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LLNL Emergency Management Plan(EPlan) Rev 26 January 2021 15 READINESS ASSURANCE LLNL maintains a formal Readiness Assurance Program that establishes a framework and associated mechanisms for assuring that emergency plans and procedures and resources are adequate by ensuring that they are sufficiently maintained, exercised, and evaluated, and that appropriate and timely improvements are made when identified. The Readiness Assurance Program serves to ensure the readiness and effectiveness of an emergency management program on a programmatic and performance level while promoting a culture of continuous improvement. The Readiness Assurance Program consists of evaluations, improvements, and the ERAP. Evaluations consist of assessments, exercises, and performance indicators. LLNL staff conducts assessments to ensure that emergency plans, procedures, emergency response activities, and resources are adequate and sufficiently maintained. LLNL staff supports DOE during the conduct of external assessments. LLNL must conduct an annual site-level exercise to test and validate emergency plans and procedures. The Laboratory reports into a national program of performance indicators. Annually, the staff at LLNL identifies program improvements based on lessons learned. The EMD staff uses the Laboratory's institutional procedures for assessment planning, issues management and lessons learned. The EPO develops an annual ERAP using the format and content guidelines provided by DOE. The ERAP highlights program status, documents evaluation results and the status of associated corrective actions, identifies what the goals were for the fiscal year that ended and the degree to which those goals were accomplished, and identifies the goals for the next fiscal year. 15.1 Self-Assessment The EPO conducts an annual self-assessment of the site's comprehensive emergency management system described in this Emergency Plan. This assessment is performed in accordance with the Emergency Programs Organization Self-Assessment Program Plan. The institutional procedure, PRO-0052,Management Self-Assessment, defines the procedural steps for planning,performing, documenting, and reporting the results of the assessment. An assessment plan is developed and approved prior to the assessment. Actions to resolve identified issues are tracked to closure using the institutional procedure, PRO-0042,Issues and Corrective Action Management, and PRO-0077, Conducting an Effectiveness Review. 15.2 Corrective Action Program LLNL has a comprehensive issues and corrective action management process described in institutional procedures, PRO-0042 and PRO-0077. The process provides effective reporting, analysis, resolution, and tracking of issues and provides an ordered process for resolving issues from causal analysis and extent-of-condition review to determining the reporting requirements and identifying the corrective action needed. The system also includes steps for tracking issues to closure and validating the effectiveness of the actions taken. 108