# Presentation: 167113

**Categorizers (CAT) Team Workshop #2004-04**

## OUR AGENDA!

**Workshop Goals**
**Point to Ponder**
**ORPS Trending**
**CAT Form Entries **
**Programmatic Bins - A Year in Review!**
**Extent of Condition**
**Cat Chat**
**Training**
**Cat Procedure and Subject area proposed rev.**
**Group 10 Criteria, resolution**
**Possible Categorizer Conflict of Interest, resolution**
**BNL “R” Process (Utility Strikes)**
**CAT Cell Phone Operation (Ken Krasner)**
**Meeting Evaluation and Wrap-up**
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## CAT Team Workshop

_**Workshop Goals:**_
-  To EVALUATE and CONTINUOSLY  IMPROVE the BNL Occurrence Reporting Program.
-  To MAINTAIN a baseline categorization process such that reportability decisions are both VALID and CONSISTENT.

-   **CAT**

## Point to Ponder

**“****Keep your eyes wide open before marriage, half shut afterwards.”**
**                                                      ****- Benjamin Franklin **
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- _[ ](http://www.geocities.com/Athens/3067/hume/h_index.html)__ _
- _[ ](http://www.ushistory.org/franklin/quotable/quote24.htm)__   _
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## BNL ORPS Report StatusFY 2004 - Present (End of Month)

## ORPS Corrective Action StatusFY 2004 - Present (End of Month)

## ORPS Reports and ActionsNovember 30, 2004

**ALD**

## BNL ORPS by Calendar Year Report Submitted

**As of 12/20**

## CAT Electronic Entries

**10/29 – PB, RWP and Transportation Safety Violations (SC3)**
**11/08 – MB, Fire Inside Power Supply Cabinet @ C-AD (SC4)**
**11/08 – RK, Employee Struck By Motor Vehicle While Riding Bicycle (SC3)**
**11/10 – RK, Accidental Fire Suppression System Discharge in B610**
**11/10 – RK, 1 gallon hyd oil to soil behind B197 - Broken leaf blower line**
**11/10 – ES, Grade 8 suspect bolts discovered in man-lifts (SC4)**
**11/16 – KK, Fire at a SNS Magnet during testing**
**11/17 – KK, Vehicle batt falls off the back of a truck, acid spill to pavement**
**11/19 – KK, Lineman trips/falls and breaks bones in forearm (SC3)**
**11/29 – AL, Pin hole leak in BNL vehicle fuel line - cup of gas to pavement**
**12/02 – KS, Unauthorized access into the STAR hall**
**12/09 – KS, Unexpected disc of 2.4K deenergized cables during excavation**
**12/10 – KS, 1 gallon of motor oil spilled to soil**
**12/15 – SC, Pre-id 0 voltage leak detection line severed during excavation**
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## CAT Electronic Entries

**12/17 – SC, 150 gal oil “spill” to secondary containment @ bldg 495**
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## ORPS Reportable and Nonreportable Cat Entriesas of 12/20/2004

## Programmatic BinsA Year in Review!

**Personnel Contamination**
**Medical Department**
**NSLS**
**Physics**
**CA-D**
**BGRR Project**
**Utilities Struck**
**Railroad Tracks**
**Material Transportation**
**Electrical Shock Hazards**
**Material Handling Issues**
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## Programmatic Review

**Personnel Contamination – 2004**
**04/14 – 5,000 dpm on top of worker’s shoe at BGRR (RAR) **
**05/21 – <50,000 dpm cont on experimenters at AGS**
**08/31 – ~ 200 dpm/100cm2 on experimenter at PET **
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## Programmatic Review

_**Medical department, 2004**_
**01/27 – MEL hot cell filters not replaced at age of 66 months**
**02/03 – Water leak floods 490 with 150 gallons**
**02/03 – Slip and fall on slick floor **
**03/10 – Failed HEPA filter efficiency test at B-801**
**03/12 – 20ml leak from D-waste storage tank in B-801**
**04/08 – Chill water spill at 801 during seasonal flushing**
**04/28 – BLIP target shaft leaks water to secondary containment**
**05/09 – New target window at BLIP leaking**
**05/25 – Herpes-B Virus Precautions in Animal Facility (SC3)**
**07/30 – Minor leak from “D” waste valve in B-801**
**08/10 – Minor I-135 spill in B-490 (RAR)**
**08/16 – Carpenter drills into water line in B-490**
**10/29 – RWP and Trans Safety Violations in B-490 (SC3) **
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## Programmatic Review

_**NSLS, 2004**_
**01/16 – Pre-action SS spurious trip **
**02/07 – Unapproved work in laser hutch (Bldg. 729)**
**04/18 – Unauthorized SDL operation**
**05/13 – Window pane falls from second floor**
**06/03 – Improper cable connection on exp floor  **
**07/12 – Worker feels mild electrical tingling in his finger**
**07/22 – Hydrofluoric Acid Contamination of Technician**
**08/07 – Trace amts. of H-sulfide leaked from gas cylinder **
**08/10 – Worker experiences electric shock (SC3)**
**09/22 – Voltage leakage through hook on crane at NSLS**
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## Programmatic Review

- _Physics, 2004_
**07/01 – Laser interlock check overdue by 3 weeks @ ATF**
**10/21 – Trimmed tree branch breaks window at physics**

## Programmatic Review

- _CA-D, 2004_
**01/13 - Worker breaks ankle while preparing for cable pull**
**03/22 - Welder’s helper receives minor eye irritation**
**05/17 - Damaged detector at STAR after 10 foot drop**
**05/21 - <50,000 dpm cont on experimenters at AGS**
**07/14 - Fire in a RHIC RF cavity power supply in Bldg 1004A**
**08/11 - Heating element inside cold box causes burn to hand (SC 3)**
**10/15 - Potential fire hazard in AGS cable tray (SC4)**
**10/15 - Low voltage leakage through hook on crane at bldg 930**
**11/08 - Fire Inside Power Supply Cabinet (SC4)**
**12/02 - Unauthorized access into the STAR hall**

## Programmatic Review

- _BGRR Project, 2004_
**04/14 - 5,000 dpm on top of worker’s shoe (RAR)**
**05/03 - Leakage of cont water from Sea-Land Container (SC4)**
**05/11 - Filter cart sep from resp during work in rad/cont area (SC3)**
**09/03 - DSB work performed outside of procedure (SC4)**
**10/05 - Injury due to steel plate falling at bldg 701 (SC3)**
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## Programmatic Review

_**Utilities struck:**_
_**2000**_
**10/02 - Sanitary line severed near 801**
**10/27 - Worker hits energized UG cable**
**11/07 - Strike of 480 volt UG cable**
_**2001**_
**03/27 - UG abandoned comm. cable struck**
**03/29 - Backhoe scraps steam line  **
**04/26 - Backhoe strike of 208 VAC cable**
**07/03 - Backhoe strike of 208 VAC cable**
**09/17 - Van hits fill ass. of LPG tank**
**09/26 - Phone line damaged when digging near FH**
**10/03 - 2 in. above grd water line broken by bulldozer**
**11/28 - Backhoe strike of 4 - inch water line  **

## Programmatic Review

_**Utilities struck:**_
_**2002**_
**04/30 - Aband. control wiring hit during sanny upgrade**
**05/07 - GC drilled anchors into elect. duct bank near 911**
**06/06 - Minor utility strike during horiz. boring activities**
**09/28 Truck driver backs into 13.8KV BAF power supply**
_**2003**_
**01/08 - Contractor severed low voltage comm. cable ****	****     ****	****         near bldg. 51**
**05/08 - Deenergized cable struck during excavation near  ****	****         911A**
**08/12 - Forklift strikes overhead wire**

## Programmatic Review

_**Utilities struck:**_
_**2004**_
**04/19 – Electrical utility conduit strike**
**07/07 – Domestic water main strike**
**09/07 – Comm. cable severed during excavation work**
**12/09 – Unexpected **_**discovery**_** of 2.4K deenergized cables during excavation**
**12/15 – Pre-Identified 0 voltage leak detection line severed during excavation**

## Programmatic Review

_**Railroad Tracks, 2004**_
**09/03 - Empty railroad car derailed at BNL track switch**
**09/04 - Off-site train car derailment (SC4)**
**09/14 - Inadequate rail safety procedures (SC4)**
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## Programmatic Review

_**Material Transportation, 2004**_
**	****	****-  06/25 - B-52 waste cont support chnl rain water ****	****accumulation (SC4)**
**	****	****-  07/26 - ****Transportation of Solidified Liquid Low-****	****Level Waste**** (SC1)**
**    **_**Note:**_**  “suspected radioactive contamination occurs involving shipment of radioactive materials” = SC1**

## Programmatic Review

_**Electrical Shock Hazards**_
_**2001**_
**  ****10/03 - Electrical Incident at Cyclotron**
_**2002**_
**   ****04/19 - Electrical Shock @ NSLS**
**   ****09/24 - Worker at AGS receives <24 VDC**
_**2003**_
**   ****06/27 - Electrical Shock @ Physics**
_**2004**_
**07/12 - Worker feels mild electrical tingling in his finger @ NSLS**
**08/10 - Worker experiences electric shock @ NSLS**

##  Programmatic Review 

- _Material Handling Issues_
_**2004**_
**03/05, Load Falls off Flatbed Truck, (SC3)**
**03/24, Recurring Material Handling Problems, (SCR)**
**05/17, Damaged detector at STAR after 10 foot drop**
**06/11, 500 # steel block falls (3 – 4 feet) from forklift**
**10/05, Injury due to steel plate falling at bldg 701 (SC3)**
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## What is the Extent of Condition?

**Is the deficiency restricted to a ****specific work activity****?**
**Is the deficiency broader in that it impacts the ****overall project**** specific activities?**
**Is the deficiency even broader in that it impacts a ****division or directorate****?**
**Is the deficiency much broader in that it impacts the ****entire site****?**
**Or, if you manage multiple sites, is the deficiency a systemic or programmatic condition within a functional area such as work control or hazard analysis spanning ****various sites****?**
**Does the deficiency reach beyond the ****Planet****?**

## Enforcement Lessons Learned

**Extent of Condition is a key mitigating factor for addressing potential Enforcement Actions**
**Extent of Condition is a key element of any Corrective Action Management system and is not just restricted to potential PAAA noncompliances**
**Extent of Condition should be integrated into all aspects of issues management processes including:**
**Issues/corrective action management procedures**
**Causal analysis procedures**
**Management/Independent assessment procedures**
**PAAA noncompliance determination/reporting procedures**
**Issues Review Board/Corrective Action Review Board charters, if applicable**

## “String Pulling” - How far is far enough?

**Deficiencies isolated to a unique work activity or project or within a specific functional area may have a limited extent of condition.**
**Deficiencies identified from trends which cross numerous projects or functional areas (i. e., work control, hazard analysis, etc.) would require a more comprehensive review for extent of condition.**
**Senior management involvement and direction is often needed to charter independent or off-project (Type-B equivalent) investigations for determining causal factors, judgements of need, and the extent of condition at a company level.**

## Methods for Accomplishing Extent of Condition Reviews

**Lessons Learned Notification Response**
**    ****Issues not rising to the level of requiring a Type-B like investigation can utilize formal lessons learned notification systems to capture lessons learned from NTS reportable events and distribute them to appropriate organizations with **_**mandatory response**_** required by each organization as to the extent of condition. Responses are maintained in the evidence files for the NTS report and any additional corrective actions added to NTS.**

## Methods for Accomplishing Extent of Condition Reviews

**Extent of Problem/Condition Procedures**
**    ****Formal procedures with roles and responsibilities for performing and assigning responsibility for structured, documented extent of problem and extent of condition reviews tied into existing procedures for issues/corrective action management, causal analysis, etc.**
**Others ???**

## Extent of Condition Feedback

**Extent of Condition (EOC) reviews should be integrated into all aspects of issues management processes including:**
**Issues / Corrective action management procedures**
**Causal analysis procedures**
**Management / Independent assessment procedures**
**PAAA noncompliance determination and reporting procedures**
**Issues Review Board and/or Corrective Action Review Board charters, if applicable**

## Extent of Condition Feedback

**EOCs need the support of Senior Mgmt. Processes need to be in place to ensure corrective action plans for significant events are reviewed by appropriate Functional Managers and Subject Matter Experts for EOC.**
**An EFCOG product on what constitutes adequate EOC reviews is recommended considering no current guidance exists.**
**Benchmarking of NRC and/or INPO best practices recommended.**
**Joint task team effort with coordination with QA working groups was recommended.**

## CAT CHAT!

**Conduct ORPS Re-design training for Department & Division Managers (1****st**** Qtr. 05) **
**CAT Procedure and Subject area proposed rev.**
**Include pushup to DDO in cat procedure**
**Include advise to FM (Grp 10) in cat procedure**
**Provide a scheme for documenting verification & effectiveness of corrective actions when required. (SA) **
**Provide the process for determination of the need to issue a "R" Recurring Occurrence Report. (SA)**
**Group 10 Criteria, resolution**
**Categorizer conflict of interest resolution**
**Will remain as is**
**Upcoming “R” Vote on Utility Strikes**
**CAT Cell Phone Operation (Ken Krasner)**

## Group 10 – Management Concerns/Issues 

**(2) 1-4† An event, condition, or series of events that does not meet any of the other reporting criteria, but is ****determined by the Facility Manager or line management**** to be of safety significance or of concern to other facilities or activities in the DOE complex. One of the four significance categories should be assigned to the occurrence, based on an evaluation of the potential risks and the corrective actions taken.**
**   “****As always, you will continue to inform the Facility Manager of this reporting option.  In addition, you will now provide your input (based on reporting experience) as to whether or not you feel that the event and/or condition under investigation should be reported under this criteria.  The **_**final decision**_** shall remain with the **_**Facility Manager**_**.”          - E. Sierra**

## CAT Team Workshop

**CAT Team Action Item Review**
**Meeting Evaluation and Wrap-Up**
- _[ ](http://sports.yahoo.com/mlb/teams/bos)_