[Hallb-engineering] Fwd: Lesson Learned "Changing Conditions Should Merit Further Review - Washington Closure Hanford"

[Douglas Tilles]

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Sent: Monday, July 14, 2014 11:00:33 AM
Subject: Lesson Learned "Changing Conditions Should Merit Further Review - Washington Closure Hanford"






	Changing Conditions Should Merit Further Review - Washington Closure Hanford 	
Statement of Lessons Learned 
For a copy of the original report, see Attachments on Lessons Learned page. 

Do not automatically assume prior hazard controls for similar tasks are valid for your task. Missed opportunities, coupled with the failure to develop a formalized engineering design, led to the failure of a cam-lock fitting during a grout pumping operation, hurting one worker, placing others in danger, and causing project delays. Discussion of Activities 
A work crew of four, including a Field Supervisor, was pumping concrete grout (design mix) into 14 bladders in a vault on the Hanford site.  The concrete pump truck, staged outside the area, was pumping the design mix through an elevated boom down to the bladder. When starting the pumping process into the second bladder, a coupling on the hose line failed.  When the coupling failed, the pressurized grout hose released and pushed one worker, struck another in the thigh, and another on the lower leg knocking him to the ground.  Design mix sprayed all around the area.

The grout delivery set up was not designed or built with pressurization being considered as a factor or a hazard when the work was planned.  The work planning team did not consider all the hazards because the grout bladders were considered construction aids, acting as a void space with no structural function.  Multiple instances were identified where signs to stop were not acted on beginning with the setup of the hoses and couplings through the final moments prior to the coupler failure.  The personal accounts of the event from the workers at the scene were consistent; a level of concern existed even before the pumping activity started regarding the design mix delivery set up and whether there was a potential for failure.  Personnel resolved the concerns informally in the field within the work group and continued despite indications of a potential problem with the set up and process. Analysis 
On multiple occasions, signs to stop work were evident and were not acted upon as workers continued to focus on resolving the issues as they arose.  The work crew was presented with changing conditions and did not adequately communicate the situation outside of the immediate work group or stop to assess the changes collectively.

Lack of a formalized engineering plan or review following the original engineering concept to utilize PVC bladders with design mix led to missed opportunities to identify unique characteristics of design mix under potential working conditions. Recommended Actions 
Below are the consequences of the above event.  They are provided for information and discussion purposes only. 

Recognize the specific hazards when planning this type of work; the potential for pressurization of the design mix, unanticipated hose movement, and the ability of the hose components to withstand pressure.

Although the work to be done may be similar to tasks already successfully completed, ensure an engineering review is done so unique characteristics of the work may be identified. 
Comments 
7/14/2014 10:58:05 AM by Bailey, Mary Jo 
SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS
SAF130B: PRESSURE SYSTEMS SAFETY DESIGN AUTHORITY
SAF130kd: PRESSURE SYSTEMS QUALITY PROCEDURE
SAF101: Work Planning and Control Familiarization 	
Summary 	Lesson ID: 	836 
	Status: 	OK 
	Doc ID: 	2014-JLAB-836 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	7/14/2014 10:50:20 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	7/14/2014 10:58:05 AM 
	Source: 	DOECRD 
	Location: 	OTHER 
	Cost Savings: 	
	Contact: 	Shannon Cartier, Lessons Learned/OPEX Coordinator, 509-372-9577 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	3 times Attachments 

    * EngineeringDesignWCH.pdf 
Hazard Issues 

    * Pressure Systems 
    * Pressurized Vacuum Lines and Piping Systems 
    * Other: Work Planning and Communication 
Skills 

    * SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS 
    * SAF130B: PRESSURE SYSTEMS SAFETY DESIGN AUTHORITY 
    * SAF130kd: PRESSURE SYSTEMS QUALITY PROCEDURE 
    * SAF101: Work Planning and Control Familiarization 
Distribution/Notification 

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