Coordinated by the Office of Analysis (HS-24)
Time: 11:00 a.m. - 12:30 p.m. EST
Call-In Number: 301-903-7073. Confirmation #: 374180 (70 lines)
GENDA
Welcome and Introduction Ashley Ruocco
Site Operating Experience Discussions All
Update on Office of Analysis and Corporate Operating Experience
Initiatives
Report on Office of Analysis performance trending and analysis of
ORPS occurrences and other information for the previous month
Roundtable / Subjects for Next Call
ELCOME
ARTICIPANTS
#
10
11
12
13
7
8
9
1
2
3
4
5
6
NAME
Alp, Asu
Anderson, Brian
Blackmon, Josie
Blackstock, Chris
Bollock, Douglas
Branson, Gary
Brown, Sharon
Butler, Michael
Cochran, Teresa
Cole, Matt
Du Bose, Rick
Estes, Tracy
Forshey, Cathy
SITE
ASO
Idaho Ops Office
PPPO
Chalk River
NRC
INL
DOE HQ
Pantex
ORNL
DOE HQ
DOE HQ
PSO
PPPO
Ashley Ruocco
Skip Searfoss;
Other HS-24 staff
All
ORGANIZATION
ANL
DOE ID
UDS - Portsmouth
AECL
Office of New Reactors
Battelle Energy Alliance, LLC
HS-24
B&W Pantex
UT-Battelle/ ORNL
SC
FE
PSO
Wastren-EnergX Mission Support, LLC
Page 1

# NAME
14
15
Garnett-Harris,
Deborah
Gile, Andrea
Goetsch, Bob 16
17
18
Hartney, Melissa
Haynes, Rick
19
20
Heller, Sara
Horning, Jeff
Hutto, Rod 21
22
23
Innocent, Jessy
Ito, Fran
24
25
Johnson, Angela
Jolly, Debora
26
27
Kohler, Tom
Langstaff, David
Larson, Jay 28
29 Lee, Paul
30 Lopez-Cardona, Emma
31 Lowry, William
32 McCallister, Russell
33 Menas, Matt
34
35
Miehls, Dennis
Minton, Lauri
Navarrete, Martin 36
37
38
Neil, Dave
Neilson, Steve
39
40
Pearson, John
Ramsey, Kenneth
41
42
Rao, Nimi
Ruocco, Ashley
Schumann, Craig 43
44 Schutt-Bradley, Joanne
45 Searfoss, Glenn
46 Shidal, Suzanne
47 Sivak, Andy
48 Staffo, Gary
49 Stone, Roger
50 Stuewe, Robert
51 Tamplain, Jeffrey
52 Thomason, Gail
53 Ward, Jonathan
54 White, J.D.
SITE
DOE HQ
NTS
SNL
TJNAF
PSO
NTS
LSO
SR
DOE NNSA
CBFO/ WIPP
SRS
PPPO
SR
RL
DOE HQ
Atomic Energy of Canada, LTD
DOE HQ
NETL
PPPO - Lexington
NETL
CBFO
Pantex
WIPP
Idaho Ops Office
TJSO
ORAU
SR - NA-26
DOE HQ
DOE HQ
ASO
OR/ETTP
DOE HQ
PPPO
NETL
DOE HQ
PEC
LANL
SPRO
PEC
Atomic Energy of Canada, LTD
PPPO
Page 2
ORGANIZATION
HS-24
NSTec
SNL
Jefferson Science Associates (JSA)
PSO
NSTec
LLNL
Savannah River Nuclear Solutions
KCSO
TRU Solutions
Perf Assurance
Swift & Staley (SST)
Savannah River Operations Office
Richland Operations Office
SC
Chalk River Laboratories
EM
NETL- Albany, Fairbanks, Morgantown, Pittsburgh, & Tulsa
PPPO
NETL- Albany, Fairbanks, Morgantown, Pittsburgh, & Tulsa
CBFO
B&W Pantex
CBFO
ID
TJSO
ORAU/ORISE
MOX Services
HS-24
HS-24
ASO
UCOR (URS/CH2M)
HS-24
LATA Kentucky
NETL- Pittsburgh
EE-3C
PEC (Support contractor to HS-20)
Los Alamos National Security
DM Petroleum Operations Co
PEC (Support contractor to HS-20)
Chalk River Laboratories
Swift & Staley (SST)

# NAME SITE ORGANIZATION
55
56
57
Whitley, Daniel
Whitney, Gerry
Williams, Tom
Yates, Dennis
PPPO
RL
DOE HQ
UDS - Portsmouth
OE Pgm Coord, Mission Support Alliance
NA-1
58 SR Savannah River Operations Office
W
I
Ashley Ruocco
– Ruocco (HS-24) welcomed all to the OEC call. Ruocco noted that the new agenda will be followed again at this call. This agenda promotes more communication among sites (this is listed as Site
Operating Experience Discussions in the agenda). Please continue to email your attendance to Gail Thomason- gthomason@pec1.net
. Gail Thomason will also be taking the minutes for the OEC calls; this support is very much appreciated.
S
O
E
D

Attendee- Rick DuBose (FE)

Rick DuBose- Shared a Lessons Learned from an event where a worker fell 5’ off a scaffold feet first.
Lesson Learned- Ensure that planking is not only in place but secured. Although the worker did not require hospitalization, he could have been seriously injured.

FE has kicked off its Heroes for Zeroes initiative to abate lost-time incidents; lost-time events in 1Q2012 were down significantly when compared with 1Q2011.

Attendees- Brian Anderson (ID), Gary Branson (INL)

Brian Anderson- Shared a Lessons Learned about the unforeseen dangers presented by manholes or other openings with homemade covers that lack flanges to keep them centered and in place. A worker stepped on such a cover that flipped, barely catching himself after one leg went in. Although he did not break any bones, he suffered significant and painful contusions. (Near miss in ORPS NE-ID--BEA-
RTC-2012-0002) A brief summary document with photos will be posted to the OE Wiki.

Attendees- Matt Menas (NETL, Morgantown, WV), Andy Sicak (NETL)

Matt Menas and Andy Sivak- Shared a Lessons Learned from a recent event where asbestos was found in legacy equipment being dismantled for disposal. Workers wore appropriate PPE for the planned job, including half-face respirators with HEPA. Based on interviews and historical process knowledge, planning did not anticipate encountering ACM, and pre-work NDA confirmed that there was no asbestos. After about 25% of the dismantling work was complete, however, workers encountered unfamiliar material and stopped work. Sampling revealed 10% amosite (asbestos). Personnel
Page 3

responded appropriately to minimize exposure and spread of the material. A licensed asbestos abatement contractor was hired. Lesson Learned: Remain diligent in order to respond appropriately to changed conditions that could introduce new hazards.

Attendee- Sara Heller (NTS)

Sara Heller- Awaiting the final report from the Line Oversight Contractor Assurance System (LOCAS) assessment and will send the report so it can be posted on Wiki.

Current Lessons Learned from a recent excavation/surface penetration event when workers found unmarked utilities and stopped work.

Attendees- Joanne Schutt-Bradley, Teresa Cochran (ORNL)

Teresa Cochran- ORNL is implementing a new, two-phased Lessons Learned tool, Fast Read. Phase 1 enables employees to share Lessons Learned in real time; Phase 2 will incorporate Lessons Learned into the site-wide procedure system, so that if someone calls up a procedure on drilling, for example, a list of the recent Lessons Learned on that topic will also be displayed.

Attendees- Matt Cole (SC)

Matt Cole- Shared a Lessons Learned concerning arc flash hazards with large banks of batteries; NFPA guidance on arc flash is inadequate for banks of batteries.

Be aware of fraudulent circuits from Vision Tech, Clearwater, FL. Sharon Brown (HS-24) will send
Safety Advisory 2010-07, Counterfeit Integrated Circuits Indictment (Revised) to committee members.

Attendee- Tracy Estes (PSO)

Tracy Estes- Following up on the skid-steer accident; investigation resulted in 24 JONs; CAP includes
2 actions related to Human Factors. PSO is bringing a peer review team from industry to look at Lab safety program. On 5/16/12 will hold a Safety Stand-down to look at the safety culture.

Note: HS-24 has drafted an OE-3 document about heavy equipment events, specifically skid-steer dangers; now in HSS review.

Attendees- JD White, Josie Blackmon, Dan Whitley, Cathy Forshey (PPPO)

Forshey- A new Lessons Learned about purchasing critical items has been submitted to the HSS Lessons
Learned database but is not yet published.

Attendees- David Langstaff, Gerry Whitney (RL)

Gerry Whitney- Ready to submit a Lessons Learned about asbestos in legacy electrical equipment based on recent experience during D&D at the K-West reactor when pump assemblies were found to have asbestos in the wiring insulation. Workers did all of the correct actions: stopped when they encountered
Page 4

a white material, had it tested. Lesson Learned: Evaluate as many hidden hazards as possible before starting work.

FYI: Near miss when a TIMOR series 600 door closure failed at a mobile office, ejecting the spring and cap with enough force that it flew across the room about 20’ and hit a SmartBoard and could have injured a worker.

Attendee- Bob Goetsch (SNL)

Bob Goetsch- SNL continues emphasis on slips/trips/falls, the seemingly minor injuries that account for lost time. A recent Lessons Learned was written about a LO/TO event where the contractor performed a zero energy check but failed to LO/TO the equipment.

Attendees- Dennis Yates, Tom Kohler, Angela Johnson, Ken Ramsey, Rud Hutto (SR)

Dennis Yates- Lessons Learned: During a recent evolution at the bioassay laboratory, workers were attempting to fill a container from a large Dewar when the ball valve froze and could not be closed.
Workers evacuated the room and let the nitrogen escape until it was expended. Subsequent inspection revealed that the valve was not properly rated. It is not yet determined if the valve was on the Dewar when it arrived at the site or if it was installed later. An extent-of-condition review discovered additional Dewars with the same valve.

Skip Searfoss (HS-24)- Suggested that the Lessons Learned that SRS provided would be useful in developing a DCS on Dewar valves.

Attendees- Steve Neilson, Mellissa Hartney

Neilson- The Lab is holding All Hands meetings to emphasize safety in preparation for a 16-month maintenance activity (switching accelerators). Emphasis is on sharing Lessons Learned from previous maintenance activities, including guidance for performing radiological surveys. The Lessons Learned are available to all Lab employees (inside the Lab firewall).

Ken Ramsey (SR) asked for the status of the Data Collection Sheet (DCS) on ratchet tie downs. Sharon
Brown (HS-24) responded that the DCS is being finalized and will be posted on the HSS S/CI database.

Matt Cole (Office of SC) pointed out that the tie downs may not be S/CI and HSS should not rush to publish until they know for sure.

Melissa Hartney (TJNAF) requested suggestions to improve training videos. Bob Stuewe (LANL) has found that workers prefer a YouTube format: 2-3 minutes long, quick download, no reconfiguring necessary, just click-and-play.

Bob Stuewe (LANL) mentioned that LANL is writing a Security Plan as part of its effort to explore
Internet/Web-based meetings. So far, security requirements, although necessary, are a roadblock. For example, microphones on all desk phones are disabled for security.
Page 5

E
O
O
E
L
L
D
No discussion.
U
O
A
C
O
E
I
ORPS Order and OE Order implementation- Ruocco
 EFCOG’s Occurrence Reporting and Processing System (ORPS) Task Group and HSS met at
EFCOG’s ISM &QA Working Group Joint Session May 1-3 to discuss DOE O 232.2 interpretation issues. This was a productive meeting where all worked together to draft interpretations. The interpretations will go through HSS review to be finalized and then posted online. These interpretations will promote consistency in ORPS reporting across the complex. It should be noted that Extent of Condition Review is a required field in the ORPS.

The EM QA Board Meeting also took place at EFCOG’s ISM &QA Working Group Joint Session on May 1 st
. HS-24 briefed the EM QA Board on the Lessons Learned Program and Database.

The Lessons Learned Database will be undergoing improvements by HSS in the near future. The near term improvements include making the search engine easier to use and adding drop-down choices; future improvements include adding a series of How To s such as: How to Search , How to
Write and Submit a LL , etc.
Corporate OE documents under development or recently released- Ruocco
 An action from April’s call was to add notification with links on the OE Wiki regarding recent OE
Documents. Ruocco added ‘Recent Operating Experience Documents’ to the home page of the OE wiki. This includes links to recent OE documents and links to all OE Level1-3 Documents and OE
Summaries.

OE-3 , Radiologically Contaminated Respirators, was finalized and signed by Mr. Glenn Podonsky,
Chief of HSS, on 4/9/12. This is posted on the HSS website, OE Wiki, and Ruocco emailed the
OEC.

OE Summary 2012-02 , will be issued this week and contains two articles: Improper Use of Dewar
Carts Results in Serious Hand Injuries and Strategic Petroleum Reserve Investigation Results –
Fatality at the Bryan Mound Site. This will be posted on the HSS website and OE Wiki home page.
The two articles are already posted on the OES Blog: http://oesummary.wordpress.com/.

Draft OE Summary Article , Department of Energy and Pacific Northwest National Laboratory
Collaborate to Deploy More Effective Readiness Process is in HSS management review .

Draft OE Summary Article , Operational Emergency: Las Conchas Fire Threatens Los Alamos
National Laboratory Property and Facilities is at HS-24 for review.

Draft OE-3 , Industrial Equipment Dangers and Accidents , HS-24 is currently drafting with emphasis on skid-steers/Bobcats.
Page 6


Draft OE-3 , Dangers of Respirable Silica , HS-24 is currently drafting related to recurring worker exposure to dust containing crystalline silica at DOE sites.
Office of Analysis performance trending and analysis of ORPS Skip Searfoss (HS-24)

Skip Searfoss (HS-24) provided an update on events that were reported to ORPS and discussed at the morning analysis meetings during April.

Total Occurrence Reports: o 101 Notification (down from 117 in March) o 57 Final (down from 75 in March)

Top three categories by HQ Keyword (Category 12 codes): o Near Miss/12K- Accounted for 14% of total reports. o Authorization Basis/12A- 12% of total (a third of these were actual violations; the` rest were
PISAs and USQs) o Electrical Safety/12C- The majority of these involved electrical but were not electrical work; the events resulted from found conditions during excavation, D&D, etc.

The analysis team is looking into material handling, particularly forklift operations and dropped loads. OE Summary articles on these topics last appeared in 2003, so it’s time to take another look.
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.

HS-24 will create an online survey as a part of this self-assessment and will request that the OEC complete the survey, which will take 10-15 minutes. HS-24 expects to send the survey in June.

The new agenda is a part of trying to improve the program, Ruocco requested feedback on how this call went today and any general ideas on improvements to the OE Program.
Follow-up from April: Video Conferencing and Webex

Ashley Ruocco took the action last month to research video conferences and Webex options for the
OEC calls. The current conferencing support through DOE has had issues due to the high number of lines. The calls have a constant static and sometimes the call goes out completely. If the call goes out, Ruocco will immediately get another number and email the entire OEC the new number.
Ruocco will look into different routes to get a clear and reliable conference call line.
Video conference

All participants must have video conferencing capability, which is a challenge or an inconvenience depending on participants’ locations.

Within DOE HQ capabilities, all need video conferencing to participate in the meeting, which may prevent some members from participating in monthly calls if they are unable to video conference.
Page 7

Webex

Shared computer screen would only be used if we had a PowerPoint presentation in order to watch together. Issue: Without additional support for minutes and documentation, Ruocco would be unable to take minutes and conduct a Webex without rough notes being distractingly visible to all.
Although additional support has been obtained for documenting the meetings, it is still unclear whether Webex is the best option for the majority of callers.

Other options, such as changing the teleconference provider, are being investigated. In all our efforts, security considerations take precedence; in addition, the ability to upgrade inside an ageing facility is an issue that arises here at HQ-Germantown, just as it does at your sites. If anyone has ideas for making these calls easier, we would like to hear them!
R
Action- Guest Speaker Volunteers requested. If you would like to present to the OEC, please call Ashley to volunteer. Thank you in advance!
T
Y
!
Thanks so much to Gail Thomason for support in recording the minutes and maintaining the roll call via e-mail.
The June 2012 Conference Call is scheduled for
Tuesday, June 12 at 11AM EST.
Call-In #: 301-903-7076, Confirmation #: 378525 (70 lines maximum).
***The Call-In Number for June may change if a better conferencing system is found.
Ruocco will notify the OEC if this happens.***
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/
Page 8