# Presentation: 013563

**Categorizers (CAT) Team Workshop #2005-04**

## OUR AGENDA!

**Workshop Goals**
**Point to Ponder**
**ORPS Trending**
**CAT Form Entries **
**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 PROMPT (via categorization) deep and lasting value-added CHANGE, which results in new ways of thinking and acting.

-   **CAT**

## Point to Ponder

**	****“****When anyone asks how I can best describe my experience in nearly 40 years at sea, I merely say:  uneventful.  I never saw a wreck and have never been wrecked nor was I in any predicament that threatened to end in disaster of any sort.”**
**- *****Titanic Captain,***** Edward J. Smith in 1907 **
**  ****	****The Titanic sank on April 14, 1912 ****	**
**  **
**	****	****	**** ****	****   ****	**

## BNL ORPS by Calendar Year Report Submitted

- As of 12/20

## BNL ORPS Report StatusFY 2005/2006 (End of Month)

## ORPS Corrective Action StatusFY 2005/2006 (End of Month)

## ORPS Reports and ActionsNovember 30, 2005

**ALD**

## CAT Electronic Entries

**10/10 – RK, Forklift spills ****~5 gallons of hyd oil between B933 to B912**
**10/11 – RK, < 1 gal**** hyd leak from PE truck by B528**
**10/14 – RK, Rain****water (deluge) causing electrical shorts/smoke in B912**
**10/14 – RK, Smoldering particles in large belt sander at B479**
**10/14 – RK, Suspicious package in B510 P Lot = bag with two light bulbs**
**10/14 – RK, ****OL (smoke) roll-up door cont caused by rainwater @ B912**
**10/17 – RK, ****Crack in tip of finger bone from mallet strike @ B905**
**10/17 – RK, Cont. discovered (95,000 dpm/100cm2) within Rad Buffer Area ****	****and on shoe covers during RBA friskout @ B801**
**10/19 – KK, Tree grinding ops @ the CFN construction site results in a ****	****piece of wood striking and damaging the rear window/trunk of an ****	****unoccupied vehicle**
**10/20 – KK, Update to 10/19 entry upon further discussion, SC4**
**10/18 – KK, < 1 gal**** hyd leak from ****electrical boom truck by B725**
**10/24 – KK, < 1 gal**** gas spill in parking lot of B488**
**10/26 – SM, ****Tritium Detection in Sr-90 Extraction Well SR-2**
** **

## CAT Electronic Entries

**10/28 – SM, AGS door interlock works but "Area Secure" light not lit**
**10/31 – MD, Low level rad cont (2K – 5K dpm) under floor tiles @ B527**
**10/31 – MD, Air Compressor Failure in B902**
**10/31 – ES, S/C bolts identified at the STAR 20-Ton crane ****(existing report)**
**11/02 – ES, Inert gas removed from HFBR vessel, (Update SC3)**
**11/02 – MD, Energized wire discovered during RF power amp repair, SC3**
**11/02 – MD, ~1.5 gal antifreeze spilled to the pavement @ B479**
**11/07 – MD, < 1 gal spill (tar/asphalt) along north street in wooded area**
**11/07 – MD, 2 gal of stripper on pavement/flower bed reported to NYS DEC ****	****and Suffolk, SC4 **
**11/11 – ES, Minor Cryogenic Injury to Visiting Scientist at NSLS**
**11/17 – ES, Oil Leak from compromised 55 Gal Drum**
**11/21 – KK, Contract Worker ejected from site after dropping a gas cylinder ****	****from the second floor of the RSB to the ground below**
**11/21 – PB, Gov vehicle strikes tree in off-road area on-site**
**11/28 – MB, 1/2 quart of motor oil on pavement behind B-488   **

## CAT Electronic Entries

**11/28 – MB, An adult female experiencing     arrhythmia trans to hospital**
**11/29 – MB, Contractor incurs 1 inch laceration to wrist working @ RSB**
**11/30 – MB, 10 gal bio-based hydraulic oil spill @ B423**
**12/02 – MB, Legacy Soil activity identified in the woods N&S of the FHWMF**
**12/05 – RK, Inadequate Work Control (ERD at former waste management    ****	****facility) Change Review **
**12/08 – RK, Fire truck backed into door @ FH causing minor damage **
**12/12 – RK, <1 gal oil spill on pavement & contained by B480 **
**12/12 – RK, Partially Disabled (Inadvertent) fire alarm syst @ B321, 326, ****	****339, 421, 423, 651 **
**12/17 – RK, < 10 gal crude oil spill from delivery truck  **
**12/19 – SM, LL rad contamination event at B650**
**12/20 – RK, (Update to 12/17 entry) > 10 gal crude oil spill from delivery ****	****truck, SC4  **
**  **
** **

## ORPS Reportable and Nonreportable Cat Entries

**ORPS Reportable ****and Nonreportable Cat Entries**

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

## Programmatic Review

**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 – ~ 200 dpm/100cm2 on experimenter at PET **
**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**
**   **
** **
**  **
**	****	**

## 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**
**10/29 – RWP and Trans Safety Violations in B-490 (SC3) **
**   **

## 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**

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

## 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 **
** **

## Programmatic Review

_**Physics, 2004**_
**07/01 – Laser interlock check overdue by 3 weeks @ ATF**
**10/21 – Trimmed tree branch breaks window at physics**
_**Physics, 2005**_
**04/25 – Smoke alarm from overheated plastic tubing @ Bldg 832**

## Programmatic Review

_**CA-D, 2004**_
**01/13 - Worker breaks ankle while preparing for cable pull (SC3)**
**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 B1004A**
**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 B930**
**11/08 - Fire Inside Power Supply Cabinet (SC4)**
**12/02 - Unauthorized access into the STAR hall**

## 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)  **
**03/14 – Cooling Water Leak at LINAC due to stuck open relief valve **
**02/22 – ****High pH detected at recharge basin HTW, Bldg 930**
**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)**
** **

## 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**_
** **
** **

## 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 **

## 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:**_

## 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)**

## Programmatic Review

_**Electrical Shock Hazards, 2004**_
**07/12 - Worker feels mild electrical tingling in his finger @ NSLS**
**08/10 - Worker experiences electric shock @ NSLS (SC3)**
_**Electrical Shock Hazards, 2005**_
**04/01 - Unexpected Discovery of Hazardous Energy Source @ Magnet Division (SC3)**

##  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**_
** **

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

##  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**

##  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**
** **

## 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)**
** **

## 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**

## CAT Team Workshop

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