Lesson Learned Statement:Procedure requirements for work planning and control, that assure health and safety professionals designate appropriate personal protective equipment (PPE), must be followed to ensure personnel performing the work are protected from identified hazards.Discussion:While performing a task to stage and loosen lids on sludge drums for sampling personnel to visually inspect the drum contents, operations personnel performed an additional step that did not have full health and safety review. The sampling and analysis plan involved adding an additional layer of a solidifying agent to the container if an aqueous layer was present. However, an adequate work package containing appropriate health and safety requirements was not provided to the operations personnel. The original task order for operations personnel only called for staging of drums and loosening of drum lids for the visual inspection of the contents by sampling personnel. The health and safety evaluation for the samplers required use of a respirator and personal air monitoring devices. The requirement for respirators and personal air monitoring devices was instituted because of the potential for personnel exposure to sludge vapors. The additional task of adding a solidifying agent to the drums by operations personnel should have required the use of an approved respirator because of the potential for exposure to the sludge vapors.An investigation was started when this problem was discovered. Based on the short duration of exposure and lack of symptoms by workers, it is believed there were no significant health effects to workers. Personal air monitors (PAMs) worn by sampling personnel revealed no radiological concerns associated with the activity. Analysis:In this event, the supervisor responsible for support of sampling activities by chemical operators initiated the work through a job order. This job order was written to stage containers for sampling/visual inspection per the visual inspection plan, assist sampling personnel, and record movements into a bar code reader, as applicable. It included a listing of waste containers to be staged.Per procedures, a job order may be used for staging of the waste only. Activities other than staging must be described in a work package. When preparing for an operation, work planning procedures require supervisors to analyze the proposed activity and determine the risks to personnel and the potential for adverse reactions, and to consult with health and safety professionals as needed. In this event, the supervisor considered the activity routine and did not contact health and safety professionals for designating PPE for adding solidifying agents to free liquids discovered in the containers of sludge waste. The work planning procedure also requires the supervisor to prepare a work package for activities (like addition of solidifying agent) beyond staging containers for sampling. Work planning procedures require a review of work packages by appropriate health and safety professionals to designate PPE. Since the supervisor did not prepare any work packages, instead relying on a job order, the work planning process did not include reviews for PPE. Since only work packages, but not job orders require a final review by health and safety professionals for PPE, no such review was conducted. An operator contacted the supervisor during this activity and told the supervisor strong odors had been detected upon opening drums, and asked if a respirator was needed. The supervisor told the operator that the job order did not require a respirator, and there was no need to wear one. Preparation for this activity should have included a review by health and safety professionals to designate appropriate PPE. Industrial hygiene personnel contacted after the event reported that air purifying respirators would have been designated for operations personnel adding solidifying agents to free liquids to protect them from potential exposure to organic vapors. The supervisor considered the activity routine and did not ensure appropriate reviews by health and safety personnel. If procedures describing project operations had been followed, health and safety professionals, not the immediate supervisor, would have reviewed the operation and designated appropriate PPE. By not following procedure requirements, workers were at risk because they were not wearing appropriate PPE for the activity being performed. Recommended Actions:The following actions were taken to minimize the chances for recurrence of this event:* A coaching and counseling session was conducted between the responsible manager and responsible person(s) to identify and discuss problems associated with this occurrence. The responsible person(s) committed to correcting the problem. * An all-hands meeting was conducted by the Project Operations Manager that emphasized the need to comply with procedures, pre-job planning, appropriate discipline reviews, and the need for integrating hazard controls in work packages. * A training program was developed for work planners and designated as required training for supervisors. * Supervisors were trained in the program. * Work control measures have been improved through revision of work planning and controlling procedures and clearly defined work package requirements. * Work package approval requirements include an approval by supervisors' management. Originator:Bechtel Jacobs Company, LLC E. Jeffry Lavender, (423) 576-4620 Performance/Quality AssuranceValidator:Brad McKeehan, (423)241-5077 Field ServicesContact:Joanne E. Schutt, (423) 574-1248Name Of Authorized Derivative Classifier:John F. PrestonName Of Reviewing Official:John F. PrestonPriority Descriptor:Red / UrgentKeywords:Sludge, PPE, Vapors, Drum Inspection, Liquid SorbentReferences:Occurrence Report: ORO--BJC-K25WASTMAN-1999-0002; Critique Summary CR-99-003 "Sludge Drum Visual Inspection and Addition of Liquid Sorbent"Information in this report is accurate to the best of our knowledge. As means of measuring the effectiveness of this report please use the "Comment" link at the bottom of this page to notify the Lessons Learned Web Site Administrator of any action taken as a result of this report or of any technical inaccuracies you find. Your feedback is important and appreciated. DOE Function / Work Categories:Environmental RestorationOccupational Safety & Health - General Radiation Protection ISM Category:Hazard:Personal Injury / Exposure - Airborne MaterialsPersonal Injury / Exposure - Hazardous Material (General) Radiological Release
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