[Eng-div] Fwd: Lessons Learned - Violation of Lab's Lock/Tag/Try Program

[Henry Robertson]

Please review this synopsis of an event from earlier this week and 
discuss it with fellow workers and supervisors. If you have any 
questions ask me or hold them for a meeting for all LTT trained staff 
that will be held next week that will hopefully answer them.

Henry


-------- Original Message --------

All,

   Late yesterday afternoon an employee reported that the main circuit
breaker for RF zone 0L04 Cathode Power Supply (CPS) had been removed
while still locked out with 2 PSS Configuration locks as well as
personal locks (LTT locks) from three RF group personnel (See
Photo).     The intent was to replace the old main breaker - the one
with the locks - with a new main breaker.  This constituted an
unauthorized removal of locks.

Although the CPS had been isolated from the panel and there was no
hazardous energy present, removing someone's LTT lock is a serious
matter.    No one is allowed to remove a LTT lock that is not their own
without special permission.

In addition, configuration control of the Personal Safety System was
also compromised.

To assure that everyone understands the importance of the Lab's LTT and
administrative lock control programs, and PSS configuration control, we
will be conducting Lessons Learned meetings early next week to discuss
this event and our requirements.  These meetings will be mandatory for
all who use LTT and their supervisors.  We will send out a notification
to all of the place and and time of these meetings.

In the meantime, please share this with your work teams, re-emphasizing
why the LTT program is so important.




Mary

-- 
Mary Logue Director, Environment, Safety, Health & Quality Thomas
Jefferson National Accelerator Facility 12050 Jefferson Avenue, Suite
602 Newport New, VA 23606 757-269-7447



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