Department of Energy
Operating Experience Committee (OEC)
Coordinated by the Office of Analysis (HS-24)
Conference Call Minutes
Tuesday, April 10, 2012
Time: 11:00 a.m. - 12:30 p.m. EST
Call-In Number: 301-903-7082. Confirmation #: 373124 (70 lines)
AGENDA
Welcome and Introduction
Ashley Ruocco
Site Operating Experience Discussions
All
Update on Office of Analysis and Corporate Operating Experience
Initiatives
-
Ashley Ruocco
Report on Office of Analysis performance trending and analysis of
ORPS occurrences and other information for the previous month
Skip Searfoss;
Other HS-24 staff
Roundtable / Subjects for Next Call
All
WELCOME / PARTICIPANTS
NAME
SITE
ORGANIZATION
1
Alp, Asu
Argonne Site Off
Argonne National Laboratory
2
Ammonet, Patti
PNNL
Battelle Memorial Institute
3
Anderson, Brian
Idaho Ops Office
DOE ID
4
Barrick, William
NSO
Nevada Site Office
5
Blank, Betsy
ORP
Washington River Prot Solu. (WRPS)
6
Booker, Craig
ORO
7
Branson, Gary
INL
Battelle Energy Alliance, LLC
8
Brown, Sharon
DOE HQ
HS-24
9
Copeland, Doug
NRC
Office of New Reactors
10
Dichard, Bob
RL
CH2MHILL Plateau Remediation Co (CHPRC)
11
Domotor, Steve
DOE HQ
HS-24, Director
12
Estes, Tracy
PNNL
Office of Science
13
Goetsch, Bob
SNL
#
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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#
NAME
SITE
ORGANIZATION
14
Hauptmann, Michael.
BNL
LL Coord, Qual Mgmt Office
15
Hutto, Rod
SR
Savannah River Nuclear Solutions
16
Innocent, Jessy
DOE NNSA
KCSO
17
Johnson, Angela
SRS
Perf Assurance
18
Jolly, Debora
PPPO
Swift & Staley (SST)
19
Langstaff, David
RL
Richland Operations Office
20
Larson, Jay
DOE HQ
SC
21
Lopez-Cardona, Emma
DOE HQ
EM
22
McCallister, Russell
Ports/ Paducah Project Office - Lexington
PPPO
23
McDuffie, Steve
Hanford
Office of the Chief of Nuclear Safety/CTA
24
Menas, Matt
NETL
Albany, Fairbanks, Morgantown, Pittsburgh, & Tulsa
25
Natoli, Ross
DOE HQ
HS-24
26
Neil, Dave
Idaho Ops Office
ID
27
Norbury, Michael
DOE HQ
NA-712
28
Owen, Donald
DNFSB
29
Pavalko, Kelly
NTS
NSTec
30
Pearson, John
ORAU
ORAU/ORISE
31
Ramsey, Kenneth
SR - NA-26
MOX Services
32
Rao, Nimi
DOE HQ
HS-24
33
Robison, Camille
INL/AMWTP
ITG/AMWTP
34
Ruocco, Ashley
DOE HQ
HS-24
OR/ETTP
UCOR (URS/CH2M)
35 Schutt-Bradley, Joanne
36
Searfoss, Glenn
DOE HQ
HS-24
37
Shidal, Suzanne
PPPO
LATA Kentucky
38
Skokan, Bryan
DOE HQ
EM-53 Project Support (PT&C)
39
Smith, Duane
Oak Ridge - TRU Project
TRU Project (EnergX)
40
Staffo, Gary
DOE HQ
EE-3C
41
Stuewe, Robert
LANL
Los Alamos National Security
42
Tamplain, Jeffrey
SPRO
DM Petroleum Operations Co
43
Thomason, Gail
PEC
PEC (Support contractor to HS-20)
44
Ward, Jonathan
Atomic Energy of Canada, LTD
Chalk River Laboratories
45
White, J.D.
PPPO
Swift & Staley (SST)
RL
OE Pgm Coord, Mission Support Alliance
Whitney, Gerry
46
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
Page 2
WELCOME AND INTRODUCTION
Ashley Ruocco – Ruocco welcomed all to the call and introduced those at HQ in Germantown. Ruocco noted
the modifications to the agenda. In order to best communicate on the call, a roll call by site with key points to
address was added to the monthly call which is listed as Site Operating Experience Discussions in the agenda.
Please, continue to email roll call to Gail Thomason as well- gthomason@pec1.net. Unfortunately, due to
contractor support reductions, Sherry Barber will no longer be taking the minutes. Ruocco and Thomason will
be taking the minutes during the calls.
In addition to the Site Operating Experience Discussions, the Office of Analysis, HS-24 will give an update on
OE initiatives, analysis, self assessment, and current OE Documents. Their focus for 2012 is self-assessments
of the OE program.
Before beginning with the planned agenda, Ruocco welcomed Larry Adkinson from SRS to give a brief
presentation on a recent ORPS event- Nylon Webbing Failures with Ratchet Tie Downs. After this discussion,
the roll call by site and discussions began.
Larry Adkinson (SRS) – Adkinson gave an overview on a recent ORPS event- Nylon Webbing Failures with
Ratchet Tie Downs. While the DOE complex continues to address S/CI concerns with Ratchet Tie-down
assemblies, and specifically the bolts, Savannah River Site tested a number of suspect items after concerns with
S/CI bolts surfaced, and found that the two inch webbing consistently failed below the ratchet tie downs'
specified failure rating. The failures occurred within a range of 6,800 to 7,800 pounds, while the failure rating
required 10,000 pounds. (The ratchet tie downs were Purchase level 3 items and are specified for non-nuclear
and non-DOT usage.) The M&O Contractor, Savannah River Nuclear Solutions, initiated an NCR and an ORPS
Occurrence Report. A First Alert was also issued. The ORPS report was submitted on March 30, 2012.
SITE OPERATING EXPERIENCE DISCUSSIONS
1.
Ames Laboratory

No attendees
2. Argonne Site Office (ASO) / Argonne National Lab


Attendee- Asu Alp, Argonne National Laboratory
Operating Experience to Share- A natural gas line was struck during a water line repair. Prior to that
incident, a few months ago, they had a similar incident when an electrical line was hit during excavation.
This topic could be a possible OE Summary: How to do safe excavation and watching for lines.
Action-Ruocco to find out if an OE document was already created or drafted on this recurring topic.
Findings- Excavators have been the subject of two OE Summaries:
 2008-11, Excavator hit overhead lines
 2007-01, Excavator accidents can be deadly
3. Berkley Site Office (BSO)

No attendees
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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4. Brookhaven Site Office / Brookhaven National Lab





Attendees- Mike Hauptmann, Brookhaven National Lab’s Lessons Learned (LL) Coordinator
Improvements have been made to BNL’s OE Program. The Program includes all subcontractors (active
or inactive) in their LL distribution where they will get all LL information.
Recently BNL implemented Quick Read programs, this is modeled after Hanford’s HILLS system. This
venue gets applicable worker health and safety issues to the site quickly. BNL is able to get Quick Reads
out in about a day.
BNL is preparing a LL to upload on the plastic Brady Universal Multipole Breaker Lockout, Product
Number- 66321.
Action- Hauptmann will send examples of Quick Reads and LL.
5. Chicago Office

No attendees
6. Carlsbad Field Office/WIPP

No attendees
7. Fermi Site Office (FSO)

No attendees
8. Idaho Operations Office (ID) / Idaho National Lab (INL)



Attendees- Brian Anderson (ID), David Neil (ID), Gary Branson (INL), Camille Robison (INL)
Brian Anderson (DOE ID) – Anderson discussed an emerging concern, representing a lesson to be
learned when transferring areas between contractors. This resulted from a D&D activity performed by
an EM contractor in a fenced off and separately controlled D&D area located within an operating facility
managed by an NE contractor (both contractors are Prime to DOE-ID). After completion of D&D work
in late February, the D&D area was vacated and turned over to the Facility operated by NE.
Subsequently, some radiologically contaminated debris or soil has been found in areas within or near the
previously fenced D&D area. An inter-contractor dispute has surfaced regarding adequacy of
radiological cleanup, surveys and coordination of turnover of the work-site from the D&D contractor to
the Facility contractor. Lessons learned highlight the importance of transfer responsibility being
formalized; including exact information on tasks and responsibilities. The contractor needs to know
what they are accepting during a transfer like this and they should be proactive in the transfer
responsibilities.
Gary Branson, Lessons Learned/Occurrence Reporting Program SME for Battelle Energy Alliance
(INL) - Branson discussed a LL improvement that is similar to Quick Read, but it is out of their issue
tracking system and reports are reviewed by LL Program and SMEs before finalized. The review
process is going to be tracked to the specific organization where they can better assess quality of work
and products.
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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9. Los Alamos Site Office (LASO) / LANL




Attendee: Bob Stuewe
Stuewe brought up the American Chemical Society has a new C&EN Blog where they track daily and
weekly events related to chemical lab and safety. This has very valuable information for R&D groups.
It was noted that: highlighted by the conclusion of ARRA work, a new pattern is emerging dealing with
the safety of power systems and cabling. These issued are coming up the past 2 years more so than
before.
Year end trending being conducted is also showing that the ARRA’s event rate at the conclusion of the
work was proportionally higher than to the beginning of work. Approaching milestones is related to
more occurrences. Looking into causes, it is noted that the dominant cause was incomplete
communications from subcontractors or M&O and contractor. From this, we need to learn what we can
do differently.
10. Livermore Site Office (LSO)/ LLNL

No attendees
11. KSO / KCP



Attendee- Jessy Innocent (KCP)
Clyde Hicks (KCP) sent the following information to Ruocco on April 10, 2012 via email: The KCP has
an internal communication sent twice a month to all managers - the "HS&E Manager's Communication
Packet" that includes the attached. Managers are requested to share the information with all employees
in staff meetings or interaction they have with their employees.
Also, an initiative this year at the KCP is an emphasis by our vice-president on the sharing of lessons
learned taken to the workers. The term we are using is shop talks. The lessons learned are shared with
the working level on a personal basis.
12. Grand Junction Project Office (MOAB)

No attendees
13. Nevada Site Office (NSO) / NTS



Attendee: Kelly Pavalko (NTS) and William Barrick
A reminder to pull out old lab work benches (120V) off of the wall and check what’s behind them, there
may be daisy chaining or may still be “live” even though they have not been used for a long time.
NTS will be able to share more OE results in approved performance in the near future.
14. Oak Ridge Site Office (OR)


Attendees- Joanne Shutt-Bradley, Craig Booker, John Pearson, Duane Smith (TRU Waste, Oak Ridge)
OR is working the issue on the tie down S/CI.
15. Pacific Northwest Site Office (PNSO)/ PNNL


Attendee- Patti Ammonet
Nothing to report at this time.
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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16. Princeton Site Office (PSO)


Attendee- Tracy Estes
Estes discussed the skid steer incident at PPPL and was a part of the causal analysis team. Main
contributing causes of the event were: deficiencies in maintenance being conducted on heavy
equipment, daily check lists not being completed, lack of training, safety culture of specific group,
and procurement contract document not specific to ensure maintenance being conducted.
17. Pantex Site Office (PSO)

No attendees
18. Richland (RL) / Hanford Site



Attendees- David Langstaff, Gerry Whitney, Bob Dichard , Betsy Blank (WRPS), and Steve McDuffie
Question on the quality of LL: is there some kind of a guideline for writing LL so that more consistent
products are produced?
Searfoss (HS-24) discussed that the LL statement should give the reader a reason to read more, to state
what is the point, why this is a lesson. Currently, the LL statement is sometimes just a summary.
Action- Ruocco will add the ‘Guidelines for Writing LL’ to the LL Improvement document and discuss with
HSS, EM and NNSA.

Gerry Whitney (Hanford) brought up the Data Collection Sheet (DCS) on S/CI ratchet type tie downs.
The DCS states a revised report is being developed. Sharon Brown (HS-24) stated that HSS is working
with Y-12, NNSA, HQ, EFCOG and SMES to review the matter to come out with clarification. No final
report yet but it will come out soon.
19. Sandia Site Office (SS) / SNL


Attendee- Bob Goetsch (SNL)
It was noted that the largest categories of injuries continue to be slips, trips, and falls. Lack of attention
and weather conditions are the main factors with these events.
20. Separations Process Research Unit (SPRU)


Attendee- Jeff Tamplain (SPRU, New Orleans)
SPRU has a lesson submitted to their internal database involving best practices on the conversion of a
crude oil storage tank to an external floating roof. The information contained in LL was very specific to
the project. Does anyone have this similar problem? If this is specific to SPRU then they won’t post to
the LL Database.
21. Savannah River (SR)/ SRSO


Attendance- Rod Hutto (SRS), Ken Ramsey
SR is working the issue on the ratchet tie down S/CI.
22. Stanford Site Office (SSO)

No attendees
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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23. Thomas Jefferson Site Office

No attendees
24. YSO/Y-12

No attendees
25. National Energy Technology Lab (NETL)


Attendee- Matt Menas (NETL, Morgantown, WV)
A LL is in progress regarding an incident that involved a Nalgene bottle containing acetonitrile. The
bottle cracked where 1L spilled into the hood and onto the lab worker. No injuries resulted. NETL has
a lot of these type of containers throughout the lab. NETL conducted a survey of the entire lab. NETL is
working on a program to ensure compatible materials of the bottles and determine the life span of the
containers. A Lab Safety Training Program exists and NETL will ensure it has various required
components.
26. Portsmouth/Paducah Project Office(PPPO)




Attendees: Suzanne Shidal, Debora Jolly, Russell McCallister, JD White
Suzanne Shidal (PPPO)- LATA suggested metrics for self-assessing the OE program, including ISM
and LL. In 2009, OE community came up with good feedback metrics, in our assessment it was obvious
that there was more interest in the effectiveness of feedback.
Debora Jolly (PPPO contractor)- Jolly echoed Suzanne’s request for metrics. They have a new VPP
committee and are interested in hearing from other sites regarding their VPP programs and how they
share LL. The site recently formed a VPP Committee working specifically with hourly workers and she
asked other members of the OpEx Committee for information/LL on how to involve hourly workers in
developing and sharing LL.
Russell McCallister (PPPO)- McCallister noted the electric cart accident which clipped a steel column of
the building. The driver’s leg was sticking outside of the cart and took the brunt of the impact.
McCallister was on the AI board for this; the root causes were that the driver had a passenger and was
somewhat distracted and the driver’s leg was outside of the cart. The doors were removed from this
cart. Carts were investigated; all of them had some external damage. There was no incentive to report
accidents. If an accident was reported the cart would be taken away for maintenance or for good. Blind
spot issue exists for this cart as well. The blind spot problem is for almost all vehicles.
UPDATE ON OFFICE OF ANALYSIS AND CORPORATE
OPERATING EXPERIENCE INITIATIVES
-
ORPS Order and OE Order implementation- Ruocco
 EFCOG’s ORPS Task Group and HSS are currently working on interpretations. They will continue
and finalize these interpretations at EFCOG’s ISM &QA Working Group Joint Session May 1-3.
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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-
Corporate OE documents under development or recently released- Ruocco
 OE Summary 2012-01, issued 3/27/12: Preparing for Tornadoes and Their Aftermath and Accident
Investigation Results- Worker Injured in Fall from Scaffold, posted at:
http://www.hss.doe.gov/SESA/Analysis/oesummary/oesummary2012/OES_2012-01.pdf
 Draft OE-3, Radiologically Contaminated Respirators, was finalized and signed by Mr. Glenn
Podonsky, Chief of HSS, on 4/9/12. This will be posted this week to the HSS website and Ruocco
will email the OEC as well.
 Draft OE Summary Article, Improper Use of Dewar Carts Results in Serious Hand Injuries,
finalized 4/10/12, will be bundled with the next approved article to comprise OES Issue 2012-02.
 Draft OE Summary Article, Strategic Petroleum Reserve Investigation Results – Fatality at the
Bryan Mound Site, within HSS management review.
 Draft OE Summary Article, Draft OE Summary Article, Department of Energy and Pacific
Northwest National Laboratory Collaborate to Deploy More Effective Readiness Process - finalizing
edits with originator, Patti Ammonet, and then it will go to HSS management review.
 Draft OE-3, Industrial Equipment Dangers and Accidents, HS-24 currently drafting with emphasis
on skid-steers/Bobcats.
Action- Ruocco to add notification with links to recent OE Documents to the OE Wiki (this was
suggested by the OEC).
Recommendation from Angela Johnson (SR)- Is it possible to do these calls with video
conferencing or Webex?
Action- Ruocco to look into video conferences and Webex. Ruocco will set up May’s call with
the call-in number and will update the OEC if any changes will be made to the meeting.
-
Office of Analysis performance trending and analysis of ORPS- Skip Searfoss (HS-24)
 HS-24 staff meets every morning to discuss ORPS notifications and final reports. HS-24 codes
every notification and final report with HQ Keywords and codes. With the HQ keywords ORPS
data can be analyzed. Looking at the material sent out, the chart has grouping number 12- EH
categories. Looking back at March, selected a few areas with concerns. Injury events were
reviewed.
 Events involving Radiological exposure were reviewed. There were 7 occurrences, 2 of which
involved workers receiving some level of contamination. Many of these events are related to legacy
discoveries.
 Increase in S/CI or defective items, the increase in March is primarily related to SCI ratchet tie down
issues.
 Increase in Equipment Failure, most found during routine checks.
 ARRA chart looks at the total DOE complex. Starting to see a reduction in funding, ARRA work,
and therefore occurrences expected to lessen. When ARRA work started, there were higher incidents
with Hazardous Energy Control. It is suspected this is due to an influx of workers who have done
subcontractor work in other arenas, and do not have a good understanding of DOE’s hazardous
energy control requirements, specifically LOTO.
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
Page 8
-
Self-Assessment reviews on the effectiveness of the OE Program- Ruocco
 HS-24 is conducting a self-assessment of the OE Program this year and feedback from the OEC is
important in improving this Program.
 The new agenda is a part of trying to improve the program, Ruocco requested feedback on how this
call went today.
o Rod Hutto (SRS)- The new agenda resulted in more feedback, more event sharing. It was very
helpful to hear about the current OE documents issued and being developed.
o There was concern that the call took 1.5 hours today and some people only have an hour slot for
this. Ruocco suggested that the OEC see how next call goes with the new agenda and if needed,
make accommodations from there.
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 May 2012 Conference Call is scheduled for
Tuesday, May 8.
Call-In #: 301-903-7073, Confirmation #: 374180 (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.
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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