[Eng-div] Lesson Learned

[Henry Robertson]

  *Human Performance Improvement - If It Does Not Feel Right, Stop and
  Discuss It with Your Work Group*

*Statement:* When evaluating work assignments remember the STAR process 
- *Stop, Think, Act and Review. *

-Stop and take a step back.
-Think about the work scope; can it be safely achieved?
-Act on your assessment of the work; does the proposed work need to be 
evaluated by a more experienced or knowledgeable person or group?
-Review and discuss with your work peers what your evaluation has 
indicated.

*Discussion:* A maintenance work package had been written to make 
adjustments on the Swipe Delivery System (SDS) Transfer Table while the 
table was controlled in the manual mode using a laptop computer. As 
adjustments were being made, the transfer table unexpectedly activated 
and began to close. Mechanical Craftsmen working on the adjustments 
called an immediate stop to the evolution. No one came in contact with 
the transfer table.

*Analysis:* Although the work package credited the laptop computer to 
mitigate the mechanical hazard, personnel involved in the planning, 
development, and work execution later stated they were unfamiliar with 
the manual operating mode of the system. The personnel individually 
recognized their unfamiliarity but did not stop the work and discuss 
their individual concerns with their work group prior to beginning the 
evolution.

The groups of personnel participating in this event were highly skilled 
and experienced in their individual fields, but there was very little 
knowledge of the design of the system, the software controls, or the 
manual operating mode. The group shared available knowledge during the 
planning and pre-job activities, but the interviews revealed that as the 
field work progressed, each individual became less certain about the 
operation but did not share their individual concerns of how this 
particular work evolution was being controlled.

*Actions:*

-Through either group meeting(s) and/or required reading reinforce the 
responsibility to stop work when work scope is unfamiliar, work quality 
has not been met, or personnel are uncertain of work assignments.
-Perform a Cognizant Engineer equipment walk down to focus on developing 
an understanding of the sequence of operations of the SDS, manual mode 
operations, and how to enter into the manual control mode.
-Extent of Condition Perform review of waste handling automated 
equipment to verify that the sequence of operations and control modes 
are understood by the responsible engineer(s) so that control over the 
equipment is maintained for each configuration implemented.



-- 
Henry Robertson
DSO, Engineering Division
Safety Systems Group
PH# - 757.269.7285
FAX - 757.269.7352
http://www.jlab.org/accel/ssg/



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