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October 2004

Introduction/Administrative News
The TRADE Industrial Hygiene/Occupational Safety Special Interest Group (IH/OS SIG) Steering Committee held their annual Steering Committee workshop on October 6, 2004 at the Le Centre Sheraton in Montréal, Québec.  Committee members who could not attend in person participated by teleconference.  IH/OS SIG Steering Committee Chair Ralph Hinterman, Argonne National Laboratory-East (ANL-E), facilitated the meeting.  The following Steering Committee members/guests participated in the meeting:

Committee Members:

• Harvey Grasso, DOE National Nuclear Security Administration, Livermore Site Office
• Ralph Hinterman, ANL-E, IH/OS SIG Steering Committee Chair
• Lowell Howard , Pacific Northwest National Laboratory (PNNL)
• Bob Kapolka, Oak Ridge Institute for Science and Education (ORISE), IH/OS SIG Steering Committee Advisory Chair
• Dr. Bruce Lippy, Michael D. Baker, Inc.
• Deborah McFalls, ORISE, IH/OS SIG Coordinator
• Rob Nicholas, Los Alamos National Laboratory (LANL)
• John Peters, Brookhaven National Laboratory (BNL)

Guests:

• Ken Barat, Lawrence Livermore National Laboratory (LLNL)
• John Cavanaugh, DOE, Richland Operations Office
• William Cooper, DOE, EH-24, Office of Facility Operations Support
• Howard Cole, Occupational Safety and Health Administration (OSHA)
• Gary Lewis, LANL
• Patricia Louie, OSHA
• Bruce Murdoch, ANL-E
• David Weitzman, DOE, EH-52, Office of Worker Protection Policy and Programs

Committee members said farewell to Bruce Lippy as he attended his last meeting as a committee member.  The Committee thanked Bruce for his numerous contributions made in serving on the Steering Committee these past 3 years.  He has done an outstanding job in supporting the Committee’s goals and will be missed by all. It is hoped that there will be opportunities to work with Bruce again in the near future. 

Committee Member Bruce Lippy , from Michael D. Baker, Inc., provided an overview of some newly developed mold guidelines for maintenance and remediation workers.  Bruce noted that OSHA addresses mold issues through guidance document, A Brief Guide to Mold in the Workplace, which is not a standard or regulation, and does not create new legal obligations.  A new guidance document Bruce helped to develop, Preliminary Guidelines for the Protection and Training of Workers Engaged in Maintenance and Remediation Work Associated with Mold, was drafted during the National Technical Workshop in January 2004 with further modified made during the National Meeting on Mold-Related Health Effects in June.  The current draft document has been posted for review at: http://www.wetp.org/wetp/.

Sponsors of the mold-related workshops supporting the development of the guideline were:

• National Institute of Environmental Health Sciences
• Society for Occupational and Environmental Health
• Association of Occupational and Environmental Clinics
• Hunter College , CUNY
• New York City Department of Health and Mental Hygiene
• School of Public Health , University of Medicine and Dentistry of New Jersey
• Johns Hopkins Bloomberg School of Public Health

• Clifford Mitchell, Johns Hopkins
• Eileen Storey, University of Connecticut
• James Cone, New York City Department of Health and Mental Hygiene
• Eckhardt Johanning , East New York Occupational and Environmental Health Center
• Kay Kreiss, National Institute for Occupational Safety and Health
• Dorr Dearborn, Case Western Reserve University
• Michael Hodgson, Department of Veterans Affairs

• What could be said with certainly about the health effects
•  What could be noted about any dose response relation
• What were the workers exposures

The December workshop participants agreed that not much could be said with certainly about any of the aforementioned topics.  All agreed that mold exposure would cause neurological problems, allergy responses, etc. but also something as simple as cold air could cause similar health problems. The second workshop, Mold Worker Protection Training Workshop, was held at Manhattan Hunter College in New York City in January 2004.   The participants focused on training guidelines for maintenance and remediation workers. The third workshop, Mold-related Health Effects: Clinical, Remediation Worker Protection and Biomedical Research Issues, occurred in June 2004 in Washington, D. C. where participants provided comments on the draft mold guidance document.  Proceedings of the workshops have been posted at: www.soeh.org. The goal for the guidance document’s training recommendations was to develop experience-based preliminary guidelines for health and safety training for mold remediation workers and workers who are exposed to mold in the course of maintaining building systems. The training suggestions were not focused on individual homes but rather on the public and private sector office buildings, public access buildings, schools, commercial properties, and multiple dwellings.

Participants considered current guidance documents during the development of the guidance document:

• 1993 NYC DOH - Guidelines on Stachybotrys
• 1995 Health Canada - Guide to Recognition and Management
• 1999 ACGIH - Bioaerosols: Assessment and Control
• 2000 NYC DOH - Guidelines on Fungi
• 2001 US EPA - Guidelines on Fungi
• 2003 OSHA – Advisory
• 2003 IICRC S520 - Mold Remediation

• Best way to remediate mold is to remove it from materials that can be cleaned and discard materials that cannot be cleaned or are physically damaged
• Occupants and workers must be protected during remediation
• Some mold situations present a small enough exposure potential that cleanup does not require containment or worker protection
• Some situations require full containment, air-pressure management, and full worker protection

• The strategy of basing recommendations on size of project made sense
• Intensity and duration of exposures differentiated maintenance and remediation workers

  The following worker protection levels were recommended by workshop participants:

Remediation workers potential exposures data that was provided to workshop participants:

Mold contamination in an Earthquake-damaged Building
Airborne molds during initial inspection

Sampling Method: Spore traps
Morey & Hunt. (1995). Proceedings of Healthy Buildings 95

Mold contamination in an Earthquake-damaged Building
Airborne molds during demolition

Morey & Hunt. (1995). Proceedings of Healthy Buildings 95

Mold contamination in an Earthquake-damaged Building
Airborne molds during first final cleaning

The newly developed guidelines include a description of the courses for maintenance and remediation workers:  

Primary knowledge objectives:

Primary skills objectives:

Training course duration:

Suggested course for remediation workers (excl. HVAC):

Suggested training topics that could be exempt for remediation workers included:

• Overlaps in training justify exemptions:
  • e.g., training on certain work practices and PPE in asbestos/lead/HAZWOPER classes
  • Training must be recent
  • Trainee must demonstrate competence with specific topic, e.g., 1/2 face respirator

Suggested training topics for HVAC systems:

• Mold remediation of HVAC systems:
  • Highly specialized skill
  • Requires specialized training, e.g., NADCA
  • 1996 National Air Duct Cleaners Association (NADCA) - "Microbial Contamination in HVAC"
  • This industry guideline evolved into the "Assessment, Cleaning, and Restoration Industry Standard" in 2002
• Maintenance and remediation workers:
  • How mold can become an HVAC problem, and how to prevent it
  • When it is appropriate to isolate an HVAC system
  • When it is appropriate to call in HVAC mold remediation workers

For remediation worker, there was a dissenting opinion on training duration and topics:

• Dissenting Opinion:
  • 0.5 hours - Introduction to indoor air pollution
  • 1.5 hours - Health and safety
  • 3.0 hours - Respiratory protection, PPE, and hands-on practice
  • 3.0 hours - Work practices and hands-on practice
  • 8 hours total

The draft guidance document is now available for review at: www.wetp.org.  Questions about this document should be directed to Bruce Lippy at: blippy@michaeldbaker.com.  In addition to this new draft guidance document, other suggested related publications can be found at: www.epa.gov/mold.  

Overview of the OSHA Audits for 10 DOE Non-Defense Science Laboratories
Congress is seeking information related to some of the DOE facilities potentially coming under OSHA regulations in the future.  At this time, only DOE regulates their sites without any oversight from OSHA.  An initiative is underway to collect information for Congress, OSHA, and DOE about transferring regulatory oversight to OSHA for some of the DOE sites. Patricia Louie and Howard Cole, OSHA, had briefed the Steering Committee at the Committee’s 2003 workshop about this initiative.  They again this year briefed the Committee on the progress that has been made the past year. OSHA has visited several DOE sites to complete audits on worker safety and health issues.    Review of the Audit Process: The DOE Office of Science determined the scope of the audit which covered all employees and contractor-lead operations including onsite construction activities. OSHA’s objectives were to identify the instances of non-compliances with current OSHA standards and to give DOE enough detail to determine the abatement cost.  OSHA looked at their standards and General Duty Clause and made recommendations where they did not have standards or believed it was not appropriate to use their General Duty Clause.  It was a snap shot in time for the period OSHA was at the DOE sites.  The pre-audit information work included OSHA developing a work plan with DOE. They completed pre-audit scoping at 7 of the 10 labs they were to visit. They asked for extensive information from each site 4 weeks prior to the audit visit. This helped OSHA review their records, develop a schedule, develop a site-specific protocol, review what the Labs had already done, and determine how they wanted to proceed.  They had extensive conference calls with DOE and staff members at each of the potential audited labs.  Upon arrival at a site, OSHA conducted a normal audit inspection starting with an open meeting that included two team leaders, lab management, labor unions, DOE management, and any other interested parties.  OSHA discussed the audit process, schedule, and addressed questions.  The walk through then started with audit team members who were knowledge about laboratories, safety, industrial hygiene, lasers, radiation, cranes, constructions, and electrical safety. During the walk through process, the site’s escorts and employees were able to question the auditor’s findings that they disagreed with as the findings were being written. Once the walk through was completed, there was a close out meeting in which OSHA gave the lab an overview of their preliminary findings. The post audit report included a punch list that DOE could use in determining their abatement cost.  OSHA noted more details on the list than what Congress has asked them to provide including providing choices for abatement actions so DOE could select what action they wanted to take. They provided a final formal audit report to DOE that included an executive summary, audit summary (punch list), protocol – sample of worksheet used by auditors, master buildings list, and PowerPoint findings presentation. OSHA provided DOE Headquarters staff with formal briefings of 2-3 lab audits combined at a time in a formal presentation.  

The following summary provides the overall picture of the completed audits:

Since the aforementioned chart was completed, 4 corrections have been made:

• Oak Ridge National Laboratory - Number of OSHA standards cited changed to 204
• Pacific northwest National Laboratory - Number of OSHA standards cited changed to 155
• Lawrence Berkeley National Laboratory - Number of OSHA standards cited changed to 237
• Total for all laboratories - Number of OSHA standards cited changed to 820

The breakout of the instances by OSHA standard at the 10 DOE laboratories audited is as follows:

The 5 most common OSHA subparts referenced at the 10 DOE laboratories audited (includes all citations for 29 CFR 1904, 29 CFR 1910, 29 CFR 1926, and the General Duty Clause):

Top 10 subparts cited in the audit were:

1. 1910.303   (3,887) General electrical requirements
2. 1910.305   (3,337) Wiring methods, components, and equipment for general use
3. 1910.37     (1,183) Maintenance, safeguards, and features for exit routes
4. 910.212     (781) General machine requirements      
5. 1910.151   (465) Medical services and first aid
6. 1910.101   (441) General compressed gas requirements
7. 1910.22     (441) General walking and working surfaces requirements
8. 1910.157   (407) Portable fire extinguishers
9. 1910.179   (406) Overhead and gantry cranes
10. 1910.219   (347) Mechanical power-transmission apparatus

General industry issues included overloaded cable trays, suspect confined space evaluation, labeling, and entry procedures, and lockout/tagout program confusion. The construction issues included fall protection, electrical, excavations, PPE, and materials handling.

Multi-employer worksite issues included:

• Lab wide responsibility
• Citation policy
• Construction
  • 55 of 75 instances referenced DOE or laboratory personnel as controlling employers
• General industry

Remediation jurisdiction issues included:

• OSHA jurisdiction:
  • Accelerators
  • Accerlator-produced materials
  • X-ray equipment
  • Electron microscopes
• NRC jurisdiction:
  • Licensed radioactive materials
  • Special nuclear materials

Radiation-related instances at the 10 DOE Laboratories totaled 319:

• Recommendations - 70%
• 29 CFR 1910.1096 - 14%
• 5 (s) (1) - 10%
• Other 29 CFR - 6%

Radiation-related instances compared to total instances at the 10 DOE laboratories were less than 2 percent reflecting that DOE is doing a good job with their radiation worker safety program. 

In summarizing the finding of the audits at the DOE facilities, OSHA identified the top 5 hazards categories as:

1. Electrical
2. Egress and fire protection
3. Machine guarding
4. Walking and working surfaces
5. Toxic and hazardous substances

The findings appear to be low-cost items to correct. OSHA noted that DOE has good written safety and health programs but do need to improve on the implementation of them.    OSHA’s, next step is to work with DOE to identify how they can assist with the top hazard categories identified in the findings which may include assisting with related training needs.     Questions related to the OSHA audits or future follow-ups should be directed to Patricia Louie at: Louie.Trese@dol.gov. 

Occupational Health Issues of Nanoscale Materials - Summary of Presentations Given at the PCIH Montreal , Canada
IH/OS SIG Committee Chair Ralph Hinterman reported on nanotechnology information collected at the Professional Conference on Industrial Hygiene (PCIH) that the IH/OS SIG Steering Committee linked this year’s meeting to for their annual workshop.  Nanoscale material is a new issue that very little is known about it. Understanding and control of material properties at the nanometer scale promises tremendous potential for the advancement of science and technology. The Center for Nanoscale Materials at ANL-E is one of 5 Nanoscale Science Research Centers sponsored by DOE that offers advanced facilities and expertise to support independent and collaborative research efforts in this area.   Ralph noted one of the most informative presenters at the 2004 PCIH about nanoscale materials was Andrew Maynard, National Institute for Occupational Safety and Health (NIOSH).  His presentation slides are available at: http://www.aiha.org/TheAcademy/html/04pcih/maynard_files/frame.htm.  

Nanoscale materials are particles and structures that are generally <5 nm in size.  Some have been referenced as:

• Fullerines (Buckey balls)
• Carbon tubes
• TiO2 (used in sun block)
• Engineered structures

The focus is on construction or fabrication of items by almost practically moving individual atoms around or putting atoms in molecules exactly where we want them. Industrial hygienists have to look at what is the impact of the size on toxicity of these materials. Typical paradigm is mass or number concentration based. There is evidence that surface area is important.  A nm particle has 1 billionth the mass of a µm particle.   

Solubility of these materials will have to be looked at:

• Low solubility particles - surface area, number, size and composition is important
• Soluble particles - log response to mass and number concentration
  • Diameter shifts the dose response curve
• Single dose-response curve when surface area is used

These particles can move in the body in non-traditional routes:

• 15 nm particles can move to liver more than 80 nm particles
• Mn particles can move to olfactory bulb and other brain tissues
• Structures are being researched to bind to specific cell membrane sites to deliver therapy

The impact of these particles on the occupational health community is now:

• Nanoscale materials are being developed now
• Occupational health community has to clearly understand the risk assessment and management practice for now in a correct manner

NIOSH is increasing their research efforts to fill in gaps of knowledge including addressing questions about:

• What is the toxicity of the materials
• How do we measure what is in theair or what people are being exposed to
• What kind of controls are going to be available to prevent exposure

Industrial hygienists may need to go to a control banding approach for the protection of workers.

There is a lot of room for discussion among occupational health professionals about:

• Exposure guidelines
• Life cycle of Nanomaterials (wastes, used materials)
• Method of categorizing materials (similar materials behave similarly)
• Measurement techniques (Mass concentration vs. Surface area)
• Revise risk assessment paradigm (these are not your father's air contaminants)
• Guide to prudent practices (need sooner rather than later)

Information from NIOSH includes a fact sheet with some basic information that is available online. By mid-November, a “Frequently Ask Questions” Web site is expected to be online, and early in 2005, an intelligence bulletin is expected to be published.    Questions related to this presentation should be directed to Ralph Hinterman at: hint@anl.gov. Update On EH IH/OS Activities

David Weitzman, DOE, Office of Health, EH-52, updated the committee about news from Headquarters.  One of the more active tasks that DOE EH is involved in is the development of proposed rule, 10 CFR 851, Worker Safety and Health Program.  About 2 years ago, Congress put a requirement in a funding bill to promulgate worker safety and health program regulations.   DOE published notice of a proposed rulemaking in December 2003 that was not well received. Due to negative comments about the approach in the proposed rule, DOE withdrew it to make improvements.  DOE will soon publish a second notice of proposed rulemaking with some morechanges to it.  That second notice has been clear by the Office of Management and Budget and is back with the General Council Office that has the lead on this action.  At this time, EH is not sure what the schedule is for the next step in the rulemaking process. 

The Chemical Safety Topical Committee is holding its seventh annual Joint Energy Facility Contractors Group (EFCOG)/DOE Chemical Management Workshop at the DOE Forrestal Headquarters Auditorium in Washington , D.C. March 8-10, 2005 . The workshop theme is "Perspectives in Chemical Hazard Identification.”  Presentation related to beryllium will also be included as part of the workshop.  Due to the maturing of the DOE community’s beryllium programs, it was believed that a separate beryllium conference would not be necessary. Additional information about the workshop can be found at: http://www.eh.doe.gov/chem_safety/index.html.

A section on “shock-sensitive” chemicals has been added in Volume I Appendix of the Chemical Management Handbook which includes additional guidance. New text has been added to Volume III.  There is a proposed overview summarizing 10 chapters of Volume III that is in the review process at this time. David reported that there is a group that is working on beryllium implementation issues within the DOE community.  The beryllium rule leaves open room for different approaches for implementation of beryllium programs at DOE sites.  The DOE community has asked Headquarters for guidance on implementation of such programs.  This working group is developing a beryllium implementation guidance document which will most likely be published as a technical standard in early 2005.   

The Beryllium Health and Safety Committee will have a meeting October 19-20, 2004 in Las Vegas , Nevada . The group meets 3-4 times a year and are active also in helping to develop beryllium related guidance to point out what is needed in research and development in beryllium controls.    Questions related to this presentation should be directed to David Weitzman at: David.Weitzman@eh.doe.gov.   Laser Eye Injury at TA-46-41-106 LANL

Gary Lewis, laser safety specialist from LANL, briefed the Committee about a laser accident that involved an undergraduate student who was injured while performing work with a class IV (neodymium) Nd:YAG laser on July 14, 2004 . The undergraduate student was a guest affiliate working on a research program through National Aeronautics and Space Administration (NASA). Following the reporting of the laser accident, operations at LANL were suspended and an investigation was completed.  Members of the Laser Incident Investigation Team members included:

• Fred Trantino, PADNWP, Chair
• Dennis Derkacs, HSR-DO/ISM Program Manager, Vice Chair
• Ron Geoffrion, HSR-DO/ADWEM-deployed, Certified DOE Accident Investigator
• Rita Henins, PS-7, Investigator/Certified DOE Accident Investigation Board Chair
• Matt Hardy, PS-7, Investigator/Certified DOE Accident Investigation Board Chair
• Tom Turner, ADSR, Physical Chemistry/Lasers
• John Milewski, MSM-5, Laser Processing
• Gary Lewis, MST-6, Materials Science and Technology/Laser Processing
• Connon Odom, DX-5, Laser Safety Officer
• Consultants:
  • Dr. William Brady, HSR-2, LANL Medical Director
  • Steve Greene, P-DO, Work Control/IWM Process
  • Phil Kruger, LC-ELL, Legal Counsel/Employment Law
  • Tim Babicke, HR-SR, Staff Relations
• Observers:
  • Deidra Yearwood, PS-PAAA, Nuclear Safety
  • Louie Lincoln, PS-2 Advisor
  • Dean Decker, NNSA LASO
• Independent Reviewer:
  • Dave Herbert, National Safety Council

The scope of the investigation focused on the task to:

• Determine the events and conditions leading up to and immediately following the event
• Determine if the equipment/system malfunctions associated with the event
• Determine the ISM causal factors, including work scope identification, hazards analyses, hazard controls, work authorization, training/qualification/authorization of workers, readiness, and work performance
• Review actions and inactions of supervisors and managers relevant to the ISM process
• Evaluate the adequacy of institutional and division-level policies, requirements, procedures, training/certification relevant to the work
• Evaluate immediate response to the event, including notifications and emergency response
• Evaluate the effectiveness of corrective actions from previous similar events
• Evaluate the effectiveness of lessons learned from previous similar events
• Develop recommendations for human performance, management systems and safety program improvements

The Laser Incident Investigation Team investigating process included interviewing many people to establish what had happened.  They inspected the laboratory where the accident happened.  The team had people in the same division as the persons involved in the accident to conduct lab measurements in the lab where the accident occurred. The team analyzed all the information by determining the timeline and causal analysis for the accident.  The team then determined the conclusions of the information and wrote a report of their findings which has now been published. 

 The undergraduate student who was hurt in the accident was a guest affiliate working on a research program through NASA. She had been tasked by NASA to conduct research on a particle in vacant (PIV) experiment analyze particle composition in comet tails.  She was a senior at John Hopkins University .  She had no experience with lasers prior to coming to LANL.  The LANL Principal Investigator had worked at the LANL for over 25 years.  He had mentored many students during this time and had been in the same group at the Lab most of his time there.  He has won R&D 100 awards and mentored 30 students in the past 25 years.  He was a very well respected person at the Lab who has many published papers.

The events of the accident occurred as follows with the Principal Investigator (PI) and the student (S1):  

July 14, 2004 Events:

• The PI and the S1 entered room 106 at TA-46, BLDG. 41 at LANL
• PI powered L1 flash lamps on, Q-switch was disconnected from SRS pulse generator (Neither S1 or PI wore eye protection)
• Light from L1 was focused at center of target chamber and propagated through chamber window (back side)
• PI fired L2 to suspend particles in target chamber (PI closed his eyes while firing L2 for about 5 seconds, S1 was not aware that L2 was fired)
• PI looked into target chamber and saw suspended particles and instructed S1 to look
• S1 bent down, putting her eye in axis of light beam and immediately experienced a flash of light followed by obscured vision in her left eye by reddish brown substance
• PI then tells S1 not to look into the beam directly and shows S1 where to stand and look into the chamber
• PI told S1 that spots or floaters may be the result or after affect similar to a camera flash bulb because the laser is  set in a non-lasing mode and to wait and see what happens
• About 20 minutes later, S1 stated that she was concerned about her eye and P1 now drives S1 to HSR-2 (Medical Department)
• 1:52 pm S1 is logged in at HSR-2 -- PI tells the Physician Assistant (PA) that the laser was off—Both PI and S1 tell the nurse and PA repeatedly the laser was off
• HSR-2 PA finds the vitreous humor clouded and PA and nurse make diagnosis of detached retina and report the injury as non-occupational (PA reported later that he relied too much on assurances that the laser was off.  Neither PA or nurse had evaluated a laser injury before), PA refers S1 to Eye Associates, in the town of Los Alamos .
•  About 3:00 pm , the doctor sees hemorrhaging and lesion suggesting a laser injury, (PI told the doctor it was not possible because the laser was off).  The doctor refers S1 to a second doctor at Santa Fe Eye Associates for the following day.  (Neither PI or S1 report back to HSR-2)
• PI and S1 return to work around 4:00 pm and PI secures the lab around 4:30 pm .  The PI goes by his group office but finds no one to talk to about the accident.

July 15 Events:

• Around 6:45 am , PI drives S1 to Santa Fe for a referred doctor visit
•  Around 9:00 am , the doctor in Santa Fe reports lesion on retina and capillary bed behind, hole near fovea of left eye, and confirms a laser injury has occurred
• PI calls his Group Leader around 10:00 am from Santa Fe, around 10:45 am the Group Leader calls Chief of Staff for his Division and reported “something was in the S1’s eye”, probably not reportable, the Chief of Staff requests a write-up report
• Around 11:00 am , PI and S1 return to the lab and describe accident in the Group Leader Office
• Around 11:15 am ,  PI and S1 return to work, PI tells others, S1 has a broken capillary in her eye, laser was off, something suspicious happened--(HSR-2 not notified that S1 had return to work)
• PI returned to lab to check for leakage (lasing from the laser)
• Around 2 pm , PI had S1 and another student to sign an interment work document (IWD) and back date it to June 29, 2004
• Around 3pm , PI calls nurse again and reports the Santa Fe doctor said it was a laser accident but says the Q-switch was off, other lights were on and laser was not pulsing.  The nurse calls a LANL Laser Safety Officer (LSO) for explanation and the LSO tells her either laser light was present or someone is lying.
• Around 3:30 pm, the Division Chief of Staff reports to the Division Leader that the Group Leader stated the S1 had something in her eye, saw a doctor, was back at work, and the event was non-reportable
• Around 5:23 pm , E-mail description from Group Leader sent to Chief of Staff’s office.  The Chief of Staff had already left for the day.
• Around 5:00 pm , word spreads from HSR-2 Group Leader to the Assistant Director of the Operations (ADO) for the Lab.  The ADO called the C-Division Office and the Occurrence Reporting Group to report a laser accident had occurred.
• Around 6:00 pm , everyone including all the way up to the Associate Directors of the Lab has been alerted about the accident.

July 16 Events:

• Around 8:30 am , event critique takes place at the lab
• In the afternoon, the LANL Lab Director stood down the Laboratory

July 19 Events:

• Room 106 and Bldg 41 secured 5 days after accident

July 21 Events:

• HSR-2 Group Leader (Medical Doctor) goes with the student to John Hopkins Hospital in Baltimore to see another retinal specialist

July 22 Events:

• HSR-2 Group Leader returns and briefs the Accident Investigation Team that a July 14 laser accident caused a traumatic hole 400 microns wide and 250 micros deep in the retina of the students left eye had been formed

The Investigative Team determined that the following principles learned in any Lasers 101 course were not followed:

• Laser eye protection must be worn at all times when Class IV lasers are powered
• Never view down the laser beam path
• Control the beam and stray reflections at all times

At the time of the accident:

• Neither PI or S1 were wearing laser eye protection
• PI fired Laser 2 for 5 seconds with eyes closed
• S1 viewed down the Laser 1 beam axis
• Laser light was not adequately controlled within the room
• Use of flash lamps for backlighting was unusual

Eye damage occurs from the laser when light entering the pupil is focused and inverted by the cornea and lens and projected onto the retina at the back of the eye. The S1 experienced the following in the left eye immediately after exposure from L1 on July 14:

• A sudden change in visual acuity
• A floater resembling a “jellyfish”
• Acute, bright-red blood over the retinal lesion

All 7 layers of the retina were vaporized near the fovea to form a hole around 400 mm diameter x 250 mm deep and a tiny bit of the choroid may remain in place. Permanent loss of the central vision occurred in the left eye.

The Accident investigative Team proposed and carried out experiments for characterizing conditions for which Laser 1 emits laser light:

• Experiments performed by another group within the same Division (C-PCS)
• Laser characterized for its different operating modes.  Determine pulse energy, temporal profile, and divergence measured
  • Flash lamps excited and Q-switch disconnected (reported condition for accident)
  • Long pulse
  • Q-switched
  • External / internal triggering
• Room viewed with IR viewer for stray beams and reflections
• IR card characterized
• Interlocks checked

The experimental results included:

• Flash lamps operating and Q-switch disconnected:
  • No lasing light seen using photodiodes
  • 0.2 μJ/cm2 light measured using flashlamps set at nominal 40 mJ lasing level
  • Maximum Permissible Exposure (MPE) is 5 μJ/cm2, or 2 orders of magnitude higher than measurement (MPE has built-in order of magnitude margin)
  • No spurious lasing seen during thunderstorm or by applying stray voltage to BNC external Q-switch trigger cable
• The Laser 1 characterized in various lasing modes:
  • Externally triggered Q-switch
  • Internally triggered Q-switch
  • Internally triggered long pulse mode
• Lab viewed through IR viewer:
  • Main beam ascending into eye level after exiting target chamber
  • Reflections from focusing lens--  These reflections were also ascending up to eye level due to tilted lens
  • Diffuse reflection emanating from lens holder clipping beam
• IR card characterization:
  • IR card PI used was badly burned
  • Burned card qualitatively performs like new IR card except that beam spatial profile cannot be discerned because of burned areas.  In one area the card was burned badly enough that the laser beam could not be seen.
  • Can readily see when laser lases
• Laser interlocks:
  • Laser warning lights not slaved to the interlock system
  • 2 door interlocks and 1 emergency-off switch powered Laser 1 down when activated
  • Interlock system had wired-in bypass switch allowing continued laser operation even when interlocks activated
  • L2 not interlocked, lased only a few times during several hundred flash lamp cycles (around 300 μJ/pulse)
• IR card characterization:
  • IR card PI used was badly burned, but lasing could be seen in certain active

The causal analysis of the accident was that two necessary conditions led to the injury:

• Unintentional or intentional production of laser light
• Lack of mitigation of laser light

These two conditions existed because of:

• Unsafe work practices
• Inadequate performance monitoring by management
• Inadequate Internment Work Package
• Inadequate mentoring of the S1

The Accident Investigative Team came to several conclusions about why the accident occurred:

Conclusion 1:

• Performance monitoring failed to identify and correct at-risk behaviors, requirement violations, work-control deficiencies, and deficient mentoring

Recommendations:

• Implement risk-based oversight program that systematically monitors performance of every employee and every work space
• Establish non-punitive processes emphasizing peer-to-peer and worker-to-manager communication of unsafe acts/near misses that would create environment of open communication that encourages legitimate concern for individual safety
• Correct C-ADI safety issues inside Building 41 including overall poor state of housekeeping

Evidence Supporting Conclusion 1:

• Lack of performance monitoring.
  • Only 1 MWA in Room 106 during last two years, then only to examine space requirements
  • Worker approached PI about safety concerns and nothing was done.  Should worker have engaged management?
  • Casual observation of conditions of Rooms 106 and 112 showed several bad safety practices:
    • Laser power supply key left in “on” position with tape covering it
    • Improperly secured high pressure gas bottles
    • Laser 2 not interlocked
    • Lack of egress throughout lab
    • Poorly made electrical connections
    • Broken window on one vacuum chamber
    • Cluttered and improper signage on entrance doors
    • Poor housekeeping throughout labs

Conclusion 2:

• Execution of IWM process failed to produce detailed work description and associated hazard analysis and controls that would have mitigated potential optical radiation hazard

Recommendations:

• C Division should implement process that ensures quality of IWDs and HCPs
• LANL should conduct “extent of condition” review regarding quality of IWM execution

Evidence:

• IWD had no detail.  HCP listed steps as align system, run experiment, etc.
• HCP / IWD failed to list backlighting as procedure and thus failed to analyze those hazards
• Laser 2 not interlocked:
• Laser 2 not registered

Conclusion 3:

• LANL mentoring program failed to provide sufficient oversight of students

Recommendations:

• Develop and implement formal mentoring program that should include training and assessment
• Recommendations would apply to all levels of mentoring

Evidence:

• S1 remembered from laser safety training about wearing protective eyewear, but did not question PI’s behavior of not wearing it
• S1 clearly did not understand HCP/IWM process.  To her, HCP was “something you had to sign.”
• S1 tended to ask questions of her other coworkers and not of the PI

Conclusion 4:

• Workers and managers involved failed to execute their roles and responsibilities which resulted in PI and S1 not performing work safely

Recommendations:

• C Division should take actions to modify worker and manager behaviors using existing institutional process

Evidence:

• S1 not authorized to do laser work (2 other students under PI also not authorized)
• Group Leader signed off on HCP at his desk
• Nobody executed stop work
• MWAs of lab minimal and not effective
• S1 lacked laser eye exam

Conclusion 5:

• Investigation revealed deficiencies in processes, programs, and procedures which did not prove to be causal, but do present opportunities for improvements to be made

Recommendations:

• LANL should address these concerns using institutional issues management system

Deficiencies:

• Some LSOs have no experience with lasers
• Higher level management oversight was minimal
• Notification system
• HSR-2 triggers only for occupational accidents

The overall summary of advice from the Team was that LANL has processes in place designed to foster a safe work environment.  They do not need new processes but do need to improve implementation of what is already in place. Advice to managers included for the managers to walk the spaces they are responsible for and to know their workers and the work being done.  The managers need to model the behaviors they expected of their workers. Managers were reminded that details are important in an HCP IWD. Housekeeping is a good indicator of safe or unsafe practices. And last, but not least, technical competence in a staff member does not always equal safety competence.  

A concern of the Team was that at-risk laser behaviors were seen with others at the Lab.  The PI’s safety philosophy was not unique or isolated only to that person.  The team was concerned that having found such lax practices in this area, would they find them in other places at the Lab as well if looked at more closely.  

Questions related to this presentation should be directed to Gary Lewis at: gkl@lanl.gov.  

Laser Safety Life Cycle Expanded View
Ken Barat , LLNL, presented information about a safe life cycle for lasers.   The majority of LSOs use guidance document ANSI Z136.1, “Safe Use of Lasers” standard, when performing laser hazard evaluations.   The ANSI Hazard evaluation list includes:

• The laser or laser systems capability of injuring personnel or interfering with task performance
• The environment in which the laser is used
• The personnel who may use or be exposed to the laser radiation

Ken and other laser safety specialists are proposing an expanded view to include for the LSO, particularly in the research setting, a more comprehensive approach over the lifetime of the laser.  This approach involves the life cycle of the equipment or project which may start with the design/development of the equipment, then on to the use of it, and finally to how to dispose of it.

This approach is for the design stage when product is being developed: sometimes for a consumer, sometimes for a technology transfer project, or for work for others. Awareness of laser product safety requirement is critical in saving time and money in the design/development stage.  Some DOE sites will make a laser product in-house and then send it off site.  If DOE follows Federal regulations, once it goes off site it will need to meet the Center for Devices and Radiological Health laser product standard.  Some DOE Labs, while having exemptions from CDRH rules, still are required to submit an exemption form (CFR 21, part 1040).

During the use of a laser, the following “Safety Use List” should be considered:

The DOE sites must also address what to do with outdated or laser devices no longer required? How do the sites dispose of unwanted lasers? Some are donated to other institutions, while others are scrapped, sold, or put in storage. Why should the sites care about the disposal of these lasers? The sites should be concerned because a large number of laser products may contain hazards chemicals of varying amounts such as beryllium (within ceramic collars), arsenic (from diodes), or fluorine (found in Excimer systems).  There are disposal options for these lasers.  If they are being donated to another institution, a letter should be obtained from the receiving institution that they have a LSO.  If the laser is going to be scrapped, hazards waste issues have to be addressed.  Consideration also should be given to the possibility that the laser would be used by unauthorized people.  Another option is to make the laser in-operative.  If they are sold, the DOE site must follow DOE regulations. When storing them, space becomes a problem, and may not be a real solution.  The site should look for users inside as well as outside their complex for disposal of unwanted laser systems.  It is important to raise the awareness level of the DOE LSO to consider and be involved in the complete life cycle of a laser project.  It is also important to have a way to view laser safety evaluations in a more complete manner.  

Questions related to this presentation should be directed to Ken Barat at: Barat1@LLNL.gov.

Briefing on ANL-E’s Laser Accident
Bruce Murdoch, ANL-E, provided some brief information about a laser accident that occurred at ANL-E on September 20, 2004 .  A laser eye injury occurred in the Advance Photon Source (APS) area.  While aligning the diagnostics for an ultrafast Ti:Sapphire class 4 laser (800 nm), an experimenter raised his laser safety eyewear to rub his eye to alleviate an irritation due to an existing eye infection. As he displaced his personal protective equipment he felt a bright flash and afterwards a light cloudiness in his left eye. Repairs on the laser which had been going on for several months were completed earlier in the day. In his eagerness to get his experiment underway, the experimenter introduced a beam onto the table while he aligned the optics. To obtain the signal he wanted, he rotated one of the polarizing beam splitters. In doing so, an unwanted/undetected beam left the plane of the table which subsequently struck his eye. The experimenter was evaluated by an ophthalmologist who determined that he suffered eye injuries resulting in vitreous floaters that will dissipate over time. All laser operations at the APS were suspended pending investigation of this incident.  In the meantime, sessions have occurred for supervisors at ANL-E to increase awareness of their responsibilities of laser control areas. 

Questions related to this information should be directed to Bruce Murdoch at: btmurdoch@anl.gov .

Hanford 200 East Area Fall Fatality Briefing
John Cavanaugh, DOE, Richland Operations Office, briefed the Committee about the fall fatality that occurred at the Hanford 200 East area on July 15, 2004 .  On July 16, an Accident Investigation Board of 5 people was appointed to investigate this accident.  Their investigation began on site July 20 when they took picture and began interviews with people.  A small company, All Mobile Transporting and Repairs (AMTR), had been hired by an outside contractor to prepare and remove a mobile office off the Hanford site. AMTR was not contracted with DOE directly in any way.  On July 15, the AMTR employee was found motionless at the bottom of a ladder with a serious head injury.  There were no eyewitnesses to the apparent fall.  The evidence indicated the employee was standing on the ladder approximately 5 to 6 feet off the ground, removing sheet metal screws from the aluminum trim of a mobile office that was being prepared for transport off the site. Three days previous to the accident, the AMTR employee working on the mobile office had undergone out patient surgery with general anesthesia and reportedly collapsed twice the next evening. The AMTR employee had medical conditions, which may have contributed to the apparent fall.  In addition, the high temperature conditions present on the day of the accident and the employee’s questionable heat acclimatization may have aggravated the AMTR employee’s medical condition. 

During the investigation process, more than 70 people were interviewed.  The Board identified issues with the work control practices associated with the subcontractor’s activities including:

• Employee did not have specific training for using the ladder correctly 
• Employee most likely was carrying loads up/down the ladder when the accident occurred
• Employee was mostly not using the 3-point contact when going up/down the ladder
• Older aluminum ladder was in good shape, but the labels on it were faded and unreadable
• PPE issues related to the employee (was wearing a hard hat):
  • Was not wearing safety glasses
  • Was wearing tennis shoes that may have contributed to the fall
• AMTR had not conducted a Hazard analysis before the work activity took place

The Board determined the AMTR employee had died from the fall.  They also determined that the main root cause was that Fluor Hanford, Inc. and AMTR did not apply and AMTR did not implement the basic elements of safety management practices dealing with work planning, hazard analysis, development of controls, and work execution to accomplish this task.  Another issue that came up was which contractor at the site had health and safety judicial oversight of this work.  Based on this conclusion, the Board developed a Judgment of Need, that when completed, should prevent recurrence of the event.

It was concluded that salvage operations were not well defined with procedures from DOE Headquarters, from the Hanford Site, or within the DOE complex.  The contractors did not have good procedures on how this type of work should be done.  As the result of this accident, DOE put out a call for a follow-up on the findings and the cause facts with the idea of setting up 4 separate project teams to address 4 specific areas:

• EM identified safety standards and expectations for non-nuclear industrial work activities
• EM oversight of industrial activities
• EM contracting process
• EM ability to lean from their mistake

The teams have formed and since started their meetings.

Questions related to this information should be directed to John Cavanaugh at: John_E_Jr_Cavanaugh@rl.gov.

Type A Accident Investigation Board Briefing on the Fatality at the Savannah River Site Pond B Dam Construction Project

William Cooper Jr., DOE, EH-24, briefed the Committee on a fatality that occurred at the Savannah River Site (SRS) Pond B Dam Construction Project area on July 26, 2004.  The parties involved with this project included the Westinghouse Savannah River Company (WSRC)/Bechtel Savannah River, Inc. (BSRI) as well as other organizations.  WSRC/BSRI awarded a contract and provided oversight to the GradeSouth Inc. who was to complete some upgrades to an earth and dam located at SRS Pond B Dam area. The METRAC Company owned the excavator that was delivered to the jobsite for GradeSouth to use. The Guthrie Grading and Hauling Company went to the jobsite to pick up the excavator at the request of the METRAC Company.

July 15 Events:

• A METRAC driver delivers excavator to Pond B jobsite and GradeSouth Operating Engineer and unloads it and informs GradeSouth that the excavator has hydraulic leaks: GradeSouth tightens fittings

July 19 Event:

• GradeSouth uses excavator to perform work and replaces o-ring to repair hydraulic leak
• GradeSouth completes work, parks excavator and calls METRAC to pickup

July 20 Event:

• METRAC makes initial contact with Guthrie Grading and Hauling to pick up excavator

July 26 Events:

• GradeSouth teamster truck driver escorts Guthrie driver to excavator at the end of Pond B Dam to load and transport excavator
• Teamster drives excavator on lowboy trailer
• Teamster extends boom/arm to raise excavator track to assist the Guthrie driver in positioning outriggers
• Excavator moves (drops/slips), crushing the Guthrie driver
• Teamster truck driver drives to other end of dam (~1/2 mile away) to a building to get someone to call for help
• Medical responders arrive at scene in just a few minutes and transport driver to the Medical College of Georgia (MCG)
• Driver expires approximately 1 1/2 hours after arriving at MCG trauma center

An Investigative Board was formed to determine what had happen.  Their activities included:

• Conducting numerous interviews with all involved groups– some with court reporters and some without
• Inspecting the accident scene
• Testing equipment at the accident scene
• Reviewing and evaluated medical information
• Reviewing and evaluated numerous documents including contracts, procedures, plans, policies, etc.
• Analyzing available facts and developed conclusions

The Board determined that WSRC needs to make sure that construction subcontractors’ and vendors’ worker protection program flows down the site requirements and integrated safety management functions and principles to the worker and emphasizes the importance and need for workers’ stop work authority, qualified and competent workers, and safe operation of construction equipment. Related issues were:

• The driver placed himself in an unsafe position under a suspended load in order to adjust the plank
• The teamster was not a qualified to operate the excavator
• There were a number of opportunities to utilize stop work and it was not exercised
• GradeSouth failed to ensure that the heavy equipment operations were conducted by qualified operators
• In the configuration that the teamster was using to lift the excavator track, the leak in the hydraulic line to the arm cylinder contributed to the accident

The Board determined that WSRC needs to make sure that hazards are identified and that controls are developed and implemented at the task level for all subcontractors on site. Related issues were:

• GradeSouth failed to provide control and oversight of their activities at the Pond B Dam Upgrade Project
• BSRI failed to provide sufficiently detailed guidance for developing a task-level hazards analysis, and safety oversight failed to identify the weaknesses of the hazards analysis
• Both hazards analyses - the TSP and AHA - for the Pond B Dam Upgrade Project failed to adequately address the full scope of work (i.e., demobilization) or identify hazards at a task or activity level, including the loading and unloading of heavy equipment

The Board determined WSRC and BSRI need to make sure that subcontractor safety issues are adequately identified and resolved. Related issues included:

• WSRC failed to fully address the causal factors for operational occurrences reported through the corrective action processes in place at the site
• Effective recurrence controls for identified deficiencies were not established

The Board determined BSRI needs to review their subcontracting controls to ensure that all applicable environment, safety, and health (ES&H) requirements are contained in the contract. Related issue included:

• BSRI imposed additional and sometimes conflicting requirements on GradeSouth over and above those in the contract

The Board determined DOE-SR needs to provide oversight of the WSCR and BSRI construction subcontractors and ensure the roles and responsibilities for oversight of WSRC and BSRI construction subcontracting are established in the DOE-SR FRAP. Related issues included:

• The current DOE-SR FRAP does not clearly define roles and responsibilities for activities related to ES&H oversight of construction projects
• DOE-SR provided no direct oversight of construction activities on the Pond B Dam Upgrade Project

The Board determined WSRC needs to ensure that the Remote Worker Notification program is effectively implemented by all affected organizations to ensure that workers have direct access to a reliable means of communication with SRSOC.  This includes ensuring all personnel on site that may be potentially remote workers are aware of the requirements of the program and understand when and how to effectively communicate emergency response with SRSOC.  Related issues included:

• Emergency Management Response was hampered by the lack of an accurate description of the incident due to poor communications
• GradeSouth failed to meet the requirements established by WSRC for the Remote Worker Notification  Program

The Board determined WSRC/WSI needs to conduct a comprehensive review with all medical responders to ensure they are able to implement the requirements and guidance in the protocol.  The technical capabilities and limitations of the WSI MEDEVAC helicopter needs to be clarified for all applicable emergency response personnel including physicians, EMT’s, emergency dispatchers, and emergency response supervisory personnel. Related issue included:

• responders did not precisely follow the approved SRS Medical protocols for trauma transport.  MEDEVAC could have decreased transport time to MCG by thirty minutes or more.

The Board also determined:

• The actions by DOE-SR, WSRC, and WSI/SRS were effective in preserving the accident scene
• WSRC/BSRI line management roles and responsibilities for ensuring safe execution of the project were established
• Line management roles and responsibilities for the GradeSouth personnel were clearly documented and understood
• The subcontract for the Pond B Dam Upgrade Project was adequate in that ISM and worker protection requirements were included

Questions related to this information should be directed to William Cooper Jr. at: william.cooper@eh.doe.gov.  

Future Steering Committee Meeting
The next Steering Committee Conference Call Meeting is scheduled for November 23, 2004 , 1:15 – 2:45 EST , conference call number is 202/287-1360.

For additional information, please contact:
Deborah McFalls, IH/OS SIG Coordinator
Oak Ridge Institute for Science and Education
P. O. Box 117, MS 10
Oak Ridge, TN 37831-0117