[Hallb-engineering] Fwd: Lesson Learned "ENG-15-0220 - Emplyee Made an Entry into Hall A Beam Dump Without a Confined Space Permit"

Douglas Tilles tilles at jlab.org
Wed Apr 29 06:50:18 EDT 2015

A good lesson to keep in mind.  Doug

----- Forwarded Message -----
From: "Tina Johnson" <cjohnson at jlab.org>
To: "Tina Johnson" <cjohnson at jlab.org>
Sent: Tuesday, April 28, 2015 5:00:39 PM
Subject: Lesson Learned "ENG-15-0220 - Emplyee Made an Entry into Hall A Beam Dump Without a Confined Space Permit"

Jefferson Lab Lessons Learned : Print Lesson 
	ENG-15-0220 - Emplyee Made an Entry into Hall A Beam Dump Without a Confined Space Permit 
Statement of Lessons Learned 
1. It seems that clear roles and responsibilities were not identified before this work began. It is imperative that roles are identified, reliable communication methods are established prior to completing high risk work.
2. It is imperative that safety requirement listed in a RWP or confined space permit be clear and concise. Although not a contributing factor in this event, upon review of the language in the RWP, it may be slightly confusing and/or could possibly be interpretted incorrectly by a worker that is reviewing the RWP for the first time. 
Discussion of Activities 
On February 20, 2015, Engineering (Installation Group) personnel entered
the Hall A Beam Dump tunnel to perform some punchlist work on the dump
upgrade.  The nitrogen system had been locked out and purged since
02/10/2015, so no imminent hazards existed, however, this entry should have
been treated as a confined space entry.  No confined space permit was
developed, and the workers entered the area without monitoring the air and
without wearing personal oxygen monitors. 
Root Cause:  	1.	Management and Supervisory Methods LTA- The final phase of
the project resulted in multiple entries by the Engineer Techs to complete
punch list items.  This transition of the project to its final phase
resulted in the lack of clear roles and responsibilities for work planning
and execution.  The assigned tasks and expectations were not made clear to
the workers prior to performing their work (Guiding Principle #2 Clear
Roles and Responsibilities)

Contributing Causes:
1.	Work execution and planning was LTA- Pre Job briefing and thorough
review of existing work planning documentation prior to the execution of
the work was less than adequate.  Not all the required work planning
documentation (ATlis, Confined Space Permit)was complete prior to this
entry.  RWP was complete and identified the need for a confined space
permit; however, in the field this requirement was not recognized nor were
the techs briefed on the hazard during the pre-job brief in the field.  
2.	Hazard signs were not visible after the entry door was open. 
3.	Work planning was LTA- It seems that clear roles and responsibilities
may not have been established prior to the work on 2/20.  Specifically who
was responsible for completing the confined space permit prior to entry. 
Both work groups were focused on the radiological hazard only. 
4.	Pre- Job walkdown did not occur.  Work was assigned verbally.  RadCon
technician was asked to review the RWP and did not recognize the confined
space requirement that was listed in the RWP.  
5.	It was also assumed that an ATlis entry had been complete for this job,
however, post event it was discovered that the entry was an umbrella ATlis
entry which did not detail the work and recognize the need for a confined
space permit. 
6.	A time lapse, from the initial authorized and proper entry until this
event, may have contributed to this event.  Employees relied heavily on
past entry experience.
7.	There were incorrect assumptions made by the parties involved in this
event based on previous successful entries.  
8.	Communication LTA-  Work groups failed to communicate the confined space
hazard and requirements with one another. 
Recommended Actions 
1. Post additional signs on the wall area that are visible when the entry door to the Hall A dump is open.
2. Complete an A Tlis entry for the tasks associated with the Hall A dump. When work is cross divisional ensure that the ATlis entry identifies a task lead.
3. Complete a confined space pennit for the schedule entry on 02/25/2015.
4. Complete confined space training for individuals that did not have the training prior to this event.
5. Brief those that may enter the Hall A Dump to the existing OSP to ensure they are familiar with the additional requirements for entry into that space.
6. Conduct a safety meeting with all of the Rad Con Technicians to reiterate the importance of allowing the workers the opportunity to read the RWP, then
follow up by reviewing the R WP line by line with the workers, and then giving the workers the opportunity to ask questions. As a quality check ensure that all identified hazards are properly mitigated before the entry as well.
7. Conduct a safety meeting to reiterate the importance of reviewing the WPC documents, identifying roles and responsibilities, and maintaining sign awareness when completing work. Also review ESH 3210 WPC flow diagram.
8. Add a tag (large enough to be a nuisance) to the existing RadCon lock that identifies the additional hazard that is unique to this space- "Confined space
permit required before entry. "
9. ES&H Manual Chapter 3210 document owner should evaluate the need to update the Work Planning and Control Diagram to include the details stating that if the work requires 2 temporary permits, you should contact your DSO and consider developing an overarching OSP for entry to the dumps that contains the Hazard Analysis, access requirements, responsible person(s) requirement,
listing of sub-system owners, coordination requirements etc. already defined and could be attached to an ATLis with detailed tasks. If this diagram is updated, there should be training given to those that frequently use Work Planning Tools.

RadCon should clarify confined space permit language within the related RWP and consider identifying a RadCon and other hazard lead within the RWP database.

IH should consider making the confined space permit an electronic form. This form would go to IH for review and concurrence before equipment is
distributed for use. The electronic form could be linked to the training database ensuring training is current before the work commences. 
JLab Preventive Measures 
4/28/2015 4:53:56 PM by Johnson, Tina 
SME has reviewed and approved.  Please share this notable event and lessons learned with those within your group. 
Summary 	Lesson ID: 	883 
	Status: 	OK 
	Doc ID: 	2015-JLAB-883 
	Priority: 	Info 
	Safety Related: 	NO 
	Originator: 	Johnson, Tina 
	Issued: 	4/28/2015 4:33:40 PM 
	Approved By: 	Johnson, Tina 
	Approved On: 	4/28/2015 4:53:56 PM 
	Source: 	TJNAF NE 
	Location: 	TJNAF 
	Cost Savings: 	0 
	Contact: 	Bill Merz 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	2 times Attachments 

Hazard Issues 

    * Oxygen Deficiency Hazards (ODH) 

    * OSHA1: OSHA General Industry Outreach Trainer 

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

Do you have a lesson learned you would like to contribute? Contact the Lesson Learned Coordinator .

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