Safety and Occupational Health Program Evaluation

Department of Interior

Bureau of Indian Education

September 23, 2011

Table of Contents

Scope and Limitations of the Department of the Interior’s Safety and Occupational Health Evaluation for the Bureau of Indian Education ................................i

1.0 Executive Summary ...................................................................................... 1

2.0 Background and Purpose of the Safety and Occupational Health Evaluation Program ......................................................................................................... 3

3.0 Approach to the SOH Evaluation ................................................................. 4

4.0 SOH Evaluation Results ............................................................................... 4

4.1 Results by Component ......................................................................................................6

4.2 Strengths and Weakness .................................................................................................15

5.0 Documents, Interviews, Walkthroughs ....................................................... 16

6.0 Maturity Model ........................................................................................... 17

7.0 SOH Evaluation Team ................................................................................ 18

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Scope and Limitations of the Department of the Interior’s Safety and Occupational Health Evaluation for the Bureau of Indian Education

Department of the Interior (DOI) Safety and Occupational Health (SOH) evaluations were conducted for the Indian Affairs (IA) Division of Safety and Risk Management (DSRM), the Bureau of Indian Affairs (BIA), and the Bureau of Indian Education (BIE). Information from these evaluations was gathered at the IA Central Office where DSRM is located, BIA regional offices and agency offices, and BIE schools to gauge effectiveness of the SOH programs. All information was rolled up into three reports; one for IA DSRM, one for the BIA safety program, and one for the BIE safety program. All reports represent results from an overall perspective rather than for any individual office reviewed. This SOH Evaluation report is for the overall BIE SOH Program. Results of the IA DSRM and BIA SOH evaluations are reported separately. However, the BIA regional safety managers and the DSRM support BIE operations; therefore, this BIE SOH Evaluation report discusses the effectiveness of BIA regional safety support and DSRM support provided to BIE. The scope of the evaluation was limited to a sample of IA, BIA, and BIE operations and schools selected by the IA DSRM Division Chief. The offices and schools evaluated that fall within the purview of this BIE report include the IA Central Office (specifically DSRM) in Albuquerque, NM; the Navajo Regional Office in Gallup, NM (specifically regarding the safety support provided to BIE); the Southwest Regional Office in Albuquerque, NM (specifically regarding the safety support provided to BIE); and several schools covering a range of grade levels, locations, and management structures.1 Even though multiple offices and schools were included, the SOH Evaluation covered only a limited sample of BIE operations. The results of the SOH Evaluation should, therefore, be viewed in the perspective of the sample evaluated. Overall results could vary if an alternate sample of offices and operations was evaluated. The Handbook to Guide Completion of the Safety and Occupational Health Program Evaluation Tool (referred to as “Handbook”) and the SOH Evaluation Protocol were used as guidance to perform the evaluation. In accordance with the Handbook, the SOH Evaluation focused on programmatic issues and was not intended to represent a worksite occupational safety and health inspection. Worksite walkthroughs were conducted only for the purpose of evaluating implementation status of the BIE SOH Program. Any findings from these worksite walkthroughs were provided verbally and informally to site personnel during the walkthroughs, daily meetings, and outbriefings.

1Schools evaluated included: To’Hajilee (grant school, K-12); Fort Wingate Elementary and High Schools; and the Southwestern Indian Polytechnic Institute (SIPI, two year college).

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1.0 Executive Summary The DOI Office of Occupational Safety and Health (OSH), with support from Federal Occupational Health (FOH), conducted SOH evaluations for IA DSRM, BIA, and BIE in April of 2011. These evaluations were intended to determine the effectiveness of the DSRM safety functions and BIA and BIE SOH programs. Results of the BIE SOH Evaluation are presented in this report. The quality and availability of BIA safety support to BIE are also addressed in this BIE report, as are aspects of DSRM support of BIE. Further information can be found in the separate IA DSRM and BIA SOH Evaluation reports. The SOH evaluation focused on six main components essential for an effective safety and health program:

1) Management and leadership 2) Employee involvement 3) Hazard recognition and prevention 4) Evaluation and analysis 5) Training and awareness 6) Program implementation and operation.

BIE has undertaken management and leadership initiatives for student safety and security, but still needs to for occupational safety and health. BIE management has established “student” safety and security as a clear organizational value and has taken actions to emphasize this area. However, occupational safety and health (which is the focus of this DOI SOH Evaluation) is not currently a BIE emphasis. Occupational safety and health requirements need to be understood and implemented by BIE management and staff. BIA is to provide safety and health technical support to BIE through its regional safety managers. However, BIA management and leadership have not been well established in support of the BIE SOH Program. BIA and BIE management need to ensure that various required elements of the SOH Program have been identified and fully implemented for BIE such as job hazard analysis (JHA), facility inspections, timely abatement actions, mandatory occupational safety and health programs required by OSHA and IA, injury and illness reporting requirements, training requirements, and others. In certain instances, BIA management has re-assigned regional safety managers away from their safety responsibilities specified in BIA safety policy, or has assigned collateral duties which dilute safety manager effectiveness and focus. It is apparent that some regional safety managers provide little technical support to BIE operations. The process or system for BIA to support BIE is not effectively structured, planned, or focused. Except for regional managers, senior executive management for both BIE and BIA chose not make themselves available to discuss the BIE and BIA SOH programs with the SOH Evaluation Team. Senior BIE and BIA management and leadership for the SOH Program are identified as a WEAKNESS. In addition, the inconsistent or inadequate level of BIA support to BIE is also a WEAKNESS. BIE school principals and presidents have established forums and assignments to achieve employee involvement in safety initiatives such as for student safety and security. At the school level, BIE needs to apply these same systems to enhance occupational safety and health. Employees and middle managers universally expressed sincere interest in worker and facility safety and voiced willingness and commitment to implement necessary safety measures.

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However, personnel at all levels almost universally lacked the knowledge and understanding of occupational safety and health requirements (i.e., OSHA-type requirements) to be fully effective in implementing appropriate worker protection measures. Through training, support, and guidance, BIE needs to enhance the safety knowledge and awareness of mid-level managers and employees to ensure safe conduct of work. Hazard recognition and prevention in facilities is accomplished through worksite inspections. The BIA regional safety managers have the responsibility for conducting these inspections at BIE schools and facilities. The inspections are performed at some but not all BIE facilities, and they are not always conducted on an annual basis, as required. IA DSRM utilizes an excellent deficiency tracking system to facilitate tracking and abatement of facility hazards (Facility Management Information System, FMIS, which is an IA STRENGTH). However, BIE and BIA allow many self-identified deficiencies and hazards to go uncorrected, without defined abatement plans, and for extensive periods of time. Lengthy delays in the correction of known hazards pose a significant WEAKNESS and vulnerability to BIE and BIA. Regarding activity-based hazard analysis, BIE generally needs to have a formal system for hazard identification, evaluation, and control for the more hazardous work it conducts. Job hazard analyses (JHAs), written safe work practices, or comparable processes need to be in place as required by IA for BIE operations. BIE needs its own internal safety resources (i.e., staff) or technical knowledge to be able to effectively conduct evaluation and analysis of SOH Program implementation. BIE relies on BIA safety managers to provide this expertise and support. However, BIA regional safety managers have not adequately assisted BIE in evaluating and identifying BIE SOH programmatic needs and, therefore, BIE has not implemented many SOH requirements. IA DSRM needs to extend its oversight evaluations to assist BIE in base-lining BIE SOH requirements. Another element of evaluation and analysis is injury and illness recordkeeping, analysis, and investigation. BIE records injuries and illnesses and enters records into the DOI Safety Management Information System (SMIS), but BIE also needs to maintain and post records in accordance with OSHA requirements (29 CFR 1904). BIE needs to provide workers with the necessary safety and health training as required by OSHA standards and IA requirements. BIE, with BIA support, needs to fully evaluate training requirements based on activities and hazards and ensure that workers receive mandatory training required under such OSHA standards as hazard communication (i.e., chemical use and storage), noise, respiratory protection, blood-borne pathogens, and others. BIE also needs to provide managers, supervisors, and employees with a basic knowledge of OSHA general industry and construction standards. The lack of basic knowledge about the OSHA standards results in a systemic vulnerability regarding lack of program implementation. To define safety and health program implementation and operation requirements, IA has developed policy and has assigned responsibilities in the Indian Affairs Manual (IAM), which applies to BIE. IA has also defined requirements in Safety and Health for Field Operations, which is also applicable to various BIE functions such as facility maintenance. Although partially followed, a variety of important aspects of the policy and requirements still need to be implemented by BIE (e.g., JHA, hazard communication, other required OSHA programs) or need to be implemented consistent with OSHA requirements (e.g., injury and illness reporting).

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BIE needs to develop and implement vital and fundamental programs to ensure worker protection and achieve compliance with many specific OSHA standards. Lack of program implementation is a BIE and BIA WEAKNESS and systemic vulnerability. In summary, BIE management and staff hold student safety and security as an organizational value and have undertaken initiatives to improve student safety and security; however, management needs to apply similar value and initiative to occupational safety and health. At all levels, BIE lacks the understanding and knowledge necessary to establish an effective occupational safety and health program. In addition, BIA needs to provide the necessary support to BIE for it to establish an effective occupational and safety and health program at the school level. As a first step, BIE with BIA support, needs to fully evaluate occupational safety and health requirements that apply and then establish responsibilities, programs, and implementation actions accordingly. IA DSRM also needs to provide support in this regard, but not in a manner that relieves BIA of its responsibilities. BIE and BIA also need to clearly establish a defined plan and process for BIA safety resources to support BIE.

2.0 Background and Purpose of the Safety and Occupational Health Evaluation Program In order to meet the requirements of the Occupational Safety and Health Act of 1970, Executive Order 12196, and 29 CFR 1960, the DOI is conducting SOH Program evaluations at its bureaus and offices. These are independent SOH evaluations conducted by the DOI Office of Occupational Safety and Health (DOI OSH, Headquarters). To ensure effective evaluations, DOI conducted a pilot evaluation in 2010 to evaluate the SOH Program at the Bureau of Reclamation (BOR) and applied the experience and lessons learned from the pilot to refine and perform the BIE evaluation. DOI obtained the support of FOH to conduct the evaluation. An SOH evaluation protocol established the approach used to conduct BIE’s evaluation. This SOH evaluation protocol provided the necessary detail to conduct this evaluation along with the Department’s Handbook. This report presents the SOH Evaluation results for BIE, including safety support provided to BIE by BIA. The SOH Evaluation reviewed the status of the overall BIE SOH Program. The evaluation included site visits to central and regional offices and schools. The primary objective of this SOH Evaluation is to evaluate the status of the BIE SOH Program with respect to its development, availability, completeness, implementation, and effectiveness, including strengths and weakness.

The Handbook to Guide Completion of the Safety and Occupational Health Program Evaluation Tool (referred to as “Handbook”) and the Evaluation Protocol were used as guidance to perform the evaluation.

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3.0 Approach to the SOH Evaluation This DOI SOH Evaluation was conducted for the BIE SOH Program, with on-site evaluation activities occurring in April 2011. Locations visited during the evaluation that apply to BIE or BIA and DSRM safety support of BIE included: IA Central Office in Albuquerque, NM (specifically the DSRM); the Navajo Regional Office in Gallup, NM (specifically BIA safety support provided to BIE); the Southwest Regional Office in Albuquerque, NM (specifically BIA safety support provided to BIE); and several schools covering a range of grade levels, locations, and management structures (including To’Hajilee grant school, K-12; Fort Wingate Elementary and High Schools; and the Southwestern Indian Polytechnic Institute, SIPI, two year college). Evaluation activities at each location were preceded by an in-briefing and concluded with an out-briefing provided to management. BIE, BIA, and IA personnel were provided the opportunity for factual accuracy review and comment regarding evaluation results. The evaluation focused on the effectiveness of the overall BIE SOH Program, rather than any individual office or school. Specific locations were visited only for the purposes of evaluating implementation and application of the overall BIE program. The SOH Evaluation was conducted using the guidance found in the SOH Evaluation Protocol and Handbook. The SOH Evaluation Team conducted personnel interviews, document and records reviews, field walkthroughs, and observations to form the basis for its evaluation results. Upon completion of site activities, the SOH Evaluation Team documented conclusions, observations, and vulnerabilities that were reviewed by DOI OSH, IA, BIE, and BIA and that are presented in this report.

4.0 SOH Evaluation Results This section presents the results of the BIE SOH Evaluation. The results are organized by the six main “components” found in the Handbook. These components along with subordinate elements are shown in Table 1. The subordinate elements provide descriptions of the topics addressed in the evaluation for each component; however, the results of the evaluation are not intended to address each element individually. For each component, one or more conclusions are presented that capture key evaluation results. Each conclusion is followed by a number of supporting observations and discoveries that form the basis for the conclusion. Conclusions and supporting observations/discoveries can indicate either an effective aspect of the SOH Program or an aspect that requires attention.

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TABLE 1 SOH Evaluation Components and Elements

Component 1: Leadership and Management (i) Management Commitment, Involvement and Communication (ii) Responsibility and Accountability (iii) Financial Resources (iv) Personnel Resources (Size and Technical Skills of Staff) (v) Policy (vi) Program Promotion and Recognition Component 2: Employee Involvement (i) Safety Committees and Councils (ii) Program Involvement Component 3: Hazard Recognition and Prevention (i) Inspection, Identification and Prioritization of Deficiencies (ii) Hazard Control and Abatement (iii) Reports of Unsafe and Unhealthful Conditions (iv) Process/Operational Hazard Analysis, Management of Change Component 4: Evaluation and Analysis (i) Program Evaluation and Assessment (ii) Accident Analysis and Prevention (iii) Data Analysis, Performance Metrics, Management Review/Follow-up Component 5: Training and Awareness (i) Mandatory Safety and Occupational Health Training (ii) Training for Safety and Occupational Health Professionals (iii) Training for Collateral Duty Safety & Health Officers and Safety Committee Members (iv) Promotion and Awareness Programs Component 6: Program Implementation and Operation (i) Accident Reporting and Investigation (ii) Industrial Hygiene and Occupational Medicine (iii) Fire Protection and Prevention (iv) Occupant Emergency Planning (v) Motor Vehicles and Motorized Equipment (vi) Contractor Safety (vii) Procurement and Design Review (viii)Specialized Programs and High Hazard Operations

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4.1 Results by Component Results for each of the six components shown in Table 1 are presented below.

4.1.1 Component 1: Leadership and Management

Conclusion 1-1: Although not a focus of this SOH Evaluation, which addresses “occupational” safety and health, the SOH Evaluation Team notes that BIE management has established “student” safety and security as a clear organizational value and has taken many initiatives to emphasize this area. However, occupational safety and health needs to also be a BIE emphasis and well understood by BIE management and staff (also see Conclusion 1-2, below).

Supporting Observations and Discoveries for Conclusion 1-1:

• BIE management has implemented practices and facility improvements to enhance student safety and security, which include measures to address physical security of school grounds, facility improvements, bullying, and others.

• School management (i.e., principals) have established safety committees and

assigned “safety specialists” to address student safety and security. Safety specialists generally do not have responsibility for and do not have a good understanding of occupational safety and health.

• BIE management needs to have a good understanding of occupational safety

and health requirements, and see that these requirements are implemented (also see Conclusion 1-2, below).

Conclusion 1-2: BIE senior line management above the school principal level needs to provide effective management and leadership for the BIE occupational safety and health program and practices.2 School principals/presidents and staff are keenly interested in safety and implement practices to enhance safety; however, principals and staff lack knowledge in occupational safety and health and receive only limited support from BIA safety managers and staff. As a result, important occupational safety and health measures are often not implemented. This is a BIE and BIA WEAKNESS (see Section 4.2).

2Management should establish safety as an organization value and ensure that its policy is implemented in a manner consistent with OSHA requirements and guidance that include the following: “State clearly a worksite policy on safe and healthful work and working conditions, so that all personnel with responsibility at the site and personnel at other locations with responsibility for the site understand the priority of safety and health protection in relation to other organizational values." 29 CFR 1960. “A statement of policy is the foundation of safety and health management. It communicates the value in which safety and health protection is held in the business organization. If it is absorbed by all in the organization, it becomes the basic point of reference for all decisions affecting safety and health. It also becomes the criterion by which the adequacy of protective actions is measured.” www.OSHA.gov Also see Handbook Component 1, Leadership and Management; Element (v), Policy for information on the development and evaluation of safety policy.

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Supporting Observations and Discoveries for Conclusion 1-2:

• BIE senior line management (e.g., education line officers and above) need to provide significant leadership for the occupational safety and health program. Senior management relies on school principals/presidents to have the overall responsibility for safety.

• School principals or presidents and staff demonstrate keen interest in safety.

Schools generally have safety committees, collateral duty safety officers (CDSOs), and safety specialists. Additionally, it is evident that principals/presidents and staff have taken various actions to enhance safety. However, management still needs to provide facility management personnel, supervisors, CDSOs, safety specialists and other staff with a base of knowledge that allows them to understand occupational safety and health requirements and implement effective worker protection measures (see Sections 4.1.2, 4.1.5, and 4.1.6).

• Management needs to clearly assign responsibility for correction of hazards

and deficiencies identified during walkthrough inspections. This lack of accountability results in delay or inattention regarding the correction of known hazards (see Section 4.1.4).

• Management and staff voiced concerns regarding the level of support received

from BIA safety managers and safety staff (see Conclusion 1-3, below).

• BIE management needs to better understand and utilize the technical support available (as resources allow) from the IA DSRM. This Division is a strength of the IA SOH Program and has professional staff to assist in various aspects of safety program implementation. However, BIA and BIE need to assure that this Division is not burdened with responsibilities that the BIA regional safety managers should be performing as part of their assigned responsibilities.

Conclusion 1-3: BIA management and safety managers need to ensure that occupational safety and health support is adequately provided to BIE. Both BIA and BIE need to establish an effective mechanism to coordinate safety support from BIA to BIE. This is a BIE and BIA WEAKNESS (see Section 4.2).

Supporting Observations and Discoveries for Conclusion 1-3:

• BIA safety support provided to BIE is limited by factors such as lack of

accountability within BIA for safety performance, the re-assignment or diversion of regional safety managers from their occupational safety and health responsibilities, and BIA not fulfilling its safety responsibilities as defined by BIA policy and 29 CFR 1960. (See the BIA SOH Evaluation report for further details on these shortcomings.)

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• Resources and budgets are often cited as limiting factors impacting the safety program. Both BIA and BIE management need to establish budget and resources for the SOH Program in an integrated manner with its operational budget. This would have the benefit of integrating safety with operations, rather than viewing them as separate functions.3

• BIA safety managers need to fully identify occupational safety and health

programs that apply to BIE and support their implementation at the BIE schools. Necessary programs required by OSHA and IA need to be implemented for both BIA and BIE (see Section 4.1.6 of this report and of the BIA SOH Evaluation report). Similarly, occupational safety and health training requirements under these programs need to be identified and supported (see Section 4.1.5).

• Overall, BIA safety managers have not evaluated the status of BIE safety and

health program implementation and have not effectively assisted BIE in addressing SOH program needs and corrective actions. IA DSRM needs to extend its SOH oversight evaluations to BIA to assist in base-lining SOH programmatic requirements that apply to BIE.

• BIA management has partially established facility walkthrough inspections to

support BIE, but not at all facilities and not always at the frequency required by IA directives and 29 CFR 1960. Some BIA regions provide these walkthroughs more consistently than others.

• BIE management, principals, and staff apparently have little ability to direct

and target safety and health support from BIA safety managers to where BIE believes it is needed.

• Overall, BIA and BIE need to establish an effective mechanism to gain

occupational safety and health support for BIE operations. Except for the understanding that facility walkthroughs are to be performed by BIA (and even these are not universally performed as required), there is a fundamental lack of planning and focus for BIA safety support to BIE. The lack of knowledge regarding the need for development and implementation of various occupational safety and health programs is one example of this flaw in management structure and coordination.

3Generally an attribute of an effective safety program is the integration of safety with operations (i.e., the mission); thereby, creating a “line management safety program” or what some refer to as “integrated safety management”. When properly implemented, this approach ensures that safety is integral to the conduct of work, ensures that mission requirements are not in conflict with safety, and ensures that both are conducted in a unified manner without considering each as separate or competing functions. Operational budgets should integrate required safety resources and functions.

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4.1.2 Component 2: Employee Involvement

Conclusion 2-1: BIE school principals/presidents have established forums and assignments to achieve employee involvement in safety (mostly student safety and security). Employees and middle managers universally expressed sincere interest in worker and facility safety and voiced willingness and commitment to implement necessary safety measures. However, personnel at all levels almost universally need the knowledge and understanding of occupational safety and health requirements (i.e., OSHA-type requirements) to be fully effective in implementing appropriate worker protection measures.

Supporting Observations and Discoveries for Conclusion 2-1:

• At the schools, BIE has generally established safety committees with

employee involvement, has assigned CDSOs from employee ranks, and has established “safety specialists” (safety specialists are more oriented to student safety and security rather than occupational safety and health).

• Much of the focus of the safety efforts deal with school/student safety and

security. However, some occupational safety and health initiatives are also underway at various schools, such as housekeeping efforts, preparation of some written procedures, and abatement of some hazards.

• BIE employees voice sincere interest in safety-related matters and express

willingness to implement necessary occupational safety and health measures. However, employees and supervisors generally need the knowledge and understanding of safety requirements associated with OSHA, National Fire Protection Association (NFPA), and other industry standards. For instance, even CDSOs need training in hazard recognition.

• The need for safety-related training inhibits effective employee involvement

in worker protection efforts (see Section 4.1.5, Training and 4.1.6, Program Implementation). However, overall, the schools have made genuine attempts to involve employees in the safety of staff and students.

4.1.3 Component 3: Hazard Recognition and Prevention

Conclusion 3-1: BIA regional safety managers and/or safety personnel are required to conduct worksite inspections of BIE facilities; however, these inspections are not consistently conducted and deficiencies (although tracked) are often not promptly corrected.

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Supporting Observations and Discoveries for Conclusion 3-1:

• BIA regional safety managers are required to conduct annual worksite safety inspections of all facilities, including BIE facilities. Some regions generally perform these inspections, while others need to complete required inspections. Where conducted, various types of hazards are identified, but a significant number of these conditions take months or even many years to correct, even if the corrections require little or no funds (also see Conclusion 3-2).

• The SOH Evaluation Team identified a variety of deficiencies at BIE schools that were either not recognized during the annual inspections or that went uncorrected from the prior year(s). This indicates both a need for hazard recognition training for the inspectors and a need for more vigilance in correcting known deficiencies.

• BIE needs to clearly assign responsibility and establish accountability by

school or school system for the correction of identified facility hazards.

• When hazards or deficiencies are identified, the safety managers enter them into a deficiency tracking system called the Facility Management Information System (FMIS), but abatement plans are often not prepared or are delayed, and deficiencies are often left open for long periods of time (also see Conclusion 3-2, below).

Conclusion 3-2: Deficiencies found during BIE inspections are entered into a deficiency tracking system (Facility Management Information System, FMIS) that is utilized by IA DSRM. However, FMIS is often not used as designed by BIE and BIA to provide assurance and documentation that identified hazards/deficiencies are properly abated. BIA regional managers, regional safety managers, facility managers, and BIE responsible parties need to effectively use the system to ensure prompt and appropriate closure of known hazards. The delayed (or even lack of) response to mitigate “known” hazards is a significant and important BIA and BIE vulnerability and WEAKNESS that BIA and BIE need to promptly remedy.4

Supporting Observations and Discoveries for Conclusion 3-2:

• The IA DSRM utilizes the FMIS system to record, track, abate, and close

facility hazards and deficiencies identified during annual facility inspections.

4This DOI SOH Evaluation is not intended to be an OSHA type inspection; however, the SOH Evaluation Team offers the following information for BIE and BIA consideration. Many of the hazards identified during facility inspections would be considered as “serious” by OSHA. If known hazards are not corrected in a timely manner, not only does the hazard present a vulnerability to worker safety, but an additional vulnerability is created in that OSHA could consider these hazards as “willful” violations. A willful violation is defined as a violation in which the employer knew that a hazardous condition existed but made no reasonable effort to eliminate it, (i.e. plain indifference or a conscious disregard to comply), and in which the hazardous condition violated a standard, regulation, or the OSH Act. Penalties in the private sector range from $5,000 to $70,000 per willful violation.

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This system is an IA strength (see IA DSRM SOH Evaluation report for further details).

• An abatement plan is to be prepared and entered into FMIS by the responsible

official at BIE or BIA to address hazards and deficiencies. However, these abatement actions are often not prepared or are delayed.

• Many abatement actions for hazards that OSHA would consider as “serious”

are not promptly addressed and corrected. Many of these hazards are not corrected for months or years after the inspection even though they require little if any expenditure. Known hazards that go uncorrected present a particular vulnerability to BIE and BIA.

• As one example, the SOH Evaluation Team identified a number of machine

guarding issues in schools’ maintenance shops and student vocational shops. These conditions have been in place for a significant time and still need to be corrected.

Conclusion 3-3: BIE needs to establish job hazard analysis (JHAs), safe work practices/procedures, or comparable processes for the identification and control of hazards for more hazardous activities. The lack of JHAs is one aspect of the WEAKNESS that deals with lack of program implementation (see Conclusion 6-1 and Section 4.2).

Supporting Observations and Discoveries for Conclusion 3-3:

• JHAs that identify tasks, hazards, and safe work procedures/practices are

needed for various BIE operations, but BIE still needs to implement this process for jobs or work activities that have “new, non-routine, or hazardous tasks,” as specified by the IA document, Safety and Health for Field Operations. As applicable to BIE, this could include various maintenance and shop operations, among others.

• Some BIE operations have prepared cursory procedures for certain hazardous

work, such as for confined space entry or lockout/tagout for electrical work. However, these cursory procedures do not meet the requirements of the associated OSHA standards.

• OSHA requires hazard assessments for the selection of personal protective

equipment (PPE) that need to be performed. As an example, respiratory protection is used for various maintenance activities, but without a proper hazard assessment, BIE cannot assure that the type of respirator used is appropriate to the hazards of the task.

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4.1.4 Component 4: Evaluation and Analysis

Conclusion 4-1: Both BIE and BIA safety managers, in support of BIE, need to conduct adequate evaluations of SOH programmatic requirements that apply to BIE operations. As a result, BIE has not implemented many SOH requirements.

Supporting Observations and Discoveries for Conclusion 4-1:

• BIE and BIA safety managers supporting BIE need to adequately evaluate

BIE operations and determined the SOH programmatic requirements that apply to various BIE activities and operations.

• Lacking these evaluations, BIE has not implemented many SOH requirements

(as examples, see SOH training and programmatic implementation shortcomings in Sections 4.1.5 and 4.1.6.)

• DSRM needs to extend its SOH oversight evaluations to BIE to baseline BIE

SOH Program status and needs. DSRM is initiating technical support to BIE in this area; however, this evaluation is primarily a responsibility of BIA safety managers in their support role to BIE.

Conclusion 4-2: Although BIE enters injuries and illnesses into DOI SMIS, BIE injury and illness recordkeeping does not meet OSHA requirements.

Supporting Observations and Discoveries for Conclusion 4-2: • The BIE needs to maintain records of injury and illnesses in accordance with

OSHA requirements. Injuries and illnesses are entered into the DOI SMIS system; however, the OSHA 300, Log of Work-Related Injuries and Illnesses is not maintained at many offices/schools and the OSHA 300-A, Summary of Work-Related Injuries and Illnesses is not maintained or posted at many offices/schools, as required by 29 CFR 1904.

• OWCP claims are not consistently submitted in a timely fashion as required by 20 CFR 10. In some cases, claims that are several months old have not been processed by the official charged with this responsibility, contrary to 20 CFR 10 which requires that if an employee incurs medical expense or loses time from work beyond the date of injury, the supervisor must send Form CA-1 to the district office with supporting information as soon as possible, but not later than ten (10) working days after receipt of Form CA-1 from the employee. Not only is this delay in processing contrary to Federal requirements, but it also results in undue financial hardship to injured parties

4.1.5 Component 5: Training and Awareness

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Conclusion 5-1: BIE needs to provide safety-related training based on job requirements, hazards, OSHA requirements, and overall needs appropriate to job position and work activities.

Supporting Observations and Discoveries for Conclusion 5-1: • BIE needs to provide workers with the necessary occupational safety and

health training that is required under OSHA general industry and construction standards. Examples of training that BIE needs to be providing to applicable workers include hazard communication, chemical hygiene practices for laboratories, possibly blood-borne pathogens depending on first aid response requirements, hearing conservation, respiratory protection, and asbestos awareness/worker, among others.

• Hazard communication training, which is fundamental to hazard awareness

and control, needs to be adequately implemented throughout BIE.5

• To determine appropriate and necessary training requirements, BIE needs to have a complete baseline hazard analysis by organization and/or job position to determine a training regime based on hazard, risk, and job requirements. Currently, BIE cannot assure that training is properly selected, or fully demonstrate the basis for providing selected training.6 Presumably this would be a responsibility of BIA regional safety managers.

• CDSOs need training in OSHA standards and requirements and in hazard

recognition that would equip them to better perform their occupational safety and health assignments and responsibilities.

4.1.6 Component 6: Program Implementation and Operation

Conclusion 6-1: A systemic vulnerability applicable to BIE is the need for occupational safety and health programs and practices to evaluate and control occupational hazards. This vulnerability is both a worker protection issue and an OSHA compliance issue. BIE, with support from BIA, needs to determine the applicability of these programs for all operations and develop and implement them where needed. This vulnerability is a BIA and BIE WEAKNESS (see Section 4.2).

5For the BIE facilities evaluated, chemicals are stored and used. A written hazard communication program and associated training as required by 29 CFR 1910.1200 and BIA requirements have not been implemented. Improper storage of chemicals also exists. Hazard communication training can contain general content common to all/most workplaces, but should also include site-specific content that deals with hazard awareness and control for chemical hazards encountered by the workers. As BIE further develops hazard communication training, it should ensure that site-specific content is included. BIE should not accept a short generic computer based course as meeting the intent of the OSHA hazard communication standard. 29 CFR 1910.1200. Similar comments apply to laboratories under the chemical hygiene standard (see 29 CFR 1910.1450). 6As examples, BIE has not determined the extent that training in hazard communication, hearing conservation, blood-borne pathogens, lead awareness, HAZWOPER, and others should be provided to various employees who may be exposed or encounter conditions that require such training.

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Supporting Observations and Discoveries for Conclusion 6-1: • BIE needs to conduct injury and illness reporting and recordkeeping

consistent with 29 CFR 1904 requirements. See Conclusion 4-2 for specific deficiencies.

• BIE does not have and needs to develop and implement hazard communication programs for operations that use and store chemicals (29 CFR 1910.1200). Certain specific elements of hazard communication, such as availability of Material Safety Data Sheets (MSDSs) are in place, but written programs, training, proper labeling and storage, and other requirements are not.7 Hazardous conditions regarding the use and storage of chemicals were identified during the SOH Evaluation. BIE also needs to implement chemical hygiene plans and other measures for laboratory operations (see 29 CFR 1910.1450).

• Where BIE requires certain employees to render first aid as part of their job

function or where employees may have a high potential to come in contact with blood or bodily fluids, such as kitchen, residential hall, facilities, and athletic staff, etc, BIE needs to develop and implement written blood-borne pathogens (BBP) programs (29 CFR 1910.1030).

• BIE makes hearing protection available to workers engaged in certain

activities with noise exposure. However, BIE needs to develop and implement written hearing conservation programs where noise exposure is at or exceeds 85 dBA as an 8-hour time weighted average. BIE does not conduct mandatory industrial hygiene exposure monitoring to determine exposures at or above this threshold. Hearing conservation requirements need to be in place for training in the selection and use of hearing protection, audiometric testing, exposure monitoring, control measure implementation, and other elements.8

• BIE issues respiratory protection to certain workers using chemicals and

paints or who are exposed to dusts/fibers. Respirators are not properly stored and maintained and workers are unaware of the type of protective cartridges to use for various agents; therefore, BIE cannot assure that the respirators offer any protection against the exposure hazards. BIE needs to develop and implement written respiratory protection programs to include training in the proper selection and use of respirators, proper selection of respirator

7OSHA requires that an employer implement a written hazard communication program when employees use and store chemicals in the work place. 29 CFR 1910.1200. 8OSHA requires that an employer implement a written hearing conservation program when employees are exposed to noise above the OSHA action level. 29 CFR 1910.95. BIE/BIA have not made determinations if personnel engaged in maintenance, shop work, and other activities could be exposed to noise above this level, and therefore has not determined the applicability of a written hearing conservation program for exposed individuals that would include audiometric testing, training, and other elements.

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cartridges, maintenance and storage, medical clearance to ensure the ability to wear a respirator, and other elements.

• BIE needs to implement medical surveillance requirements for various OSHA

standards applicable to its operations, such as for blood-borne pathogens, noise, respiratory protection, and possibly others.

• Industrial hygiene (IH) support for exposure monitoring and hazard

identification, evaluation, and control is an important capability that IA, BIA, and BIE do not have in place. IH support is important to many of the programs cited in this section.

• Other programs and procedures that need or may need to be developed include

lockout/tagout procedures to protect against electrical hazards or other sources of hazardous energy and possibly confined space entry, among others.

• BIA and BIE need to clearly assign responsibility for determining program

applicability and then assign responsibility for program development and implementation.

4.2 Strengths and Weakness

During the SOH Evaluation, areas or practices of particular strength or weakness were noted. By definition, a “strength” is considered to be a noteworthy practice that can serve as a model and that merits sharing, review, and possible implementation throughout IA/BIE/BIA or at other DOI bureaus. A “weakness” is a particular issue that represents a causal factor for performance shortcomings and/or that represents an organizational vulnerability in safety and health program implementation and/or worker protection. Four “weaknesses” were identified during the BIE SOH Evaluation, which apply to BIE directly and/or BIA’s support of the BIE safety program. No occupational safety and health strengths were identified during the evaluation. The SOH Team acknowledges BIE efforts with student safety initiatives but this area was not a focus of this evaluation; therefore, possible strengths or weaknesses in this area were not evaluated. Also, see strengths and weaknesses identified in the IA DSRM and BIA SOH Evaluation reports for additional information that may be pertinent to BIE.

Weakness: Senior BIE management (i.e., above the school principal/president level) needs to establish leadership for the occupational safety and health program, establish occupational safety and health as a value within BIE, and ensure implementation of IA occupational safety and health policy and requirements, OSHA requirements, and other Federal requirements. In addition, occupational safety and health requirements for worker protection must be understood at the school level. As a result, many important vulnerabilities and systemic issues were identified in this evaluation.

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Weakness: BIA safety support of BIE is limited in various regions and BIA does not consistently fulfill its responsibilities of occupational safety and health support to BIE as defined in BIA policy and understandings. For instance, BIA safety managers do not consistently perform facility inspections at all regions, have not identified mandatory safety programs required under OSHA standards, and have not supported their development and implementation. BIA and BIE have not clearly established an effective structure, plan, approach, and focus for BIA’s support of BIE, and BIE has little ability to direct or focus BIA’s support of its safety needs.

Weakness: The BIE and BIA allow many known hazards recorded in FMIS to languish for months or sometimes years without development of abatement plans or performing remediation of the hazard. These known hazards include hazards that would be characterized by OSHA as “serious,” and many of these hazards could be abated with little if any expenditure of funds. Failure to abate or excessive delays in abating known hazards represent a particular vulnerability to the BIE and BIA. Weakness: The BIE demonstrated a systemic vulnerability regarding its need to implement occupational safety and health programs to comply with various OSHA standards and to ensure worker protection as required by those standards. Hazard analysis and assessment (i.e., JHAs or equivalent) also need to be implemented. Neither BIE, nor BIA in support of BIE, have evaluated the applicability of various standards and ensured their implementation. Associated safety training is one part of these standards which also needs to be implemented. The BIE needs to provide middle managers, supervisors, and staff with the information and training necessary to be aware of these requirements and to implement appropriate worker protection measures. BIA support of BIE has not been sufficient to address these issues.

5.0 Documents, Interviews, Walkthroughs The SOH Evaluation was conducted through a process of document reviews, interviews, and worksite walkthroughs. Examples of types of documents reviewed included:

• SOH directives, policy, programs, and procedures; • Injury and illness records; • Worksite inspection reports; • Deficiency listings and closure documents; • Training records; • Oversight and assessment reports; • Safety committee charters, agenda, inspections, and other documentation; • Safe work procedures; • Contractor documents related to safety requirements.

Examples of personnel/positions interviewed included:

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• Senior management (e.g., DASHO, BIA regional directors, BIE education line officer, and school principals/presidents);

• Line management and supervisors for diverse operations; • Department/group managers; • Safety and health management and staff; • Safety committee chairs and members; • CDSOs; • Employees at multiple levels and in many organizations; • Facility management personnel; • Technical support personnel; • Contracting representatives.

Worksite walkthroughs were conducted in various types of facilities.

6.0 Maturity Model

The Capability Maturity Model (CMM) was developed by Carnegie Mellon University (CMU) and is used as a general model to aid in improving organizational business processes in diverse areas. When applied to existing organizational processes, CMM allows an effective approach toward improving them.

There are five maturity levels defined along the continuum of the CMM and as the quality of BIE’s SOH processes improves, BIE moves up these five levels. The five maturity levels, from lowest to highest, are:

Level 1 - Initial (Chaotic): Programs at this level are characteristically undocumented and in a state of dynamic change, tending to be driven in an ad hoc, uncontrolled and reactive manner by users or events. Level 2 – Managed/Repeatable: It is characteristic of programs at this level that some processes are repeatable, possibly with consistent results. Program discipline is unlikely to be rigorous. Level 3 – Defined: It is characteristic of programs at this level that there are sets of defined and documented standard processes established and subject to some degree of improvement over time. These standard processes are in place and used to establish consistency of program performance across the organization. Level 4 – Quantitatively Managed: It is characteristic of programs at this level that, using process metrics, management can effectively control the AS-IS process. In particular, management can identify ways to adjust and adapt the program without measurable losses of quality or deviations from specifications. Level 5 – Optimizing: It is characteristic of programs at this level that the focus is on continually improving performance through both incremental and innovative changes/improvements.

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Level OSM

5: Optimizing 5.51 to 6

5 to 5.5

4: Quantitatively Managed 4.51 to 5

4 to 4.5

3: Defined 3.51 to 4

3 to 3.5

2: Managed 2.51 to 3

2 to 2.5

1: Initial 1.51 to 2

1 to 1.5 1.38

Note: The BIE level on the Capability Maturity Model is 1.38 with a standard deviation of .55601. The highest data point is 2.7 and the lowest is 1.0.

7.0 SOH Evaluation Team

The SOH Evaluation Team is comprised of the DOI OSH Safety and Occupational Health Manager and three senior FOH occupational safety and health professionals, each with approximately 35 years professional experience in the field, including performing numerous multi-disciplined high level SOH program evaluations, technical safety appraisals, audits and assessments, and OSHA-type inspections for multiple Federal agencies and other enterprises. The SOH Evaluation Team includes:

• Barry Noll, PE, Safety and Occupational Health Manager, Office of Occupational Safety and Health, DOI (Headquarters). Overall Team Leader from the Secretary’s office.

• Frank Fitzpatrick, CIH, FOH -- Overall FOH Program Manager and primary interface

with DOI. Key responsibilities are to plan and prepare for the evaluation and develop, document, and refine the evaluation process and tools for the evaluations and future evaluations, review deliverables, and coordinate overall Team functions. Mr. Fitzpatrick did not participate in evaluation activities conducted on-site at BIE offices.

• Gary Gottfried, CIH (ret), FOH – SOH Evaluation Team Leader and Senior Industrial Hygienist and primary interface with BIE. Key responsibilities include leading the Evaluation Team during the on-site evaluation process, coordinating site evaluation activities, conducting aspects of the programmatic and field evaluations with a focus on management of the SOH program, industrial hygiene and occupational health, gathering and compiling evaluation information, and preparing results.

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• Jack Janda, MS, CSP, FOH – Senior Safety and Occupational Health Specialist. Key

responsibilities include conducting aspects of the programmatic and field evaluations with a focus on occupational safety and OSHA compliance, recordkeeping, conducting site walkthrough inspections, gathering and compiling field information, and preparing results.

• IA Participant and Liaison: Paul Holley – Chief, Division of Safety and Risk Management and IA representative on the SOH Evaluation Team. Key responsibilities included team liaison with IA, BIA, and BIE offices, arranged opening and closing conferences, selection of offices for the evaluation and attendance during interview and deliberation processes. Also provided support from a facilities, space, physical security standpoint.