SAC MESH Reviews - Guidance and Overview
Objective of the MESH Review: To evaluate the Division's management of environment, safety, and health in its operations and/or research, focusing on the implementation and effectiveness of the Division's Integrated Safety Management (ISM) Plan.
Type of Review:
- A peer review that provides a strong perspective from the research and operations community on the state of ES&H in the assessed Division.
- A self-assessment that is distinctly different from the Division self-assessments and ES&H Technical Assurance.
Scope of the MESH Review:
The MESH Review Team normally consists of three SAC members. The review usually takes about two days, spread over several weeks.
- Pre-MESH Activities
- MESH Teams receive annual MESH refresher training to review MESH scope and methodology.
- The assessed Division provides the MESH Team with its current ISM Plan prior to the review. .
- EH&S Division and the Office of Contract Assurance (OCA) provide the MESH Team with the assessed Division’s most recent Division self-assessment and MESH reports, corresponding validation reports, ES&H Technical Assurance data, and other applicable reports such as Occurrence Reporting and Processing System (ORPS) reports, Non-compliance Tracking System (NTS) reports, etc.
- MESH Team Analysis and Planning
- The MESH Team reviews the documentation provided by EH&S and OCA to develop the line of inquiry for the MESH review. The MESH Team conducts a planning meeting (1-2 hours), focusing on the following:
- identifying key issues from the Division’s ISM plan and other documentation
- evaluating for ISM implementation and effectiveness
The MESH Team can request additional information from the Division.
- MESH Review
- The MESH Team Leader coordinates with the Division to schedule the MESH review.
- The Team conducts an opening meeting with the Division Safety Coordinator. The purpose of this meeting is to clarify questions the MESH Team may have regarding the Division’s ES&H program. The MESH line of inquiry is initiated at this meeting.
- The MESH Team conducts a field visit of Division facilities (1-3 hours). Field visits are typically of high hazard locations, locations with a large number of staff, and /or a cross-section of Division space of the Team’s choosing. Field visits are performed primarily to give the MESH Team a sense of how the division safety programs and ISM plan requirements are implemented. Field visits should not focus on technical findings. Informal interviews should be a major component of this activity.
- Interviews of Division personnel are the primary review methodology and constitute the majority of the MESH Team’s efforts (3-5 hours). They are conducted throughout the review and encompass as many job levels within the Division as feasible; Division Directory/Deputy, Department Heads, PI’s, line staff, students and new staff. Some interviews are scheduled while others are conducted randomly during the field visit. The MESH Team should identify the candidates for scheduled interviews. Furthermore, in order to obtain the most candid feedback possible, Division management should not be present for interviews with staff.
The MESH Team may consider interviewing the Division Director last. By doing so, the Team can consolidate an opinion of divisional performance prior to engaging the Director. This also serves as an opportunity for the Director to hear significant findings concurrent with the review.
- The Team can meet (1-2 hours) to discuss the findings, either before or after the draft report is prepared.
- Roles of non-RSC Parties
- Aid in scheduling meetings, inspections, and related activities.
- Aid in MESH document collection and preparation; provide other review documents
- Review lines of inquiry to ensure consistency with MESH scope.
- Review draft report to ensure consistency with MESH scope.
- OCA will not participate in interviews, field activities, or report preparation.
DOE/ Berkeley Site Office Observation:
- BSO may observe the MESH Team meeting in preparation for reviews. This provides DOE the opportunity to observe discussions regarding the MESH Team’s lines of inquiry, proposed staff interviews, and proposed inspection locations.
- Following the MESH review, BSO may observe the divisional out-briefing (if conducted) and review a draft version of the final report.
- The MESH Team and subject Division will address BSO questions and concerns resulting from the review of the draft final report.
- BSO will not observe formal review activities.
- If subject Division approves, BSO may observe Division response and presentation to the Safety Advisory Committee meeting.
- MESH Report
- The MESH Team prepares a report of its review. The report includes a brief summary of the Division organization and operation, summary of the review process, and results of the review. The results are categorized as follows:
Noteworthy practices – practices conditions that are recognized for their excellence and should be considered for lab-wide application.
Observations – observations indicate room for improvement. They may be practices and conditions that are not necessarily out of compliance as observed, but could lead to non-compliance if left unaddressed. Observations also reflect practices that, with some additional level of effort, could achieve noteworthy practice status.
Concerns – clear cases of practices or conditions that do not comply with regulations or LBNL policy, and/or indicate inadequate ES&H management systems within the Division. Concerns are deficiencies and must be corrected.
Workspace safety deficiencies identified during field visits are noted to the Division Safety Coordinator for input into the Corrective Action Tracking System (CATS). If there are sufficient safety findings to indicate an unsatisfactory trend, those findings are summarized and documented in the MESH Report.
The MESH Team should consider the implications of their findings by commenting in the report on what they may reveal about the overall ES&H management within the division and/or institution. The MESH Review Report also includes the status of corrective actions taken by the Division in response to each concern, and appropriate observations, raised in its previous MESH Review.
- The MESH Team submits a draft report to the Division. The Division conducts a factual accuracy review of the report and communicates any concerns back to the MESH Team.
- The Team submits the final report, with signature sign-off by each Team member, to the SAC Chair, the assessed Division’s Director, and the Division Safety Coordinator.
- MESH Review Follow-up Activities
- The Division performs these follow-up activities:
- Enters and tracks findings in CATS.
- Presents its ES&H program and proposed corrective actions for all concerns and, as appropriate, observations from the completed MESH Report at the next available SAC meeting.
- The SAC performs these follow-up activities:
- MESH Team presents a summary of its MESH Report to the SAC. This may done at the same meeting, and just prior to, the Division’s presentation to the SAC.
- MESH Team Leaders recommend the MESH review cycle for each Division.
- SAC provides the ISM Board with its recommended MESH review cycle.
- Integrated Safety Management Board
The ISM Board consists of the Lab's Deputy Director, Chief Operating Officer, and the EH&S Division Director. The Board convenes in order to assure continued adherence of each division’s operations to the philosophy, requirements, and parameters established in the Institutional ISM Plan.
Divisions meet with the ISM Board following their periodic Management of Environment, Safety and Health (MESH) reviews. Within 6 months of issuance of the final MESH review report, the reviewed division schedules a follow-up meeting with the ISM Board. The assessed Division Director attends this meeting of the ISM Board in order to:
- Discuss findings of the MESH Review and the division’s response.
- Communicate and discuss changes to the division ISM Plan since it was last presented to the ISM Board. Some changes may include responses to the most recent MESH Review. This discussion will then serve as a revalidation of the ISM Plan by the Board.
- Discuss the recommended MESH review cycle as agreed upon by the SAC.
The Office of Contract Assurance (OCA) supports the ISM Board Activities. OCA meets with the subject division prior to Board presentations and attends Board meetings to review institutional issues and action items stemming from the MESH reviews.