ISM at the Savannah River Site Department of Energy Best Practices Workshop Hazard Analysis Patricia Allen, Deputy ESH Manager Jim Tisaranni, ISM Director Washington Savannah River Company September 12-13, 2006 Within the last 15 years the nuclear industry has done a good job in implementing what is known as Human Performance. And as many in here know, many of these utilities have demonstrated dramatic improvements in performance resulting from these initiatives. As a result, many facilities here at Savannah River have developed programs intended on implementing Human Performance initiatives modeled after the commercial nuclear industry. And while I don’t know this for a fact, I suspect that these facilities have seen similar improvements in performance. And so Human Performance is not new at SRS. Many of you have implemented Human Performance programs and could easily be up here presenting. What is new is the fact that the Site is ready to take Human Performance on and integrate it with many of our existing systems. The Site is ready to embrace the HP concepts and values and institutionalize them into our culture. So let me briefly explain what Human Performance is and then describe what the Site will do over the next several months…

Hazards Analysis – Applies to All Industries January 6, 2005, Graniteville, South Carolina Chlorine gas was released from a 90 ton railroad tanker in local community. The 42 car train crashed into an engine and 3 cars on a rail siding. The switch was in the wrong position. 5400 people evacuated 550 people injured 240 people hospitalized 9 people killed Economic downturn History of the Railroad Summary Training Value, hierarchy of controls, Eng vs Admin Cntls, Change vs Experience, Training personalized Training personalized by discussing local events. Nation’s deadliest crash since 1978 (Tennessee crash that left 15 dead) Norfolk Southern Tragedy On January 6, 2005 the deadliest U.S. Train Crash since 1978 occurred in Graniteville, SC. There were 5400 people evacuated, 550 people injured, 240 people hospitalized and 9 people killed. The costs for Law Enforcement and Emergency reached $500,000. The expected costs to the train company, Norfolk Southern, are in the $30-40 Million range. According to the Federal Railroad Administration; “[The] likely cause of the crash was human error.” The only warning for the train was a reflector disk at the intersection of the main and side tracks. This device displays red for side track and white for main track. This hand-operated switch was left in the wrong position. The administrative control that was in place failed. In order to prevent accidents from occurring, the hierarchy of controls is used to determine better methods to avoid them. An engineering control may have stopped this tragedy from happening. NOTES: Dark territory, tracks no signals, 2:40 am Cause human error. Only warning for the train that a hand operated switch was left in wrong position was a reflector disk at intersection of main and side track.

Savannah River Site Hazards Missions Operations Industrial Chemical Tritium Non-proliferation Closure Environmental remediation Waste management Natural resources & ecosystem management Deactivation & demolition Research & Development National Laboratory Hazards Industrial Chemical Criticality Environmental Operational Radiological Waste Jim notes – Start at end – One of several tools The SRS complex covers 198,344 acres, or 310 square miles encompassing parts of Aiken, Barnwell and Allendale counties in South Carolina, bordering the Savannah River. Fourth largest DOE site in the United States During the early 1950s SRS began to produce materials used in nuclear weapons, primarily tritium and plutonium-239. SRS produced about 36 metric tons of plutonium from 1953 to 1988. Closure (80%) includes the Tank Farms, Stabilization, Deactivation, D&D, Soil and Groundwater Cleanup. Operations (20%) includes the Defense Programs, Nuclear Nonproliferation programs, Spent Fuels, Nuclear Materials Management, Strategic Planning and Infrastructure, and the support laboratories (B&C Labs). Potential Future Missions Mixed Oxide Fuel Facility Pit Disassembly and Conversion Facility Waste Solidification Facility Modern Pit Facility Hazards: Industrial = Excavation, Lead, Asbestos Chemical (IH) = Mercury, Benzene

Hazard Analysis Time Evolution Job Hazard Analysis Assisted Hazard Analysis 05/97 03/03 06/05 Continuous Improvement WCP Automated Hazard Analysis Works Clearance Permit Pros -Work Release & Approval Cons-Single task, limited checklist (hazards & controls), limited SME involvement Job Hazard Analysis Pros-Job task breakdown, team involvement, management review Cons -Hazard screening limited, WCP still required Automated Hazard Analysis Pros-structured questions for identifying hazards & controls; integrated “One Stop Shopping” with linkage to procedures, forms, permits, and checklists; structured for upfront planning (reduced rework); productivity savings as library of AHAs are developed Cons- Reliance on the software to perform the hazard analysis Assisted Activity Hazard Analysis Pros-Requires involvement from all team members; real time compliance with site level requirements Cons- 00/00-01/04 05/97-03/03 03/03-01/06 06/05-Present Works Clearance Permit (WCP) Job Hazard Analysis Automated Hazard Analysis Assisted Hazard Analysis

Lessons Learned Success Areas Improvement Areas Procedures Database Simple process Walkdowns to identify hazards Improvement Areas Need a more consistent hazards analysis process Procedures Implementation Work scope must be clearly defined by knowledgeable workers Emphasis placed on hierarchy of controls Need to simplify documentation for workers More training needed on overall process including tools

Assisted Hazard Analysis Development Philosophy Core team established to improve process. Team included workers, planners, managers, and customers : Define hazard analysis improvements Crafted solutions Plan implementation Customer integrated from the start Leadership concurrence throughout process Pilot in diverse facilities Make a Jump Core group consisted of facility management, maintenance management, program management, safety & health management, customer (DOE & DNFSB), Six Sigma, user (lead planner). Pilot Facilities include: Waste Management (DWPF & FTF), Infrastructure, and D&D.

Implementation Rollout and Evaluation Process Involvement Commitment Responsibility and accountability Project/Facility Leadership Team In-brief Leadership Planning Leaders trained and develop implementation plan Performance Coached Provided dedicated coaching during rollout Obtained feedback on process and modified Implementation Facility training and rollout Established expectations Metrics – need talking points Assessments Initial Implementation Mid Term Effectiveness Review Metrics

Hazard Analysis Training Modularized training includes varying degrees of Hazard Analysis theory, ISMS, application of tools, functional needs, and facility specific practical exercises. Training Courses Manager Planner and Supervisor Worker Engineer Train-the-Trainer Subcontractor Technical Representative Subcontractor Subcontractor Lead Work Group Supervisor Procedure Writer Subject Matter Expert Expect to train everyone on site with the exception of those in totally administrative fields. Manager Training (3-5 hrs) Planner/Supervisor Training (10-12 hrs) Worker Training (2-3 hrs) Engineer Training (4-5 hrs) Train-the-Trainer (3 days) STRs (12-16 hrs) Subcontractors (2-3 hrs)

Assessment Feedback Initial Assessment – completed Purpose: Attain satisfactory working knowledge and acceptable proficiency Lessons Learned: Facilities required more tailoring (training and application) than initially anticipated Roll out duration based on facility needs Mid-term – completed Purpose: Ensure transition stayed on course Problems detected and corrected early in the roll out Picked up best practices and lessons learned to share Effectiveness Review – in progress Purpose: Evaluate overall roll out success Overall roll out effectiveness is satisfactory Receiving excellent feedback on technical accuracy of hazard tree and Site procedures Opportunities for improvement identified: Hazard analysis for Operations procedures Feedback Hazard integration (Rad Con)

If you don’t measure it - - - you can’t manage it. What’s Next – Got Data? Developed Performance Indicators SME resource demands Distribution of each hazard and associated controls Feedback analysis Distribution of hierarchy of controls Process approval cycle time Metrics capability only limited by our imagination. If you don’t measure it - - - you can’t manage it.

Metrics Hazard Control Selection by Type

Metrics IH Mandatory Hazard Analysis Reviews by Question Chart reflects the selection frequency of Hazard Tree Questions Chemical Hazards Identified

Future Vision (Continuous Improvement) Intranet Server Remote Data Input Facility Workstations Mobile Phones PDAs Telephone Network Improve hazard tree Strengthen procedures Personal Digital Assistants (PDAs) Web based

Use of Electronic Media for Hazard Analysis Benefits: Easy access to prior surveys Provides immediate trending capabilities Relational – integrates with other database systems Example of Visual Survey Data Systems (VSDS) currently in use at the Savannah River Site

Benefits of Process Consistent approach to hazards analysis Improved worker hazard analysis knowledge Improved work planning and execution performance An exportable process – Utilize the computer software Implementation Process Training developed and available Assessment Tools Metrics Procedure

Approach to Hazard Management Integrated Safety Management Systems (ISMS) Define Scope of Work Analyze Hazards Develop and Implement Controls Perform Work Feedback and Improvement Provide feedback & continuous improvement Define the work scope ISMS Perform work within controls Analyze the hazards This is the beginning Responsibilities – SWP, Time Out and Stop Work DOE required method for hazard analysis. A major concept of ISM is the integration of safety awareness and good practices into all aspects of work conducted at DOE. Simply stated, work should be conducted in such a manner that protects workers and other people, and does not cause harm to the environment. Safety is an integral part of each job. This program began due to two recommendations to DOE from the Defense Nuclear Facility Safety Board (DNFSB). These recommendations are 95-2 and 98-1. The initial focus of these recommendations was on the roles and responsibilities of DOE and how it managed the safety practices of its contractors. DOE quickly developed policy that would guide the implementation of ISM across its complex. -- DOE's Policy DOE P 450.4 last updated 10-15-96. Develop and implement hazard controls

Define Scope of Work ISMS Total scope Technical work scope Work activity Task breakdown Hazard identification Walk downs and Work Scope Definition Checklist Work environment Work method Waste streams Facility and system impacts Worker involvement Develop and implement hazard controls Analyze the hazards Define the work scope Provide feedback & continuous improvement Perform work within controls ISMS Worker involvement through the hazard analysis process.

Analyze Hazards ISMS Apply hierarchy of controls Eliminate the hazards Engineering controls Administrative controls Personal Protective Equipment Worker involvement Provide feedback & continuous improvement Define the work scope ISMS Perform work within controls Analyze the hazards Hierarchy of controls are the fundamentals Examples – how often have you eliminated the hazards? Develop and implement hazard controls

Develop/Implement Controls Orders Regulations Lessons Learned Provide feedback & continuous improvement Define the work scope Output Documents Hazards Procedures ISMS Perform work within controls Hazard Tree Analyze the hazards Requirements plus Lessons Learned included in the software programming, i.e., heat stress issues. ~ 5,000 Users Microsoft Access with an SQL server database. Requirements as well as lessons learned. Traceability Auditable Controls Hazards Radiological, Chemical, Environmental, Industrial, Operational Regulatory Requirements OSHA, EPA, NRC, DOE, DHEC, CFR, Lessons Learned Output Documents Safe Work Permit, RWP, Hot Work Permit, Confined Space Entry, & others. Develop and implement hazard controls

Replace and Test Elevated Light As an Example Test – look at hand. SCISSORS LIFTS Self Propelled Scissor Lifts from 20 feet to 56 feet working height. Battery powered. Ideally suited for slab type applications. Compact dimensions give excellent maneuverability. Tilt alarms, decent alarms, etc. are fitted, machines are suitable for going through standard doors.

Work Scope Definition Checklist Work Environment Checklist Light Replace and test elevated light. SL-46 GS N/A 123-F NSA Tested satisfactorily. Replace elevated light.. Test elevated light. Work Scope Definition Checklist Work Environment Checklist Outdoor Heat Stress 13

Work Scope Definition Checklist Can any of the hazards be eliminated? Elevated Work Determine worker involvement required to complete the work activity E&I 14 14

AHA Hazard ID Navigation Hierarchy of Controls: Hazard ID/Hierarchy of Controls AHA Hazard ID Navigation 140 Portable Ladder? Hierarchy of Controls: Consider accessing the worksite without exposing the worker to an elevated height. Consider using engineering controls such as extended tools, Chain Operators, etc. to provide access. Consider using powered platform or scaffolding if it would provide safer access to area.

Controls Selection Mandatory Controls: Perform visual inspection and test operation of platform daily Select platform which is inspected and tested Assign trained equipment operator(s) for platform Operator know maximum load capacity and weight distribution restrictions of platform Mandatory Controls: Controls Selection

Controls Disposition Disposition By Safe Work Permit Management Controls Disposition By Controls Disposition Example Person Responsible Remember these you will see them again.

Safe Work Permit Scope of Work Work Authorization Lead Work Group Supervisor Worker Sign-On 18

Safe Work Permit Tasks Hazards Auditable controls Controls

Management Control Report Example Supervisor Manager must respond and read the controls.

Technical Work Document Control Report Example Example – these items must be planned and show up in the work instructions.

Perform work within controls Use of Safe Work Permit Bounds the work scope Provides work authorization Lead work group supervisor Hazard Analysis Concurrence Implementation Worker acknowledgement Task Hazards Controls Technical work documents Permits Scope, hazard change or gut feel Workers call Timeout or Stop-Work Define the work scope Provide feedback & continuous improvement ISMS Perform work within controls Analyze the hazards Permits Hot work permit, radiological work permit, confined space entry permit, environmental permits (Resource Conservation and Recovery Act (RCRA) Permit). Stop Work Conditions If an identified condition is associated with an on going activity and the activity would result in one or more of the following: a nonconforming item, conditions outside of normal limits or technical specifications, hazardous conditions to personnel, damage to equipment or facilities, or equipment or items that had been previously tagged with a QA Hold Tag, or other condition tags, were found to be in use during a work activity, then, the activity must be immediately discontinued by the responsible management.  If discontinuation of the activity would be detrimental to the safety or health of personnel or the environment, violate criticality rules, or unnecessarily damage equipment, then the activity must be stopped as soon as practical. Time Outs The informal method used to implement stop work for safety is the “timeout”. The timeout is an informal brief break in work which allows for a practical way to deal with an emerging concern before it results in a safety event. Timeouts are warranted when one or more of the following exist: an unexpected condition or new hazard is encountered, there is a change in work scope, instructions are inadequate or unclear, issues are not covered in the pre-job brief, additional assistance is required, e.g., Radiological Control Operations (RCO), Industrial Hygiene (IH), a mistake is made, uncertainty or apprehension exists about the safety of continuing work. Conducting a Timeout: communicate timeout to the team, suspend work and place activity in a safe condition, notify supervision, determine what is needed to resolve the situation. The formality, nature and duration of the resolution will be agreed upon by supervision, the timeout is over when the team agrees that the issue is resolved and work can safety proceed. Develop and implement hazard controls

Feedback and Improvement Work history Worker experience Lessons learned Timeout feedback Post work reviews Feedback not always at the end of process. Different circle Describe the cycle Feedback throughout Continuous Improvement Process from Problem Identification Through Post Job Review

Employee Involvement Summary Define the Scope Analyze the Hazards Feedback and Improvement Identify and Implement Controls Perform Work Worker Involvement is the backbone of our Hazard Analysis process. This is our time to take a positive step on the path of continuous improvement. Workers are enthusiastic about the process. It’s simple and provides necessary information. Workers want to work safely and eliminate the hazards through proper planning. The key to success is leadership commitment.

Questions Patricia Allen Jim Tisaranni patricia.allen@srs.gov (803) 952-8359 Jim Tisaranni jim.tisaranni@srs.gov (803) 952-9382