1. 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…

2. 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.

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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)

9. 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)

10. 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.

11. Metrics Hazard Control Selection by Type

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

13. 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

14. 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

15. 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

16. 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 and 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 last updated
Develop and implement hazard controls

17. 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.

18. 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

19. 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

20. 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.

21. 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

22. 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

23. 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.

24. 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

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

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

27. Safe Work Permit
Tasks
Hazards
Auditable controls
Controls

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

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

30. 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

31. 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

32. 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.

33. Questions Patricia Allen Jim Tisaranni patricia.allen@srs.gov
(803)
Jim Tisaranni
(803)