ORNL is managed by UT-Battelle for the US Department of Energy

Enforcement Lessons Learned

Ergonomic Manual Lifting and Material Handling Investigation

Presented to EFCOG Regulatory & Enforcement Technical SubgroupDebbie JenkinsORNL Enforcement Coordinator

October 21, 2015

2 Business Sensitive

March1580 lb

chamber tipped over

onto employee, resulting

in fractures and lacerations

(surgery required)

JuneNew 800 lb glove box

tipped over and fell off

stand during installation,

nearly hitting an employee

NovemberEmployee

suffered torn bicep (surgery required) while placing electric

motor on storage cabinet

JuneEmployee diagnosed with hernia

(surgery required) after

lifting long, heavy pipe with 3 other employees

August2600 lb tank fell from a

forklift pallet while being transported

between buildings at SNS

Several incidents indicated weaknesses in material handling activities

20142013

Comprehensive investigations and detailed corrective action plans for each event

3 Business Sensitive

We missed opportunities to learn

What have we learned?

Staff did not maintain a healthy respect for what can go wrong

Supervisor presence in the field was inadequate

Staff and supervisors did not exhibit a questioning attitude or suspend work when things did not seem right

Our programs and work processes did not effectively support safe work performance

Material handling events demonstrated that we are not where we need to be

ORNL permitted to conduct internal investigation of events.

4 Business Sensitive

We conducted a common cause analysis – material handling/lifting events• Eight events were included in the analysis

• Facilitated session with attendees who were part of investigations, root cause analysis determinations, and/or individual ORPS and NTS reports

• Identified common causes and cross-walked to current corrective actions to identify gaps

• Corrective actions were determined to be comprehensive – six additional actions identified to strengthened proposed strategy

5 Business Sensitive

Six common cause statements were identified1. Personnel did not have a full appreciation of the unique hazards associated with

material handling (e.g., load configuration and instability) and their impact on safe work execution.

2. Supervisors and workers did not have a common understanding of what constituted “skill of the worker” activities, leading to inconsistent assumptions regarding hazard identification and work execution.

3. Supervisory oversight did not assure that personnel were adequately prepared to commence work through a pre-job brief or other mechanism and that expectations were understood and being met.

4. Personnel failed to reassess hazards and controls when changed conditions were encountered.

5. “Prior successful execution of material handling activities” led workers to infer that the risk of failure was low and additional planning was not necessary.

6. Information related to prior events was not communicated in a manner that enabled employees to recognize the applicability to their work activities.

Weaknesses in our safety culture contributed to material handling events

6 Business Sensitive

Corrective actions focused on event specific issues, as well as underlying safety culture issues

• Some corrective actions focused on event-specific issues

• Significant effort spent on developing actions to address cultural issues– Key safety principles codified in “The Safe Conduct of Research”– Development/Implementation of LOSA– Sustained commitment to Mentoring Program

• Efforts to change conversation regarding safety– Focus on Hierarchy of Controls – “How much can I lift?” versus

“What is the best way to lift it?”– Knowledge based approach– Improvements to Management Observation Program

Actions focused on cultural aspects of employee interactions, not just creating more paper

7 Business Sensitive

In August 2014, Notice of Intent (NOI) to Investigate was received from OE

• Document Request ReceivedAug26

• NOI transmitted to ORNL

• Enforcement Conference

• On-site Investigation

• Document Submitted

• PNOV Received

Mar 24

Aug 5

Nov 4-6

Sep 16

Jun 16

2014

2015

8 Business Sensitive

Document Request was programmatic, not event specific• Many documents requested were unrelated to events under

investigation– “Safety and health assessments of the jobs with material handling,

lifting, and ergonomics indicated as potential hazards; and the controls that were implemented to control the hazards• Maintenance – 831 documents• Accelerator operations – 967 documents• Reactor operations – 115 documents• Research operations – 788 documents

• Thousands of work control documents reviewed to identify those with identified hazards

• Significant unallowable costs

Communication with OE Enforcement Specialist is key!

9 Business Sensitive

Three-day onsite investigation conducted

• Prep meetings held with those being interviewed• Presented opening briefing with our perspective

of issues• Tour of ORNL facilities/locations where events

occurred• Interviews conducted

– Group interviews– No UT-Battelle presence– Did not interview management

personnel– Interviews included team member at

remote location (teleconference)

10 Business Sensitive

Office of Enforcement investigation report• Investigation report was factually accurate

– Did not identify any new, significant issues– Identified compliance issues related to requested documents that did

not involve events in question– Did not provide factual accuracy comments

• Regulatory citations were consistent with our event investigations

• One area of disagreement - common cause analysis did not identify all relevant factors– Addressed this issue during the enforcement conference

11 Business Sensitive

Enforcement Conference held at ORNL• Emphasis on scheduling with 30 days of receipt of

investigation report• Prepared enforcement presentation – significant

discussion on strategy for conference• Conducted three dry runs• Three presenters

– Laboratory Director– Deputy Director for Operations– ESH Director

12 Business Sensitive

Enforcement Outcome

• Final PNOV - $131,500 (mitigated)

• 50% mitigation received– Post incident measures including a common cause analysis of

ergonomics and material handling events that occurred from June 2013 to August 2014

– Identified the need to address laboratory cultural issues to improve material handling performance

– Enlisted assistance of external SMEs to drive the necessary long-term behavioral and performance changes among management and field personnel