# Presentation: 046743

**Categorizers (CAT) Team Workshop #2007-02**

## OUR AGENDA!

**Workshop Goals**
**Today's Quote**
**ORPS Trending**
**Programmatic Bins**
**Cat Form Live Demo**
**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 **REVIEW/ EVALUATE **data to determine if repeat events should be identified as _potentially_ **RECURRING** occurrences.
-  To **PROMPT** (via accurate categorization) **DEEP** and **LASTING** value-added **CHANGE,** which results in new ways of **THINKING** and **ACTING**.

-   **CAT**

## Today's Quote

**“****The happiness of a man in this life does not consist in the absence, but in the mastery of his passions."**
** **

**Alfred Lord Tennyson (1809-1892)**

## BNL ORPS by Calendar Year Report Submitted

- As of 8/22

## 3rd Qtr FY 07

## Event Categorizer Electronic Entries

## 3rd Qtr FY 07

## 3rd Qtr FY 07

## ORPS Corrective Action StatusFY 2007 (End of July)

## CAT Electronic Entries

**04/05 – KK, Warehouse Employee Injures Back **
**04/11 – PB, Instrumentation & Calibration Facility Operational Safety Limit Exceeded**
**04/13 – PB, Legacy grenade with no active explosive component located**
**04/15 – PB, Firefighter fractures foot while physical training, SC3**
**04/16 – KK, 1⁄2 gal oil spill from air compressor at STAR**
**04/17 – KK, Rad Worker Receives Splinter in Radiological Area**
**04/26 – RK, F-18 finger contamination at PET**
**05/01 – AP, Contamination in HFBR fuel vault**
**05/02 – AP, Minor brush fire in Front of building 911**
**05/03 – AP, Minor fire in ventilation system at NSLS**
**05/05 – AP, Cigarette butt results in smoldering mulch bed near B-735**
**05/09 – SM, Impairment of Water Supply to Bldgs 815 and 817**
**05/10 – SM, Power Supplies for Booster to AGS trip**
**05/10 – SM, Discovery of Disconnected O2 Sensor in B535 during Lab Calibration Audit**
**05/15 – SM/ MZ Slip/Trip/Fall Resulting in Injury Requiring First Aid**
**05/15 – MD, Microwave fire in Building 1005, SC3**
**05/15 – MD, Fire in Building 120 Butt Stop**
**05/15 – MD, Ungrounded Neutral Discovered in Building 703 Transformer, SC4**
**05/16 – MD, Employee Reports Wrist Pain after changing out 400 TLDs**

## CAT Electronic Entries

**05/16 – MD, Medical Student Passes Out after seeing blood at B-490**
**05/16 – MD, Employee lacerates arm while cleaning a microtome at B-490**
**05/17 – MD, ~2 gal of trans fluid leaked from lawn mower to pavement/lawn near B-750**
**05/18 – MD, ~ 25 gal of Veg-Based Hyd Fluid Leaks from B-423 Lift to soil**
**05/22 – KS, First-degree chemical burn due to small hole in glove @ B-490**
**05/23 – KS, Worker stung by bee**
**05/24 – KS, Brush fire at remote location in the SE corner of site **
**05/24 – SM, Discovery of Abandoned Lecture Bottle/Cylinder buried in ground**
**05/31 – MZ, Fire in portable generator during preventive maintenance**
**05/31 – MZ, Employee's back started hurting while he was turning a nut on a machine**
**06/01 – MZ, Lamp/window cleaner pulls muscle**
**06/06 – AL, < 2 gal motor oil spill onto road and soil**
**06/11 – ES, Improper Status provided by Laser/Shutter Indicators at ATF, SC3**
**06/12 – AL, Aluminum plate pinches NSLS beamline User finger tips**
**06/13 – AL, Sheet metal shop worker has carpal tunnel syndrome in both wrists**
**06/13 – AL, Foreign material enters worker eye while driving pickup truck**
**06/14 – AP, Fall at Berkner Hall**
**06/14 – AP, Tool Bag at HFBR Measures above Rad Release Limits**
**06/14 – AP, Site-wide Fire Alarm Communications Malfunction, SC4**

## CAT Electronic Entries

**06/18 – AP, Fractured Finger Tip & T-87**
**06/26 – KK, Failure of Air Compressor at HFBR**
**06/26 – KK, Lawn Mower Propels Rock Through Apartment Window**
**06/27 – KK, Electrical fire inside the cab of Rescue Vehicle at Building 599**
**06/28 – KK, Discrete Hot Particle Found in Duct Service Building**
**06/28 – KK, Butt Can Fire at Building 153**
**07/03 – KK, Employee Sustains Injury to Ankle Tripping on Stairs at NSLS**
**07/03 – SM, Box Truck Minor Collision with B-480 Loading Dock **
**07/05 – SM, Site Fire Alarm System Loop 1 Bldgs not Reporting**
**07/05 – SM, Building 801 D Tank Leak, ~5mL**
**07/09 – MD, Untrained Personnel Entry into Confined Space at HFBR**
**07/13 – SM, Power Outage Caused by Tree Cutting, SC4**
**07/17 – KS, B-912A Diesel Engine Exhaust Ignites a Small Patch of Grass**
**07/17 – KS, < 1 Gal Oil Spill to Pavement outside B-735**
**07/17 – KS, Inappropriate Change to Work Procedure at HFBR**
**07/18 – KS, Severe Weather Operational Emergency, OE**
**07/18 – KS, Ground Worker Reports Eye Injury**
**07/20 – KS, Technician receives minor electrical shock when building struck by lighting**
**07/20 – KS, 5,000dpm found on Workers Glove at BGRR**

## CAT Electronic Entries

**07/23 – MZ, Diesel fuel spill from a PE truck releases ~ 1.5 gallons to pavement**
**07/24 – ES, Loss of Power to Buildings in the East-central Portion of the Site, SC4**
**08/01 – AL, Rain water intrusion into CFN**
**08/02 – AL, BNL employee trips on asphalt lip near B-555 and bruises knee**
**08/02 – AL, Hot particle discovered in posted radiological Buffer Area at HFBR**
**08/09 – AP, Smoking air compressor electrical box @ B-902**
**08/09 – AP/ES, Hand caught in freight elevator door at 911, SC4**
**08/09 – AP, Cafeteria worker cuts hand while slicing roll**
**08/13 – RK, Small hydraulic oil leak at B911 on blacktop**
**08/14 – AL, IH audit follow-up reveals fire rescue equipment maintenance contract expired**
**08/14 – RK, Infection from chigger bites**
**08/17 – RK, Loss of BNL Fire Alarm Loops to Firehouse**
**08/17 – RK, B522 Compressed gas facility nozzle leak during operations**
**08/21 – AL, Laminar flow hood power loss results in a spread of chemical fumes**

##                   Programmatic Bins

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

**Site Fire Alarm System (new)**
**Butt Fires (new)**
**CFN (new)**

## Programmatic Review

_**Personnel Contamination – 2006**_
**02/23 – Personnel Cont at Building 901**
**03/22 – Cont Detected on Employee's Shoes at PET**
**03/28 – Cont of two workers at B-801 during removal of BLIP target filter**
_**Personnel Contamination – 2007**_
**04/26 – F-18 finger contamination at PET**
_**  **_
**	****	**

## Programmatic Review

_**Medical department, 2006**_
**03/07 – Rad Cont Outside a Controlled Area at B-490 (SC3)**
**03/10 – Survey Meter/Frisker Taken Outside Controlled Area @ B490**
**03/13 – PB, Shock from terminal in legacy installed light timer (SC4)**
**03/28 – Cont of two workers @ B801 during removal of BLIP target filter**
**05/19 – Cont found outside a posted area @ B490**
**07/31 – Trit cont on unposted benchtop in a posted RMA at B490**
**08/24 – Painter's spackling knife contacts aband live electrical wiring @ 490**
**11/16 – KK, Contamination at PET Facility, (SC3)**
**10/31 – BLIP cooling water leak detection system did not function during testing**
_**Medical department, 2007**_
**04/26 – F-18 finger contamination at PET**
**05/16 – Medical Student Passes Out after seeing blood at B-490**
**05/16 – Employee lacerates arm while cleaning a microtome at B-490**
**05/22 – First-degree chemical burn due to small hole in glove @ B-490**
**07/05 – Building 801 D Tank Leak, ~5mL**

## Programmatic Review

_**NSLS, 2006**_
**02/21 – X17C Laser Procedure Violation (Door left open while laser in operation)**
**05/08 – Improper work sequence during lead shielding removal at beam line**
**06/09 – XSXD Power Supply Shut-off Failure**
**07/17 – Chemical Spill in Wet Chemistry Laboratory (SC3)**
**08/21 – AL/ES, Accidental cutting of energized power tool line cord (SC3)**
**11/16 – Spent Fluorescent Bulbs Found Outside Waste Storage Area**
** **
_**NSLS, 2007**_
**05/03 – Minor fire in ventilation system**
**06/12 – Aluminum plate pinches beamline User finger tips**
**07/03 – Employee Sustains Injury to Ankle Tripping on Stairs**** **** **
** **

## Programmatic Review

_**Physics, 2006**_
**07/07 – Employee fractured metatarsal after tripping over rug/mat**
**08/09 – Stop Work Order issued due to antennae at edge of B510 roof**
_**Physics, 2007**_
**06/11 – Improper Status provided by Laser/Shutter Indicators at ATF, SC3**

## Programmatic Review

_**CA-D, 2006**_
**03/06 – Discovery of Radiation Monitor in Interlock-Bypass-Mode (SC3)**
**03/29 – Lack of admin approval (non-safety related) for NASA NSRL experiment **
**04/14 – 400 Amp Electrical Switch Failure (OE, SC2, SC4)**
**05/04 – CA-D Chipmunks read high and alarms at a lower dose rate than intended**
**06/02 – < 6 oz of tritiated magnet water splashed onto the workers pant-leg @ RHIC**
**06/09 – 3 gals of heat transfer fluid (oil) spilled on Storage Yard pavement by B-924**
**07/20 – Pulling cable along floor results in back strain**
**08/14 – ~ 200 gal spill from 902 Cooling Towers to parking lot and grass**
**08/21 – Leg laceration while descending ladder at B1005**
**09/05 – Non-standard installation of electrical disconnect temp wiring (SC3)**
**09/13 – Trip on stairs results in ~ 1 qt. spill of H2SO4 from battery at B901A**
**10/12 – Worker hit in head/injured by shelf while moving a workbench **
**11/02 – Fire Protection Impairment Process Not Properly Followed @ B1004B**
**11/06 – Man lift damaged during tree cutting operations **
**11/08 – Loose 120 VAC wires on a terminal block results in sparking**
**11/27 – Minor finger laceration **
** **

## Programmatic Review

_**CA-D, 2007**_
**05/02 – Minor brush fire in Front of building 911**
**05/10 – Power Supplies for Booster to AGS trip**
**05/15 – Microwave fire in Building 1005, SC3**
**08/09 – Hand caught in freight elevator door at 911, SC4**

## Programmatic Review

_**BGRR Project, 2006**_
**08/03 – Removal of fuel anchor (BGRR) not approved by work procedure**
**09/26 – Cont (80, 000 dpm) found outside the BGRR RCA (SC3)**
_**BGRR Project, 2007**_
**07/20 – 5,000dpm found on Workers Glove at BGRR**
** **
** **

## Programmatic Review

_**Plant Engineering**__**, 2006**_
**01/27 – Burning Cotton Apron In PPE/Tool Bag Causes Evac @B197 (SC3)**
**05/10 – Vehicle window damaged during concrete sidewalk removal work (SC3)**
**06/16 – Asbestos discovered during demolition of B-422**
**10/13 – Silica Exposure During Concrete Crushing Machine Operation, (SC3)**
**12/05 – PE groundskeeper received a minor injury to the chin **
**12/13 – Pump leak results in 100 gal spill of propylene glycol @ B729**
** **
_**Plant Engineering**__**, 2007**_

## Programmatic Review

_**Utilities struck, 2006**_
**08/08 – Fiber-Optic Cable inadvertently severed  at B707A, HFBR pump house swgear**
_**Utilities struck, 2007**_

## Programmatic Review

_**Material Transportation, 2007**_
**	**

## Programmatic Review

_**Electrical Shock, 2006**_
**03/13 - Shock from terminal in legacy installed light timer (SC4)**
**09/06 – AP, Table lamp electrical fault at apartment 4B results in finger tingle**
_**Electrical Shock, 2007**_
**07/20 – Tech receives minor electrical shock when B-452 struck by lighting**

##        Programmatic Review 

_**Material Handling Issues, 2006**_
**01/17, Tennelec smear counter falls during transport, (SC3)**
**06/30, Computer server unit falls out of BNL box truck grazing workers leg (SC3)**
**07/20, Pulling cable along floor results in back strain**
**08/28, During transport a forklift dropped a secured aerial lift (SC3)**
_**Material Handling Issues, 2007**_

##  Programmatic Review 

_**Waste Management, 2006**_
**01/20 – USQ on rusting HEPA exhaust stack @ B860 (SC3)**
**02/22 – Lapse in USQ training qualification**
**08/04 – HFBR Dumpster alarms BNL Radiation Truck Monitor (SC3)**
**08/16 – Walk through of HFBR identifies rad/non-rad items that are not segregated**
_**Waste Management, 2007**_
** **
** **
** **

##  Programmatic Review 

_**Chemistry, 2006**_
**01/17 – Energ ckt disc in cut conduit in floor slab @ B555, (SC3)**
**02/23 – Personnel Cont at Building 901**
**03/22 – Cont Detected on Employee's Shoes at PET**
_**Chemistry, 2007**_
** ****08/02 – BNL employee trips on asphalt lip near B-555 and bruises knee**

##  Programmatic Review 

_**Environmental Restoration Projects, 2006**_
**09/22 – HFBR air conditioning water pump seal leak (SC3)**
**10/30 – Flaw in ERP calculation of total recordable injury statistics**
**11/30 – SM, Failure to Maint Config Control of DOE-SER specified Documents (SC3)**
_**Environmental Restoration Projects, 2007**_
**05/01 – Contamination in HFBR fuel vault**
**06/14 – Tool Bag at HFBR Measures above Rad Release Limits**
**07/09 – Untrained Personnel Entry into Confined Space at HFBR**
**07/17 – Inappropriate Change to Work Procedure at HFBR**
** **

## Programmatic Review

_**Railroad Tracks, 2007**_

## Programmatic Review

_**New Construction, 2006**_
**04/21 – Sub incurs severe laceration of leg at CFN (SC3)**
**07/31 – A/C mechanic cuts arm at RSB Construction Site**
_**New Construction, 2007**_

## Programmatic Review

_**Noise, 2006**_
**01/18 – Noise over exposure per ACGIH TLV @ B902 (SC3)**
**03/07 – Over-exposure to noise hazard @ Motor Pool Repair Facility (SC3)**
_**Noise, 2007**_

##        Programmatic Review

_**CFN, 2007**_
**05/04 – Discovery of smoldering mulch bed on south side of CFN**
**08/01 – Rain water intrusion into CFN**

##        Programmatic Review

_**Site Fire Alarm System**_
**06/14 – Site-wide Fire Alarm Communications Malfunction, SC4**
**07/05 – Site Fire Alarm System Loop 1 Bldgs not Reporting**
**08/17 – Loss of BNL Fire Alarm Loops to Firehouse**

##           Programmatic Review

_**Butt Fires, 2007**_
**05/02 – Minor brush fire in Front of building 911**
**05/04 – Discovery of smoldering mulch bed on south side of CFN**
**05/15 – Fire in Building 120 Butt Stop**
**05/24 – Brush fire at remote location in the SE corner of site**
**06/15 – Issued Fact-finding/Causal Analysis/Preventive Actions No.: QMO-2007-0001, ATS 3788**
**06/28 – Butt Can Fire at Building 153**

## CAT Team Workshop

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