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(M7) ES&H
Contractor Assurance

​​​​​Management System Owner: Chief Safety Officer

Revision and Date: Revision 3, February 23, 2017

1.0   Purpose


The purpose of the Environment, Safety and Health Management System is to ensure its implementation results in compliance with the Contract and to improve Fermilab's ability to meet or exceed ES&H customer expectations. This system is to protect the public, the worker and the environment through a set of elements that Fermilab uses to plan, direct, control, coordinate, assure and improve 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 and procedures.
  • Assesses line organizations for compliance.
  • Seeks and implements improvements.
Fermilab ES&H 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 and Division/ Section Heads and Project Managers
  • Assure implementation in their line organizations.​
Division Safety Officers
  • Assist in implementation in their line organizations as subject matter experts.
All Employees, Users, Visitors, Contractors and Guests
  • Ensure compliance to all ES&H procedures pertinent to activities being performed or that are carried out under that person's supervision.

3.0  Primary Requirements


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)

  • 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

Other 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

FRA Contract Clause Mapping to Management Systems:        


4.0  Management System Description Overview


The operation of this Management System occurs through oversight, assessment, and evaluation of employee, scientist/user and contractor 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.

Operation is accomplished substantially through the Fermilab ES&H Committee (FESHCom).  Its Subcommittees' and Working Groups' chairpersons 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, Division Safety Officers and the central ESH Organization ensure the implementation, operation and integration of ES&H processes at the lab.

Information on the FESHCom, the subcommittees and working groups is shown on the Fermilab ES&H Subcommittees 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 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 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))
  • Open burn permits (authorization from IEPA to perform land management burns and fire extinguisher training)
  • 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)

4.1.2    Waste Management

The FESHM chapter General Program Statement on Waste Management outlines Fermilab's waste management policy. Several 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 Facility Decontamination and Decommissioning 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).

Other programs include the Spill Prevention Control and Countermeasures Plan, a general spill prevention policy, domestic water protection and controls on discharges to the sanitary sewer systems.

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 Monitoring 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 policy 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 Refrigeration 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 due to actions taken by Fermilab. 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 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 program is supported by:

  • Occupational, Safety & Health (OSH) management information system that provides data required by federal agencies and contractual requirements.
  • Industrial Hygiene programs developed to protect the health and well-being of working people and the public from chemical, biological and physical health hazards present at, or emanating from, the workplace.
  • Medical surveillance programs that monitor employees exposed to potential hazards.

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

4.2.1    Planning for Safe Operations

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 perform a written hazard analysis (HA).

Work Planning and Hazard Analysis

All work activities are subject to work planning and hazard analysis.  Depending on the complexity of the task and the hazards involved, the HA process may be a mental exercise and verbal discussion, or it may be more formal with a written hazard analysis and pre-job briefing.  Careful planning of a job assures that it is performed efficiently and safely. Work planning ensures the scope of the job is understood, appropriate materials are available, all hazards have been identified and mitigated efforts established.

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 including AC power distribution, cable tray systems, uninterruptible power back-up systems, grounding requirements and experimental apparatus. 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 Safety

The Fire Safety chapters describe the organization and structure of the laboratory's fire protection program. This program provides a level of fire 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, Health, & Quality Section's Fire Protection Engineer (ESH&Q-FPE).

4.2.5    Pressure/Vac​uum Vessels and Piping

This series details the requirements for design, fabrication, operation, and testing of vacuum vessels, pressure vessels, cryogenic systems, refrigeration systems and associated piping 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    Subcontractor Safety and Fall Protect​ion

Fermilab's program, procedures and safety requirements for all subcontractor work follow DOE 10 CFR 851 and are flowed down to subcontractors through the ESH&Q Requirements - 013100 document. The level of Fermilab review and oversight of subcontractor activities is commensurate with the risk and complexity of the work activity. Construction work is coordinated by a Construction Coordinator (CC) or by a Task Manager when the work is performed by a time and material contract. The significant difference between the two oversight roles lies in the assignment of responsibility for safety planning and hazard assessment. Task Managers must understand the detailed nature of work assignments for tradesmen. They serve to specify Fermilab requirements as a job progresses, working closely with subcontractors, supervisors, and workers. A Construction Coordinator oversees or coordinates construction when supervision and management is included in the subcontract scope and the work processes and required outcomes are well understood. The CC relies on the subcontractor to plan the means and methods to safely and effectively accomplish construction objectives. Service Coordinators (SC) oversee service work and must understand the activities of the service subcontractor. Understanding the work and its associated hazards ensure that appropriate work planning and controls are prepared by the SC and implemented for the activity.

Working at heights exposes workers to a fall hazard that must be addressed with properly designed fall protection systems and/or commercial fall restraint equipment. Design requirements can be found in both the FESHM chapter and referenced standards. There are also requirements for inspection of fall protection restraint equipment that will ensure damaged or outdated items are removed from service in a timely manner.

4.2.7    Material Handling and Trans​​​portation

  • 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.
  • The driving and parking of motorized vehicles on the Fermilab campus can pose a serious safety risk to motorists as well as bicyclists and pedestrians. To reduce the risk to motorists, bicyclists and pedestrians, Fermilab has adopted, as a minimum, the applicable portions of the State of Illinois Vehicle Code and the Rules of the Road publication into its Work Smart Standards. These are the same standards that motorists are legally obligated to observe when operating vehicles on public roadways in Illinois.

4.3        Radiation Prote​​ction


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 C​​ontrol Program

  • The Radiation Protection Program Plan (RPP) defines how the program is implemented at Fermilab, and assures the DOE the program is of the highest quality.
  • Radiological Control Policy governs the implementation and content of the Radiological Control Program.

4.3.2    Radiologi​​​cal 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 Rad​​iological Work

This chapter 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 chapter 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 a​​nd 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 Rec​ords

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 Circumstance

This chapter 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  Radia​tion 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  Env​ironmental 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        E​mergency Management Program


Fermilab has developed a comprehensive emergency plan that is based on an analysis of potential natural and manmade hazards, both in and around the site. Due consideration was given to guidance provided by DOE and other organizations. This analysis is documented in the Hazard Assessment Document (HAD). The Comprehensive Emergency Management Program (CEMP) outlines the procedures and conditions under which management and emergency response personnel function during abnormal events. It relies on the execution of local procedures, but the principles and arrangements described in the CEMP are designed to mitigate and recover from abnormal situations.  The Fermilab emergency program is a Base Program per O151.1C.

4.5        Fermilab Fire Depart​​ment


The mission of the Fermilab Fire Department is to protect the lives and property of every employee and visitor of Fermi National Accelerator Laboratory from the adverse effects of fire, medical emergencies, and exposures to dangerous conditions. Prevention is the main driver for the programs and processes executed on a daily, weekly, monthly and bi-annual basis.

The Fire Department responds to a multitude of emergency situations both on and off site, and should a major incident occur at the laboratory outside assistance is received. The department is associated with outside fire departments that belong to the Mutual Aid Box Alerting System (MABAS), and have implemented a prearranged response plan should such an event occur.

The Fire Department serves as first responders to a variety of situations on-site at the laboratory including responses to high rise and underground situations. The unique building structures and terrain across the laboratory requires programs and processes to be precisely implemented and personnel to be well trained. The Fire Department has implemented the following programs and procedures to support the laboratory:

4.5.1    Daily Prevention Proce​​dures

Daily prevention procedures include stretching and physical fitness routines, shift conference/safety meeting, and inspections of vehicles, emergency equipment, gear, and response tools.

4.5.2    Monthly Prevention Proced​​​ures

Monthly prevention procedures include inspections of all fire extinguishers across the laboratory. The inspection determines the need for service, conductivity test, hydro-test, and whether 6 year maintenance or annual maintenance is appropriate.  Other monthly inspections include visual inspections of the following:

  • Designated Welding Shops
  • Compressed Gas Cylinder Storage Locations
  • Fire Hydrants
  • FD Connection
  • Post Indicator Valves

4.5.3    Bi-annual inspect​​ions

Bi-annually building inspections are conducted with the assistance of the Building Managers, and include inspection of Fire Barrier Doors.

4.5.4    As-needed inspections and pro​​grams

Other programs and processes that occur on an as-needed basis include:

  • Tests of sprinkler systems
  • Public Relations Education outreach for the Day-Care and Laboratory employees
  • Participates in DASTOW and building fire drills
  • Issues Welding Permits to contractors and lab welders
  • Harmonizes the documentation of the Haz Mat program for the Fire Department
  • Trains lab employees in Air Packs, Fire Extinguishers, and CPR and BBP classes
  • Responds to all emergency calls

Other areas of testing and maintenance conducted in-house by Fire Department to ensure response readiness for an emergency incident include:

  • Minor vehicle repairs
  • Fire hose testing
  • Fire ladder maintenance
  • Fire engine pump testing
  • Breathing apparatus maintenance and other rescue equipment

4.5.5    Collaboration with D/S/​​Ps

To support the laboratory the Fire Department works in conjunction with various D/S/Ps on a variety of topics including:

  • Review of preliminary plans for various new or renovated buildings
  • Assist with prairie burns as needed
  • Recommend fire extinguishers for all new buildings
  • Participate in all safety fairs
  • Instruct Fire Extinguisher Refresher Training
  • Instruct SCBA (Self Contained Breathing Apparatus) training
  • Standby/assist for special events with large crowds

4.5.6    Fire Department Personnel Train​ing & Qualifications

Personnel have the knowledge necessary to perform their functions through Illinois State Certifications including:

  • Firefighter – Emergency Medical Technician
  • Firefighter III
  • Fire Officer II
  • Haz Mat Operations
  • Incident Command
  • Mine Rescue

Laboratory specific training includes:

  • Materials – Lead
  • Materials – Beryllium
  • Materials – Cyanide
  • BODA
  • Haz Waste Storage
  • Rad Worker
  • DO/CDF Access
  • Controlled Access
  • ODH

4.6        Traini​​​ng


Fermilab employees, users, visitors and subcontractors must complete certain Environment, Safety, Health & Quality (ESH&Q) 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 ESH&Q 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 ESH&Q and is an assessment completed by supervisors for each new employee (and annually thereafter) to ensure they are receiving the appropriate training. The FESHM chapter ESH Training Program describes this and other key elements to the ES&H training program.

5.0   Reports, Audits, Assess​​ments and Required Records


5.1     Re​ports

5.2    Reviews and Au​​dits

  • DOE ES&H Assessments occur quarterly
  • ISO/OHSAS Certification and Surveillance Audits occur every 6 months
  • Other 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 FESHM 1010.1. ES&H Self-Assessment Program

Other assessments are described in other chapters, such as:

Risks/assessments monitored by:

5.3   Required Recor​​ds


Records as required by:

  • State and Federal Regulatory agencies
  • Applicable DOE Orders
  • 3rd party Registrars
  • Internal policies and procedures

Other records including:

  • Scheduled FESHCom Minutes & Actions
  • Scheduled FESHCom Subcommittee Minutes & Actions
  • Quarterly FESHCom Subcommittee Reports
  • External Assessments
  • ES&H Assessments
  • ES&H Self-Assessments
  • Inspection Records (Computer Barcode System – Fire Department)

6.0  Additional Ref​​​erences


Many high level documents can be found at:

7.0  Definitions of 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
ESH&QEnvironment, Safety, Health, and Quality
​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
RCRAResource Conservation and Recovery Act
SHSafety & Health