# Presentation: 545605

**Categorizers (CAT) Team Workshop #2007-03**

## OUR AGENDA!

**Workshop Goals**
**Today's Quotes: It’s About Time!**
**ORPS Trending**
**Define < SCBNL Events to be Recorded**
**ORPS World: DOE Proposed Changes**
** **
**Programmatic Bins**
**Meeting Evaluation and Wrap-up**
**      **

## CAT Team Workshop

_**Workshop Goals:**_
-  To **EVALUATE** and **CONTINUOUSLY  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 Quotes:  It’s About Time!

**Better three hours too soon, than one minute too late.**     - William Shakespeare
**Killing time is like committing slow suicide.**     - Anonymous
**Time is the wisest counselor of all.**     - Pericles
**Don't let yesterday use up too much of today.**     - Will Rogers
**You cannot do a kindness too soon, for you never know how soon it will be too late.**     - Ralph Waldo Emerson
**Time is what we want most, but what we use worst.**     - William Penn
**Years of love have been forgot,****In the hatred of a minute**.     - Edgar Allan Poe
**The common man is not concerned about the passage of time, the man of talent is driven by it.**  - Shoppenhauer

## BNL ORPS by Calendar Year Report Submitted

- As of 11/30

## Event Categorizer Electronic Entries

## 4th Qtr FY 07

## 4th Qtr FY 07

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

## CY 2007 SCBNL Reports (22)

**02/04 – KK, Minor Electrical Fire in Building 1007-W**
**02/09 – PB, Torn ligament on left thumb from moving boxes for office relocation**
**02/12 – PB, Overheated Bearing on Main Magnet Water Supply Pump**
**03/05 – KS, Small brush fire **
**03/13 – SM, Smoldering debris near Cooling Tower #4 by B912A**
**03/15 – SM, Plumber Injures Tooth**
**03/19 – MD, B-197 evacuation due to fire alarm**
**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**
**05/15 – MD, Fire in Building 120 Butt Stop**
**05/24 – KS, Brush fire at remote location in the SE corner of site **
**05/31 – MZ, Fire in portable generator during preventive maintenance**
**06/18 – AP, Fractured Finger Tip & T-87**
** **

## CY 2007 SCBNL Reports (22)

**06/27 – KK, Electrical fire inside the cab of Rescue Vehicle at Building 599**
**06/28 – KK, Butt Can Fire at Building 153**
**07/17 – KS, B-912A Diesel Engine Exhaust Ignites a Small Patch of Grass**
**08/09 – AP, Smoking air compressor electrical box @ B-902**
**09/28 – Al, Motor pool worker injures back while lifting a forty pound starter**
**10/08 – RK, Brush Fire at Dear Leap Road (dirt road) at North side of RHIC Ring**
**11/14 – MZ, Condensate Tank Motor Fire at B-555**
** **

## CY 2007 ORPS Reports (22)

**Coffee-Room Microwave Oven Fire Causes Building Evacuation **
**Security Patrol Officer Injures Knee **
**Copper Sheets Pin Worker Against Work Bench **
**Irritant in Air from Cleaning Floor Tile - Bldg 400 Lobby **
**Employee Grazed by Truck **
**PISA and USQ for DOE review of Waste Management Facility Documented Safety Analysis  **
**Firefighter drops exercise weight plate on left foot causing fracture **
**Ungrounded Neutral Discovered in wye connected output of 13.8kV/208V Transformer **
**Laser Status Indicators at the Accelerator Test Facility (ATF) Not Functioning Properly**
**Operational Emergency - Severe Weather **
**Cable Fault Causes Power Outage **
**Firefighter's Hand Injured during Patient Transport**
**Bunsen Burner Ignites Disposable Lab Coat **
**Unexpected Discovery of an Uncontrolled Electrical Energy Source in Building 490**
**Simultaneous Degradation of Fire Alarm System and Water Supplies for the Apartment Area**
**Researcher Contamination (Nitrogen -13) **
**Employee Trips and Fractures Left Foot **
**Minor Electrical Shock **
**Employee Fractures Rib During Pick-up Truck Lift Gate Operation **
**Site Wide Fire Alarm Communications Malfunction **
**Tree Fell on Powerlines **
**A/C Unit Falls out of Window after being Dislodged by Lawnmower Roll Bar  **

## CY 2007 ORPS Reports (22)

**02 – Maintenance**
**03 -- Normal Operations **
**09 -- Emergency Response**
**10 -- Inspection/Monitoring**
**12 -- Research**

## CY 2007 ORPS Reports (22)

## CY 2007 ORPS Reports (22)

**A3B1C02 -- Step was omitted due to distraction**
**A3B1C03 -- Incorrect performance due to mental lapse**
**A3B2C04 -- Previous success in use of rule reinforces continued use of rule**

## CAT Electronic Entries

**08/21 – KK, Building 830 hot cell door open and adjacent safe not locked**
**08/23 – KK, ERP's LOTO Program questioned in regard to SBMS requirements**
**08/23 – KK, Work Proceeds at HFBR Without BHSO Approval**
**08/23 – KK, Flammable Mat Locker (2) contents don’t match Inventory sheets @ BGRR**
**08/27 – KK, Material Blown from Building Roof Causes Minor Damage to Automobiles**
**08/27 – KK, Radioactive Samples Freeze Resulting in Cracked Containers**
**08/29 – MD, Small Antifreeze Spill on Pavement behind B-599**
**08/30 – MD, Employee bumps elbow on door at NSLS**
**08/30 – AL, Multiple Rad Sources Exposed in Irradiator during maintenance**
**09/05 – SM, Lab Coat Sleeve burned by contact with Bunsen burner flame, SC3**
**09/06 – SM, Bldg 400 Stop Work for less than Confirmed Imminent Danger**
**09/11 – KS, Grounds worker receives minor injury (from thorn) while trimming trees**
**09/12 – KS/ES, Partial Loss of Site Fire Alarm System, SC3**
**09/12 – KS, Exposed Wiring Electrical Hazard in Building 490, SC3**
**09/12 – KS, Worker Exposure to Excessive Noise During Vacuuming**
**09/13 – KS, Research assistant suffers mild allergic reaction to chemicals**
**09/14 – KS, Installation Error in Manufactured Modular Wall Assembly**
**09/17 – MZ, Employee working offsite in Oklahoma steps in hole and injures ankle**
**09/19 – MZ, Employee injures hand closing elevator @ B-911**

## CAT Electronic Entries

**09/21 – MZ, Lawn Maintenance Results in AC unit Falling onto Mower, SC3**
**09/21 – MZ, Hydraulic fluid discovered in elevator shaft casing  **
**09/24 – MZ, Empty sharps container found in animal bedding during disposal**
**09/28 – AL, BNL retiree injured when arm grazes door strike plate**
**09/28 – Al, Motor pool worker injures back while lifting a forty pound starter, SCBNL**
**99/28 – AL, Researcher Contamination at PET (Nitrogen -13), SC4**
**09/28 – AL, NSLS fuse burns out resulting in smoke**
**09/28 – AL, Contractor vehicle spills hyd fluid onto pavement in front of B-911**
**-------------------------------------1****st**** QTR, FY 08-----------------------------------------------------------------------**
**10/01 – ES, Trip/fall when walking in grass results in ankle fracture, SC3**
**10/08 – RK, Suspicious suit case outside B555 - precautionary evacuation**
**10/08 – RK, Brush Fire at Deer Leap Road (dirt road) at North side of RHIC Ring, SCBNL**
**10/11 – RK, Worker not feeling well was transported to local hospital and released**
**10/17 – SM, Senior Stationary Engineer incurs muscle strain**
**10/17 – SM, Auto Truck Mechanic incurs contusion to elbow**
**10/17 – SM, Admin assist incurs contusion to heal of hand**
**10/18 – SM, Admin assist climbing stairs and tripped, resulting in a bruised knee**
**10/22 – KK, < 5 gal of hyd fluid spilled to the ground near the Southgate borrow pit**
**10/22 – AL, Loss of Am-241 Source, less than an accountable quantity**

## CAT Electronic Entries

**10/25 – KK, Jars of Environmental Soil Samples Arrives at Analytical Laboratory Damaged          **
**10/29 – MD, Worker cuts Fingers at Central Shops**
**10/30 – MD, Employee Injures Hand While Using Hammer**
**11/06 – KS, Minor (most editorial) Deficiencies Identified in ERD Operating Procedures**
**11/06 – KS, Worker injury (minor contusion) from falling picture frame**
**11/07 – KS, ITD employee tripped on a gas/water access pipe and fell to the ground**
**11/09 – KS/ES, Contaminated Wire Identified During Routine Masslinn Survey at BGRR**
**11/14 – MZ, Condensate Tank Motor Fire at B-555, SCBNL**
**11/15 – MZ, Bare Deenergized Electrical leads discovered during Tier I inspection**
**11/15 – MZ, Guest researcher brings liquid nitrogen onsite in personal vehicle **
**11/15 – MZ, Minor elbow injury at NSLS when worker contacts tool chest **
**11/16 – MZ, Burst disc ruptures on liquid nitrogen dewar before relief valves **
**11/18 – MZ, Contractor rigger climbs over rad shielding wall at C-AD**
**11/20 – AL, Work package review identifies lack of compliance with procedure**
**11/21 – AL, Shock, Near miss to an occupational injury, SC 3**
**11/26 – AL, Radio controlled model airplane hits exterior wall of building**
**11/28 – AP, Non work related illness**
**11/29 – AP, Discovery of contaminated tape on pipe in the building 811 yard**
**11/30 – AP, Minor Back Strain from Material Handling in B-479**

## CAT Electronic Entries

**12/04 – MZ, Police Officer re-injures shoulder opening trailer**
**12/04 – RK, Worker falls walking on wooden pallet and bruises elbow outside B1000P**
**12/05 – RK, 1 quart spill of vehicle battery acid on pavement outside B860**

## Assessment of BSA Contractor Assurance Program 

**Problem Statement:**  Event Categorizers indicated that they use discretion relative to entering events/issues into the database; this may be due in part to the lack of clear standards for defining events/issues below SCBNL.
**Action #1:**  In collaboration with the BNL Event Categorizers, define process of recording < SCBNL events/issues (E/I), which shall be recorded in the E/I database.
**Action #2:**  Revise the QMO Event Categorizer’s Procedure to include the process that will define < SCBNL events/issues (E/I), which shall be recorded in the E/I database.

## Proposed Revision of DOE M 231.1-2, Occurrence Reporting Criteria:  

- Separate and clarify the Criteria for Fires and Explosions.
- New Criteria for Hazardous Electrical Energy Control using the Electrical Severity Measurement Tool and for Other Hazardous Energy Control.
- Technical Safety Requirements (TSR) - revised to remove criticality
- Criticality Safety revised to capture TSR violations
- Facility Operations revised
- Management Concerns revised

**Proposed Revision of DOE M ****231.1-2****, Occurrence Reporting Criteria:**
- HS-30 is reviewing and finalizing proposed changes to the occurrence reporting criteria.  Will submit for REVCOM review in early 2008.

## Proposed Revision of DOE M 231.1-2, Occurrence Reporting Criteria (cont’d):

**	**Near Misses - Revised Definition:
- 10 (3) 1-3†	A near miss to an otherwise ORPS reportable event, where something physically happened that was unexpected or unintended and significant consequences were avoided only by chance because either:
- 	a)  no controls or protective equipment were in place to prevent more severe consequences, or
- 	b)  the controls or protective equipment were ineffective.
- 	The significance category assigned to the near miss should be based on an evaluation of the potential risks and planned or anticipated corrective actions.
- 	The proposed changes are intended to correct known reporting problems and enhance the Corporate Safety Indicator Process.

**Proposed Revision of DOE M 231.1-2, Occurrence Reporting Criteria (cont’d):**

##                   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**
**09/28 – Researcher Contamination at PET, B-901 (Nitrogen -13), SC4**
_**  **_
**	****	**

## 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**
**09/12 – Exposed Wiring Electrical Hazard in Building 490, SC3**
**09/24 – Empty sharps container found in animal bedding during disposal**
**09/28 – Researcher Contamination at PET, B-901  (Nitrogen -13), SC4**

## 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**
**10/01 – Trip/fall when walking in grass results in ankle fracture, 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**
**09/19 – Employee injures hand closing elevator at 911**
**11/18 – Contractor rigger climbs over rad shielding wall at C-AD**
**12/04 – RK, Worker falls walking on wooden pallet & bruises elbow outside B1000P**

## 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**_
**09/21 – Lawn Maintenance Results in AC unit Falling onto Mower, SC3**

## 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**
**11/21 – Shock, Near miss to an occupational injury, SC 3**

##        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)**
_**Manual Material Handling Issues, 2007**_
**09/28 – Motor pool worker injures back while lifting a forty pound starter, SCBNL**
**11/30 – Minor Back Strain from Material Handling in B-479**

##  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**
**10/08 – Suspicious suit case outside B555 - precautionary evacuation**
**11/14 – Condensate Tank Motor Fire at B-555, SCBNL**

##  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**
**08/23 – Work Proceeds at HFBR Without BHSO Approval**
** **

## 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**_
**09/12 – Worker Exposure to Excessive Noise During Vacuuming**

##        Programmatic Review

_**CFN, 2007**_
**05/04 – Discovery of smoldering mulch bed on south side of CFN**
**08/01 – Rain water intrusion into CFN**
**09/14 – Installation Error in Manufactured Modular Wall Assembly**

##        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**
**09/12 – Partial Loss of Site Fire Alarm System, SC3**

##           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**
**10/08 – RK, Brush Fire (cause unknown) at North side of RHIC Ring, SCBNL**

## CAT Team Workshop

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