Categorizers CAT Team Recurring ORPS Report Vote Utility Strikes

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Categorizers (CAT) Team Recurring ORPS Report
Vote Utility Strikes
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AGENDA!

• Purpose
• Facilitation
• Rules of the Meeting
• Categorizers
• Observers
• Qtr. ORPS Performance Analysis Results
• Utility Strike Events
• R Reporting Criteria
• R Report Requirements
• Presentation by Ray Costa
• Q A Session
• Categorizer Vote
• The Path Forward
•       

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Rules of the Meeting

• This meeting is primarily for the Categorizers
• Free flow discussion among Categorizers allowed
• Observers
• Must raise hand and be acknowledged prior to
  speaking
• We must remain focused on the relevant issues!

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ORPS Quarterly Performance Analysis and Summary
3rd Quarter CY 2004

• 20 utility strikes occurred from January 1, 2000
  to September 30, 2004
• 6 reportable to ORPS
• 3 utility strikes occurred in CY 2004
  Electrical Utility (Encased in Concrete Floor)
  Conduit Strike, Domestic Water Main Strike (not
  reportable in ORPS), and Comm Cable Severed
  During Excavation Work (not reportable in ORPS).
  

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ORPS Quarterly Performance Analysis and Summary
3rd Quarter CY 2004

• Procedure Not Used or Used Incorrectly was
  assigned as a cause for 4 of the 6 occurrences.
• PE Excavation Procedure (EP-ESH-801) was cited
  as a procedure to be revised in 3 different
  occurrence reports 2000, Strike Underground
  Electric Cables - Roll up Report, 2002 Minor
  Utility Strike During Horizontal Boring
  Operations, and 2003 Communication Cable Struck
  During Excavation.
• All 6 occurrences involved a contractor or
  subcontractor performing work.

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R Reporting Criteria

• The following are questions that should be
  considered as indicators or contributing
  attributes to a recurring event.
• Did the trending data for the series/group of
  events indicate a significant negative trend?
• Were there a significant number or percentage of
  implementation failures discovered to indicate
  that one or more components of the program were
  not effective in ensuring successful completion
  of the task or activity?
• Have multiple control failures within the
  boundaries of a single occurrence taken place
  indicating a common breakdown in a program or
  area of a program?
• Have small and apparently isolated series/groups
  of events been seen within various aspects of an
  overall program that collectively indicate a
  program weakness when viewed from a site
  perspective?
• Have failures been discovered that indicate
  during implementation of a particular program, or
  portion of a program, that one or more components
  of the program were not effective in ensuring
  successful completion of the task or activity?
• Was there a common underlying cause or weakness
  in controls that necessitated corrective actions?

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R Reporting Criteria

• Did the group of related events indicate a series
  of common work process breakdowns or a series of
  common quality criteria issues?
• Did related series/groups of events breach
  multiple, but not necessarily all, barriers
  protecting workers, the public, or the
  environment from potential or actual adverse
  impacts of an event?
• Did related series/groups of events, having the
  same underlying cause or having contributed to or
  were the unavoidable consequence of the
  underlying problem, occur within a single
  facility or operation?
• Did a causal factor of the series/group of events
  indicate a lack of management involvement, or
  breakdown in management controls, or errors in
  decisions/directions by managers that resulted in
  systemic problems or violation of safety rules?
• In Short . . .

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Note R Report Requirements
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• Utility Strike Evaluation
• Ray Costa
• FO ESHTQ
• Interim Manager

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Agenda

• History
• Definitions
• Data Analysis
• Corrective Actions
• Lessons Learned
• Summary

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History

• November 2003
• Jim Tarpinian, ALD ESHTQ requested Andy
  McNerney, ALD FO, to have Plant Engineering
  evaluate utility strike data presented to ORPS
  Categorizers
• Requested Plant Engineering to
• Evaluate the data and provide further information
  on any trends or recurring conditions that exist
  between these events
• Answer the following questions 
• Is there evidence verifying that the corrective
  actions from the utility strike events was
  completed?
• Is the effectiveness of corrective actions
  evaluated in the Plant Engineering
  self-assessment process?
• Does Plant Engineering review and apply the
  Lessons Learned Communications they receive?

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Terminology and Challenges

• Excavation
• Digging into soil with heavy equipment and/or
  with a shovel or pick
• Challenges
• Accurate location of known utilities
• Abandoned utilities not identified on maps or not
  known to exist
• Army era utilities poorly documented on Camp
  Upton drawings
• Many drawings date back to the 1940s, are hand
  drawn and do not accurately locate utilities
• Not all utilities added by non-Plant Engineering
  projects provided to update utilities maps
• Penetration
• Digging into cement or masonry with power tools
  (e.g., jack hammer, saw, drill) and/or with a
  hand chisel
• Challenges
• Utilities can be located close to one another in
  a small area, i.e., congested
• Rebar buried in cement, makes it hard to locate
  utilities accurately
• And those challenges noted in excavation apply
  here as well

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The Data

• To understand what is happening over a 5 year
  period we need to time phase the events
• We need to identify the activity that led to the
  utility strike
• Look at causes to identify trends

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All Utility Strikes
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Plant Engineering Utility Strikes by Activity
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Plant Engineering Activities Resulting in
Utility Strikes

• Totals over last 5 years
• Excavation 12
• Vehicle Accidents 3
• Penetrations 2
• Excavation is the highest contributor and needs
  closer analysis for possible trends

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Whats in the Ground at BNL?

• 11 miles of steam condensate piping
• 45 miles of potable water piping
• 19.7 miles of sanitary piping
• 1.6 miles of chilled water piping
• 1.6 miles of compressed air piping
• 9 miles of storm water collection piping
• In addition to
• Electric cables
• Telecommunications cables
• Network cables
• Fire Alarms cables
• Security Alarms cables
• Abandoned and unknown utilities

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Plant EngineeringExcavations Activity Vs.
Utility Strikes
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Plant Engineering Excavation Utility Strikes
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Plant Engineering Root Causes of Excavation
Utility Strikes
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What the Data Shows

• No injuries resulted from any of these utility
  strikes
• Utility marking and permit violations were the
  major contributors in 2000 2001
• Corrective actions appear to be effective
• No repeats from 2002 to present
• All corrective actions have been completed and
  appear to have been effective in reducing utility
  strikes
• Abandoned and poorly documented legacy utilities
  are the primary cause and are very difficult to
  locate

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Corrective Actions Taken

• Procedure
• Clarification of toning process
• Clarification of responsibilities
• Permit refinement
• Lessons learned incorporated
• Marking instructions and re-inspections added
• Created a Configuration Control procedure to
  address legacy issues and map errors
• Design standards updated to standardize burial
  depths
• Require the updating of site utility maps (hard
  copies) as unidentified utilities are found
• Training
• Lessons Learned communicated and shared
• Disciplinary actions taken
• Contractors
• Formal warnings issued
• Safety Inspection Report issued to contractor and
  Project Manager
• Negative impact on performance rating
• Recovery of cost of repairs from contract

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Proactive Actions

• Revised procedures to add expiration date to
  digging permits (2001)
• Training on utility locating instruments held on
  site by Staking University (2001)
• Standardized the process for how utilities are
  documented on contract drawings (2001)
• Sent Plant Engineering representatives to the
  Big Dig conference (2002)
• Re-established Excavation and Penetration
  Committee (2002)
• Purchased hydro-vacuum (2002)
• Revised procedures to have contractor sign that
  he has reviewed the digging permit and marked-up
  utility drawings with the project manager prior
  to the start of work (2003)
• Excavation safety is regular agenda item at
  monthly Plant Engineering ESH Committee Meeting
• Digitizing old hand drawings to aid in
  researching legacy issues (on-going)
• Continually evaluating new equipment to locate
  unknown utilities (on-going)
• Continually evaluating the excavation and
  penetration processes to improve them (on-going)

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Corrective Action Process

• Every Plant Engineering ORPS results in a
  critique and corrective actions
• Status of ORPS reviewed monthly, at Division
  Quarterly Reviews, and during DOE / Plant
  Engineering Quarterly Construction Reviews
• Every non-ORPS results in an Investigative
  Incident and corrective actions as appropriate
• All corrective actions tracked to completion by
  ATS or FOs FATS equivalent
• FO FATS equivalent
• Notification of action sent to lead person
• Due notice sent 90 days before due date and every
  month until closed
• Overdue report sent to Division Manager and
  responsible Manager quarterly
• Trending in process Tier Is complete for Plant
  Engineering
• All Plant Engineering Corrective Actions
  resulting from Utility Strikes have been completed

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Verification of Corrective Actions

• Job Site Inspections
• Planned as part of Tier I program
• Management walkthroughs
• Safety Inspections performed by Plant Engineering
  Contractor Safety Inspectors
• Over 900 safety inspections per year

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Assessments

• Excavation Safety Assessment performed by
  Independent Oversight (IO) in July 2003
• Reviewed documentation
• Interviewed personnel
• Observed excavations in progress
• IO found
• Processes to control excavation work and ensure
  the safety of workers are in place as required by
  both DOE and OSHA
• Identified several strengths in work control and
  excavation safety including
• Plant Engineering Division being established as
  the single Lab-wide point-of-contact for digging
  permits and the identification and marking of
  underground utilities
• Implementation of training for Competent Persons
• Proactive involvement of appropriate expertise in
  the review of excavation work plans
• The institution of an Excavation Safety Committee
  striving to minimize utility strikes
• Areas for improvement
• Predominantly subject area improvements
• Plant Engineering needed to add OSHA Trenching
  and Excavation to JTA requirements
• Training being performed, not in JTA

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Lessons Learned

• BNL shares lessons learned with all site
  personnel via e-mail, bulletin, and other
  available channels
• Lessons learned pertinent Plant Engineering
  operations are distributed via e-mail by Plant
  Engineerings ESH Coordinator or ESHTQ Manager
• Additional lessons learned from other than BNL
  sources are identified and distributed
• Lessons learned are posted in Plant Engineerings
  buildings, as appropriate on ESH Bulletin Boards
• Supervisors share lessons learned with their
  staff as a toolbox meetings

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Summary

• No persistent trends identified over the last
  three years
• Corrective actions appear to be effective as
  demonstrated in reduction of utility strikes over
  the last 3 years
• Undocumented utilities provide the potential for
  additional strikes
• Constantly updating utility maps to reflect what
  we know
• Digitizing old drawings and overlaying on BNL
  photogrametry to improve searches of legacy
  issues
• Continuing to evaluate state-of-the-art utility
  location equipment to locate the unknown