Material Handling at BNL The Past, Present

1
Material Handling at BNLThe Past, Present
Future?

• Edward A. Sierra
• Quality Management Office
• Presented to
• ALD for ESHQ
• Safety Health Services Division Manager
• Lifting Safety Committee Chair
• January 30, 2007

2
Point to Ponder

• Organizations only improve where the truth
  is told and the brutal facts confronted.
• - Jim Collins
• Good to Great, 2001

3
Why this Presentation?

• As directed by the BNL ESHQ Director
• The Quality Management Office will
• Review History of BNL Material Handling Events
• Identify DOE Lessons Learned
• Identify common causes of BNL Material Handling
  Events
• Search for material handling best practices

4
BNL Material Handling Event History

• Material Handling Issues, 2003
• 08/12, Forklift Load Strikes Overhead Lines
• 09/04, Lifting Magnet Releases Steel Plate
• 12/30, Transformer Dropped During Rigging
• Material Handling Issues, 2004
• 03/05, Load Falls off Flatbed Truck
• 03/24, Recurring Material Handling Problems,
  (SCR/NTS)
• 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
• Material Handling Issues, 2006
• 01/17, Tennelec smear counter falls during
  transport
• 06/30, Computer server unit falls out of BNL box
  truck pinning worker to ground (NTS)
• 08/28, During transport a forklift dropped a
  secured aerial lift
• Material Handling Issues, 2007
• 1/24, Worker pinned by metal sheets (NTS?)

5
BNL is not alone

• Commercial Nuclear Stations Negative Trend
• Fatality and Severe Personnel Injuries

6
Palo Verde Nuclear Generating Station
7
Palo Verde Nuclear Generating Station
8
San Onofre Nuclear Generating Station
9
Industry Identified Causes

• Policies and Procedures
• Training and Qualification
• Equipment Control, Storage, and Inspection
• Fundamental Rigging and Lifting Practices
• Supervision and Oversight

10
Industry Identified Causes Policies and
Procedures

• Skill-of-the-craft (Worker-Planned-Work)
• No central point of contact
• Self-assessments not performed, or they were
  ineffective
• Work plans lacked rigor

11
Industry Identified Causes Training and
Qualification

• Lack of Continuing training
• Inconsistent Qual standards
• Training lacked hands-on experience
• Lack of training on equip inspection
  requirements
• Proficiency evaluations lacking for
  supplemental personnel
• Maintenance Training Review Committee missed
  knowledge and skill deficiencies

12
Industry Identified Causes Equipment
Control, Storage, and Inspection

• Slings and chain falls were not inspected
  prior to use
• Damaged rigging and lifting equipment was
  staged as ready for worker use
• Some rigging and lifting equipment used by
  supplemental personnel was not qualified or
  inspected

13
Industry Identified Causes Fundamental
Rigging and Lifting Practices

• Walking under suspended loads
• Pieces of hoses/other materials were
  inappropriately used
• C-clamps were inappropriately used to attach
  slings to loads prior to lifting
• The working load limit was sometimes not
  known prior to the load being lifted
• Load cells were not used when load binding
  during the lift was possible

14
Industry Identified Causes Supervision and
Oversight

• Unfamiliar with rigging/lifting equipment
  inspections
• Unfamiliar with basic rigging and lifting
  principles
• Oversight was not routinely provided
• Reference Institute of Nuclear Power
  Operations (INPO) Significant Operating
  Experience Report (SOER) 06-1, Rigging,
  Lifting, and Material Handling, October 11, 2006
  

15
Improper Material Handling Results in Near
Misses DOE Just-in-Time Report, June 2006

• April 2006 - An employee was struck and pinned
  against a freight elevator gate by a 670-pound
  trim fixture that had fallen off a skid
• May 2006 - Two workers lost control of a
  150-pound heat exchanger, the unit fell
  approximately 2 feet onto a concrete floor
• May 2006 - An experimental device packaged in a
  wooden crate rolled off of a manual pallet jack
• May 2006 - An employee was struck and knocked to
  the floor by a forklift

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Does BNL Past This Test?DOE Just-in-Time
Report, June 2006

• Is the equipment in use designed and rated for
  the load being moved?
• Are items secured to prevent movement during
  transit?
• Are employees trained to operate
  material-handling equipment?
• Are trained spotters assigned when the equipment
  operators vision is obscured? Are spotters
  positioned such that they can observe the entire
  work zone?
• Is the number of spotters assigned adequate to
  detect all hazards and communicate these to the
  equipment operator?
• Have steps been taken to ensure continuous
  communications between spotters and equipment
  operators?
• Have unanalyzed hazards been introduced by
  deviating from the original plan?

17
BNL Material Handling Event History

• Material Handling Issues, 2003
• 08/12, Forklift Load Strikes Overhead Lines
• 09/04, Lifting Magnet Releases Steel Plate
• 12/30, Transformer Dropped During Rigging
• Material Handling Issues, 2004
• 03/05, Load Falls off Flatbed Truck
• 03/24, Recurring Material Handling Problems,
  (SCR/NTS)
• 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
• Material Handling Issues, 2006
• 01/17, Tennelec smear counter falls during
  transport
• 06/30, Computer server unit falls out of BNL box
  truck pinning worker to ground (NTS)
• 08/28, During transport a forklift dropped a
  secured aerial lift
• Material Handling Issues, 2007
• 1/24, Worker pinned by metal sheets (NTS?)

18
SCR/NTS Report ORPS Cause Codes

• Training deficiency (RC) Practice or "hands-on"
  experience LTA
• Training deficiency (RC) Testing LTA
• Training deficiency Refresher training LTA
• Management Problem Planning not coordinated with
  inputs from walkdowns/task analysis
• Management Problem Assignment did not consider
  worker's need to use higher-order skills

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Aug 04, DOE Office of Science ISM Assessment

• Findings
• Training and qualification program for riggers,
  crane operations and forklifts is inadequate.
  Competence requirements not established and
  competence not required to be demonstrated.
• Maintenance and inspection of HR equipment is
  LTA
• Work planning, feedback, and improvement, LTA
• Aug 04, DDO Appoints Hoisting, Rigging and
  Mechanical Material Handling Working Group
• Action Plan

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SCR/NTS Action Plan Status

• 50/51 Actions Closed
• Assess the effectiveness of corrective actions
  that are related to the root causes of this
  event.
• Due Date 06/30/2007
• Post-SCR/NTS Events

21
Post-SCR/NTS Report EventsORPS Cause Codes

• 10/05/04, Injury due to steel plate falling at
  bldg 701
• Management Problem Change Management LTA Risks
  / consequences associated with change not
  adequately reviewed / assessed
• Design/Engineering Problem Design Verification /
  Installation Verification LTA Independent review
  of design/documentation LTA
• Communications Less Than Adequate (LTA) Written
  Communication Content LTA Incomplete / situation
  not covered
• Training deficiency No Training Provided Work
  incorrectly considered skill-of-the-craft
• 01/17/06, Tennelec smear counter falls during
  transport
• Human Performance (LTA) Knowledge Based Error
  Individual underestimated the problem by using
  past events as basis
• Equipment/ material problem Material control
  LTA Material shipping LTA

22
Post-SCR/NTS Report EventsORPS Cause Codes

• 06/30/06, Computer server unit falls out of box
  truck pinning worker to ground
• Human Performance (LTA) Skill Based Errors
  Wrong action selected based on similarity with
  other actions
• Management Problem Work Organization Planning
  LTA Job scoping did not identify special
  circumstances and/or conditions
• Communications (LTA) Written Communication
  Content LTA Facts wrong / requirements not
  correct
• Training deficiency No Training Provided Work
  incorrectly considered skill-of-the-craft
• 08/28/06, During transport a forklift dropped a
  secured aerial lift
• Management Problem Work Organization Planning
  LTA Job scoping did not identify special
  circumstances and/or conditions
• Communications (LTA) Written Communications Not
  Used Not available or inconvenient for use
• 1/24/07, Worker pinned by metal sheets Causes
  TBD

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Common ORPS Cause Codes

• Training Deficiency
• Management Problem
• (Work Organization Planning LTA)
• Communications LTA

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Independent Assessment IO 05-19Material Handling
Corrective Action Follow-UpJanuary 31, 2006

• Assessment Focus
• Training Qualifications
• Equipment Inspection
• Operations
• Procurement

25
Independent Assessment IO 05-19Material Handling
Corrective Action Follow-UpJanuary 31, 2006

• Assessment Results
• C/As have been generally effective and
  demonstrate a clear management commitment to
  improving material handling at BNL.
• The areas of Operation and Equipment Inspection
  have improved in general, but require additional
  attention in some specific areas and more
  consistent application of requirements across
  organizational boundaries.

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Independent Assessment IO 05-19Material
Handling Corrective Action Follow-UpSCR/NTS
Report actions deemed not fully effective

• Crane operator qualifications
• Procurement Requirements
• Annual inspection of all cranes and
  below-the-hook HR equipment
• Inspection requirements to Lifting Safety
  Subject Area
• Daily and annual inspection in basic rigging,
  forklift and overhead crane training
• Cranes without load-test certificate

27
Independent Assessment IO 05-19Material Handling
Corrective Action Follow-UpAction Plan Status as
of Jan. 26, 2007

• ATS 3078
• 50 Actions Closed
• 6 Actions Open
• 3078.6.3 - Review recommendation and respond as
  appropriate  
• 3078.9.1 - Attach Operator Manual w/environmental
  storage tube  
• 3078.9.2 - Purchase missing manuals for existing
  units  
• 3078.9.3 - Conduct tool box meeting to foster
  daily cleanups  
• 3078.10.2 - Review documents weekly and report to
  line management  
• 3078.12.1 - Do not permit use of hoists without
  load tests  

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Material Handling Programs Beyond BNLInvite
Extended to QMO

• NORFOLK NAVAL SHIPYARD
• MARSHALL SPACE FLIGHT CENTER
• TURKEY POINT NUCLEAR POWER STATION
• STRATEGIC PETROLEUM RESERVE

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NORFOLK NAVAL SHIPYARD (VPP STAR STATUS)

• Contact John Heffron, Rigging Shop Supervisor
  [phone]
• 250 Professional Riggers
• Apprentice Riggers (as recommended by management)
  undergo 4 year Training Program
• Trade Theory (classroom)
• Academics (night college classes)
• OJT
• Rated every 4 months by Supervisor
• 2x Failure of same test out
• Equipment Load tested every year
• No Fault/Blame Culture
• Reporting encouraged

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MARSHALL SPACE FLIGHT CENTER
QD50/MSFC Industrial Safety
Co-located on the Armys Redstone Arsenal in
Huntsville, Alabama NASA Employees 2,700
Contractor
Employees 4,000 Located on 1,800 Acres
Approximately 256 Buildings
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NASA's Marshall Space Flight Center

• Contacts Ed Kiessling , Industrial Safety Dept
  Manager [phone]
• Judy Milburn, Safety Training, ext 4802
• Kyle Daniel, Engineer, ext 5677
• 60 Professional Riggers
• Gift Package
• PP Presentation
• SOP - Overhead Crane, Mobile Crane Lift Truck
• Marshall Work Instruction Lifting Equipment and
  Operations
• Marshall Work Instruction Personnel
  Certification Program
• NASA Standard For Lifting Equipment and Devices
  (NASA-STD-8719.9) Bible for Lifting Devices
• Rigging Contractor contacts
• Training Courses
• http//www.pe.gatech.edu/conted/servlet/edu.gatech
  .conted.course.ViewCourseDetails?COURSE_ID166
• http//www.cranesafe.com/
• http//www.cranetraining.com/

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NASA's Marshall Space Flight Center

• Overhead Cranes
• - Monthly Electrical and Mechanical Inspections
• - Annually, an Outside Contractor Specializing
  in
• crane inspections is brought in for Electrical
  and
• Mechanical Inspections

33
NASA's Marshall Space Flight Center
Foreign Made Pallet Jacks all Failed / Leaked
Hydraulic Oil Prior to Reaching Manufacturers
Rated Load During MSFC Proof-Load Testing
34
SHOCK RECORDERS
Resetable Recorders
Tri-Axial Multi-Day Recorders Recently,
there seems to be less reliance / use of shock
recording devices. The inability to determine
the actual shock hardware has been subjected to
during Shipment Handling is a concern.
35
TURKEY POINT NUCLEAR POWER STATION

• Contact, Rick Nielsen, Dept. Manager
• Has the Pulse of the Nuc Power Plants
• Audit Criteria
• Results
• Observations
• Inspections
• Problems noted throughout Industry
• Stations now engage the EXPERTS

36
STATEGIC PETROLEUM RESERVE

• Contacts, Suzanne Broussard, Safety Manager (504)
  734-4833
• Joe Shuckrow [phone]
• 10 yr. running Behavioral Safety Program (700 to
  537 Workers)
• Identify/discuss/correct at-risk behaviors
  without blame
• Provides built-in supervision
• Peers observe peers
• Program has significantly reduced events (VPP
  Status)
• From 54 to lt than double-digits
• Direct correlation between watching and reduction
  in events
• Spills over into safe behavior at home

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What does a World-Class Material Handling
Program Look Like?

• Competitive Advantage
• Consistent processes
• Independent Audits
• Benchmarking
• Eliminated
• Sustainable
• ORGANIZATIONS SEEK OUT BNL AS A MENTOR
• Adapted from Breakthrough Safety Management -
  by Sandy Smith - 06/08/2004
• http//www.occupationalhazards.com/safety_zones/47
  /article.php?id11919

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BNL World-Class in Material Handling

• Why Not Us? Why Not Now?

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Suggested Immediate Actions

• Formal Response
• SMEs - Dedicated Focused
• Real Supervision (Worker-Planned-Work)
• Nobody moves significant material alone
• Policy to limit specified material handling to
  the Pros

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What Might Have Happened!

• I have been very upset by this incident and
  I have played over and over in my mind what might
  have happened had the near miss not been a near
  miss and we killed a worker. First and foremost,
  the human suffering would have been staggering
  and far-reaching. Beginning with the painful
  death of the worker, the pain would have spread
  through his family as they learned of the loss of
  their loved one, then to his coworkers, friends,
  and community.
• There would likely have been immediate
  mental anguish and long-term emotional distress
  suffered by the rescue workers and others as they
  responded to the awful scene. A senior Laboratory
  manager would have had the responsibility of
  contacting the dead worker's family and conveying
  the devastating news. That manager would never
  forget that experience.