# Presentation: 118348

**Categorizers (CAT) Team Workshop #2004-03**

## OUR AGENDA!

**Workshop Goals**
**Point to Ponder**
**Cause and Effect, Not So Fast!**
**ORPS Trending**
**CAT Form Entries **
**Programmatic Review**
**Cat Chat**
**Group 10 Criteria, Who Makes the Call?**
**LBNL Electric Strike Incident (Patti Bender)**
**Categorizer Conflict of Interest**
**BNL “R” Process (Utility Strikes)**
**Reportable Quantity Release Discussion (Steve Moss) **
**CAT Cell Phone Operation (Ken Krasner)**
**Principles of Human Performance Improvement**
**Meeting Evaluation and Wrap-up**
**      **

## CAT Team Workshop

_**Workshop Goals:**_
-  To EVALUATE and IMPROVE the BNL Occurrence Reporting Program.
-  To MAINTAIN a baseline categorization process such that reportability decisions are both valid and _consistent_.
-   To continue to ASSIMILATE the   new ORPS Model

-   **CAT**

## Point to Ponder

_**The Causal Figment**_
**The Scottish philosopher David Hume (1711-1776) held that the idea of a causal relationship between two events occurring in sequence is nothing more than a habit of mind. **
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- _[ ](http://www.geocities.com/Athens/3067/hume/h_index.html)__ _

## BNL ORPS Report StatusFY 2004 (End of Month)

## ORPS Corrective Action StatusFY 2004 (End of Month)

## BNL ORPS by Calendar Year Report Submitted

- As of 10/28

## CAT Electronic Entries

**07/30 – KK, Minor leak from “D” waste valve in bldg. 801**
**08/02 – KK, Van sliding door injures little finger**
**08/03 – SM, Smoke in bldg. 134, suspicion of fire **
**08/06 – SM, Minor anti-freeze spill to pavement near bldg. 209**
**08/07 – SM, Trace amts. of H-sulfide leaked from gas cylinder at NSLS**
**08/10 – PB, Worker experiences electric shock at NSLS (SC 3)**
**08/10 – PB, Minor Iodine – 135 spill in bldg. 490, RAR generated**
**08/11 – ES, Suspect/Counterfeit shackles and hooks (SC 4)**
**08/11 – ES, Cold box heating element (1005R) causes burn to hand (SC 3)**
**08/12 – ES, Leaking faucet conn. results in “D” waste sump alarm bldg. 810**
**08/16 – KK, ~1 gal hydraulic leak to pavement at bldg. 1005H**
**08/16 – SC, Haz waste shipment alarms BNL vehicle rad monitor**
**08/16 – SC, Carpenter drills into water line in bldg. 490**
**08/17 – SC, ~1 qt. hydraulic leak to pavement at bldg. 855  **
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## CAT Electronic Entries

**08/31 – SC, Personnel cont. at the PET facility**
**09/03 – PB, Empty railroad car derailed at BNL track switch **
**09/03 – PB, Duct service bldg. work performed outside of procedure (SC 4)**
**09/04 – MB, Off-site train car derailment (SC 4) **
**09/07 – MB, Comm. cable severed during excavation work**
**09/13 – MB, Suspected munications found during excavation**
**09/14 – RK, Inadequate rail safety procedures (SC 4)**
**09/16 – RK, Power outage at bldg. 479 due to transformer failure**
**09/16 – RK, A/C water leak at bldg. 911B**
**09/17 & 20  –  RK, Oil leak from USTs bldgs.  244 & 422 (SC 4)**
**09/22 – KK, Low voltage leakage through hook on crane at NSLS**
**09/24 – KK, < 10 gal. hydraulic oil spill at ERD project**
**09/27 – SM, < one pint oil spill to pavement at bldg. 326**** **
**---------------------------------------4 th Qtr------------------------------------------------------**
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## CAT Electronic Entries

**10/01 – SM, ~ 3 gallons of hyd fluid spilled to concrete near bldg 206/207**
**10/05 – KS, Suspect/Counterfeit bridle sling hooks (SC4)**
**10/05 – KS, Injury due to steel plate falling at bldg 701 (SC3)**
**10/12 – AL, ~ 2 pints hydraulic oil spill onto concrete floor at bldg 96**
**10/12 – AL, < 10 gal diesel fuel spill to leaf covered ground near bldg 412**
**10/15 – AL/DDO, Potential fire hazard in AGS cable tray (SC4)**
**10/15 – AL, Worker trans to hosp due to anxiety attack/heart prob in 1005**
**10/15 – AL, Low voltage leakage through hook on crane at bldg 930**
**10/19 – ES, Suspect/counterfeit shackle discovered in bldg 930 (SC4)**
**10/19 – ES, Emerg light leaks batt acid shorting router/UPS in bldg 703**
**10/21 – ES, Trimmed tree branch breaks window at physics**
**10/20 – SC, Oil in sewage treatment plant water, no release to environment**
**10/22 – SC, Rad mat arrives at BNL with no shipping papers or placards**
**10/22 – SC, Minor antifreeze spill (SC4)**
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## CAT Electronic Entries

**10/26 – PB, Roll-up door tension gear (2-1/2 pounds) falls 25 ft at bldg. 820 **
_**Speaking about antifreeze**_
**Given: 1 gal of 50/50 water to antifreeze mix **
**	****Total of 8 pounds**
**	****4 pound of antifreeze**
**	****The state limit is 1 pound to the environment, which means a non-routine report, which is reportable to ORPS**
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## ORPS Reportable and Nonreportable Cat Entries

## 4 QTRS. (Old System)
30 out of 149 events/conditions were deemed reportable = 20%
3 events/conditions reported/week 
.6 reportable/week

**30**** **out of **149 **events/conditions were deemed reportable =** 20%**
**3 **events/conditions reported/week
**.6***** ***reportable/week

_**3 QTRS. 04 (New System)**_
**28 **out of **144 **events/conditions were deemed reportable =** 19%**
**3.7** events/conditions reported/week
**.7***** ***reportable/week

**CAT Log Entries**
**Old vs. New Criteria **

## Significance Category Distribution as of 10/21/04

_**SC**_**	****	****	**_**BNL**_**	****	****	**_**Complex**_
**OE****	****	****	****  0  (0%)****	****	****  11  (.7%)**
**“****R”****	****	****	****  1  (2.7%)****	****	****  17  (1%)**
**  ****1****	****	****	****  1  (2.7%)****	****	****    6  (.3%)**
**  ****2****	****	****	****  1  (2.7%)****	****	****214  (13%)  **
**  ****3****	****	****	****16  (43%)****	****	****698  (41%)**
**  ****4****	****	****	**_**18**_**  (49%)****	****	**_**742**_**  (44%)**
**Total****	****	****	****37****	****	****	****1688**

## Programmatic Review Areas

**Personnel Contamination**
**Medical Department**
**NSLS**
**Physics**
**CA-D**
**BGRR Project**
**Utilities Struck**
**Railroad Tracks**
**Transportation**
**Electrical Shock Hazards**
**Material Handling Issues**
**	****	**

## Programmatic Review

**Personnel Contamination - 2002**
** ****05/16 - Shoe contamination (AGS)**
**Personnel Contamination - 2003**
**01/16 - (WMD - 865)**
**03/28 - (PET)**
**09/26 - (PET)**
**Personnel Contamination - 2003**
**03/01 - Trit. cont. (865)**
**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 – (PET) **
**	****	**

## Programmatic Review

_**Medical department, 2002**_
**3/05 - Potential release of cont. water from bldg. 801**
**5/10 - L/L analytical lab samples outside of RMA in 490**
**6/20 - Small fire in 490 experimental hood**
**7/16 - < 25 ml of Ketamine (controlled substance) found in injection vial located in empty lab at 490**
**9/04 - Work performed under expired RWP at 490**
**9/13 - Unqualified worker operates CERF source**
_**Medical department, 2003**_
**01/28 - Loose Inner Electrical Panel cover (at 490) results in ****	****	****         sparking when outer door opened**
**03/06 - Liquid scintillation vials poured into 5-gallon Carboy ****	****	****         outside of the posted dispersible area in bldg. 490**
**01/09 - 120VAC light ckt. (deenergized) damaged during core drilling at 490**
**04/01 -  Improper Entry into Oxygen Deficiency Hazard Area**
**09/12 - Worker enters RWP area (490) without signing RWP**

## 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**
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## Programmatic Review

_**NSLS, 2002**_
**01/29 - 10 nG Staphyloccal Enterotoxin B crystals **
**04/19 - Electrical shock **
**09/22 - Hutch entered without signing RWP**
**10/02 - Fork truck strikes electrical panel **
**10/04 - Light beam strikes worker eye ****(Reported on 02/19/04) **
**10/06 - Staff (4) on exp. floor without TLD’s**
**12/27 - Carpenter at NSLS strikes energized 24VDC fire alarm wiring**
_**NSLS, 2003**_
**01/09 - Fire in cabinet extinguished in < 3 min.**
**01/10 - Loss of cooling to sextapole magnet results in smoke/precautionary evacuation**
**03/20 - Guest ignores restricted area posted requirements **
**06/01 - Worker slips and injures arm**
**09/08 - Injury to hand while operating lathe  **

## 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**
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## Programmatic Review

- _Physics, 2003_
**06/30 – Employee Received an Electric Shock to Hand**
**09/24 – GERT expires, same TLD worn for several months @ ATF**
**10/31 – Missing source discovered at Physics **
**12/19 – ****Attic Hatch in ATF Not Secured Prior to Beam Operation**
- _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**

## 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 (SC 4)**
**10/05 - Injury due to steel plate falling at bldg 701 (SC3)**
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## Programmatic Review

_**Utilities struck:**_
_**2000**_
**10/02 - Sanitary line severed near 801**
**10/27 - Worker hits energized UG cable**
**11/07 - Strike of 480 volt UG cable**
_**2001**_
**03/27 - UG abandoned comm. cable struck**
**03/29 - Backhoe scraps steam line  **
**04/26 - Backhoe strike of 208 VAC cable**
**07/03 - Backhoe strike of 208 VAC cable**
**09/17 - Van hits fill ass. of LPG tank**
**09/26 - Phone line damaged when digging near FH**
**10/03 - 2 in. above grd water line broken by bulldozer**
**11/28 - Backhoe strike of 4 - inch water line  **

## Programmatic Review

_**Utilities struck:**_
_**2002**_
**04/30 - Aband. control wiring hit during sanny upgrade**
**05/07 - GC drilled anchors into elect. duct bank near 911**
**06/06 - Minor utility strike during horiz. boring activities**
**09/28 Truck driver backs into 13.8KV BAF power supply**
_**2003**_
**01/08 - Contractor severed low voltage comm. cable ****	****     ****	****         near bldg. 51**
**05/08 - Deenergized cable struck during excavation near  ****	****         911A**
**08/12 - Forklift strikes overhead wire**

## 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**

## Programmatic Review

_**Railroad Tracks:**_
_**2004**_
**09/03 – Empty railroad car derailed at BNL track switch**
**09/04 – Off-site train car derailment (SC 4)**
**09/14 – Inadequate rail safety procedures (SC 4)**
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## Programmatic Review

_**Transportation Issues**_**:**
_**2001**_
**          ****07/27 - Misclass. of PCB Waste shipped offsite from      ****	****	****BGRR**
**          ****11/14 - Over-wt. Shipment of LLRW from BGRR**
**          ****11/19 - Misclass. of Rad. Material Shipped Offsite from ****	****	****BMRR**
_**2002**_
**          ****06/07 - Damaged 55 gallon drum of solidified waste**
**                      ****discovered upon arrival at Hanford Burial Ground**

## Programmatic Review

_**Transportation Issues**_**:**
_**2003**_
**          ****02/05 - Fuel cask shipped to SRS arrives with cont. > ****	****DOT ****	****limits         ****	****         **
**	****     ****11/07 - Waste oil shipping papers signed by unauthorized ****	****person**
**          ****11/07 - Unapproved carrier ships PCB cont. soil from ****	****BNL**
_**2004**_
**	****	****06/25 – B-52 waste cont support chnl rain water ****	****accumulation (SC4)**
**	****	****07/26 – ****Transportation of Solidified Liquid Low-Level ****	****Waste**** (SC1)**

## Programmatic Review

_**Electrical Shock Hazards**_
_**2001**_
**  ****10/03 - Electrical Incident at Cyclotron**
_**2002**_
**   ****04/19 - Electrical Shock @ NSLS**
**   ****09/24 - Worker at AGS receives <24 VDC**
_**2003**_
**   ****06/27 - Electrical Shock @ Physics**
_**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)**
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## CAT CHAT!

**Group 10 Criteria, who makes the call?**
**LBNL electric strike incident (Patti Bender)**
**Categorizer conflict of interest**
**BNL “R” Process, utility strikes**
**Reportable Quantity Release Discussion (Steve Moss) **
**CAT Cell Phone Operation (Ken Krasner)**

## Group 10 – Management Concerns/Issues 

**(1) 2 Any event resulting in the initiation of a Type A or B accident investigation as categorized by DOE O 225.1A, Accident Investigation.**
**(2) 1-4† An event, condition, or series of events that does not meet any of the other reporting criteria, but is ****determined by the Facility Manager or line management**** to be of safety significance or of concern to other facilities or activities in the DOE complex. One of the four significance categories should be assigned to the occurrence, based on an evaluation of the potential risks and the corrective actions taken.**
**(3) 1-4† A near miss, where no barrier or only one barrier prevented an event from having a reportable consequence. One of the four significance categories should be assigned to the near miss, based on an evaluation of the potential risks and the corrective actions taken.**
**(4) *4 Any occurrence that may result in a significant concern by affected state, tribal, or local officials, press, or general population; that could damage the credibility of the Department; or that may result in inquiries to Headquarters.**
**(5) *4 Any occurrence of such significant immediate interest to offsite personnel and organizations that it warrants prompt notification to the DOE Headquarters Operations Center (DOE HQ OC), and which is not already designated elsewhere in this set of reporting criteria to have prompt notification [denoted by having an asterisk (*) next to the significance category].**

## Principles of Human Performance

**People are fallible, and even the best make mistakes.**
**Error-likely situations are predictable, manageable, and preventable.**
**Individual behavior is influenced by organizational processes and values.**
**People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates.**
**Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events. **

## Competing Resources

- Source: James Reason. *Managing the Risks **of Organizational Accidents*, 1997 (in press).

*t**0*

*t**n*

**Accident**

**Bankruptcy**

**Notes:**
Why aren’t there “Think Megawatts” or “Think Schedule Adherence” signs in the plant or on the plant access road?
Illustration shows what may happen if distribution of resources (priority) is too much in one or the other basket.
Production - positive reinforcer; temptation to make production-oriented decisions over safety in the near term; when you do production you get $, schedule adherence, etc. (tangible)
Prevention is a negative reinforcer, punisher, or ignored; complacency builds in when nothing bad happens after taking short cuts; people do prevention, such as self-checking, and OE, to avoid undesirable outcomes like events; when you do prevention, you get nothing (no error or events).  (intangible)
Long-term vs. Near-term: The temptation is in the near-term when people are tempted to take shortcuts to achieve due dates or the work schedule.  Prevention will in the long-term enhance the productivity of the plant.

Incubation of Disasters (Man-Made Disasters, Turner & Pidgeon, p88)
I.   Existing set of beliefs and attitudes (shared?) about hazards and safe practices degraded     (Pollyanna) II.  Accumulation of unnoticed mishaps (unreported errors) and low-level events (at odds with original beliefs above; perceptions about safe practice and hazards depart from reality; values become differentiated through the workforce and management; complacency and shortcuts)III. Precipitating Event (outcomes that reveal true latent condition organization)IV. Immediate consequences of the event become evident.V.  Rescue and salvage (first stage of readjustment in values due to shock of experience)VI. Full cultural readjustment (second stage involving review and revision of existing ideas about      hazards and safe practices to avoid them)

For in-depth information, see Managing the Risks of Organizational Accidents by James Reason (1998), pp. 3-7.

## CAT Team Workshop

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