# Presentation: 294783

**Categorizers (CAT) Team  Recurring ORPS Report Vote   “Utility Strikes”**

## AGENDA!

**Purpose**
**Facilitation**
**Rules of the Meeting**
**Categorizers**
**Observers**
**Qtr. ORPS Performance Analysis Results**
**Utility Strike Events**
**“****R” Reporting Criteria**
**“****R” Report Requirements**
**Presentation by Ray Costa**
**Q & A Session**
**Categorizer Vote**
**The Path Forward**
**      **

## Rules of the Meeting

- This meeting is primarily for the Categorizers
**Free flow discussion among Categorizers allowed**
- Observers
**Must raise hand and be acknowledged prior to speaking**
**We must remain focused on the relevant issues!**

## ORPS Quarterly Performance Analysis and Summary 3rd Quarter CY 2004 

- 20 utility strikes occurred from January 1, 2000 to September 30, 2004
- 6  reportable to ORPS
- 3  utility strikes occurred in CY 2004;  Electrical Utility (Encased in Concrete Floor) Conduit Strike, Domestic Water Main Strike (not reportable in ORPS), and Comm Cable Severed During Excavation Work (not reportable in ORPS).

## ORPS Quarterly Performance Analysis and Summary 3rd Quarter CY 2004 

- Procedure Not Used or Used Incorrectly’ was assigned as a cause for 4 of the 6 occurrences.
- PE Excavation Procedure (EP-ES&H-801) was cited as a procedure to be revised in 3  different occurrence reports; 2000, “Strike Underground Electric Cables - Roll up Report”, 2002 “Minor Utility Strike During Horizontal Boring Operations”, and 2003 “Communication Cable Struck During Excavation.”
- All 6 occurrences involved a contractor or subcontractor performing work.

## “R” Reporting Criteria

**     ****The following are questions that should be considered as indicators or contributing attributes to a recurring event.**
**Did the trending data for the series/group of events indicate a significant negative trend?**
**Were there a significant number or percentage of implementation failures discovered to indicate that one or more components of the program were not effective in ensuring successful completion of the task or activity?**
**Have multiple control failures within the boundaries of a single occurrence taken place indicating a common breakdown in a program or area of a program?**
**Have small and apparently isolated series/groups of events been seen within various aspects of an overall program that collectively indicate a program weakness when viewed from a site perspective?**
**Have failures been discovered that indicate during implementation of a particular program, or portion of a program, that one or more components of the program were not effective in ensuring successful completion of the task or activity?**
**Was there a common underlying cause or weakness in controls that necessitated corrective actions?**

## “R” Reporting Criteria

**Did the group of related events indicate a series of common work process breakdowns or a series of common quality criteria issues?**
**Did related series/groups of events breach multiple, but not necessarily all, barriers protecting workers, the public, or the environment from potential or actual adverse impacts of an event?**
**Did related series/groups of events, having the same underlying cause or having contributed to or were the unavoidable consequence of the underlying problem, occur within a single facility or operation?**
**Did a causal factor of the series/group of events indicate a lack of management involvement, or breakdown in management controls, or errors in decisions/directions by managers that resulted in systemic problems or violation of safety rules?**
**In Short . . . **

## Note “R” Report Requirements

**Utility Strike Evaluation**
- Ray Costa
- F&O ESHT&Q
- Interim Manager

## Agenda

- History
- Definitions
- Data Analysis
- Corrective Actions
- Lessons Learned
- Summary

## History

- November 2003
- Jim Tarpinian, ALD ESHT&Q  requested Andy McNerney, ALD F&O, to have Plant Engineering evaluate utility strike data presented to ORPS Categorizers
- Requested Plant Engineering to:
- Evaluate the data and provide further information on any trends or recurring conditions that exist between these events
-  Answer the following questions:
- Is there evidence verifying that the corrective actions from the utility strike events was completed?
- Is the effectiveness of corrective actions evaluated in the Plant Engineering self-assessment process?
- Does Plant Engineering review and apply the Lessons Learned Communications they receive?

## Terminology and Challenges

- Excavation
- Digging into soil with heavy equipment and/or with a shovel or pick
- Challenges
- Accurate location of known utilities
- Abandoned utilities not identified on maps or not known to exist
- Army era utilities poorly documented on Camp Upton drawings
- Many drawings date back to the 1940’s, are hand drawn and do not  accurately locate utilities
- Not all utilities added by non-Plant Engineering projects provided to update utilities maps
- Penetration
- Digging into cement or masonry with power tools (e.g., jack hammer,  saw, drill) and/or with a hand chisel
- Challenges
- Utilities can be located close to one another in a small area, i.e., congested
- Rebar buried in cement, makes it hard to locate utilities accurately
- And those challenges noted in excavation apply here as well

## The Data	

- To understand what is happening over a 5 year period we need to time phase the events
- We need to identify the activity that led to the utility strike
- Look at causes to identify trends

## All Utility Strikes

## Plant Engineering Utility Strikes by Activity

## Plant Engineering Activities Resulting in Utility Strikes	

**Totals over last 5 years **
**Excavation – 12**
**Vehicle Accidents – 3 **
**Penetrations – 2  **
**Excavation is the highest contributor and needs closer analysis for possible trends**

## What’s in the Ground at BNL?

- 11 miles of steam condensate piping
- 45 miles of potable water piping
- 19.7 miles of sanitary piping
- 1.6 miles of chilled water piping
- 1.6 miles of compressed air piping
- 9 miles of storm water collection piping
- In addition to
- Electric cables
- Telecommunications cables
- Network cables
- Fire Alarms cables
- Security Alarms cables
- Abandoned and unknown utilities

## Plant EngineeringExcavations Activity Vs. Utility Strikes

| FY | Trenched Excavation in Linear Feet | Other Excavations |  | Utility Strikes
ORPS | Utility StrikesNon-ORPS |
| --- | --- | --- | --- | --- | --- |
| 2000 | 2,400 |  |  | 1 | 1 |
| 2001 | 7,500 | 11 |  | 0 | 5 |
| 2002 | 9,600 | 12 |  | 1 | 1 |
| 2003 | 4,500 |  |  | 1 | 1 |
| 2004 | 6,600 | 3 |  | 0 | 1 |

## Plant Engineering Excavation Utility Strikes

## Plant Engineering Root Causes of Excavation Utility Strikes

|  | Utility Map | Procedure Ambiguous | Permit Violation | Commun. | Marking | Legacy Debris | Unidentified Cable | Abandoned |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 2000 | 2 |  | 1 |  |  |  |  |  |
| 2001 | 1 |  | 2 |  | 1 |  |  | 1 |
| 2002 |  | 1 |  |  |  |  | 1 |  |
| 2003 |  |  |  | 1 |  |  |  | 1 |
| 2004 |  |  |  |  |  | 1 |  |  |

## What the Data Shows

- No injuries resulted from any of these utility strikes
- Utility marking and permit violations were the major contributors in 2000 – 2001
- Corrective actions appear to be effective
- No repeats from 2002 to present
- All corrective actions have been completed and appear to have been effective in reducing utility strikes
- Abandoned and poorly documented legacy utilities are the primary cause and are very difficult to locate

## Corrective Actions Taken

- Procedure
- Clarification of toning process
- Clarification of responsibilities
- Permit refinement
- Lessons learned incorporated
- Marking instructions and re-inspections added
- Created a Configuration Control procedure to address legacy issues and map errors
- Design standards updated to standardize burial depths
- Require the updating of site utility maps (hard copies) as unidentified utilities are found
- Training
- Lessons Learned communicated and shared
- Disciplinary actions taken
- Contractors
- Formal warnings issued
- Safety Inspection Report issued to contractor and Project Manager
- Negative impact on performance rating
- Recovery of cost of repairs from contract

## Proactive Actions

- Revised procedures to add expiration date to digging permits (2001)
- Training on utility locating instruments held on site by Staking University (2001)
- Standardized the process for how utilities are documented on contract drawings (2001)
- Sent Plant Engineering representatives to the “Big Dig” conference (2002)
- Re-established Excavation and Penetration Committee (2002)
- Purchased hydro-vacuum (2002)
- Revised procedures to have contractor sign that he has reviewed the digging permit and marked-up utility drawings with the project manager prior to the start of work (2003)
- Excavation  safety is regular agenda item at monthly Plant Engineering ESH Committee Meeting
- Digitizing old hand drawings to aid in researching legacy issues (on-going)
- Continually evaluating new equipment to locate “unknown” utilities (on-going)
- Continually evaluating the excavation and penetration processes to improve them (on-going)

## Corrective Action Process

- Every Plant Engineering ORPS results in a critique and corrective actions
- Status of ORPS reviewed monthly, at Division Quarterly Reviews, and during DOE / Plant Engineering Quarterly Construction Reviews
- Every non-ORPS results in an Investigative Incident and corrective actions as appropriate
- All corrective actions tracked to completion by ATS or F&O’s FATS equivalent
- F&O FATS equivalent
- Notification of action sent to lead person
- Due notice sent 90 days before due date and every month until closed
- Overdue report sent to Division Manager and responsible Manager quarterly
- Trending in process – Tier I’s complete for Plant Engineering
- All Plant Engineering Corrective Actions resulting from Utility Strikes have been completed

## Verification of Corrective Actions

- Job Site Inspections
- Planned as part of Tier I program
- Management walkthroughs
- Safety Inspections performed by Plant Engineering Contractor Safety Inspectors
- Over 900 safety inspections per year

## Assessments

- Excavation Safety Assessment performed by Independent Oversight (IO) in July 2003
- Reviewed documentation
- Interviewed personnel
- Observed excavations in progress
-  IO found
- Processes to control excavation work and ensure the safety of workers are in place as required by both DOE and OSHA
- Identified several strengths in work control and excavation safety including:
- Plant Engineering Division being established as the single Lab-wide point-of-contact for digging permits and the identification and marking of underground utilities
- Implementation of training for Competent Persons
- Proactive involvement of appropriate expertise in the review of excavation work plans
- The institution of an Excavation Safety Committee striving to minimize utility strikes
- Areas for improvement:
- Predominantly subject area improvements
- Plant Engineering needed to add OSHA Trenching and Excavation to JTA requirements
- Training being performed, not in JTA

## Lessons Learned

- BNL shares lessons learned with all site personnel via e-mail, bulletin, and other available channels
- Lessons learned pertinent Plant Engineering operations are distributed via e-mail by Plant Engineering’s ESH Coordinator or ESHT&Q Manager
- Additional lessons learned from other than BNL sources are identified and distributed
- Lessons learned are posted in Plant Engineering’s buildings, as appropriate on ES&H Bulletin Boards
- Supervisors share lessons learned with their staff as a toolbox meetings

## Summary

- No persistent trends identified over the last three years
- Corrective actions appear to be effective as demonstrated in reduction of utility strikes over the last 3 years
- Undocumented utilities provide the potential for additional strikes
- Constantly updating utility maps to reflect what we know
- Digitizing old drawings and overlaying on BNL photogrametry to improve searches of legacy issues
- Continuing to evaluate state-of-the-art utility location equipment to locate the unknown