# Presentation: 025263

**Categorizers (CAT) Team Workshop #2006-04**

## OUR AGENDA!

**Workshop Goals**
**Points to Ponder**
**On-line Categorizers Form Demo**
**System Programmer Courtney Patterson**
**ORPS Trending**
**Proposed changes to ORPS Program  **
**Programmatic Bins**
**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**

## Point to Ponder

**“****Nothing in the world can take the place of persistence.  Talent will not; nothing is more common than unsuccessful men with talent.  Genius will not; unrewarded genius is almost a proverb.  Education will not; the world is full of educated derelicts.  Persistence and determination alone are omnipotent.” **
** ****- John Calvin Coolidge, Jr. (1872 – 1933) 30th President of the United States**

## Point to Ponder

**The most exciting phrase to hear in science, the one that heralds new discoveries, is not “Eureka!” (I found it!) but “That’s *****funny***** ...” **
**- Isaac Asimov**

## On-line Categorizers Form Demo

- Courtney Patterson
- _[https://sbms.bnl.gov/authusers/IssuesEvents/default.cfm](https://sbms.bnl.gov/authusers/IssuesEvents/default.cfm)_

## BNL ORPS by Calendar Year Report Submitted

- As of 11/30

## BNL ORPS Report StatusFY 2006 (End of Month)

## ORPS Corrective Action StatusFY 2006 (End of Month)

## ORPS Reports and ActionsNovember 30, 2006

**ALD**

## ORPS Reportable and Nonreportable Cat Entries

##      Distribution of ORPS Reports by Reporting Criteria 

## SCBNL Criteria 

_**Group 2 - Personnel Safety and Health**_
- Requires hospitalization
- Results in simple fractures of fingers, toes, or nose, or a minor chipped tooth
- Causes damage to nerves, muscles, tendons, and/or ligaments as determined by a physician
- Causes third-degree burns
- Causes second degree burns with the exception of burns to extremities
- Any fire on the BNL site

## SCBNL Criteria 

_**Group 4 - Facility Status**_
- Any evacuation not due to false alarm or part of drill/exercise
- Any Stop Work issued for confirmed imminent danger
_**Group 6 - Contamination/Radiation Control**_
- Loss of radioactive material which exceeds 50% of the quantities specified in 10 CFR Part 835, Appendix E, or loss of accountability of such material for more than 24 hours.
- Identification of onsite radioactive contamination greater than 5 times the total contamination values in 10 CFR 835 Appendix D
- Identification of onsite legacy radioactive contamination greater than 5 times the total contamination values in 10 CFR 835 Appendix D
- Any single occupational exposure that exceeds an expected exposure or dosimetry result by: (1) 250 mrem Committed Effective Dose Equivalent (CEDE), or (2) the greater of 5% or 50-mrem effective dose equivalent due to external exposure.

## SCBNL Criteria 

_**Group 6 - Contamination/Radiation Control**_
**Determination of an estimated annual dose that exceeds 5 mrem Total Effective Dose Equivalent (TEDE) for offsite exposures to a member of the public from air pathways only.**
**Any onsite contamination of personnel or clothing (excluding site-provided protective clothing) that exceeds 5 times the values for total contamination identified in 10 CFR Part 835, Appendix D. The contamination level must be based on direct measurement and not averaged over any area. This criterion does not apply to tritium contamination.  **

## Use of the FM Concern ORPS Criteria as % of Site Total Submissions Over Last 3 years

- Pacific Northwest National Laboratory              	55%
- Idaho National Laboratory          	46% (over last 2 yrs.)
- Los Alamos National Laboratory 	              	40%
- Lawrence Livermore National Laboratory        	37%
- Argonne National Laboratory East                   	37%
*Brookhaven National Laboratory                     **	**36%*
- Sandia National Laboratory                             	35%
- Savannah River National Laboratory              	31%
- Oak Ridge National Laboratory                       	29%
- Lawrence Berkeley National Laboratory         	19%

## CAT Electronic Entries

**10/02 – MD, Non-Employee Injured driving vehicle through gate & crashing**
**10/05 – MD, Non-occupational motorcycle accident/injury on site with ~1 gal petro spill**
**10/09 – MD, Vehicle disregards traffic safety measures during ambulance operations**
**10/12 – AL, Worker hit in head/injured by shelf while moving a workbench @ C-AD**
**10/12 – AL, Dropped thermometer spills mercury (~ 3 grams) onto building floor @ C-AD**
**10/13 – AL, Non-Employee speeds through gate & crashes**
**10/13 – AL, Silica Exposure During Concrete Crushing Machine Operation, SC3**
**10/30 – MD, Flaw in ERP calculation of total recordable injury statistics**
**10/31 – MD, BLIP cooling water leak detection system did not function during testing**
**11/02 – MD, Fire Protection Impairment Process Not Properly Followed @ B1004B**
**11/06 – RK, Manlift damaged during tree cutting operations at C-AD**
**11/08 – RK, Loose 120 VAC wires on a terminal block @ C-AD result in sparking**
**11/13 – RK, Standpipe leak at BNL gym**
**11/15 – KK, Defective fire protection heat detectors, SC3**
**11/16 – KK, Contamination at PET Facility, SC3**
**11/16 – KK, Spent Fluorescent Bulbs Found Outside Waste Storage Area @ NSLS**
**11/17 – KK, Sparking Light Ballast @ B422 due to water intrusion following rain storm  **
**11/20 – AP, < 5 gal anti-freeze spill at the vehicle radiation monitor station**

## CAT Electronic Entries

**11/27 – SM, Minor finger laceration @ C-AD**
**11/30 – SM, Failure to Maintain Config Control of DOE-SER specified Documents, SC3**
**12/05 – KS, Late report of occupational knee injury (10/03) @ 134C**
**12/05 – KS, PE groundskeeper received a minor injury to the chin @ 490**
**12/08 – KS, Sparking of Portable Electric Heater @ C-AD**
**12/11 – AL, Minor oil spill at Main Gate**
**12/12 – AL, Fire department truck spilled < 1 gal of diesel fuel onto pavement**
**12/13 – AL, Pump leak results in 100 gal spill of propylene glycol @ B729**
**12/20 – AL, Security patrolman bruises left knee**
**12/20 – AL, False PC Monitor alarms at BGRR ** **  **
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## Proposed changes to ORPS

**ORPS Model**
**Add FR approval for SC3 events**
**Add RCA for SC2 events**
**Code ORPS Reports with ten QA criteria in Order 414.1C**
**Criteria**
**SC2* – An unplanned facility or ops shutdown directed by DOE Field Element Manager or Contracting Officer for safety reasons.**
**SC3* if directed by DOE employee**
**Near miss – sig consequences were avoided only by luck (i.e. no controls or protective equip were in place to prevent a worse case scenario, or the controls or protective equip were ineffective)**
**A noted noncompliance with worker safety and health req that, if not corrected immediately, could result in serious injury (e.g., working at heights without proper fall protection; failure to use proper PPE for electrical work; employee working in improperly shored/sloped trench or excavation).**

## 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  **
** **** **
**	****	**

## Programmatic Review

_**Personnel Contamination – 2005**_
**02/02 – Personnel Cont 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 – 500 dpm alpha cont on hand @ B650**
**10/17 – Cont. discovered (95,000 dpm/100cm2) within Rad Buffer Area and on shoe covers during RBA friskout @ B801**
**12/19 – LL rad cont event @ B650**
_**   **__**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**
_**  **_
**	****	**

## 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**
**10/17 – Cont. discovered (95,000 dpm/100cm2) within Rad Buffer Area and on shoe covers during RBA friskout @ B801**
_**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**

## Programmatic Review

_**NSLS, 2005**_
**03/03 – ****Suspect Bolts Found in Crane During Inspection (SC4)**
**04/20 – Haz concerns associated with energized magnet**
**06/28 – ****Syringes (w/needles) found in Lab ****Trash Receptacles @ Bldg 725A**
**11/11 – Minor Cryogenic Injury to Visiting Scientist **
_**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 **
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## Programmatic Review

_**Physics, 2005**_
**04/25 – Smoke alarm from overheated plastic tubing @ Bldg 832**
_**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**

## 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)**
**02/22 – ****High pH detected at recharge basin HTW, Bldg 930**
**03/14 – Cooling Water Leak at LINAC due to stuck open relief valve **
**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**
**10/14 – Rain****water (deluge) causing electrical shorts/smoke in B912**
**10/17 – ****Crack in tip of finger bone from mallet strike @ B905**
**10/28 – AGS door interlock works but "Area Secure" light not lit**
**10/31 – S/C bolts identified at the STAR 20-Ton crane ****(existing report)**
**11/02 – Energized wire discovered during RF power amp repair (SC3)**
_**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**
** **

## Programmatic Review

_**CA-D, 2006**_
**07/20 – Pulling cable along foor 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 – Manlift 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

_**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, 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)**
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## 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**
**11/21 – Gov vehicle strikes tree in off-road area on-site**
**12/12 – Partially Disabled (Inadvertent) fire alarm syst @ B321, 326, 339, 421, 423, 651**
_**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 **

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

## 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 at Envirocare (SC3)**
_**Material Transportation, 2006**_

## Programmatic Review

_**Electrical Shock, 2005**_
**04/01 - Unexpected Discovery of Haz Energy Source @ Magnet Division (SC3)**
_**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**

##  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**_
_**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)**

##  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 – 500 dpm alpha cont on hand @ B650**
**10/26 – ****Tritium Detection in Sr-90 Extraction Well SR-2**
**12/19 – LL rad contamination event at B650**
_**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**
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##  Programmatic Review 

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

##  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**
**11/02 – Inert gas removed from HFBR vessel (SC3)**
**12/02 – Legacy Soil activity identified in the woods N&S of the FHWMF**
**12/05 – Inadequate Work Control (ERD at former waste management facility) Change 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)**
** **

## 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)**
_**Railroad Tracks, 2006**_
** **

## Programmatic Review

_**New Construction, 2005**_
**10/19 – Tree grinding ops @ the CFN construction site results in a piece of wood striking and damaging the rear window/trunk of an unoccupied vehicle**
**11/21 – Contract Worker ejected from site after dropping a gas cylinder from the second floor of the RSB to the ground below**
**11/29 – Contractor incurs 1 inch laceration to wrist working @ RSB**
_**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**

## Programmatic Review

_**Noise, 2005**_
**06/07 – Personnel Exposure to Excessive Noise **** L****ab ground water treatment plants** **(SC-3)**
_**Noise, 2006**_
**01/18 – Noise over exposure per ACGIH TLV @ B902 (SC3)**
**03/07 – Over-exposure to noise hazard @ Motor Pool Repair Facility (SC3)**

## CAT Team Workshop

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