Material Handling at BNL The Past, Present Future

1. Material Handling at BNLThe Past, Present & Future? Edward A. Sierra Quality Management Office Presented to: ALD for ESH&Q Safety & Health Services Division Manager Lifting Safety Committee Chair January 30, 2007

2. Point to Ponder Organizations only improve �where the truth is told and the brutal facts confronted.� - Jim Collins Good to Great, 2001

3. Why this Presentation? As directed by the BNL ESH&Q Director: The Quality Management Office will: Review History of BNL Material Handling Events Identify DOE Lessons Learned Identify common causes of BNL Material Handling Events Search for material handling �best practices�

4. BNL Material Handling Event History Material Handling Issues, 2003 08/12, Forklift Load Strikes Overhead Lines 09/04, Lifting Magnet Releases Steel Plate 12/30, Transformer Dropped During Rigging Material Handling Issues, 2004 03/05, Load Falls off Flatbed Truck 03/24, Recurring Material Handling Problems, (SCR/NTS) 05/17, Damaged detector at STAR after 10 foot drop 06/11, 500 # steel block falls (3 � 4 feet) from forklift 10/05, Injury due to steel plate falling at bldg 701 Material Handling Issues, 2006 01/17, Tennelec smear counter falls during transport 06/30, Computer server unit falls out of BNL box truck pinning worker to ground (NTS) 08/28, During transport a forklift dropped a secured aerial lift Material Handling Issues, 2007 1/24, Worker pinned by metal sheets (NTS?)

5. BNL is not alone: Commercial Nuclear Stations Negative Trend Fatality and Severe Personnel Injuries

6.  Palo Verde Nuclear Generating Station  

7.  Palo Verde Nuclear Generating Station  

8.  San Onofre Nuclear Generating Station  

9. Industry Identified Causes: Policies and Procedures Training and Qualification Equipment Control, Storage, and Inspection Fundamental Rigging and Lifting Practices Supervision and Oversight 

10. Industry Identified Causes: Policies and Procedures � Skill-of-the-craft (Worker-Planned-Work) � No central point of contact � Self-assessments not performed, or they were ineffective � Work plans lacked rigor

11. Industry Identified Causes: Training and Qualification � Lack of Continuing training � Inconsistent Qual standards � Training lacked �hands-on� experience � Lack of training on equip inspection requirements � Proficiency evaluations lacking for supplemental personnel � Maintenance Training Review Committee missed knowledge and skill deficiencies 

12. Industry Identified Causes: Equipment Control, Storage, and Inspection � Slings and chain falls were not inspected prior to use � Damaged rigging and lifting equipment was staged as ready for worker use � Some rigging and lifting equipment used by supplemental personnel was not qualified or inspected 

13. Industry Identified Causes: Fundamental Rigging and Lifting Practices � Walking under suspended loads � Pieces of hoses/other materials were inappropriately used � C-clamps were inappropriately used to attach slings to loads prior to lifting � The working load limit was sometimes not known prior to the load being lifted � Load cells were not used when load binding during the lift was possible

14. Industry Identified Causes: Supervision and Oversight  � Unfamiliar with rigging/lifting equipment inspections � Unfamiliar with basic rigging and lifting principles � Oversight was not routinely provided Reference: Institute of Nuclear Power Operations (INPO) Significant Operating Experience Report (SOER) 06-1, �Rigging, Lifting, and Material Handling�, October 11, 2006

15. Improper Material Handling Results in Near Misses DOE Just-in-Time Report, June 2006 April 2006 - An employee was struck and pinned against a freight elevator gate by a 670-pound trim fixture that had fallen off a skid May 2006 - Two workers lost control of a 150-pound heat exchanger, the unit fell approximately 2 feet onto a concrete floor May 2006 - An experimental device packaged in a wooden crate rolled off of a manual pallet jack May 2006 - An employee was struck and knocked to the floor by a forklift

16. Does BNL Past This Test?DOE Just-in-Time Report, June 2006 Is the equipment in use designed and rated for the load being moved? Are items secured to prevent movement during transit? Are employees trained to operate material-handling equipment? Are trained spotters assigned when the equipment operator�s vision is obscured? Are spotters positioned such that they can observe the entire work zone? Is the number of spotters assigned adequate to detect all hazards and communicate these to the equipment operator? Have steps been taken to ensure continuous communications between spotters and equipment operators? Have unanalyzed hazards been introduced by deviating from the original plan?

17. BNL Material Handling Event History Material Handling Issues, 2003 08/12, Forklift Load Strikes Overhead Lines 09/04, Lifting Magnet Releases Steel Plate 12/30, Transformer Dropped During Rigging Material Handling Issues, 2004 03/05, Load Falls off Flatbed Truck 03/24, Recurring Material Handling Problems, (SCR/NTS) 05/17, Damaged detector at STAR after 10 foot drop 06/11, 500 # steel block falls (3 � 4 feet) from forklift 10/05, Injury due to steel plate falling at bldg 701 Material Handling Issues, 2006 01/17, Tennelec smear counter falls during transport 06/30, Computer server unit falls out of BNL box truck pinning worker to ground (NTS) 08/28, During transport a forklift dropped a secured aerial lift Material Handling Issues, 2007 1/24, Worker pinned by metal sheets (NTS?)

18. SCR/NTS Report ORPS Cause Codes Training deficiency (RC); Practice or "hands-on" experience LTA Training deficiency (RC); Testing LTA Training deficiency; Refresher training LTA Management Problem; Planning not coordinated with inputs from walkdowns/task analysis Management Problem; Assignment did not consider worker's need to use higher-order skills  

19. Aug 04, DOE Office of Science ISM Assessment Findings: Training and qualification program for riggers, crane operations and forklifts is inadequate. Competence requirements not established and competence not required to be demonstrated. Maintenance and inspection of H&R equipment is LTA Work planning, feedback, and improvement, LTA Aug 04, DDO Appoints Hoisting, Rigging and Mechanical Material Handling Working Group Action Plan

20.  SCR/NTS Action Plan Status 50/51 Actions Closed Assess the effectiveness of corrective actions that are related to the root causes of this event. Due Date: 06/30/2007 Post-SCR/NTS Events

21. Post-SCR/NTS Report EventsORPS Cause Codes 10/05/04, Injury due to steel plate falling at bldg 701 Management Problem; Change Management LTA; Risks / consequences associated with change not adequately reviewed / assessed Design/Engineering Problem; Design Verification / Installation Verification LTA; Independent review of design/documentation LTA Communications Less Than Adequate (LTA); Written Communication Content LTA; Incomplete / situation not covered Training deficiency; No Training Provided; Work incorrectly considered �skill-of-the-craft� 01/17/06, Tennelec smear counter falls during transport Human Performance (LTA); Knowledge Based Error; Individual underestimated the problem by using past events as basis Equipment/ material problem; Material control LTA; Material shipping LTA

22. Post-SCR/NTS Report EventsORPS Cause Codes 06/30/06, Computer server unit falls out of box truck pinning worker to ground Human Performance (LTA); Skill Based Errors; Wrong action selected based on similarity with other actions Management Problem; Work Organization & Planning LTA; Job scoping did not identify special circumstances and/or conditions Communications (LTA); Written Communication Content LTA; Facts wrong / requirements not correct Training deficiency; No Training Provided; Work incorrectly considered �skill-of-the-craft� 08/28/06, During transport a forklift dropped a secured aerial lift Management Problem; Work Organization & Planning LTA; Job scoping did not identify special circumstances and/or conditions Communications (LTA); Written Communications Not Used; Not available or inconvenient for use 1/24/07, Worker pinned by metal sheets � Causes TBD  

23. Common ORPS Cause Codes Training Deficiency Management Problem (Work Organization & Planning LTA) Communications LTA

24. Independent Assessment IO 05-19Material Handling Corrective Action Follow-UpJanuary 31, 2006 Assessment Focus: Training & Qualifications Equipment Inspection Operations Procurement

25. Independent Assessment IO 05-19Material Handling Corrective Action Follow-UpJanuary 31, 2006 Assessment Results: C/As have been generally effective and demonstrate a clear management commitment to improving material handling at BNL. The areas of Operation and Equipment Inspection have improved in general, but require additional attention in some specific areas and more consistent application of requirements across organizational boundaries.

26. Independent Assessment IO 05-19Material Handling Corrective Action Follow-UpSCR/NTS Report actions deemed not fully effective Crane operator qualifications Procurement Requirements Annual inspection of all cranes and below-the-hook H&R equipment Inspection requirements to �Lifting Safety Subject Area� Daily and annual inspection in basic rigging, forklift and overhead crane training Cranes without load-test certificate

27. Independent Assessment IO 05-19Material Handling Corrective Action Follow-UpAction Plan Status as of Jan. 26, 2007 ATS 3078 50 Actions Closed 6 Actions Open 3078.6.3 -�Review recommendation and respond as appropriate�� 3078.9.1 -�Attach Operator Manual w/environmental storage tube�� 3078.9.2 -�Purchase missing manuals for existing units�� 3078.9.3 -�Conduct tool box meeting to foster daily cleanups�� 3078.10.2 -�Review documents weekly and report to line management�� 3078.12.1 - Do not permit use of hoists without load tests��

28. Material Handling Programs Beyond BNLInvite Extended to QMO NORFOLK NAVAL SHIPYARD MARSHALL SPACE FLIGHT CENTER TURKEY POINT NUCLEAR POWER STATION STRATEGIC PETROLEUM RESERVE

29. NORFOLK NAVAL SHIPYARD (VPP STAR STATUS) Contact: John Heffron, Rigging Shop Supervisor (757) 396-4877 ~ 250 Professional Riggers Apprentice Riggers (as recommended by management) undergo 4 year Training Program Trade Theory (classroom) Academics (night college classes) OJT Rated every 4 months by Supervisor 2x Failure of same test � out Equipment Load tested every year No Fault/Blame Culture Reporting encouraged

30. MARSHALL SPACE FLIGHT CENTER

31. NASA's Marshall Space Flight Center Contacts: Ed Kiessling , Industrial Safety Dept Manager (256) 544-7421 Judy Milburn, Safety Training, ext: 4802 Kyle Daniel, Engineer, ext: 5677 ~ 60 Professional Riggers Gift Package PP Presentation SOP - Overhead Crane, Mobile Crane & Lift Truck Marshall Work Instruction � Lifting Equipment and Operations Marshall Work Instruction � Personnel Certification Program NASA Standard For Lifting Equipment and Devices (NASA-STD-8719.9) �Bible for Lifting Devices� Rigging Contractor contacts Training Courses http://www.pe.gatech.edu/conted/servlet/edu.gatech.conted.course.ViewCourseDetails?COURSE_ID=166 http://www.cranesafe.com/ http://www.cranetraining.com/

32. NASA's Marshall Space Flight Center Overhead Cranes - Monthly Electrical and Mechanical Inspections - Annually, an Outside Contractor Specializing in crane inspections is brought in for Electrical and Mechanical Inspections

33. NASA's Marshall Space Flight Center

34. SHOCK RECORDERS

35. TURKEY POINT NUCLEAR POWER STATION Contact, Rick Nielsen, Dept. Manager Has the Pulse of the Nuc Power Plants Audit Criteria: Results Observations Inspections Problems noted throughout Industry Stations now engage the EXPERTS

36. STATEGIC PETROLEUM RESERVE Contacts, Suzanne Broussard, Safety Manager (504) 734-4833 Joe Shuckrow (504) 734-4550 10 yr. running Behavioral Safety Program (700 to 537 Workers) Identify/discuss/correct at-risk behaviors without blame Provides built-in supervision Peers observe peers Program has significantly reduced events (VPP Status) From 54 to < than double-digits Direct correlation between watching and reduction in events Spills over into safe behavior at home

37. What does a World-Class Material Handling Program Look Like? Competitive Advantage Consistent processes Independent Audits Benchmarking Eliminated Sustainable ORGANIZATIONS SEEK OUT BNL AS A MENTOR Adapted from �Breakthrough Safety Management� - by Sandy Smith - 06/08/2004 http://www.occupationalhazards.com/safety_zones/47/article.php?id=11919

38. BNL World-Class in Material Handling Why Not Us? Why Not Now?

39.  Suggested Immediate Actions: Formal Response SMEs - Dedicated & Focused Real Supervision (Worker-Planned-Work) Nobody moves �significant� material alone Policy to limit �specified material handling� to the Pros

40. What Might Have Happened! I have been very upset by this incident and I have played over and over in my mind what might have happened had the near miss not been a near miss and we killed a worker. First and foremost, the human suffering would have been staggering and far-reaching. Beginning with the painful death of the worker, the pain would have spread through his family as they learned of the loss of their loved one, then to his coworkers, friends, and community. There would likely have been immediate mental anguish and long-term emotional distress suffered by the rescue workers and others as they responded to the awful scene. A senior Laboratory manager would have had the responsibility of contacting the dead worker's family and conveying the devastating news. That manager would never forget that experience.