[All_staff] Message from Hugh Montgomery: Recent Safety Events-Immediate Action Required

[Pat Stroop]

All Staff,

Over the past two weeks we have experienced a cluster of safety events which  requires our attention.  We are very fortunate that no personnel were harmed nor any equipment damaged in these events. However, they indicate significant areas of concern that need to be addressed in order to avoid more serious events in the future.

I am therefore requiring each Division Leader to organize all hands meetings with their teams within the next 24 hours. At each meeting, Group Leaders or supervisors should discuss the recent events summarized below and review our ISM policy and relevant procedures. I expect all employees will give their full attention to this important matter and ask for help or raise concerns where appropriate.

A brief summary of the events follows:

_Event 1 (14 July)_  

The LERF was brought to beam permit without minimum required staffing.  Notable Event investigation is ongoing but initial indications are responsible employees deviated from the approved procedures.

_Event 2 (26 July)_

An employee received an electrical shock in the LERF while troubleshooting a faulty power supply. Notable Event investigation has started, it appears the employee followed the correct procedure but the procedure did not protect for a previously unidentified failure mode.

_Event 3 (26 July) _

An employee breached a marked radiation area boundary in Building 95. Management is reviewing this event to determine why a properly trained and experienced employee would deviate from the approved procedures.

You will see similar root causes in Events 1 and 3. In addition, similar instances to Event 3 have occurred at Jefferson Lab in the recent past. We have invested a great deal of time and effort to develop systems, procedures, and training to protect employees. It is essential that employees follow the approved procedures at all times and seek advance approval for deviations when they believe such deviations are necessary or even beneficial to our operations.

In Event 2 we see that even when approved procedures are followed unexpected events can sometimes occur. In this case all of the potential failure modes were apparently not considered when the procedure was written. This reminds us we should always be aware of our surroundings and the presence of stored energy and induced currents. Preoccupation with failure modes is a characteristic of high reliability organizations.

All Division Leaders should report back to me when their all hands meetings are completed, including a list of the employees in attendance and any significant issues or concerns raised.

You, Jefferson Lab have worked hard to earn a reputation for maintaining an outstanding safety culture. We want every employee and visitor to go home safely at the end of each work day. Please continue to be ever mindful of the risks inherent in our operations as we continue forward with the important scientific discovery mission of the lab.

-Mont


  

-------------- next part --------------
An HTML attachment was scrubbed...
URL: <https://mailman.jlab.org/pipermail/all_staff/attachments/20160727/ba68b08f/attachment.html>