[Hallb-engineering] Fwd: Lesson Learned "Configure Fixed-Location Quick Disconnects on Compressor Tools to Prevent Injury - Lawrence Livermore National Security, LLC"

[Douglas Tilles]

FYI

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From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Monday, August 22, 2016 10:00:12 AM
Subject: Lesson Learned "Configure Fixed-Location Quick Disconnects on Compressor Tools to Prevent Injury -  Lawrence Livermore National Security, LLC"

Jefferson Lab Lessons Learned : Print Lesson 
	Configure Fixed-Location Quick Disconnects on Compressor Tools to Prevent Injury - Lawrence Livermore National Security, LLC 
	
Statement of Lessons Learned 
An employee was in the process of disconnecting an air hose when it slipped out of his grasp and struck him near his right eye. The employee was sent to LLNL Health Services, and was diagnosed as having a contusion that did not require treatment.  He was able to return to work without restrictions. 
Discussion of Activities 
The stored energy in a pressurized air hose surprised a worker when he disconnected the hose from a quick disconnect in an LLNL shop. Personnel are reminded that potential energy exists in this type of connection and to position themselves out of the way of a pressurized air hose that may be ejected during removal from a quick disconnect.  Whenever possible, quick disconnect fittings should be oriented to make it easy for workers to stay out of the way of an ejected hose. 
Analysis 
The ~100 PSIG house air pressure inside the hose caused it to travel far enough and with enough force to strike the worker as it was is not restrained during disconnection.

The worker was current on all relevant training and was performing an operation he had completed numerous times without incident. However, in this instance, instead of having a firm, positive grasp on the air hose, he held it with only two fingers. 

The plumbing for this particular quick disconnect was mounted on the floor, adjacent to other hardware. The easiest way to access it is to bend over while standing directly above it. Because the quick disconnect was oriented vertically, this position places the worker directly in line with the hose. 
Recommended Actions 
Make sure workers who use quick disconnects understand: 
-the potential energy stored in a pressurized hose,
-the potential for injury and damage when connecting to/disconnecting from a quick disconnect,
-the necessity of grasping the hose firmly and within one or two inches of the end that goes into the quick disconnect whenever connecting or disconnecting, and
-when possible, place themselves out of the way when connecting or disconnecting.

When configuring quick disconnects to systems with fixed locations (e.g., shop air systems), orient the quick disconnect such that:
-the user can easily stay out of the way while manipulating the quick disconnect, or
- orient the line of fire away from the user. 
JLab Preventive Measures 
Jefferson  Lab's Machine Tool Subject Matter Expert provided the following comment:

In accordance with ES&H Manual Chapter 6151 Pressure ad Vacuum Systems Safety Program: Pressure System System Owner (Compressed-air and pressurized air reservoirs above 15 psi):

    Shall maintain required training
    Shall ensure that systems under their purview are maintained and operated by trained personnel. This training shall include understanding of procedures.
    Shall ensure that pressure vessels, pressure systems and relief devices installed on systems under their purview are tested and inspected.
    Shall ensure that systems under their purview continue to be maintained and operated in a safe manner. Standard work planning tools (i.e. THA, ATLis, TOSP, etc.) shall be employed that describe any required system configuration and preparation prior to and following maintenance activities. 
Comments 
8/22/2016 8:54:14 AM by Bailey, Mary Jo 
Submitted to those with SAF502: FORKLIFT OPERATOR
SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS 
	
Summary 	Lesson ID: 	961 
	Status: 	OK 
	Doc ID: 	2016-JLAB-961 
	Priority: 	Best Practice 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	8/22/2016 8:51:14 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	8/22/2016 8:54:14 AM 
	Source: 	DOECRD 
	Location: 	OTHER 
	Cost Savings: 	
	Contact: 	Jeff Horning, horning1 at llnl.gov, 925-424-5393 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	1 times Attachments 

    * DOE - Configuration.pdf 
    * ES&H Manual Chapter 6151 Pressure and Vacuum Systems Safety Program 

Hazard Issues 

    * Machine Tools 
    * Pressure Systems 
Skills 

    * SAF502: FORKLIFT OPERATOR 
    * SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS 
Distribution/Notification 

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




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