[Hallb-engineering] Fwd: Lesson Learned "Pre-Job Walk-down Averts Hazardous Energy Control Procedure Failure- Savannah River Remediation "

[Douglas Tilles]

Shows the importance of a pre-job walk down, find any Hazards before the work begins.

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From: mbailey at jlab.org
To: mbailey at jlab.org
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Sent: Monday, May 12, 2014 4:01:35 PM
Subject: Lesson Learned "Pre-Job Walk-down Averts Hazardous Energy Control Procedure Failure- Savannah River Remediation "






        Pre-Job Walk-down Averts Hazardous Energy Control Procedure Failure- Savannah River Remediation         
Statement of Lessons Learned 
For a copy of the original report, see Attachments on Lessons Learned page. 

Before signing lockout plans, First Line Manger(FLM) performed pre-job walk downs and review work plan documents. Discussion of Activities 
A Savannah River Remediation (SRR) Tank Farm/ETP Shift Maintenance FLM) identified electrical heat trace in the insulation around a steam station pilot valve that was not part of the lockout established in the work plan for the valve replacement.  Isolation of the steam hazard had been established, but not the potential electrical hazard.  No controls were established in the work order task for the energized heat trace. Analysis 
The FLM, preformed a pre-job walk down prior to assigning work to replace a steam station pilot valve.  During the walk down it was identified that heat trace was present in the insulation which needed to be removed in order to support valve replacement. The FLM did not assign the work and notified the Shift Operations Manager immediately.

The analysis identified the need to label the steam line insulation that heat tracing was installed on the station pilot valve. Recommended Actions 
Below are the consequences of the above event.  They are provided for information and discussion purposes only. 

Prior to work being approved the following actions were required.

Add to the work plan: 

Self-Check - Walk downs, use of the Work Scope Definition Checklist, and print reviews during development of lockout plans and pre-job walk downs by Managers before signing the lockout are safety cornerstones.

Assumptions - This is a steam lockout. Review the lockout plan to ensure that all energy sources are isolated. 
 

Organization Operating Experience Program Coordinators shared their experience in the attached presentation with:
�        Lockout writers/developers
�        Planners
�        Supervision
�        Others as applicable 
Comments 
5/12/2014 3:44:19 PM by Bailey, Mary Jo 
This has been submitted to those current in SAF104: LOCK, TAG, AND TRY         
Summary         Lesson ID:         821 
        Status:         OK 
        Doc ID:         2014-JLAB-821 
        Priority:         Info 
        Safety Related:         YES 
        Originator:         Bailey, Mary Jo 
        Issued:         5/12/2014 3:38:25 PM 
        Approved By:         Bailey, Mary Jo 
        Approved On:         5/12/2014 3:44:19 PM 
        Source:         DOECRD 
        Location:         OTHER 
        Cost Savings:         
        Contact:         David Lester, Operating Experience Program Coordinator - (803) 208-8743 
        Queued Emails:         0 
        Sent Emails:         0 
        Viewings:         1 times Attachments 

    * M:\wcd\LessonsLearned\DOEOEC\DOE Lessons Learned - LTT1 Pics.pdf 
    * M:\wcd\LessonsLearned\DOEOEC\DOE Lessons Learned - LTT1.pdf 
Hazard Issues 

    * Electricity 
Skills 

    * SAF104: LOCK, TAG, AND TRY 
Distribution/Notification 

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