Department of Energy
Operating Experience Committee (OEC)
Coordinated by the Office of Analysis (HS-24)
Conference Call Minutes
Tuesday, August 21, 2012
Time: 11:00 a.m. - 12:30 p.m. EST
Call-In Number: 202-287-5323
AGENDA
Welcome and Introduction
Ashley Ruocco
Site Operating Experience Discussions
All
External Organizations Operating Experience and Lessons Learned
Discussion
All
Update on Office of Analysis and Corporate Operating Experience
Initiatives
Ashley Ruocco
Discussion of and request for information about fall meeting of the ORPS
and OE Committees
All
Roundtable / Subjects for Next Call
All
PARTICIPANTS
#
NAME
SITE
1
Abston, Lee Ann
OR-Isotek
2
Alp, Asu
Argonne Site Off
3
Barrick, William
NSO
4
Bentley, Jeff
DOE-SRS
5
Blackstock, Chris
Atomic Energy of Canada, Ltd
6
Blank, Betsy
ORP
7
Booker, Craig
ORO
8
Branson, Gary
INL
9
Brown, Sharon
DOE HQ
10
Cheng, Sam
LASO
11
Cochran, Teresa
ORNL
12
Cole, Matt
DOE-HQ
13
Cummings, Danae
NVSO
14
Dayani, Mosi
Savannah River Site
15
DuBose Rick
DOE-HQ-FE
Page 1
#
NAME
SITE
16
Daugherty, Paul
DOE-SRS
17
Ferguson, Scott
Atomic Energy of Canada, LTD
18
Harris, Allan
EMCBC
19
Hauptmann, Michael.
BNL
20
Heeter, Tom
OR-Isotek
21
Heller, Sara
NTS-NSTec
22
Horning, Jeff
LLNL
23
Hubbard, Chelsea
DOE-OR
24
Hutto, Rod
SR
25
Innocent, Jessy
DOE NNSA
26
Ito, Fran
WIPP
27
Johnson, Angela
SRS
28
Johnson, Thomas
EM-54
29
Jolly, Debora
PPPO
30
Langstaff, David
RL
31
Landmesser, Jim
EM-41
32
Lee, John
EM-54
33
Lin, Paul
DOE HQ
34
Lopez-Cardona, Emma
DOE HQ
35
McDuffie, Steve
Hanford
36
Mc Vey, James
WSMS
37
Menas, Matt
NETL
38
Miehls, Dennis
WIPP
39
Minton, Lauri
Pantex
40
Natoli, Ross
DOE HQ
41
Navarette, Martin
WIPP
42
Neil, Dave
Idaho Operations Office
43
Neilson, Steve
Thomas Jefferson Site Office
44
Norbury, Michael
DOE HQ
45
Orr, Jane
SHAW VCR Project
46
Patel, Jay
NRC
47
Pavalko, Kelly
NTS
48
Pearson, John
ORAU
49
Polanish, Caroline
BHSO
50
Price, Stephanie
WSI/SRS
51
Rao, Nimi
DOE HQ
52
Robison, Camille
INL/AMWTP
53
Ruocco, Ashley
DOE HQ
54
Sanchez, Ruben
DOE HQ
55
Schutt-Bradley, Joanne
OR/ETTP
56
Searfoss, Glenn
DOE HQ
57
Shidal, Suzanne
PPPO
58
Sivak, Andy
NETL
Page 2
#
NAME
SITE
59
Smith, Duane
Oak Ridge - TRU Project
60
Smith, Kathleen
Atomic Energy of Canada, LTD
61
Stolte, Bruce
NSO
62
Stuewe, Robert
LANL
63
Tamplain, Jeffrey
SPRO
64
Thomason, Gail
PEC
65
White, J.D.
PPPO
66
Whitley, Daniel
PPPO
67
Weibel, Marc
SLAC
68
Williams, Tom E.
NA-1
69
Zabel, Jennifer
Golden Field Office
WELCOME AND INTRODUCTION
Ashley Ruocco – Ruocco welcomed all to the call and introduced those at HQ in Germantown.
HIGHLIGHTED PRESENTATION
The presentation was rescheduled to the September meeting: Mild Electrical Shock During Usage of Portable
Office Heater by Paul Daugherty, Savannah River Site. Mr. Daugherty will provide additional information that
is posted on the OE Wiki regarding the topic.
SITE OPERATING EXPERIENCE DISCUSSIONS
1. Brookhaven Site Office / Brookhaven National Lab (BNL)

Hauptmann reported on four lessons learned from the recent ladder fall event:
o On a vertical ladder, because the worker’s center of gravity is away from the ladder, the worker
is more likely to fall than on an inclined ladder where the worker can stay upright.
o Vertical ladders should only be used for access, not work.
o The 1968-era ladder was manufactured to codes in effect at the time but did not meet current
codes (OSHA and 861), especially in the area where the ladder met the roof.
o Workers must communicate about perceived dangers as well as real ones. In this case, several
workers had been uncomfortable with the way they had to transition from the ladder to the roof,
but they had not said anything, assuming that “that’s the way it is.” After the worker fell, there
was a general realization that there needed to be more open communication/sharing.
2. Carlsbad Field Office/WIPP

During a recent emergency, non-essential personnel remained in the area despite being requested to
evacuate, and they used personal cell phones to discuss the situation. As a result, patient privacy was
compromised.
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3. Los Alamos Site Office (LASO) / LANL

4.
5.
6.
7.
8.






Lesson learned: don’t think your injury prevention and reporting efforts are failing because reporting
rates rise in the first year and then fall. After focusing on repetitive motion trauma in office settings,
LANL moved injury reduction efforts to glovebox operators. Reports doubled during the first year when
improvements were being made, but then fell 20% in the second year. The LL from this is that increased
reporting is a result of workers’ awareness and so it is important to look at multi-year data. LANL’s next
efforts will be to work with body positioning and reduce push-pull injuries.
Livermore Site Office (LSO)/ LLNL
Pressurized System Calibration lesson learned was submitted about a calibration device that broke when
exposed to high pressure. Fortunately, the device was aimed downward and no injuries resulted. To
relieve high pressure, workers had loosened the nut/cracked the fitting, but that action may have left the
fitting vulnerable when pressure was increased. LL is to inspect all fittings to ensure that they’re tight.
KSO / KCP
Nothing to report
National Energy Technology Lab (NETL)
In June a forklift mast struck a partially-closed bay door when a worker attempted to bring a table into
the building and the door was not fully open. There was significant damage to the door and tracks but
there were no injuries or damage to the forklift. The operator had completed forklift training and a recent
refresher but may have been distracted by the extreme heat (105°).
Nevada Site Office (NSO) / NST / NSTec
No LL to report.
NST’s self-assessment IAW Order 210.2A is not complete but the results will be shared.
Oak Ridge Site Office (OR) / Oak Ridge National Lab (ORNL)
Lessons Learned has been submitted to the database: recognize changing conditions to prevent lead
exposure.
9. Princeton Site Office (PSO)

Ruocco presented for Tracy Estes
Discharge of Halon System in NSTX Control Room
On August 13, 2012, the Halon 1301 System in the National Spherical Torus Experiment Control Room
discharged. The alarm bells did not alarm and were manually initiated to evacuate the building. No
personnel were in the Control Room/Annex at the time. Emergency Services personnel entered the
control room to assess the situation and the ventilation system was configured to provide 100% exhaust
to the area. Oxygen levels were close to normal within 20 minutes. The Simplex Fire Detection and
Alarm System had been experiencing communication/network malfunctions prior to the release,
resulting in the Emergency Voice Evacuation System not being operable; it may have indirectly caused
the Halon release. Further investigation is still necessary. A failure of a power supply for the
Warehouse portion of the system may have caused the system-wide Simplex issues. Once the power
supply was restored and the system re-booted all systems returned to normal. Until confidence can be
gained in the system stability, other gas-based suppression systems were temporarily locked out.
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
Smoldering caused by lithium reaction
On August 14, 2012, while a vacuum cleaner was being used to remove ~ 25 gm lithium from one of the
Li Droppers in the Lithium Technology Development Laboratory, a Lithium/air reaction began
occurring in the fire retardant, all-metal vacuum cleaner specifically designed to clean fireplace ash.
This vacuum cleaner had been approved by PPPL ESH and has been used in similar previous cleanups,
though the amount of Li was approximately half as much.
PPPL ESH personnel were already at the location since that had been a planned precautionary measure
for the evolution. After five minutes of vacuuming, some smoke and an acrid odor were released from
the vacuum so the applicable portions of the building were evacuated. The vacuum cleaner was removed
from the building and was eventually placed in a 30 gallon drum for temporary storage in the Hazmat
Building. The building was ventilated using forced air and negative pressure from the C-Site MG
building exhaust fans. After the odor was removed from the building, personnel were allowed to return
to their work areas. The vacuum cleaner contained the reaction and no injuries occurred.
The lithium being handled was expected to be “passivated” lithium powder which is not pyrophoric, but
this was not the case. The lithium had been used and then allowed to passivate over time (6 weeks) by
exposure to air. PPPL has issued a Stop Work order on all work with lithium at PPPL and PPPL is
formally chartering a Lithium Safety Committee.
10. Pantex Site Office (PSO)

Nothing to report
11. Portsmouth/Paducah Project Office(PPPO)

Draft LL in progress: Temporary Recovery Actions and Condition Changes about outside storage of
materials in changing weather conditions.
12. Richland (RL) / Hanford Site

PRC issued an information bulletin about LL when using ground-penetrating radar (GPR). An
excavator uncovered a multi-strand cable despite pre-work use of GPR that did not show the cable. LL is
about the limitations of GPR: need to add three feet beyond what is estimated for an underground
utilities check, particularly around buildings. In short, consider adding distance.
13. Sandia Site Office (SS) / SNL

Ruocco noted the Final Report from July 24, 2012, Lithium Fire and Explosion at Plasma Material Test
Facility in Bldg. 6530, NA--SS-SNL-1000-2011-0007
On August 26, 2011, at the Plasma Materials Test Facility, part of a test assembly containing liquid
lithium in the EB1200 vacuum chamber appears to have failed, which resulted in a small flash fire and
explosion. The initial conclusion is that lithium was released into the chamber when the part failed.
Some of this lithium went into a beam line that extends from the vacuum chamber and a second failure
occurred in a cooled ceramic sleeve in the beam line. This second failure released coolant (water and
propylene glycol) that reacted with the lithium and likely released hydrogen, as well as oxygen, resulting
in the explosion. An overpressure rupture disk on the chamber operated as designed, but the pressure
release was not sufficient to prevent the failure of a welded seam in a 22-inch tube connecting the beam
line to the vacuum vessel. Three individuals in the vicinity of the vacuum vessel reported some degree
Page 5
of ringing in their ears, but a total of four individuals were sent to Medical for evaluation. The pressure
from the explosion damaged the vacuum chamber and a panel of riveted wall siding and an exterior
door. The facility was put in a secured state prior to departure for the day. On August 27, a team was
assembled to plan re-entry into the building to ensure the facility and vacuum chamber were in a safe
state and to prepare the space for access by an independent investigation team, who will investigate the
event.
An extent of condition was conducted. The failure of the component was anticipated. However, the
manner in which the component failed and the contact of the liquid lithium with other materials inside
the vacuum chamber was not sufficiently considered or evaluated. The escaping liquid lithium contacted
surfaces that failed due to the reactive nature of molten lithium. The surface failure of the cooling line
resulted in the fire/explosion. Personnel in the area heard and felt the impact of the explosion with
temporary symptoms such as ringing in the ears.
14. Savannah River (SR)/ SRSO

Nothing to report
15. Stanford Site Office (SSO)

Nothing to report
16. Thomas Jefferson Site Office

Nothing to report
17. YSO/Y-12

Nothing to report
LESSONS LEARNED GUIDANCE DISCUSSION
Guidance for writing effective Lessons Learned for submission to the DOE Lessons Learned program is
available on the Operating Experience Committee Wiki http://operatingexperience.doehss.wikispaces.net/OEC+Home
Go to the Helpful Products section for Attributes of a Good Lessons Learned.
Camille Robison, INL/AMWTP, offered to provide the Advanced Mixed Waste Treatment Project document,
Operating Experience/Lessons Learned, MP-ISIH-2.43. Contact her at Camille.Robison@amwtp.inl.gov
EXTERNAL ORGANIZATIONS OPERATING EXPERIENCE AND LESSONS LEARNED
DISCUSSION
Nothing to report.
UPDATE ON OFFICE OF ANALYSIS AND CORPORATE
OPERATING EXPERIENCE INITIATIVES
Page 6
-
ORPS Order and OE Order implementation- Ruocco
 EFCOG’s ORPS Task Group and HSS continue to work on DOE O 232.2, Occurrence Reporting
and Processing of Operations Information, interpretation issues. The next ORPS Task Group
conference call is August 22nd.
 OE Videos of the Week- the latest video posted was “Electric Vehicle Safety Training” from the
National Fire Prevention Association and National Electrical Contractors Association. Please send
any OE relevant videos that you would like to see on the OE Wiki to Ruocco.
-
Lessons Learned Program and Database- Ruocco
 Ruocco discussed the use of Lessons Learned Reports versus ORPS Reports. ORPS Reports are not
the same as Lessons Learned Reports. ORPS Reports follow DOE O 232.2 requirements where the
basic ‘who, what when, where how’ questions of the event are answered. Lessons Learned reports
are not a copy/paste of an ORPS report. Lessons Learned reports share a good work practice or
innovative approach that is shared to promote the application or prevent recurrence of an adverse
work practice or experience. Lesson Learned reports provide specific lessons learned and discussion
that may be a result of an ORPS reportable event.
-
Corporate OE documents under development or recently released- Ruocco
 OE Summary Article, Operating Experience from Cerro Grande and Los Conchas Fires Improves
Los Alamos National Laboratory Emergency Preparedness and Response to Wildfire Events
 Draft OE-3, Lack of Familiarity with Infrequently-Operated Vehicles Puts Drivers in Danger
 Draft OE-3, Equipment Presents Crushing Dangers
 Draft OE-3, Criticality Safety
 Draft OE-3, Dangers of Respirable Silica
 Draft OE-3 or OES, Central and Eastern United States Seismic Source Characterization
 Draft OE-3 or OES, Use of Alternative Asbestos Control Methods in Demolition Activities
 Draft OE Summary Article, Department of Energy and Pacific Northwest National Laboratory
Collaborate to Deploy More Effective Readiness Process
 Draft OE Summary Article, Chemical Spill Prevention
 Draft OE Summary Article, Mower Fatality at the Bryan Mound Site
-
Self-Assessment reviews on the effectiveness of the OE Program- Ruocco
 HS-24 drafting a self-assessment of the OE Program, Ruocco summarized the requirements and
responsibilities of DOE O 210.2A and how HS-24 is meeting them, improvements made, and
improvements needed. Feedback from the OEC is important in improving this Program. Please
continue providing all feedback on improvements to the OE Program to Ruocco.
Page 7
FALL OPERATING EXPERIENCE COMMITTEE MEETING
Discussion of and request for information about fall meeting of the ORPS and OE Committees.
ROUNDTABLE
Action- Guest Speaker Volunteers requested. If you would like to present to the OEC, please call Ashley to
volunteer. Thank you in advance!
The September 2012 Conference Call is scheduled for
Tuesday, September 11.
Call-In #: 301-903-7073, Confirmation #: 390575 (70 lines maximum).
Roll Call via Email: Attendees are asked to e-mail their name, company name or government organization,
and phone number to Gail Thomason, gthomason@pec1.net, at the beginning of the conference call.
Ashley Ruocco, DOE HS-24, E-Mail: Ashley.Ruocco@hq.doe.gov. Phone number: (301) 903-7010.
Operating Experience Websites:
OE Documents (HSS) - http://www.hss.doe.gov/SESA/Analysis/oel.html
OE Summaries (HSS) - http://www.hss.doe.gov/sesa/Analysis/oesummary/index.html
OE Wiki - http://operatingexperience.doe-hss.wikispaces.net/
OES Blog - http://oesummary.wordpress.com/
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