Document z71GEYyzdqeR5NMyJDgxJKQn

SUMMARY OF EO CENTER PSM AUDIT Co n d u c t e d d u r in g Oc t o b e r , 1991 MAJOR STRENGTHS Kn o w l e d g e a b l e l in e , t e c h n ic a l , a n d w a g e r o l l e mp l o y e e s t h a t d e mo n s t r a t e a HEALTHY RESPECT FOR THE HAZARDS INVOLVED WITH THE EO CENTER OPERATIONS. Us e o f PLC's t o e l imin a t e h u ma n e r r o r d u r in g o p e r a t io n o f EO r e a c t o r s . Op e r a t o r s f o r ma l l y in v o l v e d in 01 r e v ie w s a s p a r t o f IS0-9000 c e r t if ic a t io n e f f o r t . 01*S a n d p r o c e d u r e s w e r e in v e r y g o o d s h a p e . Se l e c t io n a n d c o n t r o l o f c o n t r a c t o r s . On g o in g e f f o r t t o u p g r a d e a r e a d o c u me n t a t io n , p a r t ic u l a r l y g e n e r a t io n o f d e t a il e d e q u ip me n t a n d in s t r u me n t a t io n d e s c r ip t io n s . AREAS FOR IMPROVEMENT El imin a t io n o f c r it ic a l p ip in g a n d e l e c t r ic a l d e v ic e s t h a t d o n o t me e t EXISTING CODES. De v e l o p me n t /u p g r a d e o f p r o c e d u r e s d e a l in g w it h c o mp l e t e u t il it ie s l o s s a n d E&D s it u a t io n s . Imp r o v e c o n d it io n o f e x is t in g g r o u n d in g d e v ic e s a n d c o n t r o l p a n e l in d ic a t o r l ig h t s a n d a l a r ms . Qu a l if ic a t io n a n d t r a in in g o f o p e r a t o r s , me c h a n ic s , a n d t h e ir s u p e r v is o r s (a p p l ie s t o e n t ir e p l a n t s it e ). De v e l o p me n t o f a p r o c e d u r e f o r t r a c k in g o f o p e n PHR r e c o mme n d a t io n s v s . r e l ia n c e o n e x p e r ie n c e (a p p l ie s t o e n t ir e b u s in e s s u n it ). Co mp l e t e n e s s , p r o p r ie t o r s h ip o f e q u ip me n t f il e s a n d e q u ip me n t ma in t e n a n c e h is t o r y (a p p l ie s t o e n t ir e u n it ). Pr o c e d u r e s /me c h a n is ms f o r e v a l u a t in g e q u ip me n t a n d v e s s e l in s p e c t io n /TEST d a t a (a p p l ie s t o u n it ). Mo r e f r e q u e n t u p d a t in g o f b u il d in g c h e mic a l h a z a r d l is t (a p p l ie s t o u n it ) . Eme r g e n c y Re s p o n s e d r il l s a n d t e s t in g o f e v a c u a t io n a l a r ms n e e d t o b e u p g r a d e d (f r e q u e n c y a n d /o r d o c u me n t a t io n ) , COMMENTS A NUMBER OF PROGRAMS ARE UNDER WAY OR UNDER CONSIDERATION FOR BUILDING UPGRADE Ex is t in g d e f ic ie n c ie s e mp h a s iz e t h a t u p g r a d e s h o u l d c o n t in u e t o b e a p r io r it y . o We s t w a l l is f a il in g . o So me s e c t io n s o f EO p ip in g d o n o t me e t p ip e c o d e a n d w e r e n o t in c l u d e d in "t h ic k n e s s c h e c k s ". o El e c t r ic a l f ix t u r e s t h a t d o n o t me e t t h e e l e c t r ic a l c l a s s if ic a t io n g u id el in es . o In a d e q u a t e s p r in k l e r p r o t e c t io n a n d w a t e r s u p p l y c o n c e r n s . o Ex it d e f ic ie n c ie s . It 's d if f ic u l t t o d r a w c o n c l u s io n s b a s e d o n a "f e w " f ie l d o b s e r v a t io n s . Ho w e v e r , t h e a r e a s h o u l d f o l l o w -u p t o in s u r e t h a t t h e r e is a n u n d e r s t a n d in g o f "s a f e t y " p r e c a u t io n s v s . a "b y t h e n u mb e r s " a p p r o a c h . o Al a r m l ig h t s t e s t e d b u t d e f ic ie n c ie s w e r e n o t c o r r e c t e d . o Br o k e n (t h r o u g h ) g r o u n d w ir e in u s e a t f l a mma b l e l o a d in g /u n l o a d in g s p o t . o EO Ra il Ca r g r o u n d a l a r m n o t f u n c t io n in g p r o p e r l y . DUP050073880 RECOMMENDATIONS FOR THE CHAMBERS WORKS SITE... De v e l o p g u id e l in e s f o r d e a l in g w it h c h a n g e s t o 01rs t h a t o c c u r d u r in g START-UP ON TA. De v e l o p p r o g r a m t o p r o v id e r o u t in e in s p e c t io n o f g r o u n d w ir e s . De v e l o p g u id e l in e s f o r a d d r e s s in g t r a in in g o f n e w l y a s s ig n e d SUPERVISION. Ch a n g e s t a r t d a t e f o r o n e y e a r l imit o n PHR c l o s u r e t o d a t e s t a t u s REPORT ISSUED (VS. DATE PHR NUMBER REQUESTED), OR INSTRUCT PHR CHAIRPERSON TO REQUEST NUMBER OUST PRIOR TO ISSUANCE OF STATUS REPORT. Ne e d b e t t e r e d u c a t io n a r o u n d a v a il a b il it y o f De c is io n Tr e e f o r d e t e r min in g a p p r o a c h t o PHR. Cu r r e n t l y r e l y v e r y h e a v il y o n ex per ien c e. FOR PERFORMANCE PRODUCTS (in c l u d in g THE EO Ce n t e r )... In c l u d e u p d a t e o f a r e a c h e mic a l h a z a r d l is t imme d ia t e l y (v s . a n n u a l l y ) WHEN A NEW MATERIAL IS ADDED TO AREA. De v e l o p t r a c k in g s y s t e m f o r o p e n r e c o mme n d a t io n s o n PHR's . Cu r r e n t l y , MANY LOW PRIORITY ITEMS "MASK" PRIORITY OF POTENTIALLY SIGNIFICANT ITEMS REQUIRING IMMEDIATE ATTENTION. Up g r a d e b u il d in g E&D ma n u a l s t o in c l u d e c u r r e n t p h o n e n u mb e r s , LOCATION OF PULL STATIONS FOR DELUGE SYSTEM, EMERGENCY SHUT DOWN PROCEDURES, ALARM TEST FREQUENCY, AND BUILDING EVACUATION ROUTES. Pr o v id e a d d it io n a l t r a in in g in PHR me t h o d o l o g y f o r PHR c h a ir p e r s o n s . Ne e d a b e t t e r u n d e r s t a n d in g o f t h e w h y a n d w h a t f o r e q u ip me n t f il e s (p u mp s , PVIs , v e s s e l s , t a n k s ). DUP050073881 FOR THE EO CENTER.... Br in g f r e q u e n c y o f e me r g e n c y d r il l s in t o c o mp l ia n c e . De v e l o p b u il d in g "Eme r g e n c y Sh u t d o w n " p r o c e d u r e d e t a il in g h a z a r d s b y PRODUCT IN THE EVENT OF THE LOSS OF VARIOU$/ALL UTILITIES. De v e l o p c a t a s t r o p h ic f a il u r e p r o t e c t io n in S02 h a n d l in g s y s t e m s imil a r TO THE ONE IN PLACE FOR EO (XS FLOW VALVES). In s t a l l b a r r ic a d in g a r o u n d w e s t w a l l t o l imit h a z a r d s f r o m f a l l in g BRICKS WHILE PIPE SUPPORTS ARE BEING RELOCATED PRIOR TO WALL DISMANTLEMENT. Co mmu n ic a t e in s p e c t io n r e q u ir e me n t s o n f ir e d o o r s a n d f ir e e x t in g u is h e r s . Al s o s u g g e s t r o t a t in g r e s p o n s ib il it y o f Eme r g e n c y /Sa f e t y Eq u ip me n t c h e c k s (s a f e t y s h o w e r , f ir e e x t in g u is h e r s , e t c .) t o in c r e a s e a w a r e n e s s Of l o c a t io n s a n d f u n c t io n . Ex p a n d in v o l v e me n t o f w a g e r o l l e mp l o y e e s in PHR p r o c e e d in g s . De v e l o p t e s t p r o g r a m f o r "Fe e d in g EO" w a r n in g l ig h t o u t s id e r e a c t o r r o o m, OR CONSIDER ALTERNATE APPROACH TO WARNING/COMMUNICATION SYSTEM THAT WILL ELIMINATE THE WARNING LIGHT ALTOGETHER. De v e l o p p r o c e d u r e /p r o g r a m t o a d d r e s s in o p e r a t iv e p a n e l l ig h t s in b o t h EO REACTOR CONTROL ROOM AND PET ADDITIVES REACTOR PANELS. Te s t b u il d in g v e n t il a t io n s y s t e m v s . d e s ig n c a p a c it y t o e n s u r e ADEQUATE DILUTION OF EO IN THE EVENT OF LEAKS. Ad d s t a t e me n t t o v a r io u s EO a d d u c t s 0Irs t o e x p l a in h a z a r d a s s o c ia t e d WITH REACTOR NITROGEN PRESSURE BELOW 9 PSIG. Ad d s t a t e me n t t o 01's r e q u e s t in g l a b e l c h e c k o n in c o min g $02 c y l in d er s . DUP050073882 GENERAL Ha z a r d o u s c h e mic a l s in u s e in EO Ce n t e r : -S02 in t o n s . Tr a n s f e r r e d u s in g v a p o r p r e s s u r e in t o b r in e -c o o l e d WEIGH TANK. - ETHYLENE OXIDE (EO) FROM RAIL CARS. EMBRYQTOXIN, TERATOGEN, FLAMMABLE. - SODIUM HYDRIDE. VIOLENT RXN WITH MOISTURE (SAME AS ELEMENTAL Na ) - LUBRIZOL 11 - TERT BUTYL PEROXIDE WHICH AUTODECOMPOSES >40C. - FLAMMABLE SOLVENTS; TOLUENE, XYLENE EO CENTER CONSISTS OF 6 PROCESSES WHICH YIELD APPROX. 70 PRODUCTS. Mo s t o f h a z a r d s in v o l v e h a n d l in g o f r a w ma t e r ia l s r a t h e r t h a n r x n s o r f in is h ed pr o d u c t s . 2 MAJOR INCIDENTS IN RECENT PAST: Ex p l o s io n in RE-2 in '89 d u r in g mf g o f THP 20E0. Rx n ma s s w a s s t il l IN f l a mma b l e r e g io n d u e t o in a d e q u a t e p u r g in g . N2 p r e s s u r e r a is e d FROM 3PSIG t o 9 PSIG TO AVOID REPEAT. SAME PROBLEM MAY HAVE RESULTED IN "BLACK" CHARGES OF PDG-15. Ap p r o x 10 l b s o f t o l u e n e d is c h a r g e d f r o m c a u s t ic s c r u b b e r in t o d it c h WHILE WELDING WAS GOING ON. SPARKS IGNITED TOLUENE. TOLUENE PRESENCE UNDETECTABLE EXCEPT IF MEASUREMENT TAKEN DIRECTLY OVER DITCH. Sc r u b b e r c o n t e n t s n o w d is c h a r g e d t o T/T f o r d ir e c t d is c h a r g e t o WWTP. Al s o a v ic t im o f a "Ne a r mis s " w h e n t a n k l id f r o m OV e x p l o s io n r o l l e d PAST LOADED EO RAILCARS. ***************************4^***************************************** QUESTION REVIEW NOTES I. PROCESS TECHNOLOGY Ha z a r d s o f Ma t e r ia l s Ha z a r d in f o o f MSOS s u mma r iz e d in 01's, w h ic h a r e t h e ma in s o u r c e o f HAZARD INFO FOR THE OPERATORS. HAZARD INFO ALSO APPEARS IN AREA CHEMICAL LIST (SPILL CONTROL PROCEDURE), BUT UPDATES REFLECTING THE ADDITION OF NEW MATERIALS TO AREAS WON'T OCCUR UNTIL LIST IS SUBMITTED FOR ANNUAL UPDATING. DUP050073883 TEC HNI CAL./ PRODUCT! ON PERSON MAKES DECISION ON HOW NEW HAZARD INFO IS COMMUNICATED TO OPERATORS, WITH "UNIQUE" HAZARDS, THE NEW 01 'S ARE REVIEWED PAGE-BY-PAGE WITH OPERATORS. IF THE TECHNOLOGY IS SIMILAR TO THAT WHICH IS ALREADY IN PLACE, THE OPERATORS ARE EXPECTED TO REVIEW THE OI'S ON THEIR OWN. Pr o c e s s De s ig n Ba s is Pr o c e s s f il e s in JL h a v e b e e n f o u n d t o b e l a c k in g c o p ie s o f a l l PROCESSES, SO A "MASTER" FILE IS BEING SET UP IN SUE BOWEN'S OFFICE TO PROVIDE READY REFERENCE FOR CONSULTANTS AND ATOS. Ne w t e c h n ic a l s t a n d a r d s (s in c e '89) u s e d f o r DMA 450 p r o c e s s s h o w n INTENSIVE APPROACH TO HAZARDS OF INDIVIDUAL RAWS, HAZARDS OF PROCESS STEPS ARE COVERED IN PHRS. A PROCESS UPDATE WILL NOT NECESSARILY TRIGGER AN 01 UPDATE, BUT THIS SHOULD NOT CREATE A HAZARD SINCE THE 01 WILL BE "CURRENT" WITH ALL TA'S. Pr o c e s s c h e mis t r y is d e s c r ib e d a s b e s t a s i t 's u n d e r s t o o d . Sid e r x n s , BY-PRODUCTS ARE ONLY DESCRIBED IF THEY ARE DEEMED "SIGNIFICANT" BY THE R&D CHEMIST. De s c r ip t io n o f s a f e t y a n d h e a l t h c o n s e q u e n c e s o f p r o c e s s d e v ia t io n s ARE DONE ON AN EXCEPTION BASIS. MOST DEVIATIONS IN EO CENTER LEAD TO QUALITY, RATHER THAN SAFETY, PROBLEMS (COLOR FORMATION). PLC'S FOR ETHOXYLATORS PROVIDE "FAIL SAFE" PROTECTION DURING LOSS OF UTILITIES WHICH REMOVE RELIANCE ON OPERATOR ACTION FOR CORRECTIVE a c t io n . Th is p r o t e c t io n is n o t in p l a c e f o r k e t t l e s l a c k in g PLC CONTROL (PROJECT ACTIVITY UNDER WAY TO INSTALL THIS CAPABILITY). Eq u ip me n t De s ig n Ve s s e l s , in s t r u me n t a t io n , a n d in t e r l o c k s a r e d e s c r ib e d in d e t a il in a s e r ie s o f o p e r a t in g p r o c e d u r e s (v s . in c l u s io n o f s a me in f o in mu l t ip l e OI's). Bl u e p r in t s , p u mp c u r v e s , r e l ie f in f o , e t c n o t k e p t in b u il d in g FILES TO ENSURE INFO IS CURRENT WHEN NEEDED. Ap p e a r s t o me e t n e c e s s a r y d e s ig n c o d e s r e f e r e n c e d e x c e p t f o r NFPA, a l o n g w it h el ec t r ic al an d pipe c o d e d is c r epan c ies n o t ed abo v e. No e n e r g y b a l a n c e s e x is t f o r EO p r o c e s s e s . Sp r in k l e r s y s t e m o n Pe t Ad d it iv e s s id e o f EO c e n t e r is n o t a d e q u a t e , l imit e d b y s u p p l y c a p a c it y o f w a t e r l in e . Pr o j e c t a c t iv it y u n d e r w a y TO REMEDY SITUATION. II. PROCESS HAZARDS ANALYSIS Ge n e r a l DUP050073884 Co n s e q u e n c e s o f v a r ie t y o f f a il u r e s is a v a il a b l e , b u t n o t INCLUDED IN SITE ER PLAN, NO EMERGENCY RESPONSE PROCEDURES FOR CATASTROPHIC FAILURES OF S02 SYSTEM, Pr o c e s s Ha z a r d Re v ie w s Se v e r a l PHR's w e r e a d d e d t o b u il d in g s c h e d u l e in r e c o g n it io n o f EXISTING HAZARDS THAT HAD NOT BEEN PREVIOUSLY ADDRESSED: EO T/C MOVEMENT FROM THE PLANT GATE TO EO UNLOADING SPOT; CATALYST FEEDING OPERATION. An r e v ie w o f 4 PHR's f o r t h e EO c e n t e r s h o w e d g o o d a w a r e n e s s o f "OUTSIDE" FACTORS (OVERHEAD PIPES THAT MIGHT LEAK, AIR MOVEMENT FROM AGITATOR DRIVE). MOST OF THE PHR COMMITTEE'S LACKED PARTICIPATION FROM WAGE ROLL EMPLOYEES, LARGELY DUE TO CONFLICTS WITH THE ROTATING SHIFT SCHEDULE, CWIK JLDOC SYSTEM USED TO TRACK STATUS OF PHR'S. THE START OF THE ONE YEAR LIMIT ON CLOSURE OF PHR'S BEGINS THE DATE THE PHR NUMBER WAS ISSUED, NOT THE DATE THE PHR STATUS REPORT WAS ISSUED. IN SEVERAL EXAMPLES, THE LAG BETWEEN THE ISSUANCE OF THE NUMBER AND THE STATUS REPORT DATE WAS 4-6 MONTHS. EO CURRENTLY HAS ELECTRIC VALVES IN PLACE ON THE EO STORAGE TANK VENTS. IN THE EVENT OF AN ELECTRICAL FAILURE DURING AN UNLOADING OPERATION, THESE AUTOMATIC VALVES WILL REMAIN LOCKED IN THEIR EXISTING p o s it io n . Du r in g t h is e v e n t , a n o p e r a t o r mu s t r e me mb e r t o c l o s e a MANUAL VALVE TO PREVENT VENTING THE TANK CONTENTS TO THE ATMOSPHERE. NO SYSTEM IN PLACE TO TRACK SPECIFICS OF OPEN RECOMMENDATIONS, ' WHICH MAY CONTRIBUTE TO LOW PRIORITY FOR CRITICAL IMPROVEMENTS. THIS IS CURRENTLY BEING ADDRESSED THROUGH THE EXPERIENCE OF THE PRODUCTION STAFF, BUT RAPID TURNOVER IN PERSONNEL COULD UNDERMINE THIS APPROACH. Mo s t s c h e d u l e d PHR's h a v e a t l e a s t h a d a s t a t u s r e p o r t is s u e d . Re p o r t s f r o m '89 a r e c ir c u l a t in g f o r c l o s u r e . Ge n e r a l l y g o o d p r o g r e s s s een in t h is ar ea. III. MANAGEMENT OF CHANGE - TECHNOLOGY De t a il s o f TA c o mmu n ic a t e d t o o p e r a t o r s v ia mo d if ie d 01's a n d , w h e r e DEEMED NECESSARY, COMMENTS IN "NlGHT BOOKS". ELECTRONIC APPROVAL OF TA'S HAS BEEN USED DURING TIME CRUNCHES, BUT THIS APPROACH MAY NOT PROVIDE AN "OFFICIAL" SIGNED COPY FOR AN OPERATOR TO SEE SHOULD HE/SHE REQUEST IT, TMR'S INCLUDE A COPY OF MSDS FOR ANY NEW MATERIALS INTRODUCED TO AREA, BUT TMR WILL NOT APPEAR ON THE OPERATING FLOOR. TMR IS NOT SIGNED BY BARBARA DAWSON u n t il MSD Sh e e t is in e l e c t r o n ic f il e . DUP050073885 Ch a n g e s t o 01's o f t e n o c c u r d u r in g s t a r t -u p o n TA, Ch a n g e s ma y b e "min o r ," b u t a r e o u t s id e o f t h e n o r ma l a u t h o r iz a t io n s y s t e m f o r TA a p p r o v a l . Le f t t o d is c r e t io n o f c o n s u l t a n t s a n d ATO's . Ve r y f e w o p e r a t o r s w il l a s k t o s e e c o p y o f TA t o p r o v e c h a n g e is a u t h o r iz e d . Mo s t r e l y o n s e e in g a u t h o r iz e d 01 rs (s ig n e d b y Ar e a Mg r ). IV, OPERATING INSTRUCTIONS Sa f e t y & Oc c u p a t io n a l He a l t h To x ic e f f e c t s o f t h e v a r io u s r a w ma t e r ia l s a r e d is c u s s e d in t h e INTRODUCTORY PAGES OF THE OI'S. SPECIFIC PPE NEEDS ARE ADDRESSED AT THE ACTUAL OPERATING STEP WITHIN THE 01 S, Th e r e s p o n s e t o a COMPLETE l o s s o f u t il it ie s is n o t s p e c if ic a l l y ADDRESSED IN 0IrS. THE LOSS OF MULTIPLE UTILITIES IS ADDRESSED IN THE PLC PROGRAMMING. SUGGEST DEVELOPING A MATRIX BY PRODUCT ADDRESSING SPECIFIC RESPONSE STEPS FOR THE LOSS OF UTILITIES TO BE in c l u d e d in "Eme r g e n c y Sh u t d o w n " p r o c e d u r e . Th is c a n a l s o s e r v e a s a TRAINING TOOL, PROCEDURE DOES NOT CURRENTLY EXIST FOR THE EO CENTER. Sp il l a n d Ch e mic a l Re l e a s e Co n t r o l Th e l is t o f c h e mic a l h a z a r d s in t h e EO Ce n t e r is n o t in c l u d e d in a Sp il l Co n t r o l OP, n o r s h o u l d it b e a s t h is w o u l d s u b j e c t it t o a 2->3 YEAR REVIEW CYCLE. Th e r e is g o o d c o v e r a g e o f s p il l c o n t r o l r e q u ir e me n t s in t h e a r e a OP, EXCEPT FOR TRAINING IN SPILL CONTROL RESPONSE. THIS INFORMATION IS READILY ACCESSIBLE, OTHER THERE WAS SOME QUESTION AS TO HOW MANY PEOPLE KNEW OF ITS EXISTENCE. Th e AREA HAS HAD 1 SPILL YTD. A DMA-65SD T/C WAS FOUND TO HAVE A LEAKING LEAKING INTERNAL VALVE AND WAS SENT TO RAIL YARD FOR r e p a ir s . Wh il e a t y a r d , a l e a k in g s t e a m c o il w a s n o t ic e d . Th e c a r WAS NOT PLACARDED OR TAGGED FOR THE LEAKING COIL. EVENTUALLY, THE T/C WAS RETURNED TO THE AREA WITHOUT NOTIFICATION OF THE LEAK. Th e CAR WAS RELOADED AND SUBSEQUENTLY LEAKED. EO NOW TRACKS CARS SENT FOR REPAIRS ON A BOARD AND CONFIRMS REPAIRS PRIOR TO USE. Eq u ip me n t a n d In s t r u me n t a t io n Sk e t c h e s o f a l l e q u ip me n t s e t s a p p e a r in t h e a p p r o p r ia t e 01's f o r KETTLES NOT CONTROLLED BY THE PLC. FOR THE PLC CONTROLLED VESSELS, THE PANEL GRAPHICS ARE USED TO DISPLAY THE EQUIPMENT CONFIGURATIONS. Ke y INSTRUMENTS ARE LISTED IN A BUILDING OP, SIMILAR TO THE OP FOR EQUIPMENT. DUP050073886 Op e r a t in g St e p s As PART OP THE 01 UPDATES TO COMPLY WITH ISO-9000 REQUIREMENTS, OX'S ARE BEING REVIEWED BY KNOWLEDGEABLE OPERATORS FOR AGREEMENT WITH FIELD EXPERIENCE. Ma n y TEMPERATURE AND PRESSURE TARGETS ARE BEING MODIFIED TO INCLUDE A RANGE (X00 +/- 2) INSTEAD OF JUST A TARGET (100). Th e r e is n o e x p l a n a t io n f o r t h e n e e d f o r a min imu m 9 p s x n it r o g e n PRESSURE (TO AVOID A FLAMMABLE CONCENTRATION REGION) IN THE MERPOL 00 0I7S. Ch ECKSHEETS ARE USED FOR START-UP OF PRODUCTS THAT ARE NOT COVERED BY THE PLC. Fo r PRODUCTS CONTROLLED BY THE PLC, A SERIES OF INTERLOCKS ENSURE APPROPRIATE COMPLETION OF INERTING, VALVE SETTINGS, ETC. Dir e c t d e l iv e r ie s f r o m t h e S02 v e n d o r in c o l o r -c o d e d c y l in d e r s a r e USED TO MINIMIZE RISK OF USING WRONG MATERIAL. HOWEVER, THERE IS NO SPECIFIC STATEMENT IN OI'S REQUIRING OPERATORS TO CONFIRM IDENTITY OF ma t e r ia l By r e a d in g l a b e l . CQA's FOR "c r it ic a l " r a w ma t e r ia l s (e s s e n t ia l t o f in is h e d p r o d u c t q u a l it y ) a r e f a x e d t o QCL p r io r t o r e c e ip t o f ma t e r ia l * Th e o v e r a l l RAW MATERIAL ACCEPTANCE PROCEDURE IS DEFINED IN THE UNIT-WIDE RAW MATERIAL PROCEDURE. Sa f e Wo r k Pr a c t ic e s Th is t o p ic a d d r e s s e d in Sa f e t y Ho w Te c h n o l o g y Ce n t e r Ar e a 01's a r e c u r r e n t l y r e -is s u e d o n a 2 y e a r r e v ie w c y c l e . Th e ir CONFORMANCE WITH PROCESS TECHNOLOGY IS RECORDED IN A STATEMENT ON THE SIGNATURE PAGE OF THE QIrS. AS STATED ABOVE, OPERATORS ARE NOW INTIMATELY INVOLVED IN THE OX REVIEW PROCESS AS PART OF THE EFFORT TO COMPLY WITH IS0-9000 r e q u ir e me n t s . Ma j o r c h a n g e s t o t h e 01's a r e c o mmu n ic a t e d v ia a SPECIAL TRAINING SESSION FOR THE OPERATORS. OPERATORS ARE MADE AWARE OF MINOR CHANGES THROUGH A NOTE TO THEIR TEAM MGR. Du r in g t h e f ie l d t o u r , s e v e r a l 01's w e r e s p o t c h e c k e d f o r "UNAUTHORIZED CHANGES1. ALL WERE FOUND TO BE IN COMPLIANCE WITH PSM r e q u ir e me n t s (in it ia l e d b y Ar e a Mg r ). V. PERSONNEL TRAINING AND PERFORMANCE Co mp l ia n c e w it h ma n d a t e d r e q u ir e me n t s r a n g e s f r o m g o o d t o POOR, DEPENDING ON THE SUBJECT MATTER. HISTORICALLY THERE HAS BEEN A LOW AWARENESS LEVEL OF THE AMOUNT OF MANDATED TRAINING THAT IS NEEDED. DUP050073887 Tr a in in g p r o g r a ms a r e l imit e d b y t h e a v a il a b il it y o f a s u it a b l e TRAINING FACILITY, Th e r e is o n l y a l imit e d a mo u n t o f t r a in e r s e l e c t io n t a k in g p l a c e o n THE SITE, AS GUIDELINES DO NOT CURRENTLY EXIST, A NEW EMPLOYEE CHECKLIST IS NOT YET AVAILABLE, BUT IS BEING DEVELOPED. Th e s it e 's 30/60/90 d a y f o r m f o r n e w e mp l o y e e s is in u s e . Th e r e is n o f o r ma l b u d g e t f o r o p e r a t o r t r a in in g . To d a t e , 23 OPERATORS HAVE ATTENDED THE FIRST WEEK OF A 3 WEEK BASIC SKILL TRAINING PROGRAM (NUS) THROUGH PPD. Re f r e s h e r a n d b a s ic j o b t r a in in g f o r EHS s k il l s is in g o o d s h a p e THROUGH THE USE OF CLASSROOM AND FIELD TRAINING. TRAINING WEAKNESS USUALLY EXIST WHERE NOT MANDATED BY STATE OR FEDERAL RETIREMENTS. Le s s o n p l a n s a r e b e in g d e v e l o p e d (s imil a r t o t h e f o r ma t u s e d b y Bo b La w l e s s ) f o r in it ia l a n d r e f r e s h e r t r a in in g . A LISTING OF THE MANDATED TRAINING HAS BEEN DEVELOPED ALONG WITH A RATING FOR EACH TRAINING REQUIREMENT IN THE FIRST STEP TOWARDS DEVELOPING A PLAN TO MEET ALL OF THE MANDATED TRAINING REQUIREMENTS. Th e u n it is f o c u s in g o n c o mp l ia n c e w it h ma n d a t e d t r a in in g b e f o r e ATTEMPTING TO EXPAND BASIC SKILL TRAINING. Op e r a t o r s a r e g e n e r a l l y q u a l if ie d f o r t h e ir j o b t h r o u g h t h e "b u d d y s y s t e m". Ea c h b u il d in g W/x n Pe r f . Pr o d u c t s is d e v e l o p in g a QUALIFICATION LIST AS PART OF THE ISO-9000 CERTIFICATION EFFORT. VI. CONTRACTOR SAFETY Th e Pe r f . Pr o d u c t s Un it a n d t h e E0 Ce n t e r u t il iz e d ir e c t c o n t r a c t in g . Co n t r a c t o r s a r e s e l e c t e d f r o m a ML&S l is t o f v e n d o r s . Th e a r e a USUALLY RELIES ON ML&S FOR SAFETY STATISTICS ON THESE CONTRACTORS. ON A LIMITED BASIS, PERF. PRODUCTS REPRESENTATIVES HAVE PARTICIPATED IN THE SAFETY MEETINGS OF SOME CONTRACTORS TO AUDIT THE CONTENT OF CONTRACTOR SAFETY MEETINGS, Pl a n t o r ie n t a t io n is h a n d l e d b y t h e Pe r f . Pr o d u c t s Co n t r a c t Ad min is t r a t o r (s) u s in g s it e p r o g r a m d e v e l o p e d b y Da v e Sp a r k s . Th e a r e a o r ie n t a t io n is h a n d l e d b y t h e b u il d in g p r o p r ie t o r (Ze k e Ev a n s ) USING A CHECKSHEET FROM THE SITE PROGRAM. THIS AREA ORIENTATION INCLUDES RALLY SPOTS, HEADCOUNT PROCEDURES, AND SAFETY SHOWER LOCATION. Ne w a d d it io n s t o c o n t r a c t o r c r e w s a r e p r o v id e d o r ie n t a t io n t h r o u g h ADDITIONAL SAFETY MEETINGS. THE SKILL LEVEL OF THE CONTRACTOR CREW IS NOT EVALUATED IN ADVANCE, BUT FIELD AUDITS (w/ AND W/OUT CONTRACTOR SUPERVISORY PERSONNEL) ARE CONDUCTED TO ENSURE QUALIFICATION SKILLS. Co n t r a c t o r e q u ip me n t is c h e c k e d b y DFO (Du Po n t Fl e e t Op e r a t io n s ) o r b y PLANT EXPERTS FROM CONSTRUCTION OR OTHER MECHANICAL GROUPS. DUP050073888 VII. MANAGEMENT OF CHANGE - PERSONNEL Th e s it e c u r r e n t l y h a s n o g u id e l in e s r e g a r d in g t h e ma n a g e me n t o f PERSONNEL CHANGE. THERE IS NO SPECIFIC REQUIREMENT FOR NEW SUPERVISION TO DEMONSTRATE PROFICIENCY IN THEIR NEW ASSIGNMENT. FOR THE EO Ce n t e r , t h e a n t ic ip a t e d r e t ir e me n t o f Ze k e Ev a n s p r o mp t e d THE ASSIGNMENT OF MEL STILES TO THE BUILDING TO PROVIDE ADEQUATE TRAINING TIME. VIII. UNUSUAL INCIDENT INVESTIGATION/REPORTING/COMMUNICATION Limit e d t r a c k in g o f c l o s u r e o f o p e n it e ms f o r UI/SIR/EIR RECOMMENDATIONS FOR THE ENTIRE UNIT. SYSTEM HAS BEEN IN PLACE FOR QUARTERLY r e v ie w , b u t t h e s t a t u s r e p o r t s h a v e s e e n n o t b e e n c ir c u l a t e d RECENTLY DUE TO ISO WORKLOAD. IX. EMERGENCY PLANNING AND RESPONSE Al l EO Ce n t e r o p e r a t o r s (3/s h if t ) p a r t ic ip a t e in t h e 8 h o u r a n n u a l Fir e Br ig a d e t r a in in g . Ne w e mp l o y e e s a r e e s c o r t e d t o e a c h e v a c u a t io n b u t t o n , f ir e b o x , a n d e me r g e n c y s h u t d o w n s w it c h . Pl a n s a r e in p l a c e t o t r a in a l l Pe r f . Pr o d u c t s w a g e r o l l p e r s o n n e l t o c o mp l y w it h HAZWOPER "Fir s t Re s p o n d e r " l e v e l . Cu r r e n t l y c o n s id e r in g ADDITIONAL TRAINING FOR EHS OPERATORS TO PROVIDE "SECOND RESPONDER" LEVEL QUALIFICATION. E&D MANUAL FOR UNIT IS BEING BROUGHT INTO COMPLIANCE. TRAINING IS SCHEDULED TO START PROCESS OF BRINGING BUILDING MANUALS INTO c o mp l ia n c e . Ov e r a l l , t h e n e e d s a r o u n d HAZWOPER h a v e b e e n r e c o g n iz e d AND ARE BEING ADDRESSED THROUGH UPGRADES TO PROCEDURES AND TRAINING. Th e EO Ce n t e r e v a c u a t io n a l a r m h a s g e n e r a l l y b e e n t e s t e d a t n Ig h t . Th e r e is n o r e c o r d o f f r e q u e n c y f o r t h e t e s t in g o f t h e 5 s w it c h e s . Bu il d in g e me r g e n c y d r il l s a r e n o t c u r r e n t . X. AUDITING (Pe r f o r ma n c e v s . PSM Gu id e l in e s ) XI. QUALITY ASSURANCE Cr it ic a l e q u ip me n t q u a l it y a s s u r a n c e p r o c e d u r e is d e f in e d in Ma in t e n a n c e Pr o c e d u r e MP-32 a n d ML&S in s p e c t io n p r o c e d u r e . De s ig n c r it e r ia a r e u s u a l l y c o mmu n ic a t e d t o p r o d u c t io n a n d me c h a n ic a l PERSONNEL THROUGH A "PROJECT TEAM" USUALLY CONSISTING OF REPRESENTATIVES FROM DESIGN, R&D, AND PRODUCTION. A SCOPE OF WORK IS DUP050073889 USUALLY USED AS THE COMMUNICATION FORUM. WAGE ROLL INVOLVEMENT IS NORMALLY SEEN AT THE PRINT REVIEW STAGE. Fa b r ic a t io n QA is p r o v id e d b y Dic k Ge s s n e r o r Ch a r l ie Ha l l (SO mil e RADIUS OF PLANT) OR BY ML&S (MORE THAN SO MILES FROM PLANT). Th e Du Po n t v e n d o r r a t in g s y s t e m p r o v id e s a s e c o n d a r y a p p r o a c h f o r o n l y SPOT CHECKING VENDORS ACCORDING TO THEIR SUPPLY HISTORY. THERE IS A MINIMAL AMOUNT OF DIRECT CONTACT WITH VENDORS, ALTHOUGH THERE ARE SEVERAL INDIVIDUAL EXCEPTIONS. Th e r e is min ima l u s e o f a c h e c k s h e e t s f o r v e r if ic a t io n o f e q u ip me n t INSTALLATION AGREEMENT WITH DESIGN. GENERALLY, PUNCHLISTS OR PHR RECOMMENDATIONS ARE USED TO ENSURE PROPER INSTALLATION. XII. MECHANICAL INTEGRITY Mo s t o f t h e me c h a n ic a l in t e g r it y p r o c e d u r e s a r e d r iv e n b y e it h e r c o d e REQUIREMENTS (PRESSURE VESSELS) OR TCPA REGULATIONS (EHS SERVICE). Th ic k n e s s t e s t in g f o r n o n -r a t e d v e s s e l s is p r o v id e d f o r p o s t -in c id e n t INVESTIGATIONS. SUBSTANTIAL INSTRUMENT CALIBRATION EFFORT UNDER WAY AS PART OF ISO-9000 CERTIFICATION PROGRAM. Mo s t o f t h e me c h a n ic a l p r o c e d u r e t r a in in g is a c c o mp l is h e d v ia l a r g e GROUP MEETINGS WHICH IS FACILITATED BY DAYWORK SCHEDULE. SELECTED CLASSROOM TRAINING PROGRAMS ARE USED WHERE AVAILABLE/APPROPRIATE. Ha r d c o p ie s o f t r a in in g r e c o r d s a r e r e t a in e d w h e r e r e q u ir e d b y OSHA r u l e s . Ot h e r w is e , VTS is u s e d t o r e c o r d t r a in in g h is t o r y . A $5M/mo n t h b u d g e t e x is t s t o f u n d t r a in in g a c t iv it ie s . In a d d it io n . Bo b Sl ip p e y h a s b e e n r e j o in e d t h e a r e a f r o m t h e PDC t o l e a d t r a in in g PROGRAMS AND IMPROVE DOCUMENTATION. Th e r e is a l imit e d a mo u n t o f r e f r e s h e r t r a in in g p r o v id e d f o r MECHANICS. MOST OF THE NON-REGULATORY TRAINING FOCUSES ON ENHANCEMENT ON SKILL FLEXIBILITY. Tr a in e r s a r e s e l e c t e d v ia "w o r d o f mo u t h " a n d r e p u t a t io n a s n o s it e g u id el in es f o r t r ain er s el ec t io n e x is t . Me c h a n ic s a r e q u a l if ie d f o r j o b s v ia o b s e r v a t io n a n d "g u t f e e l " o f s u p e r v is o r s a n d p e e r s . Th e "b u d d y s y s t e m" is u s e d f o r t r a in in g in t h e AREA, WHILE THE PDC IS GENERALLY THE HOME OF CLASSROOM TRAINING. NO FORMAL QUALITY CONTROL PROCEDURE EXISTS FOR INCOMING MAINTENANCE MATERIALS. GENERALLY RELY ON TOOL ROOM MEN TO OVERSEE QC. GASKET VERIFICATION PROGRAM (BORROWED FROM PPD) IS BEING STARTED IN THE AREA. Re l ia b il it y e n g in e e r in g is n o t y e t in p l a c e , b u t is e x p e c t e d t o b e PART OF MERP CERTIFICATION EFFORT DURING '92. SEVERAL PILOT p r o g r a ms (Pu mp s Ru n n in g , s t e a m t r a p s ) a n d e s t a b l is h e d p r o g r a ms (LUBRICATION ROUTES, VIBRATION ANALYSIS) ARE IN PLACE. SOME EQUIPMENT DETAILS EXIST IN 3MCS, BUT EQUIPMENT HISTORY COMMENT SECTION HAS NOT BEEN UTILIZED. DUP050073890 Re c e n t r e -o r g a n iz a t io n o f p l a n t QA g r o u p h a s t r a n s f e r r e d r e s p o n s ib il it y o f s a f e t y e q u ip me n t t e s t s t o a r e a s . Th is t r a n s f e r t o THE AREA HAS APPARENTLY CREATED A GAP REGARDING INTERPRETATION OF VESSEL AND PIPE INSPECTION DATA. IN THE CASE OF SEVERAL VESSELS AND PIPE THICKNESS MEASUREMENTS, A HISTORY IS BEING DEVELOPED WITH A FOCUS ON "CHANGE", BUT THERE DOES NOT APPEAR TO BE A MEANS FOR DECIDING HOW MUCH CHANGE IS SIGNIFICANT AND WHAT MINIMUM THICKNESS IS ACCEPTABLE. Re c o r d s a l s o in d ic a t e d e f ic ie n c ie s in EQ t a n k s (1"X 6", 1/16 d e e p CRATER, WELDS "WASHED OUT , BUT "BLESSED BY EXPERTS") WITH NO DOCUMENTATION OF WHO IS MAKING THE "APPROVAL". Se c t io n s o f EO p ip e a r e id e n t if ie d a s "o u t o f c o d e ", b u t l a c k a n y INSPECTION RECORD DUE TO PENDING REPLACEMENT ACTIVITY. ONE ROUND OF THICKNESS TESTS AROUND EO & $02 LINES HAVE BEEN COMPLETED. No "As Fo u n d " c o mme n t s a r e a v a il a b l e o n RV's , s in c e a l l v a l v e s h a v e t o BE DECONTAMINATED PRIOR TO DELIVERY TO THE CENTRAL SHOP, XIII. MANAGEMENT OF SUBTLE CHANGES No SITE OR UNIT GUIDELINES EXIST. XIV. PRE-STARTUP SAFETY CHECKLISTS Ch e c k l is t f o r m in c l u d e d in PSM Ma n u a l , b u t t h e f o r m is n o t c o n s is t e n t WITH THE NEW S&OH GUIDELINES. MOST OF THE PRE-STARTUP INSPECTIONS IN EO ARE ACCOMPLISHED VIA PUNCHLISTS GENERATED OUT OF PHR'S AND/OR THE EXPERIENCE OF THE BUILDING PROPRIETORS. ********************************************************************** FIELD TOUR NOTES TWO OPERATORS WERE INTERVIEWED IN THE FIELD AND FOUND TO BE KNOWLEDGEABLE OF AUTHORIZATION REQUIREMENTS AROUND OI/TA CHANGES AS WELL AS EVACUATION RESPONSES. Se v e r a l c o n c e r n s s u r f a c e d a r o u n d g r o u n d in g . Th e r e is n o s t a n d a r d INSPECTION FREQUENCY ON GROUND WIRES, WHICH HAS ALLOWED SEVERAL TO BECOME b a d l y w o r n . On e g r o u n d in g c l a mp w it h a b r o k e n w ir e w a s f o u n d ATTACHED TO A T/T AND CORRECTED. THE T/C GROUNDING ALARM SYSTEM (FIELD ALARM LIGHTS UP AND RINGS IF A GROUND WIRE IS DISCONNECTED) DID NOT WORK WELL. NO INDICATION OF INSPECTION FREQUENCY ON THIS DEVICE. Se v e r a l it e ms (s a f e t y s h o w e r l ig h t s , l ig h t f ix t u r e s ) in t h e r e a c t o r ROOM DO NOT MEET THE REQUIRED I-2-B ELECTRICAL CLASSIFICATION, THE AREA IS AWARE OF THESE PROBLEMS. CONSTRUCTION WILL START THE UPGRADE WORK WITHIN 2 WEEKS AS PART OF A CAPITAL PROJECT. DUP050073891 A NUMBER OF LIGHTS AND THE ANNUNCIATOR ON THE PET ADDITIVES CONTROL PANEL WERE FOUND TO BE NOT WORKING. No INDICATION THAT THE PANEL LIGHTS HAD BEEN TESTED RECENTLY. IN THE ETHOXYLATOR CONTROL ROOM, SEVERAL LIGHTS WERE ALSO BURNED OUT BUT THE CORRECT SIZE SPARES ARE IN s h o r t s u p p l y . Ch e c k s h e e t s a r e k e p t d a il y a n d s h o w t h a t t h e p r o b l e m HAD BEEN OBSERVED. Th e d e l u g e Sy s t e m (3-01A) f o r o n e o f t h e b u l k s t o r a g e t a n k s a p p e a r e d TO BE MISSING A "TEST/ALARM" SWITCH. Th e is s u e o f b a r r ic a d in g a r o u n d t h e w e s t w a l l o f t h e EO c e n t e r w a s DISCUSSED, AS THE QUESTIONABLE STRUCTURAL INTEGRITY MIGHT PRESENT A HAZARD TO LOCAL PERSONNEL. WORK IS UNDER WAY TO RELOCATE LINES ADJACENT TO THE WALL PRIOR TO DISMANTLEMENT. A SPOT CHECK OF AN OPERATOR1S ABILITY TO ACCESS THE ELECTRONIC MSDS DATA BASE REVEALED A GOOD UNDERSTANDING OF SEVERAL WAYS TO RETRIEVE in f o r ma t io n . A SPOT CHECK OF TWO PHR RECOMMENDATIONS (GROUND WIRE FOR UNLOADING PUMP, CHECK VALVE IN JET LINE) FOR THE K-3 INSTALLATION INDICATED THAT THE FIELD INSTALLATION WAS CONSISTENT WITH THE RECOMMENDATIONS. NO INDICATION OF TEST FREQUENCY ON "FEEDING EO" WARNING LIGHT OUTSIDE OF REACTOR ROOM. A FLAME PERMIT FOR 2 PAINTERS WAS NOT PROPERLY LOCATED AT THE JOB SITE. IT HAD BEEN LEFT IN THE TEAM MGR'S OFFICE. NFPA WEAKNESSES EXIST FOR THE NUMBER OF FIRE EXITS AND FIRE PROTECTION. DUP050073892