Department of Energy
Operating Experience Committee (OEC)
Coordinated by the Office of Analysis (AU-23)
Webinar Minutes
Tuesday, February 9, 2016
Time: 11:00 a.m. - 12:30 p.m. ET
Call-In Number: 303-248-0285 Access Code: 5863657
AGENDA
Welcome and Introduction
Ashley Ruocco
Highlighted Presentation: NSTEC Flood Damage
Richard Schmidt, NSTEC
Site Operating Experience Discussions
All
External Operating Experience Discussions
All
•
External Operating Experience Presentation: California
OSHA – Skylight Fall and Fatality and Los Alamos Arc Flash
T. J. Lyons
Update on Office of Analysis and Corporate Operating Experience
Initiatives
Ashley Ruocco
Roundtable / Subjects for Next Call
All
WELCOME / PARTICIPANTS
#
NAME
SITE
1
Adams, Shauna
SRS-MOX
2
Allen, Randi
LAFO
3
Alp, Asu
ANL
4
Blackstock, Chris
Chalk River Laboratories
5
Booker, Craig
ORO
6
Brown, Rosalie
SC-HQ
7
Chalk, Steve
RL
8
Clark, John
NETL
9
Clay, Marc
SLAC
10
Collier, Linda
LANL
11
Estes, Tracy
PSO
12
Forness, Ed
NFO
13
Gooding, William
MA-433
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NAME
SITE
14
Goplin, Bruce
Ames Laboratory
15
Ha, Trang
LFO
16
Harvey, Beth
ANL
17
Heeter, Tom
ORNL
18
Houston, C.J.
NNSS
19
Hicks, Clyde
KCP/Honeywell
20
Hiteshew, Kathleen
PEC
21
Horning, Jeff
LLNL
22
Joy, Donna
PEC
23
Lyons, T.J.
Gilbane
24
Martinez, Ramon
INPO
25
Owen, Donald
DNFSB
26
Pavalko, Kelly
NNSS
27
Polanish, Caroline
BHSO
28
Prestridge, Jason
NNSS
29
Price, Stephanie
SR
30
Puglin, Nicole
BNL
31
Risley, David
PEC
32
Rogers, Jessica
SNL
33
Schmidt, Richard
NNSS
34
Schumann, Craig
ASO
35
Schutt, Joanne
ETTP
36
Schwehm, Kelly
SPRO
37
Shah, Riz
AU-20
38
Simmons, Jerry
ICP
39
Smith, Duane
OR
40
Spencer, Donna
BSO
41
Staffo, Gary
AU-23
42
Stracka, Mike
AU-23
43
Swafford-Bennett, Carrie
PNSO
44
Wadsworth, Lynn
INL
45
Watkins, Mike
ORNL
46
Weibel, Marc
SLAC
47
Whitley, Dan
PPPO
48
Winters, Jacki
ORP
#
WELCOME AND INTRODUCTION
Ashley Ruocco – Ruocco welcomed all to the call and webinar. Please continue to email your attendance to
Donna Joy, djoy@projectenhancement.com, so we credit all attendees that we might not hear. Donna will also
be assisting with the minutes to the OEC calls; this support is very much appreciated.
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HIGHLIGHTED PRESENTATION
Highlighted Presentation: NSTEC Flood Damage
Richard Schmidt has a B.S. in Business Administration from Pepperdine University and 43 years of experience
supporting nuclear and non-nuclear maintenance, operations, and engineering services at Nevada National
Security Site (NNSS), Rocky Flats Environmental Technology Site, and in the private sector.
Mr. Schmidt spoke about the planning for all events, including climate related events. Lessons learned from a
severe rainstorm (referred to as a 1,000 year storm) which resulted in catastrophic flooding to the NNSS.
Although flash flooding is not uncommon to the area, the overall duration and extent of this storm was much
more widespread than typical “single-cell” events, and covered a broad swath of the NNSS. The NNSS is
located in the high desert. Evaporation rates are high, and except for a number of small springs, there is no
permanent natural surface water on the NNSS. Runoff is conveyed via normally dry drainage ways or dry
washes to interior basins, exiting the NNSS only in a few places of the site. Lessons learned included:
 Dangerous and unsafe conditions must be addressed first to eliminate further issues from developing

Understanding the need to mitigate hazardous conditions to avoid injuries, prioritization of roads
needing attention first and what was needed for mitigation.

Reducing speed limits in areas where shoulders were washed away.

Start rebuilding the shoulders on our main access road for the site, Mercury Highway.

When available to break Teamsters and Equipment Operators off Mercury Highway, and expanded the
effort to other roadways.

Many areas that require clearing debris or dumping a few yards of dirt, compacting, and providing
appropriate shoulder repair can be completed on an “as available” basis.

National Security Technologies (NSTec) had previously developed a Task Order Subcontract which
helps us shorten the time to get new subcontracts turned on by having four contractors prequalified for
construction activities.

Many of the roads were made in the early days of the site, NNSS will be looking into adding culverts
and drainage, but will not be rebuilding infrastructure to the 1,000 year storm level.

Best way to disseminate information about hazards/road conditions.

Need to keep information up to date, Geocast telephone system had wrong phone numbers and people
lost passwords to access the system.
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SITE OPERATING EXPERIENCE DISCUSSIONS
1.


Los Alamos National Laboratory (LANL)
LANL discussed the recall of Vornado Space Heaters- Type 110 manufactured in 2013. On January 7, a
Vornado space heater failed and completely melted. Only this model has been recalled due to a faulty
thermostat that can stick and cause a meltdown.
ORP asked why the heaters were still on site when they were previously recalled in 2014. Even though
LANL did walkdowns after the incident, it’s possible they were brought to the site after the walkdowns.
2. National Energy Technology Lab (NETL)

3.


After receiving the heater recall, NETL did a site search and found none of these specific heaters.
NETL has a policy in place that no personally owned heaters are allowed onsite.
Nevada Field Office / NSTec / Nevada National Security Site (NNSS)
NSTec reported on three trips and falls reported in ORPS:
 An employee tripped over some tools that had fallen into doorway and broke their collar bone
 An employee tripped over a doorstop hit their head requiring stitches
 An employee tripped over a skid hit their head requiring stitches
Also noted was the OPEXShare recall notice on AC power cords with the Surface Pro Tablets catching
fire resulted in NSTec locating some power cords, and notifying users to replace those power cords:
https://opexshare.doe.gov/lesson.cfm/2016/2/3/5690/Microsoft-Recalls-power-cords-for-Surface-Pro-tablets
(public website on this issue is under OR’s update below)
4. Oak Ridge Site Office (ORO) / Oak Ridge National Lab (ORNL)

5.

OR reported a recall involving AC power cords sold with Surface Pro tablets. There have been reports
of the AC cords overheating and emitting flames and five reports of electrical shock to consumers. The
recall involves power cords sold with some models of the Microsoft Surface Pro convertible tablet
devices before March 15, 2015. Access the recall notice at
http://www.cpsc.gov/en/recalls/2016/microsoft-recalls-ac-power-cords-for-surface-pro-devices/
Stanford Site Office
SLAC National Accelerator Laboratory spoke about an Uninterruptable Power Source (UPS) failure that
occurred in the computing center. The alarms were not configured to page out or notify anyone,
therefore, the servers’ shutdown when the temperature reached 123 degrees F. The failure was not due
to a power outage, but a problem with the UPS itself, which cut power to everything. SLAC also
mentioned that data on the servers were backed-up, but one application for E-logging on a single server
was not backed-up, which caused logging to be done manually until the system could be brought back
up and the application could be re-started. Make sure that all critical applications as well as data are
backed-up.
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EXTERNAL ORGANIZATIONS OPERATING EXPERIENCE AND LESSONS LEARNED
DISCUSSION
•
California OSHA - Skylight Fall Fatality and Los Alamos Arc Flash
Presented by TJ Lyons, Gilbane Company.
Skylight fatality: - On July 22, 2009, a 56-year-old warehouse worker fatally fell through a skylight
approximately 30 feet to the concrete floor. The victim had been allowed to climb onto the roof to
service an air conditioning unit. This was not part of his usual duties. The victim’s employer did not
have procedures for working on the roof. It is recommended that skylights be replaced with skylights
that you cannot fall through. Only three percent of skylights will bear the weight of a person. Also the
use guards on skylights can be used to prevent accidents. Keep in mind that direct sunlight can
deteriorate materials in skylights.
Arc flash incident – On May 3, 2015, an arc event occurred, causing a Laboratory electrician a serious
burn injury, and eight other employees had respiratory distress while performing preventive
maintenance on an electrical substation at the Los Alamos National Laboratory (ORPS Report NA-LASO-LANL-PHYSTECH-2015-0003). A joint Accident Investigation Team (JAIT) was formed to
investigate the event. The JAIT report is available, but the electrician has not been interviewed. The
overall root cause was less-than-adequate management of control implementation, which the Team
considered a combination of two specific root causes:
 Failure to require and implement zero-voltage checks; and
 Lack of established physical barriers.
Lamps or other visual indicator in cabinets to warn users that voltage is present are other safety features
that can be considered.
It was also brought up that energized items such as solar panels, and experimental vehicles including
hydrogen vehicles need to be carefully considered by maintenance and or first responders when
encountered.
UPDATE ON OFFICE OF ANALYSIS AND CORPORATE
OPERATING EXPERIENCE INITIATIVES

Review of DOE O 210.2A
o Waiting for determination of DOE-STD-7501
o DOE O 232.2 Justification Memo to be completed this month requesting a revision,
anticipate formal revision in the April/May timeframe

Review of DOE-STD-7501
o DOE-STD-7501, The DOE Corporate Lessons Learned Program, is up for review
o First meeting last week on DOE-STD-7501
o Team agreed 7501 could be archived
o Team must first determine what information should be kept and where
 Handbook or
 Appendix to 210
Page 5

-
Review of DOE-STD-1197
o DOE-STD-7501, The DOE Corporate Lessons Learned Program, is up for review
o AU-23 is forming a small team of to assist with the review process
o Update or cancellation (and/or incorporation with 210.2A) will be determined
o Email your interest to be a part of the team to Mike Stracka at
michael.stracka@hq.doe.gov
Corporate OE documents under development or recently released
 Newly released:
o OES published in January
 Arc Flash Accident at LANL TA-53
o OE-3 published in December
 Winter Preparedness – Slips on Ice

Draft OE-3s
o Ergonomically Correct Equipment Can Decrease the Risk for Work Station Injuries
o Danger! Equipment Hits Overhead Lines (being published this week)

ORPS Update
o ORPS Training Modules coming soon- mid-February
o DOE O 232.2 Justification Memo to be completed this month requesting a revision

OE Wiki Update
o CSB: Dangerously Close: Explosion in West, Texas
 April 17, 2013 fire and explosion at the West Fertilizer Company in West, Texas
 15 fatalities, 260 injuries, and widespread community damage.

OE Wiki Links
o February is American Heart Month - CDC
o How to Prevent a Power Strip Fire – AU-11
o FSU – October 2015 Worker Fatality during Attempted Removal of Blind Flange on
Magnetic Cooling Water System (info sent from LANL) – LOTO issue
o ASSE Article December 2015: Don’t Forget About Overhead Doors
o Winter Safety Resources – CDC
o Security Awareness Newsletter January 2016- Securing Your New Tablet
Webinar Schedule:
– Tuesday, April 12
– Highlighted Presentation: Documented Safety Analysis Legacy Reviews, Mark
Mitchell, LLNL
– Tuesday, June 14
– In person OEC workshop planned for fall 2016 (most likely will meet at the EFCOG ISM&QA
meeting)
Please send any OE relevant videos that you would like to see on the OE Wiki to Ruocco.
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ROUNDTABLE
Action- Guest Speaker Volunteers requested. If you would like to present to the OEC, please call Ruocco to
volunteer. Thank you in advance!
The next OE Committee Webinar is scheduled for
Tuesday, April 12, 2016.
Call-In #: 303-248-0285 Access Code: 5863657
Roll Call via Email: Attendees are asked to e-mail their name, company name or government organization,
and phone number to Donna Joy, djoy@projectenhancement.com, at the beginning of the conference call.
Ashley Ruocco, DOE AU-23, E-Mail: Ashley.Ruocco@hq.doe.gov. Phone number: (301) 903-7010.
Operating Experience Websites:
OE Wiki - http://operatingexperience.doe-hss.wikispaces.net/
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