Lesson Learned Statement:Regardless of our intentions, good communications are essential to understanding requirements and properly accomplishing tasks.
During swing shift on March 13 and 14, 2001, Utilities Operators changed Air Handling Unit (AHU) filters in several AHUs where Beryllium (Be) contamination existed. The changing of the filters could possibly have disturbed Be contamination in the filters and AHUs, creating a potential safety concern for the Utilities personnel and the personnel who would work in the facility following the filter changes. The Industrial Hygiene (IH) section of the Occupational Safety and Health Department (OS&H) provides safety expertise regarding Be issues. IH, as part of an ad hoc review of the Utilities filter change work package, had provided additional instructions for notification and personnel protective equipment (PPE).
These additional instructions were not incorporated into the work package. The critique also showed that the work control process did not have a formal means of incorporating health hazards for all types of Utilities and Crafts work packages. The work control process should provide for adequate safety and functional reviews. The need for follow-up monitoring after the filter changes but before personnel could work in the area was not recognized by all parties as a requirement. The failure to incorporate IH's additional instructions and the lack of a proper review process made the Utilities work package inadequate, plus the misunderstanding about follow-up coordination led to potential safety concerns. Although the Facility Manager (FM) was aware of the potential safety concerns late Thursday, March 15, 2001, IH sampling results were needed before reportability could be determined. IH presented those results at the critique on Monday, March 19, 2001. Although the results did not validate any safety hazard, Pantex management decided to report the event on March 20, 2001. IH wanted the Utilities Operators to wear full tyvek hooded suits instead of the laboratory coats called for in the work package. Although IH wanted this increased level of PPE, the Operators were shielded by IH specified full face respirators, they took air and swipe samples from the areas two shifts (about 16 hours) after the filter changes. All of the air samples were below instrument detection level, and the swipe analysis results were well below the DOE defined housekeeping levels of 3 micrograms per 100 centimeters squared.
Consequently, no actual safety hazard from the filter changing actions can be confirmed. The technicians who worked in the facility after the filter change were advised of the negligible results. There were no other safety hazards to personnel, no personnel injuries, no damage to equipment or facilities, and no adverse effects to the environment as a result of this event.
Two root cause methodologies were used to analyze this event: 1) Barrier and Control Analysis; and 2) Events and Causal Analysis.
Characterization of potentially Beryllium-contaminated facilities was started in January of 2000. Building 12-64 was identified as one of these facilities due to its historical operations involving Beryllium. On inspection, Bays 1 through 10, 12 and 14 were found to have Be contamination from previous operations. In November of 2000, the AHUs in Building 12-64 Bays 1 through 5, 7 through 10, 12 and 14 were identified as Be contaminated. The AHUs in Building 12-64 are situated within each individual bay. Because each outside air intake has been capped, the AHUs only cool/heat recirculated air within the bay. The AHUs in Building 12-64 do not have High Efficiency Particulate Air (HEPA) filters installed. The potential for beryllium (Be) exposure occurred during a preventive maintenance (PM) activity on the Be contaminated AHUs which involved opening a side panel, removing the filter, and replacing it with a clean filter. While the individual who actually changed the filter was wearing a respirator, lab coat, and gloves, other personnel who were in the bay during the filter change, and personnel who entered the bay during the next two shifts were not wearing any protective equipment.
DIRECT CAUSE: Inattention to Detail:
IH, as the health hazards subject matter experts, had previously determined the PPE to be worn by the Utilities Operators when performing the filter change out. Utilities had included that information in the work package. IH modified the PPE to be worn and requested notification "... at least 4 hours prior to working in the affected bays." The Utilities Supervisor did not include this new information provided by IH in the PM work package. The Utilities Section Manager will counsel the supervisor about the importance of including the health and safety information in the work package.
Procedure Not Used or Used Incorrectly - The safe work process was not followed per the requirements of Plant Standard STD-3020. STD-3020 requires a Safety Work Permit (PX-30) for, "[work on any systems suspected of being contaminated with explosives or other hazardous materials not covered under technical procedures" and that "[the Industrial Hygiene Section issues PX-30s for work involving the presence of a health hazard from hazardous materials . . ." In this case, however, an Industrial Safety representative completed the PX-30 that did not reflect the requirements established by IH. Instead, the PX-30 focused on restrictions to maintenance type work around nuclear explosives.
IH will provide standing work permits to Maintenance Work Control for Craft and Utilities Supervisors to use with the work packages affected by Be contamination.
Communication Problem - The communications between all parties involved in this event were less than adequate. First, IH and the IS engineer did not properly communicate the requirements for the Safety Work Permit concerning Be work. STD-3020 requires IH to issue Safety Work Permits for health hazards. IH did not tell the IS engineer on duty of the need to identify the Be hazard on the Safety Work Permit. Consequently, the IS engineer did not discuss the requirements when issuing the Safety Work Permit. Instead, IH sent the PPE information to the Utilities Supervisor by e-mail. The applicability of previous guidelines given to Utilities were not understood. The previous memo was not intended to address the AHU tasks since the AHU contamination had not yet been identified at the time of the memo but was intended to address other tasks performed above an eight foot level. However, the PPE identified in these previous guidelines is the PPE that was being called out in the filter change out work pack! age. Given the lack of hazard knowledge for the AHU tasks, IH wanted more stringent PPE used. However, the e-mail identified the extra PPE for just prevention of contamination on the worker's clothing. In neither the memo nor the e-mail was it clear that this requirement applied to anyone but the particular worker performing overhead work. Personnel below the work were not identified or addressed. The new IH requirements were intended to also institute monitoring to characterize the health hazards associated with the filter change out. The new guidelines for monitoring were not totally understood. The mechanism for determining when monitoring would take place lacked specificity. The reliance by IH on a four-hour notification was overlooked. The Utilities Supervisor and the FM/Assistant Facility Manager (AFM) had asked for assistance with this task but did not assimilate the significance of the new IH guidance nor the impact of the changed guidance on all personnel an! d operations. Consequently, the AFM and Utilities Supervisor di! d not r the Day maintenance coordination meeting. Additionally, the FM/AFM did not recognized that the new instructions were not included when they reviewed and signed the work package. Since the intended instructions were not in the work package, the Utilities Swing Shift Supervisor could not provide the intended briefing to the workers.
MANAGEMENT PROBLEM - Policy Not Adequately Defined, Disseminated, or Enforced. In the case of Maintenance and Utilities corrective and preventive maintenance work packages, no formal system exists for communicating and incorporating health hazard information into work packages or procedures. Instead, an informal e-mail process was used. IH provided the new PPE and notification comments in an e-mail to the Utilities Supervisor, another IH representative , and the AFM about six weeks before the PM was performed. Additionally, neither IH, the AFM, or Utilities Supervisor provided review or feedback of the changed information prior to performance of the work package. The process did not allow IH to follow up to make sure the work package included the information. The process did not establish scrutiny of the indicated changes. The Utilities Supervisor and the AFM did not question the change from lab coats to hooded tyvek suits or the methodology/effect of monitoring that required the four hour notification. The work packages also do not go through a centra! lized review process, that would include all safety considerations, as most procedures do. Even then, this centralized review is an after the fact look at the procedure. It is not real-time responsive to changes. And the review often focuses on nuclear and explosive requirements without regard to the industrial, chemical, and health hazards. Most technical procedures do receive some waste material identification as they are written, before going through the centralized review. But the work packages do not. Management is to establish a formal process for communicating IH controls to plant personnel to ensure health hazards are addressed and appropriate controls are included in work packages and procedures. Additionally, a team will evaluate means to communicate health hazards, such as the Hanford Model, and develop an implementation plan based on the evaluation.
FM Evaluation: From the monitoring information gathered approximately 17 hours after the first potential exposure of the grave shift, the IH Section determined that it was very unlikely that an actual Be exposure had occurred. It was, however, decided that there was, and still is, the potential for an exposure during maintenance of these systems.
This incident indicated an overall problem with the formal communication of health hazards controls/requirements/ information for incorporation into Maintenance, Utilities, and other organization's work packages and procedures.
Fixing the work order package with the correct PPE information provides for an immediate correction to the PPE situation and rectifies to whom it applies. Corrective Actions are interim measures to effect better and more formal communications and will include corrections for a means of communicating health hazard issues as a major element of longer-term solutions to the formalizing of these communications. Management will decide if any interim corrective actions are continued.
Originator:David C. Murchison, (806) 477-6431
Contact:Beverly Hall, Infrastructure, (806) 477-3222
Name Of Authorized Derivative Classifier:None provided.
Name Of Reviewing Official:John Rayford, LL Program Manager, (806) 477-4009
Priority Descriptor:Yellow / Caution
Keywords:Air Handling Unit (AHU) filters, Beryllium (Be), contamination
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DOE Function / Work Categories:Environmental Protection - General
Environmental Protection - Releases
ISM Category:Analyze Hazards
Develop / Implement Controls
Hazard:Personal Injury / Exposure - Beryllium
Personal Injury / Exposure - Hazardous Material (General)
Personal Injury / Exposure - Infectious Agents
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