Operating Experience Committee
Conference Call Minutes
Tuesday, August 9, 2011
August 9, 2011 Call
Time: 11:00 a.m. - 12:00 p.m. EST
Call-In Number: 301-903-7082. Confirmation #: 330796 (80 lines)
AGENDA
Welcome
Jeannie Boyle
Group Sharing of Recent Lessons Learned – Be prepared to discuss YOUR
recent LL.
All
Sharing of Lessons Learned from OPEX assessments (i.e. HS-64, PSO, Site
Office, and internal assessments) - SR Assessment – Paul Daugherty,
All
DOE SR
Identification of External Events for Review
All
Discussion on a paper entitled Management Walk-Arounds: Lessons from
the Gulf of Mexico Oil well Blowout (by Professor Andrew Hopkins,
Australian National University)
Brian Anderson,
DOE ID
Fall OEC Meeting at Hanford – September 13, 2011 (ISM Champions
Workshop 2011 Website - http://www.ism2011.com/)
Jeannie Boyle
Roundtable / Subjects for Next Call
All
WELCOME / PARTICIPANTS
#
NAME
SITE
ORGANIZATION
1
Alp, Asu
Argonne Site Office
Argonne National Laboratory
2
Andersen, Bill
Canada
CANDU Owners Group Inc. (COG)
3
Barber, Sherry
ORO
Navarro Research & Engineering Inc.
4
Barrick, William
NSO
Nevada Site Office
5
Bentley, Jeffrey
SR
Savannah River Operations Office
6
Blank, Betsy
ORP
Washington River Protection Solutions (WRPS)
7
Boyle, Eugenia
DOE HQ
HS-24
8
Branson, Gary
INL
Battelle Energy Alliance, LLC
9
Brown, Sharon
DOE HQ
HS-24
Pantex
B&W Pantex
10 Butler, Michael
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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#
NAME
SITE
ORGANIZATION
11 Cheng, Sam
LASO
Los Alamos Site Office
12 Clarke, Debbie
ORP
Bechtel National Inc (BNI)
13 Cochran, Teresa J.
Oak Ridge - ORNL
UT-Battelle/ ORNL
14 Collier, Linda
LANL
Los Alamos National Security
15 Doane, Bob
Thomas Jefferson National Accelerator
(TJNAF)
Jefferson Science Associates (JSA)
16 Du Bose, Rick
DOE HQ
FE
17 Emanuelson, Kay
INL/ AMWTP
BBWI/AMWTF
18 Estes, Tracy
Princeton Site Office
PSO
19 Fong, Jackey
Atomic Energy of Canada, LTD
Chalk River Laboratories
20 Forshey, Cathy
PPPO
Wastren-EnergX Mission Support, LLC
21 Foster, Steven
RL
Washington Closure Hanford (WCH)
22 Haynes, Rick
PSO
Pantex Site Office
23 Heard, Marie
Stanford Site Office (SSO)
SSO
24 Horning, Jeff
Livermore Site Office (LSO)
Lawrence Livermore National Laboratory (LLNL)
25 Hubbard, Chelsea
Oak Ridge
ORO (for EM)
26 Hutto, Rod
SR
Savannah River Nuclear Solutions
27 Langstaff, David
RL
Richland Operations Office
28 LaPointe, Todd
DOE HQ
CNS
29 Longpre, Dan
PPPO
Wastren-EnergX Mission Support, LLC
30 Lopez-Cardona, Emma
DOE HQ
EM
31 Lowry, William
NETL
Albany, Fairbanks, Morgantown, Pittsburgh, & Tulsa
32 Menas, Matt
NETL
Albany, Fairbanks, Morgantown, Pittsburgh, & Tulsa
33 Mitcheltree, Brian
RL
CH2MHILL Plateau Remediation Company (CHPRC)
34 Napier, Amanda R
PPPO
Wastren-EnergX Mission Support, LLC
35 Neil, Dave
Idaho Operations Office
ID
36 Norbury, Michael
DOE HQ
NA-712
37 Owen, Donald
Defense Nuclear Facilities Safety Board
DNFSB
38 Patel, Jay
Rockville
Nuclear Regulatory Commission (NRC)
39 Pearson, John
Oak Ridge
ORAU
40 Pottelberg, Paul
Atomic Energy of Canada, LTD
Chalk River Laboratories
41 Price, Stephanie
SR
Wackenhut Services, Inc
42 Ramsey, Kenneth
SR - NA-26
MOX Services
43 Roberson, Waynette
PPPO
Swift & Staley (SST)
44 Robison, Camille
INL/ AMWTP
BBWI/AMWTF
45 Roddy, Michael
Watts Bar Unit 2
Tennessee Valley Authority (TVA)
46 Roggenkamp, Ken
Kansas City Site Office
KSO
47 Schutt Bradley, Joanne East Tennessee Technology Park
Bechtel-Jacobs
48 Schwehm, Kelly
SPRO
SPRPMO
49 Shidal, Suzanne
PPPO
LATA Kentucky
50 Staffo, Gary
DOE HQ
EE-3C
51 Sterling, Michael
ORO
Navarro Research & Engineering Inc.
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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#
NAME
SITE
ORGANIZATION
52 Stolte, Bruce
Nevada Site Office
NSO
53 Warwick, Keith
LSO
Livermore Site Office
54 Wright, Natasha
V. C. Summer Units 2 & 3
South Carolina Electric & Gas Co.
GROUP SHARING OF RECENT LESSONS LEARNED
1. Crane Operation
Steve Foster (WCH, RCC) – In June 2011, they submitted a Lessons Learned about a crane incident that
occurred at Hanford. During a work pause, the crane operator stayed in the cab reading the manual and did not
properly set the brake lever. The brake knob could give the appearance that it was engaged, when in fact it was
not. Because of the wind, the crane boom began to move, and the crane operator was not aware of it. Another
worker saw the problem and stopped the crane, but not before it struck the side of a building. The older model
cranes (1960’s) had this type of knob that could turn and make you think it was engaged. They installed a
locking mechanism so it wouldn’t happen again.
Question: Was this a human error?
Answer: Yes. The crane operator was not aware of the wind and did not verify the lever was in the right
position because he was focused on reading.
Question: Do the current crane models also have this design issue?
Answer: This is a common design.
Question: What is the Lesson Learned?
Answer: The lessons learned are 1) the crane operator needs to be familiar with the crane and its operation, and
2) the crane operator needs to be conscious of the site and conditions; maintain situational awareness. In this
case it was the wind.
Reference Lessons Learned: RCCC-2011-0015, BLUE - Attention to Detail is Important When Operating
Equipment, at https://ll.hss.doe.gov/FoundLesson.asp?mItem=4231&websearch=yes&keyword=1@.
2. Data Plates on Forklifts
Kay Emanuelson (AMWTP, Idaho) – Published a Lessons Learned concerning the importance of checking
the data plates for the ratings on tires before putting them on forklifts. The vendors sometimes are not aware of
this tire rating. The lesson learned is that rolling stock tires should comply with the data plate’s tires rating.
Comment: Jeff Horning (LSO, DOE) – Based on the issued lessons learned, they looked at five forklifts.
Three new ones have tire info on the data plates. The ratings don’t match on one older forklift. Now we
question the practice of replacing tires. Tires with cuts were noticed on the 6-month preventive maintenance,
but should have been seen by the daily inspection.
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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Reference Lessons Learned: 2011-ID-AMWTP-0010, GREEN - Forklift Air Pressure and Tire Ply Rating
Issue, at https://ll.hss.doe.gov/FoundLesson.asp?mItem=4217&websearch=yes&keyword=1@.
3. Interrupted Asphyxiation
Todd LaPointe (CNS, DOE HQ) – The Firebird Forum sends out a monthly newsletter and this one was about
a near miss during a nuclear power plant test. The plant performs butterfly valve purges routinely. On this day
the engineer’s test plan included a mechanic, the supervisor, and an Environmental Safety & Health
representative. To test the valves, the mechanic needed to enter a 4-foot enclosed room that was narrowed down
to 2.5 feet when the valves were open. The test plan acknowledged that the confined space would be an issue,
but it failed to mention that nitrogen gas would be used to fill the confined space. The mechanic donned the
safety gear and attempted to perform the test. Unknowingly he began to feel the effects of the nitrogen,
incorrectly thinking it was his poor health state. His supervisor noticed his symptoms and also incorrectly
attributed it to the mechanic’s known health issues. When the supervisor requested that the mechanic conclude
the test, the mechanic declined and continued on. As it turned out, the mechanic came out without injury, but
this was a situation that should not have happened. The lessons learned are that they were lucky, and they
should not have done a test using the nitrogen gas; they should have used compressed air instead. There was a
breakdown in the pre-job brief, because it did not adequately cover the work scope.
Reference article: The Firebird Forum -Interrupted Asphyxiation - Oxygen-Deficient Space Created
20110808.pdf, at http://operatingexperience.doe-hss.wikispaces.net/file/view/The+Firebird+Forum+Interrupted+Asphyxiation+-+Oxygen-Deficient+Space+Created+20110808.pdf.
SHARING OF LESSONS LEARNED FROM OPEX ASSESSMENTS (I.E. HS-64, PSO,
SITE OFFICE, AND INTERNAL ASSESSMENTS)
Savannah River Site
Paul Daugherty (SRS, DOE) – SRS has a good program. They had one deficiency on their self-assessment
and the deficiency is in dispute. The Site Track Analysis and Reporting (STARS) database is excellent and
there is information available for Lessons Learned. There is one drawback for Lessons Learned: some people
feel that reporting Lessons Learned is negative reporting; i.e., the less that is known about their issues, the better
it is. SRS has a flagship program, but perhaps it could be more procedures-driven.
Comment: There was a side discussion about the availability of the Occurrence Reporting and Processing
System (ORPS) Daily Summary e-mail, which resulted in an interest by some on the call to be added to the
daily distribution of it.
Action: If you are interested in receiving the ORPS Daily Summary e-mail and you are a DOE or a DOE
contractor employee, then please send Jeannie an email with a request to be added to the distribution.
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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IDENTIFICATION OF EXTERNAL EVENTS FOR REVIEW
Seasonal Allergies
Gary Staffo (EE-3C, DOE HQ) – Some people have an allergy to bee stings. Since this is the time of year for
bee stings, it might be useful to send out a cautionary reminder about this. People who are allergic should wear
medical bracelets or carry an EpiPen.
DISCUSSION ON A PAPER ENTITLED - MANAGEMENT WALKAROUNDS:
LESSONS FROM THE GULF OF MEXICO OIL WELL BLOWOUT
Brian Anderson (DOE ID) Four company VIPs from BP and the rig owner, Transocean, went on a management visibility tour of the
Deepwater Horizon rig. They were all experts in the field. They wanted to talk to crew members and the ship
control group. They looked at safety and congratulated the crew for its good safety record. The VIPs looked at
harnesses, hand injury incidences, and falling objects. They entered the drilling shack and the crew was having
a discussion. It was at a critical point; checking the seal on the well. The drillers seemed to be confused,
because there were several other things going on to make it hard for the crew to confirm there were no leaks.
The VIPs did not ask how they were performing the actions, instead they said that they (the VIPs) should leave
so that the crew could resume their work, and indicated that a crew manager should help them. The VIPs later
asked the manager how things went and the manager gave a “thumbs up”. In hindsight it was poor follow-up
on the VIPs part. Four months previous to this incident, there was a similar situation but without a catastrophe.
That company wrote a Lessons Learned, but it didn’t get out to the Deepwater Horizon and the VIPs were not
aware of it either. Behavior and Conditions are usually the audit focus. Conditions are easier to audit because
they are statistics. Behaviors are harder to audit because they change and they require knowledge of the correct
procedure. By chance the VIPs were there, but they did not question the crew because they did not want to
undermine the managers in charge. The article also talks about personnel vs. process safety. We should
recognize that both are important—not just personnel safety.
Comment: David Langstaff (RL, DOE) – This is similar to the urgency to finish the ARRA work. He will
write an article about the importance of oversight, because senior management wants them to back-off on
assessments (audits) so that the ARRA work will finish on time.
Reference article: Deepwater Horizon: Management Walk-Arounds - Lessons from the Gulf of Mexico Oil
Well Blowout.pdf, at http://operatingexperience.doe-hss.wikispaces.net/file/view/Deepwater+Horizon++Management+Walk-Arounds+-+Lessons+from+the+Gulf+of+Mexico+Oil+Well+Blowout.pdf.
FALL OEC MEETING AT HANFORD – SEPTEMBER 13, 2011
The Fall OEC Meeting will be held at Hanford on September 13, the day before the ISM conference. Speakers
for the meeting are being requested. Also, people planning to attend the meeting should notify Jeannie.
Logistical information for the Fall OEC Meeting is the same as that for the ISM Champions Workshop 2011.
The ISM Champions Workshop 2011 website is at http://www.ism2011.com/.
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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There will not be an OEC conference call on September 13, since that is the day of the Fall OEC Meeting.
The next OEC conference call will be on October 11th.
Action (ALL) – Those willing to present at the Fall OEC meeting, please email Jeannie your info so it can
be added to the agenda.
Action (ALL) – If there are any changes to the agenda, please contact Jeannie so she can make the
changes.
Action (ALL) – If you are planning to attend the meeting, please contact Jeannie.
ROUNDTABLE
No discussion.
THANK YOU!
Thanks so much to Sherry Barber, with assistance from Michael Sterling, for the very fast and compressive
recording of the minutes. Thanks also to Theresa Perry and DOE ORO for financially supporting the OEC in
this very important way.
The October 2011 Conference Call is scheduled for Tuesday, October 11th.
Call-In #: 301-903-7076, Confirmation #: 330798 (80 lines maximum).
Note: To save time, attendees are asked to e-mail their name, company name or government
organization, and phone number to Jeannie Boyle at the beginning of the conference call to make the
roll call and welcome process less time consuming.
Eugenia Boyle, DOE HS-24, E-Mail: Eugenia.Boyle@hq.doe.gov. Phone number: (301) 903-3393.
OE Wiki @ http://operatingexperience.doe-hss.wikispaces.net/
OE Summary Blog @ http://oesummary.wordpress.com/
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