Categorizers CAT Team Workshop

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Categorizers (CAT) Team Workshop 2004-04
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OUR AGENDA!

• Workshop Goals
• Point to Ponder
• ORPS Trending
• CAT Form Entries
• Programmatic Bins - A Year in Review!
• Extent of Condition
• Cat Chat
• Training
• Cat Procedure and Subject area proposed rev.
• Group 10 Criteria, resolution
• Possible Categorizer Conflict of Interest,
  resolution
• BNL R Process (Utility Strikes)
• CAT Cell Phone Operation (Ken Krasner)
• Meeting Evaluation and Wrap-up
•       

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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.

CAT
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Point to Ponder

• Keep your eyes wide open before marriage, half
  shut afterwards.
• 
  - Benjamin Franklin

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BNL ORPS Report StatusFY 2004 - Present (End of
Month)

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ORPS Corrective Action StatusFY 2004 - Present
(End of Month)
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ORPS Reports and ActionsNovember 30, 2004
ALD
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BNL ORPS by Calendar Year Report Submitted
As of 12/20
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CAT Electronic Entries

• 10/29 PB, RWP and Transportation Safety
  Violations (SC3)
• 11/08 MB, Fire Inside Power Supply Cabinet _at_
  C-AD (SC4)
• 11/08 RK, Employee Struck By Motor Vehicle
  While Riding Bicycle (SC3)
• 11/10 RK, Accidental Fire Suppression System
  Discharge in B610
• 11/10 RK, 1 gallon hyd oil to soil behind B197
  - Broken leaf blower line
• 11/10 ES, Grade 8 suspect bolts discovered in
  man-lifts (SC4)
• 11/16 KK, Fire at a SNS Magnet during testing
• 11/17 KK, Vehicle batt falls off the back of a
  truck, acid spill to pavement
• 11/19 KK, Lineman trips/falls and breaks bones
  in forearm (SC3)
• 11/29 AL, Pin hole leak in BNL vehicle fuel
  line - cup of gas to pavement
• 12/02 KS, Unauthorized access into the STAR
  hall
• 12/09 KS, Unexpected disc of 2.4K deenergized
  cables during excavation
• 12/10 KS, 1 gallon of motor oil spilled to soil
• 12/15 SC, Pre-id 0 voltage leak detection line
  severed during excavation

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CAT Electronic Entries

• 12/17 SC, 150 gal oil spill to secondary
  containment _at_ bldg 495

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ORPS Reportable and Nonreportable Cat Entriesas
of 12/20/2004
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Programmatic BinsA Year in Review!

• Personnel Contamination
• Medical Department
• NSLS
• Physics
• CA-D
• BGRR Project
• Utilities Struck
• Railroad Tracks
• Material Transportation
• Electrical Shock Hazards
• Material Handling Issues

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Programmatic Review

• Personnel Contamination 2004
• 04/14 5,000 dpm on top of workers shoe at BGRR
  (RAR)
• 05/21
• 08/31 200 dpm/100cm2 on experimenter at PET

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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)

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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

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Programmatic Review

• Physics, 2004
• 07/01 Laser interlock check overdue by 3 weeks
  _at_ ATF
• 10/21 Trimmed tree branch breaks window at
  physics

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Programmatic Review

• CA-D, 2004
• 01/13 - Worker breaks ankle while preparing for
  cable pull
• 03/22 - Welders helper receives minor eye
  irritation
• 05/17 - Damaged detector at STAR after 10 foot
  drop
• 05/21 -
• 07/14 - Fire in a RHIC RF cavity power supply in
  Bldg 1004A
• 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 bldg 930
• 11/08 - Fire Inside Power Supply Cabinet (SC4)
• 12/02 - Unauthorized access into the STAR hall

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Programmatic Review

• BGRR Project, 2004
• 04/14 - 5,000 dpm on top of workers 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)

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Programmatic Review

• Utilities struck
• 2000
• 10/02 - Sanitary line severed near 801
• 10/27 - Worker hits energized UG cable
• 11/07 - Strike of 480 volt UG cable
• 2001
• 03/27 - UG abandoned comm. cable struck
• 03/29 - Backhoe scraps steam line
• 04/26 - Backhoe strike of 208 VAC cable
• 07/03 - Backhoe strike of 208 VAC cable
• 09/17 - Van hits fill ass. of LPG tank
• 09/26 - Phone line damaged when digging near FH
• 10/03 - 2 in. above grd water line broken by
  bulldozer
• 11/28 - Backhoe strike of 4 - inch water line

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Programmatic Review

• Utilities struck
• 2002
• 04/30 - Aband. control wiring hit during sanny
  upgrade
• 05/07 - GC drilled anchors into elect. duct bank
  near 911
• 06/06 - Minor utility strike during horiz. boring
  activities
• 09/28 Truck driver backs into 13.8KV BAF power
  supply
• 2003
• 01/08 - Contractor severed low voltage comm.
  cable near bldg. 51
• 05/08 - Deenergized cable struck during
  excavation near 911A
• 08/12 - Forklift strikes overhead wire

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Programmatic Review

• Utilities struck
• 2004
• 04/19 Electrical utility conduit strike
• 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
• 12/15 Pre-Identified 0 voltage leak detection
  line severed during excavation

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Programmatic Review

• 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)

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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

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Programmatic Review

• Electrical Shock Hazards
• 2001
• 10/03 - Electrical Incident at Cyclotron
• 2002
• 04/19 - Electrical Shock _at_ NSLS
• 09/24 - Worker at AGS receives
• 2003
• 06/27 - Electrical Shock _at_ Physics
• 2004
• 07/12 - Worker feels mild electrical tingling in
  his finger _at_ NSLS
• 08/10 - Worker experiences electric shock _at_ NSLS

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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)

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What is the Extent of Condition?

• Is the deficiency restricted to a specific work
  activity?
• Is the deficiency broader in that it impacts the
  overall project specific activities?
• Is the deficiency even broader in that it impacts
  a division or directorate?
• Is the deficiency much broader in that it impacts
  the entire site?
• Or, if you manage multiple sites, is the
  deficiency a systemic or programmatic condition
  within a functional area such as work control or
  hazard analysis spanning various sites?
• Does the deficiency reach beyond the Planet?

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Enforcement Lessons Learned

• Extent of Condition is a key mitigating factor
  for addressing potential Enforcement Actions
• Extent of Condition is a key element of any
  Corrective Action Management system and is not
  just restricted to potential PAAA noncompliances
• Extent of Condition should be integrated into all
  aspects of issues management processes including
• Issues/corrective action management procedures
• Causal analysis procedures
• Management/Independent assessment procedures
• PAAA noncompliance determination/reporting
  procedures
• Issues Review Board/Corrective Action Review
  Board charters, if applicable

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String Pulling - How far is far enough?

• Deficiencies isolated to a unique work activity
  or project or within a specific functional area
  may have a limited extent of condition.
• Deficiencies identified from trends which cross
  numerous projects or functional areas (i. e.,
  work control, hazard analysis, etc.) would
  require a more comprehensive review for extent of
  condition.
• Senior management involvement and direction is
  often needed to charter independent or
  off-project (Type-B equivalent) investigations
  for determining causal factors, judgements of
  need, and the extent of condition at a company
  level.

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Methods for Accomplishing Extent of Condition
Reviews

• Lessons Learned Notification Response
• Issues not rising to the level of requiring a
  Type-B like investigation can utilize formal
  lessons learned notification systems to capture
  lessons learned from NTS reportable events and
  distribute them to appropriate organizations with
  mandatory response required by each organization
  as to the extent of condition. Responses are
  maintained in the evidence files for the NTS
  report and any additional corrective actions
  added to NTS.

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Methods for Accomplishing Extent of Condition
Reviews

• Extent of Problem/Condition Procedures
• Formal procedures with roles and
  responsibilities for performing and assigning
  responsibility for structured, documented extent
  of problem and extent of condition reviews tied
  into existing procedures for issues/corrective
  action management, causal analysis, etc.
• Others ???

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Extent of Condition Feedback

• Extent of Condition (EOC) reviews should be
  integrated into all aspects of issues management
  processes including
• Issues / Corrective action management procedures
• Causal analysis procedures
• Management / Independent assessment procedures
• PAAA noncompliance determination and reporting
  procedures
• Issues Review Board and/or Corrective Action
  Review Board charters, if applicable

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Extent of Condition Feedback

• EOCs need the support of Senior Mgmt. Processes
  need to be in place to ensure corrective action
  plans for significant events are reviewed by
  appropriate Functional Managers and Subject
  Matter Experts for EOC.
• An EFCOG product on what constitutes adequate EOC
  reviews is recommended considering no current
  guidance exists.
• Benchmarking of NRC and/or INPO best practices
  recommended.
• Joint task team effort with coordination with QA
  working groups was recommended.

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CAT CHAT!

• Conduct ORPS Re-design training for Department
  Division Managers (1st Qtr. 05)
• CAT Procedure and Subject area proposed rev.
• Include pushup to DDO in cat procedure
• Include advise to FM (Grp 10) in cat procedure
• Provide a scheme for documenting verification
  effectiveness of corrective actions when
  required. (SA)
• Provide the process for determination of the need
  to issue a "R" Recurring Occurrence Report. (SA)
• Group 10 Criteria, resolution
• Categorizer conflict of interest resolution
• Will remain as is
• Upcoming R Vote on Utility Strikes
• CAT Cell Phone Operation (Ken Krasner)

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Group 10 Management Concerns/Issues

• (2) 1-4 An event, condition, or series of events
  that does not meet any of the other reporting
  criteria, but is determined by the Facility
  Manager or line management to be of safety
  significance or of concern to other facilities or
  activities in the DOE complex. One of the four
  significance categories should be assigned to the
  occurrence, based on an evaluation of the
  potential risks and the corrective actions taken.
• As always, you will continue to inform the
  Facility Manager of this reporting option. In
  addition, you will now provide your input (based
  on reporting experience) as to whether or not you
  feel that the event and/or condition under
  investigation should be reported under this
  criteria. The final decision shall remain with
  the Facility Manager. - E. Sierra

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CAT Team Workshop

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