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Categorizers CAT Team Workshop

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Years of love have been forgot, In the hatred of a minute. - Edgar Allan Poe ... 10/30 Flaw in ERP calculation of total recordable injury statistics ... – PowerPoint PPT presentation

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Title: Categorizers CAT Team Workshop


1
Categorizers (CAT) Team Workshop 2007-03
2
OUR AGENDA!
  • Workshop Goals
  • Today's Quotes Its About Time!
  • ORPS Trending
  • Define
  • ORPS World DOE Proposed Changes
  • Programmatic Bins
  • Meeting Evaluation and Wrap-up
  •       

3
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
4
Today's Quotes Its 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

5
BNL ORPS by Calendar Year Report Submitted
As of 11/30
6
Event Categorizer Electronic Entries
7
4th Qtr FY 07
8
4th Qtr FY 07
9
ORPS Corrective Action StatusFY 2007 (End of
Month)
10
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

11
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
    _at_ 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

12
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

13
CY 2007 ORPS Reports (22)
  • 02 Maintenance
  • 03 -- Normal Operations
  • 09 -- Emergency Response
  • 10 -- Inspection/Monitoring
  • 12 -- Research

14
CY 2007 ORPS Reports (22)
15
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

16
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
    dont match Inventory sheets _at_ 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 _at_ B-911

17
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
  • -------------------------------------1st 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, ground near the Southgate borrow pit
  • 10/22 AL, Loss of Am-241 Source, less than an
    accountable quantity

18
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

19
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

20
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 events/issues (E/I), which shall be recorded in
    the E/I database. 
  • Action 2 Revise the QMO Event Categorizers
    Procedure to include the process that will define
    recorded in the E/I database. 

21
Proposed Revision of DOE M 231.1-2, Occurrence
Reporting Criteria HS-30 is reviewing and fina
lizing proposed changes to the occurrence
reporting criteria. Will submit for REVCOM
review in early 2008.
  • 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

22
Proposed Revision of DOE M 231.1-2, Occurrence
Reporting Criteria (contd)
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 prote
ctive equipment were in place to prevent more
severe consequences, or b) the controls or pro
tective 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 int
ended to correct known reporting problems and
enhance the Corporate Safety Indicator Process.
23
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)

24
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

25
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 _at_ B490
  • 03/13 PB, Shock from terminal in legacy
    installed light timer (SC4)
  • 03/28 Cont of two workers _at_ B801 during removal
    of BLIP target filter
  • 05/19 Cont found outside a posted area _at_ 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 _at_ 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 _at_ 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

26
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

27
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

28
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 onto the workers pant-leg _at_ 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 _at_ 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

29
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

30
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

31
Programmatic Review
  • Plant Engineering, 2006
  • 01/27 Burning Cotton Apron In PPE/Tool Bag
    Causes Evac _at_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 _at_ B729
  • Plant Engineering, 2007
  • 09/21 Lawn Maintenance Results in AC unit
    Falling onto Mower, SC3

32
Programmatic Review
  • Utilities struck, 2006
  • 08/08 Fiber-Optic Cable inadvertently severed
    at B707A, HFBR pump house swgear
  • Utilities struck, 2007

33
Programmatic Review
  • Material Transportation, 2007


34
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

35
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

36
Programmatic Review
  • Waste Management, 2006
  • 01/20 USQ on rusting HEPA exhaust stack _at_ 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

37
Programmatic Review
  • Chemistry, 2006
  • 01/17 Energ ckt disc in cut conduit in floor
    slab _at_ 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

38
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

39
Programmatic Review
  • Railroad Tracks, 2007

40
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

41
Programmatic Review
  • Noise, 2006
  • 01/18 Noise over exposure per ACGIH TLV _at_ B902
    (SC3)
  • 03/07 Over-exposure to noise hazard _at_ Motor
    Pool Repair Facility (SC3)
  • Noise, 2007
  • 09/12 Worker Exposure to Excessive Noise During
    Vacuuming

42
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

43
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

44
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

45
CAT Team Workshop
  • CAT Team Action Item Review
  • Meeting Evaluation and Wrap-Up
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