1. 1 Department of Energy Corporate Operating Experience Committee Spring Webinar May 14, 2013 11 AM – 3 PM ET Ashley Ruocco Office of Analysis Office of Health, Safety and Security

2. Welcome to the first OEC Spring Webinar Webinar feature overview Webinar as an open forum Agenda Provided via Calendar Invite last week 11:00 - 11:30: Welcome, Roll Call, and Update from the Office of Analysis 11:30 - 12:00: EM ARRA Lessons Learned Initiative Presentation 12:00 - 12:30: Slip Simulator Presentation 12:30 - 1:00: OPEX Share Presentation 1:00 -1:45: Prevention Through Design 1:45 - 2:15: Lessons Learned Discussion 2:15 - 2:45: OE Program Self-Assessments Discussion 2:45 - 3:00: Open Discussion and Closing Welcome and Agenda 2

3. Reminder to email Gail Thomason, gthomason@pec1.net, that you are in attendance gthomason@pec1.net Welcome from Stephen Domotor, HS-24 Director Roll call by site/lab/organization –Please introduce yourself and bring up any Operating Experience/Lessons Learned that you would like to share 3 Introductions

4. Ames Laboratory Argonne Site Office (ASO) / Argonne National Lab Berkeley Site Office (BSO) Brookhaven Site Office / Brookhaven National Lab (BNL) Carlsbad Field Office / WIPP Chicago Office 4 Introductions

5. Fermi Site Office (FSO) Idaho Operations Office (ID) / Idaho National Lab (INL) Kansas City Plant (KCP) / KSO Livermore Site Office (LSO) / LLNL Los Alamos Site Office (LASO) / LANL Grand Junction Project Office (MOAB) 5 Introductions

6. National Energy Technology Lab (NETL) Nevada Site Office (NSO) / NST / NSTec Oak Ridge Site Office (OR) / Oak Ridge National Lab (ORNL) Pacific Northwest Site Office (PNSO)/ PNNL Pantex Site Office (PSO) Princeton Site Office (PSO) 6 Introductions

7. Portsmouth/Paducah Project Office(PPPO) Richland (RL) / Hanford Site Office of River Protection (ORP) Sandia Site Office (SS) / SNL Savannah River (SR)/ SRSO Separations Process Research Unit (SPRU) 7 Introductions

8. Stanford Site Office (SSO) Thomas Jefferson Site Office YSO/Y-12 External Organizations 8 Introductions

9. DOE Spotlight 9

10. 10 External Operating Experience NRC INFORMATION NOTICE 2013-06: CORROSION IN FIRE PROTECTION PIPING DUE TO AIR AND WATER INTERACTION (this was a Highlighted Presentation on OEC’s April Meeting) –More insight from Livermore Site Office A couple of factors that may have contributed to the corrosion: 1) Compressed air is a source of water- pre-action and dry pipe systems are usually pressurized with compressed air and water eventually collects in the piping system due to poor air drying or just from long periods of supplying compressed air. Therefore, draining the system may not solve the problem, unless done frequently. 2) Potential galvanic corrosion (galvanized pipe were common for most of the cases) and use of dielectric unions should be emphasized.

11. Two Bangladesh Garment Factories Fatal Events –Bangladesh Factory Collapses, April 24, 1127 fatalities. Officials say the building's owner illegally added three floors and allowed the garment factories to install heavy machines and generators, even though the structure was not designed to support such equipment. Structural issues visually apparent before the collapse. The disaster is the worst ever in the garment sector. –Bangladesh Factory Fire, May 9, 8 fatalities. A fire on the first floor fed by acrylic products. Issues: safety problems and poor working conditions. Bangladesh is the world's second-biggest clothing exporter that supplies global retailers- $20 Billion garment industry. Bangladesh government has announced that unions will now be allowed and there is a possibility of raising minimum wage. External Operating Experience 11

12. CSB Investigates Massive Explosion and Fire at Fertilizer Plant Near Waco, Texas April 17, ~8PM, ammonium nitrate explosion,14 fatalities, ~200 injured A large investigation team from the U.S. Chemical Safety Board (CSB) is investigating the massive fire and explosion at the West Fertilizer Plant located in West, Texas. External Operating Experience 12

13. Mulch Fire, Upper Marlboro, Maryland April 24, ~8PM, spontaneous combustion possible reason, no injuries or fatalities Wind gusts of up to 30 mph fueled the fire and blew embers into nearby brush. The flames spanned an area about 100 feet wide and shot 30 feet into the air http://articles.washingtonpost. com/2013-04- 25/local/38801429_1_mulch- pile-spontaneous-combustion- mark-bradyhttp://articles.washingtonpost. com/2013-04- 25/local/38801429_1_mulch- pile-spontaneous-combustion- mark-brady External Operating Experience 13

14. Wednesday, April 17, 2013 Milwaukee 18-volt, lithium-ion battery fire A Milwaukee 18-volt, lithium-ion battery caught fire inside of an office trailer during routine charging on a Milwaukee 18v Li-ion Charger (catalog number: 48-59-1801). The charger was new and this event occurred on its initial charging sequence. The battery involved had previously been used with a Milwaukee drill and had been charged before. The employee verified that the battery was compatible with the charger prior to placing it on the charger. The charger indicated the battery was receiving a charge via a red- light indicator and it did not indicate a battery error. Approximately 5 minutes into the charge cycle, the battery began to pop and smoke. The employee saw the smoke and small flames, retrieved an ABC fire extinguisher, extinguished the flames, unplugged the charger, and placed the battery and charger outside of the office trailer. The fire department arrived and verified that the flames were extinguished. Milwaukee has been contacted and their representatives have stated that they have not heard of similar events with the 18-volt, lithium-ion batteries and chargers, and there are not any recalls associated with these items. Milwaukee has requested the battery and charger be sent to them for further investigation. Once Milwaukee receives these items and performs its investigation, any recommendations from Milwaukee will be shared with interested parties. POC: Jason Chapple, 533-0018, Jason.Chapple@icp.doe.gov Jason.Chapple@icp.doe.gov ACTION: Ensure this message reaches the appropriate personnel in your organization as applicable. External Operating Experience 14 Provided by Brian Anderson, NE-ID

15. NIOSH Developing Free Mobile Pocket Guide to Chemical Hazards NIOSH Pocket Guide App The current, 424-page edition contains descriptions of 677 common chemicals with details on exposure routes, PPE, first aid, incompatibilities, and more. NIOSH officials want feedback from users to help them decide how to organize the content. http://ohsonline.com/articles/2013/04/17/niosh- developing-free-mobile-pocket-guide.aspxhttp://ohsonline.com/articles/2013/04/17/niosh- developing-free-mobile-pocket-guide.aspx External Operating Experience 15

16. Increased Near-Miss Reporting Results in Improved Safety Performance (EHS Today article) –Companies that focus on leading indicators, such as near miss reporting, show improved organizational safety performance. –Near Miss Reporting – a Missing Link in Safety Culture, a peer- reviewed feature in the May issue of Professional Safety, examines several studies that have shown that near misses greatly outnumber serious accidents involving fatality, injury or property damage. –To achieve a culture-based safety system: –Define expectations that all employees report unsafe conditions or perceived risks –Provide employees with safety training –Provide measurement for how near-miss reporting has improved safety performance –Recognize and reward employees and crews for pro-active safety actions. –http://ehstoday.com/safety/increased-near-miss-reporting- results-improved-safety-performancehttp://ehstoday.com/safety/increased-near-miss-reporting- results-improved-safety-performance External Operating Experience 16

17. HQ Lessons Learned Database improvements/upgrades are being assessed. External Lessons Learned Programs and Databases are being benchmarked at this time. Suggestions for the Lessons Learned Database/Program are welcomed. Office of Analysis Update: Lessons Learned Program and Database 17

18. Recently Released OE Documents –OE-1, Improving DOE Capabilities for Mitigating Beyond Design Basis Events –Required Actions »All Program Offices, in coordination with responsible contractors, shall evaluate their site emergency management programs' response to severe accidents/events (including BDBEs) that could have a site- wide impact, using the guidance in Attachment 1 of the OE document, and make appropriate enhancements. (By 12/31/14) »Program Offices shall direct contractors responsible for hazard category 1 and 2 nuclear facilities that have the potential to exceed DOE's 25 rem public dose evaluation guideline based on an unmitigated accident analysis, to conduct an evaluation using the guidance in Attachment 2 of the OE document in conjunction with the 2015 annual update of their Documented Safety Analyses (DSAs). This action is not applicable to Transportation DSAs. (By 12/31/15) OE Documents 18

19. Under Development –Draft OE Summary Article, Fall Fatality While Installing Work Platform at Remote Bonneville Power Administration Project, within HS-20 management review –Draft OE Summary Article, Management and Oversight Inadequacies at the Integrated Waste Treatment Unit, updating draft soon to be in management review OE Documents 19 Direct links and more are available on the OE Wiki. http://operatingexperience.doe- hss.wikispaces.net/

20. Most Recent OE Wiki Video- Animation of Fire at Chevron's Richmond Refinery –This video provides an overview of a catastrophic pipe failure at Chevron USA, Inc. refinery in California. The CSB investigation revealed inspection deficiencies and replacement issues. OE Wiki Video- I Fell Off the Roof Today –This video reviews the importance of fall protection equipment. A roofer shares an experience where he lost his balance while working on a three- story residential project and how the fall protection gear he donned saved his life. OE Wiki 20

21. ORPS Order and OE Order Implementation- –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. The One-Year Accuracy Review was completed in early 2013 and no changes were needed at that time to the Order. Office of Analysis Update: Directives 21

22. A memo is drafted and within review that requests line programs and the field to formally verify OE Program Coordinators and members, as well as to remind all of the requirements and responsibilities listed in DOE O 210.2A. Appreciate all who updated their information, people would like to join, and those who are no longer involved. Any feedback on the OE Program is appreciated. Self-Assessment Reviews on the Effectiveness of the OE Program 22

23. Highlighted Presentations –Goal to increase Highlighted Presentations on monthly OEC calls OE Program Themes –Discussion on OE Program Theme topic areas Specific to Lessons Learned Program/Database OE Self-Assessment site-specific or in general OE Document topics Other ideas? OE Program Themes 23

24. Since this is the OEC’s first Half Day Webinar, Ruocco is requesting your feedback. After this webinar, please email/call Ruocco with any feedback and lessons learned from this meeting. Thank you for your support and efforts towards continually improving the OE Program. Feedback on the OEC Spring Webinar 24

25. 25 Questions/Comments Ashley Ruocco General Engineer Office of Analysis (HS-24) 301-903-7010 ashley.ruocco@hq.doe.gov OE Documents (HSS) - http://www.hss.doe.gov/SESA/Analysis/oel.htmlhttp://www.hss.doe.gov/SESA/Analysis/oel.html OE Summaries (HSS) - http://www.hss.doe.gov/sesa/Analysis/oesummary/index.htmlhttp://www.hss.doe.gov/sesa/Analysis/oesummary/index.html Operating Experience Wiki: http://operatingexperience.doe-hss.wikispaces.net/http://operatingexperience.doe-hss.wikispaces.net/ Operating Experience Summary Blog: http://oesummary.wordpress.com/http://oesummary.wordpress.com/

26. BREAK SESSION We will resume the webinar at: ET Department of Energy Corporate Operating Experience Committee Spring Webinar 26