MONTH IN REVIEW – DECEMBER 2012

DAILY REVIEW OF OCCURRENCE REPORTS

Notification Reports

Number or reports reviewed: 79 Number reviewed in November: 103

The percentage of SC3 reports increased from 50% to 58% because of the reduction in SC2 and SCR reports.

The number of ORPS reports involving nuclear safety issues decreased in December following an increase in November. December saw a slight increase in the number of reports involving environmental issues.

The top two PSO’s were EM and NA, contributing to 66% of the reports. The remaining PSO’s contributed34% of the total.

HQ KEYWORDS
A / Authorization Basis (USQ/TSR Violation) / K / Near Miss
B / Conduct of Operations / L / Criticality Safety
C / Electrical Safety / M / Radiological Control/Contamination
D / Environmental Compliance / N / Radiation Exposure (external/internal/skin)
E / Equipment Degradation/Failure / O / Safeguards & Security
F / Fire/Explosive Safety / P / Shipping / QA
G / Industrial Operations / Q / Vehicle Accidents
H / Injury / R / S/CI and Defective Items
I / Hazardous Energy Control / Z / Other
J / Industrial Hygiene Exposure

The top two keyword groups for December were Injuries (19%) and Equipment Failures (16%). The following charts show the 2-year trends with 3-month moving average. Both are showing increasing trends.

Slips, trips and falls caused 60% of the injuries in December and fractures resulted in 55% of these injuries. There was one heart attack (snow removal), two concussions, one laceration, two exposures to chemicals, and one torn rotator cuff.

Reported equipment failures appear to cycle around surveillance and equipment testing schedules.

Last month’s top two keyword groups were Authorization Basis and Injuries.

November 2012 had the highest number of authorization basis reports then any month over the past two years, but authorization basis reports reduced significantly in December. A breakdown of the authorization basis reports for December shows a 50% split between TSR violations and DSA inadequacies. The distribution from March 2012 through December 2012 (10 months) is as follows:

  • TSR and Other Hazard Control Violations – 49%
  • DSA Inadequacies – 48%
  • Nuclear Criticality Safety Violations – 3%

A look at the 2-year trend of all of the keyword groups shows the following:

Continuing Favorable Trends

  • Electrical Safety
  • Environmental Compliance
  • Industrial Hygiene Exposures & Occupational Safety
  • Fire / Explosive Safety
  • Near Miss

Beginning a Favorable Trend

  • Shipping / QA
  • Authorization Basis
  • Conduct of Operations
  • Industrial Operations

Unfavorable Trends

  • Injuries
  • Equipment Failures

Flat

  • Hazardous Energy Control
  • Radiological Controls
  • Criticality Safety
  • Vehicle Accidents

The following is a list of the keyword groups with more than five occurrences for December:

  • Injury (12H)
  • Near Miss (12K)
  • Authorization Basis (12A)
  • Environmental Compliance (12D)
  • Conduct of Operations (12B)
  • Equipment Failure (12E)

Integrated Safety Management –Feedback and Continuous Improvement was cited the most for reports in December, while Analyzing the Hazards was cited most inNovember. December showed an overall improvement in ISM from November.

Facility Function - The distribution of ORPS reports by facility function for the top four categories is shown in the following table.

December / November
Balance of Plant – Infrastructure / 21 / Balance of Plant – Infrastructure / 27
Laboratory R&D / 19 / Laboratory R&D / 17
Nuclear Waste Operations/Disposal / 8 / Nuclear Waste Operations/Disposal / 13
Uranium Conversion/Processing & Handling
Environment Restoration Operations / 5
5 / Tritium Activities / 13

Note:Two categories were tied in the fourth position in December.

Subcontractors–Looking at occurrences in which subcontractors were involved showed a decrease from 19% in November to 13% in December. The percentage for the calendar year is 17% percent.

Significant Reports –No reportsfor December were designated as HQ Significant (13A).

Final Reports

Number or reports reviewed: 54 Number reviewed in November: 44

Number of reports that included an Extent of Condition review: 38(70%)

Operating Experience Consideration

The following final reports were flagged for OPEX product consideration:

Lesson Learned

  1. Mechanical Subcontractor Creates a Short Circuit During Renovation at Building 804 (SNL)
  2. Discovery of potentially shock sensitive material represents a PISA. (ORO)
  3. Management Concern: Potential Issues with Document Review Process (LANL)
  4. Fall From Failed Step Due to Rusted Parts (West Valley)
  5. Discovery of Potentially Shock Sensitive Material in CHGB represents PISA (ORO)
  6. Carpenter received arm injury requiring treatment above first-aid. (Hanford)
  7. Incorrect O-ring installed on vent port plug TRUPACT-II Unit 196 (WIPP)
  8. Failure to Comply with PISA Control (Y12)
  9. Unguarded power transmission apparatus discovered in FTLB penthouse (NREL)
  10. Near Miss - Hand Held Hydraulic Shear Blade Break (Paducah)
  11. Video Inspection of Tank 241-AY-102 Identifies Material on Annulus Floor (Hanford)
  12. Hitch Uncouples Resulting in Detached Trailer (ORNL)
  13. Fall Protection Near Miss During Air Conditioning Work at Building 531 (LLNL)
  14. Failure to Enter LCO Properly for TAM 406 - TSR Violation (U (SRS)
  15. Natural Gas Line Cracked During Excavation Activities (ANL)
  16. NDA Measurements on 9212 E-Wing furnaces (Y12)
  17. Service subcontractor exposed to electrical shock hazard (NREL)
  18. Discovery of Equipment above Surface Contamination Limits at Off-Site Location (Paducah)
  19. Discovery of an uncontrolled non-electrical hazardous energy source (WIPP)
  20. Inadequate Analysis of Material Storage Area Criticality Interaction Condition in a Co-Mingled Array (SRS)
  21. Unexpected Limited Flow of Water During Deluge Preventive Maintenance (Pantex)
  22. DT Shipping Package Foam Concerns(Y12)
  23. Laboratory Hood Fire Event (ANL)
  24. Management Concern for Radiological Skin Contamination (Paducah)
  25. Injured Power Lineman (INL)

Operating Experience Document (Level 1-3)

None

Operating Experience Summary

  1. Recurring Event Report for Employee Exposure to Noise(Hanford)
  2. Workers Receive Mild Electrical Shock from Portable Misting Unit (Hanford)

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