Mobile Crane Tips Forward Discussion and Lessons Learned Doug Fogel, Performance Assurance Manager Portsmouth Gaseous Diffusion Plant Fluor B&W Portsmouth May 7, 2015 1
Mobile Crane Tips Forward EM--PPPO-FBP-PORTSDD-2012-0027 / NTS--PPPO-FBP-PORTSDD-2012-0002 Near Miss -- Mobile Crane Tips Forward On October 9, 2012, a wheel-mounted mobile crane tilted forward coming to rest on both its front end and extended boom. There were no injuries. A licensed crane operator was extending the boom from a 60 ton capacity mobile crane with the intent of inspecting the end of the cabling near the spool. When the boom was extended approximately 100 feet w/o the use of outriggers, the weight of the block, cable and boom caused the crane to tip. The crane tilted forward and came to rest on the boom and the front bumper of the crane. Once the crane had stabilized, the operator was able to safely exit the cab and contact his supervisor who reported the event. As a result of the crane being tilted, approximately 1 to 2 gallons of diesel fuel spilled. 2
3
Immediate Actions Taken Notified Plant Shift Superintendent and Emergency Response initiated. Verified no injuries of crane operator. Incident Commander directed that a boundary be erected to control the area and prevent unauthorized entry. Environmental Compliance notified of fuel drip coming from fuel tank cap area. Contained fuel leak. FBP Management, Safety, Performance Assurance and the on-site DOE Facility Representative were notified. All mobile crane usage suspended until further notice. Operator was sent for drug-screening. 4
Immediate Actions Taken A Fact Finding meeting was held. Revoked operating qualifications of personnel involved in the incident. Performed an extent of condition review and developed a matrix of qualifications/certifications status of all site operators for mobile cranes, fixed building cranes, forklifts, and specialty/heavy equipment. Inspected all the mobile cranes and boom trucks for satisfactory operation and/or tagged out of service. Implemented access control for all mobile cranes via key checkout and supervisor authorization process. Developed a pre-op checklist for mobile cranes, which was implemented by Long Term Order (LTO). 5
Corrective Actions Taken 22 Corrective Actions were identified. Among others, the following actions were taken: Briefings given to all Maintenance personnel on ISMS principles and the event Meetings held with all Maintenance Supervisors on roles & responsibilities Additional training developed and presented on: Work Control process Hoisting & Rigging Mobile crane safety (made an annual refresher) 6
Corrective Actions Taken (continued) 22 Corrective Actions were identified. Among others, the following were actions were taken: Hoisting & Rigging Manual Developed Formalized heavy equipment key control program Formalized the use of heavy equipment pre-operational checklists Heavy equipment operating procedures reviewed & revised Required accredited, trained crane operators from subcontractors 7
Timeline of Events 10/31/11 FBP D&D Project Assumes GDP Custody & Site Operations. Moves from NRC to DOE Regulation 10/9/12 Prompt Notification made; ORPS report filed on following day 10/12 12/12 RCA Event Investigation and CAP development 01/25 02/14/13 Fulfilling Document Requests 11/13 1/14 Enforcement Conference preparation 07/24/14 FBP Acknowledges PNOV 10/9/12 Crane Tip Event 11/15/12 NTS Report Submitted 01/16/13 Notice of intent to Investigate 04/8 04/12/13 OE Investigation Conducted 10/28/13 Investigation Report Issued 01/22/14 Enforcement Conference 07/08/14 PNOV Issued 8
Preparation for OE Investigation FBP Preparations included the following: Team introduction and preliminary detail conference call Charge Number set up for segregation of costs Established team to address DOE OE document requests Documents sent electronically and by disc Documents printed, indexed, and available in interview room Encouraged early completion of corrective actions identified in CAP Requested time in Entrance Meeting to make short presentation Assembled Senior Managers and SMEs to prepare Entrance Meeting presentation Self-identified program weaknesses Held dry runs of presentation Conducted tour of event scene and limited site tour 9
Preparation for OE Investigation ESH&Q Manager and Performance Assurance Manager briefed interviewees OE investigation process and selection of interviewees Conduct of interviews: Individual interviews Union members may have Union Representation Can be conducted one-on-one or by investigation team Information will be confidential Interview Tips: Review pertinent information prior to the interview Relax they re not out to get you Answer the questions asked -- honestly and completely Don t relay assumptions/fill in the gaps It s okay to say I don t know but will get back with you. 10
OE Investigation Entrance Meeting Senior Manager Briefing All Directors in attendance Site Project Director, Event Owning Director, and ESH&Q Director presented overview of site transition: Most complex transition in DOE history Regulatory transition: NRC to DOE Dual operations SAR and BIO Consolidation of contracts Phased transition of 2 former contractors into FBP, Teaming Subcontractor, and 2 mentor Protégé Subcontractors Security program and infrastructure maintenance provided by another DOE prime contractor 11
OE Investigation Entrance Meeting Senior Manager Briefing D&D contract scope significantly expanded to complete accelerated delease of all former NRC regulated facilities Nuclear operations Uranium management Utility operations and service provider ISMS implementation status Immediate focus on highest hazard operations 5 event common cause analysis performed Implemented Reach-back program/process Numerous improvement initiatives centered on 5 ISMS Core Functions Site Project Director s Areas of Focus Where are we now? 12
Enforcement Conference Attendance limited to involved senior site management, corporate parent ESH&Q Directors, and Performance Assurance Manager Presentation: Senior Manager input, reviews, and dry runs Agreed with OE Investigation Report conclusions Summarized adjudication key points Emphasized accelerated and improved safety culture initiatives Provided factual accuracy comments Reviewed root and contributing causes for each noncompliance Provided summary corrective action lists and effectiveness evaluations for each Discussed mitigating factors: Event was self-revealing Prompt reporting Immediate actions and comprehensive investigation Programmatic ally focused corrective actions Prior fee reduction associated with event, 10 CFR 851.5(c) referenced 13
Enforcement Conference Room Preparation: Layout Name Tents Presentation computer-projected Presentation materials provided to OE to facilitate note-taking Call-in number provided Post-conference: Senior Manager debriefing Published meeting minutes / shared with OE for information 14
Final Investigation Results PNOV identified three noncompliances: Severity Level 1 Crane Operational Safety Severity Level 2 Hazard Identification, Assessment, Prevention and Abatement Severity Level 2 Training and Information Contract fee reduction previously imposed; no civil penalty proposed 15
Lessons Learned Incident Response: Immediate responsive actions and interim corrective actions are often necessary for safety issues and scene preservation Prompt reporting ORPS & NTS Ensure investigation is thorough and comprehensive Root Cause identified Contributing Causes identified Thorough extent of condition review Document document document 16
Lessons Learned Investigation preparation: Maintain open communications with OE promotes a good working relationship and ensures that additional information is provided if not requested Document Requests set up an electronic file transfer protocol if possible; it works better than e-mail and Fed-Ex. Prepare your interviewees; most are apprehensive and have never gone through an OE investigation Provide a site tour promotes better understanding of event, the site, and provides opportunity for informal discussion If unique circumstances exist, request opportunity to discuss at inbriefing Be available and flexible interview schedules will change routinely 17
Lessons Learned Enforcement Conference: This is your meeting: Use table tents it s helpful for both DOE OE and site personnel Provide a handout good for note-taking Do dry runs of presentation until comfortable Provide factual accuracy comments Provide an update on corrective actions and an effectiveness statement(s) Discuss mitigating factors 18
Questions? 19