[Hallb-engineering] Fwd: Lesson Learned "Incident Averted because of Good Work Planning and Hazard Analysis"

[Douglas Tilles]

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From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Thursday, May 28, 2015 5:00:53 PM
Subject: Lesson Learned "Incident Averted because of Good Work Planning and Hazard Analysis"

Jefferson Lab Lessons Learned : Print Lesson 
	Incident Averted because of Good Work Planning and Hazard Analysis 
	
Statement of Lessons Learned 
When removing a pressure gauge used for routine testing, it was discovered that the threads were worn.  It was taken out of service and replaced immediately. 
Discussion of Activities 
An Ashcroft Test Gauge was being used for routine testing.  It had been recently calibrated (three months before), and was in good working order.  When it was removed from the test piece, it was discovered that the first three rows of threads had worn down (see photo below).  The technician removed it from service and replaced it with one that that was in good working order. 
Analysis 
Jefferson Lab�s Work Planning Control and Authorization Work Process incorporates a hazard analysis phase.  This is included so employees consciously review their task to identify unmitigated hazards.  Using the hazard analysis processes steps during the assignment, it was recognized that the test pressure gauge would not be acceptable for another test and it was replaced. 
Recommended Actions 
Below are the consequences of the above event.  They are provided for information and discussion purposes only. 

When asked about the lesson learned regarding the pressure gauge, and that an incident had been averted, the technician stated �[It was]�a pressure gauge that we discovered had worn threads from multiple installs and removals.  All this shows is to pay attention to your equipment�s condition.� 
JLab Preventive Measures 
Jefferson Lab�s Work Planning Control and Authorization Work Process is introduced to employees on their first day of work and incorporated within all phases of work.  Often the process steps become so ingrained employees do not recognize they are doing them. 
Comments 
5/28/2015 4:08:00 PM by Bailey, Mary Jo 
Submitted to those with Pressure System Safety Awareness Training 
	
Summary 	Lesson ID: 	889 
	Status: 	OK 
	Doc ID: 	2015-JLAB-889 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	5/28/2015 4:05:22 PM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	5/28/2015 4:08:00 PM 
	Source: 	TJNAF Other 
	Location: 	TJNAF 
	Cost Savings: 	
	Contact: 	Will Oren, Pressure Systems Committee Chair, (oren at jlab.org) 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	3 times Attachments 

Hazard Issues 

    * Pressure Systems 
    * Other: Work Planning and Communication, 
Skills 

    * SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS 
Distribution/Notification 

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




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