mm 13-01 mm) FOR IMPROVEMENT IN comaor. 0? MIXING HAZARDOUS CHEMICALS 03/15/13 04/18/13 REPLY: 1. Summing of Problem: The Environmental, Safety and Health Department reviewed NSR Item 13-01 and agrees improvement is needed in several aspects of hazardous chemical handling, use and response during unusual events. The item identifies instances where normal processes were inadequate or were not followed resulting in potential personnel exposure to hazardous chemicals vapors. Additionally, response personnel were unnecessarily exposed to the chemical vapors due to poor response planning and training for such events. Background information: - Unanticipated Exposure of Personnel to Hydrogen chloride and chlorine Vapor, 2001114245 (20002--127282) (11/25/12). During transfer of wastewater from Building 973 Electroplating shop to two separate tanks in Building 1109 Industrial Waste Treatment Facility, hydrogen chloride vapor formed and escaped out of one tank and at the same time, chlorine gas formed and escaped out of another tank. Two shop 95 employees involved in the transfer and two Code 106 employees responding to investigate the problem were exposed to these vapors. Additionally, during the investigation a shop 31 employee stated he also smelled a strong chlorine odor in Building 973. In this Case the Shop 31 Tank Chemical Coordinator did not Conduct required weekly conductivity readings/inspections on the rinse tanks resulting in a higher concentration of hydrogen chloride, the transfer process to transfer waste water between Building 673 and Building 1105 did not specify analytical ranges and or limitations for the waste water prior to transfer, and Building 1109 ventilation was modified allowing chlorine and hydrogen chloride vapor to enter the working platforms where personnel were standing. I Water Added to Concentrated Sulfuric Acid Resulting in a Reaction, (01/31/13)l A Code 134 chemist was cleaning up a chemistry lab and found a bottle of sulfuric acid that was no longer required. The chemist poured the contents of the bottle into a waste container containing concentrated sulfuric acid. After rinsing the battle, the Chemist poured the combined content Oi Water and sulfuric acid into the same waste container. The addition of the rinse water resulted in a chemical reaction generating heat and a fuming sulfuric acid vapor NSR 13~01 NEED FOR IMPROVEMENT IN CONTROL OF MIXING HAZARDOUS CHEMICALS '03/15/13 mist. In this case the chemist was not familiar with the work area, did not follow basic chemistry safety requirements and was not adequately briefed concerning the hazardous waste streams in use in this area of the laboratory. 0 Chemical Exposure in Building 862, (02/11/13). Inadvertent mixing of two chemicals in the incorrect sequence created an exothermic reaction and visible offngassing. In this case chemicals were mixed out of sequence resulting in an unexpected off gassing event and the evacuation of the building. Employees Potentially Exposed to Chlorine above the Permissible Exposure Limits, (03/04/12). During the processing of waste water and metals in Building 1109, which normally ends with a pH level of approximately 9.5, the waste water was transferred from the processing tanks to the treated effluent tanks and was subsequently found to have a pH of 11.3. The plant supervisor attempted to adjust the pH in the one treated tank which resulted in a pH level <2 in that tank. The plant supervisor decided to return the waste water back to the processing tank for pH adjustment. EMIing the transfer back to the processing tank Via a temporary hose to the open top of the tank, the combination of the low pH waste water being aerated. with. a concentration. of bleach from the pmevious cyanide treatment resulted in chlorine being released into the building. In this case chemistry of the waste water was not verified prior to treatment {not required by the Operation and Maintenance Manual) and values from the previous day were used. Additionally, a partial batch pH adjustment was attempted vice treatment of the whole process tank, contrary to the Operation and Maintenance Manual, In three of the four examples, in addition tn: the problems identified in the individual reports, the following additional problems were identified during the team?s review: NRNW was not called to reapond to the evacuation of a building or space and assess the atmosphere in the area or the individuals exposed to chemical vapors and Code 106.22 entered these areas without NRNW assessing the atmosphere for entry without breathing protection. NSR 13-01 NEED FOR IMPROVEMENT IN CONTROL OF MIXING HAZARDOUS CHEMICALS 03/15/13 Causal Analysis Process: A team consisting of representatives from Codes 106, 134, 250, 980 and Shops 31, 64 and 99 assembled to review the facts of the individual events identified within the agenda item. The team used the causal analysis process to compare the planned process to the actual, identifying gaps, potential causes and corrective actions. A summary of the analysis is listed below. 2. Problems, Causes, and Actions: Problem 1. Personnel are not identifying out of normal conditions when handling chemicals. Cause 1.. High risk chemical processes have not been identified. Supervisors and managers do not recognize the level of risk and-are not indoctrinated into the specifics of their chemical mixing processes and therefore lack sufficient knowledge to provide adequate oversight. Temporary Action(s): a. Define and identify high risk chemical processes. Action: Code 106.31 lead, Code 106.11, 0106.22, Code 134, Code 250, Code 980, Code 1124 EMTR assist Due Date: COMPLETE Permanent ?ction (3) a. Review identified hi ris - ical processes to ensure adequate controls are place for continued operations. Action: Code 106.2 lead, Code 106.22, Code 134, Code 900, Code 200 assist (process shop and technical code) or)? b. Develop process specific in cat on training for Due Date: 05/2/14 supervisors and managers not fa iliar with their specific high risk chemical processes. Training should identify process risks and required response actions. Action: Code 900T.5 lead, Shop 31, Shop 64, Shop 99, and Code 134 assist Due Date: 03/98714 . . FolloJitJ?p Action(s) 2% at Review supervisor and managementai?dogtrination training for identification of high risk chemical processes and response actions. Discuss with supervisors and managers to NSR 13-01 NEED FOR IMPROVEMENT IN CONTROL OF MIXING HAZARDOUS CHEMICALS 03/15/13 determine the effectiveness of the training. Review results with Code 900. Action: -Code SOOP Due Date: 06/27/2014 Cause 2. Supervisors and workers do not recognize or have become desensitized to the level of risk associated with chemical mixing processes. The use of type principles- in the handling and use of chemicals has not been utilized as a standard to prevent chemical exposure. Training, qualification and proficiency requirements are informal and incomplete, missing basic chemistry principles. Temporary Action(s): a. Issue an Environmental, Safety, and Health Bulletin detailing the minimum response actions for chemical exposures. Action: Code 106.1 Due Date: COMPLETE . Permanent Action{s): - a. Review, modify and/or op training, qualification, and proficiency requirements for high risk chemical processes. Include proper response actions for unusual or unexpected results. Action: Code 900T.5 lead, Shop 31, Shop 64, Shop 99, Code 106.11, Code 106.22, Code 106.31, Code 134, Code 980, and Code 124 EMTR assist Due Date: 04/28/14 b. Training in the Industrial?was reatment Facility is principally on~the~job experi ed based with no curriculum structure or worker qualification standards. Develop a new training curriculum that features the fundamentals of wastewater treatment principles along with on~theujob practical factors that lead to qualification standards as plant operators. Action: Code 980 lead, Code 106.22, Code 106.32, Code 900T and Shop 99 assist Due Date: 03/31/14 Follow-Up Action(s): a. Review training associated - gh risk chemical processes and interview process operators and supervisors to assess their understanding of the process chemical risks and response actions. Review results with Code 900. Action: Code 900P Due Date: 03/27/15 NSR 13-01 NEED FOR IMPROVEMENT IN CONTROL OF MIXING HAZARDOUS CHEMICALS 03/15/13 Cause 3. Personnel receive little support when problems are identified because of poor communication and integration between all shops/codes involved in high risk chemical processes. Temporary Actionts}: a. Create a core Chemical High Risk Advisory Committee. The primary purpose of the group is to identify and bring together responsible shops and code to define and review high risk chemical processes, to ensure open communication and sharing of integrated processes and support ownership in the use of high risk chemicals. . Action: Code 106.2 chair, Code 106.22, Code 106.31, . Code 106.33, Code 134, Code 980 as core members Due Date: COMPLETE Summary: A core Chemical High Risk Advisory Committee has been created and is routinely meeting working on the issues associated with this agenda item. Members to this committee will be added or subtracted as the scope of issues being addressed change. Permanent Action(s): a" Develop_a codified proces eview high risk chemical process changes or the addition of new processes. Action: Code 106.2 lead with shops and codes assigned to the Chemical High Risk Advisory Committee. Due Date: 02/28/14 Follow-Up Action{s): a. Review the codified process for proper implementation. Action: code 135 ?1 15* Due Date: 03/28/14 Problem 2. Personnel are not taking appropriate response actions for unusual or unexpected chemical process results. Cause 1. Training, qualification and proficiency requirements do not include periodic testing of response actions and proficiency standards. Temporary Action(s): a. See Problem 1, Cause 2, Temporary Action Action: Code 106.1 Due Date: COMPLETE NSR 13-01 NEED FOR IMPRUVWNT IN CONTROL OF MIXING HAZARDOUS CHEMICALS 03/15/13 b, Code 106.2 brief Industrial Hygienists on Correct response to unusual events resulting in building or space evacuation. Action: Code 106.22 Due Date: COMPLETE Summaryx Following the Building 1109 exposure event in November 2012, the Code 105.22 Branch Head briefed the Industrial Hygiene staff on the tenants of that: event and the expected response actions for future instances of unusual events where Code 106.22 assistance Permanent Action") a. see Problem 1, Cause 2, Fe (Training) Action: Code 9001.5, Shop 31, shop 64, shop 99, Code 106.11, Code 105.22, Code 106.31, Code 134, Code 960, and Code 112 Due Date: 04/23/14 Corrective Action (3) . b. Develop an integrated exercise 111 program for high risk chemical processes. (Traini Code 106.11 lead, Code 134, Code 1124 EMTR, and Code 1130 assist Due Date: 04/01/14 C. Develop standard Operating Procedure detailing response actions for industrial hygienists responding to unusual events resulting in building or space evacuation. (Training) Action: Code 105.22 Due Date: COMPLETE Follow-g Action(s): 0'0 3" z' e. Evaluate the integrated air as and drill program. (Performance) Action: Code 1130 Due Date: 02/20/15 Problem 3. The Industrial waste Treatment Facility (suilding 1109) is experiencing continuing process re1ated problems requiring the continued use of the non-standard procedure (procedure 1) on a routine sis to meet processing requirements. Cause 'cal treatment processes in the Building 1109 Industrial Waste Treatment Facility have not been evaluated in sufficient NSR 13?01 NEED FOR IMPROVEMENT IN CONTROL OF MIXING HAZARDOUS CHEMICALS 03/15/13 detail by Code 106 Safety and Environmental, Code 134 Chemistry Lab and Code 980 Engineering to identify the.chemical exposure risks inherent with the treatment processes and controls. Temporary Action(s): a. Identify all chemical treatment processes accomplished at Building 1109. Identification will include capturing the process description, characterization of the wastewater load pH, conductivity, waste stream, associated etc.), procedures and work practices employed, frequency the process is accomplished, and PPR worn during the process. Action: Code 106.22 lead, Shop 99 assist Due Date: COMPLETE b. Identify chemical processes of concern accomplished at ilding 1109 based on the chemical reactions occurring during the receiving and treatment process. The primary byproducts of concern from the chemical reactions are chlorine gas, hydrogen cyanide and sulfur dioxide. Action: Code 106.22 lead, Shop 99 and Code 134 assist Due Date: COMPLETE c. Cenduct daily/weekly meetings to assess process controls and determine additional actions that need to be taken for transfer of liquids at Building 1109. Meetings are facilitated by Code 106.2 and attended by Code 106.22, Code 106.32, Code 106.33, Code 134, Code 980 and Shop 99. Action: Code 106.2 lead, Code 106.22, Code 106.32, Code 106.33, Code 134, Code 980, Shop 99 assist Due Date: COMPLETE d. Perform appropriate monitoring for each work process performed at Building 1109 to ensure the controls are effective at keeping the chemical exposures to less than established limits. Action: Code 106.22 Due Date: COMPLETE Summary: After a routine worksite assessment identified unexpected chlorine gas in a treatment process at Building 1109 last April, PSNS IMF halted all treatment of acid/alkaline, hexavalent chromium and cyanide wastewaters at Building 1109. Each treatment process is being evaluated by Code 106.22 to ensure exposure to chemicals is kept as far below the authorized permissible exposure limits as possible. Monitoring data collected to date indicates exposures during processes currently authorized are below applicable eXposure limits. Only approved? use 13-01 uses son IMPROVEMENT IN CONTROL OF MIXING HAZARDOUS CHEMICALS 03/15/13 processes which have been evaluated to verify that procedures and controls are effective to keep exposures below applicable exposure limits for each treatment process are permitted at this time. . CjcvaEL73 Permanent Action{s): a. Coordinate with Naval a1 Industrial Hygiene staff to update the worksite assessments fer all processes accomplished by Shop 99 at Building 1109 once process controls have been established and stabilized. Action: Code 106.22 Due Date: G??3??i4 Cause 2. Building 1109 Industrial Waste Treatment Facility plant controls and equipment has not been maintained in good working order resulting in the need for continuous work a rounds by plant operators in order to continue treatment operations? Temporary Actionts): a. Identify and address Building 1109 equipment configuration, controls and maintenance issues with specific focus on inoperable equipment requiring Shop 99 employees to be on the mezzanine during the receiving and treatment process (e.gt, pH meter, ORP repair) Action: Code 980 lead, Shop 99 assist Due Date: COMPLETE b. Develop interim step?by?step procedures to operate and control equipment necessary to process and treat wastewater at Building 1109. Action: Code 980 lead, Code 106.22, Code 106. 32, Code 134 and Shop 99 assist Due Date: COMPLETE Permanent Action(s): a. Revise the existing Operation Maintenance Manual for Building 1109 and implement changes to the technical procedures to include a new Industrial Process Instruction to improve the control and operation of the plant, Shop 99 has identified that the existing Manual appears more of a text book vice the standard Shipyard industrial procedures that are used by Production and is not consistent with how all processes are currently being executed mainly due to facility and equipment issues. NSR 13-01 NEED FOR IMPROVEMENT IN CONTROL OF MIXING HAZARDOUS CHEMICALS . 03/15/13 Action: Code 980 lead, Code 106.22, Code 106.32, Code 134 and Shop 99 assist Due Date: 05/30/14 b. Conduct an Architectural and ginee tudy and design review of the Building 1109 facilitq??gd?::iipment configuration and operations to identify necessary facility, equipment and process improvements. Action: Code 980 lead Due Date: 06/30/14 Follow?Up Action(s): a. Review the completion of the pe igneot?dgrrective actions in Problem 3 with the Chemical High Ris Advisory Group to ensure the facility, the equipment, the process controls, procedures and training support the plant operations. Action: Code 980 lead Due Date: 08/2912014 Problem 4. The Hazardous Waste evaluation,-control and oversight processes do not account for the possibility of continuing chemical reactions throughout the time from generation to final disposition of liquid waste resulting in heat production, off? gassing, bulging waste containers (drums) and other undesirable conditions. Cause 1. . The Code 106.3 Hazardous Material, Waste and Pollution Prevention (P2) programs do not use a cradle to grave approach when evaluating chemical selection, use and disposition in the shipyard. Temporary Action(s): a. Identify and evaluate for adequacy existing Code 106.33 procedure/process for identifying and mitigating gas-generating waste streams Problem 2, TCA 7; CATS 2013~05895). Action: 106.33 Due Date: COMPLETE SUMMARY: No guidance exists to assist designators in identifying the possibility for gas generation. Code 106.33 to create document see PCA a. Additional corrective actions per have put into place in advance of PCA a's completion. NSR 13~01 NEED FOR IMPROVEMENT IN CONTROL OF MIXING HAZARDOUS CHEMICALS 03/15/13 b. Review and evaluate effectiveness of internal Waste Stream Review Process Problem 3; CATS 2013?05873). Action: 106.33 Due Date: COMPLETE SUMMARY: Process within Code 106.33 is inadequate and course of action is in development to revise it see PCA b. Memo 106.33/0150 issued on 7/17/13 directed additional review of Waste Information Sheets by Environmental Coordinators. Memo discussed at 7/25/13 Environmental Coordinator Meeting. c. In concert with the Hazardous Material Management System (HMMS) software deployment (approximately 8/22/13), determine what functionality is missing to support hazardous waste management and submit software change request(s) via DLA to IRS. Action: 106.33 Due Date: COMPLETE Permanent Action(s): a. Codify any required changes to the process for identifying and mitigating gas~generating waste streams from TCA a (ZOOCR- 13-097, Problem 2, PCA 3; CATS 2013?05900). Action: 106.33 Due Date: COMPLETE b. Code 106.33 implement changes based upon TCA b(2000R?13?097, Problem 1, PCA 3; CATS 2013?05882). Action: 106.33 Due Date: COMPLETE c. Transition hazardous material management into HMMS in accordance with pre~established timelines. Action: 106.32 Due Date: COMPLETE d. Following software change submittal from TCA and understanding of functionality, transition hazardous waste management into HMMS. Additional database development is required to ensure adequacy of waste manifesting, designation and record keeping.] Action: 106.33 Due Date: 05/06/14 e. Restructure Code 106.3 to revigeirolesf?here employees are responsible for the authorization of hazardous material, understanding of the processes by which the materials are used, and how the wastes are disposed. 10 NSR 13~01 NEED FOR IMPROVEMENT IN CONTROL OF MIXING HAZARDOUS CHEMICALS 03/15/13 Action: 106.3 Due Date: 06/15/14 Follow-Up Aotion(s) 00 . a. Conduct audit of restrut?gred?code 106.3 to assess use of HMMS for systemic managemen of hazardous material, waste and P2 efforts. Action: 106.11 Due Date: 08/15/14 Cause 2. Hazardous waste generators have not been actively engaged in managing and controlling their hazardous waste. Temporary Action(s): a. Issue a memorandum to all Environmental Coordinators on the tenants of current waste issues, use of the waste stream dictionary, and expectations for waste management Problem 1, TCA 5). Action: 106.33 Due Date: COMPLETE SUMMARY: Memo 106. 33/0150 issued on 7/17/13 Memo discussed at 7/25/13 Environmental Coordinator uw - - ?(9035? b. Develop a to validate and popula -ooropriate Waste Information Sheets (WIS) for Waste ?eam Numbers WSNs in revised electronic tool Problem 1, TCA 6; CATS 2013-06582). Action: 106.33 Due Date: 02/15/14 Permanent ActiOn(s): a. Modify or create an electronic to ovide the individual to Waste Originators 13? ~03 Problem 1, PCA 1; CATS 2013~06583). Action: 106.33 Due Date: 02/01/14 0 3Q3) .m b. Complete from TCA 1, PCA 2; CATS 2013-06585). Action: 106.33 Due Date: 06/05/14 11 NSR 13-01 NEED FOR IMPROVEMENT IN CONTROL 0? KING HAZARDOUS CHEMICALS 03/15/13 3? c. Based off PCA a, make appropiiate"modification to 5090. 13" 098, Problem 1, PCA 3; CATS 2013- 06586). Action: 106.33 Due Date: 06/05/14 00 Follow-Up Actionta): wa??ww? a. Engage Hazardous Waste Stakeholders [Code 900, ECS, AAOS, Code 134, etc.] to evaluate effectiveness of changes in Waste Stream Dictionary for increasing awareness and accountability for Waste Management Plan compliance Problem 1, FUA l; CATS 2013?06589). Action: 106.33 Due Date: 12/20/14 Preblem 5. High risk chemiea1 mixing processes are:managed by several organizations within PER321MF with no 912912 erganization eoordinating and previding guidelinee concerning cauSB 1. Shiyyard Management failed ta 2ecognize the neea fer a single organi2ation to integrate high 212k chemical mixing operation policy and procedures 222935 organizatienal lines. taking a comprehensive vieW'ei safety, technical requirements, training and oversight. {Re?ex t2 91, 03} high 213k chemical sharing of integrat?a and euppert eenerehip in the use of high 2122 chemicals (Refer tW 91 c3). Action: 4292222106. 2 Chair, ?092,106 22, cede-106.31, Code 106.33, 980 12 Eere members Due Date! TEQMPLETE Permanent ??zx 1911(3) . mixing operation policy ane-proceduree lines to ensu2e a eomprehen51ve-view of safety, teahnieal reguiremente,. training and oversight. Action: Code 900 12 NSR 13?01 NEED FOR IMPROVEMENT IN CONTROL OF MIXING HAZARDOUS CHEMICALS 03/15/13 .Due Date: COMPLETE b; Eatablish and coaiqu'*? purp??e, abjectivea, memb?f?m? . Actien abde 980 LeaW Due?Date: 02/28/14 n9 operation acraes the Shipyard organizations to include rglea. and reapansihilitaes, praceas ownership, safety, technl?al regulr?mAnt? includlng induction at new- pxaaesaes, training, oV?rsight and surveillances. Actipn:. Code a'zon assist. Follow-up- a. Assess and report the e??ecti'enesa vi the policy and procedures enacted V- A above by a review a: ?2?fillanc23ncvar Aha perzad 01 JAN ?30 JUN 2615 to th?" OAHFEEC Action: Code 980 Lead Chemical High Ri?k Adviaary Committ?? assist Due Date: 06f30/15 (ITEM CLOSED) 3. summary to: Clonure: Prob1em 5 was added to identify Productien Engineering and Facilities (Code. 980) as the lead technical co?e. b. Problem 1, Cause 1, Aarmanegt Antiunif Bate change Code 106 2 will a PAN, to codi?y the process and estabima? baa mantxOAH f-ar high risk prongs-Bea. Draft notice has" been pregamed under internal dea 196. 2 review.. Notice wiil requir? I Hir?-Wide review as it will assign- actraga au?gidg the committee. wil1 the notic? has been issued a. 1 Cause 3, 2ermanent Actidn a: m?ua: pate change Code 106. 2 wil be issuing a A IMF Notice to co?i?y the procesa._. Draft np-tige has been prepared 3nd unA?r interhal code 106 2 review. Natice will 2equire ahipyard~wide review as it will assign actions out?i?e -the committee. 13 use 13~01 NEED FOR IMPROVEMENT IN CONTROL OF MIXING HAZARDOUS CHEMICALS 03/15/13 d. Problem 3, Cause l, 9&5 change Process control-?111 niche as .Other dates piggy?ss.and expected completion; A Chemical High Risk Advisory Committee has been created to focus on developing corrective actions associated with the Industrial Waste Treatment Facility (Building 1109). These corrective actions will be used as a template to perform a ?gap analysis? type review of other high risk chemical processes, identifying weaknesses and implementing corrective actions to shore up weaknesses. High risk chemicals were identified using health and reactivity rating and coupling this information with a total amount of chemical used in the process, input was requested from across the command to identify current high risk chemical processes. The information collected was reviewed by the advisory committee and compared to known high risk chemical processes as part of a quick assessment of potential risks and to provide a list of processes for future review. Building 1109 has restarted some water treatment process, but is in the middle of an Architectural and Engineering study and design review of the Building 1109 facility and equipment configuration and operations to identify necessary facility, equipment and process improvements. The Architectural and Engineering study and design review final report is expected to be completed by the end of June 2014 at which time Production Engineering and Facilities {Code 980) will review and develop a plan to address the recommendations. Additionally, a 16 hour vendor provided Wastewater Treatment Plant Training course was conducted November 20th and Elst. The course provided attendees a broad range of information related to methods or removing, neutralizing and/or destroying a broad range of pollutants found in metal finishing wastewater. Employees from Shop 99, Code 106, Code 134 and Code 980 attended the training and provided feedback the trainings was very helpful in broadening their understanding of the overall process. Production Engineering and Facilities (Code 980) has been assigned the overall responsibility as lead technical code for . integrating high risk Chemical mixing operation policy and 14 NSR 13-01 NEED FOR IMPROVEMENT IN CONTROL OF MIXING HAZARDOUS CHEMICALS 03/15/13 procedures across organizational lines to ensure a comprehensive View of safety, technical requirements, training and oversight. Code 980 is continuing the review of the commands high risk chemical processes, currently focusing on the Electroplating Shop (building 873). 15