Department of Energy Operating Experience Committee (OEC) Coordinated by the Office of Analysis (HS-24)

Conference Call Minutes Tuesday, July 9, 2013

Time: 11:00 a.m. - 12:30 p.m. ETCall-In Number: 303-248-0285 Access Code: 5863657 (Use for Call and Webinar)

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

Roundtable / Subjects for Next Call All

W ELCOME / P ARTICIPANTS

# NAME SITE1 Allen, Randi LASO

2 Bailey, Mary Jo JLAB

3 Barrick, William NVSO

4 Blank, Betsy WRPS

5 Booker, Craig ORO

6 Brown, Sharon DOE HQ

7 Butler, Mike SNL

8 Calloway, Greg SLAC

9 Clark, John NETL

10 Day, Nancy SRS

11 Farrell, Richard CBFO/WIPP

12 Fogel, Doug PORTS

13 Forshey, Cathy WEMS-PORTS

14 Gould, Wes NNSA

15 Ha, Trang LSO

16 Harness, Jerry OR

17 Harris, Allan EMCBC

18 Hauptmann, Michael BNL

19 Heeter, Tom OR

20 Hicks, Clyde KCSO

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# NAME SITE21 Horning, Jeff LLNL

22 Hutto, Rod SRS

23 Ito, Fran WIPP

24 Kirkes, Brenda WIPP

25 Langstaff, Dave RL

26 Lopez-Cardona, Emma DOE HQ

27 Lowry, William NETL

28 Lyons, Tom ITSI

29 Menas, Matt NETL

30 Minton, Lauri Pantex

31 Mitchell, Lisbeth BEA-INL

32 Moussa, Frank DOE HQ

33 Napier, Amanda WEMS-PORTS

34 Neil, David ID

35 Perkins, Larry DOE HQ

36 Polanish, Caroline BSO

37 Rao, Nimi DOE HQ

38 Robison, Camille AMWTP

39 Rogers, Jessica SNL

40 Ruocco, Ashley DOE HQ

41 Schumann, Craig ASO

42 Schutt-Bradley, Joanne OR/ETTP

43 Shidal, Suzanne LATA-KY

44 Skokan, Bryan PT&C

45 Staffo, Gary EE

46 Stirling, Larry DOE HQ

47 Stone, Roger PEC

48 Stuewe, Bob LANL

49 Thomason, Gail PEC

50 White, JD SS/Paducah

51 Whitney, Gerry RL

52 Williams, Cherylynne DOE HQ

53 Williams, Heidi DOE-CH

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WELCOME AND INTRODUCTION

Ashley Ruocco – Ruocco welcomed all to the call and introduced those at HQ in Germantown. Please continue to email your attendance to Gail Thomason gthomason@pec1.net so we credit all attendees that we might not hear. Gail will also be assisting with the minutes to the OEC calls; this support is very much appreciated.

SITE OPERATING EXPERIENCE DISCUSSIONS

1. Livermore Site Office (LSO)/ LLNL Recently submitted a Lesson Learned about the importance of like-for-like when replacing components.

Workers did not use like-for-like recently when replacing light sources in equipment. They used higher wattage bulbs than the specifications called for, resulting in heat damage to the equipment and a potential burn and fire hazard.

2. Los Alamos Site Office (LASO) / LANL The cause of the June 2011 Los Conchas wildfire in New Mexico was determined to have been a power

line downed by a fallen tree. It was the largest fire in New Mexico history and consumed more than 156,000 acres. The recent wildfire was also caused by a downed power line in tinder-dry conditions – and homeowners who lost property are suing the power company for not maintaining the power lines by cutting and removing at-risk trees. LL for sites and property owners: Be proactive and trim or remove questionable trees and branches.

3. Portsmouth/Paducah Project Office(PPPO) Recently submitted a Lesson Learned about controlling contamination on equipment (in this case a drill

rig) used during soil sampling operations. The drill rig had undergone pre-job inspections and surveys and was not contaminated; however, after the work, it underwent surveys for release to another job and contamination above release limits was found in several places. Investigation showed that contaminated dirt, mud, and debris had dropped out of the carrier and onto several places below, including under the battery box. In order to prevent recurrence, the project changed how drill tooling was handled. An expanded metal carrier was purchased that fit into a trailer receptacle at the back of the unit to prevent dirt and debris from falling onto the rig. Also, a pickup truck was used for tool staging; it was lined with plastic to avoid contamination. After the changes were implemented, outbound surveys found no contamination. (2013G-LL-LATA-0889)

4. Stanford Site Office (SSO) Reported that the shared SLAC - PNNL Lessons Learned program has gone “live” and has received

positive feedback from users. HS-24 will be interested in learning more about the partnership.

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EXTERNAL ORGANIZATIONS OPERATING EXPERIENCE AND LESSONS LEARNED DISCUSSION

ITSI Gilbane CompanyAn update regarding chain failures on powered industrial trucks (PPT file on OE Wiki) was provided by TJ Lyons. Chain failures highlight the ongoing issues all sites have when dealing with rental equipment:Has the maintenance been performed? When? Is it documented?

Lyons cautioned against the urge to maintain the work schedule by attempting to correct a problem on the spot, such as performing a quick lube on unlubricated chains. A quick fix does not address other potentially unseenproblems and doesn’t correct the basic problem: that the rental company did not maintain equipment.LANL-Stuewe concurred, saying that their walkdowns had discovered the same chain issue and as a result, it had been added to the pre-operation checklist. LANL has had similar problems with sheared bolts on rental equipment and the issue of verifying that rental equipment has been maintained.

External OE Presented by HS-24 (all files/links are available on the OE Wiki):

DOE Spotlight- July 2013

User Advisory Notice on 3M Model 6000 Full-Face Respirators o DCS 1787o ORPS Report: NA--YSO-BWXT-Y12SITE-2013-0013 (Discovery

Date 6/13/13)o The filter has three points of contact, one of which may come loose.

NSC Employee Wellness: Make Healthy Decisions

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OH&S Article: Hong Long Closely Monitoring Avian Flu Caseso Hong Kong’s Centre for Health Protection's latest update, issued July

3, said 50 suspected human cases have been received since March 31. o http://ohsonline.com/articles/2013/07/04/hong-kong-closely-

monitoring-avian-flu-cases.aspx

Arizona Wildfire Tragedy- 19 Firefighters Killedo On June 30, 19 members of the Prescott-based Granite Mountain

Hotshots positions were overrun by the wildfire, which was fanned by extreme, heavy winds, according to the Serious Accident Investigation Team of local, state and federal officials.

o The Hotshot crew was building a fireline to keep it from the mountain town of Yarnell.

o http://www.usatoday.com/story/news/2013/07/06/preliminary-report- on-yarnell-harizona wildfire 19ill-fire-deaths-19-firefighters-were-trapped-by-flames/2495613/

UPDATE ON OFFICE OF ANALYSIS AND CORPORATE OPERATING EXPERIENCE INITIATIVES

- ORPS Order and OE Order implementation- Ruocco DOE O 232.2, Occurrence Reporting and Processing of Operations Information. Responses to

Frequently Asked Questions is currently within HS-20 management review. One-Year Accuracy Review of DOE Order 232.2, Occurrence Reporting and Processing of

Operations Information. . In April, HS-24 updated the ORPS Task Group and requested feedback on specific Reporting Criteria. Suggestions are in review with HS-24 management.

DOE O 210.2A, DOE Corporate Operating Experience Program. No issues/questions on DOE O 210.2A were presented.

- Corporate OE documents under development or recently released- Ruocco Newly released:

o OES Article: Fall Fatality While Installing Work Platform at Remote Bonneville Power Administration Project (located on OES Blog; will be bundled with the next OES article that is finalized)

Under Development: o Draft OE-3: Dangers of Respirable Silica- adding the recent ORPS Report: SC--TJSO-JSA-

TJNAF-2013-0003, FML-13-0702-NEW Silica over 2005 ACGIH TLV exposure limits in Test Lab, to the current draft

o Draft OES Article: Accident Investigation into Serious Injuries from Fall Off Fixed Laddero Draft OES Article: Accident Investigation: Contamination at Los Alamos Neutron Science

Center due to Deficiencies in Conduct of OperationsPage 5

o OEC Member provided a possible OE Summary article topic on Lock Out / Tag Out (LOTO) events during June 2013 OEC Call. HS-24 is researching LOTO events and preparing an analysis report for HS-24 management. From January 1 to July 8, 2013, 50 ORPS reports have been issued on LOTO violations. The rate of LOTO ORPS reports is on the rise as compared to previous years (2010: 73, 2011: 66, 2012: 89)

- OE Wiki - Ruocco OE Wiki Use (Data from January 2010- May 2013)

o The wiki has had visitors from all 50 states and Washington, DC.

o 93% of the visitors to the wiki come from the United States. The remaining 7% comes from 136 additional countries across six continents.

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The next OE Committee Call is scheduled for Tuesday, August 13, 2013.

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 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.

Recent OE Wiki Video

o University of California, San Diego, Stay Protectedo To access the Video: http://operatingexperience.doe-hss.wikispaces.net/

Please send any OE relevant videos that you would like to see on the OE Wiki to Ruocco.

- Self-Assessment reviews on the effectiveness of the OE Program- Ruocco A memo is drafted and within review that requests line programs and the field formally verify OE

Program Coordinators and members, as well as reminds all of the requirements and responsibilities listed in DOE O 210.2A.

Please continue providing feedback on OE Program improvements.

- Lessons Learned Program and Database- Ruocco HQ Lessons Learned Database improvements/upgrades will be reviewed with HS-24 management

the week of July 8, 2013. Next steps will be discussed.

ROUNDTABLE

Action- Guest Speaker Volunteers requested. If you would like to present to the OEC, please call Ruocco to volunteer. Thank you in advance!

After ending the meeting, a few members had individual questions or items that they discussed with Ruocco. This was a great way to speak with members one-on-one and answer any questions. On future calls, please feel free to stay on the line after the end of the call if you have any items that you would like to discuss with Ruocco.

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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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