# Presentation: 410279

**Tier 1 Team Workshop #2005-01**

## OUR AGENDA!“Underway on Nuclear Power”

**Workshop Goals**
**Point to Ponder**
**Workshop Participants and Responsibilities**
**ESH&Q (Tier I) Inspections – Subject Area**
**Fourth Qtr CY 04 Tier 1 Inspection Results**
**A Year in Review**
**      **

## Point to Ponder

**“****Keep your eyes wide open before marriage, half shut afterwards.”**
**                                                      ****- Benjamin Franklin **
** **
- _[ ](http://www.geocities.com/Athens/3067/hume/h_index.html)__ _
- _[ ](http://www.ushistory.org/franklin/quotable/quote24.htm)__   _
**   **

## Common Misunderstandings (Myths) about Human Performance

**Myth 1**
**If there are no events, there is no human performance problem.**

## Slide 5

## Tier 1 Team Workshop

_**Workshop Goals:**_
**To drive and sustain ESH&Q improvement at the Laboratory:**
**To review ESH&Q (Tier 1) Inspection tracking/trending data at the organizational and/or institutional levels;**
**To identify Laboratory-wide issues and program vulnerabilities/gaps and share information to facilitate lessons learned in process/program effectiveness;**
**To discuss corrective actions taken and evaluate their effectiveness; and**
**To identify the path forward toward continual improvement, the potential institutional impact and the need for institutional corrective action(s).**
** **

## Tier 1 Team Workshop

**List of Personnel Designated to attend ESH&Q Inspection Workshop:**
**Instrumentation****	****	****Bob DiNardo**
**ESH&Q****	****	****	****Kay Conkling**
**F&O****	****	****	****Nick Houvener; Peder Martino**
**Life Sciences****	****	****Bob Colichio**
**CFN****	****	****	****Arnie Moodenbaugh**
**ISD****	****	****	****Madeline Windsor**
**ITD****	****	****	****	****Mary Lynn Heinrich**
**HR & OMC****	****	****Donna Dowling**
**CAD****	****	****	****Dick Savage; Dave Passarello (alt.)**
**Physics****	****	****	****Ron Gill**
**BES****	****	****	****John Taylor**
**EENS****	****	****	****Pat Carr; John Boccio (alt.)**
**MSD****	****	****	****Bob Sabatini**
**Finance****	****	****	****April Gray, Greg Ogeka**
**CEGPA****	****	****	****Scott Bronson, Rick Backofen**
**S&HSD****	****	****	****Jack Ellercamp**

## Tier 1 Team Workshop

**Workshop Participants and Responsibilities:**
**The Laboratory’s Quality Management Office will schedule and facilitate the workshop.**
**Line Management designates representatives who are knowledgeable of the results of the Tier 1 program and data (e.g. ESH Coordinator, Tier 1 Leader) in their directorate, and who have the authority to identify, develop and support institutional corrective actions as needed.**
**Representatives are required to summarize and submit data one month prior to the scheduled Tier 1 Improvement Workshop.**
**Data are to be summarized and submitted based on the Deficiency Category Table and must include:  Date of Tier 1, Buildings/Facilities in each deficiency category.**
**Action items will be identified**
**Tracking will be by institutional ATS**

## Disaster Pyramid

- Source: Frank Bird, Jr., *Practical Loss Control Leadership*, Det Norske Veritas (formerly International Loss Control Institute), 1969.

- 600

- 1

- 30

- 10

**Notes:**
The error that caused a major accident and the error that is one of hundreds with no consequence can be the same error that has historically been overlooked or uncorrected.  Significance is determined by degree of consequence to the core process, the physical plant.  Therefore, for a significant event to occur, breakdowns in multiple defenses have to occur.  The existence of so many flawed defenses can only be an outcome of faults in the organization or management control domains. (Frank Bird, Jr., Practical Loss Control Leadership, Det Norske Veritas (formerly International Loss Control Institute), 1969.)

## Fourth Qtr CY 04 Tier 1 Inspection Results

## Fourth Qtr CY 04 Tier 1 Inspection Majority Results

## Percent of Total Findings for the Top Three Categories

## BNL ORPS by Calendar Year Report Submitted

- As of 02/08

## ORPS Reportable and Nonreportable Cat Entriesas of 12/31/2004

## 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**
**	****	**

## 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 **
**	****	**

## 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) **
**   **

## 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**
** **
** **

## 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)**
** **
** **

## 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)**
** **
** **

## 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**_
_**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)**
** **

## Tier 1 Team Workshop

**Tier 1 Team Action Item Review**
**Meeting Evaluation and Wrap-Up**
- _[ ](http://sports.yahoo.com/mlb/teams/bos)_