# Presentation: 693721

## Office of River ProtectionFacility Representative 

- <date/time>

- Office of River ProtectionFacility Representative
- Lessons Learned from Extremity Overexposure Event

*Mark C. Brown*
*Facility Representative*

**Notes:**
Introduction:
Mark Brown, Facility Representative for the Office of River Protection at Hanford

During operations or work activities when unexpected and/or hazardous conditions are encountered, what do we expect supervisors and workers to do?  

Most of us have heard the term “place the plant in a safe condition.”  But what does that really mean?  Let me ask you a couple of questions to consider based on the following scenario:
	- crane operations
	- removing highly contaminated equipment from an underground tank
	- unexpectedly, dose rates exceed your work permit void limits.  

What does it mean to you, the FR, to “put the plant in a safe condition”?
What does it mean to your contractor to “put the plant in a safe condition”?

I’m going to share with you how we define “safe condition”, and some things we learned from an event that occurred at the Tank Farms last summer.   

## Hanford Tank Farms

- ~ 5 miles

***Hanford Tank Farms***

**Notes:**
177 large underground storage tanks in 18 tank farms
44 smaller (<50K gal) underground storage tanks (4 tanks in CR Vault)
53 million gallons of highly radioactive, toxic waste as a result of plutonium extraction from spent nuclear fuel
ORP’s Mission:  Retrieve and treat Hanford's tank waste and close the tank farms to protect the Columbia River 

## Date:	July 22, 2004
Location:	Hanford Tank Farms – C Tank Farm 
Activity:	Crane removal of long length contaminated equipment (thermocouple tree) from buried tank
Event:	Worker extremity exposure of 22 Rem to the hands (exceeded extremity administrative control limit)

- Location:	Hanford Tank Farms – C Tank Farm
- Activity:	Crane removal of long length contaminated equipment (thermocouple tree) from buried tank
- Event:	Worker extremity exposure of 22 Rem to the hands (exceeded extremity administrative control limit)

***Event Description***

## 244-CR Vault Arrangement

***244-CR Vault Arrangement***

**Notes:**
This shows the arrangement of the 4 tanks within the CR Vault.  The thermocouple being removed was 37 ft long, extending to the bottom of the tank.

## Containment Tent Over Vault

***Containment Tent Over Vault***

## Workers Preparing Thermocouple Tree for Removal

***Workers Preparing Thermocouple Tree for Removal***

**Notes:**
This is an old photo.  At the time of the CR Vault event, workers wore self-contained breathing apparatus (SCBA) due to tank vapor concerns.   

## 244-CR Thermocouple Event Timeline

***244-CR Thermocouple Event Timeline***

**Notes:**
Event Description:
0257—T/C removal begins at 2-4 inches per second
	- six workers in the tent during T/C removal
	- The work supervisor was in the tent; another work supervisor, assisting the in-tent 	  supervisor, was located outside the tent.
0302—dose rates exceed 50 r/hr
0303—RCT tells supervisor readings are “hot” and to stop the pull and reinsert the T/C
0303—FWS stopped T/C removal, while RCT left tent to discuss readings with RCT first line 	     supervisor (located outside tent and outside tank farm fence) 
0305—Outside supervisor, RCT and RCT first line supervisor discuss readings and determine 	     best course of action is to continue lift
0306—RCT enters tent and indicates that it’s OK to continue with the lift
0308—T/C is removed from the tank
0309—T/C is placed on flatbed trailer, double sleeved the T/C and applied shielding
0315—RCT’s discover high levels of contamination at top of riser; 
	     pocket dosimeters read 400 mrem and 200 mrem
0640—FR learns of dose rates exceeding permit limits during morning Plan of the Day meeting
0730—FR informs DOE management of sketchy work issues during regular conference call 			between FRs and DOE management

Note that most of the dose was received while “placing the work in a safe condition” 
Prior to this event, work supervisors were given unwritten latitude to make necessary decisions to place the work in a safe condition if unexpected conditions were encountered.

## Wrapped, Shielded Thermocouple on Flatbed Truck

***Wrapped, Shielded Thermocouple on Flatbed Truck***

**Notes:**
Note how the sleeving was taped in a barber pole fashion.

Back-up Information--Dose Summary:

Operator A (taping)—	Deep Dose:  28 mrem; Extremity Dose:  22,331 mrem
Operator B (sleeving)—Deep Dose:  10 mrem; Extremity Dose:    2,831 mrem
Rigger A (tent/choker)--Deep Dose:    0 mrem; Extremity Dose:    3,682 mrem
RCT A (in tent dose)--	Deep Dose:    0 mrem; Extremity Dose:       792 mrem
RCT B (in tent dose)--	Deep Dose:  11 mrem; Extremity Dose:    4,062 mrem
RCT C (trailer)--	Deep Dose:  12 mrem; Extremity Dose:    7,908 mrem

## Notifications
Stabilization activities
Event investigation
Near-term response
Regular status reports
Compensatory measures
Common cause review

- Stabilization activities
- Event investigation
- Near-term response
- Regular status reports
- Compensatory measures
- Common cause review

***Immediate Facility Representative Response***

**Notes:**
Notified DOE management when the event was discovered--contractor didn’t 	consider it to be an adverse event worthy of investigation until prompted by 	DOE
Monitored field stabilization activities to decontaminate pit area
Attended event investigation; ensured appropriate contractor response
Regular status reports to DOE management—including verbal briefs to 	management throughout the day of the event and during event investigation 	and recovery, including daily written briefs
Ensured development of adequate immediate compensatory measures—	required a significant amount of FR involvement
Reviewed past events for similarities; prompted contractor to evaluate common 	causes

## Personal accountability
Safe condition means people first
Plan the work and work the plan 
Plan for contingencies
Hazard analysis based on sound data
Conduct of Operations 

- Safe condition means people first
- Plan the work and work the plan
- Plan for contingencies
- Hazard analysis based on sound data
- Conduct of Operations

***What the Contractor Learned***

**Notes:**
Personal accountability--workers and supervisors need to know the permit limits, know the dose rate and contamination limits, and work within the established limits, without relying on RCT as a Rad-cop.
“Safe Condition”--Need to define what is meant by “safe condition” as a 	planned work package contingency; ensure that people are placed in a safe 	condition first, sufficiently removed from the hazard
Plan the work and work the plan—if you get outside the box, stop and re-plan
Contingencies—include conceivable contingencies in the work plan
Hazard analysis must be based on sound data—can’t make assumptions without supporting source data; can’t use 20-30 year old data to plan work; if old information is all you have, then plan the work conservatively, assuming higher risk source values (more rigorous planning, contingencies, etc.)
Conduct of Operations—
ensure critical communications are clearly identified and adequately communicated to the right people; 
critical communications should be made to the work supervisor; 
the work supervisor is in charge of 	the job, not the RCT first line manager and not the assisting supervisor
procedure compliance is mandatory 

##  Coordination with line management
 Investigation of event
 Post-event response 
 Contractor held accountable

 Common Cause Analysis
 Contingencies adequately planned

-  Investigation of event
-  Post-event response
-  Contractor held accountable
-  Common Cause Analysis
-  Contingencies adequately planned

***What the Facility Representatives Learned***

**Notes:**
Worked Well
- Close coordination between FRs and DOE line management—regular, open communications kept management 	informed and facilitated their communications with contractor senior management
- FR investigation of the event revealed system weaknesses not identified by the contractor
 FR post event response included:
	- Monitored decontamination efforts and work site stabilization
	- Observed contractor’s event investigation
	- Developed a reactive oversight plan with specific focus areas, including:  compensatory measure implementation, 		work planning, work execution, corrective action completion, etc. 
	- Observed all high risk work to ensure compliance with compensatory measures
 - FRs consistently held the contractor accountable to:
	- Establish adequate immediate compensatory measures
	- Conduct extent of condition reviews
	- Perform common cause analysis 
	- Implement corrective actions as defined and when scheduled
	- Ensure corrective action implementation problems were remedied
	- Ensure management involvement in corrective action implementation
-
Improvements
 More regular proactive reviews of events, occurrences and FR observations for commonalities and recurring themes  
- More scrutiny and vigilance regarding instances where work is performed without approved work instructions or procedures (e.g. skill of the craft work, etc.)

## Questions?

## DC01	Worker directly touched thermocouple without shielding
RC01	The hazard identification process failed to identify the magnitude of the hazards and account for data uncertainty
RC02	Conduct of Operations principles were not implemented during fieldwork
RC03	Management has not defined a standard and process for what constitutes placing the “plant in a safe condition”
CC01	Past lessons learned from LLCE removal activities for use of beta shielding materials (leaded gloves/rubber matting) and remote handling techniques were not adequately applied 
CC02	The engineering control was not verified to be operating correctly (spray washer) 
CC03	Failure to plan for and stage shielding to reduce beta radiation exposure 
CC04	Continuous monitoring methods contributed to higher beta exposures during direct handling of the thermocouple
CC05	HPT did not communicate actual dose rates to workers and supervisor, and did not understand limits of radiological work permit 
CC06	The supervisor did not direct workers to a low dose area during a pause in the work

- RC01	The hazard identification process failed to identify the magnitude of the hazards and account for data uncertainty
- RC02	Conduct of Operations principles were not implemented during fieldwork
- RC03	Management has not defined a standard and process for what constitutes placing the “plant in a safe condition”
- CC01	Past lessons learned from LLCE removal activities for use of beta shielding materials (leaded gloves/rubber matting) and remote handling techniques were not adequately applied
- CC02	The engineering control was not verified to be operating correctly (spray washer)
- CC03	Failure to plan for and stage shielding to reduce beta radiation exposure
- CC04	Continuous monitoring methods contributed to higher beta exposures during direct handling of the thermocouple
- CC05	HPT did not communicate actual dose rates to workers and supervisor, and did not understand limits of radiological work permit
- CC06	The supervisor did not direct workers to a low dose area during a pause in the work

***Root Cause Analysis Results***

## Personnel contamination during AW-01A jumper removal
Personnel dose level exceeded during C-106 eductor removal
Clean out Box (COB) AW-2 work performed outside scope of package
Clothing contamination during AN-101 pump disposal 
Pressurization alarm response during AP 01-A jumper removal

- Personnel dose level exceeded during C-106 eductor removal
- Clean out Box (COB) AW-2 work performed outside scope of package
- Clothing contamination during AN-101 pump disposal
- Pressurization alarm response during AP 01-A jumper removal

***Recent Similar Events***