Waste Treatment Plant Project

WTP Material Handling

Notice of Violation

Dawn Kammenzind

PAAA/Regulatory Interface Manager

May 15, 2014

2

The Cleanup Challenge

56 million gallons

radioactive waste

149 single-shell tanks built between 1943-1964

28 double-shell tanks built between 1968-1986

(67 presumed to have leaked)

3

2001: Vit Plant Construction Began

4

Vit Plant Now

5

Issue #1 Pretreatment Millwright Event

(EM-RP--BNRP-RPPWTP-2010-0005)

Background

Millwright repositioning steel rail weighing 569 lbs. using a sleever bar, rail became unstable and fell making contact with his left foot.

Employee failed to perform work safely within the controls.

It was documented on the STARRT card that if lifting over 50 lbs. get assistance.

It was also documented on the STARRT card that if lifting over 300 lbs. use a hoist.

Because this event was considered compliant with 10 CFR 851, it was not reported into NTS.

Result

Millwright sustained injury to left foot resulting in surgical amputation of two toes.

Issue #1 Pretreatment Millwright Event

Immediate Actions

Directed standdown of work activity

Briefed entire site on the event

Focused Senior Supervisory Watch on material handling/staging

Focused Safety Education Through Observation (SETO) on material handling

Corrective Actions

Revised Assisted Job Hazard Analysis (AJHA) and pre-job briefing to increase emphasis on material handling/staging

Held senior management review session with supervision, field engineers, and work crew

Issued a Lessons Learned 6

7

Issue #2 Material Handling & Rigging Incident

(NTS-ORP--BNRP-RRPWTP-2011-0002)

Background

Two double duty lift brackets (maximum vertical lifting of 2000 lbs. each) used to lift 16x22 ft. formwork panel weighing 5600 lbs.

Result

Brackets cracked under stress of load.

Reported into NTS

Issue #2 Material Handling & Rigging Event

Immediate Actions

Directed standdown of all work at the Construction Site

Corrective Actions

Conducted a rigging review

Identified and trained appropriate personnel to act as formwork rigging Person in Charge (PIC)

Enhanced inspection rigor on lift brackets

Isolated Symons lifting brackets

Briefed entire site (MHF and Construction Site) on event

8

9

Issue #3 Near Miss During Steel Beam Loading

(EM-RP--BNRP-RPPWTP-2011-0007)

Background

Ironworker attempted to stop momentum of a crane-lifted I-beam with his body.

Material Handling Facility was not considered a 10 CFR 851 covered work place at this time. Event not reported into NTS.

Result

Ironworker carried by beam from loading trailer to adjacent rigging trailer, moving him onto stored dunnage.

Issue #3 Near Miss During Steel Beam Loading

10

Immediate Actions

Directed standdown of all work at MHF

Corrective Actions

Modified AJHA to reinforce requirement to use tag lines and recognize changing environmental conditions

Installed weather monitoring equipment at MHF

Briefed entire site (MHF and Construction Site) on event

Material Handling Noncompliances

11

• Lack of procedure

compliance

• Did not identify

potential hazards

• Did not select

hazard controls

• Failed to properly

train personnel

12

Timeline of Events

Jan 2011 Jan 2012

Jul 2010 Aug 2012

PNOV

May 2012

Final Order

Jul 2012

Steel Beam Loading Event

(MHF)

Apr 2011

Independent RCA

Dec 2011

Additional Info Sent to OE

Mar 2012

Millwright Injury

Jul 2010

WTP Millwright RCA Rev. 2

Nov 2010

Notice of Investigation

Jun 2011

Request for Consent Order

Oct 2011

Paid Civil Penalty

Jun 2012OE Investigation

Aug 2011

Formwork Rigging Event

(Reported into NTS 5/2/11)

Mar 2011

OE Investigation

Report

Jan 2012

13

Preparation for Office of Enforcement’s Investigation

What WTP did:

Established segregation of costs

Developed an internal schedule and check-off sheet to keep track of items complete

Sent out internal schedule daily to responsible senior management

Sent out daily reminders of what items were coming due

Established team to gather documents requested by the Office of Enforcement

Established a team, including subject matter experts to prepare the opening presentation to be given by senior Management.

Conducted dry runs with WTP team and WTP senior management

Senior management made presentation to interviewees

Engaged Office of River Protection Enforcement Coordinator

14

Office of Enforcement’s Investigation

Prepared the Participants

– Initial Meeting

–Discussed what the investigation was about and why interviewees were selected

– Discussed the Construction Site Tour

– Provided participants with the related materials they would need to review before the interview

– Final Preparation Meeting

–Done by interview group

–Discussed

– Who should take the lead

– How the Office of Enforcement may conduct the meeting (i.e. rapid fire questioning)

– Do’s and Don'ts in the Interview Process

15

Enforcement Conference

Presentation Preparation

– Engaged project-level senior management

– Developed a presentation with input from Safety Assurance, Construction Management, and Senior Management

– Reviewed compensatory and corrective actions previously initiated

– Included Office of River Protection in presentation development

Prepared the conference room

– Room layout

– Charts and drawings related to the issue posted

– Nametags for participants

– Binders

Post Conference

– Debrief held with senior management

– Developed internal schedule for items due for completion

16

Preliminary Notice of Violation Identified

– A total of three noncompliances noted

– Two Severity Level I (Hazard Identification & Hazard Prevention and Abatement)

– One Severity Level II (Training and Information)

– With an initial penalty of $187,500

– Mitigation for corrective actions to $150,000

17

Lessons Learned – The Enforcement Process

Cause Analysis

– Ensure cause analysis identifies process weaknesses that contribute to the event.

Corrective Actions

– Discuss how corrective actions specifically prevent recurrence of this issue and how they will stand the test of time.

– What barriers are now in place.

– Discuss the importance of the compensatory actions put into place.

Consent Order

– Timely request for Consent Order.

18

Lessons Learned – The Enforcement Process

Schedule

– Be prepared to change - Schedules change at a moments notice.

– Investigation conference allotted time ran over so you will need to ensure your team is flexible.

– Developing an internal schedule helped keep management informed and WTP Enforcement Team on track.

Presentation

– Time your presentation. Too short may give the perception that you don’t understand the issue and too long could result in disengagement.

– Prepare presentation binders for them.

–Gave Office of Enforcement an opportunity to take notes.

Nametags

– Office of Enforcement appreciated the use of nametags so they knew who was who and who to direct questions to.

Site Tour

– Beneficial if given the opportunity

– Brought words to life (e.g., seeing work activities at construction site and MHF).