[Hallb-engineering] Fwd: Lesson Learned "Failure to Follow Lock, Tag, and Try (LTT) and Configuration Management Procedures"

[Douglas Tilles]

Good reading! Shows what good planing can do when it comes to safety.   Doug

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From: cjohnson at jlab.org
To: cjohnson at jlab.org
Cc: robertl at jlab.org
Sent: Tuesday, October 29, 2013 11:01:13 AM
Subject: Lesson Learned "Failure to Follow Lock, Tag, and Try (LTT) and Configuration Management Procedures"






        Failure to Follow Lock, Tag, and Try (LTT) and Configuration Management Procedures         
Statement of Lessons Learned 
1.  Even when there is no hazardous energy present, it is imperative to always follow the Lab's LTT policies and procedures with no exceptions.
2.  During coordination of tasks in Project Planning, effective communication of deadlines to all stakeholders can be a key factor in avoiding unnecessary delays for scheduled tasks. Discussion of Activity 
** Please click on the source link to view the full report

A main circuit breaker was removed from a Cathode Power Supply (CPS) while both personal safety locks and tags (LTT) and administrative Personnel Safety System (PSS) configuration LTT were still attached. These did not belong to the individual removing the breaker Analysis 
Work Planning � Less Than Adequate (LTA)
A4 B3 C09 � Work planning not coordinated with all departments involved in task
Although there was a blanket ATLis in place which covered the removal of the previous Cryomodule and its support systems by multiple groups, the ATLis was not well coordinated between the groups especially over the long duration the project would require.  

A4 B3 C08 � Job scoping did not identify special circumstances and/or conditions
The original ATLis was written in June of 2012 and did not take into account: 
a.        Multiple interruptions/time gaps over the course of the job which necessitated the rotation of workers due to time and availability of resources
b.        The loss or lack of resources over the life of the job and its effects on the overall project
c.        Re-sequencing of tasks due to loss or lack of resources which introduced unexpected issues/hazards (i.e. Removal of power cables before removal/relocation of Personnel Safety and Configuration locks on an immediately downstream breaker � or � Removal of power cables from an existing LTT�d breaker before removal/alteration of the breaker panel leaving a LTT�d breaker with reduced ability for configuration control)
d.        Expressing the importance of good communication between work groups to notify each other of the progress or planned special needs to avoid delays of process
e.        The need for repeated job walk downs to identify change of conditions due to length of duration of the job and coinciding adjacent tasks Recommended Action 
1.  Update LTT procedures and training to clearly identify that removal of articles with LTT devices in place is the same as removing the LTT devices
2. All Lock, Tag and Try (LTT) qualified staff attended the Lock/Tag/Try training and Personnel Safety System (PSS) Configuration Management refresher training.
3.  All Division Safety Officers should remind work staff within division that Work Planning tools should be used to provide timely updates especially when utilities, infrastructure or hardware is altered which affects other work groups. 
Comments 
10/29/2013 10:58:15 AM by Johnson, Tina 
Subject matter reviewed and approved LL.         
Summary         Lesson ID:         762 
        Status:         OK 
        Doc ID:         2013-JLAB-762 
        Priority:         Caution 
        Safety Related:         NO 
        Originator:         Johnson, Tina 
        Issued:         10/18/2013 10:24:31 AM 
        Approved By:         Johnson, Tina 
        Approved On:         10/29/2013 10:58:15 AM 
        Source:         TJNAF NE 
        Location:         TJNAF 
        Cost Savings:         - 
        Contact:         Harry Fanning 
        Queued Emails:         0 
        Sent Emails:         0 
        Viewings:         533 times Attachments 

    * Picture.docx 
Hazard Issues 

    * Electricity 
    * Industrial Hazards 
    * >50 amps OR >50 Vac OR 60Vdc AND >5 mA 
    * AC Electrical Equipment 
    * Stored energy >10 joules, capacitive, inductive, or battery 
    * Boiler 
    * Commercial Appliances 
    * Heating Systems 
    * Hydraulic 
    * Mechanical 
    * Pneumatic 
    * Stored Energy Sources 
Skills 

    * SAF104: LOCK, TAG, AND TRY 
    * SAF104A: LOCK & TAG PART I 
    * SAF603A: ELECTRICAL SAFETY AWARENESS 
    * SAF603N: NFPA-70E BASIC ELECTRICAL SAFETY 
    * SAF604: HIGH VOLTAGE IN R&D 
    * SAF603S: NFPA-70E for Supervisors 
    * SAF603M: NFPA-70E for Managers 
    * SAF603N1: Arc Flash: Safety Awareness (ELEDEFV) 
    * SAF603N2: Electrical Emergencies: Proper Response (ELE9EFV) 
    * SAF603N3: Electrical Safety for the Qualified Worker (ELECEFV) 
Distribution/Notification 

    * *Division Safety Officers (DSOs) 
    * *Safety Wardens 
    * *DOE Notification 
    * *ESH&Q Liaisons