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