[Hallb-engineering] Fwd: Lesson Learned "Bypassed Hold Points on Critical Lift - Savannah River Site - MOX Project"

[Douglas Tilles]

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From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Monday, April 11, 2016 3:00:17 PM
Subject: Lesson Learned "Bypassed Hold Points on Critical Lift - Savannah River Site - MOX Project"

Jefferson Lab Lessons Learned : Print Lesson 
	Bypassed Hold Points on Critical Lift - Savannah River Site - MOX Project 
	
Statement of Lessons Learned 
Prior to conducting critical lifts/planned lifts, work crew supervision must ensure that all work package inspections have been conducte d and that no hold points, Non-Conformance Reports (NCRs), and open issues exist which would prevent the successful, safe and compliant conduct of the lift. To that end, corrective actions have been implemented to ensure complete communication and understanding of the clearance status for the lift by all involved parties. 
Discussion of Activities 
A critical lift for took place without Hold Points for weld repairs on lifting lugs being released by Quality Control. This lift occurred on 12 May 2015 after an approximately 2 week period of daily anticipation of making the lift. Almost daily during this period one or more new issues emerged that prevented the lift from occurring. On 12 May 2015, a NCR addressing inadequate vendor welding of three lugs on the filter housing was dispositioned ӵse as-isԮ Upon removal of the NCR hold tags, the filter housing was lifted under a planned lift plan approximately 10 inches from its resting position to verify the rigging inst allation . Almost immediately it was determined that a hold point(s) applicable to a field weld(s) in the body of the work package/work packet had not been cleared. The filter housing was returned to its rest position for resolution of the hold point issues. Upon resolution of the hold point issues the lift of the filter housing occurred. It was later determined during this investigation that one hold point in the body of the work package had never been cleared. Therefore, both lifts of the filter housing violated one or more hold points. 
Analysis 
Recommended Actions 
Action 1 (Preventive): Counsel personnel in charge for this lift on attention to detail implementing pre-lift verifications. 

Action 2 (Preventive): Revise procedure for Rigging and Lifting Equipment- Equipment Inspections to require the above cited Pre-lift verification to be incorporated into every planned lift plan and every critical lift plan. 

Action 3 (Preventive): Revise procedur e for Wo rk Package Planning to require that the Pre-lift verification established above to be incorporated into every work package/work packet for which a planned lift or a critical lift is required. 
JLab Preventive Measures 
(Jefferson Lab�s Welding Subject Matter Expert has read and provided the following preventive measure recommendations.)

If you reject [a work processes/step] in the SRF/LCLS pansophy system it notifies a whole set of folks and you have to complete a NRC.  ...If it were a safety related rejection like welds on lifting lugs/eyes I would certainly tag thru the hole so there would be no way someone could say they did not see the tag.

If the lifting lugs or rings were rejected, I would tag them out with our QA Hold Red Tag just to be sure there would be no way to attached a sling or chain to the affect part. 
Comments 
4/11/2016 2:26:23 PM by Bailey, Mary Jo 
Submitted to those current in:
SAF150: WELDING SAFETY
SAF402: CRANE OPERATION AND RIGGING 
	
Summary 	Lesson ID: 	943 
	Status: 	OK 
	Doc ID: 	2016-JLAB-943 
	Priority: 	Info 
	Safety Related: 	NO 
	Originator: 	Bailey, Mary Jo 
	Issued: 	4/11/2016 2:25:02 PM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	4/11/2016 2:26:23 PM 
	Source: 	DOECRD 
	Location: 	SRNL 
	Cost Savings: 	
	Contact: 	Leonard Alexander / 803-226-6787 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	2 times Attachments 


Hazard Issues 

    * Hot Work 
    * Material Handling Equipment 
    * Welding, Cutting, Brazing, and Grinding 
    * Cranes & Hoists - Critical Lift 
Skills 

    * SAF150: WELDING SAFETY 
    * SAF402: CRANE OPERATION AND RIGGING 
Distribution/Notification 

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




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