Project Specifics

Longenecker & Associates, a Geosyntec Company, was engaged by national laboratory management to conduct an effectiveness review (ER) to assess the effectiveness, sustainability, and resilience of two corrective actions (Actions 1 and 2) from a recently implemented corrective action plan (CAP) developed following a series of low-oxygen alarm events at laboratory facilities. Our review was the final step in evaluating these critical safety improvements.

Both corrective actions were implemented by the laboratory’s occupational safety and health division, as detailed below:

• One-Time Oxygen Monitor and Assessment Review (Action 1): The laboratory’s occupational safety and health division conducted a comprehensive snapshot analysis to identify every oxygen monitor in the laboratory, along with its status and the status of its associated exposure assessment. Identified deficiencies were promptly corrected, and the review was documented. New procedures for hazard identification and industrial hygienist evaluation for any new alarm-related activity or potential oxygen deficiency hazard (ODH) were established, and master equipment lists are now reviewed monthly for accuracy.
• Management Report Modification (Action 2): We added two columns to the monthly and quarterly reports sent to senior management: the percentage of current and approved exposure assessments and the number of exposure assessments remaining to be performed. While not a direct corrective action to a specific cause, these changes provided ongoing management oversight and were deemed a prudent improvement to management reporting.

Geosyntec Scope of Services

To confirm our client had effectively and sustainably closed identified safety gaps, we assembled a team of subject matter experts to conduct an ER to rigorously assess the two corrective actions listed above. We conducted comprehensive document and record reviews, including examining procedures, plans, the original causal analysis report, the CAP, integrated work documents, and communications. We also interviewed key management personnel. Additionally, our team included a mission assurance specialist who was directly involved in the corrective actions to gather qualitative insights into implementation.

The areas of interest and resulting actions included the following:

• Inadequate Exposure Assessments: We reviewed whether the exposure assessments for systems with the potential to displace oxygen and contribute to safety risks had been adequate and effective.
• Systemic Deficiencies: We identified and addressed institution-wide problems related to oxygen monitor status and the management of associated safety data.
• Management Awareness: We addressed a need for senior leadership to have clear, consolidated, and routine visibility into the status of these critical safety assessments.
• Sustainable Resolution: We developed and implemented corrective actions that would fix immediate issues and establish resilient processes to prevent the recurrence of similar low-oxygen events.

The ER concluded that both corrective actions were completed consistent with their plan and intent, and they sustainably resolved the gaps addressed by the CAP.

Notable Accomplishments

Overall, our review provided critical validation that our client’s actions to improve management of low-oxygen hazards were successful and sustainable, contributing to a safer working environment, as follows:

• Confirmed the Effectiveness of Action 1: Action 1 was rated “EFFECTIVE.” We confirmed that current exposure assessments exist for all areas with existing oxygen monitors. Our review established a new, proactive requirement for industrial hygienist evaluations and exposure assessments for new alarm-related activities.
• Improved Management Oversight as Planned (Action 2): Although Action 2 was categorized as a “Completed Non-Corrective Action,” it was recognized as a prudent improvement. Routinely providing senior management with clear metrics on exposure assessment status significantly enhances oversight and reduces the likelihood of incomplete assessments.
• Sustainable Hazard Control: The implemented actions support processes that identify, assess, and manage potential low-oxygen hazards across the institution, moving beyond reactive responses to proactive prevention.
• Enhanced Safety Protocols: By verifying oxygen monitor status, correcting deficiencies, and improving the documentation and ongoing review of exposure assessments, the laboratory has strengthened its safety protocols for oxygen-deficient environments.
• Recommendation for Continuous Improvement: The ER recommended that occupational safety and health procedures be reviewed to confirm control over oxygen monitor needs, locations, and maintenance. It also recommended periodic surveillance to maintain compliance.

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