# Presentation: 151787

**Categorizers (CAT) Team Workshop #2005-03**

## OUR AGENDA!

**Workshop Goals**
**Point to Ponder**
**ORPS Trending**
**CAT Form Entries **
**Programmatic Bins **
**Cat Chat**
**BNL “R” Report Process**
**“****R” Reports in the Complex**
**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 PROMPT (via categorization) deep and lasting value-added CHANGE, which results in new ways of thinking and acting.

-   **CAT**

## Point to Ponder

-  **    “****GREAT MINDS discuss ideas,**
**Average minds discuss events,**
**Small minds discuss people.”**
**	****	****	**** ****	****- Admiral Hyman G. Rickover **
**	****	****	**** ****	****   ****	**

## BNL ORPS by Calendar Year Report Submitted

- As of 09/30

## BNL ORPS Report StatusFY 2005 (End of Month)

## ORPS Corrective Action StatusFY 2005 (End of Month)

## ORPS Reports and ActionsSeptember 30, 2005

**ALD**

## CAT Electronic Entries

**07/07 – KK, < 1 gal hyd oil spill from PE line truck**
**07/07 – KK, Chemistry ****student passes out, taken to hosp, not work related**
**07/12 – AL, EOC opened to track hazardous waste shipment**
**07/13 – AL, Chemical Hole contract worker ill, not work related**
**07/14 – AL, Momentary ****loss of LIPA power, no fault of BNL**
**07/18 – KS, LIPA Power Dips Cause Unplanned Shutdown of Cyclotron**
**07/21 – KS, Minor Occupational Injury ****(wood splinter)**** at Building 1005R**
**07/26 – AL, Safety Notice - Faulty Pressure Relief Valve (SC4)**
**08/01 – PB, Simple Fracture of Pinky Finger while working on dump truck**
**08/05 – MB, ****NSLS User trans from BNL Dorm to Hospital, ****non-work related**
**08/06 – MB, Discovery of fixed Rad Cont @ Bldg 527**
**08/08 – MB, Rail Car (Gondola) Derailment at BNL (SC3)**
**08/10 – MB, BNL Fire Department extinguishes small brush fire**
**08/15 – RK, <1Cup oil spilled at railroad track by south firebreak**

## CAT Electronic Entries

**08/15 – RK, BNL Initiated “time out” at New Research Building site**
**08/16 – RK, <1-gallon hydraulic fluid on pavement in rear of B326**
**08/17 – RK, Rail jitney radiator cracks, ~ 7 gals of anti-freeze spill **
**08/17 – RK, Hg laden soil temp stored at Old HWMF **
**08/18 – MB, Fire Rescue responds to smoke detector false alarm at NSLS**
**08/21 – RK, Phones/fire alarm trans to BNL Firehouse oos for ~ 1 hour**
**08/24 – PB, Contractor -  4K dpm skin cont on neck @ B650**
**08/26 – RK, (Update) Hg/**_**Cs-137**_** laden soil stored at Old HWMF **
**08/29 – SM, P/U truck damages wall at B1002B**
**09/06 – MD, (Update) ****Contractor - ****4K dpm skin cont on neck @ B650 (SC4)**
**09/06 – MD, GW treatment system (Sr-90) fitting leak, to sump @ B855 **
**09/07 – ES, (Update) ****Contractor - ****4K dpm skin cont on neck @ B650 (SC3)**
**09/08 – MD, 09/08 - ****PE truck hung up on berm behind B912**
**09/13 – KS, Tritiated water (****2200 pCi/L) leak (30-50 gal) to soil near B930A**

## CAT Electronic Entries

**09/16 – KS, 500 dpm alpha (Americium 241) skin cont on hand @ B650**
**09/19 – AL, Non-occupational illness results in trans to hospital**
**09/23 – AL, Worker has allergic reaction to chigger bites around B257 &258 **
**09/26 – AL/PB, Custodian cuts hand on window pane during fall @ B815**
**09/29 – PB, Inert gas removed from HFBR vessel without written approval**
**09/29 – ES, (Update of 8/8 entry) Recurring Railcar Events (SC“R”)**

## ORPS Reportable and Nonreportable Cat Entries

**ORPS Reportable and Nonreportable Cat Entries**

## Programmatic Bins

**Personnel Contamination**
**Medical Department**
**NSLS**
**Physics**
**CA-D**
**BGRR Project**
**Plant Engineering ****(New Bin)**
**Utilities Struck**
**Material Transportation**
**Electrical Shock Hazards**
**Material Handling Issues**
**Waste Management **
**Chemistry**
**Environmental Restoration**
**Railroad Tracks**
** **** **
**	****	**

## 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**** **
**Personnel Contamination – 2005**
**02/02 – Personnel Contamination 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 – KS, 500 dpm alpha cont on hand @ B650 **
**  **
**	****	**

## 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

_**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**

## 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

_**NSLS, 2005**_
**03/03 – ****Suspect Bolts Found in Crane During Inspection @ NSLS (SC4)**
**04/20 – Haz concerns associated with energized magnet**
**06/28 – SC, ****Syringes (w/needles) found in Research Laboratory**
**   ****Trash Receptacles @ Bldg 725A**
** **

## Programmatic Review

_**Physics, 2004**_
**07/01 – Laser interlock check overdue by 3 weeks @ ATF**
**10/21 – Trimmed tree branch breaks window at physics**
_**Physics, 2005**_
**04/25 – Smoke alarm from overheated plastic tubing @ Bldg 832**

## Programmatic Review

_**CA-D, 2004**_
**01/13 - Worker breaks ankle while preparing for cable pull (SC3)**
**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

_**CA-D, 2005**_
**01/07 – Employee falls while walking (Reason Unknown, SC3)**
**02/09 – ****Slip and Fall Results in Hairline Fracture of Kneecap (SC3)  **
**03/14 – Cooling Water Leak at LINAC due to stuck open relief valve **
**02/22 – ****High pH detected at recharge basin HTW, Bldg 930**
**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**** **

## 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, 2005**_
** **
** **

## 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**

## 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, 2005:**_

## 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 arriving at Envirocare (SC3)**

## Programmatic Review

_**Electrical Shock Hazards, 2004**_
**07/12 - Worker feels mild electrical tingling in his finger @ NSLS**
**08/10 - Worker experiences electric shock @ NSLS (SC3)**
_**Electrical Shock Hazards, 2005**_
**04/01 - Unexpected Discovery of Hazardous Energy Source @ Magnet Division (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, 2005**_
** **

##  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 – KS, 500 dpm alpha cont on hand @ B650 **
** **

##  Programmatic Review 

_**Chemistry, 2005**_
**02/02 – Personnel Contamination 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**

##  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**
**09/29 – Inert gas removed from HFBR vessel without written approval**
** **

## 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)**
** **

##  Proposed BNL “R” Report Process

**On going data collection**
**Tracking and Trending of data – ongoing**
**Identification of potential “R” recurring issue**
**Determine issue ownership**
**Inform DOE/BHSO ****ORPS Coordinator**
**Present ****potential recurring issue to owner for discussion/insight**
**Owner decision - Is this issue “R” reportable to DOE?  Y/N?**
**Yes – Issue “R” report**
**No – Is BNL ORPS Coordinator in agreement? Y/N? Yes, Stop – No, continue to step 8**
**Presentation made to categorizers for “R” reportability vote**
**Yes – Issue “R” report**
**No – Stop**
**NOTE:****  All data/determinations captured in Quarterly Performance Analysis Report**
**   **

## “R” Reports in the Complex45 as of 10/05/2005

-        **BBWI Bechtel BWXT Idaho, LLC. **
**       ****BHI Bechtel Hanford Incorporated  BNFL BNFL INC. **
**       ****BNL Brookhaven National Laboratory****  BNRP Bechtel National River Project  BSYM Bechtel SAIC Company LLC.  BWO Babcock and Wilcox of Ohio, Inc.  BWXP BWXT PANTEX **
**       ****BWXT BWXT Y12 **
**       ****CHG CH2M HILL Hanford Group, Inc.  CWI CH2M*WG Idaho, LLC **
**       ****GOAL Albuquerque Operations **
**       ****KHLL Kaiser-Hill Company, L.L.C.  LANL Los Alamos National Laboratory  LLNL Lawrence Livermore National Lab.  ORNL Oak Ridge National Laboratory  PHMC PROJECT HANFORD MANAGEMENT CONTRACTO **
**       ****SNL Sandia National Laboratories  WSRC Westinghouse Savannah River  WVNS West Valley Nuclear Services**

## “R” Reports in the Complex45 as of 10/05/2005

**Procedure Non-Compliance during a Nuclear Explosive Operation that was determined to be of recurring nature.**
**RCRA Compliance Order resulting from 2001 Annual Inspection**
**Recurring Material Handling Problems ****(BNL)**
**Repetitive Issue on Noncompliance with Facility Operational Mode Requirements**
**Failure to apply Lockout/Tagout (LOTO) while working on an electrical system removing a light fixture**
**Recurring Events Involving Degradation Of Hydrogen Monitors/LFL Analyzers**
**Performance Analysis Identifies "Inadvertent Transfers/Siphons" As A Recurring Event**
**Performance Analysis Identifies "WSRC TSR Violations" As A Recurring Event**
**Management Concern of Lock and Tag Issues**
**Repetitive Issue with Subcontractor Performance**
**Recurring - Discovery of Beryllium Contamination in a non-Beryllium Use Facility **
**Five Technical Safety Requirement (TSR) violations occurred at the Plutonium Finishing Plant during the period from Sept. 2003 to July 2004**
**Recurring CAAS/PRDI Events**
**Temporary Suspension of ESF Underground Activities**
**Evacuation Alarm System Malfunction (Recurring)**
**Permit Exceedance for Copper, September and October 2004**
**Repetitive Issue Related to Management of Waste Transport Tankers**
**Management Concern With Recurring Radiological Control Events**
**Recurring Events Involving Subcontractor Performance**

## “R” Reports in the Complex45 as of 10/05/2005

**20.****	****Recurring Event Report involving Tools or Materials Dropped from Heights**
**21.****	****Quarterly Perfomance Evaluation Reveals Reportable Trend in ISM Program Implementation**
**22.****	****Repetitive Issue with Electrical Safety **
**23.****	****Management Concern - Conduct of Operations at the 100 K Area.**
**24.****	****Recurring Events at the INTEC Spent Nuclear Fuel Facilities**
**25.****	****Under-Reporting of Radiation Contamination Events**
**26.****	****Repetitive Issue Related to Spacing of Containers in Accordance with Criticality Safety Postings**
**27.****	****Performance Analysis Identifies "Multiple PISA/USQ Events in the SWMF" As A Recurring Event**
**28.****	****Occurrence Reports Associated with Facilities Construction Operations **
**29.****	****Evacuation of Shandiin Child Development Center (SCDC) Due to Broken Natural Gas Pipe**
**30.****	****Repetitive Issue with Heavy Equipment Operations**
**31.****	****Performance Analysis Identifies Deficiencies in Facility Hazard Categorization as a Recurring Event **
**32.****	****Recurring Issues Associated With Hazardous Energy Control**
**33.****	****Recurring Issues Associated with Radiological Control**
**34.****	****Performance Analysis Identifies WSRC Electrical Safety Performance As A Recurring Problem**
**35.****	****Inadequate Work Control Process**
**36.****	****Evacuation of Shandiin Child Development Center (SCDC) Due to Natural Gas Leak**
**37.****	****Multiple Criticality Working Requirement Violations Cause Management Concern**
**38.****	****CO Monitors Alarm Causing Tunnel Precautionary Evacuations**
**39.****	****Survey Activities Extended Outside Radiologically Cleared Area**

## “R” Reports in the Complex45 as of 10/05/2005

**40.****	****Delay in Placing SCW Packet Assay into Suspension Vilolates Limiting Condition for Operation and Recurring TSR Implementation Events**
**41.****	****Recurring Issues Associated With Respiratory Equipment**
**42.****	****Recurring Occurrence on Work Control Issues**
**43.****	****Management Concern - Procedural Compliance Issues**
**44.****	****Recurring Railcar Events ****(BNL)**
**45.****	****Near Miss [Electrical] Incidents at the WTP (Recurring)**

## CAT Team Workshop

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