2005 Hanford FU Worker Vapor and Occ Med new blue-final and... · BNI Bechtel National,...

OV

ER

SIG

HT

Table of Contents

EXECUTIVE SUMMARY ...................................................................1

1.0 INTRODUCTION .......................................................................3

2.0 ASSESSMENT OF CORRECTIVE ACTIONS FORORP AND CH2M HILL ..............................................................6

2.1 Industrial Hygiene Programs ...................................................72.2 Work Planning and Control ................................................... 122.3 CH2M HILL Injury and Illness Reporting .............................. 152.4 CH2M HILL Corrective Action Management ........................ 162.5 ORP Line Management Oversight ........................................ 19

3.0 ASSESSMENT OF CORRECTIVE ACTIONS FORRL AND AMH .......................................................................... 22

3.1 Contractor Administrative Processes ..................................... 223.2 Interfaces Between the Medical Program and Site Operating Contractors ....................................................... 233.3 RL Line Management Oversight of the Corrective Action Process ................................................. 24

APPENDIX A – SUPPLEMENTAL INFORMATION ......................... 27

Abbreviations Used in This ReportAMH AdvanceMed HanfordBNI Bechtel National, IncorporatedCAIRS Computerized Accident/Incident Reporting SystemCATS Corrective Action Tracking SystemCFR Code of Federal RegulationsDOE U.S. Department of EnergyEM DOE Office of Environmental ManagementES&H Environment, Safety, and HealthES&Q ORP Office of Environmental Safety and QualityFY Fiscal YearGAP Government Accountability ProjectJHA Job Hazards AnalysisMSDS Material Safety Data SheetOA Office of Independent Oversight and Performance AssuranceOEL Occupational Exposure LimitORP Office of River ProtectionOSHA Occupational Safety and Health AdministrationPER Problem Evaluation RequestPPE Personal Protective EquipmentRL Richland Operations OfficeSCBA Self-Contained Breathing ApparatusSWE Safe Work EnvironmentVOC Volatile Organic Compound

1

Executive Summary

The U.S. Department of Energy (DOE)Office of Independent Oversight and PerformanceAssurance (OA) conducted a follow-up reviewin May-June 2005 of its 2004 investigation ofallegations of deficiencies in worker protection andmedical practices at the DOE Hanford Site. Thepurpose of this OA follow-up review was to assessthe status of the corrective actions for selectedfindings identified by OA during its 2004investigation. OA reports to the Director of theOffice of Security and Safety PerformanceAssurance, who reports directly to the Secretaryof Energy.

The follow-up review examined correctiveactions taken by: (1) the Office of River Protection(ORP) and the Tank Farms contractor, CH2MHILL, for vapor exposure findings; and (2) theRichland Operations Office (RL) and the medicalprogram contractor, AdvanceMed Hanford(AMH), for medical program findings. In each ofthese areas, OA’s objective is to provideconstructive feedback to ORP, RL, CH2M HILL,and AMH. OA focused on providing a set ofspecific recommendations for enhancing currentsite programs and initiatives and/or addressingspecific weaknesses in the approach to managingthe corrective actions for the identified findings.

After the 2004 OA investigation, ORP andCH2M HILL instituted a number of correctivemeasures, most notably the extensive use ofsupplied air respirators for workers in a positionto be exposed to tank vapors. These measuresare still being applied and are still appropriate toensure that workers are protected from tank vaporexposures; ORP and CH2M HILL plan to maintainthese measures until the hazards are fullycharacterized and controls are reassessed. Theyhave made significant progress in addressing thevapor issue. Their strategic approaches andprograms are generally well designed, are of hightechnical quality, and are appropriate to establisha longer-term protection strategy. ORP and CH2MHILL also have made improvements in workplanning and control and in their injury and illnessinvestigation and reporting processes thatappropriately address the OA findings. ORP and

CH2M HILL have completed the actionscommitted to in the approved corrective actionplan, and they plan to evaluate the effectivenessof all the corrective actions before November2005.

Although CH2M HILL has implemented or isin the process of implementing improvementactions in all areas where OA had previouslyidentified findings, some additional actions areneeded. For example, through field observations,the OA team found that the recent enhancementsassociated with work planning and control had notbeen effectively implemented at the working level.The OA team also determined that much workremains to address the underlying issues of the2004 investigation findings. As a result ofobservations during this follow-up visit, the OAteam recommends that ORP and CH2M HILLkeep the findings of the 2004 investigation openuntil the effectiveness of the corrective actionshas been verified.

ORP and CH2M HILL have devotedsignificant management attention and resourcesto the corrective action process, and RL hasenhanced its oversight of the medical contractor.CH2M HILL recognizes that much work remainsto be accomplished, particularly in the industrialhygiene area, to address the complex andtechnically challenging aspects of tankcharacterization, exposure assessment strategies,and monitoring program design (including the needto develop operational exposure limits, monitoringequipment and methods, and protection strategiesfor a wide range of chemicals) before reducingthe personnel protection requirements. Eventhough CH2M HILL had identified many of theseactions, the OA team found, as ORP did in its mostrecent evaluation of the CH2M HILL industrialhygiene program, that CH2M HILL has notdeveloped a detailed plan and associated schedulefor these actions, and that these actions have notbeen entered into a formal tracking system. Whilethe new CH2M HILL Program Plan fills the needfor a comprehensive strategic plan for addressingvapor issues, it lacks sufficient detail and controlsto ensure timely and effective implementation of

2

the many ongoing efforts. Continued ORP and CH2MHILL attention is needed to ensure that acomprehensive plan and schedule are developed toinclude and track these actions.

In the medical area, RL and AMH have adequatelyaddressed the two medical-related findings from the2004 investigation. Their corrective action plan wasadequate and has been effectively implemented. Thetransition to a new contractor was timely and effective,and the new contractor is making improvements in anumber of areas, such as establishing the riskcommunicator position. RL has been actively involvedin the program enhancement and has provided effective

oversight. Continued RL and AMH managementattention is warranted in some areas, including riskcommunication and collection and analysis of historicaland medical surveillance information. In addition, RLmanagement attention is needed to ensure that RLapplies sufficient medical expertise in its oversightefforts and addresses the current weaknesses in itsPerformance Evaluation Plan for the medicalcontractor.

This OA review did not result in any new findings.Recommendations for continued improvement andenhancements to ongoing initiatives are provided in thisreport.

3

Introduction1.0

The U.S. Department of Energy (DOE) Officeof Independent Oversight and PerformanceAssurance (OA) conducted a review in May-June2005 to follow up on its earlier investigation ofselected aspects of worker safety and healthsystems at the DOE Hanford Site. OA reports tothe Director of the Office of Security and SafetyPerformance Assurance, who reports directly tothe Secretary of Energy. OA performed the originalinvestigation in February-April 2004 at the directionof the Secretary of Energy to evaluate allegationsof deficient safety and medical practices.

The purpose of this OA follow-up review wasto assess the status of corrective actions forselected findings identified by OA during the 2004investigation in two areas:

• Corrective actions taken by the Office of RiverProtection (ORP) and the Tank Farmscontractor (CH2M HILL) for safety (vaporexposure) findings.

• Corrective actions taken by the RichlandOperations Office (RL) and the medicalprogram contractor, AdvanceMed Hanford(AMH), for medical program findings.

In each of these areas, OA’s objective is toprovide constructive feedback to ORP, RL, CH2MHILL, and AMH. As discussed in this report, thefollow-up review did not identify any furtherdeficiencies that are outside the scope of thefindings identified in the original investigation report,and the site organizations either have adequatelyaddressed the previous findings or have ongoingprograms in place that are generally appropriateto address the previous findings. Consequently,OA focused on providing a set of specificrecommendations for enhancing the current siteprograms and initiatives and/or addressing specificweaknesses in the approach to managing thesecorrective actions.

The original investigation identified 18 findings.Thirteen of these findings addressed CH2MHILL’s approach to vapor protection, oneaddressed ORP’s oversight of the vapor issue, andtwo addressed the medical program and RL’s

oversight of the medical program. The other twofindings addressed injury/illness investigation andreporting by other site organizations; these findingshave been addressed through other DOEHeadquarters initiatives and were not included inthis review. In addition, three of the thirteenfindings applicable to CH2M HILL dealt withengineered systems and were not explicitlyaddressed during this review. OA’s preliminaryreview of the three engineered system findingsindicated that the related corrective actionsgenerally address the actions that need to beperformed; however, ORP and CH2M HILL arestill assessing the application of engineered systemsin the overall protection strategy, so a review byOA is not yet appropriate.

Hanford Tank Farms

The Hanford Site, located in southeasternWashington state, incorporates a number of TankFarms that store and process highly radioactiveand hazardous waste. The Hanford Site TankFarms include 177 large underground tanks, all ofwhich are aging, and some of which aredeteriorating. Some of these tanks are of a single-shell design that provides less assurance ofcontainment than the newer double-shell design.Tank Farm activities involve various potentialhazards that need to be effectively controlled:exposure to external radiation, radiologicalcontamination, hazardous chemicals, and variousphysical hazards associated with facility operations.Of particular relevance to this investigation is thatthe materials in the tanks generate various gases,such as hydrogen, and vapors that contain ammoniaand various volatile organic compounds (VOCs).These gases and vapors can escape the tanksthrough normal venting and other leak paths.Some of the vapors produce unpleasant odors andcan cause such reactions as coughing and skinirritation; at higher concentrations, some of thevapors could be hazardous to human health.

The DOE Office of EnvironmentalManagement (EM) is the lead program secretarialoffice for the Hanford Site. As such, it has overallHeadquarters responsibility for most activities at

4

the site. At the site level, line management responsibilityfor the Tank Farms falls under the Manager of ORP,which manages the prime contract for the Tank Farms– CH2M HILL – and one other ORP prime contract –Bechtel National, Incorporated (BNI). ORP wasestablished as a separate organization reporting to EMin 1998 in an effort to increase accountability for thesuccess of the tank waste remediation efforts and tostreamline the management structure and the decision-making process.

Medical Program

The Hanford Site has an occupational medicineprogram that serves all Hanford Site contractors exceptBNI (which was authorized by DOE to subcontract itsown occupational medical provider). The occupationalmedicine program performs the various functionsrequired by DOE Order 440.1A, Worker ProtectionManagement for DOE Federal and ContractorEmployees. For example, the occupational medicineprogram provides medical treatment, performs requiredexaminations, maintains medical records for HanfordSite workers, and has responsibility for performingoccupational medicine services and for tracking andcoordinating medical issues, including trending healthissues for all site contractors.

At the direction of EM, RL manages varioussitewide programs at the Hanford Site, including thesite occupational medicine contract. Since the 2004OA investigation, the site occupational medicineprogram has transitioned to a new contractor. AMHwas awarded the medical program contract in June2004 and assumed responsibilities for operation of theHanford Site occupational medicine program, whichencompasses all site workers (including Tank Farmworkers) except BNI.

Allegations

In September 2003, the Government AccountabilityProject (GAP) issued a report entitled “KnowingEndangerment,” which alleged that deficiencies inworker protection at the Hanford Tank Farms had ledto worker vapor exposures and illnesses. Specifically,GAP alleged that workers were sick and injured afterbeing exposed to vapors from high-level nuclear wastetanks and other toxic and carcinogenic substances. TheGAP report and subsequent GAP statements alsoalleged that there were instances of improper medicalrecord keeping (including falsifying records and collusion

to undermine worker compensation claims) andimproper reporting of injuries and illnesses.

OA Investigation in 2004

The 2004 OA investigation focused on the adequacyof Tank Farm safety and health programs in areasrelevant to the allegations, such as industrial hygiene,work planning, and engineering controls. OA alsoreviewed the Hanford Site medical program and injuryand illness reporting practices. In addition, OAevaluated relevant safety management systems, suchas contractor feedback and improvement systems andDOE line management oversight. In a separate effort,the DOE Office of the Inspector General investigatedthe allegations regarding potential violation of laws.

OA’s 2004 review of worker vapor exposuresconcluded that there have been no known cases ofworkers being exposed to chemical vapors at theHanford Site Tank Farm in excess of regulatory limits,and available sampling data indicated that workerexposures were low. However, the Tank Farm’spersonal sampling data was too limited to conclude thatno worker has had any exposure that exceededregulatory thresholds for any chemical to which workersmight be exposed. In addition, weaknesses wereidentified in the Tank Farm industrial hygiene program,hazard analysis and controls, engineered controls,communications, contractor feedback systems, andDOE oversight. During the investigation, ORP andCH2M HILL took appropriate actions to mitigateworker risks until the hazards could be bettercharacterized and began to evaluate longer-termsolutions.

In reviewing the occupational medicine programin 2004, OA concluded that the allegations concerningthe falsification of workers’ medical records and theinappropriate medical treatment were not substantiated.The occupational medicine program maintains detailedpatient records and no major problems in occupationalmedicine were identified, although a few improvementswere warranted in some medical contractoradministrative processes and in RL’s coordination ofthe interfaces between site contractors. In the area ofinjury and illness investigation and reporting, OA’sreview of a sample of reports from the Tank Farmcontractor and four other Hanford contractors showedthat most injury and illness events were appropriatelycategorized and no egregious examples of misreportingwere identified, although a few cases were not clearlyaddressed in the regulation and the decisions to treat

5

them as non-recordable were questionable in a fewcases.

Following the OA investigation, the Secretary ofEnergy directed EM to develop and implementcorrective action plans to comprehensively andeffectively address the resultant findings andrecommendations. In response, ORP and C2M HILLdeveloped a corrective action plan for the vaporexposure findings, and RL developed a corrective actionplan for the findings related to the medical programand sitewide injury and illness reporting. OA’s reviewof the initial corrective actions plans indicated that many

of the identified corrective actions could beaccomplished in a short time but that some would entaillarge, multi-year efforts.

Organization of This Report

Sections 2 and 3 of this report provide OA’sassessment of the corrective actions for vaporexposures and the medical program, respectively.Appendix A provides supplemental information,including team composition.

6

Assessment of Corrective Actions forORP and CH2M HILL2.0

The 2004 OA investigation identified a numberof weaknesses in the CH2M HILL programs fordefining, monitoring, and controlling the hazardsassociated with workers’ exposure to vapors fromwaste storage tanks. During that investigation, ORPand CH2M HILL determined that the correctiveactions for the identified weaknesses would requirea long-term project to characterize the tanks andvapors, determine the potential health risks toworkers, and establish an effective system ofworkplace monitoring and controls. In light of theuncertainties, ORP and CH2M HILL then decidedto take the conservative step of requiring TankFarm workers to use supplied air—such as selfcontained breathing apparatus (SCBA) or portablesupplied air systems—for any work activities inareas where vapors could be present. OAconcluded that the extensive use of supplied airwas an appropriate measure to protect the workersfrom tank vapors while hazards are being analyzedand engineering controls are being developed.

At the time of this 2005 follow-up review,extensive SCBA usage was still being required.As long as this measure remains in effect andeffectively implemented, the risk of workers’exposure to vapors is adequately controlled.However, ORP and CH2M HILL recognize thatuse of SCBA for essentially all work activities atthe Tank Farms is not the optimal long-term solution.The SCBA air tanks are heavy and awkward towear, and they reduce workers’ field of vision andability to communicate. These factors could leadto other (non-vapor) types of health hazards, suchas heat stress, falls, and muscle strains, and maycontribute to injuries; a study by CH2M HILLattributed 57 injuries to SCBA use for the 14-monthperiod ending May 2005. While OA did notindependently evaluate injury trends, SCBA useinvolves potential safety hazards that warrantconsideration. In addition, the SCBAs reduceworker efficiency, and some workers complainabout the inconvenience and discomfort (e.g., heatand dry air).

The overall ORP/CH2M HILL approach is towork toward a sufficient understanding of thevapors, the release conditions and dispersal patternsof the vapors, and their health effects to determinethe best combination of engineered controls,personal protective equipment (PPE), andadministrative controls. ORP and CH2M HILLbelieve that the use of SCBAs can be substantiallyreduced through some combination of engineeringcontrols (e.g., extended stacks, ventilation systems),administrative controls (e.g., designated areas oractivities with controls that are graded accordingto the potential for exposure), air monitoring, andvarious types of respiratory protection. Accordingto the conceptual strategy, the type of respiratoryprotection required would vary based on thepotential for exposure and the types of vaporsanticipated (ranging from none for areas with verylow vapor exposure potential, to air-purifyingrespirators for areas with low risk from airbornecontaminants, to SCBAs for areas with significantpotential for vapor exposure). As discussed inSection 2.1, CH2M HILL has made progress incharacterizing the tank vapors, developingprocedures, and sampling the workplace air, butcontinuing efforts remain to develop the specificprotection strategies approaches and fill in theknowledge gaps; for example, some occupationalexposure limits (OELs) need to be determined, andsampling methods need to be developed.

OA’s review of the vapor exposure findingsand associated corrective actions taken by ORPand CH2M HILL addressed five categories offindings: vapor exposure characterization and theassociated industrial hygiene program controls,work planning and control, CH2M HILL injury andillness reporting, the CH2M HILL corrective actionmanagement process, and ORP oversight of thevapor exposure findings. The effectiveness of thecorrective actions must be considered both in thecontext of the current conditions (extensive SCBAuse) and the anticipated future conditions (additionalengineering controls, with SCBAs used only forselected activities).

7

2.1 Industrial Hygiene Programs

2.1.1 Summary of 2004 Results

The 2004 investigation concluded that there wereno known instances of exposures above regulatorylimits, but the longstanding deficiencies in thecharacterization of the Tank Farm vapors and industrialhygiene program were such that the site could notadequately ensure that all exposures have been belowregulatory limits. The 2004 OA investigation identifiedfive findings for CH2M HILL related to the industrialhygiene program. These findings were in the areas of:(1) vapor characterization, (2) exposure assessmentprogram, (3) industrial hygiene instrumentation, (4)industrial hygiene training and qualifications, and(5) respiratory protection.

2.1.2 Site Corrective Actions

CH2M HILL’s current corrective action (i.e.,extensive SCBA usage) is still being implemented toprotect workers from vapor exposures while long-termsolutions are under development. In addition, CH2MHILL has a number of ongoing projects to address thevapor protection issues, which are in various stages ofdevelopment and implementation. Corrective actionsrelevant to the five industrial hygiene findings arepresented below. CH2M HILL has closed theidentified corrective actions for the five OA industrialhygiene findings, ORP has verified the correctiveactions, and an effectiveness review is scheduled.(However, see Sections 2.4 and 2.5 for discussion ofsome concerns involving premature closure of correctiveactions.)

2.1.3 OA Assessment

The OA team interviewed industrial hygiene andengineering staff, reviewed reports and correctiveaction closure documents, and observed a few selectedfield work activities. The following paragraphs providean evaluation of the status of the corrective actionswith respect to these findings and associated issues.

Tank Vapor Characterization

The OA concerns with respect to the lack of tankvapor characterization are captured principally inFinding #C-1 of the 2004 investigation, which statesthat “CH2M HILL tank vapor characterization is not

sufficient to support industrial hygiene exposureassessment and respiratory protection programs.”CH2M HILL identified 15 corrective actions associatedwith this finding. All of these corrective actions havebeen closed by CH2M HILL, most before 2005.Collectively, the 15 corrective actions address most ofthe concerns identified by the 2004 OA investigation.

Significant accomplishments with respect to vaporcharacterization have been achieved since April 2004.Several actions are noteworthy, such as theestablishment of a panel of nationally recognizedtoxicological experts to review the “chemicals ofpotential concern” list and develop additional OELs forover 1400 tank chemicals for which OELs do notpresently exist. Another CH2M HILL accomplishmentis the issuance of several technical reports on tankvapor characterization, such as the Industrial HygieneChemical Vapor Technical Basis report and otherreports on vapor chemistry and headspace mechanics.

As part of their extent-of-condition review, CH2MHILL, to their credit, included additional necessarycorrective actions that were not identified in the 2004OA investigation report. For example, one of thecorrective actions requires evaluation of the 242-AEvaporator as a potential vapor source, although theOA report did not explicitly address the 242-AEvaporator. In addition, CH2M HILL has aggressivelysought to analyze the potential hazard in the tank vaporspaces resulting from a number of potential chemicalhazards.

Tank vapor characterization is a complex andchallenging activity, and CH2M HILL is applyingsignificant scientific expertise to assess the technicalchallenges and uncertainties. As examples ofuncertainties that were identified since the 2004 OAinvestigation, CH2M HILL identified 30 to 40 newchemicals that are now being evaluated in the vaporheadspaces, encountered some cases of higherchemical concentrations than those observed in the1990s, and experienced infrequent short-termconcentrations of VOCs exceeding the 200 ppmsaturation limit of some detection instruments placedon single-shell tank breather filters.

In a few cases, the corrective actions for thisfinding were either missed or incomplete. One of theconcerns identified by the OA investigation team wasthe lack of a process for analyzing and estimatingsampling errors. This concern was identified in twocorrective actions associated with headspace samplingand direct reading instruments. For example, althoughmethods have been established for estimating error,these methods have not been implemented in field

8

procedures. In addition, some of the corrective actionsfor this finding resulted in the issuance of technicalreports that identified additional recommendations.Some of these recommendations have not beenincorporated into any follow-on corrective actions toensure effective evaluation and/or implementation.

While the corrective actions for this finding havebeen closed by CH2M HILL (but not by ORP in theCorrective Action Tracking System, or CATS),considerable work with respect to vaporcharacterization remains before the OA finding can beresolved. CH2M HILL has scheduled additional vaporcharacterization activities to continue through 2007.The determination of OELs and development ofsampling and analysis protocols to implement the OELsis ongoing and may not be completed until later thisyear. Although tank headspaces for 30 additional tankshave been sampled for vapors through the VaporsSolutions Project since April 2004, the number ofsamples for most tanks is limited, and the results do notreflect the variety of work activities in the Tank Farms.Furthermore, at present, there is no headspace vaporcharacterization for 30 single-shell tanks. Because ofthe complexity of vapors in the tank headspaces, it isdifficult to predict a time in the future when headspacevapors will be “fully characterized.” However, uponcompletion of each future sampling campaign, such asthe initial sampling campaign for the A-prefix TankFarms scheduled for May 2006, sufficient vaporcharacterization should be available for these tanks tosupport industrial hygiene exposure assessmentprograms. At that time, modifications to the currentprotection strategy (e.g., relaxing current supplied airrespiratory protection requirements for selected workactivities) can be assessed.

Exposure Assessment Program

The OA concerns with respect to the CH2M HILLexposure assessment program are encompassed inFinding #C-2 of the 2004 investigation, which statesthat “Compliance with Occupational Safety and HealthAdministration (OSHA) and DOE exposure limits forchemical vapors cannot be sufficiently demonstrateddue to weaknesses in the CH2M HILL exposureassessment program.” CH2M HILL identified ninecorrective actions associated with this finding, all ofwhich have been closed. The CH2M HILL correctiveactions for this finding were wide-ranging and includedthe development of an exposure assessment strategy,development and issuance of industrial hygieneprocedures, and development of industrial hygiene

technician training and industrial hygiene instrumenttraining. Corrective actions associated with theexposure assessment program are addressed in thissection, and the following sections address correctiveactions associated with industrial hygieneinstrumentation (and associated procedures) andtraining.

A number of accomplishments with respect to thedevelopment of the CH2M HILL exposure assessmentprogram are evident since the issuance of the 2004OA investigation report. A robust ExposureAssessment Strategy document was issued andcontinues to be refined. The strategy provides a detaileddescription of the exposure assessment processenvisioned for the Tank Farms, including roles andresponsibilities (including the role of occupationalmedicine), establishes the basis for OELs and personalmonitoring, and addresses other hazards indirectlyassociated with the tank vapors, such as physical,biological, and ergonomic hazards. During March 2005,the Tank Farm Industrial Hygiene Database was issuedfor use by the industrial hygiene staff. It provides acomprehensive exposure data record-keeping andanalysis tool that will allow Tank Farm industrialhygienists and the AMH medical staff easy access topersonal sampling data and direct reading instrumentrecords for workers’ breathing zones, as well as tankventilation system chemical sampling data. Thedatabase also catalogs direct reading instrument datarecords, provides instrument range and calibration data,and is directly linked to a variety of chemicalinformation. The database addresses a number of the2004 OA concerns about poor instrument record-keeping practices and CH2M HILL’s previous inabilityto provide a timely, consistent, and accurate catalogand analysis of tank ventilation and personal exposurerecords. Another noteworthy accomplishment is thesignificant increase in the amount of sampling of tankventilation vapors and sampling for worker exposures.During the past 14 months, several hundred suchsamples have been collected and analyzed.

As with tank vapor characterization, much remainsto be completed with respect to the implementation andrefinement of the exposure assessment strategy.CH2M HILL plans to continue breathing zone samplingfor workers and sampling of vapor sources. Historicalexposure data will continue to be verified and enteredinto the new Tank Farm Industrial Hygiene Database.The exposure assessment strategy has not been fullyimplemented in the field, and the strategy is in somecases inconsistent with current work practices.Because workers are currently using supplied air, there

9

has been limited effort to integrate the exposureassessment strategy with current work activities. Forexample, one work package observed by the OA teamincluded outdated action limits of 2 ppm VOCs and 25ppm ammonia, and void limits (i.e., a limit at which anevacuation is required) of 25 ppm VOCs and 300 ppmammonia. These limits do not reflect either the currentknowledge of the tank vapors or the fact that workersare using supplied air; instead, these limits are associatedwith the air monitoring zones and limited respiratoryprotection that existed prior to the 2004 OAinvestigation. Based on this observation by the OA team,CH2M HILL has recently issued guidance concerningaction and void limits when workers are in supplied-airrespirators. However, CH2M HILL has not yetentered in their corrective action tracking system theactions necessary to assure timely implementation ofthe exposure assessment strategy.

During the past few months, the CH2M HILLIndustrial Hygiene Department has drafted a vaporpermit that should provide a useful work control toolfor translating requirements from the technical basisdocuments to vapor controls that can be implementedin the field. However, the vapor permit is a new conceptthat has not been finalized, procedures have yet to bedrafted, the process has not been incorporated in theCH2M HILL work control process, and the industrialhygiene staff and CH2M HILL workforce have notbeen trained concerning its use.

Before the exposure assessment strategy can beimplemented in the field, OELs for chemicals in theheadspace and sampling and analysis protocols mustbe completed, the appropriate field instrumentation mustbe readily available, work control processes must beadjusted, and workers and industrial hygiene techniciansmust be appropriately trained. The ongoing A-PrefixTank sampling campaign, which is scheduled forcompletion in the autumn of 2005, appears to be theinitial opportunity to implement these actions.

Industrial Hygiene Instrumentation

The OA concerns with respect to industrial hygieneinstrumentation are encompassed by Finding #C-3 ofthe 2004 investigation, which states that “Chemicalvapor exposure data obtained by CH2M HILL throughthe use of field instrumentation, particularly directreading instruments, is in some cases unreliable andmay not accurately reflect exposures of workers tosome chemical vapors being released from the tanks.”There are four corrective actions that are unique toFinding #C-3, as well as four corrective actions from

Finding #C-2 that also apply to industrial hygieneinstrumentation. All of the corrective actions areidentified by CH2M HILL as being closed.

A number of significant accomplishments have beenrealized in the area of industrial hygiene instrumentationsince the 2004 OA investigation. For example, aspreviously mentioned, the Tank Farm Industrial HygieneDatabase provides a useful tool for collecting field datafrom direct reading instruments. In addition, thedatabase provides a way to record instrument calibrationdata, and if an instrument has exceeded the calibrationperiod a warning is provided to the technician. Thedatabase also requires a supervisory and managementreview of all data recorded by the industrial hygienetechnician before the data record can be completed.The Tank Farm Industrial Hygiene Database, whenfully implemented, is an appropriate mechanism foraddressing a number of concerns about instrumentationdata records previously identified by the OA team.Another recent accomplishment has been theidentification, acquisition, and field testing of additionalindustrial hygiene instrumentation consistent with themonitoring and sampling strategy. A significantinvestment has recently been made in personal samplingequipment, direct reading instruments for nitrous oxidesand ammonia, and data loggers that can continuouslymonitor and record VOC levels associated with single-shell tank breather filters and stack effluents. Prior tothe 2004 OA investigation, there were few industrialhygiene instrument procedures, and technicians reliedon their interpretation of various instrument vendormanuals. However, during the past year, 18 newprocedures have been completed, and 3 additionalinstrument procedures are in development.

Although there has been significant progress in thearea of industrial hygiene instrumentation, considerableeffort remains. For example, a number of instrumentprocedures have been completed, but few of theseprocedures have been issued or implemented in thefield since much of the technician training has yet to beconducted (see the following section). In some cases,the direct reading instrument required for detecting aprimary chemical contaminant in the work space hasnot been field-prototyped or issued to technicians foruse in the field (e.g., mercury detection), or theinstruments are in short supply (e.g., nitrous oxidedetection). Because the Tank Farm Industrial HygieneDatabase was only made available for field use inMarch 2005, training and implementation issues willcontinue to require management attention in theupcoming months. Furthermore, much of the historicalinstrument data requires a quality review before

10

inclusion in the Tank Farm Industrial HygieneDatabase.

Industrial Hygiene Training andQualifications

The OA concerns with respect to training andqualification of industrial hygiene technicians,particularly with respect to exposure monitoring andsampling, and the use of direct reading instruments,are encompassed in Finding #C-4 of the 2004investigation, which states that “Limitations in thecurrent CH2M HILL industrial hygiene techniciantraining and qualification program, and the lack ofinstrument procedures, do not ensure consistency orproficiency when conducting vapor exposure andmonitoring activities.” CH2M HILL identified threecorrective actions associated with this finding, two ofwhich were addressed in Findings #C-2 and #C-3 andare discussed above. All of these corrective actionshave been closed by CH2M HILL.

Although CH2M HILL had implemented anindustrial hygiene technician qualification program priorto the 2004 OA investigation, training and qualificationactivities were often informal and inconsistent, andimplementation varied considerably among industrialhygienists who were assigned responsibility for thisprogram. However, since the 2004 investigation, theindustrial hygiene training and qualification program hasbeen completely revised, formalized, and restructuredto be consistent with the exposure assessment strategy.The current industrial hygiene training consists of 40hours of classroom instruction in industrial hygienefundamentals, and additional training and qualificationin two areas: industrial hygiene fundamentals andindustrial hygiene instrumentation. CH2M HILL hasrequired all technicians, including lead technicians, toqualify or requalify in the new program. Currently,over 90 percent of the industrial hygiene technicianshave completed the fundamentals classroom andqualification requirements. Based on OA fieldobservations and interviews with industrial hygienetechnicians, the level of knowledge concerningindustrial hygiene fundamentals and instrumentation hasimproved considerably. Another improvement is therecent development of a qualification program for TankFarm staff industrial hygienists, consisting of requiredreading, continuing education, and practical fieldexercises.

However, considerable training remains to becompleted on a number of the instruments used by thetechnicians. At present, training has been conducted

on only two instruments: the ITX Multi-Gas monitor(currently used for ammonia monitoring) and theppbRAE VOC monitor. Training has yet to beconducted on multi-gas monitors, mercury analyzers,another commonly used ammonia monitor, Gillian lowflow samplers, industrial hygiene pumps, noise surveyand dosimeters, and heat stress monitors. Industrialhygiene management anticipates that this training canbe completed before the end of calendar year 2005. Apolicy was established in March 2005 for modifiedqualification or “grandfathering” of technicians whohad previous experience with some instruments, buthad not completed their instrument qualifications inaccordance with the new qualification program. Inaddition, of the seven industrial hygienists who arerequired to qualify based on the new requirements, onlytwo have completed all of their qualificationrequirements.

Respiratory Protection

The OA concerns with respect to the CH2M HILLrespiratory protection program in the areas ofrespiratory protection procedures, respirator cartridgeselection, and issuance of voluntary respirators areencompassed in Finding #C-5 of the 2004 investigation,which states that “The CH2M HILL respiratoryprotection program has not facilitated the voluntary useof respirators, ensured that respirator issuers are trained,or adequately demonstrated that workers are protectedfrom the variety of chemical contaminants in tankvapors.” CH2M HILL identified four correctiveactions, three focusing on additional training forrespirator issuers and one focusing on revising therespiratory protection procedure to address thevoluntary issuance of respirators. Corrective actionsincluded a training needs analysis, which was conductedby the respiratory protection core team (consisting ofrespirator issuers, industrial hygienists, trainingpersonnel, and the respiratory protection programadministrators). The needs analysis concluded thatrespirator issuers should receive additional training onevaluating, maintaining, and issuing respirators.Changes to the respiratory protection procedure maystreamline the process for voluntary issuance ofrespirators and adequately address OA’s previousconcern that the process was so cumbersome thatworkers were reluctant to request a respirator.Respiratory protection procedures were further revisedto more clearly define responsibilities within the variousimpacted organizations, thereby addressing anotherconcern from the 2004 investigation. Several additional

11

corrective actions were identified by CH2M HILL withrespect to the development of a respiratory issuersforum, issuance of a charter for this group, schedulingand conduct of meetings, and the development andissuance of a qualification card for mask issuers. Allof these corrective actions have been closed by CH2MHILL.

The corrective actions for the voluntary issuanceof respirators are appropriate and appear to have beensatisfactorily completed, pending an effectivenessreview to be performed by CH2M HILL. Correctiveactions have also been identified and completed toensure that the respiratory protection that is issued,including filter cartridges, is consistent with the chemicalcontaminants in tank vapors. CH2M HILL currentlyrequires the use of supplied air for all work conductedwithin the Tank Farms. CH2M HILL has alsodeveloped a path forward for chemical vapor protectiveequipment decisions that, if carried to completion,provides an appropriate mechanism for ensuring theappropriate selection of respiratory protection,consistent with the vapor hazard.

Although progress has been achieved in resolvingrespiratory protection concerns raised during the 2004OA investigation, some issues remain. For example,respirator issuers have received some training, but aqualification process for respirator issuers has yet tobe formalized; additionally, there is not yet a formalcharter for the new respirator issuers group. Therespiratory protection procedure identifies someresponsibilities of the respiratory protection core teambut does not fully address the corrective action.Furthermore, until the completion of the CH2M HILLeffectiveness review, there is limited evidence that thechanges to the respiratory protection program havebeen effective.

Summary

Since the 2004 OA investigation, CH2M HILL hasachieved significant progress in each of the areas ofindustrial hygiene concern identified by the 2004 OAinvestigation team. Several of the corrective actionshave resulted in noteworthy accomplishments, such asthe Industrial Hygiene Chemical Vapor TechnicalBasis document and the Tank Farm Industrial HygieneDatabase. In a number of cases, CH2M HILL hasinitiated additional corrective actions to address rootcauses and extent-of-condition concerns related to theCH2M HILL industrial hygiene program. CH2M HILLhas spent and continues to expend significant resourcesin addressing tank vapor issues by developing and

implementing a comprehensive plan, which was notevident during the 2004 investigation. Industrial hygienetechnical basis documents and procedures have beendeveloped, the industrial hygiene staff has increased,and additional industrial hygiene instrumentation andtraining programs have increased the capability andcredibility of the industrial hygiene program.

Significant work remains in the characterization oftank vapors and worker exposures, as well as the controlof vapors to minimize exposures. The path forwardfor the industrial hygiene program, as described inseveral CH2M HILL documents, appears appropriate.As discussed in Sections 2.4 and 2.5, the correctiveactions for the findings from the 2004 OA investigationassociated with the CH2M HILL industrial hygieneprogram have been closed. However, additionalactions, ongoing or planned, that are needed to resolvethe underlying causes of the findings are not tracked ina formal issues management system. Also, the newindustrial hygiene technical basis documents, permits,training, and instrumentation have not been adequatelyintegrated with work planning and work controls at theTank Farms. Because CH2M HILL implementationschedules lack sufficient focus on work controlintegration, the necessary industrial hygiene controls(i.e., work documents, procedures, monitoring, vaporpermits, sampling, and training) may not be in place tosupport the A-Prefix sampling campaign scheduled forlater this year.

2.1.4 Recommendations forContinued Improvement

The following recommendations address ongoinginitiatives/enhancements to the current industrialhygiene initiatives:

1. Continue the development and enhancement of theindustrial hygiene program in the following areas:

• Continue to aggressively sample, analyze, andcharacterize vapor sources (e.g., breatherfilters and stacks) and tank headspaces.Provide a method for estimating sampling andinstrument errors in field procedures, andinclude error estimates within the data compiledin the Tank Farm Industrial Hygiene Database.

• Continue to evaluate, field test, and issue newindustrial hygiene instrumentation, particularlyfor direct reading of mercury vapors and data

12

logging of VOCs as required to support ongoingwork activities.

• Complete the development and issuance ofindustrial hygiene procedures.

• Develop and implement qualification standardsfor respirator issuers.

• Complete the industrial hygiene instrumenttechnician training and qualification. Expandthe current industrial hygiene technician trainingand qualification to include additional trainingon tank vapors and scenarios relating toindustrial hygiene support of work activities(i.e., interpretation of action limits). Completethe training and qualification of Tank Farmindustrial hygienists.

• Perform effectiveness reviews uponcompletion and implementation of significantindustrial hygiene program milestones.

2. Ensure that the exposure assessment strategy isintegrated into work control practices anddocuments, and maintain consistency betweenindustrial hygiene technical basis documents andwork practices. Complete the development,issuance, integration, and training for the vaporpermit process (or a comparable process).

2.2 Work Planning and Control

2.2.1 Summary of 2004 Results

The 2004 OA investigation concluded thatimplementation of work planning and safety controlswas not sufficiently rigorous. Consequently, in somecases, workers were not aware of appropriate controlsor did not appropriately implement the specified controlswhile performing work. The investigation reportidentified three findings for CH2M HILL in the workplanning and control areas of: (1) insufficient rigor inhazard analysis processes, (2) insufficient identificationand communication of hazards and controls to workersthrough work packages, and (3) insufficient rigor andspecificity in the processes for implementing hazardcontrols.


CH2M HILL conducted two assessments inresponse to the 2004 OA findings related to workplanning and control at the Tank Farms. Theseassessments included an Independent Assessment ofALARA, Radiological Work Planning, and WorkExecution Process, performed by the CH2M HILLindependent assessment group, and a Mission ControlManagement Assessment of Work Planning, whichexamined the identification, analysis, and flowdown ofhazards to workers in the work planning process. Theseassessments included an extent-of-condition review,determined that the weaknesses were programmaticin nature, and identified a need for improvement in thehazards analysis process. Specific corrective actionsrelevant to the three findings are presented below.CH2M HILL has closed the identified corrective actionsfor the three OA work planning and control findings,ORP has verified the corrective actions, and aneffectiveness review is scheduled. (However, seeSections 2.4 and 2.5 for discussion of some concernsabout the closure of corrective actions.)

2.2.3 OA Assessment

OA reviewed the CH2M HILL assessments,hazards analysis procedures, selected work packages,and related records. OA also interviewed selected TankFarm managers and workers and observed selectedwork activities.

Hazards Analysis

CH2M HILL took appropriate corrective actionsto address the OA finding about insufficient rigor inhazards analysis processes. CH2M HILL establisheda task team, consisting of representatives from theappropriate line and safety organizations, thatdeveloped an integrated strategy for hazardidentification, analysis, and flowdown of controls intothe work planning process and made specificrecommendations for improving procedures andtraining. Expectations for work planners (e.g., aprogram to ensure that planners periodically observework and identify improvements in work instructionsor hazard controls) were also developed. Work planningqualification cards were modified to reflect clearemphasis on work scope task breakdown, and workplanners have been required to requalify on modifiedqualification cards.

13

Communication of Hazards to Workers

CH2M HILL actions were also appropriate toaddress the OA finding about insufficient identificationand communication of hazards and controls to workersthrough work packages. Many of the actions foraddressing the hazards analysis deficiency (discussedabove) were also part of the integrated approach toflow down controls to the work activity level.Additionally, the work control procedure was modifiedto clarify the roles of the job hazards analysis (JHA),radiation work permit, and work instructions in the workplanning process. These revisions emphasize the useof work instructions to control work and identify hazardcontrols at the work activity level. Training plans weredeveloped for each procedure revision and appropriatelyaddressed all affected personnel. Requisite trainingwas developed, scheduled, and tracked to completion,and updates to qualification cards were required.

Implementation of Controls

The corrective actions discussed above alsoaddressed the OA finding about insufficient rigor andspecificity in the processes for implementing hazardcontrols. In addition, CH2M HILL evaluatedcommunication processes for abnormal events (suchas vapor releases) and concluded that no changes toprocedures were indicated. CH2M HILL alsoconducted briefings for CH2M HILL and constructionsubcontractor radiological workers on recent issues andperformance expectations in an effort to improveimplementation of controls. These briefings addressedappropriate topics, such as conduct of operations,enhancements to the Management ObservationProgram, definition and implementation of work scopesand controls, observation of field activities, hazardidentification and mitigation, post-job analysis, procedurecompliance, and conservative decision making.

OA’s review of a sampling of work packages andfield work observations showed that CH2M HILL hasincreased rigor in the work planning process andimproved JHA documentation (with some exceptions,noted below). Personal protective equipment (primarilyuse of SCBAs) was used extensively to prevent vaporexposures. Workers demonstrated proficiency in thedonning, use, and doffing of respiratory protection andwere able to complete observed tasks without anyvapor-related (or SCBA use-related) incidents orinjuries. However, OA identified a few deficiencies inwork packages and implementation of controls, asdiscussed in the following paragraphs.

The work package for removal of the three valvepit covers for 241 AP 08A did not reflect the currentindustrial hygiene technical basis, and the industrialhygiene action levels and void limits (i.e., stop-workcriteria) in the work package were not consistent withthe use of SCBAs or based on recent tankcharacterization data or exposure monitoring data. Forexample, Steps 2.7 and 3.11 of the work packageincluded industrial hygiene action levels that are basedon the use of air purifying respirators, not SCBAs, eventhough SCBAs have been in use for over a year.According to the work package, if the specified actionlevels of 2 ppm VOCs and 25 ppm ammonia areexceeded, then supplied air is required and the breathingzone must be monitored. However, workers are alreadyon supplied air (i.e., SCBAs), and the technician hadno plans to monitor the breathing zone of workers basedon exceeding these action levels, because the workersare already in SCBAs. The action levels and void limitsspecified in the work package (for example, 2 ppm forVOCs) do not have a documented basis in theIndustrial Hygiene Exposure Assessment Strategy,which the work package indicates is the source of thelimits. Although a number of new technical documentsand exposure assessment programs have beendeveloped as a result of the 2004 OA investigation,many of these programs are new, are not fullydeveloped, and have yet to be implemented andintegrated into the work control processes at the TankFarms. A work package that contains requirementsthat are no longer applicable and are not expected tobe followed may confuse workers and create a workenvironment where procedure non-compliance istolerated.

The work package for the C farm 241-C-103application of fixative to the tank vault had somedeficiencies. The JHA was revised (to address thenew chemical fixative to be used) between the timethe crew was dispatched to the job site and the actualstart of work, necessitating an additional briefing andworker sign-in on the new JHA. The JHA referred tothe material safety data sheet (MSDS) for the fixativemedia for potential hazards and controls associated withthe use of the material; this MSDS was not part of thework package, but was available at the job site. TheJHA could have provided the relevant information sothat workers would not have to search for the MSDS.No workers were observed requesting or reviewingthe MSDS during the job. The work package and JHAcontained good linkage between work tasks, potentialhazards, and required controls; however, the JHA didnot include potential hazards related to the use of sharps,

14

(i.e., razor knives used to remove tape and large scissorsused to cut pump line), and controls, such as cut-resistant gloves, were not considered. Additionally,although workers were required to don PPE (i.e., silvershield gloves) for protection against potential mercuryhazards in tank wastes, the permeation times were notkept for the individual (health physics technician) withthe greatest potential to come in contact with thesematerials, to limit the individual’s potential for absorption.Finally, CH2M HILL field work supervisors and workersassume that mercury is present only if radiologicalcontamination is present, but there is no documentedtechnical basis for this assumption. This observation issimilar to industrial hygiene findings from the 2004 OAinvestigation regarding the technical basis for vaporsand the various tank constituents.

Some aspects of work planning and work conductfor the replacement of an inlet high efficiencyparticulate air filter at SX Tank Farm did not followPPE requirements, as prescribed by the procedure forprotection against mercury. Furthermore, tools andsupplies required for conducting this work were notreadily available at the work location. The pre-jobbriefing and the work package procedure for the SXTank Farm inlet filter replacement appropriatelyaddressed the required PPE for worker protectionagainst potential contact with mercury-bearing wastes(primarily contaminated liquids). Because these (orsimilar) filters had been replaced previously, workersand planners knew that free standing liquids could beencountered, typically from less than a quart to as muchas five gallons of water potentially containing mercury.During the observed evolution, more than four gallonsof liquid spilled from the filter and filter housing; somewas captured by the pre-staged plastic bag, and somemissed the bag and spilled onto the concrete pad beneaththe filter. Three of the five individuals conducting thefilter replacement had donned PPE to protect againstpotential mercury contamination: one individual woresilver shield gloves, sleeves, and apron, and two otherswore sleeves and gloves. This PPE was worn overthe PPE required by the radiation work permit (coveralls,booties, latex gloves, etc.). The two additional workersinitially wore only the PPE designed to protect againstradiation. Once the cover to the filter housing wasbreached, water started to seep between the bag andouter surfaces and leak to the ground, where the twoindividuals who did not wear PPE for mercury helpedcollect the water (mopping up by hand), reattach thebag to the filter housing, and remove the filter wipearound the gasket material. They did not don silvershield gloves before this activity, though they did

subsequently don gloves or sleeves. Additionally,although the potential contact time was monitored forthe primary individuals (i.e., 15-minute duration for gloveeffectiveness), no such control was placed on thesetwo workers. This lack of appropriate controls may ormay not be attributed to the assumed correlationbetween mercury and radioactive materials describedabove.

Some aspects of the readiness to perform workfor the replacement of the same air filter at SX TankFarm also had shortcomings in implementation. Forexample, the equipment pre-staged for the work activitydid not include the needed tools, resulting in the workersbeating a pry bar on a wing nut used to tighten down afilter housing cover for approximately 15 minutes, untila field supervisor directed a worker to get the neededchannel lock pliers from elsewhere in the Tank Farm.This delay caused unnecessary consumption of thework crew’s SCBA air supply. Additionally, the plasticbags used to capture the liquids and dispose of the filterwere not large enough to readily contain a water-ladenfilter, so additional liquid was lost when the attempt toplace the filter punctured the bag. Furthermore, theabsorbent material placed in the waste bag was notsufficient to entrain all the liquids, leading to additionalcleanup after the bag puncture.

CH2M HILL recognizes that continued attentionis needed in work planning and control, particularly inimplementation of controls at the work activity level.A recent ORP assessment stated that “benefits ofcorrective action implementation were beginning to berealized” and that “a year or more of continueddeliberate management attention will likely be requiredto assure sustained improvement and culture change.”As discussed in Sections 2.4 and 2.5, a review of theimplementation of the corrective actions is essential toverify their effectiveness before closure.

Summary

CH2M HILL actions to enhance hazards analysisprocesses and communication of hazards and controlsto workers have been generally adequate.Improvements are evident in work packages, andCH2M HILL has devoted significant attention tocommunicating expectations to workers and enhancingimplementation of controls at the work activity level.However, the observed deficiencies in implementationof controls indicate a need for additional improvementin a number of areas, including readiness to performwork, ensuring that information contained in workpackages is current and complete, and communication

15

of abnormal events and the need to stop work whenunexpected conditions are encountered. Continued andincreased attention is needed to assess and verifyperformance effectiveness in this area.

2.2.4 Recommendations for ContinuedImprovement

The following recommendation addresses ongoinginitiatives/enhancements to the current work planningand control initiatives:

3. Continue and enhance efforts to improve workplanning and control processes, with particularemphasis on implementation of controls at the workactivity level in the following areas:

• Ensure readiness to perform work, current andcomplete information in work packages, andcommunication of processes for unusual eventsand the need to stop work when unexpectedconditions are encountered.

• Substantially increase observation of workactivities in the planned effectiveness review,and perform regular assessments of workplanning and control at the work activity level.

2.3 CH2M HILL Injury andIllness Reporting

2.3.1 Summary of 2004 Findings

The 2004 OA investigation concluded that CH2MHILL injury and illness evaluation and reportingprocesses were generally adequate, and there wereno indications of significant or pervasive underreportingof injuries and illnesses. However, the finding in thisarea noted that injury and illness cases were not alwaysproperly classified and reported and also identifiedweaknesses in the CH2M HILL records keepingsystems, which are needed to support injury and illnessreporting requirements.


To address this finding, CH2M HILL took a numberof corrective actions, including revising their recordkeeping procedure to include more specific expectationsand establishing a process for regular audits of the case

files. CH2M HILL also hired a second recordsspecialist and provided training to the records specialistson OSHA injury and illness record keepingrequirements. In coordination with the medicalcontractor, CH2M HILL established regular interfacesbetween records specialists (case managers) andmedical program personnel. CH2M HILL also auditedcase files generated during the past two years todetermine whether cases had been properly classifiedand whether OSHA record keeping requirements weremet; deficiencies identified during the audit werecorrected. In addition to CH2M HILL actions, theHeadquarters Office of Environment, Safety andHealth changed applicable requirements so that injuryand illness data is now reported electronically andprovided training to DOE and contractor injury andillness record keeping specialists.

2.3.3 OA Assessment

The OA team reviewed the revised proceduresand training records, and interviewed one recordsspecialist (the second was on leave) and various CH2MHILL managers. OA also reviewed a sample of casefiles (28 files from the past two years) to determineeffectiveness of CH2M HILL actions.

OA found that the CH2M HILL corrective actionshave been appropriate and effectively implemented.The revised procedures are adequate, and trainingrecords verify that training was performed. TheHeadquarters actions to require electronic reportinghave resulted in more efficient reporting processes andmore timely records.

The 28 case files reviewed by OA indicated thatCH2M HILL personnel have a good understanding ofOSHA record keeping. All 28 files contained therecords required by CH2M HILL procedure: a problemevaluation request (PER) if generated, record of visit,event report, Computerized Accident/Incident ReportingSystem (CAIRS) report if reportable, and a casemanager’s report. All were correctly classified forreporting pursuant to OSHA 29 CFR 1904 criteria.CAIRS reports were issued for each recordable injuryand illness.

Further refinements are needed in the interfacebetween CH2M HILL and AMH, the medical programcontractor. In four case files, the CH2M HILL casemanager’s report indicated that the employee’s personalphysician had prescribed medicine, but AMH’s updatedrecord of visit did not indicate that prescriptionmedication was provided. In these four cases, the casemanagers had been able to find the information about

16

prescriptions by informal means and include it in thefile; however, the information should have beensystematically provided by AMH through an updatedrecord of visit because accurate information aboutprescription medicine is needed to make correctdecisions about reportability. Such information couldhave been omitted from the record of visit for variousreasons—for example, employees not followingprocedures for reporting to AMH before returning towork, or AMH not properly reporting information aboutmedicine prescribed by a non-AMH physician. Asdiscussed in Section 3.1, AMH managers indicated thatthis potential interface concern will be addressed withCH2M HILL.

Summary

CH2M HILL has adequately addressed theweaknesses in injury and illness reporting noted in 2004.To further refine the process, CH2M HILL shouldcontinue to follow up with AMH to ensure that completeinformation about medicine prescribed by employees’personal physicians is reliably included in the case filesto support reportability decisions.

2.4 CH2M HILL CorrectiveAction Management


The 2004 OA investigation concluded that CH2MHILL had made some improvements but that there wereweaknesses in the CH2M HILL corrective actionmanagement process and in other aspects of feedbackand improvement systems (assessments, issuesmanagement, lessons learned, and employee concernsprograms). The finding in this area (Finding #C-13)indicated that the corrective action program had notalways been effective in defining and investigatingissues related to Tank Farm vapor releases andexposure incidents or in establishing actions thateffectively prevented recurrence of personnel vaporexposures.


CH2M HILL actions specifically to address Finding#C-13 included revising procedures to require morethorough review of future vapor exposures andpreviously-issued vapor exposure PERs to identify

lessons learned. CH2M HILL has also used its PERprocess to manage corrective actions for the other 12findings from the 2004 OA investigation that weredirected toward CH2M HILL. ORP and CH2M HILLdeveloped a corrective action plan that defined specificactions to be completed for each of these findings.CH2M HILL reported that it had completed all of therequisite actions and had closed all 13 of the findingswithin its PER tracking system; the last finding wasclosed in March 2005. In its fiscal year (FY) 2005annual assessment of the CH2M HILL industrialhygiene program, ORP verified that CH2M HILL hadcompleted the corrective actions committed to in thecorrective action plan, based on reviewing a sample ofthese corrective actions. The OA team found that ORPhad updated CATS to reflect this verification. ORPplans to conduct an effectiveness review by November2005.

2.4.3 OA Assessment

OA reviewed the specific actions identified in thecorrective action plan for the 2004 finding that dealtwith corrective action management (Finding #C-13),as well as the application of the CH2M HILL correctiveaction management process to the other 12 CH2MHILL findings from the 2004 investigation. OA alsoexamined the broader set of actions that CH2M HILLis undertaking to address the vapor issue, includingefforts by CH2M HILL to improve communicationsand trust between management and workers, such asan initiative by CH2M HILL to create a safe workenvironment (SWE). OA reviewed the correctiveaction plan and closure packages, toured facilities,watched selected work activities, and examinedselected documents (e.g., operating procedures, airmonitoring records, and training records) to assess thecompleted actions.

CH2M HILL has devoted significant managementattention to the application of the PER process to the13 findings. Each finding was reviewed to determinethe extent of condition and causal factors, and allcorrective actions were reviewed by a CorrectiveAction Review Board before the PER was closed.CH2M HILL’s review of the problems and correctiveactions included steps that were more rigorous thanthe minimum requirements of the PER process for mostof these findings.

The PER process is generally adequate formanaging corrective actions. In some cases, theprocess was effective in identifying and tracking theexecution of an appropriate set of corrective actions

17

that corrected the identified problem and eliminatedunderlying causes. For example, the actions in responseto the injury and illness finding and the vacuum breakerfinding were effective. For the most part, CH2M HILLeffectively implemented the closure process andverified that actions were complete.

In some cases, however, the actions identified inthe PER process were limited to identifying a pathforward or establishing an action plan, and did notinclude plan implementation. Thus, the actions werecompleted and the PERs were closed before theplanned improvements were made and the underlyingcauses of the problems were corrected. For example,OA Findings #C-1 through #C-5 identified the needfor better vapor characterization, exposure assessment,and monitoring. Progress has been made in each ofthese areas, but much work remains to be done toreduce the dependence on supplied air respirators.

Some of the PERs that were written to addressOA investigation findings were closed because thecorrective action specified in the PER had beencompleted; however, the underlying causes of the findingremain to be corrected. CH2M HILL has identifiedthe actions needed to address these causes, but theactions are not identified in a formal corrective actiontracking system. For example, PERs for the followingtasks, which were part of the response to the 2004 OAfindings, were closed even though corrective actionswere continuing and are not formally tracked throughPERs:

• A PER for the task, “Align the IH [industrialhygiene] vapor monitoring program to thedocumented technical basis,” was closed, eventhough the monitoring procedures were not up todate with vapor characterization studies and theprocedures and training for use of some industrialhygiene instrumentation were incomplete.

• A PER for the task, “Establish an exposureassessment strategy that incorporates the IH[industrial hygiene] vapor monitoring technicalbasis,” was closed based on development of adocumented exposure assessment strategy, but thestrategy was not fully implemented in the field.

• A PER for the task, “Establish a formal IH[industrial hygiene] Instrument Program toensure a systematic and methodical approachto instrument selection, use, calibration, andmaintenance,” was closed, even though

development of an instrument control process wasincomplete, some instrumentation has yet to beselected (e.g., field instruments for mercurydetection) and training of industrial hygienetechnicians is incomplete.

The corrective actions have continued after closureof these PERs, but these ongoing actions are not alwaystracked in PERs (or another corrective actionmanagement process). Application of the PER processto planned tank vapor actions is important to ensuretimely and effective completion. The current CH2MHILL PER process does not contain definitive closurecriteria and thus does not preclude closure based solelyon development of a path forward.

CH2M HILL recently issued a management plan,Program Plan for Resolution of Tank Farm VaporIssues, that provides a comprehensive strategic planfor addressing vapor issues. This plan lays out a logicalapproach for controlling Tank Farm vapors that isconsistent with the DOE safety management policy.If effectively implemented, the plan would addressconcerns previously identified by OA and could reducethe dependence on supplied air respirators. However,the plan lacks sufficient detail to ensure timely andeffective implementation of the many ongoingimprovement initiatives. Because specific tasks arenot well defined, the responsibilities for accomplishingthese tasks are not clearly defined; milestones andcompletion dates are not established; and severalplanned activities are not included in a referenced VaporSolutions Matrix (which is described as a tool foridentifying, tracking, and ensuring the effectiveness ofcorrective actions).

Without a project management approach, there isa potential to miss actions or encounter delays becauserequisite interfaces are not managed. For example,research projects are under way to develop newmonitoring methods for some chemicals; implementingthese methods will require a number of further actions(e.g., equipment procurement, technician training, andprocedure development). Also, a number oforganizations (line, industrial hygiene, engineering, andvarious laboratories and subcontractors) haveresponsibilities for implementing ongoing action items,but there is no clear process for ensuring that all ofthese organizations coordinate their effort, apply thenecessary resources, and meet established milestones.In addition, if priorities and funding change, these itemsmay not be completed, because they are not in a formaltracking system. A project management approach will

18

facilitate risk-based application of resources and willprovide a formal process for balancing priorities.

At the end of the onsite portion of this OAinvestigation, CH2M HILL indicated that they plan toimplement a project management approach. CH2MHILL has identified a senior manager to manage theproject, has identified key tasks, and is working on aproject plan and milestones.

ORP and CH2M HILL plan to perform aneffectiveness review by November 2005; this timingmeets the requirement to conduct the review within sixmonths of closing the PERs, consistent with DOE Order414.1B, Quality Assurance. However, manyimportant actions will not be completed by then, notablycharacterization of tank vapor. While a review inNovember 2005 could verify some actions, it wouldnot provide for full verification that the corrective actionshave adequately addressed the findings.

OA confirmed that the corrective actions specifiedin the PER and associated Electronic SuspenseTracking and Routing System (ESTAR) items for thecorrective action management finding (Finding #C-13)were satisfactorily completed. However, the analysisof this finding did not identify the past failure toadequately address workers’ concerns as a causalfactor, even though workers had been raising concernsabout vapor exposures for several years beforeappropriate actions were initiated. A Lessons LearnedBulletin, issued in 2004 as part of the corrective actionfor this finding, appropriately recommends bettercommunication between management and workers,with a focus on how management can better provideinformation to workers. However, the Bulletin doesnot address how management can be more responsiveto worker concerns. Discussions with workers duringthis follow-up review, and interviews conducted duringthe recent ORP review of the CH2M HILL industrialhygiene program, indicated a continuing belief by someworkers that CH2M HILL management has notadequately addressed their concerns.

Recently, CH2M HILL has taken additional stepsto communicate with workers and to respond to workerconcerns and feedback, with the goal of improvingworker confidence in the monitoring and control ofvapor exposures. CH2M HILL recently initiated theSWE program, which is an approach commonly usedin the commercial nuclear industry to encourageworkers to raise concerns to management. Theprogram includes mechanisms for workers to raiseconcerns without fear of reprisal and ensuring thatmanagers are responsive to these concerns. A baselinesurvey conducted last year indicates a need for

improvement in this area, and management is placingpriority on implementation of this approach.Expectations have been conveyed through policystatements, procedures, and all-hands meetings andhave been incorporated into performance standards anddisciplinary procedures. Managers have been trained,and workers have been engaged. Although the SWEis in the early stages, the SWE approach is promisingand has the potential to enhance communications,worker confidence, and activity-level feedback aboutpotential vapor exposures.

Summary

CH2M HILL has devoted significant managementattention and resources to resolution of the findingsidentified in the 2004 OA investigation. Most of theactions specified in the corrective action plan for the2004 OA investigation have been completed and havebeen verified complete by CH2M HILL and ORP.However, much work remains to address the underlyingissues that resulted in the original findings, and theseactions should be rigorously tracked in a formalcorrective action management system. CH2M HILL’snew program plan fulfills the need for a comprehensivestrategic plan for addressing vapor issues but requiresadditional detail and controls to ensure timely andeffective implementation of the many ongoing efforts.


The following recommendation addresses ongoingCH2M HILL initiatives/enhancements to the currentcorrective action management control initiatives:

4. CH2M HILL should strengthen the managementof corrective actions associated with worker vaporexposures:

• Revise the Program Plan for Resolution ofTank Farm Vapor Issues to incorporate aproject management approach for assigningtasks, establishing milestones, and setting duedates for accomplishing program objectives.The program plan should be supported withclear responsibilities and lines of authority andshould identify the estimated funding andresources needed to complete the identifiedtasks.

19

• Reopen PERs, or establish new PERs, for OAfindings with continuing corrective action andimprovement initiatives. Use the PER processto track and manage these items until analternative system, such as the projectmanagement system discussed above, isavailable for management of these items.

• Include closure criteria in the PER procedureto ensure that planned corrective actions fullyaddress stated problems.

• Coordinate with ORP to scheduleeffectiveness reviews after corrective actionsare fully implemented and sufficiently matureto allow for an adequate review and verificationthat the underlying issues for findings have beenaddressed. Multi-phased reviews should beconsidered as a mechanism for timely reviewof actions as they are completed.

2.5 ORP Line ManagementOversight


The 2004 investigation concluded that ORP hadperformed a number of appropriate reactive reviewsand interim actions to obtain industrial hygiene supportfrom other DOE organizations. However, the 2004OA finding on ORP oversight (Finding #C-14) indicatedthat ORP had not adequately addressed weaknessesin its oversight of the CH2M HILL industrial hygieneprogram and had not ensured timely corrective actionsfor identified issues. In addition, the investigationconcluded that ORP did not have sufficient industrialhygiene expertise to adequately perform its linemanagement oversight responsibilities and had notdevoted sufficient attention and resources to performingeffective line management oversight of the industrialhygiene program, issues, and ongoing corrective actionsat the Tank Farm.

2.5.2 Site Corrective Action

During the past year, ORP has provided industrialhygiene training to the technical staff as part of a 40-hour OSHA course and augmented its staff withcontracted certified industrial hygienists. Training wasalso provided on injury and illness record keeping and

reporting. Two additional Facility Representatives wereassigned to oversee Tank Farm activities.Programmatic assessments by technical specialistshave focused on Tank Farm environment, safety, andhealth (ES&H). ORP also developed and implementeda corrective action plan to address the OA investigationfindings as required by DOE Order 470.2B,Independent Oversight and PerformanceAssurance Program, and DOE Order 414.1B, QualityAssurance.

2.5.3 OA Assessment

To assess enhancements in ORP oversight, OAreviewed training materials, staffing, various procedures,selected assessment reports (industrial hygiene andinjury and illness assessments), and records (e.g.,quarterly reports, training records). OA alsointerviewed ORP managers and selected staff.

The actions taken by ORP are appropriate andstrengthen ORP oversight of vapor exposure issues.The industrial hygiene training and contracted industrialhygienists, and the return of a Federal industrial hygienistto the ORP staff, have provided ORP with adequatecapabilities to oversee industrial hygiene issues.

The Facility Representative activities have beenstrengthened by the additional staff assignments. ORPnow has ten Facility Representatives assigned to theTank Farms, eight fully qualified and two trainees. TheTank Farm Project Group Facility Representativesprovide daily oversight of Tank Farm activities byobserving and assessing such activities as field work,job planning, post-job review meetings, training, andoral board exams. Facility Representatives areexpected to spend 60 percent of their time in the fieldand 40 percent observing Tank Farm activities, and todocument their activities in weekly and quarterly reports.

ORP management discusses the results ofoperational awareness activities with CH2M HILLmanagement on a monthly basis and formally reportsresults to CH2M HILL management in quarterlyreports. Deficiencies requiring corrective action aredocumented by CH2M HILL as PERs, which arereferenced in weekly and quarterly reports. A reviewof the four most recent quarterly reports, supportingweekly reports, and related assessments indicates thatFacility Representatives and technical staff areeffectively performing their line oversightresponsibilities. The reports include assessment of TankFarm work controls and management of vapor exposureissues. ORP’s conclusions were based on observations

20

of work activities, when appropriate, and substantiveproblems were entered into the PER process formanagement of corrective actions.

However, corrective actions have not always beenfully effective, as evidenced by the fact that someweaknesses previously identified by ORP were alsoobserved during this OA follow-up review. For example,ORP identified PERs that were closed before correctiveactions were complete and identified the need for vaporproject efforts “to be managed to predeterminedobjectives or coordinated toward proper respiratoryprotection” (see Section 2.4).

Technical specialists from the ORP Office ofEnvironmental Safety and Quality (ES&Q) also assessTank Farm activities. Results of these assessmentsare communicated to CH2M HILL in formalassessment reports, and corrective actions are trackedin CATS. ORP discusses assessment results and thestatus of corrective actions (including corrective actionsassociated with OA findings) with CH2M HILLmanagement during weekly meetings. ES&Q hasscheduled and performed assessments of CH2M HILLTank Farm activities in a variety of programmatic areas.Ten assessments have been completed, and four othersare scheduled for FY 2005.

OA’s review of the ORP assessment of injury andillness record keeping determined that the scope andcriteria were appropriate and that the conclusions werewell supported. The results of the assessment indicatethat corrective actions taken by CH2M HILL inresponse to its earlier self-assessment were effective.The results of the ORP assessment were consistentwith the results of this OA follow-up review (seeSection 2.3).

ORP recently performed a comprehensive reviewof the CH2M HILL industrial hygiene program, Reviewof the CH2M Hill Hanford Group, Inc. (CH2MHILL) Industrial Hygiene (IH) Program, April, 2005.The report for this review concludes that the industrialhygiene program complies with regulatory requirementsand is effectively implemented, but the basis for theseconclusions is not clear in some cases. For example,the report states that the contractor can achieve fullimplementation of its industrial hygiene program goalsby April 2006. This statement was based upon thefact that issues to be resolved were identified andfindings for resolution had been provided; however, thecontractor does not have a comprehensive project planin place to achieve the defined goals by that date. Also,the report does not provide clear conclusions about someimportant aspects of the program, such as the qualityof the new industrial hygiene technical basis document,

the ability to monitor chemicals of potential concern, orthe effectiveness of CH2M HILL’s management ofvapor issues.

ORP has had a contractor perform three reviewsof integrated safety management for Tank Farmactivities since the 2004 OA investigation of vaporexposures. The OA team reviewed the most recent ofthese reports, Post-Implementation Portion of theIntegrated Safety Management (ISM) ImprovementValidation at the Hanford Tank Farm, Final Report,March, 2005, and determined that the review waswell planned, team members were well qualified,conclusions were well supported, and the reviewappropriately included observation of work activities.The contractor’s report identified needs forimprovement in determining the readiness to proceedwith work so that proper personnel equipmentresources are available and in upgrading the issuesmanagement program with respect to closureeffectiveness, timeliness, and feedback. However,because the report identified no findings, no formalcorrective action was required. Corrective actionappears to have been warranted because similarproblems were observed by OA during this follow-upreview.

ORP has held the Tank Farm contractor financiallyaccountable for ES&H performance. For example,ORP withheld fee from the contractor last August whenES&H performance expectations were not met. Inaddition, ORP established financial incentives last yearto encourage the implementation of engineered controls(stack extensions) and headspace vapor sampling.CH2M HILL met the performance criteria (e.g.,extending the stacks and collecting samples) and wasawarded the incentive fee.

ORP has been actively monitoring CH2M HILLefforts to address the 13 OA findings that wereapplicable to CH2M HILL. ORP reviewed the CH2MHILL corrective action plan submitted to DOEHeadquarters, and also has monitored CH2M HILL’simplementation of the corrective action plan throughoversight of work activities and weekly status meetingswith CH2M HILL management. To meet therequirement for an effectiveness review for the 2004OA investigation findings, ORP has directed that CH2MHILL perform such a review, and ORP intends toparticipate in and assess the CH2M HILL efforts. ORPhas verified completion of CH2M HILL correctiveactions based on an assessment of a sample of theseactions and has updated CATS to reflect thisverification.

21

Although ORP personnel indicated that they intendto close the 13 CH2M HILL findings in CATS, it ispremature to do so for some of the findings (#C-1through #C-5) for the reasons discussed in Section 2.1and 2.4. In addition, OA’s review of one work activityindicates that additional assessment of work planningand control should be considered before the CH2MHILL actions in the work planning area are closed.Further, the effectiveness review is scheduled for atime period in which many of the most important actionsin the areas of tank characterization and industrialhygiene will not be complete, as discussed in Sections2.1 and 2.4, and thus their effectiveness cannot beadequately verified.

Summary

ORP has strengthened its oversight of the TankFarm contractor since the 2004 OA investigation.Oversight by Facility Representatives has beenstrengthened by increased staffing, and the technicalstaff has been augmented by contracted industrialhygienists. Increased priority has been placed onassessment of ES&H programs, and assessments havebeen conducted in most areas where the OAinvestigation identified problems. Continuing attentionis needed to ensure the quality of such products as theindustrial hygiene technical basis document and tankvapor characterization results and to ensure that theTank Farm contractor establishes an effective processfor corrective action management. ORP should ensurethat findings from the 2004 OA investigation are notclosed until their effectiveness has been adequatelyevaluated and verified.


The following recommendation addresses ongoingORP initiatives/enhancements to the current correctiveaction management control initiatives:

5. Strengthen the ORP management of CH2M HILLcorrective actions associated with worker vaporexposures:

• Review and approve the CH2M HILLprogram plan, after it is revised to incorporatea project management approach, to ensure thatimplementation of this plan will fully resolveOA findings and adequately manage otherimprovement initiatives.

• Provide line management oversight to ensurethat CH2M HILL uses its PER process, or analternative management system (such as theprogram plan discussed above), to track andmanage corrective actions and improvementinitiatives associated with each OA finding.

• Continue to assess the technical adequacy ofcorrective actions taken by CH2M HILL,including tank vapor characterization studiesand the industrial hygiene program technicalbasis document.

22

Assessment of Corrective Actions forRL and AMH3.0

For the medical program findings, OA focusedon the corrective actions taken by RL and AMHto enhance the medical program contractor’sadministrative processes and the actions taken byRL to enhance the interfaces between the medicalprogram and the site operating contractors(including CH2M HILL). OA also examined RL’sline management oversight of the medical program,with emphasis on RL’s oversight of the transitionof the medical program from the previouscontractor to AMH; this transition occurred at aboutthe same time as the 2004 OA investigation reportwas released by the Secretary of Energy andprovided to EM and RL.

3.1 Contractor AdministrativeProcesses


The 2004 OA investigation determined that theprevious contractor’s clinical protocols wereconsistent with standard occupational medicalpractices. However, weaknesses were identifiedin the previous contractor’s administrative protocolsin the areas of internal communications, use ofthe results of patient surveys to driveimprovements, and completeness of records ofvisits provided to other site contractors (whichcontributed to a few instances of incorrectrecording of injuries).


RL took actions with the previous contractorto address the identified weaknesses in the recordsof visits, including revising the protocol to providemore specificity on work restrictions andprescriptions of pharmaceuticals. The revisedprotocol was carried through to the new medicalcontractor. RL also took actions to ensure thatthe new contractor was aware of and had plansto address the weaknesses in internalcommunications and use of patient surveys. These

RL actions included a review of AMH proceduresand survey practices. In addition, RL hadpreviously taken action to clarify expectations inthe scope of work and contractual provisions forthe contract award. AMH has submitted revisedprocedures and survey instruments in accordancewith the corrective action plan provisions. AMHhas also established a “risk communicator” position,which is filled by a licensed physician, to enhancecommunications.

3.1.3 OA Assessment

OA reviewed selected AMH procedures andprocesses relevant to the identified deficiencies,as well as RL corrective action plans andassessments. OA also interviewed RL and AMHpersonnel with medical program responsibilities.

The RL corrective action plan for the findingin this area identifies appropriate actions and hasbeen adequately implemented. RL has beeneffective in ensuring that AMH was aware of andeffectively addressed weaknesses in the previouscontractor’s administrative protocols. Training onthe AMH corporation policies is in process.

OA’s review indicated that the AMHprocedures are appropriately rigorous and detailedand address the identified concerns about recordsof visits, internal communications, and use of surveyresults. During the transition period, AMHadequately addressed a number of challengesassociated with establishing new office/clinicalspace and transferring custody of DOE equipmentand records. AMH has also converted previouscontractor files to electronic files/databases thatare searchable and is now assessing how to bestuse the data to perform trend analysis. Further,AMH is planning to use patient and customer(contractor) survey information to makeimprovements in specific contractor interfaces andhas subcontracted with an external organizationto perform regular, independent patient/customersurveys.

As discussed in Section 2.3, AMH needs tocontinue to clarify its process for records of visits

23

to ensure that prescription medications, whenprescribed by an employee’s personal physician, areincluded on record-of-visit forms, which are providedto the contractor case manager to enable properdecisions about OSHA recordability. AMH managersindicated that they would work with CH2M HILL tomake the needed changes to the record-of-visit processand forms.

OA’s review indicates that establishing the riskcommunicator position has been effective in addressingthe significant challenges with communicating medicalrisk information to the workforce. The AMH riskcommunicator and other AMH personnel staff are nowactively participating in the CH2M HILL health effectscommittee, vapor solutions team, mercury surveillanceforums, and several other informational meetingsinitiated by CH2M HILL to enhance communicationwith the Tank Farm employees. Independent interviewswith several Tank Farm workers indicated that AMHhas been helpful in establishing a positive communicationprocess at various forums and informational meetings.

However, much work remains in communicatinginformation about health risks to the workforce andaddressing concerns on the part of some Hanford Siteworkers. In addition, although some progress has beenmade, AMH is only in the early stages of developing astrategy for collecting and analyzing the various sourcesof historical health-effects data and using clinicalinformation to provide trend analysis of medicalsurveillance data.

Summary

RL and AMH actions have adequately addressedthe finding in the area of medical contractor processes(e.g., internal communications, use of surveys,expectations for record-of-visit forms). However,continued efforts are needed in communications and inusing health-effects data.


The following recommendation addresses ongoinginitiatives/enhancements to the current medical provideradministrative process program initiatives:

6. AMH should accelerate their efforts in the areasof risk communication (among site managementand the site worker population), collection andanalysis of historical Tank Farm health-effectsdata, and trending and analysis of medical

surveillance data, and should ensure that record-of-visit processes and forms are revised to reflectinformation about medicines prescribed by non-AMH physicians.

3.2 Interfaces Between theMedical Program and SiteOperating Contractors


The 2004 OA investigation determined that RL hadnot adequately coordinated with other site organizationsto ensure that adequate interface agreements were inplace between the occupational medical programcontractor and site operating contractors. Theinsufficient interfaces contributed to instances wherehealth-related information was not adequatelyexchanged to ensure that medical programrequirements were met and that site safety coordinatorscould accurately determine whether an event is OSHA-reportable.


RL took actions to complete formal interfaceagreements and enhance communications among thevarious organizations, such as regular meetingsbetween RL and AMH to exchange information anddiscuss issues. RL and AMH have also worked withthe various site contractors to promote consistency inhandling, storage, and retention of medical records.

3.2.3 OA Assessment and Summary

OA reviewed interface agreements and recordsof meetings that were relevant to the identifieddeficiencies. OA also interviewed RL and AMHpersonnel with responsibilities for interfacing with otherHanford Site organizations.

The RL corrective action plan for the finding inthis area identifies appropriate actions and has beenadequately implemented. The interface agreementsare in place and provide appropriate information aboutexpectations and roles and responsibilities for thevarious organizations. OA’s review indicates thatcommunications have improved and that AMH isworking to further enhance site contractorcommunication and interfaces. Overall, RL hasadequately addressed the finding in this area.

24

3.3 RL Line ManagementOversight of the CorrectiveAction Process

3.3.1 OA Assessment

RL has appropriately closed the two medicalprogram-related findings from the 2004 OAinvestigation. RL ensured that the corrective actionplans for these findings were adequate and thatmilestones were met (a few justifiable delays wereencountered and were accepted by management). RLalso performed appropriate assessments to verify thecompletion of the corrective actions for the medicalfindings. RL plans to perform effectiveness reviewsof AMH’s new and ongoing programs and initiativesafter sufficient time has passed to evaluateperformance data.

RL has also been generally effective in overseeingthe transition from the previous contractor to AMH.RL has been actively involved in the AMH effortsduring the transition period and has provided appropriateassistance in addressing transition issues.

RL has established a strategic approach andschedule for performing regular assessments of medicalprogram contractor performance. Specifically, the U.S.Public Health Service has been contracted to helpperform quarterly reviews of various aspects of medicalcontractor performance, including reviews that provideinformation for the annual contractor performanceevaluation. In addition, RL has required AMH tocoordinate with an accreditation agency (AMH selectedthe Accreditation Association for Ambulatory HealthCare) to perform accreditation reviews of the medicalprogram starting in December 2005.

Although RL actions to oversee the correctiveactions and medical program issues have generally beenappropriate, OA identified two areas that warrantadditional management consideration. First, RL haslimited expertise in the occupational medicine andindustrial hygiene disciplines. Some of the recentsuccesses and enhancements in managing the medicalcontract can be attributed to the current contractadministrator, who was appointed in June 2004 (aboutthe time the OA investigation report was issued) andhas some medical background. However, this individualis retiring soon and his designated replacement hasminimal expertise in occupational medicine. RL needsto ensure that its contract administrator develops asufficient understanding of requirements and

responsibilities of DOE occupational medical serviceproviders, the medical interface with industrial hygieneprograms, and the complex interfaces among thevarious Hanford Site organizations; such understandingis essential to meet medical program requirements andthe specific provisions of such DOE programs as thechronic beryllium disease prevention program,protective force medical and fitness requirements, andthe human reliability program. In addition, medicalexpertise is needed to effectively assess theperformance of the medical program contractor.

Second, the RL Performance Evaluation Plan forthe AMH medical program contract has not beenfinalized, even though the first annual evaluation(covering the first contract year) is scheduled forSeptember 2005. The criteria in the draft plan arelimited in scope and do not adequately address importantaspects of a quality occupational medical program, suchas case management, medical record charting, and useof relevant occupational health data (e.g., industrialhygiene, MSDSs, and health physics). Further, thesecriteria do not provide sufficient specificity in theexpectations for strategic planning or work site visits.A review of established occupational medicine programcriteria (e.g., criteria promulgated by the AccreditationAssociation for Ambulatory Health Care) could provideinsights on the general structure and form of criteriafor evaluating the quality of an occupational medicineprogram.

Summary

RL actions to close the two OA medical program-related findings from the 2004 report and oversee thecontract transition have been effective, and theiroversight of the medical program has improved.Additional attention is warranted in the areas of RL’smedical expertise and performance evaluation criteriafor the medical contract.


The following recommendation addresses ongoinginitiatives/enhancements to current RL line managementoversight of medical program initiatives:

7. Continue to strengthen line management oversightinitiatives in the following areas:

25

• Continue to use external expertise, such as theU.S. Public Health Service, to support the RLcontract administrator and to performassessments of the occupational medicalprogram at the Hanford Site.

• Continue to improve the PerformanceEvaluation Plan criteria for evaluatingoccupational medical program contractorperformance, including substantive criteria foroccupational medicine, strategic planning, andwork site visits, and finalize the Plan in a timelymanner.

26

This page intentionally left blank.

27

APPENDIX ASUPPLEMENTAL INFORMATION

A.1 Dates of Review

Onsite Data Collection May 31 - June 9, 2005Report Validation and Closeout June 22 - 24, 2005

A.2 Review Team Composition

A.2.1 Management

Glenn S. Podonsky, Director, Office of Security and Safety Performance AssuranceMichael A. Kilpatrick, Director, Office of Independent Oversight and Performance AssurancePatricia Worthington, Director, Office of Environment, Safety and Health EvaluationsThomas Staker, Deputy Director, Office of Environment, Safety and Health Evaluations

A.2.2 Quality Review Board

Michael Kilpatrick Patricia WorthingtonDean Hickman Robert Nelson

A.2.3 Review Team

Patricia Worthington (Team Leader)Marvin Mielke Al GibsonJoe Lischinsky Jim Lockridge

A.2.4 Administrative Support

Tom Davis

28

This page intentionally left blank.

Date post:	25-Mar-2018
Category:	Documents
Upload:	phungnhi
View:	214 times
Download:	1 times

2005 Hanford FU Worker Vapor and Occ Med new blue-final and... · BNI Bechtel National,...

Documents