390 likes | 554 Views
Point to Ponder. Organizations only improve where the truth is told and the brutal facts confronted."- Jim Collins Good to Great, 2001. Why this Presentation?. As directed by the BNL ESH
E N D
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.