# Presentation: 013568

**Categorizers (CAT) Team Workshop #2006-01**

## OUR AGENDA!

**Workshop Goals**
**Point to Ponder**
**Guest Speakers/Topics**
**Bob Selvey **
**Noise & ORPS **
**Joe Levesque **
**Precautionary Evacuations: A Working Definition (provide input to DOE)**
**Biologics and the Effects on Iron Piping**
**ORPS Trending**
**Categorizer Work (Cat Form Entries)**
**Cat Chat!**
**Possible Changes to ORPS **
**Programmatic Bins**
***Potential***** Recurring Issues on Sonar **
**Chemistry contaminations**
**Noise**
**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

- “The more we stress only what we can measure in school, the more we need to remember that not everything that is measurable matters, and not everything that matters is measurable.”
-                                                   - Elliot Eisner

## BNL ORPS by Calendar Year Report Submitted

- As of 3/31

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

## ORPS Corrective Action StatusFY 2006 (End of Month, 3/30)

## ORPS Reports and ActionsMarch 30, 2006

**ALD**

## CAT Electronic Entries

**12/21 – SM, S/CI Grade 5 Bolt in ratchet assembly @ B855, (SC4)**
**12/22 – SM, Overflow of Domestic Water Inside Bldg 855 Sr-90 Treatment System Area**
**12/23 – KK, Employee falls @ Berkner Hall, minor facial injuries**
**--------------------------------------------------------------------------------------------------------------------------------**
**01/06 – PB, Fire in BNL Step Van**
**01/17 – AL, Tennelec smear counter falls during transport, (SC3)**
**01/17 – PB, Energized circuit found in cut conduit in floor slab @ B555, (SC3)**
**01/18 – PB, Nuclear Safety Basis USQ on rusting HEPA exhaust stack @ B860**
**01/18 – PB, Noise over exposure per ACGIH TLV @ B902, (SC3)**
**01/20 – PB/ES, (Update) NSB USQ on rusting HEPA exhaust stack @ B860, (SC3)**
**01/27 – MB, Burning Cotton Apron In PPE/Tool Bag Causes Evac @B197, (SC3)**
**01/31 – RK, Slip off RADTEC Test Vehicle Results in Hip Fracture, (SC3)**
**02/06 – KK, Odor Detected in Building 725-B **
**02/07 – KK/ES, Rad Cont in Roadbed Near Main Gate, (SC4)**** [cancelled on 3/31]**
**02/21 – SM, X17C Laser Procedure Violation (Door left open while laser in operation)**
**02/22 – MD, Lapse in USQ training qualification at waste management**
**02/23 – MD, Wheel Falls off Personal Vehicle after Repairs at Site Service Station**
**02/23 – MD, Personnel Contamination at Building 901**
**02/27 – AL, < 1 gallon of antifreeze on pavement near the main gate**

## CAT Electronic Entries

**03/02 – AL/ES, Transport to Hospital from gym due to non-occupational illness**
**03/06 – KS, < 6 gallons of motor oil spilled to pavement outside south gate**
**03/06 – AL, Discovery of Radiation Monitor in Interlock-Bypass-Mode (SC3)**
**03/07 – KS, Safety Hotline Call in regard to steam leaking from manhole No. 48**
**03/07 – KS, Over-exposure to noise hazard @ Motor Pool Repair Facility (SC3)**
**03/07 – KS, Rad Cont Outside a Controlled Area at B-490 (SC3)**
**03/07 – KS, Minor oil spill (approx. 8 oz.) from transformer fitting outside B-958**
**03/10 – KS, Survey Meter / Frisker Taken Outside Controlled Area at B-490**
**03/13 – PB, Exposed electrical terminal in legacy installed light timer (SC4)**
**03/18 – PB, Discovery of fixed legacy contamination at B-527**
**03/21 – MB, 1 pint of a rad liquid (Cs) on black top due to weeping leak from oos tanker**
**03/22 – MB, Contamination Detected on Employee's Shoes at PET**
**03/28 – RK, Contamination of two workers at B-801 during removal of BLIP target filter**
**03/29 – RK, Lack of admin approval (non-safety related) for NASA NSRL experiment**
**03/30 – RK, Minor hydraulic oil spill to pavement outside B-86**
** **

## ORPS Reportable and Nonreportable Cat Entries

## CAT CHAT!

**Faction of DOE HQ not happy with quality of some “complex” issued occurrence reports (BNL has an overall reputation of submitting excellent reports)**
**DOE proposal - Facility Rep approval of all reports?**
**Causal Analysis for SC4 reports? (back to notification & U/F Reports)**
**DOE HQ asking for BNL input on thoughts to improve reports**
**E. Sierra to attend ORPS meeting in NM on 4/26.**

## 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 (New) **
** **** **
**	****	**

## Programmatic Review

_**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 – 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 contamination event @ B650**
_**   **__**Personnel Contamination – 2006**_
**02/23 – Personnel Contamination at Building 901**
**03/22 – Contamination 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 at B-490**
**03/13 – PB, Shock from terminal in legacy installed light timer (SC4)**
**03/28 – Cont of two workers at B-801 during removal of BLIP target filter**

## 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 – ****Syringes (w/needles) found in Research Laboratory**
**   ****Trash Receptacles @ Bldg 725A**
**11/11 – Minor Cryogenic Injury to Visiting Scientist **
_**NSLS, 2006**_
**02/21 – SM, X17C Laser Procedure Violation (Door left open while laser in operation)**
** **

## Programmatic Review

_**Physics, 2005**_
**04/25 – Smoke alarm from overheated plastic tubing @ Bldg 832**
_**Physics, 2006**_

## 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 **
** **

## 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**_
_**BGRR Project, 2006**_
** **
** **

## 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)**

## 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**_

## 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)**
_**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)**

##  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)**

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

##  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**
_**Chemistry, 2006**_
**01/17 – Energ ckt disc in cut conduit in floor slab @ B555, (SC3)**
**02/23 – Personnel Contamination at Building 901**
**03/22 – Contamination 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**_
** **

## 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**_
** **

## “TapRoot For Seven”“R”ecurring Railcar TapRoot Causal Factors

| 1.  Partial Derailment at BNL Dirt Road Overpass, 9/04/02                                                       | 2.  Traversing railcars in an unsafe Manner, 8/12/03  | 3.  Railcar Movement While Loading, 8/27/03  | 4.  Empty Railcar Derailed at BNL Track Switch, 9/03/04 | 5.  Inadequate Rail Safety Procedures, 9/14/04 | 6.  Empty Railcar Derailed, 1/5/05  | 7.  Unplanned Railcar Movement/Derailment, 8/8/05 |
| --- | --- | --- | --- | --- | --- | --- |
| Significance of soil build-up on tracks not appreciated

Significance of derailment (as “event”) not appreciated   | All supervisors at a morning meeting

Workers rewarded for getting the job done fast i.e. they can leave for the day  | Wheel chocks were not installed on cars 1 – 4 (not required by procedure) | No criteria for successful track switch operation

No periodic maintenance performed on switch   | The Supervisor (of the Laborers) did not know that the railcars were in motion

The Laborers did not park a safe distance from the tracks | Significance of soil build-up on tracks not appreciated | The wheels were not chocked and the hand brake was not applied |

## “TapRoot For Seven”“R”ecurring Railcar TapRoot & (ORPS) Causes

| 1.  Partial Derailment at
 BNL Dirt Road Overpass,
 9/04/02
                                                       | 2. Traversing railcars in an unsafe Manner, 8/12/03  | 3.  Railcar Movement While Loading, 8/27/03  | 4.  Empty Railcar Derailed at BNL Track Switch, 9/03/04 | 5. Inadequate Rail Safety Procedures, 9/14/04 | 6.  Empty Railcar Derailed, 1/5/05  | 7. Unplanned Railcar Movement/Derailment, 8/8/05 |
| --- | --- | --- | --- | --- | --- | --- |
| No SPAC
(Job perform standards not adequately defined)

  | No supervision during work
(Appropriate level of in-task supervision not determined prior to task)
  | Confusing or Incomplete  SPAC
(Unclear/complex wording or grammar & Incomplete/situation not covered )
 | No SPAC
(Job perform standards not adequately  defined)
 | No SPAC
(Job perform standards not adequately defined)
 | No SPAC
(Job perform standards not adequately defined) | Confusing or Incomplete  SPAC
(Unclear/complex wording or grammar)

 |
| Comm of  SPAC NI
(Management policy guidance/expectations not well-defined, understood or enforced)
 | Sch of work needs imp 
(Emphasis on schedule exceeded emphasis on methods/doing a good job)  |  | Comm of  SPAC NI
(Man policy guidance/expectations not well-defined, understood or enforced)
 | Pre-job briefing needs improvement
(Job scoping did not identify special circumstances and/or conditions)  
 | C/A NI
(C/A for previously identified problem or event was not adequate to prevent recurrence) | Employee Comm NI
(Comm between work groups LTA)
---------------------------
Team Selection NI
(Personnel selection did not assure match of worker mot/job descriptions)
  |

## 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**_

## 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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