3 3679 00047 4488 Type Investigation of Hanford Tank Farms Vapor Exposures April 1992 Richland Field Office U.S. Department of Energy Type Investigation of Hanford Tank Farms Vapor Exposures TABLE OF CONTENTS 1.0 SCOPE OF INVESTIGATION . . . . . . . . . . . . . . . . . 1-1 2.0 SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . 2-1 2.1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . 2-1 2.2 CAUSES . . . . . . . . . . . . . . . . . . . . . . . . . .-. 2?1 2.3 PREVIOUSLY IDENTIFIED PROBLEMS2-2 2.4 VAPOR CHARACTERIZATION PROBLEMS . . . . . . . . . . . . . . . 2-3 2.5 INDUSTRIAL HYGIENE PROGRAM INADEQUACIES . . . . . . . . . . . 2-4 2.6 TANK FILTERS OFFINDETERMINATE VALUE . . . . . . . . . . . 2-4 2.7 INADEQUATE CORRECTIVE ACTION TRACKING . . . . . . . . . . 2-5 2.8 NEED FOR OCCURRENCE REPORT TRENDING . . . . . . . . . . . . 2-5 2.9 REQUIRED ACTION TO CHARACTERIZE THE WORK SPACE . . . . . . . 2-5 2.10 OSHA PARTICIPATION . . . . . . . . . . . . . . . . . . . . . 2-6 2.11 CLOSING . . . . . . . . . . . . . . . . . . . . . . . . . 2-6 3.0 FACTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1 3.1 WASTE TANK HISTORY AND DESIGN . . . . . . . . . . . . . . . . 3-1 3.1.1 Odors and Tank Chemistry . . . . . . . . . . . . . . 3-2 3.2 OCCURRENCE FACTS . . . . . . . . . . . . . . . . . . . . . . 3-3 3.3 MANAGEMENT RESPONSE . . . . . . . . . . . . . . . . . . . . . 3-17 3.3.1 HHC Line Management Response . . . . . . . . . . . . 3?17 3.3.2 HHC Safety and Industrial Hygiene Organization Response . . . . . . . . . . . . . . . . . . . . . . 3-21 Pagei? Type Investigation of Hanford Tank Farms Vapor Exposures 3.4 3.5 3.6 3.7 3.3 ?3.9 3.10 3.3.3 Engineering Organization Response . . . . . . . . . . 3-25 3.3.4 DOE Response . . . . 3-27 CORRECTIVE ACTION . . . . . . . . . . . . . . . . . . . . . . 3-29 3.4.1 Past Event Investigations . . . . . . . . . . . . . . 3-29 '3.4.2 Corrective Action Tracking and Closure . . . . . . . 3-30 MEDICAL EVALUATION . . . . . . . . . . . . . . . . . . . . . 3-32 3.5.1 Summary of Medical Attention Received . . . . . . . . 3-32 3.5.2 Medical Response and Reporting . . . . . . . . . . . 3-32 3.5.3 Professional Qualifications . . . . . . . . . . . . . 3-34 ORGANIZATIONAL HISTORIES . . . . . . . . . . . . . . . . . . 3-34 3.6.1 NHC Organizational History . . . . . . . . . . 3-34 3.6.2 DOE History and Organization . . . . . . . . . . . . 3-36 NHC INDUSTRIAL HYGIENE PROGRAM . . . . . . . . . . . . . . . 3-37 3.7.1 Organization . . . . . . . . . . . . . . . . . . . . 3-39 3.7.2 Qualifications of Personnel3-40 EMPLOYEE COMMUNICATIONS . . . . . . . .- . . . . . . . . . 3-41 TANK 103-C CHARCOAL FILTER INSTALLATION . . . . . . . . . . . 3-42 TANK EMISSION CHARACTERIZATION . . . . . . . . . . . . . . . 3-43 3.10.1 Tank Farms Vapor Space Sampler . . . . . . . . . . . 3-44 3.10.2 Grab Sampling . . . . . .3-44 3.10.3 Cryogenic Sampler . . . . . . . . . . . . . . . . . . 3-45 Pageiv Type 8 Investigation of Hanford Tank?Farms Vapor Exposures . . . . . . . . ..4-1 4.1 DISCUSSION OF CAUSAL SEQUENCES . .- . .. . . . . . . . . . . . 4-1 4.1.1 AnaIysis: Conditions . . . . . . . . . . . . . . . . 4-1 4.1.2 AnaIysis: CausaI Sequence . . . . . . . . . . . 4-1 4.2 ANALYSIS OF SEPTEMBER 1991 EVENT . . . . . . . . . . . . . 4-4 5.0 CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . 5-1 5.1 FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1 5.2 CAUSES . . . . . . . . . . . . . . . . . . . . .- . . . . . . 5-10 5.2.1 Root Cause . . . . . . . . . . . . . . . . . . . . . 5-10 5.2.2 Direct Cause . . . . . . . . . 5-11 5.2.3 Contributing Causes . . . . . . . . . . . . . . . . . 5-12 5.3 JUDGMENTS 0F NEED . . . . . . . . . . . . . . . . . . . . . . 5?15 SIGNATURES BOARD AUTHORITY APPENDICES Appendix A - OSHA Report Appendix - Inadequacies of Industrial Hygiene Practice Appendix - Conduct of the Investigation Appendix - List of Acronyms Page Type Investigation of Hanford Tank Farms Vapor Exposures 1.0 SCOPE OF INVESTIGATION ?This investigation was initiated to examine the technicaT and management probTems re1ated to the exposure of personne1 to potentiaTTy hazardous vapors from the radioactive waste Tank Farms at the Hanford Site. A series of exposures to personne1 were reported during the period Ju1y 1987 to January 1992. Adverse hea1th effects from the exposures ranged in severity from nausea and headaches to one report of a_partia1 FoTTowing the JuTy 1987 occurrence, Westinghouse Hanford Company (WHC) initiated a number of corrective actions intended to precTude recurrence of the exposures. Other actions were identified foTTowing some of the Tater occurrences. A11 of these corrective actions were overseen by the U.S. Department of Energy (DOE) Rich1and Fie1d Office (RL) as part of its contractor and faciTity oversight responsibiTity. The need for this investigation is based on the fai1ure of the corrective actions-to prevent recurrence of the exposures. The purpose of this investigation was to: - identify the root causes of the 1034C exposure occurrence in September 1991 - identify the root causes of the exposure occurrence on January 28, 1992, at the 200-BP-1 OperabTe unit - deveTop a database for ana1ysis, using avaiTabTe history of simiiar Tank Farm exposures - - determine the reasons for the fai1ure of efforts initiated foTTowing the Ju1y 1987 exposure incident to adequateiy protect workers - review and eva1uate the adequacy of measures to controT exposure of personne1 to hazardous vapors in the Tank Farms. FoTTowing initiation of the investigation, Kaiser Engineers Hanford Company (KEH), WHC, and RL concTuded that the exposures to workers in the operabTe unit did not resuTt from vapors originating in the Tank Farms. The Board of Investigation did not find any reason to disagree with this Page 1-1 Type Investigation of Hanford Tank Farms Vapor Exposures determination. Because of this, the Board restricted its investigation of this event to an examination of the effectiveness of the WHC and RL industriai hygiene programs in providing appropriate technicai support to management during the event. Page 1-2 Type Investigation of Hanford Tank Farms Vapor Exposures 2.0 SUMMARY 2.1 INTRODUCTION On January 30, 1992, the Manager, Richland Field Office directed that a Type investigation be conducted to evaluate recurring exposures of workers to hazardous vapors at the Hanford radioactive waste Tanks Farms. One disability has been reported to be associated with the exposures. A series of investigations and analyses conducted by the operating contractor have failed to prevent continued recurrence of this problem. This report examines each of the exposure occurrences, evaluates management response to the events, and determines the probable causes for failure of corrective actions to prevent recurrence. The investigation was conducted in accordance with DOE Order 5484.1, "Environmental Protection, Safety, and Health Protection Information Reporting Requirements." The Management Oversight and Risk Tree (MORT) method of analysis was used to determine the root, direct, and contributing caUses of the recurrences. The Board of Investigation evaluated 16 different events from 1987 until 1992 that ranged considerably in severity. One exposure was reported to be associated with a partial disability from a loss of lung capacity. In some other cases, workers reporting an unusual smell and a headache went to the first aid station, were given an analgesic, and returned to work. In still other cases, there was no disability, but workers received medical attention at a local hospital. 2.2 CAUSES The report concludes that the MORT-defined root cause of the recurring exposures is that implementation of management systems was less than adequate. For example, there has not been a properly developed industrial hygiene program that would correctly apply the appropriate technology to work space characterization and specify the technically correct engineering and work controls. Also, the design control system did not assure that a technically Page 2-1 Type Investigation of Hanford Tank Farms Vapor Exposures adequate filtration system was installed on Tank 103-C, and the corrective action tracking system did not assure that all action items were followed through to final completion. The direct cause was failure to characterize the work environment and develop the appropriate engineering controls. As early as 1987, WHC determined that characterization of tank emissions was essential to determining the risk to workers, establishing the correct technical controls, and communicating the significance of the hazard to workers. After four and a half years, a technically adequate characterization has not been completed. Contributing causes were that controls were less than adequate in the following areas: - risk assessment (cause analysis) - data collection and analysis (corrective action tracking) 9 operational specifications - general design process - industrial hygiene monitoring system - communications - safety program review. 2.3 PREVIOUSLY IDENTIFIED PROBLEMS In 1990, DOE recognized that many safety issues at the Tank Farm were not resolved due to the following: - The Tank Farms have suffered from a lack of adequate staffing and funding. - J15. Blush, et al., July 1990, Report on the Handlinq of Safety Information Concerning Flammable Gases and Ferrocvanide at the Hanford Haste Tanks, Finding U.S. Department of Energy, Office of Nuclear Safety, Office of Environment, Safety and Health. Page 2-2 Type Investigation of Hanford Tank Farms Vapor Exposures - DOE waste management line programs have failed to adequately oversee contractor safety performance at the Tank Farms. It is not the purpose of this investigation to rediscover these conditions. Since the first quarter of 1990, DOE and WHO have acted to rectify the funding and technical management problems, and the Board of Investigation noted improvement in the technical management of the Tank Farms. However, this improvement was not sufficient to have decisively resolved the vapor exposure issue. 2.4 VAPOR CHARACTERIZATION PROBLEMS When the need for vapor spaCe characterization was identified in 1987, responsibility for accomplishing this task was assigned to the NHC industrial safety organization. This group was not technically equipped or properly staffed to accomplish the task. Instead of approaching the problem with conventional methods, development of an unproven, but apparently expedient analytical technology was pursued. This was the development of a cryogenic sampling device, which condensed vapor samples for subsequent laboratory analysis. In the following years, there was insufficient support to sustain the sampler development and characterization effort to a successful and timely conclusion. Even now, it is not clear to the Board that the role of the cryogenic sampling system in vapor characterization has been adequately defined: At RL, both line and safety program personnel were aware of the vapor exposures from 1987, though most of the attention was from individual contributors and first line management. The field office did not recognize that WHC had not made an appropriate decision in selecting an unvalidated method for characterizing the tank emissions, or that much of work Space characterization activities did not conform to conventional industrial hygiene practice. This is attributable to historically inadequate industrial hygiene professional staffing and a lack of knowledge in line management regarding industrial hygiene practice and technology. One reason that the vapor exposure problem has not been resolved is the attention focused on the flammable gas and ferrocyanide issues. These issues diverted attention from the vapor exposures, and syphoned away resources that could have been used to resolve the problem. When the RL Tank Farms Project Office was established in 1990, the vapor exposure problem was formally prioritized at a level below the flammable gas 21bid. Page 2-3 Type Investigation of Hanford Tank Farms Vapor Exposures and ferrocyanide unreviewed safety questions. As a result, it did not receive the technical resources and attention required to obtain a decisive resolution. Without technically adequate characterization of the tank emissions, WHO has been unable to communicate the specific degree of hazard to workers. This has contributed to an atmosphere of suspicion and anxiety among many workers. 2.5 INDUSTRIAL HYGIENE PROGRAM INADEQUACIES The industrial hygiene programs_at WHC and RL can best be described as "struggling." The WHC program has been plagued by funding problems, lack of a documented program, and high employee turnover. Industrial hygiene procedures of the appropriate scope are only now being issued, and there is a continuing shortage of certified industrial hygiene professionals. At RL, the safety program office has had minimal staffing for many years, and there were no staff resources from August 1991 until April 1992. As a result of these factors, industrial hygiene activities with respect to the vapor exposures have been technically inadequate. Because of the historical shortage of technical resources in the WHC and RL safety and health organizations, line management has not viewed these organizations as a resource for assistance in decision making. For example, in the January 1992 occurrence at the drill site, there was minimal participation by safety technical personnel in the decisions to establish respiratory protection zones. These-were industrial hygiene decisions, with nuclear safety and industrial safety consequences. The Board noted, however, that there was extensive involvement of industrial hygiene professionals in the decisions to relax the respiratory protection zones. The Board is concerned that many managers in RL and NHC do not understand the' role of the industrial hygiene program in ensuring the health and safety of the work force. The managers also lack essential knowledge regarding the technology of industrial hygiene. Line managers must have this knowledge because they are ultimately responsible for the safety_of their workers. 2.6 TANK FILTERS OF INDETERMINATE VALUE Management accepted a false sense of confidence that the problem had been resolved following installation of charcoal filters on.Tank 103-C in December 1989. Despite evidence to the contrary, it was common to associate the vapor problem exclusively with this tank. The Board found that because of failures of the design control and work control systems, the filter installation is of Page 244 Type Investigation of Hanford Tank Farms Vapor Exposures indeterminate value. The Board believes that NHC should re-evaluate the filters, considering that they may be forcing unfiltered emissions from other points in the tank system. Depending on the results of this re-evaluation, NHC should consider removing the filters. . 2.7 INADEOUATE CORRECTIVE ACTIONTRACKING The investigation found that WHC is not tracking corrective actions from current Tank Farms occurrence reports. For many of the corrective actions identified in other documents, it was difficult or impossible to determine whether the action had been completed. Often, an action to resolve an issue was closed out based on a promise in an internal memorandum to take some follow-up action, but the follow-up action was not tracked. It appears that many of these corrective actions were simply never completed. 2.8 NEED FOR OCCURRENCE REPORT TRENDING RL is not presently trending Occurrence reports, although they intend to create a system for this. An effective trending program will identify emerging safety issues and bring them to the attention of the level of management required to achieve resolution. 2.9 REQUIRED ACTION TO CHARACTERIZE THE WORK SPACE The Board considers that resolution of the vapor exposure problem requires an expeditious, but technically adequate characterization of the work space. This must include characterization of tank emissions for both organic and inorganic constituents. Technically correct engineering controls and work controls must be developed based on the results of the characterization. A plan for the characterization and development of controls should be prepared by WHC and approved by RL. The relationship between the cryogenic sampling method and other proven sampling methods should be defined in the plan. Progress on completion of the plan should be reported periodically to RL. Employees should be informed of the progress of the characterization work and should be presented with the results. Employees should also be informed of the results of this investigation and should be provided with any other information that will demonstrate meaningful progress in resolving the vapor exposure problem. Page 2-5 Type Investigation of Hanford Tank Farms Vapor Exposures 2.10 OSHA PARTICIPATION The Board of Investigation requested that the Occupational Safety and Health Administration (OSHA) perform their own assessment of the vapor exposure probIem in the context of OSHA reguiations. In response to this request, personneI from the OSHA Salt Lake TechnicaI Center visited the site during the period of March 3-5, 1992, to review documents and interview personnei. The resuIts of their evaIuation were generaIIy consistent with the findings of the Board. The OSHA report is incIuded as Appendix A. 2.11 CLOSING During the course of the investigation, it was ciear to the Board that both WHO and RL management aIready recognize many of the probIems described in this report and are taking various actions to resoIve them. It is intended that this report wiII document the probIems and keep them sufficientiy visible that each one wiII be pursued to finaI resqution. Page 2~6 Type Investigation of Hanford Tank Farms Vapor Exposures 3 .0 FACTS 3.1 WASTE TANK HISTORY AND DESIGN A total of 149 single-shell radioactive waste tanks are located in the Hanford 200 Areas, with operating liquid volumes of 50 thousand, 500 thousand, 750 thousand, and 1 million gallons. These tanks were used to contain high? level radioactive wastes generated by processing irradiated nuclear reactor fuels to recover plutonium for weapons programs. The single-shell tanks received reprocessing wastes from late 1944 until 1972, The last single-shell tanks to be built were the four 1-million gallon 241-AX tanks, constructed in 1962-1964. All tanks constructed since 1968 were double-shell design, with l-million gallon nominal working liquid volume. In the mid-19705, separation and removal of liquids from single-shell tanks was initiated in order to reduce the extent of tank leakage. The double-shell tanks_were used to receive and store concentrated liquid wastes from this program. Except for Tank 103-C, the removal of liquids from the single-shell tanks to a level of less than 2 ft above solids was completed in November 1980. No wastes were added to single-shell tanks after that date, and all high-level wastes have subsequently gone to double-shell tanks. The single-shell waste tanks are all of the same basic design. The 50-thousand gallon tanks are 20 ft in diameter, and all larger tanks are 75?ft inside diameter. The tanks consist of a reinforced concrete structure designed to bear the soil and hydraulic loads. The inside is lined with carbon steel to just above the normal design liquid level. The upper walls and domed top are unlined. The top of the dome has a minimum of 3 ft of soil cover for biological shielding. 3ch-EP-0182-42, Tank Farm Surveillance and waste Status Report,' September 1991. Page 3-1 Type Investigation of Hanford Tank Farms Vapor Exposures The single-shell tanks built prior to 1955 have no active ventilation systems, and are normally vented to atmosphere via a breather vent "gooseneck" pipe. When some tanks containing waste began boiling, they were fitted with an active ventilation system with condensers. The newer 241-A and -AX tanks built to receive wastes from the PUREX reprocessing plant are designed with active ventilation systems. In the late 19605, the vents were fitted with high-efficiency particulate air (HEPA) filters to remove particulates. The single-shell tanks that have active ventilation systems functioning now are through -109, and ?106, and and -105. WHC has I sometimes connected a trailer-mounted portable exhauster to force-ventilate single-shell tanks in support of in?tank sampling or surveillance activities. The 28 double-shell tanks built since 1968 are all 75-ft inside tank diameter, with a nominal working volume of 1 million gallons. The basic configuration of these consists of a free standing carbon steel primary tank, located inside of a carbon steel-lined reinforced concrete structure. There is a leak detection space below and around the annulus to detect and collect any leakage from the primary tank. The primary tank and the space between the primary . tank and the concrete tank liner are each ventilated by active ventilation systems through HEPA filter systems. The 241-AY and -AZ tanks are also fitted with air sparging systems to provide agitation of radioactive solids, to facilitate heat removal; and to prevent subsurface accumulation of gases. Typical cross sections of the single- and double-shell-tank features are shown in Figures 3?1 and 3-2. 3.1.1 Odors and Tank Chemistry Odors have always been associated with Tank Farms operations. The incidents that are the subject of the investigation fall into two general categories: - incidents involving double-shell tanks with ammonia odors - incidents involving single-shell tanks with "musty" or "foul" odors, that may include ammonia odors. Several double-shell tanks emanate ammonia due to an ammonia-containing solution originating from PUREX decladding wastes. These wastes were transferred to 241-Aw and 241-AP Tank Farms while PUREX was operating. Other double-shell tanks, including 241-SY, contain complex concentrates that generate ammonia as a product of radiolysis and chemical degradation. Some volatile organics also may be released. Page 3-2 Type Investigation of Hanford Tank Farms Vapor Exposures Some of the more significant reports of odors from single?shell tanks are from the 241?0 Farm and Tank 103-C specifically. Tank 103-C is unique to single- shell tanks for the following reasons. - The single?shell tanks were to have been pumped to less than 2 ft supernatant (above solids) by January 1981. However, this tank has over 5 ft of supernatant (133,000 gal). - The supernatant chemical analysis shows that the nitrite concentration is about seven times the nitrate concentration. Normally nitrate concentration is much higher than nitrite. - The radioactivity is quite low, so radiolysis would not explain the very high nitrite content. - The solution is dilute, with a specific gravity of 1.06significantly lower than most tanks. - There may be a separate organic phase. Tank 102-0 was pumped to Tank prior to 1979, and Tank 102-0 had a separate organic phase. 3.2 OCCURRENCE FACTS The Board of Investigation evaluated 16 events that occurred during the period from July 1987 through January 1992. Personnel were interviewed and documentation was reviewed. What follows is a compilation of the facts identified by the Board that are relevant to each of these occurrences. July 3, 1987 Location: 241-C Tank Farm Employees Affected: 2 electricians, 1 radiation protection technician (RPT) Work Activity: Troubleshooting problems on a portable exhauster connected to Tank Medical Response: First aid with follow-up at hospital. Medical reports from a personal phySician stated that there appeared to be about a 40% reduction in lung capacity for the RPT. One electrician returned to work the same day, the other returned after 7 weeks, and the RPT returned after 13.5 weeks. Event Details: Two electricians, a Tank Farm operator, and an RPT entered Tank Farm to troubleshoot the electrical system on a portable exhauster Page 3-3 Type Investigation of Hanford Tank Farms Vapor Exposures connected to Tank 103-C. The exhauster was installed to evacuate the cloudy vapor space within the tank in order to prepare for in?tank photographs. The tank had not been ventilated thoroughly for several years. The electricians and the RPT worked for about 15 minutes in the vicinity of a continuous air monitor cabinet, where a sample pump was drawing from the waste tank atmosphere. The sample pump discharged locally, and the workers noted a strong odor. Some time later, the two electricians and the RPT developed headaches, burning noses, and had difficulty breathing. They reported to first aid and were administered oxygen. One electrician and the RPT were_ transported to Kadlec Hospital for examination, where both individuals were found to have nasal passage and throat irritation. Air sampling subsequent to the event identified ammonia as the probable irritant. As a result of the exposure, one electrician was off work for 7 weeks and the RPT was off work for 13.5 weeks. Subsequent Activities: As a result of this occurrence, "Danger Limited Access" signs were posted at all entrances to 241-C Tank Farm. The Industrial Hygiene and Hazardous Materials organization performed air sampling for ammonia, oxides of nitrogen, combustible gases, and organics. The 241-C Tank Farm was placed "on mask" with combination chemical cartridge and HEPA filter reqUired for entry into the Tank Farm, and supplied air required for access to the exhauster. Air sampling was performed at the exhauster shortly after the event. The samples were taken with colorimetric detector tubes and showed no significant hazardous vapor concentrations._ On July 7 and 1 July 9, 1987, the Hanford Environmental Health Foundation (HEHF) performed air sampling at the exhauster. The results showed that there was a significant (>60 ppm) concentration of ammonia present along with low levels of various unidentified organic vapors (70 to 90 ppm).5 These results suggested to WHC that the normal odor of ammonia was being masked by the organic vapors, resulting in the unusual odor present in the Tank Farms. Subsequent to the event, HEHF conducted sampling to characterize Tank 103-C vapor space gases in an attempt to identify the causative substance(s). Initial characterization of vapor space gases was based on selecting those substances that were known to have been introduced into the tank, and/or that were easily detected by available direct reading or instantaneous detection methodologies. Additional sampling was conducted using silica gel and charcoal sorption tubes to further characterize inorganic acid gases and organic vapors. The direct reading instruments and detector tubes measured vapor space gases at the immediate opening of a small exhaust port located in 4Industrial Safety and Fire Protection to G. G. Meade, Memorandum #12920-87-170, August 3, 1987. via. H. St. John to G. G. Meade, Memorandum July 17, 1987. Page 3-4 Type Investigation of Hanford Tank Farms Vapor Exposures the main exhauster housing. Sampling with sorption tubes measured the concentration of exhausted gases in the exhaust plume approximately 12 in. away from the exhaust port opening. Subsequent to the sampling, HEHF recommended that air line reSpiratory protection be required for those employees directly involved in exhauster maintenance. This was because of the unknown chemistry of Tank 103-C contents and the potential presence of other unidentified irritating or harmful substances in the vapor space gases. HEHF did not recommend mandatory respiratory protection for employees working away from the exhauster. Ammonia, acid gases, and volatile organics were detected in some vapor space samples taken from Tank 103-C during the week of September 14, 1987.? Vapor space samples were withdrawn from the tank head space by vacuum through a section of plastic tubing positioned such that the inlet was half the distance from the liquid surface to the tank dome. During sampling, various devices were sequentially placed in the sampling train to collect specific constituents contained in a measured quantity of gas. An exploratory liquid surface sample was taken from Tank on September 15, 1987, using the standard bottle-on-a-string sampling method.7 No Environmental Protection Agency (EPA) priority pollutant volatile organics were detected in the liquid sample; other nontargeted volatile organics were found, however. The major tasks of the continued characterization project were identified. WHC conducted a Type investigation of the event, in accordance with DOE Order 5484.1. MORT analysis techniques were used as appropriate in developing the conclusions, and results were presented in the format of a Type investigation. The investigation found the primary cause to be a failure to recognize the localized high concentration of irritating fumes. A major contributor to the incident was determined to be an open pathway for nonfilterable fumes through an open inlet valve for the operating sample pump. As a result_of the investigation report, a list of "judgments of need" was generated for consideration. Additional corrective actions were identified in a final critique report submitted July 20, 1987.9 The industrial hygiene organization was assigned the action to characterize the Tank 103-C vapor V?Tank Farms Plant Engineering to Distribution, Memo #13331-88?018, January 20, 1988. 71bid. 8R. E. Lerch to J. J. Keating,.WHC Letter #87021263 R2 and attached Investigation Report, January 15, 1988. 9WHC Critique Report WHC-C-87-008-TF-01, July 20, 1987. Page 3-5 Type 8 Investigation of Hanford Tank Farms Vapor Exposures space. The cryogenic sampler was developed as a method to perform the characterization. July 15, 1987 Location: 241-6 Tank Farm Employees Affected: 2 nuclear operators Work Activity: Moving an inlet filter housing from Tank to Tank 103-C. Medical Response: Reported to first aid_and sent back to work same day-- throat irritation.- Event Details: At approximately 8:30 two operators and an RPT began moving the inlet filter housing from Tank 106-C to Tank While moving the filter, personnel detected an odor, then exited the farm after the filter housing had been moved. Later in the day, the two operators indicated that they were experiencing an irritating feeling in their throats and reported to first aid. The RPT did not experience any difficulties. Construction personnel working in the same vicinity did not detect odors or experience any medical difficulties. The operators were sent back to work the same day. Air samples taken in Tank Farm the same day indicated negative results for ammonia. WHC judged this to be a recurrence of the July 3, 1987, event. September 4, 1987 Location: Tank Farm Employees Affected: 1 RPT Work Activity: Routine monitoring. Medical Response: Reported to first aid with a nose bleed. Sent back to work the same day. Event Details: On September 4, 1987, an RPT was exposed to vapor while working near the tank exhauster. The RPT was wearing no respiratory protection, though all other personnel working in the vicinity were. He smelled an odor and immediately exited the area. Shortly afterward he experienced a nose bleed. He was taken to first aid and was subsequently 1?Ibid. Page 3-6 Type Investigation of Hanford Tank Farms Vapor Exposures transported to HEHF for evaluation by a physician. He returned to work the same day. Subsequent Activities: The area near the tank exhauster was placed on chemical cartridge respiratory protection. Air sampling did not find detectable concentrations of ammonia at distances greater than 2 to 3 ft from the exhauster. Industrial hygiene monitoring was not conducted immediately prior to the work, but monitoring conducted the previous day (September 3, 1987) found the following ammonia concentrations: - 700 at the Aw exhauster test port - >1000 at the 242-A evaporator test port - 200 at the Aw beta-gamma sample port. November 9. 1987 Location: Tank Farm Employees Affected: 1 operator Work Activity: Testing ventilation system. Medical Response: Evaluated at first aid station and returned to work. Event Details: While vent and balance personnel were performing a scheduled test on the ventilation system, an operator smelled ammonia vapors near a constant air monitoring enclosure. The operator was sent to first aid and was sent back to work the same day. No reporting of medical difficulties or lost time injuries occurred as a result of the event. Subsequent Activities: Operations management requested the industrial safety organization to sample the vicinity for ammonia vapors. The sample results indicated loo-ppm ammonia concentrations were being discharged from the exhaust stack, while 50-ppm and 70-ppm ammonia concentrations were being discharged from the air sample pumps. The area within 10 ft of the ventilation system was roped off. Placards requiring GMD-H ammonia/amine filter cartridge respirators were posted at the perimeter of the area. 11Event Fact Sheet 0-EFS-059, approved November 18, 1987. Page 3?7 Type Investigation of Hanford Tank Farms Vapor Exposures Januarv 6. 1989 Location: 241-C Tank Farm Employees Affected: 1 operator Work Activity: Routine duties. Medical Response: Sent to first aid and released to return to work same day. Event Details: A Tank Farm operator smelled an odor at Tank Farm while performing routine duties. The operator was sent to first aid and released for work the same day. No reportable lost work time was associated with the exposure. Auoust 16. 1989 Location: Tank Farm Employees Affected: 1 RPT Work Activity: Routine surveillance. Medical ReSponse: Sent to first aid with headache and nausea. Administered - oxygen, sent to HEHF for evaluation. Went to hospital for further evaluation. Returned to work the next day. - Event Details: The RPT was performing routine work in 241?6 Tank Farm. While walking in the farm alongathe southeast fenceline, the employee briefly noticed a "musty" smell. The employee immediately held his breath and continued upwind until he was past the Farm tanks. Upon exiting the farm, the employee experienced a headache and nausea. The RPT reported to first aid and was administered oxygen. The RPT was subsequently examined by a physician at HEHF, then went home. Later that evening he experienced another headache and went to Kadlec Hospital for further evaluation. The employee went home from the hospital following the examination and returned to work the following . day. Subsequent Activities: Tank 103-C breather filter was isolated until a procedure could be issued and the breather filter tested. Vapors in 103-C were being filtered through the 102-C breather filter via cascading lines between the tanks. J?ZEvent Fact Sheet approved August 17, 1989. Page 3-8 Type Investigation of Hanford Tank Farms Vapor Exposures Based on a preliminary investigation and review of the July 3, 1987, critique report, WHC concluded that the vapors inhaled may have been released from Tank 103-C. Air sampling was performed in the general area where the odor was noted, the exhauster area, and the area around the 102- and 103-C breather filters. The samples were taken with colorimetric detector tubes and showed no abnormal conditions. ReSpiratory protection was required for personnel working in the Tank Farm, with combination chemical cartridge full-face respirator specified. This limitation was subsequently changed to supplied air respirators as an added precaution. Employee meetings were held with all Tank Farm personnel to communicate actions and concerns with the 241-6 Farm vapor release. Additional Farm entry controls consisted of a sign-in/out log and a buddy system. It is not clear how long these restrictions were in place. September 28, 1989 Location: 241-AP Tank Farm Employees Affected: 1 operator Work Activity: Walking near fenceline outside the AP Tank Farm. Medical Response: Sent to first aid and administered oxygen. Sent to hospital for further evaluation and sent home the same day. Event Details: An employee walking near the East AP Tank Farm fence smelled ammonia and subsequently developed a headache.13 He also stated that he had an identical experience a few days earlier. The employee was tranSported to the East Area Medical Aid Station where he experienced difficulty breathing and was administered oxygen. The employee was sent to Kadlec Hospital for further evaluation and was sent home the same afternoon. The evaluation consisted of chest x-rays, blood gas analysis, and pulmonary function tests. Results of the evaluations indicated no medical evidence of excessive ammonia inhalation. Subsequent Activities: HHC evaluated the event and found that the Tank Farm was in normal operating condition at the time of the event. No transfers 13ch Critique Report October 13, 1939. Page 3-9 Type Investigation of Hanford Tank Farms Vapor Exposures were being conducted into or out of the Tank Farm. 0n the day previous to the event, a PUREX transfer was made from Tank G7 to Tank The transfer contained detectable levels of ammonia, but with concentrations approximately 100 times lower than a normal ammonia transfer. The routine colorimetric detector tube samples taken on September 28, 1989, and prior to that date indicated about 300?ppm ammonia. The area around the exhaust stack was immediately monitored for ammonia. Results of the area sampling for ammonia showed no detectable amounts. Ammonia concentration in the stack was reconfirmed to be 300 from a sample taken by industrial safety personnel. The Tank Farm and area between the east fence and the road was posted to require a respirator with chemical combination cartridge. It is not clear how long these restrictions were in place. - Following this event, WHC performed a MORT root cause analysis. The scope included exposure reports back to the July 1987 event. The repert concluded that communications was the primary root cause, and made three recommendations to improve communications. The report did not identify any contributing causes. . ?Agril 19, 1990 Location: 241-AX Tank Farm Employees Affected: 1 health physics technician (HPT), several others Work Activity:? Routine work. Medical Response: The HPT wasasent to first aid for evaluation, and returned to work same day. Another individual did not report to work next day, complaining of nausea, headache, etc. .Event Details: An HPT and several other individuals working in the AX Tank Farm noticed a foul odor. The HPT also observed a helicopter spraying liquid near the ground some distance away. Later that evening (and during the next day), the HPT experienced a loss of appetite, nausea, stomach cramps, diarrhea, and headaches. 0n the evening of the event, one of the other individuals involved reported to the Kadlec Hospital emergency room, experiencing severe dizziness, sweating, and nausea. An electrocardiogram was performed on the employee to check for of a heart attack. During the initial testing there were reported of elevated blood pressure and dehydration. One liter of saline solution was administered intravenously. The employee did not report for work the following day. Page 3?1 0 Type Investigation of Hanford Tank Farms Vapor Exposures Further investigation found that the helicopter was spraying Amine weed killer, R-11 spreader activator, and Banvel-D. However, there is no documentation of a formal conclusion regarding the relationship of the spraying to the medical complaints. March 15, 1991 Lecation: 241-C Tank Farm Employees Affected: 1 HPT. Work Activity: Routine monitoring near a pit for Tank 103-C. Medical Response: Employee developed headache and was sent to first aid. Returned to work later the same day. Event Details: An HPT inhaled unknown vapors while performing routine coverage near a pit for Tank 103-C. The employee developed a headache and was sent to first aid. She returned to work the same day. September 6, 1991 Location: 24l-C Tank Farm Employees Affected: 2 insulators, 1 operator Work Activity: Insulating exhaust filter vent system. Medical Response: Reported to first aid and was then referred to hospital for blood tests and evaluation. Returned to work the next day. Event Details: Two insolators were installing insulation on two 55-gallon drums of activated charcoal filters on Tank Prior to beginning the work, Tank Farm Operations personnel were told by industrial hygiene technicians that monitoring for chemical hazards would not be required. Supplied air requirements had been in place around the filters from December 1989, but were relaxed in June 1991. The two insulators and one nuclear operator noted an unidentified odor and became nauseous. The three employees left the work area and reported to first aid.1 They were subsequently returned to work. Later in the day,_the two insulators still felt some nausea and throat soreness. They were sent to Kadlec Hospital for blood tests and further medical evaluation. HHC concluded that the insulators, who were on loan from another organization, had not received 14Occurrence Report RL-NHC-TANKFARM-1991-1038, September 10, 1991. Page 3-11 Type Investigation of Hanford Tank Farms Vapor Exposures adequate training regarding the potential hazards associated with Tank Farm vapors. Subsequent Activities: Sampling by a Respiratory Protection TeChnician immediately subsequent to the event indicated 4-ppm organic vapor 2 in. from the vent port and less than 1 on the other three sides of the filters. On September 10, 1991, the Tank Farm operations organization requested an investigation into the occurrence. A knowledgeable Tank Farm operations manager and a certified accident investigator evaluated the event for a root cause and suggested corrective actions to prevent recurrence. As a result of the investigation,15 the following major concerns were identified: - A lack of communication, both formal and informal, exists. - The Tank Farm orientation training is inadequate for the potential hazards associated with working in the Tank Farms. - No developed administrative controls have been placed on this tank. - Tank Farm workers display a lack of confidence in the industrial safety organization. - There is a lack of an adequate hazard analysis of Farm tank vapors. The updated 10-day occurrence report16 determined the root cause category to be a management problem regarding inadequate administrative control. In addition, a task force headed by the Tank Farms Manager for Environmental Engineering was established to develop and implement corrective actions. The corrective actions included erection of barriers around the Farm to control entry and a requirement that supplied air be used for all entries and work activities. The report also noted that the tank would continue to be a safety and health concern until identification of tank vapor constituents was completed and an appropriate ventilation system was installed. 15K. E. Myers to J. A. Eacker and D. G. Hamrick, NHC Internal Memorandum, 76314-91-KEM-040, "Personnel Exposure of Noxious Vapors from Farm Investigation Report," October 22, 1991. ?65. Marchetti to R. E. Gerton, Memo #9159378 (with attachment), December 20, 1991. Page 3-12 Type Investigation of Hanford Tank Farms Vapor Exposures Although HEHF had performed studies which indicated that the activated charcoal filters on Tank 103-6 were adequate for filtering organic emissions, emissions from other pathways were not controlled and allowed tank vapors to escape unfiltered. WHC management had not recognized the impact of removing sealing tape between concrete blocks installed at the access point to the tank pump pit. Prior to removal, the tape had isolated a gaseous escape path and forced tank vapors through the carbon filters. Subsequent to the event, industrial hygiene monitoring, using an organic vapor monitor (OVM), found high levels of organic vapors at the pump pit. Studies conducted by HEHF early in 1990 concluded that the activated charcoal filters were adequate in filtering out organic vapors. The industrial hygiene organization had released 24l-C Tank Farm from supplied air requirements on February 9, 1990, based on the study. WHC conducted a review of the circumstances surrounding the September 6, 1991, event and issued an investigation report17 that identified concerns, causes, and recommendations. An in?depth MORT root cause analysis was not conducted to identify or validate the causes of the event. September 16, 1991 Location: 241-C Tank Farm Employees Affected: 1 Kaiser Engineers Hanford Company (KEH) construction worker Work Activity: Excavating an area in the Tank Farm. Medical ResponSe: Sent to first aid for evaluation. Returned to work same day. Event Details: A construction worker excavating an area in 241-C Tank Farm inhaled an unknown vapor.18 The Tank Farm was evacuated and the employee was sent to first aid for evaluation. The employee returned to work a short time later. The farm was monitored using OVMs and colorimetric tubes, but no vapors were detected. The farm was then released for reentry. 17K. E. Myers to J. A. Eacker and D. G. Hamrick, MHC Internal Memorandum, "Personnel Exposure of Noxious Vapors from Farm Investigation Report," October 22, 1991. 18Occurrence/Notification Report September 17, 1991. Page 3-1 3 Type Investigation of Hanford Tank Farms Vapor Exposures Subsequent Activities: WHC determined the direct cause of the event to be personnel error in that a safe work environment had not been established. This was documented via the occurrence reporting system. In addition, WHC concluded the root cause category of the event to be a management problem with respect to imprOper resource allocation stemming from a deficiency in past practices associated with waste management. Because of the poor past practices, WHC management felt they had to react to safety issues as they were identified and provide resources based on the level of safety that was compromised by each issue. Contributing causes consisted of inadequate or defective design, inadequate administrative control, lack of knowledge as to the contents of the tank, and lack of analysis of the vapors it vents. WHC also concluded that the effort necessary to correct actions associated with the root cause would impact current schedules. Tank vapor space sampling, analysis, ventilation engineering, design, permitting, and continuous monitoring instrumentation would all be necessary to assist in understanding and resolving the tank vapor issue. September 17, 1991 Location: 241-C Tank Farm Employees Affected: 2 insulators Work Activity: Constructing a greenhouse. Medical Response: Reported to first aid and returned to work the same day. Event Details: Two insulators were exposed to unknown vapors while constructing a greenhouse in Tank Farm. The insulators experienced nose, throat, and irritation and reported to first aid. They were returned to work the same day. The insulators were the same two employees who had been involved in a similar vapor inhalation incident on September 6, 1991. ?thember 17, 1991 Location: 241-C Tank Farm Employees Affected: 2 construction workers (KEH) Work Activity: Working just outside Tank Farm gates. Medical Response: Reported to first aid and returned to work the same day. Page 3-14 Type Investigation of Hanford Tank Farms Vapor Exposures Event Details: Two construction workers noticed an unknown odor while performing activities outside the 241-C Tank Farm gate. The employees reported to first aid and returned to work the same day. October 12, 1991 Location: 241-SY Tank Farm Employees Affected: 1 HPT Work Activity: Routine radiological monitoring. Medical Response: Sent to first aid and diagnosed with upper airway irritation. Returned to work on the same day. Event Details: An HPT inhaled a vapor while performing routine duties at the SY Tank Farm. The event occurred as he opened the door to the exhauster radiation monitor. The HPT indicated the odor was partially ammonia and another chemical. He reported to first aid, where irritation of the upper airway was observed. He returned to work the same day. December 4, 1991 Location: 241-BY Tank Farm Employees Affected: 1 HPT Work Activity: Removing pump pit cover at Tank 102-BY. Medical Response: Employee developed headache, reported to first aid, and returned to work the same day. Event Details: On December 4, 1991, an HPT noted a strong unidentified odor in the BY Tank Farm during activities involving lifting a pump pit cover at Tank 102-BY. The HPT became nauseous and reported to first aid. He returned to work the same day. January 28, 1992 Location: Drill Site, near Farm Employees Affected: 5 construction workers (KEH) Work Activity: Drill site activities (various). Page 3-15 Type Investigation of Hanford Tank Farms Vapor Exposures Medical Response: All five sent to first aid. Two employees sent to hospital for additional evaluation. All employees returned to work or home the same day. Later that evening, one individual returned to the hospital from home, reporting heart palpitations. He was evaluated further and was again sent home. Event Details: Five KEH well-drilling personnel noticed unusual odors upon entering a radiological controlled area within the operable unit ,drill site.19 The odors were described as resembling "rotten eggs or battery acid." The area was immediately evacuated and the five KEH employees were sent to first aid as a precautionary measure. Subsequently, two KEH personnel. were transported to.Kadlec Hospital for further evaluation, but were sent home the same day. Some of these employees reported of nausea, dizziness, chest pains, and an unusual taste in their mouths. At the time of the event, KEH personnel were preparing for work activities at the drill site. This area is located just north of the Tank Farms. Subsequent Activities: Subsequent to the incident, organic vapor sampling was initiated in the immediate affected area and all adjacent walking spaces. This sampling was performed with a photoionization detector. No organic vapors were detected. Additionally, air monitoring was initiated in the Tank Farm complex. Sample results indicated no detectable constituents in the respiratory protection zones and ammonia readings of 15 and 40 in the breather filter outlet ports of Tanks 104-BX and 104-BY. Additionally, respiratory protection and industrial safety personnel completed sampling/monitoring for acid gases, organics, nitrous oxide, ammonia, and from along the perimeter road to the 200-BP-1 well site and on the outside perimeter of the complex." All results were negative. During the period of January 28 to February 12, 1992, extensive gas monitoring in and around the Tank Farms was conducted. More than 1,000 ambient air organic vapor samples obtained indicated less than detectable levels at 19 specific monitoring stations within the restricted access areas. Barriers were established as a protective measure to exclude all personnel from the operable unit and surrounding areas. Restricted zones of 500 yards were also established around all single-shell Tank Farms, and supplied air was required within 250 yards of all single-shell Tank Farms.20 19WHC Occurrence Report February 12, 1992. 2"ch Occurrence Report Page 3?1 6 Type Investigation of Hanford Tank Farms Vapor Exposures This continued until February 14, 1992.m These were extraordinary measures that caused considerable disruption of routine activities in.the 200E and 200w Areas. An evaluation of the potential for releases from the Tanks Farms was conducted by the Pacific Northwest Laboratory (PNL), which included mathematical modeling of gas dispersions. This evaluation concluded that in the worst case, no threshold limit values could have been exceeded more than 40 feet from the tank vents.22 Based on further evaluation of the occurrence, it was concluded that the odors detected by the workers came from a lead acid battery at'a local sample trailer, which was known to have overheated and boiled over. 3.3 MANAGEMENT RESPONSE 3.3.1 WHC Line Management Response For the significant inhalation occurrences, typical immediate management responses consisted of one or more of the following actions: a) initiate forced ventilation of the tank vapor space, b) provide respiratory protection for personnel within specified boundaries, and c) initiate area industrial hygiene-monitoring. Forced ventilation was accomplished using portable blowers, while respiratory protection involved the use of supplied air or canister-type respirators. Forced ventilation was eventually discontinued because of the lack of the required regulatory permit. However, there is no indication that a serious effort was made to obtain a permit. The most extensive response to vapor inhalations followed the January 1992 occurrence at the 200-BP-1 drill site. BecaUse vapors from this occurrence .were originally believed to have come from the Tank Farms, large exclusion zones were established around all Tank Farms, and access was permitted only using supplied air. The Board was told that professional industrial hygienists were not consulted when the decision to establish the 21J. D. Wagoner to Contractors, DOE Letter, Richland, Washington, "Precautionary Safety Actions - Tank Farms Fumes," February 14, 1992. 2&1. V. Ramsdell, Jr., PNL Letter Report, "Evaluation of Potential Releases from Single-Shell Tanks," February 14, 1992. 23T. M. Anderson to J. 0. Wagoner, ch Letter, DOE 92006403 R1, "Respiratory Protection Requirements for Single?Shell Tank Farms," February 12, 1992. I Page 3-17 Type Investigation of Hanford Tank Farms Vapor Exposures zones was made, although there was participation when the restrictions were finally relaxed. Beginning with the July 1987 occurrences, NHC has conducted a series of evaluations and investigations. These have ranged in scope from investigations approximating the Type investigation of DOE Order 5484.125 to the evaluations required for routine event reporting of DOE Order 5000.3A. There were three efforts to accomplish more detailed root cause lanalyses. '2738 These were in response to the July 1987 occurrences, the September 1989 occurrence, and the September 6, 1991, occurrence. One outcome of the evaluation of the September 1989 occurrence was that management became aware that'there was a series of reported exposures that could have commonality. Previously, these occurrences were considered to be isolated events. Following the July 1987 event, WHC initiated action to characterize the vapor space gases. This effort, combined with the development of engineering controls, was the primary pathway expected to resolve the vapor inhalation problem. Engineering controls that were considered included installing filters on tank vents, forced ventilation of the tank vapor spaces, and increasing ventilation stack heights. The only design change that was actually carried out was the installation of charcoal filters on Tank 103-0 in December 1989.29 Most managers believed that potentially hazardous vapors were coming only from Tank 103?0, and that the constituent of concern was ammonia. The Board was told that most 24M. A. Payne to R. E. Gerton, WHC Letter 92006408 R2, "Respiratory Protection Requirements for Single-Shell Tank Farms," February 20, 1992. 25F. E. Boyd et al., Westinghouse Hanford_Company Investigation Report, Investigation of Occuoational Injury at 241-0 Tank Farm on July 3. 1987, October 1987. - 2e"mid. 27R. T. Kimura to J. J. Badden, WHC Internal Memorandum, Serial No. 13220-89-0088, November 15, 1989. 28K. E. Myers to J. A. Eacker and D. G. Hamrick, WHC Internal Memorandum, "Personnel Exposure of Noxious Vapors from Farm Investigation Report," October 22, 1991. 29Westinghouse Hanford Company Engineering Change Notice No. 1546434, August 21, 1990. Page 3-18 Type Investigation of Hanford Tan-k Farms Vapor Exposures contractor management believed that installation of these filters removed the risk of any immediate danger to health that may have been posed by the tank vapors. Because of this impression, further actions did not get significant attention. For example, a recommendation was made during the spring of 1990 to install charcoal filters and change the ventilation systems on other tanks that might be sources of vapor.30 This recommendation was initially disapproved. After the initial disapproval, the proposal was resubmitted for budgetary consideration, but it still has not been funded. The characterization of the vapor space gases was to be accomplished using the cryogenic sampling process under development. However, most managers interviewed by the Board stated that this effort did not get consistent budgetary support. Responsibility for vapor space characterization, including development of the cryogenic sampling process, was given to the HHC industrial safety organization. At that time, the safety organization did not have an industrial hygiene capability. A manager in the safety organization was made the cost account manager for this effort, although this type of assignment was outside the scope of the safety organization?s normal responsibilities. The Board was told that this assignment was made because of confidence in the personal abilities of the manager in the safety organization and an expectation that the other technical organizations would not be able to accomplish the work. The Board noted that the customary technical development plan was not prepared. The Board was also told that management attention on the vapor inhalations was influenced by the very high level of interest in two Tank Farm unreviewed safety questions: 1) the flammable gas concern at Tank and 2) the ferrocyanide concern. These issues began to receive significant attention in early 1990. The effort to resolve these issues diverted management attention and syphoned resources away from the vapor inhalation issue. In response to many of the occurrences, boundaries were established around areas where a requirement for respiratory protection was established. The Board identified at least nine occasions where this occurred. It appears that the industrial safety organization and/or the industrial hygiene organization would sometimes participate in the decisions to establish these boundaries; however, there is no evidence that documented criteria were used to make the 30T. E. Arndt to G. L. Dunford, NHC Internal Memorandum "Implementation Plan for the Design, Fabrication, and Installation of Charcoal Filters, and Exhaust Stack Height Modifications," May 4, 1990. Page 3?19 Type Investigation of Hanford Tank Farms Vapor Exposures decisions. In two cases,3?32 documentation exists of the decision-making process for relaxing the boundaries. For other actions to relax boundaries, most personnel interviewed believed that decisions were made by management based simply on negative grab sampling results. Since the January 1992 occurrence, DOE has directed HHC to develop a plan to resolve the vapor issue. As of this writing, the plan is expected by NHC management to consist of the following elements: - characterization of the tank contents for each tank characterization of the vapor space for each tank - installation of permitted ventilation on single-shell_tanks. Safety and health issues in Tank Farm operations are presently addressed by prejob planning, including hazardous work permits, radiation work permits, and operating procedures. These documents and requirements are discussed with the workers at a prejob safety meeting.3 However, some employees stated that there is dissatisfaction with the adequacy of meetings intended to provide training and information regarding potential hazards associated with Tank Farm operations. . Tank Farms management stated to the Board that, as a Resburce Conservation_and Recovery Act (RCRA) treatment, storage, and disposal facility, the Tank Farms was exempt from the OSHA requirements for a site-specific safety and health plan. However, a written safety and health.program is required for treatment, storage, and disposal facilities in section (1) of 29 CFR 1910.120. This plan must also contain certain elements that are similar to the requirements of a site-specific plan. The plan must also be maintained at the site and must adequately communicate the hazards at the site to employees. A written safety and health plan which adequately addresses hazards and control measures would also improve pre-job planning. G. Meade to P. Hinojosa, ch Internal Memorandum 33230-88-079, "Revision of Personal Protective Equipment Requirements at the Ventilation System Stack Areas," April 22, 1988. 32M. A. Payne to R. E. Gerton, WHC Letter 92006408 R2, "ReSpiratory Protection Requirements for Single-Shell Tank Farms," February 20, 1992. 33M. E. Hevland to D. G. Hamrick, WHC Internal Memorandum, "Respiratory Protection for SY-101 Window Activities," December 6, 1991. Page 3-20 Type Investigation of Hanford Tank Farms Vapor Exposures 3.3.2 WHC Safety and Industrial Hygiene Organization Response The safety organization?s initial support to Tank Farms concerning the vapor exposure incidents was to participate in the investigation of the July 1987 incident at Tank Farms and to oversee HEHF sampling of the Tank 103-C vapor space gases. The results of the HEHF sampling showed the presence of organic vapors and ammonia.34 Despite the_identification of organic constituents and qualifications on the sampling results stated by HEHF, protective actions recommended by the NHC safety organization for Tank Farms continued to be based on a belief that the constituent of concern was only ammonia. The investigation of the 1987 event continued during the fall and winter of 1987 and was completed in January 1988. As a result of the occurrence, the industrial safety organization was tasked with developing a method to characterize the vapor emissions from Tank 103-0. The industrial safety organization pursued the development of an experimental cryogenic sampler proposed by the analytical laboratory group. An event at Tank Farm and the Technical safety Appraisal (TSA) conducted for the Tank Farms in 1989 increased pressure for an immediate characterization of the tank vapors. Vapor sampling using the cryogenic method was performed at Tank 103-C in July 1988 with additional sampling of Tanks 102-C-and 103-C in September 1989. No formal sampling protocol, procedures, or validation of the cryogenic sampler was conducted prior to sampling. Analysis of many of the samples was never conducted, and data from this sampling did not have documentable quality. The industrial safety organization hired an industrial hygienist in the summer of 1989 to increase personal monitoring in the Tank Farms, as well as to characterize tank emissions. Extensive area and personal monitoring was conducted in Tank Farms for ammonia using colorimetric tubes and dosimeters. However, these data have been lost, and the quality of the data cannot be ascertained. Existing records do show that some sampling data collected by NHC did not follow appropriate sampling protocol or provide records that would establish that the results were representative of employee exposures.35 By the fall of 1989, the industrial hygienist had left, and the industrial safety office was again without industrial hygiene support. The Tank Farm was placed on supplied air entry requirements, and industrial hygiene sampling was generally discontinued. Report co #11735. 35HEHF Report to #14360. Page 3-21 Type Investigation of Hanford Tank Farms Vapor Exposures breathing air. During late December and early January, the RL Employee Concerns Manager brought three recent employee concerns on the inhalations to the attention of senior management. This prompted the decision to initiate this Type investigation. When the January 1992 vapor exposures at the drill site were reported, line management concluded that there was a need to demonstrate decisiveness in ensuring worker safety. RL management met daily with top management of the four Hanford Site prime contractors, treating the situation as a crisis. RL and WHC management jointly made the decisions concerning establishment of respiratory protection zones and specification of respiratory protection. They considered these decisions to be extremely conservative, with the intention of demonstrating to employees that they were willing to, incur a significant disruption of productivity in order to ensure worker safety. RL management also assured themselves that NHC was taking extraordinary measures to establish adequate communications with workers regarding the management decisions. RL line management did not involve the RL Technical Support Division (TSD) in the decisions regarding establishment of respiratory protection zones. These were industrial hygiene and industrial safety decisions with nuclear safety implications. TSD found out about the decisions after they had essentially been made, and only by accident. ?One reason that TSD was not involved in the decisions is that TSD had no industrial hygiene specialists on staff. The - Board was also told that DOE line management is accustomed to viewing the safety organization.as an oversight function rather than a resource for assistanCe in technical decision making. The Board noted that the decisions to establish the respiratory protection zones had nuclear safety consequences in that not all Operational Safety Requirements regarding instrument monitoring could be carried out. There were also industrial safety consequences, in that use of air lines during I Operations caused some violations of industrial safety requirements. For example, the doors had to be removed from a truck in order to transport workers in breathing equipment. Some employees expressed concern regarding safety violations, and action was taken to resolve them. The Board also noted that RL obtained substantial professional industrial hygiene advice through WHC when deciding to relax the reSpiratory protection zones. A. Payne to R. E. Gerton, ch Letter 92006408 R2, "Respiratory Protection Requirements for Single-Shell Tank Farms," February 20, 1992. Page 3-28 Type Investigation of-Hanford Tank Farms Vapor Exposures 3.4 CORRECTIVE ACTION 3.4.1 Past Event Investigations During the period from July 1987 to January 1992, three formal investigations and/or causal analyses were conducted regarding the vapor inhalation All three activities were initiated by NHC as internal' inquiries, and each resulted in a set of causes and recommendations for preventing recurrence. The July 1987 Type investigation was expanded at the request of RL and developed under the Type format. The investigation, however, was not developed to include any formal root cause analysis methodologies. The final report included recommendations regarding the need to perform detailed characterization on Tank 103-C, reroute sample pump discharge lines, revise exhauster shutdown procedures, conduct chemical emissions training, and evaluate characterizing the vapor space on all waste tanks. The November 1989 analysis was conducted in response to a corrective action item from the September 1989 event. In this instance, a formal root cause analysis was conducted. Subsequent to review of applicable documentation and personnel interviews, the Board concluded that the root cause analysis did not approach standard MORT-based techniques and was performed by an individual who had not received adequate technical training in this area. Additionally, the root cause of the vapor inhalation occurrence was determined to be a lack of communication. While this may have been a contributing cause, the NHC analysis did not find the root cause of less than adequate management system implementation. The third investigation was conducted in response to the September 6, 1991 event. No formal root cause analysis was performed. The Board concluded that the investigation only involved the activities normally required in the generation of an occurrence report. A list of recommendations was developed which again included the need to perform sampling and characterization of Tank Late in 1991, DOE-Headquarters reviewed a draft copy of the 45F. E. Boyd, "Investigation of Tank 241-C-103 Incident," January 15, 1988. 46I. J. Austin, Root Cause Analysis - Personal Injury November 15, 1989. 47M. S. Garrett and K. E. Myers, "Personnel Exposure of Noxious Vapors from Farm Investigation Report," October 22, 1991. Page 3-29 Type Investigation of Hanford Tank Farms Vapor Exposures September 6, 1991, investigation report and noted that it failed to identify' the systemic factors associated with recurrence. The Board noted that, although vapor space sampling and characterization of Tank 103-C emissions had been viewed as a significant issue in each of the analyses, a meaningful action plan to accomplish this activity was not developed. 3.4.2 Corrective Action Tracking and Closure Several methods have been used to track and close corrective actions and recommendations associated with Tank Farm problems. At one time there were as many as five independent systems; this has been reduced to the following two systems: - The Quality, Environmental, Safety Tracking System this is for audits, surveillances, etc. The waste tank commitment tracking system; this is for internal commitments. Currently there is no system in place to monitor and follow closure of current occurrence report open items. Tank Farms occurrence report action items were entered into the QUEST, but no entries have been made since June 1991. The Board summarized the corrective actions and recommendations from occurrence reports and other supporting documentation covering the period of July 1987 to January 1992 (see Table 3.1 at the end of Section 3). This information was compared to closure data available from the Administrative Support and Waste Tank Commitment organizations to determine the extent of item closure. The focus of this portion of the investigation was to evaluate the adequacy of the tracking and subsequent closure of open items applicable to Tank Farms within the framework of existing mechanisms. The intent was not to evaluate the appropriateness and adequacy of corrective actions. 0f the corrective actions and recommendations evaluated, approximately 16% were identified as "closed" within the confines of past or current tracking mechanisms. The status of most of the remaining items could not be determined by the Board based on available information. This conclusion does not necessarily mean open items have not been addressed; however, there is insufficient information to adequately determine present status. It should also be recognized that some of the corrective actions date back as far as 1987. Of particular interest was the fact that, in some cases, an open commitment may be adequately tracked and closed; however, the accomplishment of the Page 3-30 Type Investigation of-Hanford Tank Farms Vapor Exposures commitment may produce additional corrective attions.? There is not a clear and effective mechanism in place to adequately track and close-out these "daughter" actions. Consequently, several recommendations and corrective actions have never been monitored for closure on any past or current tracking database. For example: - Evidence could not be located that would substantiate the adequate tracking and closure of recommendations made in a NHC Tank 103-C characterization interim status memo distributed in January 1988.48 - Evidence could not be located that would substantiate the development and implementation of a periodic media replacement schedule for the Tank 103-C carbon filter'system. This schedule was a recommendation by HEHF in a memo documenting the close-out of a commitment to provide engineered controls on Tank 103-C to maintain emissions within safety limits.? This commitment was made subsequent to the July 3, 1987, event. - Evidence could not be located that would substantiate the tracking and closure of recommended improvements resulting from the completion of an AP Farm technical assessment of ammonia emissions. This assessment was performed as a close-out item from Critique Report WHC-C-89-106-TF-08. - Evidence could not be located that would substantiate the tracking and closure of recommendations resulting from a root cause analysis performed in November 1989. The root cause analysis was performed in response to an open item commitment as a result of the July 3, 1987, event. G. Carothers to Distribution, NHC Memo #13331-88?018, January 20, 1988. 49c. H. St. John to H. N. Bowers, HEHF Memo #c01soo1, January 29, 1990. SOMemo from Defense Waste Engineering/Safety, Quality Assurance and Security, to R. J. Baumhardt, October 19, 1989. 51To J. J. Badden from Single-Shell Tank Process Engineering, WHC Memo Root Cause Analysis," November 15, 1989. Page 3-31 Type Investigation of Hanford Tank Farms Vapor Exposures Table 3.1 presents the results of the review. Each identified open item was evaluated based on the following criteria: Open - The item is being tracked; however, closure has not been accomplished to date. Closed - Appropriate documentation exists that substantiates adequate closure within the tracking systems. Cannot Be Determined - The item could not be identified within the tracking systems. 3.5 MEDICAL EVALUATION 3.5.1 Summary of Medical Attention Received HEHF provides occupational medical services to WHC and other Hanford contractors. Employees injured on the job report to the nearest HEHF first aid station where HEHF nurses provide first aid care. If more extensive treatment is required, such as suturing or hospitalization, the employee is sent to the emergency room of Kadlec Hospital. A summary of the medical attention received by Tank Farm_employees during vapor exposure events is as follows: - Approximately 80% were first aid cases with upper respiratory irritation; there were no reported of irritation. - Approximately 20% were emergency room observations. - No employees were admitted for hOSpital care. 3.5.2 Medical Response and Reporting A total of eight "First Aid Reports of Occupational Injury or Illness" were reviewed to determine if adequate information had been collected to use for Page 3-32 Type Investigation of Hanford Tank Farms Vapor Exposures epidemiological evaluations of the potential causes of the Tank Farm vapor exposures. The first aid report contains two major sections for information to be collected by the nurse: . "What was the employee doing when injured or exposed? Name object or substance which injured employee." - "Describe injury or illness, indicate diagnosis and part of body affected." 0n the first item, the following entries were made on a total of eight reports: Information Item Number of Responses Type of Respiratory Protection Horn 2 (may have been considered obvious) Odor Description 3 Potential Source - Duration of Exposure 4 Activity of Employee 6 Specific Location of Employee 5 On the second item, the following entries were made on a total of eight reports: Medical Condition Number of Resoonses Description of Injury or Illness 6 Identification of Body Part Affected 6 (The injury or illness was described as "chemical inhalation" or "inhalation of toxic fumes" on two reports.) The quality and amount of occupationally related information in the eight first aid reports reviewed ranged from four or five responses to the above information items to as low as one or two. Entries of the medical condition of the employee were much more consistent. The lack of occupationally related information reduces the usefulness of epidemiological studies, such as the Page 3-33 Type Investigation of Hanford Tank Farms Vapor Exposures medical review conducted by Dr. R. H. Ronish on Tank Farm incidents.52 This study could only conclude that the incidents were epidemic or pseudoepidemic. were described as consistent but nonSpecific, and odor descriptions were consistent Unfortunately, out of the eight cases reviewed in this study, only four contained a description of the odor. In 1991, HEHF initiated the use of an "Occupational Injury/Illness Information Sheet" to augment the information collected on the first aid report. This sheet provides additional information that would be valuable in lost Work day case management, but provides little additional event?related information. 3.5.3 Professional Qualifications Professional standing in occupational medicine is provided through the certification of nurses and physicians. In 1987, HEHF had three certified occupational health nurses out of a total of seventeen, and two board certified occupational physicians. At the present time, HEHF has eight certified nurses out of a total of fifteen nurses on staff, with one physician currently completing a residency in occupational medicine. HEHF is actively pursuing increased occupational medicine qualifications and training of its medical staff. 3.6 ORGANIZATIONAL HISTORIES 3.6.1 WHC Organizational History The organization responsible for management and operation of the Tank Farms was incorporated into WHC in July 1987. This occurred when WHC became responsible for the Tank Farms under a new maintenance and Operation contract. The incorporation was accomplished with relatively minor personnel and organization structural changes. WHC immediately assigned a Level 2 manager and a Level 3 manager to the Tank Farms who were long?time Westinghouse employees, and were new to the 200 Areas. Since the beginning of the WHC contract, there have been five major reorganizations impacting the Tank Farms, an average of about one per year. 52R. H. Ronish to M. Hevland, "Medical Records Review Relative to the Tank Farm," HEHF Memorandum, September 23, 1991. 53R. H. Ronish to 5. Coleman, "Tank Farm Incidents," HEHF Letter, March 13, 1992. Page 3-34 Type Investigation of Hanford Tank Farms Vapor Exposures Shortly after assuming management responsibility for the 200 Areas, WHC eliminated the $10.99/week isolation pay that had been afforded workers north of the Wye Barricade since the 19405. The new company also made available many positions for technical and administrative staff in the 300 and 400 Areas and in town that were not previously available to Rockwell and UNC Nuclear Industries personnel. Even though the isolation pay was quite small, it did compensate for the cost of travel to the outer areas. The elimination of this was perceived as a cut in pay. Consequently, technical and administrative personnel saw incentive to take available positions nearer town. It was difficult to fill openings in the 200 Areas within NHC, and most required hiring from outside. These two factors contributed to the high turnover rate of personnel in the Tank Farms. Following the November 1988 reorganization and shut down of Reactor, there was a transition from managers and engineers with chemical processing backgrounds to personnel with reactor backgrounds. The Board was told that this created some resentment among long-time 200 Area personnel with chemical processing backgrounds. The December 1990 organizational change has expanded the organization overseeing Tank Farm activities significantly. For instance, the engineering staff reporting directly to Tank Farms has grown from about 40 engineers to about 148 at present. Part of the growth was achieved by relocating staff from the Engineering Department located in town out to the 200 Area, now directly reporting to Tank Farms management. The growth and turnover has resulted in a reduced average level of Tank Farms experience and knowledge among technical personnel. The following is a chronology of reorganizations (reorganizations marked with asterisks are considered to be significant reorganizations): July 1987 New maintenance and operations contract. WHC is the new contractor; New Level 2 and operations managers with reactor backgrounds. March 1988 New Level 2 manager. November 1988 New Tank Farm Operations manager from Reactor. *April 1989 Number of changes in managers and organizations. *January 1990 Change in Tank farms Operations manager and below; several new managers from Reactor. June 1990 Change in Level 2 manager. Page 3-35 Type Investigation of Hanford Tank Farms Vapor Exposures *July 1990 Numerous changes in Tank Farms organizations below Level 2; engineering organization realigned to report to operations managers; Waste Tank Safety Programs Office created. *December 1990 Two new senior management positions created: Vice President of Waste Tank Safety, Operations and Remediation, as well as Director, Tank Farms Projects; engineering centralized, with authority to significantly expand staffing; numerous other changes. ?*December 1991 Major changes to implement new organization structure; January 1992 new Operations manager. 3.6.2 DOE History and Organization Through numerous reorganizations, the RL branch responsible for industrial safety programs had maintained an industrial hygienist of one?half of a "full- time equivalent." This resource was to cover the industrial hygiene program for each contractor over the entire site. The industrial hygienist was also expected to perform some collateral duties with reSpect to fire protection, industrial safety and contract management. From August 1980 until August 1991, one specific individual was reSponsible for this function. This individUal was promoted to another position during 1991, and the safety organization was without an industrial hygienist until April 1992. This organization is presently called the Technical Support Division (TSD). TSD is currently in the process of hiring two new industrial hygienists and has some resources available through the existing support services contract. The new oversight organization, called the Office of Compliance (CMP), was established in 1991. It has had an industrial hygienist on board since July. 1991. The CMP industrial hygiene capability, using the new employee, is only beginning to function. TSD provides program management and consulting services (such as advice on industrial hygiene issues) to line management. It does not proactively follow industrial hygiene issues. CMP provides oversight by work sampling, as well as by routine auditing and appraisal activities. Generally, CMP follows issues that it has identified itself. It does not normally follow issues identified by others, unless requested to do so by line management. Presently, occurrence reports are provided to RL, as required by DOE Order 5000.3A. They are brought to the attention of the TSD and CMP organizations only on a case basis. There is no trending of these reports, Page 3-36 Type 8 Investigation of- Hanford Tank Farms Vapor Exposures such as might be used to provide early identification of recurring industrial hygiene problems. The Assistant Manager for Operations told the Board that action is being initiated to create a trending system that would provide this function. 3.7 WHC INDUSTRIAL HYGIENE PROGRAM When WHC became responsible for operation of the Tank Farms in July 1987, industrial hygiene expertise was concentrated in program development rather than technical support. Late in 1988, WHC did hire a technical support industrial hygienist, but this individual left MHC after approximately 3 to 4 weeks. From that time until 1990, there was no professionally qualified industrial hygiene technical support capability. In May 1990, a new in- dustrial hygienist was hired by MHC for field support activities of the Industrial Safety North Area Office. This position was elevated to Manager of Industrial Hygiene in the reorganization of 1991, and a total of seven industrial hygienists was hired. The present staff consists entirely of recent college graduates, some with masters degrees. Unfortunately, these new industrial hygienists lack field experience. HEHF was tasked to perform monitoring evaluations as a service for NHC but was not comprehensively tasked to help solve the vapor inhalation problem. The Board noted the following regarding the HEHF evaluations: - Comprehensive sampling designs were not develOped for area or personal monitoring. (Emphasis was an short term grab sampling.) - HEHF did not have input to development of an adequate sampling design. - There was no scope of work between NHC and HEHF describing industrial hygiene services of HEHF. HEHF only provides industrial hygiene services requested by NHC. - Recommendations in HEHF reports were not identified, dispositioned, tracked, or implemented by WHC safety or Tank Farms management. The 1990 Tiger Team identified a need for MHC to develop a separate program for industrial hygiene. As a result, the new WHC-CM-4.3, Volume 4, for industrial hygiene is being developed. When issued for use, it will be a Level 2 controlled manual, which means NHC will require its implementation across the company. There are 33 parts to this new volume, and 6 will be implemented in July 1992, including the following: - Page 3-37 Type 3 Investigation of Hanford Tank Farms Vapor Exposures . confined space entry program - respiratory protection - hazard communication - chemical storage handling. Actions from the Tiger Team evaluation also resulted in a change from an overhead costing method to a mandatory funding requirement to each of WHC line office; This included the Tank Farms. This process requires a submittal of requirements and an assignment of a task package control number by Tank Farms line office for all industrial hygiene support functions. In the past, funds were allocated for vapor space characterization but not dedicated. No work order package was made up and the funding was lost. . The new hiring and organization changes brought about by the Tiger Team evaluation provide for independent oversight. Because of a shortage of qualified personnel, there is competition for resources between the oversight and technical support organizations. 7 Page 3-38 Type Investigation of Hanford Tank Farms Vapor Exposures 3.7.1 Organization The occupational safety and health organization is given below: Occupational Health and Health Safety Safety Manager . Assurance Manager - 9 Industrial Hygienists Industrial (2 6 Vacancies Hygiene Safety Deputy Manager Personnel Industrial Protective- Hygiene Contracted - Equipment Manager services Manager provided on 1 request Respiratory Industrial HEHF Technicians** Hygiene Industrial Hygiene (IH Technicians Technical Monitoring* For Monitoring) Support 6 Technicians 7 IHs Certified Industrial Hygiene personnel. Respiratory Protection Technicians are directed by the manager of the Industrial Hygiene Unit to carry out services requested by Tank Farms Operations. The current HHC octupational safety and health organization, as shown, has been adversely affected by-a lack of experienced and certified industrial hygienists or safety professionals in management positions. The industrial hygiene group also lacks adequate resources for field monitoring support to Page 3-39 Type Investigation of HanfOrd Tank Farms Vapor Exposures the Tank Farms. This support is provided by HEHF as noted in the previous section and by respiratory protection technicians. Respiratory protection technicians report to the Manager, Personal Protective Equipment Unit, who is located in the 200w Area. However, they report to the 200E Area for daily work assignments. Work assignments are provided by Tank Farms management and the manager of the Industrial Hygiene Unit. Training and technical supervision is provided by the Industrial Hygiene Unit on a part- time basis. No written procedures have been developed for this monitoring, and no formal training is documented. The results of this sampling are used as the primary indicator for the need for respiratory protection in the Tank Farms. 3.7.2 Qualifications of Personnel The NHC safety and health program has historically lacked employees certified as industrial hygienists (CIH), certified as safety professionals (CSP), or registered as professional safety engineers (PE). At the present time, only one employee in this entire department has any of these credentials. None of the employees in the industrial hygiene group, including the manager, are CIHs. The following positions provide direct support to Tank Farms in the area of safety and health: Manager, Occupational Health and Safety Deputy Manager, Occupational Health and Safety Manager, Industrial Hygiene - Manager, Personal Protective Equipment Manager, Waste Tank Health and Safety Senior Scientist (IH) Advanced Scientist (IH) Plant Engineer (IH) Respiratory Technician. Job descriptidns (excluding the Manager, Personal Protective Equipment) do not describe the depth and breadth of safety? and health-related knowledge (Section 3.A of the standard HHC position description format). The education and experience requirements section (Section 3.8) does not mention industrial hygiene or safety degrees and does not define professional experience in _safety and health. It is conventional that a majority of professional experience should be in health and safety, but this is not stated. Certified industrial hygienist, certified safety professional, or registered safety engineer are not listed as desirable or required qualifications. Page 3440 Type Investigation of Hanford Tank Farms Vapor Exposures Job descriptions for industrial hygienists do not describe the objectives or responsibilities of the practice of industrial hygiene. These job descriptions also do not specify knowledge, education, experience, or certification requirements in the area of industrial hygiene. The job description for respiratory technicians (who are used as industrial hygiene technicians in the Tank Farms) does not contain a description of the industrial hygiene field monitoring function. These employees are primarily qualified for industrial hygiene work through classroom and on-the-job training. There is no formal training for industrial hygiene instrument monitoring activities or internal qualification for industrial hygiene technicians documented in technician training records. 3.8 EMPLOYEE COMMUNICATIONS Interviews with Tank Farm employees and management suggest that approximately 10% of the Tank Farm employees are totally dissatisfied with the management response to the vapor problem, while another 10% are basically not concerned. The majority (approximately 80%) are concerned and expect management to provide an adequate explanation of the health effects associated with the vapors. They are also waiting to see management take appr0priate protective actions. Effective communication of occupational hazards is required by OSHA standards. A root cause analysis conducted by NHC in 1989 found that poor communication by management was the root cause of the recurrences. However, both Tank Farm management and the industrial safety (or later, the industrial hygiene) organization have frequently attempted to communicate to Tank Farm employees an understanding of the health risks associated with the vapor problem. The difficulty has been that management has not had valid characterization data on which to base an assessment of risk for presentation to the workers. The first attempts by the industrial safety organization to explain the nature of health risks after the July 1987 incident emphasized the "hypersensitivity" of some employees. It did not appear to the Board that they had successfully addressed the concerns of employees. Several Tank Farm exposure events involving first aid visits were not reported to Tank Farm management or the industrial safety organization. In addition, results of vapor space sampling and personal monitoring required as much as 54I. E. Austin, Root Cause Analysis - Personal Injury November 15, 1989. Page 3-41 Type Investigation of Hanford Tank Farms, Vapor Exposures 1-1/2 year turnaround time, during which no status reports were made to employees. This resulted in perceptions among some employees that information was being withheld and that the problem was much more serious than management was communicating. In meetings with employees in the summer of 1991, management again attempted to explain that vapors Were not a health hazard. However, employees were generally unconvinced for the following reasons: - They had observed irregularities in the vapor space sampling. - They were suspicious of the very long turnaround time on sample results (1-1/2 years in one case). They were aware that the vapor emission characterization was incomplete. Employees and management have indicated that the industrial safety organization has lost credibility by 1) failing to respond to reported Tank Farm safety problems in a timely manner, 2) lack of specific information on events, and 3) lack of expertise in industrial hygiene. 'Employees have expressed some Confidence in communications from the personnel protective equipment group, but definitive information that addresses all employee concerns has not been provided. An Operations Advisory Council has been set up by WHC to allow a team of employees the opportunity to receive feedback from fellow workers on issues of concern. Some employees have resigned from the council because they believe that there is a lack of responsiveness on the part of management in addressing and adequately solving important concerns. Communications between WHC management and Tank Farm employees significantly increased after the January 1992 occurrence at the drill site. Explanation of the event and protective actions taken by NHC were provided to all employees in writing within 24 hours. A plan was developed for removing access barriers and reducing respiratory protection requirements, which included personal monitoring. This plan was also provided to all employees in writing. 3.9 TANK 103-C CHARCOAL FILTER INSTALLATION The Board reviewed the installation of the charcoal filters on Tank 103-C. The filters were installed in response to the September 1989 event, and were placed in service on December 20, 1989. (Alignment of tank vent systems is such that Tanks lOl?C and 102-C also vent through 103-C.) The final design was specified in ECN 146434, and the work was performed under work package Page 3-42 Type Investigation of Hanford Tank Farms Vapor Exposures document No. 2E-89-01829/w. During its reviews work, the Board noted the following: A of the filter installation The filters were placed in service on December 20, 1989, but the ECN specifying the final design was not released until August 21, 1990. Procedure EP 2.2, Paragraph 5.1.5 requires that design documentation be released prior to accomplishment of work. HHC was unable to locate documentation of design verification for the installation. ECN 146434 specified that design verification was required for this design, and EP 4.1, Sections 4.11 and 5.1.1.5 require that documentation of design verification be retrievable. Section 5.3 of EP 4.1 identifies this documentation as a lifetime quality record. . From installation of the filters_until August 1991, there was no heat trace or insulation on the system. The purpose of the insulation and heat trace is to ensure that no moisture is carried into the filters. The manufacturer of the filters recommends that moisture must be removed from the vapor before it enters the filters. Plugging of filters may have occurred because moisture from the tank vapors entered them. A number of WHC managers believe that the charcoal filters, placed in line with the HEPA filter, may have caused an increase in vapor emissions from unfiltered portions of the system. The filter arrangement could have caused a flow restriction in the design vent path, so tank vapors were instead emitted through a number of other unfiltered leak paths out of the tank system. . There was no forced ventilation through the filters. Instead, normal tank breathing, due to barometric pressure changes and temperature differentials, was relied upon to cause vapors to flow through the filters. Actions to verify charcoal filter efficiency did not attempt to determine whether there was flow through the filter when efficiency measurements were taken. 3.10 TANK EMISSION CHARACTERIZATION Characterization of 241-C Tank Farm vapor space emissions was initiated by Tank Farms management in response to the July 3, 1987, event at Tank 103-C and was continued until 1990, when the vapor space sampling program for 101-SY Page 3-43 Type Investigation of Hanford Tank Farms Vapor Exposures preempted the use of sampling equipment. An additional vapor space sample was taken in Tank in April 1991. Three general approaches were used to collect samples for analysis: - the Tank Farms vapor space sampler - grab samples from the tank vents - the cryogenic sampling system. 3.10.1 Tank Farms Vapor Space Sampler This was a portable device consisting of particulate filters, rotameter, vacuum pump, and gas volume meter. A gas sample was drawn from the tank vapor space. Bubblers and a Tenax adsorption tube were used to collect samples for ammonia, oxides of nitrogen, acid gases, and organic vapors. This system was used at 103-C in September and October 1987, but was discontinued because of breakthrough and poor collection efficiency. 3.1 0.2 Grab Sampling Grab samples have been periodically taken from the 103-C and other single- shell breather exhausts since 1987. These samples have been taken using 'colorimetric tubes, charcoal adsorption tubes, Tenax adsorption tubes, and evacuated canisters. These samples were typically taken after a vapor exposure event to determine potential exposures. Grab samples are collected over a short period (1 to 30 minutes). These were typically obtained a few hours to several days after a vapor exposure event. Sampling has generally been conducted by HEHF or WHC industrial safety personnel. Results of this type of sampling have generally been significantly below occupational health standards and have frequently been used as justification to remove or reduce respiratory protection requirements in Tank Farms. The grab sampling conducted by HEHF and WHC contains no documentation of flow conditions at the tank breather exhausts during sampling. Insufficient flow . out of the tank could result in dilution of the sample by ambient air. The sample would then not be representative of emissions to which employees were exposed. .The potential for dilution of the sample and the limits of detection for sample analysis limit the usability of grab sampling for tank emission characterization. Tank Farms management has recently proposed an automated grab sampler for the 103-C exhaust. The sample would be collected in an evacuated canister when Page 3-44 Type Investigation of Hanford Tank Farms Vapor Exposures the mass flow indicator shows that gas is flowing out of the tank. This system would sample the infrequent puff-type emissions, but makes the assumption that the 103-C Tank emissions come from the filtered tank vent. Comments by Tank Farm engineering, as well as from industrial safety and health, suggest that the added resistance of the charcoal filter system results in unfiltered emissions from valve and pump pits, which are also connected to the tank vapor space. 3.10.3 Cryogenic Sampler The cryogenic sampler was developed by WHC under the management of the industrial safety group, beginning in 1988. it originally consisted of two cold traps that were filled with glass packing material to provide a large surface area for vapor condensation. The two traps are connected in series with a flow meter and vacuum pump and immersed in baths of dry ice and ethanol at A bypass is provided for impingers and Tenax adsorption tubes. Impingers were used to collect ammonia, oxides of nitrogen, fluoride, cyanide, and acid gases. The cryogenic traps were used to collect condensable organic vapors with the Tenax tube as an additional method for collecting organic vapors. Samples were taken from 103-C in July 1988, from and 103-C in September 1989, from 103-C in April 1991, and from 104-BX in August 1991. The samples are extracted from the cold traps in a methanol wash. Analysis of the blank wash prior to sampling and the wash containing the sample has resulted in inconsistencies between samples of similar vapor space conditions and VOC samples collected in parallel to the cold traps. Questions concerning quality assurance-of gas chromatography/mass spectrometry analysis of the methanol solutions and a need for a validation and quality assurance plan are noted in a WHC report of the 1989 sampling and HEHF reviews of the method in 1990 and 1991.515617 The design of the cryogenic sampling system has been altered since its original development. The sampler is now housed in a van and is connected to a portable gas chromatograph, with computer data collection equipment. The dry ice bath has been replaced with a refrigeration device, and the trap configuration has been changed to improve collection efficiency. However, the sampling plan developed for the ferrocyanide waste sampling project does not contain a detailed quality assurance plan for the cryogenic sampler. 55w. H. Ulbricht, "Report on 241-C Tank Farm Sampling Results of 1989,? June 1991. 56HEHF Report co #15885. 57HEHF Report co #16487. Page 3-45 Type Investigation of Hanford Tank FarmsVapor Exposures A validation plan for the cryogenic sample was developed in 1991. This plan proposes a five-step process for validation of the method. - Characterize analysis of five analytes in methanol (acetone, benzene, carbon tetrachloride, methylene chloride, and carbon disulfide). - Trap recovery using mixtures of analyte in methanol injected into the trap, chilled, and removed with a methanol rinse. The trap would be rinsed, heated, and purged between uses. - Trap collection efficiency using mixtures of analyte at various gas flow rates. Vapors of the analyte mixtures would be generated in dry nitrogen and the trap would be analyzed as above. . - Increase number of analytes validated. - Overload or challenge system with air mixtures, moisture, etc. The validation plan may ultimately establish which analytes can be reasonably collected, described, and analyzed by the cryogenic sampler, but the plan has some potential weaknesses: - The list of chemicals for initial analysis does not reflect the list of the most commonly found Species reported in previous tank vapor space sampling (n-butanol, normal paraffin hydrocarbons, and ammonia). - The trap is to be rinsed, heated, and purged between validation samples, but this method was not used during field application of the sampling 'process. - The vapor collection validation testing is conducted with dry nitrogen as the carrier gas rather than the moist air that is representative of field conditions. - The validation plan does not reference recognized sources of validation study design, such as the EPA Office of Research and Development, "Agency Guidelines for Validation (Draft)," January 1986. Interviews with NHC and HEHF chemists suggest that the cryogenic sampler design has some problems that may reduce its ability to be a "universal" sampler for tank vapor space gases. The EPA method for cryogenic sampling (EPA Method T03, Revision 1, April 1984) has a much lower flow rate, requires moisture removal using a dryer, and operates at The EPA trap is then "desorbed" in a programmable heater that acts as a molecular still, rather than by solvent rinsing with methanol. The solubility of a number of organics in methanol at is questionable and may likely make the sampler Page 3-46 Type investigation of Hanford Tank Farms Vapor EkpoSures unsuitable for quantification of normal paraffin hydrocarbons. These would then become an additional contaminant of the trap system for sampling tank vapor space gases. A lack of long?term funding by Tank Farms management was cited as a problem in the optimization of the cryogenic sampler design and the delays in method validation. - Page 3-47 Waste Surlace? Breather Level Observation- Pli Wealher 1? 7 Thermocouple; Fm? Port Cover. Riser Terminating iTransier Lines . a 3 it Below :Blanked at High Ground Hydraulic End I . 34., hum-.- - I - i ysuun LI uid - Isa? we" . I . I Seal Loops - Filled /Observaiion ll Noi Required ior Cooling 'Weu Steel Walls Eliicade i. /and Floor Fill Lines Blanked (Len as ls) In Diversion Box In Which They Sail Cake and/or Sludge P8840845 Figure 341 Typical Single-Shell Tank . H, DRY WELL I TANK PRESSURE LEAK DETECTION PIT SLUICE PIT PROFIIE PUMP PIT PUMP 51 ANNULUS I, . . PUMP our DRAIN .. . - ANNULUS AIR OUT ANNULUS mu SIDE FII RADIATION DETECTION WELL PIPE TO LEAK PIT clacuLAmn 22 1: LONG 1711mm; (TYPICAL or 1 0F 5) INSULATING 5mm? HEATING 2P58706-35 Figure 3?2 Typical Tank Type Investigation of Hanford Tank Farms Vapor Exposures TabIe 3.1 Open Item and Commitment Status 7/87 - 1/92 Recommendation/Corrective Originai Cannot Action Commitment Commitment Be Description Document Open Ciosed Determined Require air Iine HEHF respiratory protection for Evaiuation, exhauster maintenance Juiy 17, 1987 activities. Obtain ammonia sampies prior to and immediateiy 059, November after air Iancing 1987 activities at SY Farms. Reroute sampie pump discharge above breathing Investigation zone. Report,. I Design January 1988 documenta- tion was inciuded in tracking system; however, actuai implemen- tation couid not be deter- mined. Revise Tank Farm procedures regarding exhauster Investigation shutdown. Report, January 1988 Perform detailed WHC-87-008 characterization on Tank Investigation 103-C. Report, January 1988 Page 3-48 Type Investigation of Hanford Tank Farms Vapor Exposures Cannot Recommendation/CorreCtive Original Action Commitment Commitment Be Description Document Open Closed Determined Evaluate need for WHC-C-87-008 additional Investigation sampling/treatment Report, following Tank 103-C January 1988 characterization. Conduct chemical emissions HHC-C-87-008 training. - Investigation Report, January 1988 Restart 103-C exhauster and NHC-C-87-008 sample for chemical vapors. Critique Report, January 1988- Evaluate characterizing the WHC-C-87-008 vapor space on tanks. Critique Report, January 1988 Evaluate cause of the cloudy vapor space in Tank CritiQue 103-C. Report, January 1988 Isolate/sample Tank 103-C. Carothers memo Evaluate isolation and 13331-88-018 sampling of Tanks 101 and of January 20, 1988 Complete a transaction Carothers memo history of 241-C Tank Farm 13331?88-018 to evaluate further farm of January 20, sampling. 1988 Sample the vapor Spaces of Carothers memo the cascade Tanks 101 and 102-C. 13331-88-018 of_January 20, 1988 Page 3-49 Type Investigation of Hanford Tank Farms Vapor Exposures Recommendation/Corrective Originai Cannot Action Commitment Commitment Be Description Document Open Ciosed~ Determined Sampie vapor spaces of Carothers memo 'Tanks 101, 102, and 103-C 13331-88-018 periodicaiiy to determine of January 20, composition/ 1988. concentration. Determine maximum airborne U0-89-044-TF- vapor concentration in 07, August vapor spaces. 1989 Identify SSTs containing waste simiiar to 07, August 1989 Perform detaiTed anaiysis U0-89-044-TF- and evaiuation of 07, August vapor space chemicai 1989 concentrations. Provide engineered controis U0-89-O44-TF- on 103-C to maintain 07, August emissions within safety 1989 Timits. Impiement U0-89-O44-TF- monitoring/sampiing in 07, August Tank Farms. 1989 Perform and document root cause analysis. 07, August 1989 'Resampie vapor space Tank Farm memo under in-tank conditions. August 21, 1989 Ventiiate 103-C after Tank Farm memo sampie resuits received. TF-89-237, August 21, 1989 Page 3-50 Type Investigation of Hanford Tank Farms Vapor Exposures Recommendation/Corrective Original Cannot Action Commitment Commitment Be Description Document Open Closed Determined Repair exhauster Tank Farm memo to release 1000 CFM exhauster for 101/102/103. August 21, . 1989 Provide routine Tank Farm memo sampling/monitoring of Farm work areas. August 21, 1989 Provide training to all Tank Farm memo personnel at Tank Farms. TF-89-237, August 21, 1989 Stabilize 103-0 by removing Tank Farm memo supernate and interstitial liquids. August 21, 1989 Evaluate stabilization of Tank Farm memo 103?0 with respect to vapor TF-89-237, space gas source ID and August 21, control. 1989 Evaluate all SSTs for Tank Farm memo potential safety impacts TF-89-237, due to gas generation based August 21, on tanks with compositions 1989 similar to 103-0. Sample and evaluate all Tank Farm memo breather filtered tank exhausts using industrial August 21, sampling equipment. 1989 Setup routine monitoring Tank Farm memo schedules for all SSTs as TF-89-237, appropriate. August 21, 1989 Page 3-51 Type Investigation of Hanford Tank Farms Vapor Exposures Recommendation/Corrective Original Cannot Action Commitment Commitment Be Description Document Open Closed Determined Modify the Tank Farm plant- Tank Farm memo specific training. TF-89-237, August 21, 1989 Evaluate new sampling Tank Farm memo devices for applicability to enhance tank vapor space August 21, sampling and 1989 characterization. Perform technical assessment of data on ammonia releases in AP Tank September 1989 Farms to determine if additional engineered and/or administrative ,controls are required. Provide personnel exposure WHC-C-89-106- isampling and general area monitoring plan for Tank September 1989 Farms. If required per technical WHC-C-89-106- assessment, perform an TK-08, engineering study to ID September 1989 recommended engineering controls. Develop an implementation WHC-C-89-106- plan for recommended TK-08, actions. September 1989 Continuous monitoring of Defense waste the exhaust system. engineering, October 19, 1989, memo to R. J. Baumhardt Page 3-52 Type Investigation of Hanford Tank Farms Vapor Exposures all procedures for Farm, including those for Radiation Protection Technologists. Root Cause Analysis, November 1989 Recommendation/CorrectiVe Original Cannot Action Commitment Commitment Be Description Document Open Closed Determined Reduction in the ammonia 7 Defense waste concentration in the engineering, exhaust gas. October 19, On Imple- 1989, memo to . mentation R. J. Plan .Baumhardt Increase stack heights. Defense waste engineering, October 19, On Imple- 1989, memo to mentation R. J. Plan Baumhardt Modification to eliminate Defense waste the need for operators to engineering, climb up on platforms to October 19, . take gas samples. 1989, memo to R. J. Baumhardt Provide a personnel S. G. Hodge exposure sampling and memo, November general area monitoring 20, 1989 lan for Tank Farms. Fabricate and post, on all entrances to all single- Root Cause and double-shell Tanks Analysis, Farms, specific master November 1989 safety rules. 'Review content and reduce NHC-UO-89-O44, the number of signs that Root Cause are currently posted at Analysis, Farm. November 1989 Add caution statements in NHC-UO-89-O44, Page 3-53 I Type Investigation of Hanford Tank Farms Vapor Exposures Recommendation/Corrective- Original Cannot Action Commitment Commitment Be Description Document Open Closed Determined Institute a tickle system NHC-UO-89-O44, for all pre-job safety Root Cause meetings to verify that all Analysis, involved support November 1989 organizations are present and informed. Develop a system to HHC-UO-89-O44, formally communicate and Root Cause document Tank Farm hazards Analysis, to all Operations personnel November 1989 and support personnel who work in Tank Farms. Develop a periodic media C. H. St. John replacement schedule for Memo the Tank filter January 29, system. 1990 Increase stack heights at Gov?t. Ops. the Tank Farms and Business Unit other SST exhausters. memo to w. H. Hamilton, March 2, 1990 Use carbon adsorption Gov?t Ops. canisters on tanks that Business Unit breath. memo to w. H. Hamilton, March 2, 1990 Accelerate vapor space Gov?t Ops. characterization program. Business Unit memo to N. H. Hamilton, March 2, 1990 Consider increasing the Gov?t Ops. height of any other double- Business Unit shell tank stacks where memo to w. H. vapor smells are Hamilton, noticeable. March 2, 1990 Page 3-54 Type Investigation of Hanford Tank Farms Vapor Exposures Recommendation/Corrective Original Cannot Action Commitment Commitment Be Description Document Open Closed Determined Design criteria for 103-C Implementation charcoal filters. Plan 82331- Has TFD-062, May Scheduled 1990 Determine installation Implementation criteria for 103-C charcoal Plan 82331? Has filters. TFD-062, May Scheduled 1990 Design stack height Implementation increases at Farms. Plan 82331- Mas TFD-062, May Scheduled 1990 Identify funding for stack Implementation height increases. Plan 82331- Has TFD-062, May Scheduled 1990 1 Install new stacks. Implementation Plan 82331- Mas TFD-062, May Scheduled 1990 Ensure all prejob safety NHC-TANKFARM- meetings for Farm work 1991-1038, include a formal discussion September on the noxious odors of 1991, Farm and actions required Investigation if odors are detected. Report 76314- 91-KEM-040 Upgrade Tank Farm orientation training 1991-1038, course. September 1991, Investigation Report 76314- 91-KEM-040 Page 3-55 Type 8 Investigation of Hanford Tan?k Farms Vapor Exposures Recommendation/Corrective Original Cannot Action Commitment Commitment Be Description Document Open Closed Determined Develop a standard operating procedure 1991-1038, regarding the requirements September for working in the vicinity 1991, of ?watch list? tanks._ Investigation Report 76314- 91-KEM-040 Ensure sampling and WHC-TANKFARM- characterizing of 103?6 1991-1038, vapor space is performed in September a timely manner. 1991, Investigation Report 76314? 91-KEM-040 Communicate 103-C vapor NHC-TANKFARM- space characterization 1991-1038, information to the first September line workers of Tank Farms 1991, in a professional/organized Investigation manner. Report 76314- 91-KEM-040 Develop a method for the WHC-TANKFARM- Industrial Safety groups to 1991-1038, gain back lost credibility. September 1991, Investigation Report 76314- 91-KEM-040 Page 3-56 ?Type Investigation of Hanford Tank Farms Vapor Exposures 4.0 ANALYSIS 4.1 DISCUSSION OF CAUSAL SEQUENCES 4.1 .1 Analysis: Conditions The following conditions prevailed throughout most of the period of the? exposure reports: - lack of a meaningful industrial hygiene program - management-worker communications impeded by employee relations problems - frequent reorganization - ineffective root cause analysis - ineffective corrective action tracking system. 4.1.2 Analysis: Causal Sequence Odors have always been associated with Tank Farm operations, but in July 1987, an exposure to vapors occurred that had medical consequences. A Type investigation was conducted by WHC, which was reported to RL in the Type format. As a result of the investigation, WHC assigned responsibility for characterizing the tank vapor emissions to the industrial safety organization. This organization was not technically structured or staffed to accomplish the task. At that time, WHC did not have a meaningful industrial hygiene program, and industrial hygiene resources within HHC were nearly nbn-existent. (Less than adequate implementation; less than adequate safety program review.) In approaching the problem, the industrial safety organization chose the cryogenic sampling system as the technology to be applied to the task. This process was not validated, and other conventional technologies available were Page 4-1 Type 3 Investigation of Hanford Tank Farms Vapor Exposures not adequately evaluated for use. Time and funding were therefore expended on development of the sampling process, rather than on characterizing the vapors. The industrial safety organization did not normally participate in technology development, and the required development planning was not accomplished. Funding for this effort was inadequate, although there were brief periOds when sizable amounts of money were budgeted for the work. (Less than adequate general design process.) Reorganization was a constant feature of the period when the exposures occurred. This affected the continuity of efforts to resolve the issue. Major reorganizations occurred at a rate of almost one per year, along with frequent minor reorganizations. (Less than adequate implementation.) Following the September 1989 event, NHC recognized that there were several vapor exposure events and that these were probably related. WHC conducted an analysis of the exposures and found less than adequate communication to be the root cause. While this was a contributing cause of continued exposures, the Board found this was not the root cause. (Less than adequate risk assessment.) In December 1989, charcoal filters were installed on Tank 103-C to remove organic and ammonia vapors from tank emissions. WHC design control and work control procedures were not followed, and the installation was technically inadequate. However, WHC and RL management believed that this installation had resolved any real threat to worker safety, reducing management interest in the vapor issue. (Less than adequate general design process.) At about the same time, WHC attempted to characterize the work spaces in several farms, including Farm. This effort did not haVe an appropriate level of professional industrial hygiene direction, and the work was technically inadequate. This was caused by the lack of technically adequate procedures and a lack of qualified industrial hygienists. When the individual responsible for the characterization left WHC, the work was never completed. (Less than adequate industrial hygiene monitoring systems.) Throughout the period of the exposure reports, a number of corrective actions were identified that were never completed. This occurred when action items were closed out in the action tracking systems by initiating a new action evaluating a situation and making recommendations). The new action items were not tracked and subsequently disappeared. (Less than adequate data collection and analysis system.) In 1990, management attention was directed to the flammable gas and ferrocyanide unreviewed safety questions. The various Tank Farm safety issues were prioritized, with the vapor issue well below these two new issues. For some time, lower-tier issues received little attention. Management systems Page 4-2 Type Investigation of Hanford Tank Farms Vapor Exposures 'did not assure that the problem continued to receive the appropriate level of attention. (Less than adequate management system implementation.) During the summer of 1990, the DOE Tiger Team found that the WHC industrial- hygiene program was not adequately developed. As a result, NHC began to upgrade the program and recruit new industrial hygienists. This was a time- consuming process, and still has not been completed. (Less than adequate safety professional staff.) During much of the period of the inhalations, NHC relied heavily on HEHF industrial hygiene field capability. However, HEHF worked under NHC direction, which lacked valid industrial hygiene guidance. The result was that the industrial hygiene work, even when accomplished by HEHF, was of little or no value. (Less than adequate safety program review; less than adequate industrial hygiene monitoring systems.) - When new reports were made of exposures, one NHC response was to establish respiratory protection zones in the affected farms. Establishment of the zones was not based on any specified criteria; therefore, no criteria existed for relaxing the zones. Some of the exposures occurred shortly after the respiratory zones were relaxed. (Less than adequate safety program review.) On at least one occasion, workers were told that the exposures were occurring because workers were "hypersensitive.? This happened some time ago, but HHC has had difficulty gaining worker confidence that the vapor problem was being resolved. During the summer of 1991, management attempted to communicate to workers that the problem was being controlled, but without tank emission characterization data, management did not have the necessary information to convince the workers. Some exposure events were as much expressions of employee dissatisfaction over management failure to resolve the problem as they were episodes of adverse health effects. (Less than adequate communications.) After the September 1991 event, WHC'conducted another analysis of the inhalations, but still did not find true root causes. (Less than adequate risk assessment.) 1 RL and WHC management responded decisively to the January 1992 event, however, they did not seriously seek the involvement of their respective safety technical support organizations in the initial response decisions. The response had industrial hygiene, industrial safety, and nuclear safety implications. (Less than adequate safety program review.) It should be noted that efforts to significantly improve management oversight and communications were evident. Significant technical participation from industrial hygienists was clearly evident in the event recovery. Page 4-3 Type Investigation of Hanford Tank Farms Vapor Exposures For most activities pertaining to the_vapor exposure events, RL and WHC management did not take a consistently aggressive approach to solving the problem. Most of the actions to resolve the vapor problem did not have technically qualified management oversight. (Less than adequate management system implementation.) 4.2 ANALYSIS OF SEPTEMBER 1991 EVENT . In the letter chartering this investigation, the Board was directed to identify the root causes of the 103-C exposure occurrence in September 1991. The Board reviewed the occurrence documentation and re?interviewed participants in an attempt to determine factors that made this event unique. The Board concluded that the causes and circumstances of this event are not significantly different from those of other vapor exposures. Elements such as incomplete root cause analysis, lack of work space characterization, and poor communications were c0nsistent with other occurrences. Page 4-4 7/3/87 Event mask." 8/16/89 Event 8/17 - Tank Farm respiratory protection "on mask." 9/16/91 Event Evacuation 1000 hours. Re-entry w/o restrictions 1330 hours. 7/15/87 Event 7/9/89 - Tank Farm respiratory protection "on 9/28/89 Event 9/17/91 Event Figure 4-3 Barrier Analysis - PPE 9/4/87 Event 7/16 - Restricted Area. Respira- tory protection Tank Farm "on mask." 11/9/87 Event 1/6/89 Event 9/4 - Respiratory Respiratory Protection "on mask" protection within K1 Tank exhauster. 10 ft. of vent system. 4/19/90 Event 3/15/91 Event 9/6/91 Event AP Tank Farm 12/90 - Work controls 6/26 - Ropes in respiratory removed (7/90 place. Supplied protection "on requirement). mask." Air monitoring sampling 1015 air for entry. hours. 6/28 Barriers 1/90 - Supplied removed (after air. 10 months). Barriers (rope) and posting fur limited access, filter area 1330 8/27 - Barriers hours. 20 ft around pump pit; supplied air. 12/4/91 Event 10/12/91 Event 1/92 Event Air monitoring. Notes: Respiratory protection. - All barriers/controls as used failed to prevent recurrences. - For most incidents, there was no documentation of criteria Access boundaries, to place barriers. buffer zone. - Usually there was no evidence of criteria or date when barriers were removed. Figure 4-4 Change Evaluation - Recurring Vapor Exposures. (page 1 of 2) Factor A. Event Situation B. Comparable. Safe Situation C. Distinctive About D. Weaknesses 3 Workers Supervision Various disciplines Familiar boundaries/warning Various disciplines Familiar to TF New to TF PPE boundaries/warning None None Unfamiliar with vapor No respiratory protection No boundaries/barriers None None Unfamiliar with vapor No barriers Posting LTA Not present at site Inadequate Changing Not present at site Only knows about event after the fact ReSponsibility LTA Management Various and changing Various and changing Lack of continuity Communication and follow-up LTA WHAT Barriers PPE Warning Signs Monitoring: - Prework activities - During work activities Not in place/no criteria PPE required (inside and outside farm boundaries) Not used Used but not understood Not performed No requirements No acceptance criteria In place/no criteria PPE not required Used with PPE barriers, understood Performed Requirement Criteria No barriers No PPE or controls or criteria to implement No warning signs,-poor communication No monitoring Barriers LTA Controls LTA Communications LTA Monitoring LTA Figure 4-4 Change Evaluation Recurring Vapor Exposures. (page 2 of 2). Factor A. Event Situation B. Comparable Safe Situation C. Distinctive About D. Weaknesses WHERE dominantly re 41-C Tank Farm HE Variable No particular time Met. Conditions Calm to low winds Variable Calm Calm air conditions Temp. Variable Variable Nothing EXTENT How Bad Variable depends on employee Variable depends on employee'reporting Reporting event No policy for reporting odors Recurrence No trending Recurrence - 16 Events has not corrected problem MANAGEMENT CONTROL Response Reactionary per event Reactionary vs. proactive Very little planning or schedule to correct problem Monitoring Recurring problem not closely monitored (corrective action plan) No monitoring Recurrence Poor management oversight LIA Poor RCA Inadequate corrective action system 'hazards Analysis Focused on radiological concerns with very little emphasis on chemical exposure issues. Focused on industrial hygiene and chemical with a balance approach to radiological issues. Poor management understanding of safety program requirements. LTA management system implementation. Type Investigation of Hanford Tank Farms Vapor Exposures 5.0 CONCLUSIONS 5.1 FINDINGS Significant facts and the anaIyticaI conciusions of the investigators. Section 3.1. Waste Tank History and Desiqn a. There have aIways been_odors associated with Tank Farms operations. However, this was not considered to be a probIem untiI the July 1987 event. b. The content of Tank is different from the other singIe-sheII tanks. This may have resuIted in more odor and empioyee exposures at the Tank Farm. Section 3.2. Occurrence Facts a. Since JuIy 1987, there have been 16 reports of vapor exposure in or near the Tank Farms that have required some form of medicaI attention. RL and NHC management have not effectiveiy prevented the recurrence of these events. Section 3.3.1. NHC Line Manaqement Resoonse a. When reguIatory probIems were encountered regarding ventiIation of singIe~ sheII tanks, HHC did not pursue obtaining a permit. b. Often, NHC management did not consuIt professionai industriai hygienists in making decisions to estainsh respiratory protection zones. c. NHC recognized the recurring nature and commonaIity of the inhaIation events when evaIuating the September 1989 occurrence, but faiIed to impIement effective corrective actions. Page 5-1 Type Investigation of Hanford Tank Farms Vapor Exposures WHC assigned responsibility for characterization of vapor space gases to the industrial safety organization. This organization was neither technically equipped nor funded to properly carry out this task. Many managers believed that installation of the charcoal filters on Tank 103-C resolved any significant hazard to health posed by the vapors. Because of this belief, further corrective action did not get adequate attention. Once established, decisions to relax respiratory protection zone boundaries were made based on negative grab sample results, rather than rigorous work space characterizatiOn. ?As a result of the January 1992 event, WHC is now preparing a plan to characterize waste tank contents, characterize waste tank vapor emissions, and provide vapor space ventilation. . Tank Farms management relied on respiratory protection as the primary control measure rather than implementing engineering controls recommended in reports and investigations of the inhalation problems. . - Use of prejob safety planning does not comply with 29 CFR 1910.120, paragraph (1), which requires a written safety and health plan. WHC management did not directly involve the industrial hygiene organization in the immediate actions following the January 1992 event, even though these were industrial hygiene decisions. Section 3.3.2. WHC Safety and Industrial Hygiene Organization Resoonse a. Protective actions recommended to Tank Farms management have been based on inaccurate assumptions and incomplete data. Experimental sampling techniques have been used in an effort to characterize tank vapor Spaces, without adequate verification or quality assurance. HEHF and WHC industrial hygiene sampling in Tank Farms did not follow recommended practices and resulted in many inadequate characterizations of personal exposures. Attempts by HEHF and NHC to characterize tank vapor space emissions did not include verification of air flow out of the breather ports and were not adequate for recommending protective actions. 'Page 5-2 Type Investigation of Hanford Tank Farms Vapor Exposures A relationship between odors, employee and potential chemical constituents of tank vapor space gases has not been developed. No measurement of air flow was made through the charcoal filter system on Tank 103-6 during efficiency testing to determine effectiveness of chemical vapor removal. The NHC safety organization did not identify to Tank Farms management corrective actions reCommended by consultants and HEHF. (A task force is now taking action on some of the corrective actions previously recommended.) The first systematic approach to industrial hygiene monitoring in the Farm did not begin until October 1991 with general area and personnel sampling of the work place by HEHF. WHC safety has not maintained a field presence in the Tank Farms capable of carrying out all industrial hygiene tasks. It has depended upon HEHF and consultants to collect field data. a As a result of the January 1992 event, an event?related sampling method and continuous monitoring are presently being developed by WHC for the Tank Farms. Section 3.3.3, Enqineerinq Orqanization Resnonse., a. Prior to the 1990 reorganization, Tank Farms engineering provided minimal technical support for develOpment of tank vapor space characterization and for implementation of engineering controls. The design specifications for the new Tank Farm ventilation units do not reflect adequate industrial hygiene review of breakthrough monitoring for VOCs. Tank Farm engineering has not established requirements for the degree of vapor space characterization necessary to proceed with system design, even though characterization has apparently been adequate determination. Section 3.3.4. DOE Resoonse a. RL safety and line organizations have been aware of the vapor exposure prOblem since 1987. The corrective actions were judged by them to be acceptable, even after repeated recurrence of exposures. Page?5-3 Type Investigation of Hanford Tank Farms Vapor Exposures The flammable gas and ferrocyanide issues diverted RL line management attention away from the vapor exposure issue. RL senior management did not act to resolve the vapor exposure issue until the September 1991 event and the receipt of three employee concerns on the matter. . RL senior management took extraordinary actions following the January 1992 vapor exposures at the drill site. This was done to demonstrate a strong commitment to worker safety. RL senior and line management did not involve the safety organization in the immediate actions following the January 1992 event, even though these decisions had nuclear safety, industrial safety, and industrial hygiene consequences. Section 3.4.1, Past Event Investigations 'ao WHC has conducted three cause analyses of the vapor exposure occurrences. However, these analyses were not rigorous. The cause analyses for the September 1988 and September 6, 1991, events noted the recurring nature of the events. A formalized method of analysis was not used for two of the three root cause evaluations. Some root cause analyses have been performed by individuals withoUt the proper qualifications. None of the WHC cause analyses found systemic root causes that, when corrected, would prevent recurrence of the exposures. For example, none .of them identified the lack of industrial hygiene program implementatio as a cause. Section 3.4.2. Corrective Action Tracking and Closure a. Currently there are two databases used to track the closure of open items relating to Tank Farms. Neither of these systems adequately tracks corrective actions. The method for tracking and closure of Tank Farm-related open items allows items to be closed out based on untracked follow-up actions. As a result, many closed corrective actions have actually not been completed. Page 544 Type Investigation of Hanford Tank Farms Vapor Exposures c. There is no tracking of corrective actions from Tank Farms occurrence reports. Section 3.5. Medical Evaluation a6 b. Occupationally related data on HEHF first aid reports were inadequate. Additional occupational health data collected on the HEHF occupational injury/illness sheet are not event oriented. Occupational training and certification of HEHF nurses has substantially increased, and HEHF has placed_more emphasis on occupational medicine since 1987. Section 3.6.1. NHC Organizational History a. There have been five major HHC reorganizations since July 1987. Some reorganizations introduced new management personnel who had little, if any, experience ianank Farm operations. Significant growth and hiring from outside organizations has resulted in a reduction in the general level of Tank Farm experience and knowledge among technical personnel. The reorganizations and management changes since 1987 have caused discontinuities in efforts to resolve the vapor exposure problem. Section 3.6.2. DOE History and Organization a. The RL T50 is responsible for the industrial hygiene program. TSD was provided with a limited industrial hygiene staff from 1980 until August 1991. Presently, there are no industrial hygienists in TSD, but two vacancies are being filled. The RL CMP is the safety oversight organization. CMP was created in early 1991 but is only now beginning to function in the industrial hygiene area. CMP identifies specific issues of concern through its own work sampling and auditing activities. CMP does not normally follow issues identified by others, unless requested to do so by line management. TSD provides consulting services (such as advice on industrial hygiene issues) to line management on a request basis. Action is being initiated to RL is not trending occurrence reports. create this capability. Page 5-5 Type Investigation of Hanford Tank Farms Vapor Exposures Section 3.7. WHC Industrial Hygiene Proqram a. The NHC industrial hygiene program has historically lacked experienced, certified industrial hygienists. The WHC safety organization relied on HEHF for monitoring, but did not have the expertise to recognize their need for other inputs such as hazard recognition, deveTOpment of controls, and employee education. In response to the Tiger Team findings, NHC emphasized industrial hygiene in program development and oversight. This resulted in locating senior industrial hygiene personnel resources outside of the technical support function. WHC has changed the funding of industrial hygiene technical support to Tank Farms from an overhead costing method to a mandatory funding requirement. This should improve the consistency of funding levels for industrial hygiene support projects. NHC does not have a formal statement of work for HEHF industrial hygiene support. Section 3.7.1, Organization a. There is a lack of experienced or certified safety and health professionals in management positions in the NHC health and safety organization. Presently, there are seven industrial hygienists in the Occupational Health and Safety organization, and there is one first line manager who is a certified industrial hygienist. There are nine, industrial hygienists in the Health and Safety Assurance organization, two of whom are certified. Management of the respiratory technicians (industrial hygiene technicians) is divided between two separate organizations. There are no written procedures for Tank Farm industrial hygiene monitoring. Section 3.7.2, Qualifications of Personnel I a I The NHC industrial hygiene program has historically lacked employees certified as industrial hygieniSts, certified as safety professionals, or registered as professional safety engineers. None of the employees in the industrial hygiene unit, including the manager, are certified as industrial hygienists or safety professionals. Page 5-6 Type'B Investigation of Hanford Tank Farms Vapor Exposures The majority of job descriptions for the HHC industrial hygiene organization do not desCribe the depth and breadth of safety? and health- related knowledge required for the positions. This includes middle and senior level management positions. Respiratory protection technicians are serving as industrial hygiene technicians for Tank Farm monitoring, but there is no formal industrial hygiene training or internal certification for them. Section 3.8. Employee Communications a. Without technically adequate characterization of the tank emissions, WHC has been unable to communicate the degree of hazard to the workers and the basis for respiratory protection zones. Early associations of employee "hypersensitivity" with the vapor exposures have created communication problems. The WHC safety organization has lost credibility with workers by failure to respond to Tank Farm safety problems in a timely manner, by lack of specific information on events, and by lack of expertise in industrial hygiene. . After the January 1992 event, WHC and DOE made a concerted effort to improve employee communications. There have been significant delays in obtaining some tank vapor sample analytical results. In one case, it took 1-1/2 years to obtain results. The Operations Advisory Council is intended to provide a means of communication on safety issues between employees and management. employees-have resigned from the council because they believe that management has not responded adequately to their concerns. Some Section 3.9, Tank 103-C Charcoal Filter Installation a. There is no evidence that a proper design verification of the filter installation was ever accomplished, which is a violation of administrative procedures. number of managers believed that the effect of the installation of the charcoal filters may have been to reduce flow through the normal vent path and force vapors out through unfiltered leak paths. Technical evaluation of the charcoal filter performance was inadequate. Page 5?7 Type Investigation of Hanford Tank Farms Vapor Exposures Section 3.10. Tank Emission Characterization a. Section 4.1.1, Analysis: a. Section 4.1.2. Analysis: a. Short-term grab sampling methods were not adequate to characterize single- shell tank vent emissions. Flow conditions at the single-shell vents were not documented during sampling. The cryogenic sampler was chosen as the method for tank emission characterization without adequate technical evaluation of alternatives. Lack of consistency in project funding has contributed to the lack of testing, development, and validation of the cryogenic sampling method. The validation plan for the cryogenic sampler was not developed prior to applying the methodology to tank characterization. This resulted in questions concerning the quality of data. An adequate sampling plan was not developed for field use of the cryogenic sampler. This resulted in questions concerning the quality of data. The initial phases of the cryogenic sampler validation plan do not duplicate field conditions or the analytes determined to be present in Tank The present design of the cryogenic sampler and removal of the trapped volatiles for analysis may not be to sample Tank vapors containing a high concentration of normal paraffin hydrocarbons. Conditions Throughout most of the period of the exposure reports, the following conditions prevailed: lack of a meaningful industrial hygiene program management/worker communications impeded by employee relations problems frequent reorganization ineffective root cause analysis ineffective corrective action tracking system. Causal Sequence Management system implementation has been less than adequate in that insufficient funding and personnel resources have been provided for industrial hygiene and tank emission characterization activities. Page 5-8 Type Investigation of Hanford Tank Farms Vapor Exposures- b. Safety program review has been Tess than adequate in that industriaT hygiene activities in the Tank Farms have consistentTy been technicaTTy inadequate. c. The generaT design process has been Tess than adequate in that the charcoaT fiTter instaTTation and deveTopment of the cryogenic sampTing system did not conform to the HHC design and technoTogy development processes. d. Root cause anaTyses have been Tess than adequate in that they have not identified the true root causes. e. The corrective action system is Tess than adequate in that it is not tracking and reporting corrective actions through to finaT compTetion. f. The safety professionaT staff has been Tess than adequate in that industriaT hygiene technicaT support work has not been performed or managed by personneT with the appropriate quaTifications. g. IndustriaT hygiene monitoring systems have been Tess than adequate in that there has been very TittTe sampTe pTanning, and monitoring methods have been technicaTTy incorrect. h. Communications have been inadequate in that management has been unabTe to convince workers that their work environment is safe. 1. Vapor space characterization became the uTtimate barrier preventing resoTution of the vapor exposure probTem. Section 4.2, AnaTysis of September 1991 Event a. The caUses and circumstances of the September 1991 occurrence were not significantTy different from those of the other inhaTation events. Appendix B. Inadequacies of IndustriaT Hygiene Practice a. The history of industriaT hygiene monitoring in the Tank Farms has been characterized by consistent and serious technicaT inadequacy. Page 5-9 Type Investigation of Hanford Tank Farms Vapor Exposures 5.2 CAUSES The Board used the MORT Fault Tree, as well as event and causal factor analysis methods to evaluate the facts identified during the investigation. Some change and barrier analysis was also applied. These analytical techniques were the tools used to judge the adequacy of the management systems to prevent and respond to this type of occurrence. The intent of these analyses was to determine the probable causes of the vapor exposures and of the failure to prevent their recurrence. The MORT-defined root cause for the recurring vapor exposures in the Tank Farms was found to be less than adequate management system implementation. The direct cause of the exposures was the failure to characterize the work environment and implement appropriate engineering controls. Contributing causes were the following: - less than adequate risk assessment (cause analysis) - less than adequate data collection and analysis (corrective action tracking) - less than adequate operational specifications - less than'adequate general design process - less than adequate industrial hygiene monitoring system - less than adequate communications - less than adequate safety program review. The following sections discuss each cause. 5.2.1 Root Cause Less than adequate management systems implementation. WHC and RL management did not control and correct the vapor exposures in the Tank Farms because the management systems were not in place to provide the appropriate multidisciplinary approach to resolve the problem. The management systems did not provide a disciplined technical assessment of the problem, identify the technically correct actions, assign actions to the appropriate parties, or follow?up to assure proper completion of the actions. Page 5-10 Type 8 Investigation of Hanford Tank Farms Vapor Exposures In particular, the industrial hygiene program has not been fully developed and implemented. Procedures and training did not cause management to involve professionals with the skills to identify the correct technology for characterizing the work space and then to assure that the technology was correctly applied. Also, when exposure events occurred, decisions were sometimes made in the absence of documented criteria and without the' participation of qualified industrial hygiene professionals. Following the July 1987 exposures, the industrial safety organization was tasked with characterizing the tank vapor space. ,This organization was neither technically equipped nor adequately funded to carry out this task. Instead of conducting a technological assessment of existing methods for the characterization, they chose an apparently expedient but unvalidated technology. Tank vapor space sampling was conducted without validation because of a lack of consistent funding. This resulted in inadequate quality assurance of the data and a loss of confidence among Tank Farm employees that the problem was being adequately investigated by management. Following the September 1989 exposures, the engineering organization was tasked with providing charcoal filters on Tank but this did not resolve the vapor problem. The design control program failed to assure that a design verification would identify that the filters might be ineffective, Also, sampling to verify_effectiveness of the filters was carried out incorrectly, and provided a false sense of confidence that the vapor problem was resolved. The corrective action tracking system did not function to keep corrective actions visible and to keep action organizations accountable. Instead, actions could be closed out and removed from the system even though the action was not really completed. 5.2.2 Direct Cause Failure to characterize the work environment and develop effective engineering controls to minimize or alleviate the problem. The need for characterization of tank vapor emissions and modification of the ventilation systems was documented as early as 1987, but these actions have still not been accomplished. Beginning with the July 1987 event, there were recommendations to characterize the Tank vapor emissions and install an active exhaust system. There has been vapor space and emission sampling and some exhauster design development during this period; however, management priority assigned to these efforts has been variable. Page 5-11 Type Investigation of Hanford Tank Farms Vapor Exposures Without vapor space characterization, the true health effects of employee exposure are unknown. Also, without adequate characterization, management is unable to accurately communicate to workers the risks to which they are being exposed. 5.2.3 Contributing Causes a. Less than adequate risk assessment (cause analysis). The Board evaluated the various cause analyses that were performed for the occurrences and found them to be inadequate. For example, none of the analyses identified the less than adequate management system implementation, which is the root cause finding of this investigation. This is due, in part, to the fact that some of the analyses were performed by personnel without training in root cause analysis. For the analysis of the September 1991 event, cause classifications from the event reporting system were used. The result is that WHC has not identified true root causes that, when corrected, would have prevented recurrence of the problem. in. Less than adequate data collection and analysis (corrective action tracking). - The Board attempted to identify and determine the closure status of all corrective actions associated with the inhalation occurrences. It found that, for many of the actions, the completion status could not be ascertained. The Board noted a number of action commitments that were closed based on a memorandum from the action party. The action party had evaluated the problem and identified in the memorandum the actions actually required to correct the condition. These new actions were not tracked, and in many cases, appear never to have been accomplished. The result of this practice is to render the corrective action tracking system ineffective. The Board was particularly concerned that corrective actions from occurrence reports are not being tracked. 0. Less than adequate operational specifications. Criteria for responding to and mitigating the events have not been fully I developed. This in turn appears to have intensified employee sensitivity to the vapor issue. The Board considers that criteria for responding to vapor events should be based on sound industrial hygiene practices. Page 5?12 .Type Investigation of Hanford Tank Farms Vapor Exposures d. Less than adequate general design process. The Board noted that the customary design development plan was not prepared for the cryogenic sampling system until recently. This may be related to 1) the long amount of time that has been expended on the development of this sampling method and 2) the lack of funding for development of the method. WHC pursued development of the cryogenic sampling system as the technology to characterize the tank vapor emissions. It does not appear that adequate consideration was given to conventional and already validated methods of performing this analysis. In the opinion of the Board, considerable time and cost could have been saved had conventional technology been adequately evaluated for this application. This appears to be related to the historic lack of qualified industrial hygiene capability on staff and the lack of multidisciplinary problem solving by management. In the design of the charcoal filters for Tank 103-C, it does not appear that the required design verification was ever accomplished. The purpose of design verification is that a qualified independent party will take a complete look at the design and the design basis to verify their adequacy. Problems, such as that of forcing vapors out through alternate leak paths, should be identified through this process. e. Less than adequate induStrial hygiene monitoring system. WHC did not employ conventional industrial hygiene practices, either in work Space monitoring or personal monitoring. This appears to be related to the historic lack of industrial hygiene capability on staff and lack of a properly defined program. Even now, work space monitoring is restricted to entry control, rather than work Space characterization. Also, use of personal monitoring equipment is not in accordance with conventional industrial hygiene practice. The Board favorably noted efforts that WHC and RL are making to staff industrial hygiene positions with qualified personnel and to develop an adequate program. However, staffing should emphasize technical support rather than oversight if the technical problems are to be quickly resolved. f. Less than adequate communications. WHC has not adequately communicated to workers the hazard posed by the vapors or the basis for actions that have been taken to protect them. HHC recognizes this weakness and is taking action to correct it. However, uncertainty -regarding the vapors has only served to exacerbate the problem. Page 5-13 Type Investigation of Hanford Tank Farms Vapor Exposures It is the opinion of the Board that NHC will be unable to communicate the hazard posed by the vapors until the tank vapor spaces have been characterized. Some level of anxiety regarding the vapors will continue until this work is completed and the results have been explained to workers in a credible manner. On some occasions, workers reporting vapor exposures or questioning the level of risk from the vapors have been told that the workers are "hypersensitive." While this does not appear to have occurred recently, it still influences the way that employees view safety organization and management attitudes. This has probably led some employees to use the HEHF first aid station as a mechanism to get some response to their concerns. Occurrence reports, memoranda, and management statements have not clearly distinguished between first aid station visits, emergency room observation, medical treatment, and hospital admittance. This may have fostered employee misconceptions on the seriousness of some of the exposures. 9. Less than adequate safety program review. The safety program has not ensured that work areas are adequately characterized, that appropriate barriers are in place, or that appropriate personnel protection is always used. This has occurred because of a lack of an adequately defined industrial hygiene program, a historic lack of qualified industrial hygienists, and a lack of understanding of industrial hygiene principles among management. The result of this is that much of the industrial hygiene monitoring that has been done in the Tank Farms over the past few years has been inadequate. The Board noted that WHC is about to issue a new set of industrial hygiene procedures and recently increased its staff of industrial hygienists. 'However, the WHC industrial hygiene program is still not fully functional. WHC is still dependent on HEHF for much of its industrial hygiene capability. The Board also noted a lack of industrial hygiene qualification in management above the first level of supervision. It is unlikely that the WHC industrial hygiene program will ever function properly unless its purpose and principles are better understood among managers. The Board believes that the method originally chosen for vapor characterization (the cryogenic sampler) did not represent best available technology. It was chosen because an interdisciplinary approach with a fully developed sampling plan was not perceived by the industrial safety organization as a quick enough response to the problem. The industrial safety group was not technically competent to recognize that, although seemingly expedient, the cryogenic sampler was actually the slowest method. This was Page 5-14 Type Investigation of Hanford Tank Farms Vapor Exposures because of the necessary validation required for the method. Subsequent withdrawal of promised funding further delayed validation and has left much of the data collected over a 4?year period inadequate for vapor characterization. 5.3 JUDGMENTS OF NEED a. Characterization 1. There is a need for WHC to continue to develop and implement a comprehensive action plan to characterize the work space, including the tank emissions. Appropriate steps, including engineering controls, should be develOped based on the results of the characterization. The work should include development of the relationship between odors, employee and the constituents of tank vapor emissions. The plan should be approved by RL. Progress on completion of the characterization should be reported periodically to RL and to the workers. Results of the characterization should be presented to the workers. 3.10.a,b,d,e,f,h; 3.3.2.b,e) (Findings There is a need for WHC to provide assurance that the role of the cryogenic sampling system in work space characterization has been adequately defined. This should take into account potential limitations on the capability of the system and the availability of proven alternative methods. (Findings 3.10.c; 3.10.g; 3.10.h) b. Industrial Hygiene Program Development 1. There is a need for WHC to train all levels of line management in industrial hygiene principles and technology. (Findings 3.3.1.b,d,e,f,h,i,j; 3.3.2.a,c; Appendix B, item a) There is a need for WHC to place additional emphasis on acquiring experienced, certified personnel in the safety and health technical support organizations. (Findings 3.3.1.f; 3.3.2.b,c,d,f,h; 3.7.a,b,c; 3.7.l.a; 3.7.2.a,b,d; 3.8.c; 4.1.1.a; 4.1.2.b,f,g; Appendix B, item a) There is a need for WHC to complete the development and implementation of a written safety and health plan for Tank Farm operations in accordance with 29 CFR 1910.120 section (Finding 3.3.1.i) . Page 5-15 Type 3 Investigation of Hanford Tank Farms Vapor Exposures 10. 11. 12. There is a need for WHC to review the recommendations of the "Draft Baseline Hazard Assessment of Tank Farm," EBASCO Where appropriate, action items should be developed and entered into a formal tracking system. (Finding 3.3.2.9) There is a need for NHC senior management to verify that funding procedures ensure that industrial hygiene technical support continues to receive adequate funding. (Findings 3.7.d; 4.1.2.a) There is a need for NHC to continue to develop their industrial hygiene field capability, consistent with any specific direction from DOE. (Findings 3.3.2.a,c,d,f,h; 3.7.b,c; 3.7.1.c; 3.8.c; 3.10,a,b; 4.1.2.a,b,g; Appendix B, item a) There is a need for HEHF and HHC to develop procedures to ensure more comprehensive industrial hygiene sampling protocols and sampling plans. (Findings 3.3.2.c; 4.1.2.9; Appendix B, item a) There is a need-for NHC to review and revise management position descriptions in safety and health to reflect necessary industrial hygiene and safety qualifications. This should include certifications as industrial hygienists or safety professionals. (Findings 3.7.a; 3.7.1.a; 3.7.2.a,b,c; 4.1.2.f) There is a need for NHC to develop criteria for establishment and relaxation of respiratory protection zones in the Tank Farms using recognized industrial hygiene methods. (Findings 3.3.1.f; 3.3.2.a) There is a need for the WHC industrial hygiene organization to increase its field presence and knowledge of Tank Farm operations. (Findings 3.3.1.b,j; 3.3.2.a,d,f; Appendix 8, item a) There is a need for WHC to formalize the method for involving the safety and health organization in safety and health decisions. (Findings 3.3.1.b,J; Appendix 8, item a) There is a need for WHC to review the organizational structure of the Industrial Hygiene and Safety organization. Consideration should be given to reassigning personnel performing industrial hygiene field monitoring work directly to the Industrial Hygiene Unit. (Finding 3.7.1.b) 'Page 5-16 Type Investigation of Hanford Tank Farms Vapor Exposures c. Contractor Interfaces 1. There is a need for NHC to establish a formal statement of work with HEHF for industrial hygiene services. (Finding 3.7.e) There is a need for HEHF to improve the collection of occupational health-related information for first aid events. (Findings 355.a,b) There is a need for WHC to determine methods to improve the turnaround time on sample results associated with industrial hygiene activities. Improvement should also be obtained from both PNL and HEHF. (Finding 3.8.c,e) d. RL Organization 1. There is a need for RL to continue the development of a trending program for occurrence reports. This program should identify problems and ensure that these problems are brought directly to the attention of responsible managers. (Finding 3.6.2.e) There is a need for RL management to ensure that the TSD organization receives adequate industrial hygiene staff resources. (Finding 3.6.2.e) There is a need for RL line management to reassess how they use TSD organization technical resources when making decisions with safety consequences. The results of the reassessment should be formalized. (Finding 3.3.4.e) e. CommUnication 1. There is a need for WHC to train both line and safety managers on recognized methods of risk communication. (Findings 3.8.a,b; 4.1.2.h) There is a need for WHC to determine effective methods for communicating to employees the purpose for respiratory protection zones. (Finding 3.8.a) There is a need for WHC to determine a method for communicating the_ status and results of industrial hygiene sampling activities to workers. (Finding 3.8.c) Page 5-17 Type Investigation of Hanford Tank Farms Vapor Exposures 4. There is a need for WHC to review management interface with the Operations Advisory Council to assure that there is adequate response to all safety and health concerns. (Finding 3.8.f) f. Corrective Action 1. There is a need for NHC to re?evaluate the corrective action management system and make necessary changes to ensure that all issues and actions throughout the company are appropriately accounted for. (Findings 3.4.2.b; 4.1.2.e) 2. There is a need for WHC to re-evaluate their corrective action management system and make appropriate changes to begin including Tank Farms occurrence report corrective actions. (Findings 3.4.2.c; 4.1.2.e) 3. There is a need for WHC to re-evaluate their corrective action management system to ensure that all actions are followed through to final completion. (Findings 3.4.2.b,c; 4.1.2.e) 4. There is a need for WHC to review all previously identified action? items where there is not definitive closure and provide appropriate disposition. (Findings 3.4.2.b,c; 4.1.2.e) g. Charcoal Filters 1. There is a need for HHC to evaluate the continued use of the charcoal filters on Tank 103-C. Action should be taken to correct emissions from unfiltered points in the 101-C, 102-C, and 103-C tank systems. If necessary, the filter units should be removed. (Finding 3.9.b,c) 2. There is a need for WHC to determine the root cause for the omission of an adequate design verification of the charcoal filter unit installation on Tank 103-0. Appropriate corrective actions should be developed to correct these causes. (Findings 4.1.2.c) 3. There is a need for NHC to determine why action was not taken to resolve the question of potentially radioactive emissions from unfiltered points in the Farm tank systems when it was believed that filtered ventilation was restricted. (Finding 3.9.b) - Page 5-18 Type Investigation of Hanford Tank Farms Vapor Exposures h. Root Cause Analysis 1. There is a need for WHC to reevaluate the application of root cause analysis to ensure that analyses are sufficiently thorough. Procedures should be developed which assure that analyses are performed by personnel with appropriate qualifications. (Finding 3.4.1.a,c,d,e; 4.1.2.d) i. Ventilation Project 1. There is a need for Tank Farm Engineering to review the design of the new ventilation units with the Tank Farm Task Force to provide multidisciplinary input to design specifications. (Finding 3.3.3.b) There is a need for Tank Farm Engineering to determine what characterization is adequate to proceed with expedited design and procurement of the new tank ventilation systems. If necessary, a sampling plan should be developed. (Finding 3.3.3.c) j. WHC Reorganizations 1. There is a need for NHC to find a mechanism for weighing the utility of reorganization against its disruptive influences. - (Findings 3.6.1.a,c) k. Other Reports 1. There is a need for RL and NHC to continue to assure effective implementation of corrective actions resulting from the 1990 DOE Headquarters report, "Report on the Handling of Safety Information Concerning Flammable Gases and Ferrocyanide at the Hanford Waste Tanks." There is a need for HHC to review and reSpond to the recommendations of the appended OSHA report. The response should be addressed to RL. (Appendix A) Page 5-19 Type Investigation of Hanford Tank Farms Vapor Exposures SIGNATURES Investigators: -David H. Brown, Chairman 7 Date -Nuclear Engineer U.S. Department of Energy ,7 4M Nu Sheldon R. Coleman Date Certified Industrial Hygienist Kaiser Engineers Hanford Company [a Men. ?2 James J. DeMyer - 0 Date Certified Accident Investigator Pacific Northwest Laboratory Paul A. Knight Date Industrial Hygienist U.S. Department.of Energy r/xa/Qz/ Steven Jf'VEitenheimEr Date Nuclear Engineer U.S. Depar Energ Robert C. Roal Date Chemical Engineer Westinghouse Hanford Company Type 8 Investigation of Hanford Tank Farms Vapor Exposures Reviewed by: Melvin First, P.E. Certified Industrial Hygienist Harvard School of Public Health Allan P. Heins, P.E. Certified Industrial Hygienist Occupational Safety and Health Administration, Salt Lake Technical Center Health Response Team . A. 4; hide*zoaakaxu;r\ .M Stephen H. Prawdzik Industrial Hygienist Occupational Safety and Health Administration, Salt Lake Technical Center Health Response Team RicE J, Cee Branch Chief, Inorganic Methods Development Occupational Safety and Health Administration Salt Lake Technical Center Type Investigation of Hanford Tank Farms VapOr Exposures BOARD AUTHORITY United States Government memorandum DATE: REPLY TO ATTN OF: SUBJECT: TO: 30 1992 TYPE INVESTIGATION OF EXPOSURE OF PERSONNEL T0 POTENTIALLY HAZARDOUS VAPORS IN THE HANFORD TANK FARMS - David H. Brown, NucTear Engineer Office of CompTiance You are hereby appointed the Chairman of a board of investigation to examine technicai and management probiems reiated to the exposure of personneT to potentiaTIy hazardous vapors from the high-Tevei waste Tank Farms at Hanford. This is to.be conducted as a Type investigation, in accordance with DOE Order 5484.1. Exposures to vapors have been a chronic probTem for a number of years, despite numerous attempts by site contractors to resoTve it. In particuiar, Tank has been a source of recurring exposures to personneT. ATso, on January 28, 1992, personneT working at the operabie unit were exposed to vapors . which may have come from the Tank Farms. Westinghouse Hanford Company (HHC) formed a task team in September 1991, to investigate the specific exposure incidents. I beiieve that whiTe formation of this team was appropriate, this team?s charter is too narrowTy focused to resoTve the issues associated with the exposure probTem. Using the MORT system of root cause anaTysis; you are to:' 1. Identify the root causes of the C-103 exposure occurrence in September 1991 (reported as occurrences NHC-TANKFARM-1991-1038 and 1043). - 2. Identify the root causes of the exposure occurrence on January 28, 1992. 3. Use the avaiTabTe history of simiTar tank farm exposures to obtain a compTete data base for anaiysis. -- - 4. Determine the reasons for the faiTure of efforts initiated foTTowing the JuTy 1987 exposure incident (occurrence 87-001) to adequateTy protect workers. 'This shoqu incTude an evaTuation of the actions taken by the DOE contractors, as weTT as the Richiand Fier Office. Department of Energy Richiand Operations OffiCe David H. Brown -2- - JAN 30 1999 5. Review, evaiuate, and recommend to me the adequacy of measures to controi exposure of personnei to hazardous vapors. 6. Identify to me the need for any poiicy, practice, procedure, management system, or engineering changes required to controT exposure of personnei to hazardous vapors in the Tank Farms. The foiiowing individuals have.aTso been appointed to serve as board members: Mr. PauT Knight RL-CMP Industriai Hygenist Mr. J. John DeMeyer PNL Certified Accident Investigator Mr. Steven J. Veitenheimer Investigator Mr. Sheron Coieman KEH . Certified IndustriaT Hygenist You are authorized to appoint additionai members as you see necessary. You are authorized to draw upon the resources of RL and contractor staff for a thorough and expeditious investigation into this probiem. Mr. Guy E. Bishop of the Tank Farm Project Office is avaiiabie to provide advice and information regarding operations and management of the Tank Farms, though you may obtain that information by any appropriate means. FinaTTy, you may obtain the services of any externai consuitants that you desire. Dr. P. Brassy of the University of Washington and Dr. Meivin First of the High-Lave] Waste Task Force Technicai Advisory Pane] have offered their services. Your finaT report must address the areas described above, and is to be in the format describedain DOE_Order 5484.1. The finai report must be submitted to me by-Aprii.1, 1992. ohn D. Wagoner Manager Type Investigation of Hanford Tank Farms VaporExposures APPENDICES Appendix A OSHA Report Appendix lnadequacies of Industrial Hygiene Practice Appendix Conduct of the Investigation Appendix Acronyms Salt Lake Technical 1731 South 300 West v.0. Box 65200 Salt Lake any, UT 84165?0200 April 14, 1992 David H. Brown Department of Energy Richland Operations Office P.O. BOX 550 825 Jadwin A552 Richland, Washington 99352 Dear David: In response to your letter of February 13, 1992, Stephen Prawdzik, Rick Cee, and I met with you and your colleagues March 3-5, 1992 regarding your investigation into the apparent re- occurrence of employee exposures to potentially hazardous vapors at the Hanford Tank Farms. The tank farms are presently a Part A permitted Resource Conservation and Recovery Act (RCRA) facility and an application is in progress for a Part permit. Westinghouse Hanford Company (Westinghouse).is presently the prime contractor responsible for safety and health on the farms. During our visit we consulted with the members of your Board of Investigation, Melvin First, Harvard School of Public Health, toured three tank farms, and reviewed Department of Energy and Westinghouse records and documentation. Additionally,. we conducted interviews with a number of Westinghouse personnel including management, union representatives, industrial hygienists, radiation protection technicians, and employees associated with tank farm operations. Your request specifically asked us to address two concerns: 1. To review the adequacy of measures taken to control exposures of employees to vapors, including compliance with 29 CFR 1910.120 and other applicable OSHA standards as they pertain to employee exposures. 2. To review the adequacy of sampling and characterization of potential sources of contaminant exposure at the tank farms. Our comments concentrate on these two specific areas and also -address several other concerns which were observed during our visit. BACKGROUND Since 1987, approximately sixteen incidents involving employee exposures to chemical vapors at the tank farms have been reported. The exposures have normally been confined to tank farms of the single shell type (C?tank and BY?tank farms) and one double shelled type (SY-tank farm). The C-tank farm has been implicated the most often. Recent reported exposures appear to have spread to other locations and may reflect enhanced employee awareness and concern regarding workplace conditions. The majority of these incidents involved employees reporting odors primarily of an organic or ammonia?like nature, especially those emanating.from the C-tank farm. The employees reported which included headache, dizziness, nausea, throat irritation, burning sensation of upper airway and lungs, and cramping. Most incidents were treated with limited first aid and employees resumed their duties within a short time. An exception to this was the incident which occurred in July, 1987 involving a radiation protection technician and a portable exhauster unit in the C-tank farm. The employee was exposed to chemical vapors which apparently resulted in a significant loss (reported to be approximately 40%) of his pulmonary function. The exposure occurred when employees were working in a cabinet while environmental sampling was being conducted in the immediate area; The exhaust from a sampling pump was discharging into this partially confined space area, resulting in the transfer of vapors directly from the tank headspace into the breathing zone of the employee. There is very little information prior to 1987 regarding employee exposures, the chemical content and reactions occurring in each tank, tank farm chemical vapor emissions, and the industrial hygiene monitoring of the tank farms. Following the 1987 incident, sampling was conducted to characterize the chemical emissions from the tank farms. The chemical vapor monitoring at the time of this incident was conducted primarily using detector tubes. Until 1991, the industrial hygiene monitoring has been primarily in reaction to reports of employee exposures or odors, with the majority of samples still being conducted using detector tubes. In October, 1991, the Hanford Environmental Health Foundation (HEHF) [Note: HEHF is a private medical contractor for the site and provides medical services, including industrial hygiene monitoring.] conducted extensive monitoring of compounds suspected of being released from the tanks. This attempt to measure potential chemical exposures indicated that some tank emissions contain a mixture of ammonia and low levels of organic substances. A cryogenic sampling technique, implemented by personnel from Pacific Northwest Laboratory and Westinghouse, was recently used 2 in an attempt to characterize tank emissions. The report discussing this sampling technique, sampling strategy, and associated results was not available during our evaluation. Some air monitoring is currently being performed during work operations by the industrial hygiene group from Westinghouse using photoionization detectors and organic vapor monitors. A MIRAN 1B2 infrared spectrometer was recently purchased to assist in emission characterization. The tanks contain large quantities of radioactive waste. Radiation determinations are conducted by a group within Westinghouse which is independent of the industrial hygiene group. The contents of most tanks have been classified according to hazard. [References: Tank Farm Surveillance and Waste Status Report for September, 1991 Vapor Space Sampling Criteria for Single-Shell Tanks containing Ferrocyanide Waste - July 1991 (WHC-EP-O424 REV Certain tanks have been placed on a "Watch Tank List" in accordance with Washington State's Public Law 101?510. The hazards associated with some tanks are incompletely characterized and further monitoring is being conducted in an attempt to fully characterize these tanks. Westinghouse considers these tanks as "unreviewed safety questions." FINDINGS During our brief visit to your facility, we noted a number of concerns, many of which we have already discussed with you. Presented below is a brief discussion of these concerns. Compliance with 29 CFR 1910.120 - Hazardous Waste Operations and Emergency Response: Certain requirements of 29 CFR 1910.120 have not been met. Because the tank farms are considered to be a permitted RCRA treatment, storage, and disposal facility, the requirements contained in 29 CFR 1910.120 "Certain Operations Conducted Under the Resource Conservation and_Recovery Act" are applicable. While certain elements such as training and emergency response appear adequate, the final development and implementation of the written safety and health plan has not been completed. The draft copy of this plan is not scheduled for release until May, 1992. While the industrial hygiene staff at Westinghouse felt that the major program elements required by 1910.120 are essentially in place, a written plan must be available on site for compliance with 29 CFR 1910.120. Compliance with other OSHA standards: Due to the limited time frame and narrow focus of this investigation, a thorough OSHA inspection of the tank farms was not conducted. A review of Westinghouse?s recordkeeping system revealed a well-organized and apparently thorough system for tracking employee injuries and illnesses. Our review of the accident and illness reports indicated that Westinghouse employees have a high repeated occurrence of finger, hand, and back injuries. Strains, contusions, and lacerations account for approximately 75% of all reportable injuries. The continued occurrences of strains and sprains, particularly involving the back, was the major cause of lost time during the past several years. Characterization of tank emissions: Historically, Westinghouse's treatment of chemical exposures at the Tank Farms is indicative of a reactionary response rather than a well~organized, systematic approach addressing hazardous waste concerns. Reacting to incidents rather than planning for their prevention may in part be due to the failure to completely characterize tank contents and emissions. A draft tank farm management plan addressing tank farm contents was developed by a contractor, EBASCO Services, Inc., but was not implemented by Westinghouse (Draft Tank Farm Waste Management Health and Safety Program Plan, December 31, 1990 Task Order No. of Order No. MLW-SVV-037106). Part of the RCRA permit application requires chemical and physical analyses of the hazardous waste to be handled at a permitted facility. The September 1991 Tank Farm Status Report is a compilation of the classification of tanks according to hazard; however, specific contents of each tank still have not been itemized and not all tank emissions have been characterized. The lack of a thorough emission characterization has been compounded by the lack of characterization of tank contents. Individual tank contents can change after characterization due to on-going chemical reactions, "burping", crust disruption, and from the "cross-ventilation" systems in place. A significant degree of variability exists as to the chemical "consistency" of the tank contents._ Current monitoring of tank emissions: currently, Westinghouse is using direct reading instrumentation for air monitoring. Some of the direct reading devices, photoionization detectors and organic vapor monitors, are not very sensitive to ammonia, the substance suspected of causing the incident in 1987. 4 The report discussing the cryogenic sampling technique was unavailable for our review. Although this technique was recently utilized, its effectiveness in providing a complete characterization of emissions is questionable. Low boiling point inorganic substances may not be efficiently collected and analyzed using this procedure. According to interviews, employees observed condensation in sample tubing remote from the cryogenic trap. This condensation suggests potential organic vapor sample loss. Determination and usage of personal protective equipment: 29 CFR 1910.120 specifically requires the written safety, and health program be designed to identify, evaluate, and control safety and health hazards in their facilities. Employee personal protective equipment is then provided based on this program. Typically at a hazardous waste site, entry into an area of unknown exposure requires the use of a high level of PPE until site characterization and - appropriate monitoring allows downgrading to a lower, yet still adequate, level. 'There appears to be some confusion at Westinghouse concerning the utilization of appropriate personal protective equipment at the tank farms and the Uroping-off?, of certain work areas. Employee confusion was evident ,?regarding the rationale used to identify areas where a high level of personal protective equipment is required. While current Westinghouse policy indicates personal protective requipment is required when "breaking containment" on a specific tank, employee confusion is apparent regarding protection for other tank farm tasks. Active ventilation of existing tanks: Employee interviews indicated a wide-spread belief that an active, rather than passive, ventilation system was needed on the single-shelled tanks, especially for the C-tank farm. Some of the tanks have passive filtration systems, including charcoal filters. The use of the charcoal filters has resulted in an increased back pressure within these tanks, thus increasing the potential for chemical vapor exposure as a result of vapors escaping via the path of least resistance leakage). Resources: The perception exists that resources and emphasis, in the past, has been on production and not on chemical storage at the tank farms. The belief was expressed in interviews that insufficient resources, lack of consistent long-range planning, and good engineering design have not traditionally .5 been an integral part of the tank-farm operation. Accountability: Prior to 1987, the tank farm operations were the responsibility of Rockwell Hanford Operations Company. In 1987, Westinghouse became the prime contractor. Since that time, many reorganizations have occurred at Westinghouse, making it difficult to determine employee accountability and to assign responsibilities. This continual reorganization and lack of accountability have not been conducive to a well?functioning safety and health program. Industrial hygiene and medical support: Until recently, there has been minimal direct industrial hygiene support by industrial hygienists, physicians, and nurses. This support was mainly provided on a "per call" basis by HEHF. Many of the Westinghouse industrial hygienists have either been recently hired or have been transferred from environmental functions. The level of WestinghouSe industrial hygiene experience in chemical sampling and.monitoring is low, in part due to the dependency of Westinghouse on HEHF to carry out personnel monitoring functions. Employer/employee communication: The lines of communication between the various levels of management and the support organizations involved with the_ tank farms need improvement. _Additionally, some lines of communication between employees, management, and safety and health personnel are inadequate. Employees are confused as to the hazards associated with the tank emissions and the policy regarding respiratory equipment. This confusion is enhanced by the policy of placing certain areas of the tank farms on and off supplied air systems numerous times in reaction to odors and reported exposures. RECOMMENDATIONS: Complete the development and implementation of the written safety and health program for the tank farms to meet the requirements of 29 CFR 1910.120 The written safety and health plan, as a minimum, must address-the following elements in 29 CFR 1910.120 1. Development and implementation of a written safety and health program for employees involved in hazardous waste operations. 2. Hazard communication program. 3.. Medical surveillance program. 4. Decontamination program. 5. New technology program. 6. Material handling program. 7. Training program. 8. Emergency response program. Strengthen efforts to determine the "root cause" of the high incidence of accidents. Examine the causes of strains, contusions, and lacerations in an effort to implement preventative measures to minimize future occurrences. Complete the characterization of the tank contents and emissions to allow for a more informative criteria to use when considering.protective measures for employees. The characterization of vapor emissions needs to be conducted using an approach which addresses both organic and inorganic vapors. A mobile mass spectrometer (apparently already present at the site) for organic materials, and specific sampling methods for inorganic substances may need to be utilized. Evaluate exposure results to determine if any additive or synergistic effects exist certain individual chemical exposures may have to be combined and 'considered as a mixture as stated in 29 CFR 1910.1000 (1) (ii) 1 Continue monitoring using appropriate equipment such as photoionization detectors, organic vapor monitors, and/or portable infrared instruments. It-is important to note that these are mainly "sniffers" for leak detection, and may entirely miss certain inorganic species such as ammonia and oxides of nitrogen. The use of portable infrared spectrometers (specifically the Miran 1B2) should be discouraged for monitoring reactive gases such as ammonia and oxides of nitrogen. These substances are known to react with the lenses of the infrared instruments and will eventually cause equipment malfunction. Thoroughly explore the option of installing active ventilation systems on specific single shell tanks. Strengthen accountability for all employees through clear, measurable performance elements. These elements should include measurable safety and health?related responsibilities. Allow the safety health personnel a more active, visible role in Tank Farm safety and health policy. Encourage professional development among the industrial hygiene' personnel. Increase communications between Westinghouse safety and health personnel and employees. Allow for active input from employees. Increase information regarding safety and health policies to the employees. Inform employees regarding environmental monitoring results and their significance. 29 CFR 1910.20, "Access to employee exposure and medical records", states that employees must have the right and opportunity to examine and copy certain records, including environmental (workplace) monitoring results. Commonly used mechanisms for accomplishing this include discussions at safety meetings, posting or distribution of results, and discussion in an'employee newsletter. CONCLUSION Our overall perception is that, while the overall program involving safety and health of the workers still needs improvement, it is moving in the right direction and has made significant improvement in recent months. We hope that long- range management commitment and the allocation of appropriate resources will be directed at the issue of worker safety and health. Regarding the additional items in your request, we will be happy to assist with a peer review of your report, and to participate in a meeting presenting a summary of the peer review to Department of Energy management. "If you have any questions, please contact us at 801?524-5896. W03 Am Allan P. Heins, CIH Rick J. Cee Senior Industrial Hygiene Branch Chief, Inorganic Engineer Methods Development U0 Stephen W. Prawdzik Industrial Hygienist Type Investigation of Hanford Tank Farms Vapor Exposures . APPENDIX INADEQUACIES OF INDUSTRIAL HYGIENE PRACTICE During this investigation, the Board observed a number of systemic weaknesses in the practice of industrial hygiene and the use of industrial hygiene resources by management. This appendix is written to expand upon the facts described in Section 3.0 of this report, and to provide references and guidelines that were used by the Board to determine adequacy of the industrial hygiene practices at the Tank Farms. The practice of industrial hygiene involves the following activities, many of which are more fully developed in DOE Order RL 5480.10: - the evaluation of potential chemical, physical, organic, or biological hazards that can adversely affect employees - the development and/or implementation of protective measures, including respiratory protection, engineering controls, and administrative controls - the proposal to management of recommended actions to effectively manage risk, based on knowledge and experience in toxicology; occupational safety and health regulations, protective actions, employee concerns, and operations. Evaluation of the Occupational Environment The industrial hygiene survey is the principal method used to evaluate occupational hazards. Survey practices have been used for many years and have recently been compiled.' The American Industrial Hygiene Association Journal has published a guideline for pccupational hazard assessment titled "Good Exposure Assessment Practice." 8 The use of this guideline increases the assurance that the correct, scientific interpretation of exposure data is developed using an appropriate industrial hygiene monitoring plan. There are 58M. C. Hawkins, M. A. Joyjock, and J. American Industrial Hygiene Association Journal, Volume 53, Number 1, Rationale and Framework for Establishing the Quality of Human Exposure Assessments," January 1992. Page 8-1 Type Investigation of Hanford Tank Farms Vapor Exposures four components to this guideline. Each component should be considered by the industrial hygienist for inclusion in a formal report of the monitoring. The components are the following: - develOpment of a protocol for the study--This should be prepared prior to the study. The protocol should connect the study with the conclusions that can be made when the purpose of the assessment is achieved. - consideration of available resources the funds and facilities committed to the study should be adequate to complete the study as designed) - - specification of an exposure assessment model dispersion of gas clouds, route from source to breathing zone) - a study design that includes the sampling statistics, data collection methods, and the analysis procedure-~The design should be formalized and shown to be adequate in yielding results that will permit the possible conclusions to be drawn within the stated levels of confidence. The Board reviewed a number of sampling activities that were conducted throughout the period under review. These activities were characterized by serious technical inadequacies. An example of the inadequacies Occurred when WHC requested HEHF to perform sampling at the 241-C Tank Farm (customer order #11735). HEHF performed the sampling on July 7, 1987. The protocol for this sample was developed by HHC to characterize Tank 103-C vapor space gases in an attempt to identify the causative substance(s) that earlier caused injury to employees working on a mobile exhauster connected to Tank 103-C. HEHF provided the resources and developed a study design. In the conclusion of this evaluation, HEHF states, "Although not conclusive, the results of sampling suggest ammonia as a possible causative agent associated with the workers illness." The conclusion was not comprehensive, and it suggested ammonia as a causative agent. Therefore, the study design was inadequate to meet the protocol of the assessment. The conclusion should have been that the causative agent could not be identified and that more resources were needed to develop an adequate study design. WHC took a grab sample on August 16, 1989, and requested HEHF lab services to analyze it (Customer Order 14360). The sampling had no apparent study design I Page 3?2 Type Investigation of Hanford Tank Farms Vapor Exposures and represented an inadequate attempt by NHC to evaluate employee exposures following an event. The available resources committed to sampling were inadequate because: - A colorimetric tube pump was used to collect the sample rather than a battery-powered pump designed for integrated continuous sampling. As a result, inadequate sample volume was drawn, and sensitivity requirements were not met for a valid sample. - - Preparation of the sample for shipment to HEHF was inadequate and no prefilter was used in line to prevent radioactive contamination.- Specificatidn of an exposure assessment model was never considered for this study. There were no ventilation measurements taken and, therefore, no way to tell if a measurable emission was occurring from the tank vent. Industrial hygiene sampling is routinely conducted for Tank Farm entries by WHC respiratory protection technicians. The technicians use photoionization detectors (P105) and colorimetric tubes. Monitoring is conducted as requested by Tank Farms management. The sampling results are used to determine respiratory protection requirements, but a protocol for this sampling has not been formally developed. Resources are inadequate in that the sampling methods used are not appropriate to monitor vapors of unknown composition, and should not be relied upon for routine tank entries. The study design has also not been developed. No procedures are provided for field use of equipment or guidance for evaluation of data. Selection of Protective Measures Protective measures are developed to minimize a potential exposure to employees. Protective measures include engineering controls, administrative controls, and respiratory protection. The OSHA standards and DOE Order RL 5480.10 require that engineering controls be used whenever feasible to control occupational hazards and that employee exposures to carcinogens be "as low as reasonably achievable." The past reliance on respiratory protection in the Tank Farms without implementing proposed engineering controls does not comply with these standards. Proposed engineering controls included stack height increases and installation of tank vent scrubbers. The design of effective engineering controls is an interdisciplinary effort that requires input from industrial hygiene, chemical engineering, design engineering, operations, and environmental compliance. The controls must a) adequately neutralize, contain, or remove the identified hazard, b) meet good design engineering practice, c) adequately address operational parameters, and d) comply with environmental regulations. Page 3-3 Type 3 Investigation of Hanford Tank Farms Vapor Exposures For example, the carbon adsorption scrubber system, which was installed on Tank 103-C, did not meet many of the above criteria. It was selected to remove organic vapors and ammonia from the tank emissions with little or no consideration of the nature of vapor space gases, good design engineering practite, or operational (process) knowledge. In the ECN for installing the assembly, the efficiency of the charcoal for organic vapors known or suspected to be present in the tank vapor space were not individually considered. Also, the presence of moisture and its effect on capacity or efficiency of the charcoal scrubber was also not considered. The system is designed to remove vapors from an air stream passing through the system, not as a static filter.. The vacuum pump originally proposed by engineering for this system was removed due to environmental permitting requirements, without an assessment of the consequences on filter performance. Also, the design of the installation did not consider the effect of adding an additional pressure drop to the tank system. This apparently forced vapors out through unfiltered points in the tank system, such as at valve pits, pump pits, and risers. The best available control technology (BACT) study developed for the three active ventilation units proposed for Tank Farms shows an improved design over the passive vent system presently installed. However, specifications for the replacement of the adsorption media do not reflect adequate knowledge of the monitoring instrument suggested for organic vapors. The BACT study design recommends a photoionization continuous analyzer for breakthrough monitoring of the charcoal filter. However, the relative sensitivity of the instrument is not-evaluated for all of the organic chemicals considered in the design. The trigger selected should be based on the chemical with the lowest sensitivity at the appropriate occupational health standard. Most of the administrative controls used at the Tank Farms are barriers. These barriers establish areas or zones that require respiratory protection. To be effective, the purpose and criteria for establishing or removing barriers-must be communicated both to management and to employees. The review conducted by this Board and the Tank Farm Task Force established by HHC has shown that there is a lack of understanding by both management and employees on the purpose of these barriers. There is also a lack of documentation on the criteria by which these barriers were installed or removed. The development of effective administrative controls must also be an interdisciplinary effort involving the industrial hygiene, operations, and training organizations. The most detailed criteria for respiratory protection applicable to Hanford are the ANSI Standard 288.2, "Practices for Respiratory Protection" and OSHA Standard 29 CFR 1910.134 "Respiratory Protection." These standards specify the requirements for a respiratory protection program that include a) training, b) fitting, c) medical surveillance, and d) respiratory selection. Respiratory selection requires an adequate exposure assessment. Page 844 Type Investigation of Hanford Tank Farms Vapor Exposures Once the exposure is identified, the protective factor of the respirator must be adequate to reduce the in-mask exposure to below the applicable occupational health standard. Also, for cartridge-type respirators, the device must provide the wearer with adequate warning that breakthrough is occurring. If any of the above selection factors cannot be ensured, then the highest level of respiratory protection must be provided. At Hanford this is the pressure demand, air supplied unit with OSHA standards for hazardous waste sites and RCRA treatment, storage and disposal facilities (29 CFR 1910.120) reinforce this selection criteria by requiring air supplied respirators for exposures to unknown or inadequately characterized emissions from wastes. As previously noted, the exposure assessments presently conducted in Tank Farms are not adequate for selection of respiratory protection. This must be recognized by management and Industrial Safety and Health, even if common sense would suggest that there is no significant hazard. "Common sense," inadequate emission characterization, or poorly designed exposure assessment do not comply with occupational health standards and result in a loss of credibility when communicating potential health risks to employees. Development of Recommended Actions The develOpment of recommended actions and the effective communication of these actions to management and employees requires the highest level of professional practice. The American Board of Industrial Hygiene (ABIH) is an internationally recognized body that has set minimum standards for recognition as a professional industrial hygienist. Certification by the ABIH requires a degree in the sciences or engineering, a minimum of five years of experience, and demonstrated knowledge in the principles of indUstrial hygiene. The lack . of a certified industrial hygienist in the area of technical support significantly reduces the ability of management to recognize and adequately respond to occupational hazards. For example, the Board has observed that employee communications concerning the Tank Farm vapor issues were most readily accepted from the Personnel Protective Equipment Unit. Input from an experienced, certified industrial hygienist improved the credibility of this group with Tank Farm employees. The Board has also identified a lack of dependence on industrial hygiene in general by WHC and RL management, which has resulted in a long-term inability to adequately resolve industrial hygiene problems. An example of actions taken by management without adequate industrial hygiene input include a) design and use of the cryogenic sampler for tank vapor characterization, b) design of personal monitoring programs for Tanks Farms, c) removal of respiratory protection zone barriers at Tanks Farms, d) development of Page 3-5 Type Investigation of Hanford Tank Farms Vapor Exposures training programs for Tank Farms, e) design of engineering controls, and f) implementation of protective actions in the recent January 28, 1992, event. The cause of this management problem is not apparent to the Board, since some qualified, senior industrial hygienists are available at the Hanford Site. Our observations suggest that there are perceptual barriers that prevent the effective use of industrial hygienists by management. The greatest of these is that management seems to show little understanding of the practice of industrial hygiene. Also, senior managers tend to rely on operations and engineering rather than on safety and health technical support to resolve problems that are critical enough to get their attention. a Senior managers need to be aware that exposure to chemicals is a significant portion of'occupational safety and health associated with the remediation of wastes at Hanford and will become even more important as the remediation continues to grow in scope. Senior managers need training in the industrial hygiene aspects of waste remediation, and need to recognize situations where they must obtain technical advice from a competent authority in this critically important area. Senior industrial hygieniSts also need to recognize their role in providing management and employees with adequate information and effective recommendations. Adequate fulfillment of this role necessitates extensive professional experience as well as a current understanding of Hanford field operations and employee concerns. This understanding cannot be obtained by remaining in offices conducting paperwork. Industrial hygienists must be involved with field work and be familiar with the occupational environment at Hanford work sites in order to be able to provide reliable information to management. Page 3?6 Type Investigation of, Hanford Tank Farms Vapor Exposures APPENDIX CONDUCT OF THE INVESTIGATION The Board of Investigation was convened on February 4, 1992. It consisted of three RL employees, as well as one employee each from NHC, PNL, and KEH. One of these individuals was a certified industrial hygienist and one was a certified accident investigator. - . . The Board conducted extensive interviews with WHC, HEHF, and RL employees. It also reviewed many documents that were relevant to the vapor exposure problem. Using the information it had gathered through these activities, the Board performed its evaluation and developed its conclusions. The Board also invited personnel from the Occupational Safety and Health Administration to participate in the investigation. Three senior level- individuals from the Salt Lake Technical Center visited the site from March 3-5, 1991, and conducted an.evaluation within the context of OSHA regulations. They provided a report of their findings, which has been included in this report. When a draft report was completed, it was provided to HHC and RL for comment. Comments were requested regarding factuality of the report only. When the Board was satisfied that all concerns regarding factuality were appropriately resolved, peer review was requested from Dr. Melvin First of the Waste Tank Technical Advisory Panel, as well as from the OSHA Salt Lake Technical Center. The members of the Board of Investigation were: David H. Brown, Chairman, RL, Nuclear Engineer Sheldon R. Coleman, KEH, Certified Industrial Hygienist James J. DeMyer, PNL, Certified Accident Investigator Paul A. Knight, RL, Industrial Hygienist Steven J. Veitenheimer, RL, Nuclear Engineer Robert C. Roal, HHC, Chemical Engineer Ms. Rosemarie Laudert of PNL served as secretary to the Board, and Ms. Kelly A. Parnell of PNL was technical editor for the report. Page 0-1 Type Investigation of Hanford Tank Farms Vapor Exposures BACT CIH CMP CSP DOE ECN EMO EPA HEHF HEPA HPT KEH LTA MORT NPH OSHA OVM PID PNL PPE QUEST RCA RPT SST TSA TSD VOC NHC APPENDIX LIST OF ACRONYMS American National Standards Institute Best Available Control Technology cubic feet per minute Certified Industrial Hygienist Office of Compliance, Richland Field Office Certified Safety Professional U.S. Department of Energy Engineering Change Notice Environmental Management Operations, Pacific Northwest Laboratory Environmental Protection Agency feet Gas Chromatograph/Mass Spectrometer Hanford Environmental Health Foundation high-efficiency particulate air filter Health Physics Technician IndUstrial Hygiene/Industrial Hygienist Kaiser Engineers Hanford Company Less Than Adequate Management Oversight and Risk Tree Normal Paraffin Hydrocarbons U.S. Department of Labor, Occupational Safety and Health Administration Organic Vapor Monitor Professional Engineer Photoionization Detector Pacific Northwest Laboratory Personal Protective Equipment parts per million Quality, Environmental, Safety Tracking System Root Cause Analysis U.S. Department of Energy, Richland Field Office Radiological Protection Technologist Single-Shell Tank Tank Farms Technical Safety Appraisal Technical Support Division, Richland Field Office Volatile Organic Compound Westinghouse Hanford Company Page 0-1