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Environmental Health & Safety and Risk Management
Annual Report Department of Safety and Risk Management
California State University Maritime Academy
200 Maritime Academy Drive Vallejo CA 94590
2019
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 1
In accordance with Executive Order 1039 and 1069, California State University Maritime Academy Department of Safety and Risk
Management (SRM) has prepared this annual report for Fiscal Year July 1, 2018- June 30, 2019 and the OSHA recordable injury/illness
Calendar Year of January 1, 2018- December 31, 2018. This report summarizes department activities, performance and key initiatives in
the program areas of occupational environmental, health, safety, emergency management, business continuity, and risk
management. While this report is not intended to provide an exhaustive detail for each area, it will serve to highlight key initiatives,
milestones and future direction for process management prioritization within SRM work streams. SRM is delegated with the
administrative oversight and programmatic responsibility for these program areas as outlined in the applicable Executive Orders.
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 2
EXECUTIVE SUMMARY
Safety Doesn't Happen by Accident
Welcome to the second annual report of the Cal Maritime Department of Environment,
Health, Safety and Risk Management (SRM). This report is our mechanism for communicating
the activities of the EHS and Risk management and our ongoing support efforts toward a
safe campus community.
The role of the Department is to have programmatic administrative oversight of campus
environmental, safety and health compliance regulations through collaborative efforts, and to
provide compliance assistance through targeted outreach, education and training as a means
to emphasize increased awareness on the part of both employees and students of the
importance of an environmental, safety and health culture. The Department strives to provide
assistance in achieving compliance with regulatory standards before enforcement measures
become necessary and, more importantly, before a campus community member is seriously
injured. It is through partnership and collaborative programming that the fundamental
components of an integrated safety management system are derived.
Fiscal Year 2018-19 Performance Highlights
Internal Processes Customer Services Education • 25 EHS Programs developed
and released
• Continued Job Safety
Ana lysis development
• Improve trending analysis
based on injuries/near
misses.
• 1 C O H S A u d i t
• 2 C a l O S H A I n s p e c t i o n
• S e t b a c k w i t h s a f e t y
e m a i l c o m m u n i c a t i o n
v e h i c l e
• Recipient of the President’s
Cabinet Award for Excellence
in Commitment
• Director completed Masters of
Science in OHS
• Enterprise Services Retreat
Facilitator
• Special Event Insurance
processed
• TSGB Day on the Bay Insurance
• FTIP enrollment work flow
improvement
• Facilitated Facilities Use
Agreement Red Oak Victor &
USCG
• Workspace & Ergonomic
Assessments conducted
• Safety Equipment Inspections
• Academic Programming
support to Marine Insurance
curriculum
• SRM webpage iteration 2.0
• 35 First Aid/AED/CPR
Training
• 40 Defensive Driver
Enrollment
• 300 Zombie
Emergency
Preparedness-
Leadership Hour • 78% completion rate
for IIPP.
• 80% completion rate
for Cal-OSHA HazCom.
• 63% completion rate
for Cal-OSHA PPE.
• 83% completion rate
for HWaste.
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 3
Scope of Campus Operations
The California State University Maritime Academy (Cal Maritime) is committed to providing a safe and healthy working environment for the
campus community. Faculty, students, and other personnel in both the operational and academic settings may work with hazardous
materials, equipment, and processes. As a California employer, the Cal Maritime has a general duty and responsibility to provide a safe
Campus environment under the laws and regulations implemented by the California Division of Occupational Safety and Health
(Cal/OSHA) for all shore side operations, Federal OSHA and US Coast Guard for activities taking place aboard the Training Ship Golden Bear
(TSGB). In addition, state law requires the University to maintain an Injury and Illness Prevention Program (IIPP) that includes procedures to
investigate occupational injuries or illnesses, and methods for correcting unsafe or unhealthy conditions in a timely manner. The TSGB Safety
Management System (SMS) is an operational specific program that is required by the maritime industry that supports the overall campus
IIPP.
SRM Resources
Director: Marianne Spotorno, CSP
Phone: 707-654-1076
email: [email protected]
Number of SRM FTE Staff: 1
Number of departmental safety coordinators: 0
SWOT Summary
Str
en
gth
•Committment
•Collaboartive resources
•Program and resource availability
We
akn
ess •Legal, regulatory
compliance
•Resistant and slow to change/modernize existing practices
•Aging infrastructure
•Limited budget resources to champion/drive change manangement strategies
•Understanding hazard/risk potential
•Business Continuity Plans are outdated/not updated
Op
po
rtu
nity •Fostering an
incident/impact free culture
•Enhancing community safety awareness through ongoing communication and training
•Optimizing process management
•Deploying business intelligence and data analytics to increase data-driven decision making
Thre
at •Regulatory compliance
• High rate of injuries
•Student travel/off campus actitive transperency for risk, emergency preparedness and assurance of insurance protection
•Special Event activity transperency for risk and assurance of insurance protection
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 4
What We Do
Road Map to Success
Risk-Opportunities-Action Items-Deliverables, Metrics and Performance
Each service section within SRM has unique and specific management duties and responsibilities that are determined by any number of
compliance requirements, state and federal regulatory agencies, university policies, industry standards, and a commitment to going
beyond compliance, when possible, to ensure a safe and healthy cam-pus, community and state.
• Our Purpose: is to enhance the quality of life for our campus community through the use of an integrated safety management system
• Our Vision: is to be a trusted partner by providing innovative solutions to ensure the health and wellbeing to the campus community.
To improve the environment, reduce risk, and cease opportunities to enhance the vitality of our community.
Risk Management Environment Health & Safety Emergency Preparedness &
Business Continuity Clery Compliance
The main function of the
Safety & Risk
Management is to
manage the process of
improving safety through
education, compliance,
and the constant task of
identifying and evaluating
potential safety hazards in
order to reach the
destination of a safe
academic environment.
Because the breadth and
depth of Cal Maritime is
always expanding, the
process of safety
improvement is fluid,
ongoing and ever-
changing.
The Environmental
Affairs component
proactively manages
the environmental
component of the
campus compliance
with the programmatic
oversight of hazardous
materials management
including the auditing
of storage and
facilitation of disposal.
It is through the use of
knowledge and
experience that
industrial hygiene,
asbestos management,
air and water quality
and safety engineering
are deployed
Occupational Health and Safety
ensures that campus operational
environments are conducive to
good health and wellbeing by
recognizing, evaluating and
controlling health and safety
hazards.
EHS assesses potential safety
hazards, possible instances of
exposure and suitability of
protective equipment.
Collaborating with operating
units and facilities services
personnel to keep historical
buildings functional, while
protecting employee health.
The University maintains a
campus-wide Emergency
Operations Plan that is applicable
to all students, faculty and staff,
departments and work units are
still required to provide employees
emergency procedures specific to
their work area. To assist
departments and work units in this
task, occupational specific
Emergency Action Plans are
developed to align with over all
Campus EOP. This process
provides a worksheet for
departments and work units to
collect emergency information
specific to their department and
develop Business Continuity
strategies. The information is
routinely reviewed and placed, so
that it is ready for use in any
emergency.
The Clery Act is a
consumer protection
law that aims to
provide
transparency
around campus
crime policy and
statistics. In order to
comply with Clery
Act requirements,
Cal Maritime must
understand what the
law entails, where
their responsibilities
lie, and what they
can do to actively
foster campus
safety.
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 5
How We Do It
With the depth of Cal Maritime continuing to expand, the process of EHS compliance management is ongoing and ever changing, requiring
a robust and adaptive management system. In 2018, the department continues to utilize an integrated management system format for the
University's environment, health, and safety compliance programs. This effort is designed to ensure continuous improvements by
incorporating a process for ongoing monitoring, review, and revisions of procedures and policies through the use of the Plan - Do - Check -
Act (PDCA) model. Just as a circle has no end, the Plan - Do - Check - Act cycle is a four step process model for carrying out change,
cycling through each step for continuous improvement.
PDCA Integrated Management System EHS Management System
Plan
• Objectives
• Targets
• Goals
• Objectives
• Work plans
• Program development
Do
• Implementation and Operations • Training
• Communications
• Consultation
• Outreach
• Lab Safety & Hazard Management Plans
• Emergency response
Check
• Check • Inspections
• Accident/Incident statistics
• Monthly reports
• Annual reports
• Performance reviews
Act • Corrective and Preventative Actions • Police and procedure adoption
• Strategic planning process
The SRM department continues to develop and implement tools and processes to proactively assist the campus in the areas of
regulatory compliance and industry best management practices. Periodic reporting metrics as well as the University's safety
committee structure support this process. A critical component of the management system is having the staff perform
compliance verification and utilize this data for planning. Understanding and expertise is essential toward the development and
integration of a safety management system.
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 6
What It Looks Like
Integrated Campus Safety Management System- 5-Year Strategic Plan
Injury, Illness and Impact Free (I-3 Free) System. Creating an environment that empowers people to work safely, to be at their best, and to
respect one another.
Injury, Illness and Impact Free (I-3 Free) System. In alignment with the requirements of Cal Maritime’s Five-Year Strategic Plan, the
Department has incorporated the three OSHA goals as its founding direction. The three overall strategic objectives are centered upon
creating an environment that empowers people to work safely, to be at their best, and to respect one another.
• Key Objective 1. Secure safe and healthy workplaces, particularly in high-risk activities, and improve workplace safety and health
through enforcement and consultative assistance.
• Key Objective 2. Promote workplace cultures that increase employee and student awareness of, commitment to, and involvement
in safety and health.
• Key Objective 3. Maximize Department’s effectiveness and enhance Campus Community confidence.
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 7
Environmental Health & Safety
FY 16/17 FY 17/18 FY 18/19
Total number of buildings 30 30 30
Number of research facility with known hazards 1 1 1
Number of teaching labs with known hazards 8 8 8
Number of teaching shops with known hazards 2 2 2
Total square feet of operational space 280,000sf 280,000sf 280,000sf
Square feet of teaching space 230,500sf 230,500sf 230,500sf
Square feet of laboratory space 17,700sf 17,700sf 17,700sf
Square feet of academic shop space 28,853sf 28,853sf 28,853sf
Square feet of operational shop space 8200sf 8200sf 8200sf *Operational space as determined from the CSURMA Property schedule, does not include residences. Labs: Mechanical, Fluids, Steam, Refrigerant, Electrical, Chemistry,
Physics, 3D printing. Academic Shops: Machine, Welding. Operational Shops: Facilities and Waterfront.
Campus Laboratory & Shop Evaluation
Laboratory: The term, “laboratory” refers to any part of a building used or intended to be used by the University for scientific activities which
may be hazardous; this includes teaching laboratories, shared support facilities, and research laboratories. The safety programs support off-
campus facilities, Training Ship Golden Bear and any other fieldwork locations where approved educational or research activities are
conducted.
Shop: The term “shop” refers to a place where machinery and tools to support the academic mission are used. This includes but is not limited
to, engineering shops, art workshops, and other sites supporting both academic and non-academic operations. It does not include shops
associated with construction.
FY 16/17 FY 17/18 FY 18/19
Hazard assessment conducted (RSS Assess) # of Audits completed ND ND 1
Hazard Inspection conducted (RSS Inspect) / # of observation ND ND 1 58
Hazard Inspection conducted (RSS Inspect) # of non-compliance ND ND 8
Hazard Inspection percent safe ND ND 87%
Chemical inventory conducted (RSS Chemical)/(MSDS Online) 0 1 1
Lab / Shop Safety Evaluation Report conducted / # of observation 1 50 2 100 2 100
Lab / Shop Safety Evaluation Report # of non-compliance 7 23 17
Lab / Shop Safety Evaluation Report percent safe 86% 77% 83% *ND = No data available [due to new program matrix]. Cal Maritime was the last of the CSU Campuses to have the RSS Assess and Inspect tools were installed. Cal Maritime
utilizes MSDS online for its shore side chemical inventory support. TSGB scans SDS into the SMS database. Hardcopy binders are maintained by applicable departments.
Lab/Safety Shop Evaluation Report is a hard copy inspection tool better suited toward Cal Maritime operational dynamics.
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 8
Other Campus Assessments & Evaluations
FY 16/17 FY 17/18 FY 18/19
Office and/or General Administrative Area assessments 5 0 1
Ergonomic assessment 5 0 2
Campus Infrastructure Night Walk assessment 1 0 1
Workspace/Academic space safety assessments 3 2 1 * Workspace Assessments distributed to the campus community through email as well as through request or periodic inspection.
Safety Equipment Inspected
2018 Performance
Total
Inventoried
# Annual
Inspected by due
date
# Annual
Inspected post due
date*
% Inspected &
Certified
First Aid Kits/Stations 30 August August 100%
AED Stations 16 August August 100%
Emergency Showers 4 August August 100%
Emergency Eyewashes 1 August August 100%
Fume Hoods 5 August September 100%
Biological Safety Cabinets N/A N/A N/A N/A
Fire Extinguishers 220 April 0 100% *With the exception of Fire Aid kits and stations, safety equipment annual inspections are managed by Facilities and audited by SRM throughout the academic year. If
inspections conducted after due date, reason(s) for delays are included. Fire Aid kits and stations are management directly by SRM. TSGB “Safety Equipment” is certified
inspected by USCG prior to Cruise each spring.
HVAC Systems Inspected
2018 Performance Total number of
systems
# Inspected by due date # Inspected post
due date*
% Inspected
HVAC Building Systems 39 39 0 100% *HVAC system inspections are managed by Facilities through the use of the campus Preventative Maintenance (PM) system. If inspections conducted after due date,
reason(s) for delays are include.
Occupational Injury and Illness Rate Trending
CY 2016 CY 2017 CY 2018
Total number of employees by FTE 620 509 524
Total Number of Recordable Injuries (by calendar year) 14 13 13
Total Loss Time Cases 6 6 6
Days Away Restricted or Transferred (DART) 3.59 CSU Avg. 1.15 3.0 CSU Avg. 1.10 2.64 CSU Avg. 1.13
Loss Time Incident Rate (LTIR) 2.16 CSU Avg. 0.63 2.10 CSU Avg. 0.60 1.76 CSU Avg. 0.59
Total Recordable Incident Rate (TCIR) 5.03 CSU Avg. 1.74 4.19 CSU Avg. 1.76 3.81 CSU Avg. 1.71
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 9
*Recordable Incident Rate = the number of work-related injuries/illnesses resulting in medical treatment beyond first aid and/or lost work days: (TRIR = # recordable
injuries/illnesses X 200,000) / Total number of hours worked during a calendar year (CY).
Written Program Review
FY 16/17 FY 17/18 FY 18/19
Number of EH&S written programs 0 3 25
Number of programs/process management reviewed 30 3 5
Percentage of programs/process management reviewed 100% 100% 100% *Program Reviews include a documented report on program compliance status
Health and Safety Training
FY 16/17 FY 17/18 FY 18/19
Number of employee training sessions assigned ND 26 649
Number of new employees trained ND 1 195
Number of employees trained via refresher ND ND 0
Number of students with appropriate safety training in courses with
identified hazards and requiring PPE
272 256 288
Number of students in courses with identified hazards and requiring PPE* 20 20 20 *ND = No data available due to no program data. 18/19 CSU LMS transitions to SumTotal. Occupational training matrix standardization in progress. Enrollment numbers
used to calculate student training requirements.
Regulatory Compliance Review
FY 16/17 FY 17/18 FY 18/19
Chancellor’s Office Audit 0 0 1
Cal OSHA Inspection/Citation 0 0 2
County Inspection/Citation 1 0 0 *Cal OSHA Inspection/Citation reflected a Complaint review of the Chemistry lab as a result of the State of California Audit findings from four CSU Campuses which resulted
in a monetary fine of $900 and a Post-Accident investigation that resulted in a serious monetary penalty of $12K.
Safety Committee Meetings
List of Safety Committees: FY 16/17 FY 17/18 FY 18/19
EHS Steering Committee number of meetings held 2 2 4
TSGB Safety Committee number of meetings held 12 12 12 *Mission: Through providing a conduit of communication to improve the campus working environment the EHS Steering Committee is a regulatory required group that
involves teamwork, problem-solving, and discussion toward identifying and developing improvement strategies related to occupational EHS and Emergency
Management process management components.
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 10
Accident Incident Management (AIM)
Lagging Indicators-Comparison Performance Trending within CSU-Systemwide
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 11
Accident Incident Management (AIM)
Lagging Indicators-Comparison Trending for Campus
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 12
Accident Incident Management (AIM)
Lagging Indicators-Comparison Trending for Campus
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
1
2
3
4
5
6
7
8
OSHA RECORDABLE INJURY MECHANISM
CY 2018 CY 2017 CY 2016 Pareto
0
5
10
15
20
25
FY: ALL INJURY TRENDING MODELYearly Monthly '15 Monthly '16
Monthly '17 Monthly '18
Dining
Services
8%Student
Health
8%
Marine
Programs
15%
TSGB
15%
Athletics
15%
Facilities
23%
Police
8%
Faculty
8%
2018 DEPARTMENT DISTRIBUTIONDining
Services
14%
TSGB
22%
Facilities
43%
Police
14%
Accounting
7%
2017 DEPARTMENT DISTRIBUTIONDining
Services
7%
TSGB
14%
Facilities
29%
Admissions
22%
Residential
Life
7%
Marine
Programs
21%
2016 DEPARTMENT DISTRIBUTION
OSHA
Citations
County
Citation
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 13
Risk Management
Insurance Claim Activity
FY 16/17 FY 17/18 FY 18/19
Liability 0 $85 $105,025
Workers Compensation $88,621 $152,978 $231,964
IDL NDI UI $131,222 $154,082 $157,401 * Payroll: 2 years in arrears; i.e., FY 17/18 payrolls are used to calculate FY 19/20 premiums. Premiums: rated on Claims Activity over 5 years; FY 13/14 to FY 17/18 claims
activity used for FY 19/20 rating. Claims Activity: total claim payments during the fiscal year. Liability: claims are capped at $500,000 maximum. Workers' Comp: claims are
not capped.
Travel Services
The SRM supports travel for employees and students on University business with insurance review, risk assessment and emergency
preparedness.
EO 1062: A field trip is a university course-related, off-campus activity led by a faculty or staff member and designed to serve educational
purposes. A field trip would include the gathering of data for research (such as at a geological or archaeological site), museum visit,
participation in a conference or competition, or visits to an event or place of interest. The duration of a field trip may be a class period or
longer, and could extend over multiple days. This definition does not apply to activities or placements in the context of a teacher
preparation program, intercollegiate sports, or service-learning placements, all of which are governed under separate policy.
FY 16/17 FY 17/18 FY 18/19
International Travel-Individual ND 10 12
International Travel-Group Trips( International Experience) 4 4 3
Domestic Off Campus Activities & Field Trips ND 25 29 * Does not include athletics. Geographical component tied to Clery Compliance. Key operational gap is Travel Risk Assessments are not consistently completed.
Procurement & Contracts
FY 16/17 FY 17/18 FY 18/19
Total # of Insurance Exception Requests processed 20 31 13 * Insurance Exception Requests typically applies to campus service providers with low risk, long term incident free relationship and specialty service- sole proprietors
whereby no other option is readily available.
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 14
Special Event
FY 16/17 FY 17/18 FY 18/19
Total # of Special Events w/Alcohol 45 50 32
Total # of Level 2 Special Events ND ND 691
Total # of Level 3 Special Event (Multiple Locations & Service Providers) ND ND 93
Total # of Level 4 Special Event (All Campus & Service Providers) ND ND 917
Total # Special Event Insurance Coverage Purchased 3 5 6 * In today's litigious society, event organizers face potential liability suits from spectators, contractors, and customers. Even if a suit is unjustified, the cost of defense can be
significant. Special Event Insurance applies to public assembly events beyond that of a guest speaker and whereby multiple service providers and/or alcohol may be
present. Key action item is to fully understand campus event dynamics, simplify and streamline the process for campus customers and stakeholders in order to ensure
appropriate insurance coverage is in place. $2,000,000 General Aggregate $1,000,000 Products/Completed Aggregate $1,000,000 Personal & Advertising Injury $1,000,000
Each Occurrence $ 50,000 Fire Damage $ 5,000 Medical Payments. ND = No data available due to new program matrix.
Business Continuity
FY 16/17 FY 17/18 FY 18/19
Number of Business Continuity Plans 27 27 27
Number of Plans reviewed 27 0 0
Percentage of Plan updated 0 0 0
Business Interruption: Campus Closure 0 3 3
Business Interruption: Campus Delay Start or Classes Cancelled 0 3 2 * BCP draft date on file from 2012. New format launched to CLC and campus community in 2017 and 2018. 2018 Business Interruption due to Air Quality from Paradise
Wild Fire, 2017 Business Interruption due to Air Quality from Sonoma/Napa Wild Fire. Review period – August/September of each academic year or as key personnel
changes.
Emergency Preparedness
FY 16/17 FY 17/18 FY 18/19
Zombie Emergency Preparedness Scavenger Hunt participants NA 60 300
First Aid/ AED/CPR Training 17 75 30
Operational Fire Drills “unplanned “conducted 2 4 2
Residential Fire Drills conducted 8 8 10
Earthquake Preparedness & Great Shake Out Drill 1 1 1
Building Monitor Training ND 10 0 * For more details, refer to Annual Fire Safety Report.
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 15
Clery Compliance
Clery Compliance is governed under EO # 1107. The Campus trending models provide insight toward community climate that can be
contributing factors in workplace violence and/or other behavior-based risk exposures. This data will prove to be invaluable as the Campus
grows its footprint in the overall Vallejo community.
Performance
0123456789
10
On Campus Trending2016 2017 2018
0 03
23
13
40
2016 2017 2018
On Campus Liquor Trending
Liquor Arrest Liquor Referral
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 16
Where We Are Going
2019-2020 Goals
External and Internal Context
External and internal factors are driving and shaping our overall safety and risk management performance business model. Cal Maritime is
recognized as a leader in recruiting, developing, and retaining a highly diverse, engaged, and productive workforce that fully supports the
University’s mission in a meaningful and authentic way, while remaining adaptive, relevant, and responsive to the changes in higher
education and its impact to the Maritime industry. The intent of adopting an Integrated Campus Safety Management System (ICSMS) will
provide the necessary framework, tools, resources, and opportunities to build a high-performing incident free workforce.
Accountability is critical to having a proactive safety
culture. The Plan-Do-Check-Act (PDCA)
management system provides the framework of
policies, processes and procedures. The integration
structure is a systematic resource information for
people that can be readily adapted to technology.
The primary driver for an integrated management
system is the empowerment of the individual. Without collaboration and communication with all the members of the campus community,
the viability of the system is significantly limited. It is through approaching every task with self-situational awareness, focused actions and
continued vigilance the objective of an impact free environment can provide us with a safer and healthier life.
We have developed an overall operational strength, weakness, opportunities and threats (SWOT) summary analysis based on where we
were and what we learned during FY18/19. The analysis helps to uncover strengths and opportunities, which we can then leverage to
further prioritize and deliver key program support to our campus community during the next fiscal period and beyond. It is through
understanding our weaknesses, we can better manage and mitigate risks or threats. In developing the SWOT analysis, we look at Cal
Maritime, our fellow campuses in the CSU-system and other universities as well as throughout the global industry landscape for best
management practices. The key initiatives outlined in this Plan align with Cal Maritime’s overall campus strategic plan.
LeadershipOrganizational
Design
Empowerment of the
IndividualSafety Culture
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 17
Strength- Weakness-Opportunities-Threats (SWOT)
Continuous Improvement Developing and enhancing a strong campus safety culture can change the landscape of an operation and pay incredible dividends. Without
active participation by all members of an operation, a safety culture will not evolve and the safety management system cannot reach its full
potential.
What’s not working/Needs different approach… What’s needed…Improvement Opportunities
Weakness Threats Mitigating Weakness & Defending Against Threats
Internal Processes Customer Services Education Driving a change in culture
• Modernizing/Prioritizing/Integrati
ng EHS process implementation.
• Traditional reactive model
versus behavior based
proactive
Regulatory Compliance
• Policy/ Procedure / Program
consistency
• Lack of documented/ readily
available safe work practice
records.
Communication
• Key safety communication
vehicle campus disrupted
without functional alternative in
place.
• Effectively responding and
addressing report of unsafe
condition
• Engaging and driving a root
cause corrective action or
improvement item to closure.
Safety Training
• Lack of documented training
• Safety training follow-
up/completion in a timely
manner
• Personnel know
the safe work
process or how it is
“done in industry”
but elect not to.
• Knowingly
performing work
actives outside of
compliance norms.
• Operational
impact with
outdated Business
Continuity Plans
• Continued commitment
and drive toward the
Modernizing/Prioritizing/I
ntegrating of EHS
process management.
• Improve safety
communication
strategy.
• More timely
performance
assessment metrics,
• Identifying training
needs and develop
effective support
programming • Develop an action plan
which drives education
with the ultimate goal of
the reduction of
incidents
• Drive action items to
closure
• Increase outreach toward
reinforcement of desired
behaviors and expected
performance
• Continue to work with
Facilities Services on
development and
implementation of campus
safe work practices for
impact free.
• Implement and distribute
the updated Business
Continuity Plan (BCP) form
to department/unit
leadership track
compliance and follow-up
with departments on
campus as needed.
• Relaunch Safety
communication
vehicle to
enhance and
drive the safety
culture across
campus.
• Implement Cal
OSHA Mandated
Training Matrix by
Occupation
• Complete Safety
Training in a timely
manner.
• Launch new I-3
safety campaign
for AY1920
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 18
Appendix 1: Creating an Injury, Illness & Impact (I-3) Free Environment
Create an Effective EHS Program that Meets OSHA General Industry Requirements Creating an effective workplace training program requires care and planning but will reward your organization and employees with a safe and
productive workplace
1. Determine What EHS Programming is Needed • Determine if programming can solve the problem at hand. If problems stem from employee performance, rather than the workplace environment
itself, program training is the most effective way to remedy the problem. If problems are stemming from employee motivation or attitude, training
is less effective at correcting these issues.
• When evaluating safety performance issues, it is important to assess the type of issue to determine the best approach.
• Training programs are most effective at addressing an employee’s lack of knowledge about proper procedures or equipment usage.
2. Identify Workplace Safety Programming Needs • Correctly identify the specific programming requirement to address the compliance or knowledge gap.
• A proven method for determining the depth of programming required is to conduct a Job Hazard Analysis. This process documents each step of
a task while identifying and analyzing possible safety hazards along the way. The campus can translate high risk activities into a prioritized
training plan by taking the time to assess the process.
3. Identify Safety Goals and Objectives
• Once programming needs have been clearly identified, it is important that learning goals and objectives are set. Effective learning objectives
must be clear and measurable, making it possible to evaluate the training at a later date. Process management and Training objectives should
precisely spell out the desired skill or behavior using specific, action-oriented language. 4. Develop Workplace Safety Learning Activities
• After learning objectives are clearly identified, learning activities that support those objectives must be developed. Operations should consider
which methods, materials, and resources will be needed to most effectively convey the message.
• Ideally, learning activities will include opportunities for employees to demonstrate the skills and knowledge they have learned in the training.
These activities will directly apply to the employee’s actual job and include lessons arranged in sequential order according to the job process.
5. Evaluate Workplace Program Effectiveness & Behavior Based Modeling After program is implemented and training is conducted, it is vital to evaluate its effectiveness in accomplishing defined goals. There are three ways to
conduct an evaluation:
• Seek feedback from employees who are using the program for its functionality.
• Follow up with supervisors and their observations about employee behavior before and after the training. This shows whether the training had a
noticeable outcome.
• Evaluate workplace data to examine if long term there is a trend toward reduced incident or near miss rates. This will be the bottom-line
indicator of a program’s success rate.
6. Improve the Safety Program Based on the program feedback, look for ways to improve future training sessions. A critical re-examination of all the steps of a job and in training will
determine what gaps existed in the training program. Items to revisit include:
• The method chosen to determine if there is a better way to conduct the training.
• The presentation of training materials to determine if it was effective for the audience chosen.
• The key concepts and skills that were highlighted. If there was a gap, it may be beneficial to review the Job Hazard Analysis to identify any
missing components or any new steps added to the process since the program was developed.
• Revise programming and training as improvements are identified.
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Appendix 2: Campus Map
ANNUAL EHSRM REPORT & STRATEGIC PLAN UPDATE-2019 20
Appendix 3: Org Chart