OCCUPATIONAL SAFETY, HEALTH, AND ENVIRONMENTAL Ref: 5090.54 DEFICIENCY REPORT (OSHEDR) Title: Potential Exposure To Chlorine/Hydrogen Chloride Above Exposure Limits PART I OSHEDR Event 11/26/2012 Ship I Area Number 12-106.22-234-OSH Date/Time. 1300 Work Site Building 873 (Completed by Date Identified Location Bunlding 1109 Code106.12-) to Code 106 11/26/2012 I . Name Shop/Code Phone Employee Identifying De?ciency Rande Williams Shop 99 476-0377 Other Comments/Remarks - - revisions, critique information. etc.) OSHE QueSt'onnalre 201 2'01 19 OSHE Program 7 General Occupational Health Description of Safety, Health, or Environmental De?ciency 991 Process Changes Not Adequately Captured In Written Procedures On 11/26/12, Shop 31E notified Shop 99HM they needed to transfer approximately 1480 gallons of waste water from the pickling rinse water tank at Building 873 over to Building 1109. Shop 31E verbally stated the pH level of the waste water was 2.4. This pH level was lower than what is normally processed at Building 1109 from this tank. Subsequent investigation identified the pickling rinse water tank had not been cleaned as frequently as in the past likely resulting in a higher concentration of hydrochloric acid. It was also identified that pH measurements were taken at the top of the tank and were not representative of the tank contents. Actual pH level was likely lower than what was measured. Upon the verbal noti?cation discussed above, Shop 31E proceeded to transfer the waste water from the pickling rinse water tank to Building 1109. Shop 99 received approximately 800 gallons of the waste water into Tank 30. Shop 99 then proceeded to add 300 gallons of the waste water into Tank 3A at which time the Building 1109 chlorine alarms were triggered. Shop 99 stopped the pumping process, evacuated the building and contacted Code 106.22 to monitor air quality. Multiple Code 106.22 personnel then entered Building 1109 to perform air monitoring. Subsequent investigation identified changes associated with the pickling rinse water tank cleaning frequency, abnormal pH readings, methodology for measuring pH, associated waste water processing at Building 1109, and alarm response procedures were not adequately captured in written procedures. 002 Chemical Overexposure To Multiple Code 106 And Shop 99 Personnel During performance of air monitoring, three Code 106.22 personnel were exposed to chlorine gas above the OSHA permissible exposure limit (PEL). The current PEL for chlorine gas is 1 as a ceiling limit (Le, a worker's exposure to chlorine shall at no time exceed this ceiling limit). The Building 1109 alarm and Code 106.22 meter identified chlorine gas levels at 8 ppm. Source of the chlorine gas is unclear as cyanide waste water treatment was not being accomplished at the time the alarm sounded. Code 106.22 personnel may have also been exposed to hydrochloric acid above the OSHA PEL of 5 (ceiling limit). In addition to the exposure received by Code 106.22 during air monitoring, Shop 99 personnel in Building 1109 were also exposed to chlorine gas above the OSHA PEL and may have been exposed to hydrochloric acid above the OSHA PEL. This is a severity level 1 event in accordance with 5090.54, enclosure (1). Number each item if multiple de?ciencies are listed. Immediate Corrective Actions Taken 1. Secured pumping process. 2. Evacuated Building 1109. 3. Contacted supervisor. 4. Contacted Code 106 to evaluate air quality. Number each item if multiple de?ciencies are listed. PART II UPON COMPLETION, SUBMIT T0 CODE 106.12 e-mail to PSNSIMF C106 OSHEDR Surveillances, hand-carry to Building 445, or fax to 476-0606 (Building 445). CODE 106.12 SERIALIZEITRACKING Date Sent to Cognizant Branch 12/04/2012 Cognizant Code 106 Branch 50901258 (Rev. 4-12) (Front) 9 OCCUPATIONAL SAFETY, HEALTH, AND ENVIRONMENTAL DEFICIENCY REPORT (OSHEDR) (CONT.) COGNIZANT CODE 106 BRANCH ACTION DETERMINATION Requirement Violated Instruction, etc.) PART 001: 29 CFR 1910.119 Process safety management of highly hazardous chemicals 1910.119(l) Management of change. (1) The employer shall establish and implement written procedures to manage changes (except for ?replacements in kind?) to process chemicals, technology, equipment, and procedures; and, changes to facilities that affect a covered process. (2) The procedures shall assure that the following considerations are addressed prior to any change: The technical basis for the proposed change; (ii) Impact of change on safety and health; Modifications to operating procedures; (iv) Necessary time period for the change; and, Authorization requirements for the proposed change. (3) Employees involved in operating a process and maintenance and contract employees whose job tasks will be affected by a change in the process/Shall be informed of, and trained in, the change prior to start-up of the process or affected part of the process. (4) If a change covered by this paragraph results in a change in the process safety information required by paragraph of this section, such information shall be updated accordingly. (5) If a change covered by this paragraph results in a change in the operating procedures or practices required by paragraph of this section, such procedures or practices shall be updated accordingly. 002: 29 CFR 1910.1000 Air Contaminants Substances with limits preceded by - Ceiling Values. An employee's exposure to any substance in Table Z-1, the exposure limit of which is preceded by a shall at no time exceed the exposure limit given for that substance. lf instantaneous monitoring is not feasible, then the ceiling Shall be assessed as a 15-minute time weighted average exposure which shall not be exceeded at any time during the working day. Responsible Party of the OSHEDR i 7. . . Party prior to issuing (Superintendent or Equivalent) 204-2854 Responsible Party of the Deficiency (Sh?opICode/Other) Sho 31 (This is the shop or code that wlli be entered into OPS for metrics purposes.) Action Required by Responsible Party of the OSHEDR Action: Responsible Manager (or designated representative) review OSHEDR, submit a completed Problem Notification form (Link to Non~Nuclear Problem Notification Form) ,Timeline and Gap Analysis (Link to Timeline and Gap Analvsis for Non-Nuclear Critiques) and Statements of Fact (Link to Statement of Fact Form) to Code 2000 at email PSNS-IMF 2000 Problem Notification or fax to (360)476-4636. 991: OSHSOZ Improper Work Practice Item Number(s) and OPS Code(s) 992: OSHSO1 Chemical or Biological Exposure (Item number, QPS code and OPS title) Cognizant Code 106 Review . (Name, Code, Phone) Jeffrey L. Clzek, Code 106.23, 476-9683 Date 12/12/2012 Responsible Party Response Due Date no later than 2 workin- da 5 from date sent to Res- CODE 106.12 DATA EN 12/12/2012 CATS Item Number 2012_10472 12/21/2012 Date Entered into QPS PART IV 12/12/2012 (if used) RESPONSIBLE PARTY RESPONSE Date and Time the Discrepant Condition Was Placed Back in a Compliant State Date Sent to Responsible Party ?If the OSHEDR response includes additional action. create _a CATS item and reference the new CATS item number in the OSHEDR response. investigation PackageSumetted tjo Critique Yes No [3 MIA Date Pack_ge Submitted (Include OSHEDR number With package) (Double cliok on box to check.) Shani/Code COGNIZANT CODE 105 CODE CONCURRENCE ignizant00de106concurs Yes No (include additional actions below, if required) KT '1 "3 955' PART VI CODE 106 2 CLOSE OSHEDR 5090/258 (Rev. 4 12) (Back)