[Hallb-engineering] Fwd: Lesson Learned "FML-15-0710 Golf Cart 55 Event"

[Douglas Tilles]

Sent from my iPhone

Begin forwarded message:

> From: cjohnson at jlab.org
> Date: October 9, 2015 at 10:00:13 AM EDT
> To: cjohnson at jlab.org
> Subject: Lesson Learned "FML-15-0710 Golf Cart 55 Event"
> 
> 
> FML-15-0710 Golf Cart 55 Event
> Statement of Lessons Learned
> 
> 1. Although not required, it is beneficial to all persons that use the motorized (electrical and gas) vehicles and carts, to take the online training which will familiarize users with the motorized carts and vehicles.
> 
> 2. A quick visual inspection is required before you use the motorized vehicles to ensure there are no safety issues prior to using the vehicles.
> Discussion of Activities
> 
> There was a golf cart incident on Friday, July 17, 2015 around 1530.  An employee was driving cart 55 behind the TEDF building to park it for the weekend when the accelerator pedal got stuck in the acceleration position.  The employee reported he was unable to engage the break and the cart went over the wheel stop and hit the charging station prior to hitting the barricade wall.  The employee was not injured and immediately reported this incident to his supervisor and the guards. The employee also reported to the Medical Department that afternoon, and had a follow-up visit on Monday, July 20, 2015.   The guards and FM&L staff reported to the scene and evaluated the cart.  The pedal remained in the engaged position until the FM&L mechanic turned the cart off and then pressed on the pedal which disengaged the pedal.    
>   
> The golf cart experienced minor damage.  The cart was immediately placed out of service.  The Facilities mechanic took the cart and test drove it to try and repeat the sticking pedal.  He was unable to repeat this situation until he pushed the pedal down with excessive force.  At that point the pedal¿s top section deflected (bent) which caused the deflected section of the pedal to wedge against the floor board.  It was noted that the rubber portion of the pedal had a cut on it right at the point of the deflection.  The cart was sent on Monday morning to a golf cart sales and repair vendor for further evaluation.  
> Analysis
> 
> Root Cause:  	Equipment malfunction- Excessive force when pushing down the accelerator pedal to try and go faster, or disengage the brake caused the rubber section of the pedal to tear and deflect.  This tear and deflection while pressing hard on the pedal caused the pedal to stick to the cart¿s floor board.  
> 
> Contributing Causes:
> 1.	It may have been known that this sticking of the pedal happened before, but it was never reported to Facilities Management and Logistics.
> 2.	Out of habit, golf cart users are accustomed to pressing hard on the accelerator pedal to quickly disengage the brake verses pressing the lower section of the brake to easily release the brake.
> 3.	Pressing down hard on the accelerator while operating the cart (similar to that of a car) does not provide more speed, yet people press hard on the pedals, as seen by the ware marks on the floor board rubber.
> 
> Recommended Actions
> 
> Extent of Condition:
> 
> Check to verify that other carts at the lab that are of the same model and age also have accelerator pedals that touch the floor board and operate properly.
> 
> Corrective Actions:
> 1. Ensure that the existing maintenance schedule matches the manufacturer¿s recommendations and includes the accelerator pedals.
> 2. Publish a weekly brief article informing people to report known issues with any motorized vehicles or carts.
> JLab Preventive Measures
> 
> See corrective actions
> Comments
> 
> 10/9/2015 9:58:30 AM by Johnson, Tina
> 
> Please share with your co-workers and within your work groups.
> Summary
> Lesson ID:	910
> Status:	OK
> Doc ID:	2015-JLAB-910
> Priority:	Info
> Safety Related:	NO
> Originator:	Johnson, Tina
> Issued:	10/2/2015 9:30:12 AM
> Approved By:	Johnson, Tina
> Approved On:	10/9/2015 9:58:30 AM
> Source:	TJNAF NE 		           		           		        
> Location:	TJNAF
> Cost Savings:	
> Contact:	Bob Sperlazza
> Queued Emails:	0
> Sent Emails:	0
> Viewings:	13 times
> Attachments
>  Hazard Issues
> Other: Golf Cart safety and maintenance
> Skills
> GEN401kd: GSA VEHICLE REFUELING PROCEDURE
> GEN400kd: GOLF CART DRIVER FAMILIARIZATION
> GEN400: Local Driving Conditions
> GEN403: Passenger Vehicle Training
> Distribution/Notification
> *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.
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <https://mailman.jlab.org/pipermail/hallb-engineering/attachments/20151009/16ee323c/attachment.html>