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HEPA Related Lessons Learned
| Identifier: |
2004-RL-HNF-0041 |
| Date: |
10/13/2004 |
| Title: |
Vital Safety System Filter Degradation |
| Summary: |
Contractors must institutionalize site-wide processes/programs that guide facility management in determining operability of safety class equipment such as HEPA filters.
Potential age-related degradation of two ventilation filters at PFP resulted in an Unreviewed Safety Question (USQ). |
| Identifier: |
2004-LL-NUCL-0002 |
| Date: |
9/30/2004 |
| Title: |
Age Degradation of High Efficiency Particulate Air Filters |
| Summary: |
Implementation of new information, such as the tensile strength testing results published in the recent version of the DOE Nuclear Air Cleaning Handbook, can have a significant impact on the validity of design and safety basis assumptions. Therefore, prompt communication and analysis of new information, such as was performed by DOE and PNNL is critical to promptly maintain the safety basis of a nuclear facility such as the RPL. |
| Identifier: |
2004-SR-WSRC-0039 |
| Date: |
9/14/2004 |
| Title: |
Effective Team Approach to Handling and Removal of UF-6 Line |
| Summary: |
During deactivation of the 247-F Facility at SRS, uranium hexafluoride (UF6) process lines needed to be removed. The project team evaluated the hazards and devised a plan to eliminate or mitigate each hazard; one process line was plugged with material and blanked over 10 years ago. Project personnel employed a "team hazards analysis" approach using the Automated Hazards Analysis (AHA) program. Team members from Industrial Hygiene, Engineering, Radiological Controls, and Project Management participated in briefings and conducted mockup training. This team AHA approach led to the successful removal of the UF6 and associated process lines. |
| Identifier: |
2004-RL-HNF-0023 |
| Date: |
6/21/2004 |
| Title: |
HEPA Filter Bank Left in Service without Being Tested |
| Summary: |
A HEPA filter bank at the Plutonium Finishing Plant was found in service following installation of new filters before the filter bank had been leak tested and declared operable by the Surveillance Shift Manager (SSM). Imprecise and incomplete communication between the Person-in-Charge (PIC) and the SSM did not allow the SSM to clearly recognize that the filter dampers were open. A Technical Safety Requirement (TSR) was violated because the SSM did not know existing plant conditions. |
| Identifier: |
2004-RL-HNF-0021 |
| Date: |
5/28/2004 |
| Title: |
Fissile Material Stored in Unapproved Location |
| Summary: |
Transuranic (TRU) fissile waste material was stored in an airlock that was approved by criticality safety but was not covered by the facility safety basis. Two separate people did not properly apply the complex Unreviewed Safety Question (USQ) screening and evaluation process. Plant personnel did not recognize this vulnerability even after two previous events related to storage in airlocks. |
| Identifier: |
2004-SR-WSRC-0014 |
| Date: |
3/30/2004 |
| Title: |
Radiological Operations Support Center - Best Practice |
| Summary: |
At the Savannah River Site (SRS), the Radiological Operations Support Center (ROSC) has been established to provide a centralized resource for practical applications of the "as low as reasonable achievable" approach to work as well as a clearinghouse of information. The ROSC consists of mutually supporting groups targeted at efforts in waste minimization and pollution prevention, radiological hazard reduction and safe, cost effective operations.
In 2003, the ROSC earned an SRS Facility Evaluation Board (FEB) Noteworthy Practice communicated during a FEB evaluation, indicating that this is a particularly effective and efficient, innovative method that has been developed and implemented to meet SRS business needs. |
| Identifier: |
2003-RL-HNF-0004 |
| Date: |
2/21/2003 |
| Title: |
Incorrect Volume of Oil in Hot Cell Window Used in Safety Basis Calculations |
| Summary: |
An Unreviewed Safety Question (USQ) was declared at the Waste Encapsulation and Storage Facility (WESF) because the hot cell shield windows contain more oil than is assumed in the WESF Basis for Interim Operations (BIO). The incorrect amount of oil was obtained from the fire hazard analysis (FHA) but was not verified by the BIO authors before using it in calculations of combustible loading. |
| Identifier: |
Y-2002-OR-BJCX10-1201 |
| Date: |
12/13/2002 |
| Title: |
Site Contamination Due to HEPA Filter Changeout |
| Summary: |
When performing HEPA filter changeouts, the hazard analysis should consider environmental protection as well as worker protection. This is especially important for old and deactivated facilities. |
| Identifier: |
2002-RL-HNF-0059 |
| Date: |
10/17/2002 |
| Title: |
Controlling One Hazard Introduced Another |
| Summary: |
Occasionally controls implemented to mitigate hazards identified during pre-job planning can introduce other unidentified hazards into the job. Those additional hazards must be adequately controlled to maintain a safe work environment. |
| Identifier: |
2002-RL-HNF-0037 |
| Date: |
7/1/2002 |
| Title: |
Adequacy of HEPA Filter Testing |
| Summary: |
Adequacy of downstream aerosol mixing on many older HEPA filter systems has neither been assured through system design nor validated through acceptance testing. Therefore, incorporating compensatory measures into selected test procedures may be necessary to minimize potentially overstating filter performance and to increase confidence that in-place leak tests can reliably identify adverse filter performance on less than ideal HEPA system designs. |
| Identifier: |
2002-RL-HNF-0027 |
| Date: |
5/30/2002 |
| Title: |
ALARA Good Work Practices |
| Summary: |
Many techniques are available for making radiological work safer and more efficient. This document contains brief descriptions of some collected from past reports from the Hanford ALARA Center. They are compiled here for introduction into the DOE Lessons Learned process. |
| Identifier: |
2002-OH-WVNS-004 |
| Date: |
5/5/2002 |
| Title: |
Radioactive Contamination from the Main Plant Stack |
| Summary: |
Excess moisture on a systems high efficiency particulate air (HEPA) filters may allow migration of radioactive contamination through the filters. Engineered systems need to be in place, to ensure moisture build-up is minimized. Any changes, even temporary, to the operational parameters must be incorporated into operator round sheets used to monitor plant conditions. It is also important that even temporary changes (not only physical changes) are incorporated into plant procedures. Further, personnel needs to understand the interaction of environmental changes along with changes in operational parameters during initial design and later modifications. |
| Identifier: |
L-2002-OR-BJCX10-0301 |
| Date: |
3/5/2002 |
| Title: |
Pressurization of Drain Trap |
| Summary: |
Whenever performing a design or design change on any vessel configuration, assure inadvertent pressurization of the vessel is considered in the design. |
| Identifier: |
2002-OH-WVNS-003 |
| Date: |
2/28/2002 |
| Title: |
Flame Observed During HEPA Filter Aerosol (PAO) Challenge Testing |
| Summary: |
To help ensure the safety of personnel and the safe operation of potentially dangerous equipment, it is extremely important that manufacturer's operations and maintenance instructions are strictly adhered to. Manufacturers instructions may include: periodic maintenance and testing of equipment, training of personnel, equipment configuration, and proper operating parameters (ie. air pressure, temperature, etc.). In addition, when manufacturers make administrative changes to the operation and/or equipment modifications, site specific operational procedure changes may be necessary.
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| Identifier: |
2001-RL-HNF-0043 |
| Date: |
12/3/2001 |
| Title: |
HEPA DP Gauge Piping Not Fully Tested after Installation |
| Summary: |
Acceptance tests for installation of new equipment should include full loop tests for instruments with a potential for sensing line errors. Similar care should be exercised following system modifications or major repairs having a potential to affect sensing line configuration. |
| Identifier: |
ALO-AO-BWXP-PANTEX-2001-0013 |
| Date: |
10/11/2001 |
| Title: |
Potential Safety Concern Due to HVAC Filter Change Disturbance of Beryllium Contamination |
| Summary: |
Regardless of our intentions, good communications are essential to understanding requirements and properly accomplishing tasks. |
| Identifier: |
2001-707/776/777PROJECT-01 |
| Date: |
10/5/2001 |
| Title: |
Odorous Full-Face Respirators |
| Summary: |
Always perform a complete pre-use inspection before donning your respirator. If you smell an irritating odor coming from the respirator, reseal it along with the laundry date tag in the bag it came in, and turn it over to your Industrial Hygiene and Safety (IH&S) representative. |
| Identifier: |
L-2001-OR-BWXTY12-0902 |
| Date: |
9/17/2001 |
| Title: |
Use of Portable Vacuum Cleaners Not Intended for Hazardous Materials |
| Summary: |
Portable vacuum cleaners may not be acceptable for use in clean-up of hazardous materials. |
| Identifier: |
2001-NV-NTSWSI-001 |
| Date: |
8/22/2001 |
| Title: |
Airborne Lead Detected in Indoor Firing Range |
| Summary: |
Security companies that operate indoor firing
ranges must ensure the ventilation system is operational during firearms
training activities and that routine clean
up of lead dust occurs.
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| Identifier: |
2001-OH-WVNS-ARPR-006 |
| Date: |
8/20/2001 |
| Title: |
Waste Characterization |
| Summary: |
Sampling activities, such as determining the number of waste streams present, the number of samples required and the containers required for the waste materials for waste characterization should be performed prior to the start of a Project. Because these activities weren’t completed until after the commencement of the dismantlement activities, the Acid Recover Pump Room (ARPR) project was delayed, both in the packaging of the waste materials which were being generated and the sampling which was required to perform characterization. |
| Identifier: |
2001-OH-WVNS-ARPR-005 |
| Date: |
8/20/2001 |
| Title: |
Electronic Dosimetry |
| Summary: |
Electronic dosimetry can save time that would otherwise be spent attempting to read a direct reading dosimeter while in a work area. |
| Identifier: |
2001-OH-WVNS-ARPR-004 |
| Date: |
8/20/2001 |
| Title: |
Dedicated Personnel/Multiple Entries allowed consistency on the Project |
| Summary: |
Keeping personnel consistent through the entirety of an evolution, can reduce the amount of pre-job briefings having to be held and can make the completion of the operation much easier to accomplish. |
| Identifier: |
2001-OH-WVNS-ARPR-003 |
| Date: |
8/20/2001 |
| Title: |
Placement encapsulate any remaining radioactive particulate |
| Summary: |
Grouting the floor of the Acid Recovery Pump Room (ARPR) provided a smooth surface, assisted in encapsulating remaining radioactive particulates and Asbestos Containing Material (ACM) within the work area. |
| Identifier: |
2001-OH-WVNS-ARPR-002 |
| Date: |
8/20/2001 |
| Title: |
Polymeric Barrier Seal (PBS) Encapsulant reduces the level of Asbestos Containing Material |
| Summary: |
Reduction of Asbestos Containing Material (ACM) and radioactive particulate can be achieved by using an encapsulant in the area. This can eliminate unacceptably high Derived Air Concentration (DAC) levels within the area. |
| Identifier: |
2001-OH-WVNS-ARPR-001 |
| Date: |
8/20/2001 |
| Title: |
Roller System Utilized to Remove Waste |
| Summary: |
A roller system was utilized to remove waste from the Acid Recovery Pump Room (ARPR) clean out work area. This system enabled D&D Operators to move the containers with ease, as well as contributing to the ALARA (As Low As Reasonably Achievable) concept requiring D&D personnel to spend minimum time in a radiation the area. |
| Identifier: |
2001-RL-HNF-0030 |
| Date: |
8/16/2001 |
| Title: |
HEPA Vacuums Draw Current above the Rating of Power Cords |
| Summary: |
Euroclean Model UZ948 HEPA vacuum cleaners draw current above that for which the cords and plugs are rated. |
| Identifier: |
ANLW-2001-DI# 2000-0112 |
| Date: |
4/3/2001 |
| Title: |
Solid-State Relay Failure Mode Considerations |
| Summary: |
A common failure mode for solid-state relays (SSR) is shorted or in the "ON" state. When used as part of a heater control circuit, the consequences of such a failure and the resulting uncontrolled temperature increase must be evaluated not only during the design phase, but also during subsequent modifications that affect the established design criteria. |
| Identifier: |
2001-RPP-CHG-IB-01-05 |
| Date: |
3/22/2001 |
| Title: |
HEPA Filtered Exhausters Air Flow |
| Summary: |
Portable HEPA filtered exhausters used for ventilation may be capable of generating air flows higher than the rated flow of the HEPA filters in the exhausters. |
| Identifier: |
2001-OH-WVNS-006 |
| Date: |
2/19/2001 |
| Title: |
Mask Protection Factor Exceeded During D & D Work |
| Summary: |
When planning work in areas with high concentrations of contamination that can become airborne, it is important to identify the levels of contamination prior to work starting and to continuously monitor personnel working in these conditions. Always calculate with a conservative safety factor when determining the required PPE. |
| Identifier: |
2001-RF-KH-0003 |
| Date: |
12/14/2000 |
| Title: |
Beryllium Contamination from Equipment Removal |
| Summary: |
Prior characterization of beryllium contamination is not
sufficient to predict the generation of airborne beryllium contamination
when the work involved may uncover or disturb hidden contamination.
Therefore respiratory protection must be used if there is any question.
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| Identifier: |
L-2000-OR-BJCY12-0802 |
| Date: |
8/24/2000 |
| Title: |
Work Planning and execution need close attention to detail |
| Summary: |
Work planners need to be familiar with the exact configuration of the work site. All people involved in job planning and execution need to share the same understanding of work conditions, requirements, and definitions. In this instance, misunderstood details and incomplete communications led to a confinced space entry violation. |
| Identifier: |
2000-CH-BNL-EP-001 |
| Date: |
7/25/2000 |
| Title: |
Multiple Work Permits Needed on Multi-Work Crew Jobs |
| Summary: |
Some work permit jobs require several service providers or trades phased over a period of time. For jobs like this, the original work permit should be split into multiple work permits to keep the hazards, work controls, and pre-job briefing information well organized by job phase or job crew. The multiple work permits can utilize the original work permit number with suffix letters (A, B, C, etc.) attached for tracking purposes |
| Identifier: |
OH-MD- LL00-170 |
| Date: |
7/6/2000 |
| Title: |
Respirator Failed During Operations |
| Summary: |
PPE should be carefully inspected prior to use. |
| Identifier: |
2000-RL-HNF-0022 |
| Date: |
6/20/2000 |
| Title: |
USQ from Inability to Test HEPA Filtration Efficiency |
| Summary: |
Assumptions in Safety Analysis Reports (SAR) for High-Efficiency Particulate Air (HEPA) filtration efficiency during design basis accidents should be consistent with values actually achievable during periodic testing. |
| Identifier: |
2000-RL-HNF-0017 |
| Date: |
5/22/2000 |
| Title: |
Procurement, Handling, and Storage of Equipment and Components |
| Summary: |
Purchased equipment and components should be packaged, stored, and handled to the same level of requirements imposed on suppliers to prevent damage, deterioration, or contamination of the items before they installed. |
| Identifier: |
2000-LA-LANL-ESH7-0004 |
| Date: |
3/28/2000 |
| Title: |
Recognizing What is Included in Your Work Scope |
| Summary: |
Because certain types of work such as research and development, decontamination and decommissioning, and work with legacy materials inherently involve unknown hazards, work planners should consider establishing hold points for these types of work activities to ensure that workers periodically evaluate current conditions against established hazard controls and work authorization documents. |
| Identifier: |
2000-LA-LANL-ESH7-0003 |
| Date: |
1/21/2000 |
| Title: |
Glovebox Maintenance and Control Issues |
| Summary: |
Glovebox gloves should be routinely inspected regardless of location or frequency of use.
Procedures should address actions for unanticipated conditions discovered during work or at startup.
Line and facility ownership of equipment should be formally documented to prevent loss of information through reorganizations or reassignments. |
| Identifier: |
Y-1999-OR-BJCETTP-0702 |
| Date: |
7/14/1999 |
| Title: |
Respirator Protection Factor for Lead Exceeded |
| Summary: |
Change control processes should ensure that a hazard assessment is conducted any time the work process changes.
Hazard controls should include personal protective equipment that protects workers against the highest potential air concentrations reasonably
expected until air monitoring verifies that engineering controls are adequate.
Indicators should be visible to workers so they can tell when ventilation equipment malfunctions.
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| Identifier: |
1999-OH-WVNS-011 |
| Date: |
5/10/1999 |
| Title: |
Potential Fire Hazard Associated with Polyalphaolefin (PAO) |
| Summary: |
Only one procedural barrier exists that prevents possible fire with
personnel injury or equipment damage when performing PAO testing with a
NUCON model *F-1000-DG-F* Thermal Generator. Site/facility operating
procedures need to comply with vendor recommendations. A new hazard
analysis needs to be performed if a different aerosol is used.
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| Identifier: |
L-1998-OR-BJCETTP-0703 |
| Date: |
7/27/1998 |
| Title: |
Personnel Contamination Event at ORNL |
| Summary: |
The failure to periodically check high-efficiency particulate air (HEPA) filters
for contamination, when on the discharge of a diaphragm pump, can result in
the HEPA filter becoming saturated and contamination exiting the barriers setup
to contain it. It should also be noted that a diaphragm can leak through and
remain operational. |
| Identifier: |
L-1998-OEWS-11 |
| Date: |
4/6/1998 |
| Title: |
Preliminary Notice of Violation (PNOV) at LLNL for Failure to Protect
Workers |
| Summary: |
Failure to implement radiological protection requirements and provide the
quality controls necessary to protect workers involved in High Efficiency
Particulate Air (HEPA) filter shredding operations or to take timely and
appropriate corrective actions when deficiencies are noted, can result in
a Price Anderson Amendments Act (PAAA) Preliminary Notice of Violation
(PNOV). |
| Identifier: |
1998-EM-HQ-0001 |
| Date: |
1/14/1998 |
| Title: |
Nuclear Ventilation HEPA Filter Degradation |
| Summary: |
The fiberglass "paper" media that provides filtration in ventilation filters is subject
to embrittlement with age. This is of concern because many old filters remain in service in DOE Nuclear facilities where they provide an important filtration safety function under normal operating and accident conditions. |
| Identifier: |
Y-1997-OR-LMESCENT-0601 |
| Date: |
6/30/1997 |
| Title: |
Failure to Recognize Changed Conditions Leads to Injury and Contamination |
| Summary: |
Hazard analysis must be an ongoing process that continues throughout
the duration of a project. Supervisors and workers must recognize changes
in job scope, work practices, methods, or operating conditions. Such
information must be communicated to safety and health personnel for
re-evaluation in order to determine whether new or modified controls will
be necessary. Work plans or activity hazard analyses should contain
provisions to temporarily suspend work under such conditions. |
| Identifier: |
1996-DOE-DP-0001 |
| Date: |
10/31/1996 |
| Title: |
Radiation Exposure from Low-Energy Photons
|
| Summary: |
Radiological controls inspector coverage is required for specific work
activities where there is a high potential for unanticipated exposure. In order
to minimize exposure, the use of proper protective equipment for both the
inspector and those performing assigned tasks must be thoroughly evaluated
during job planning. Remember, inspectors can potentially become exposed
to the same radiation sources as those performing the assigned work.
Also, when low-energy photon activity from plutonium is present, electronic
dosimeters must be used, as this low-energy activity is not within the sensitivity
range of self-reading dosimeters (SRDs). |
| Identifier: |
INEL #96251 |
| Date: |
6/22/1996 |
| Title: |
Re-Use of Chemical/Combination Respirator Cartridges
|
| Summary: |
To safeguard the health and safety of respirator users,
facilities need to verify that service received from
respirator vendors is adequate and appropriate. Facilities
need to verify that respirators issued to workers are clean,
in good repair, and that cartridges/canisters supplied by
the vendor provide adequate protection in hazardous
atmospheres. |
| Identifier: |
Y-1996-OR-LMESCENT-0502 |
| Date: |
5/23/1996 |
| Title: |
Contamination Incident and Price-Anderson Amendments Act
Non-Compliance
|
| Summary: |
Clear and timely Contractor-Subcontractor communication is
vital to minimize the potential for violations of work
permits and radiological worker exposures. Not only are
safety and health consequences at risk, but failure to
properly communicate performance expectations could lead to
fines or other penalties to the company under
Price-Anderson Amendments Act (PAAA) provisions.
Additionally, the work control agreements between safety
and health professionals familiar with Contractor protocols
and Subcontractor personnel are essential to safe and
efficient work performance.
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| Identifier: |
L-1995-OR-LMESX10-1201 |
| Date: |
12/21/1995 |
| Title: |
Ventilation Filter Bypass Through Drain Line
|
| Summary: |
Facility management should assess a facility's High
Efficiency Particulate Air (HEPA) ventilation system
configuration against the testing method used to challenge
and measure that system's performance.
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| Identifier: |
1995-RL-WHC-0023 |
| Date: |
5/4/1995 |
| Title: |
Unplanned Exposures to Lead (Pb) |
| Summary: |
Lead is one of several heavy metals that present a hazard to workers at
DOE facilities. Frequent exposure to levels above permissible limits
can result in a body burden that can cause long term health problems.
Jobs that have the potential for creating airborne materials must be
carefully analyzed to ensure adequate respiratory protection is provided
to the workers. In the case at Hanford the powder actuated tool was
evaluated purely for its physical hazards. No one had considered the
fumes from the ignition of the gunpowder as a potential source of
exposure.
The other two cases resulted from inaccurate estimates of the levels of
dust that would be generated.
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This page was last updated on
May 13, 2009
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