# Presentation: 173613

**Categorizers (CAT) Team Workshop #2007-01**

## OUR AGENDA!

**Workshop Goals**
**Today's Quote**
**Guest Speaker**
**Joe Levesque - Evacuations**
**ORPS Trending**
**Programmatic Bins**
**Meeting Evaluation and Wrap-up**
**      **

## 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**.
-  To **REVIEW/ EVALUATE **data to determine if repeat events should be identified as _potentially_ **RECURRING** occurrences.
-  To **PROMPT** (via accurate categorization) **DEEP** and **LASTING** value-added **CHANGE,** which results in new ways of **THINKING** and **ACTING**.

-   **CAT**

## Today's Quote

**"The lecturer should give the audience full reason to believe that all his powers have been exerted for their pleasure and instruction."**
** **

**Michael Faraday (1791-1867)**

## BNL ORPS by Calendar Year Report Submitted

- As of 4/10

## BNL ORPS Report StatusFY 2007 (End of Month)

## ORPS Corrective Action StatusFY 2007 (End of Month)

## ORPS Reports and ActionsMarch 31, 2007

**ALD**

## CAT Electronic Entries

## Evacuation Criteria

- (SC3)  Any facility evacuation, not including a precautionary evacuation, in response to an actual event. If the event fell under another reporting criterion, then evacuation should be reported as well by noting multiple reporting criteria for the single occurrence.
- SCBNL: Any evacuation not due to false alarm or part of drill/exercise

## 3 categories of false fire alarms that NY State and National Fire Reporting Systems use:

***False Malicious*** - An intentional activation of an alarm system for a non-fire reason (as in pulling a fire alarm box to see the fire trucks arrive or pulling a fire alarm to get out of a final test in school).
***False Malfunction*** - A fire alarm equipment malfunction that causes the system to alarm (shorting of wires, power dip tripping the system).
***False Environmental*** - A fire alarm produced by environmental conditions that are not related to a fire (added by Joe - water in a detector, steam leak setting off a fire detector, diesel "smoke" tripping a smoke detector, cutting wood tripping a smoke detector).  The system is doing its job, but the thing it detected is really a fire.
- There are some situation that fall under "good intent."  Good intent is when someone thinks that there is a fire and pulls an alarm, when in reality the condition is not a fire (smoke from steam rising from a road after a summer rain or fog rising from a cooling tower, smell of burning food that is not on fire).

## CAT Electronic Entries

**12/27 – AP, Work on energized machine by vendor, SC3**
**12/27 – KK. Legacy Contamination in Building 703, SC4**
**01/02 – RK, HFBR Standby Building Exhaust Blower Damper Found Open**
**01/03 – RK, Sparking from Flex-lamp at BGRR**
**01/03 – RK, F-18 Personnel contamination at MicroPET, Building 906**
**01/05 – RK, Fuel Oil Found in Pipe Trench east of filling station B639**
**01/05 – RK, Shredder overheats in B179**
**01/10 – KK, Low Levels of Tritium Detected at the Sewage Treatment Facility**
**01/16 – KK, Security Patrolman Injures Left Knee, SC3**
**01/18 – SM, Plant Engineering LO/TO Procedure Nonconformance**
**01/18 – SM, BNL Firefighter fractures bone in right wrist, SC3**
**01/23 – MD, Abandoned couch on fire - North Firebreak, SCBNL**
**01/24 – MD,  Worker pinned by metal sheets, SC3**
**01/25 – MD, HFBR Regulator Failure During Testing (FP system supervisory air system)**
**01/26 – ES, Update to 01/18 Entry – No fracture in Firefighter wrist (ORPS Cancelled)**
**01/26 – MD/ES, Toolbox Contamination at HFBR**
**01/30 – KK, Steam Fitter Injures Knee**
**01/30 – KK, Graduate Student Injured In Automobile Accident**
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## CAT Electronic Entries

**02/04 – KK, Minor Electrical Fire in Building 1007-W, SCBNL**
**02/09 – PB, Torn ligament on left thumb from moving boxes for office relocation,** **SCBNL**
**02/09 – PB, Leak Detected on Secondary Water Supply for RHIC Refrigeration System**
**02/12 – PB, Overheated Bearing on Main Magnet Water Supply Pump, SCBNL**
**02/15 – AL, Plant Engineering Division** **worker experiences pain in his thumb**
**02/16 – ES, Personnel Exposure to Dilute Muriatic Acid Vapors, SC3**
**02/22 – AP, Failure of heater/air conditioner line cord plug**
**02/22 – AP, Delivery truck backs up without warning and grazes employees knee, SC3**
**02/26 – AP, Crane training deficiency**
**02/28 – RK, Injury while lifting bags of salt**
**02/28 – RK, Fall from ladder causes ankle sprain**
**03/01 – RK, Truck lift-gate fractures employee rib, SC3**
**03/02 – RK, 1 gal oil release in B902**
**03/05 – KS, B-801 Ventilation System and associated Alarm Failure**
**03/05 – KS, Small brush fire, SCBNL**
**03/06 – KS, PISA & USQ for Safety Analysis and potentially unanalyzed hazards, SC2**
**03/06 – KS, Minor injury while handling dry ice in outdoor windy conditions**
**03/07 – KS, Employee receives minor eye injury from tree branch**
** **

## CAT Electronic Entries

**03/13 – SM, Smoldering debris near Cooling Tower #4 by B912A, SCBNL**
**03/14 – SM, Right index finger injury at Production Services**
**03/15 – SM, Violation of BGRR RAD Admin Control**
**03/15 – SM, Plumber Injures Tooth, SCBNL**
**03/19 – MD, B-197 evacuation due to fire alarm, SCBNL**
**03/21 – MD, Unidentified substance at Chemistry Building determined to be harmless**
**03/22 – MD, Fire Alarm (false alarm) at Building 479 Central Fabrication Services**
**03/22 – MD, Minor finger laceration at Central Fabrication**
**03/28 – AL, Radiological Continuous Air Monitor alarm triggered by a cell phone**
**03/30 – AL, Leak test of receipted source reveals its integrity has been compromised**
**04/03 – KS, Water Leak at NSLS Causes Shorts and Sparking in Electrical Equipment**
**04/09 – PB, Excess Plant Watering Causes Limited Electrical Outage      **
** **

## Programmatic Bins

**Personnel Contamination**
**Medical Department**
**NSLS**
**Physics**
**CA-D**
**BGRR Project**
**Plant Engineering **
**Utilities Struck**
**Material Transportation**
**Electrical Hazard**
**Material Handling Issues**
**Waste Management **
**Chemistry**
**Environmental Restoration**
**Railroad Tracks**
**New Construction**
**Noise  **
** **** **
**	****	**

## Programmatic Review

_**Personnel Contamination – 2005**_
**02/02 – Personnel Cont at Cyclotron**
**02/08 – ****Radioisotope Production Lab Cont Identified @ 901 **
**03/30 – 14,000 dpm of beta/gamma on sneaker at PET**
**09/07 – ****Contractor - ****4K dpm skin cont on neck @ B650 (SC3)**
**09/16 – 500 dpm alpha cont on hand @ B650**
**10/17 – Cont. discovered (95,000 dpm/100cm2) within Rad Buffer Area and on shoe covers during RBA friskout @ B801**
**12/19 – LL rad cont event @ B650**
_**Personnel Contamination – 2006**_
**02/23 – Personnel Cont at Building 901**
**03/22 – Cont Detected on Employee's Shoes at PET**
**03/28 – Cont of two workers at B-801 during removal of BLIP target filter**
_**Personnel Contamination – 2007**_
**01/03 – F-18 Personnel contamination at MicroPET, Building 906**
_**  **_
**	****	**

## Programmatic Review

_**Medical department, 2005**_
**01/17 – Steam Leak in Basement of Building 490**
**01/26 – Meth Chloride Spill and Overexposure @ 490 (SC3)**
**04/21 – Post-doc faints when taking blood samples @ 490**
**06/07 – Researcher transport Rad experiment in private vehicle**
**10/17 – Cont. discovered (95,000 dpm/100cm2) within Rad Buffer Area and on shoe covers during RBA friskout @ B801**
_**Medical department, 2006**_
**03/07 – Rad Cont Outside a Controlled Area at B-490 (SC3)**
**03/10 – Survey Meter/Frisker Taken Outside Controlled Area @ B490**
**03/13 – PB, Shock from terminal in legacy installed light timer (SC4)**
**03/28 – Cont of two workers @ B801 during removal of BLIP target filter**
**05/19 – Cont found outside a posted area @ B490**
**07/31 – Trit cont on unposted benchtop in a posted RMA at B490**
**08/24 – Painter's spackling knife contacts aband live electrical wiring @ 490**
**11/16 – KK, Contamination at PET Facility, (SC3)**
**10/31 – BLIP cooling water leak detection system did not function during testing**

## Programmatic Review

_**Medical department, 2007**_
**01/03 – F-18 Personnel contamination at MicroPET, Building 906**

## Programmatic Review

_**NSLS, 2005**_
**03/03 – ****Suspect Bolts Found in Crane During Inspection (SC4)**
**04/20 – Haz concerns associated with energized magnet**
**06/28 – ****Syringes (w/needles) found in Lab ****Trash Receptacles @ Bldg 725A**
**11/11 – Minor Cryogenic Injury to Visiting Scientist **
_**NSLS, 2006**_
**02/21 – X17C Laser Procedure Violation (Door left open while laser in operation)**
**05/08 – Improper work sequence during lead shielding removal at beam line**
**06/09 – XSXD Power Supply Shut-off Failure**
**07/17 – Chemical Spill in Wet Chemistry Laboratory (SC3)**
**08/21 – AL/ES, Accidental cutting of energized power tool line cord (SC3)**
**11/16 – Spent Fluorescent Bulbs Found Outside Waste Storage Area**
_**NSLS, 2007**_
**04/03 – Water Leak at NSLS Causes Shorts and Sparking in Electrical Equipment**
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## Programmatic Review

_**Physics, 2005**_
**04/25 – Smoke alarm from overheated plastic tubing @ Bldg 832**
_**Physics, 2006**_
**07/07 – Employee fractured metatarsal after tripping over rug/mat**
**08/09 – Stop Work Order issued due to antennae at edge of B510 roof**

## Programmatic Review

_**CA-D, 2005**_
**01/07 – Employee falls while walking (Reason Unknown, SC3)**
**02/09 – ****Slip and Fall Results in Hairline Fracture of Kneecap (SC3)**
**02/22 – ****High pH detected at recharge basin HTW, Bldg 930**
**03/14 – Cooling Water Leak at LINAC due to stuck open relief valve **
**04/19 – ****Worker breaks finger while climbing ladder @ AGS**
**05/04 – Sparking From ATR Main Magnet Cooling Water Pump**
**07/21 – Minor occupational injury (wood splinter) at Bldg 1005R**
**08/29 – P/U truck damages wall at B1002B**
**09/13 – Tritiated water (****2200 pCi/L) leak (30-50 gal) to soil near B930A**
**10/14 – Rain****water (deluge) causing electrical shorts/smoke in B912**
**10/17 – ****Crack in tip of finger bone from mallet strike @ B905**
**10/28 – AGS door interlock works but "Area Secure" light not lit**
**10/31 – S/C bolts identified at the STAR 20-Ton crane ****(existing report)**
**11/02 – Energized wire discovered during RF power amp repair (SC3)**
_**CA-D, 2006**_
**03/06 – Discovery of Radiation Monitor in Interlock-Bypass-Mode (SC3)**
**03/29 – Lack of admin approval (non-safety related) for NASA NSRL experiment **
**04/14 – 400 Amp Electrical Switch Failure (OE, SC2, SC4)**
**05/04 – CA-D Chipmunks read high and alarms at a lower dose rate than intended**
**06/02 – < 6 oz of tritiated magnet water splashed onto the workers pant-leg @ RHIC**
**06/09 – 3 gals of heat transfer fluid (oil) spilled on Storage Yard pavement by B-924**
** **

## Programmatic Review

_**CA-D, 2006**_
**07/20 – Pulling cable along foor results in back strain**
**08/14 – ~ 200 gal spill from 902 Cooling Towers to parking lot and grass**
**08/21 – Leg laceration while descending ladder at B1005**
**09/05 – Non-standard installation of electrical disconnect temp wiring (SC3)**
**09/13 – Trip on stairs results in ~ 1 qt. spill of H2SO4 from battery at B901A**
**10/12 – Worker hit in head/injured by shelf while moving a workbench **
**11/02 – Fire Protection Impairment Process Not Properly Followed @ B1004B**
**11/06 – Manlift damaged during tree cutting operations **
**11/08 – Loose 120 VAC wires on a terminal block results in sparking**
**11/27 – Minor finger laceration**
** **
_**CA-D, 2007**_
**02/04 – Minor Electrical Fire in Building 1007-W, SCBNL**
**02/09 – Leak Detected on Secondary Water Supply for RHIC Refrigeration System**
**02/12 – Overheated Bearing on Main Magnet Water Supply Pump, SCBNL**
**03/13 – Smoldering debris near Cooling Tower #4 by B912A, SCBNL**

## 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)**
_**BGRR Project, 2006**_
**08/03 – Removal of fuel anchor (BGRR) not approved by work procedure**
**09/26 – Cont (80, 000 dpm) found outside the BGRR RCA (SC3)**
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## Programmatic Review

_**Plant Engineering**__**, 2005**_
**08/01 – Simple Fracture of pinky while working on dump truck**
**09/08 – ****PE truck hung up on berm behind B912**
**11/21 – Gov vehicle strikes tree in off-road area on-site**
**12/12 – Partially Disabled (Inadvertent) fire alarm syst @ B321, 326, 339, 421, 423, 651**
_**Plant Engineering**__**, 2006**_
**01/27 – Burning Cotton Apron In PPE/Tool Bag Causes Evac @B197 (SC3)**
**05/10 – Vehicle window damaged during concrete sidewalk removal work (SC3)**
**06/16 – Asbestos discovered during demolition of B-422**
**10/13 – Silica Exposure During Concrete Crushing Machine Operation, (SC3)**
**12/05 – PE groundskeeper received a minor injury to the chin **
**12/13 – Pump leak results in 100 gal spill of propylene glycol @ B729 **

## Programmatic Review

_**Plant Engineering**__**, 2007**_
**03/01 – Truck lift-gate fractures employee rib, SC3**

## Programmatic Review

_**Utilities struck, 2004**_
**04/19 – Electrical utility conduit strike (SC3)**
**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**
_**Utilities struck, 2006**_
**08/08 – Fiber-Optic Cable inadvertently severed  at B707A, HFBR pmp house swgear**

## 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**
_**Material Transportation, 2005**_
**03/17 - Excessive Drainage from BNL Rail Cars at Envirocare (SC3)**

## Programmatic Review

_**Electrical Hazard, 2005**_
**04/01 - Unexpected Discovery of Haz Energy Source @ Magnet Division (SC3)**
_**Electrical Hazard, 2006**_
**03/13 - Shock from terminal in legacy installed light timer (SC4)**
**09/06 – AP, Table lamp electrical fault at apartment 4B results in finger tingle**
_**Electrical Hazard, 2007**_
**12/27 – Work on energized machine by vendor, (SC3)**

##  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)**
_**Material Handling Issues, 2006**_
**01/17, Tennelec smear counter falls during transport, (SC3)**
**06/30, Computer server unit falls out of BNL box truck grazing workers leg (SC3)**
**07/20, Pulling cable along floor results in back strain**
**08/28, During transport a forklift dropped a secured aerial lift (SC3)**

##  Programmatic Review 

_**Waste Management, 2005**_
**01/07 – WMD Worker Enters Controlled Area with Expired Training**
**06/30 – ~2 inches (150 -200 gallons) of water flooded the equipment level at the BMRR**
**04/21 – Worker injures back while moving drum**
**09/16 – 500 dpm alpha cont on hand @ B650**
**10/26 – ****Tritium Detection in Sr-90 Extraction Well SR-2**
**12/19 – LL rad contamination event at B650**
_**Waste Management, 2006**_
**01/20 – USQ on rusting HEPA exhaust stack @ B860 (SC3)**
**02/22 – Lapse in USQ training qualification**
**08/04 – HFBR Dumpster alarms BNL Radiation Truck Monitor (SC3)**
**08/16 – Walk through of HFBR identifies rad/non-rad items that are not segregated**
_**Waste Management, 2007**_
**03/06 – PISA & USQ for Safety Analysis and potentially unanalyzed hazards, SC2**
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##  Programmatic Review 

_**Chemistry, 2005**_
**02/02 – Personnel Cont at Cyclotron**
**02/08 – ****Radioisotope Production Lab Cont Identified @ 901**
**03/30 – 14,000 dpm of beta/gamma on sneaker at PET**
**05/11 – ****R.A. Cuts Hand/Requires Stitches ****@ Bldg 555**
_**Chemistry, 2006**_
**01/17 – Energ ckt disc in cut conduit in floor slab @ B555, (SC3)**
**02/23 – Personnel Cont at Building 901**
**03/22 – Cont Detected on Employee's Shoes at PET**

##  Programmatic Review 

_**Environmental Restoration Projects, 2005**_
**05/26 – Technician Cuts Thumb During Cable Repair ****@ Bldg 811**
**06/07 – Personnel Exposure to Excessive Noise **** (SC-3)**
**06/21 – White Powder Substance Found Behind Bldg 657**
**08/26 – H****g/Cs-137 laden soil stored at Old HWMF**
**09/07 – ****Contractor - ****4K dpm skin cont on neck @ B650 (SC3)**
**09/06 – GW treatment system (Sr-90) fitting leak, to sump @ B855**
**11/02 – Inert gas removed from HFBR vessel (SC3)**
**12/02 – Legacy Soil activity identified in the woods N&S of the FHWMF**
**12/05 – Inadequate Work Control (ERD at former waste management facility) Change Review**
_**Environmental Restoration Projects, 2006**_
**09/22 – HFBR air conditioning water pump seal leak (SC3)**
**10/30 – Flaw in ERP calculation of total recordable injury statistics**
**11/30 – SM, Failure to Maint Config Control of DOE-SER specified Documents (SC3)**
_**Environmental Restoration Projects, 2007**_
**12/27 – Legacy Contamination in Building 703 (SC4)**
** **

## Programmatic Review

_**Railroad Tracks, 2003**_
**08/27 - Rail Car movement while loading (ON)**
_**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)**
_**Railroad Tracks, 2005**_
**01/05 - Empty Railroad Car Derailed**
**08/08 - Rail Car (Gondola) Derailment (SC3)**
**09/29 - (Update of 8/8 entry) Recurring Railcar Events (SCR)**
_**Railroad Tracks, 2006**_
** **

## Programmatic Review

_**New Construction, 2005**_
**10/19 – Tree grinding ops @ the CFN construction site results in a piece of wood striking and damaging the rear window/trunk of an unoccupied vehicle**
**11/21 – Contract Worker ejected from site after dropping a gas cylinder from the second floor of the RSB to the ground below**
**11/29 – Contractor incurs 1 inch laceration to wrist working @ RSB**
_**New Construction, 2006**_
**04/21 – Sub incurs severe laceration of leg at CFN (SC3)**
**07/31 – A/C mechanic cuts arm at RSB Construction Site**

## Programmatic Review

_**Noise, 2005**_
**06/07 – Personnel Exposure to Excessive Noise **** L****ab ground water treatment plants** **(SC-3)**
_**Noise, 2006**_
**01/18 – Noise over exposure per ACGIH TLV @ B902 (SC3)**
**03/07 – Over-exposure to noise hazard @ Motor Pool Repair Facility (SC3)**

## CAT Team Workshop

**CAT Team Action Item Review**
**Meeting Evaluation and Wrap-Up**
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