Air Act. An inventory of air emission sources is updated on a regular basis and calculations provide a means to show compliance. The FESHM chapter Refrigerant Management specifically addresses the use of refrigerants at Fermilab in compliance with the protection of the stratospheric ozone.

4.1.6   National Environmental Policy Act (NEPA)

The FESHM chapter National Environmental Policy Act Review Policy outlines the NEPA review program and provides a mechanism for all Fermilab activities to receive a NEPA review. The Environmental Review Form database catalogs many of these reviews which identify potential environmental impacts and the mitigation of those impacts. Fermilab has a set of Generic Categorical Exclusions (CX) containing previously approved actions that may be taken without further DOE approval. For actions that do not meet the Generic CX, an Environmental Evaluation Notification Form must be submitted to DOE FSO for approval prior to any activity.

 4.2   Occupational Safety & Health

Fermilab's Worker Safety and Health (SH) Program is a system of policies, procedures, training and communication channels implemented to ensure compliance with applicable standards and Local, State, and Federal legal requirements through Fermilab's Work Smart Set of Standards (WSS) and the contract between Fermilab Research Alliance and the Department of Energy.

Fermilab's policy for Safety and Health is described in the Safety & Health Policy. The policy identifies the major goals of the SH program including prevention of injury and ill health, and prompt abatement of recognized hazards.

The SH program includes policies and procedures for identifying safety risks and health hazards in advance of procurement and construction activities, and incident investigations.

The following FESHM chapter series describes certain key safety and health program elements:

4.2.1   Planning for Safe Operation

Environment, Safety & Health for Projects

Projects of a wide range of sizes and complexity constitute a major focus of activities at Fermilab.  Project Managers, upon initial assignment to this role, shall determine the environment, safety, and health impact on their projects.  Some projects are subject to the requirements of DOE O413.3B and its hazard analysis (HA) and critical decision processes.  Other Fermilab projects below the applicability threshold of this DOE Order are still required to follow FESHM requirements.

Work Planning and Hazard Analysis

All work activities are subject to work planning and hazard analysis in order to mitigate hazards associated with the work to an acceptable risk level. At a minimum, the work planning and control process will require a pre-job briefing and depending on the complexity of the task and the hazards involved, it may require a written hazard analysis or SOP.

4.2.2   Industrial Hygiene

Fermilab's Industrial Hygiene (IH) program has been developed to protect the health and well-being of working people and the public from chemical, microbiological and physical health hazards present at, or emanating from, the workplace. Fermilab members of the Industrial Hygiene Subcommittee will utilize the anticipation, recognition, evaluation, and control process (AREC) to ensure that employees are not overexposed to physical, chemical or biological agents during the course of their work. Medical surveillance programs are in place that monitor employees expose to potential hazards.

4.2.3   Electrical Safety

The Electrical Safety chapters address all electrical systems across the site. Proper installation and maintenance of electrical systems will help protect employees, visiting scientists, and equipment from injury or damage due to electrical shock.

4.2.4   Fire Protection

The Fire Protection chapters describe the organization and structure of the laboratory's fire protection program. This program provides a level of fire prevention, protection and fire suppression capability sufficient to minimize losses from fire and related hazards consistent with the best protected class of industrial risks that is Highly Protected Risk (HPR). With regard to facilities, the "code of record" (the code in effect at the time of design) is in effect for the life of the facility. The current code will apply to the facility in the event of a major renovation or if a significant hazard endangers the building occupants as determined by the Environment, Safety and Health Section's Fire Protection Engineer (ES&H-FPE).

4.2.5   Mechanical, Cryogenic, and Structural Safety

This series details the requirements for design, fabrication, operation, and testing of vacuum vessels, pressure vessels, cryogenic systems, refrigeration systems, associated piping and structures which are in use to support daily operations and experiment activities. Engineering notes are required for systems such as evacuated beam pipes, thin windows on experiment targets using cryogenic fluids, gas storage membranes, and cryogenic storage tanks and piping.

4.2.6   Occupational & Subcontractor Safety

Fermilab's program, procedures and safety requirements for all work follow DOE 10 CFR 851 and are flowed down to subcontractors through the ES&H Requirements - 013100 document. The level of Fermilab review and oversight of activities is commensurate with the risk and complexity of the work activity. Understanding the work and its associated hazards ensure that appropriate work planning and controls are implemented for the activity.

 4.2.7   Material Handling and Transportation

Material handling operations involving overhead cranes, mobile cranes, forklift activities and transportation of materials are part of everyday work in many locations across the Fermilab site. These chapters define the equipment and operator training requirements that ensure each and every activity is conducted in a safe manner and minimizes the risks to employees and equipment.

4.3   Radiation Protection

Radiation protection at Fermilab is achieved through the implementation of the Fermilab Radiological Control Program. The Radiological Control Program is a lab-wide program that ensures DOE activities conducted on site comply with current regulations and standards through the management of activities that have the potential to produce radiation and/or radioactive materials that could result in radiation exposure to workers, the public and the environment. In order to attain these goals, the Fermilab Radiological Control Manual (FRCM) as a part of FESHM, has been established in the context of the Laboratory's programs of Integrated Safety Management.

The FRCM chapter series contain the following elements:

4.3.1   Fermilab Radiological Control Program

The Radiation Protection Program plan (RPP) defines how the program is implemented at Fermilab and assures DOE that the program is of the highest quality.

Radiological Control Policy governs the implementation and content of the Radiological Control Program.

4.3.2   Radiological Standards

Radiological standards define the acceptable dose limits per applicable standards and regulations, the yearly administrative goal as set by the director, contamination control and control levels, posting (signage) requirements, and the Release Certification Program for Facilities Containing Radioactive Materials.

4.3.3   Conduct of Radiological Work

This includes procedures that define planning, work preparation, entry and exit requirements, work controls, and Fermilab's ALARA (As Low As Reasonably Achievable) Program when conducting radiological work.

4.3.4   Radioactive Materials

This includes procedures that define how radioactive material is identified, stored and controlled, how it is released to other areas and for transport, the Source Control & Accountability Program, Radioactive Waste Disposal Program, Low-Level Waste Certification Program (LLWCP), and Radioactive Waste Minimization Program, and the control of radioactive liquids and airborne radioactivity including the Water Management Program.

4.3.5   Radiological Health Support Operations

Radiological Health Support Operations defines requirements for the External Dosimetry Program and Internal Dosimetry Program, Radiological Respiratory Protection Program, the requirements for the Dosimetry Program Manager, explains how instruments are calibrated through the Maintenance Program of radiological instrumentation, and  how  exposure investigations are conducted, and how radiologically contaminated personnel are handled.

4.3.6   Training and Qualification

Training and qualification requirements ensure personnel have the appropriate training to work safely in and around radiological areas and to maintain their individual exposure and the radiation exposure of others ALARA.

4.3.7   Radiological Records

Radiological control and management of records is needed to demonstrate the effectiveness of the overall program. These records document the radiological safety afforded to personnel on site. These records include, individual radiation dose reports, radiological surveys, and instrument calibration.

4.3.8   Accelerator Shielding and Radioactivation

Fermilab's policy on Accelerator Shielding Design ensures radiation exposures are as low as reasonably achievable (ALARA) and compliant with regulations and applicable DOE orders.

4.3.9   Special Circumstances

This describes more restrictive procedures placed upon the areas within the site which may present possibilities of exposure of visitors to radiation and radioactive materials in the building, as well as for the possibility of loss or theft of such materials.

4.3.10   Radiation Safety Interlock Systems

Responsibilities and requirements for Radiation Safety Interlock Systems (RSIS) prevent injury, death, or serious overexposure to high radiation levels.

4.3.11   Environmental Radiation Monitoring and Control

An Environmental Radiation Monitoring and Control program to protect members of the public and the environment against undue risk from radiation.

4.4   Training

Fermilab employees, users, visitors and subcontractors must complete certain ES&H training before engaging in work activities. Training is intended to prepare employees to recognize hazards, and to protect themselves and the environment by responding appropriately.

The ES&H Section routinely identifies regulatory driven training requirements (and qualification periods) which apply to the Laboratory and make these known to management. Those courses are documented in TRAIN. Individual Training Needs Assessment (ITNA) questions and content is managed by ES&H and is an assessment completed by supervisors for each new employee (and annually thereafter) to ensure they are receiving the appropriate training.

5.0   Policies

6.0   Key Processes, Procedures, and Manuals

7.0   Approach to Collaboration and Communication

The ES&H Management System expectations are communicated to D/S/P through FESHM and FRCM, ES&H training requirements, and routine communications (such as meeting minutes, weekly status, Division Safety Officers, etc.).   

8.0   Contractor Assurance Requirements

8.1   Metrics and Key Performance Indicators (KPIs)


  • Injury/Illness rates (employees and subcontractors)
  • Compliance status (environmental permitting)
  • Training (Individual training needs assessment and training course completion)
  • Human Performance Improvement (rate/severity of incidents)
  • Radiation dose to Radiological Workers


  • Construction safety walkthroughs/observations, subcontractor hours
  • Environmental monitoring, sampling program
  • Fire run response times
  • Industrial Hygiene monitoring, sampling program
  • Occupational safety walkthroughs, observations
  • Radiological sampling analysis throughput

8.2   Assessments

  • DOE ES&H Assessments
  • Tripartite Assessments
  • Peer Reviews
  • Reviews and audits performed on Fermilab by outside regulatory agencies
  • ES&H Assessments and other structured operational awareness activities are all part of Fermilab's ES&H Assurance Program. The ES&H assessment program is described in Quality Assurance Manual Chapter 12080 - Self- Assessments

Additional assessments are described in other chapters, such as:

  • Planning and Review of Accelerator Facilities and their Operations,
  • High Protected Risk Inspection Program,
  • Environmental Protection Program,
  • FRCM Article 122 Radiological Assessments

8.3   Approach to Issues Management

The ES&H Management System follows the Issues Management process described in QAM 12030, and utilizes iTrack for documenting issues, tracking to resolution, and assessing effectiveness.

8.4   Lessons Learned

The ES&H Management System follows the Lessons Learned process described in QAM 12010 and utilizes iTrack for documenting lessons.  Lessons are distributed via email to affected personnel. 

8.5   Risk Management

ES&H Management System risks are identified by various mechanisms, including:  employee concerns, Division Safety Officers, FESHCom chairs, incidents and near misses, and assessments.  Risks are monitored by the subject matter expert and tracked by the ES&H Risk Officer.

Risks/assessments monitored by:

  • Predictive Solutions
  • Self-Assessment Program
  • iTrack Procedures and Risk Assignment
  • Corrective Action Plans – in iTrack
  • Effectiveness Reviews – in iTrack
  • Fermilab Risk Register
  • ES&H Risk Register

9.0   Required Reports and Records

9.1   Required Records

Records as required by:

  • State and Federal Regulatory agencies
  • Applicable DOE Orders
  • Internal policies and procedures

       Other records including:    

  • Scheduled FESHCom Minutes & Actions
  • Scheduled FESHCom Subcommittee Minutes & Actions
  • Quarterly FESHCom Subcommittee Reports
  • External Assessments
  • Quality Assurance Assessments
  • ES&H Self-Assessments
  • Predictive Solutions database

9.2   Required Reports

  • Fermilab Leading Lagging Indicators


  • Worker S&H Plan

  • Tripartite Assessments

  • FSO Assessments

  • Fermilab ES&H Committees and Working Groups

  • Dashboard

  • Other reports as required by DOE O 231.1B Environment, Safety, and Health Reporting

10.0   Extension of Management System to SDSTA (SURF)

Integrated ES&H management is required through the Fermilab Environmental, Safety & Health Manual (FESHM), which applies to all work performed in the leased space in South Dakota. Activities on the rest of the site are governed by SDSTA ES&H policies which Fermilab assures are sufficient and adequately implemented. The SDSD is supported by a dedicated department within the ESH&Q Section based in Illinois and, like all Divisions, has a Division Safety Officer (DSO).  The SDSD DSO is 100 percent dedicated to SURF ESH oversight and onsite at SURF ~50 percent of the time. This team assures that the SDSTA Services provided to DOE activities meet all ES&H requirements. Additional support for specific issues or technical processes is provided by the ESH&Q Section or through other subject matter experts. The SDSD DSO will also provide ES&H oversight for non-LBNF FRA sponsored construction activities.

Refer to the SURF Governance Matrix

11.0   Additional References

Many high-level documents can be found at:  ESH Assessments Web Page

12.0   Acronyms and​​ Terms

BODABeam-On Dose Assessment
CEMPComprehensive Emergency Management Plan
​CPR​Cardiopulmonary Resuscitation
DOEDepartment of Energy
D/S/PDivisions, Sections, and Projects
EMSEnvironmental Management System
EOEnvironmental Office
ES&HEnvironment, Safety, and Health
​FESHCom​Fermilab ES&H Committee
FESHMFermilab Environmental, Safety and Health Manual
FPEFire Protection Engineer
HADHazard Analysis Document
HPRHighly Protected Risk
IEPAIllinois Environmental Protection Agency
IHIndustrial Hygiene
ISOInternational Organization for Standardization
NEPANational Environmental Policy Act
NPDESNational Pollution Discharge Elimination System
NTSNoncompliance Tracking System
ORPSOccurrence Reporting and Processing System
QAQuality Assurance