[Hallb-engineering] Fwd: Lesson Learned "Radiation Area Not Identified or Posted During Survey"

[Douglas Tilles]

FYI

----- Forwarded Message -----
From: "Tina Johnson" <cjohnson at jlab.org>
To: "Tina Johnson" <cjohnson at jlab.org>
Sent: Wednesday, May 25, 2016 10:27:42 AM
Subject: Lesson Learned "Radiation Area Not Identified or Posted During Survey"

Jefferson Lab Lessons Learned : Print Lesson 
	Radiation Area Not Identified or Posted During Survey 
	
Statement of Lessons Learned 
When performing routine work, it is always best to revert back to the procedure to ensure that you are following every step as if you were a new employee. 
Discussion of Activities 
On 3/11/16 the RadCon Field Operations Group Leader (FOGL) surveyed and re-posted an existing radiation area at the warm region girder between SL23 and 24 to a smaller area.  The survey conducted to shrink the size of the area did not identify the true extent of the radiation area.  An area beneath the SL24 cryomodule extending about six feet downstream from the girder had whole body dose rate above 5 mrem/hr, but the survey did not reveal this portion of the radiation area. The area beneath the cryomodule was not posted as a radiation area until another survey was performed on 3/16/16, when the condition was discovered. 
Analysis 
A3B3C01: Attention was given to wrong issues (in this case, more focus on historically known activation patterns)
A4B4C07: Too many concurrent tasks assigned to worker
A3B2C03: Too much activity was occurring and error made in problem solving
A3B2C01: Strong rule incorrectly chosen over other rules
A4B3C08: Job scoping did not identify special circumstances and/or conditions 
Recommended Actions 
Extent of condition:
Survey of both linacs completed as part of the initial finding.

Corrective Actions:

1. Communicate new activation phenomenon to all ARMs and RCTs.
2. Incorporate the new activation patterns into standard ARM/RCT training materials.
3. Investigate training exercises which strengthen problem-solving techniques for novel or unfamiliar situations. Include in RCT continuing training.
4. Enhance procedures for de-posting radiological areas.  Posting and surveys are covered by two procedures within RadCon, but neither specifically speaks to de-posting a radiation area.  Consider whether radiation area de-posting should be restricted only to RCTs. Train RCTs and ARMs on revised procedures.
5. Enhance procedures for de-posting radiological areas.  Posting and surveys are covered by two procedures within RadCon, but neither specifically speaks to de-posting a radiation area.  Consider whether radiation area de-posting should be restricted only to RCTs. Train RCTs and ARMs on revised procedures.
6. Conduct a workload/resource analysis of the Field Operations Group.  Make recommendations to management based on results. 
JLab Preventive Measures 
See above corrective actions. 
Comments 
5/25/2016 9:22:39 AM by Johnson, Tina 
Please review and share within your work areas. 
	
Summary 	Lesson ID: 	947 
	Status: 	OK 
	Doc ID: 	2016-JLAB-947 
	Priority: 	Caution 
	Safety Related: 	NO 
	Originator: 	Johnson, Tina 
	Issued: 	5/3/2016 1:59:05 PM 
	Approved By: 	Johnson, Tina 
	Approved On: 	5/25/2016 9:22:39 AM 
	Source: 	TJNAF NE 
	Location: 	TJNAF 
	Cost Savings: 	
	Contact: 	Keith Welch 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	1076 times Attachments 


Hazard Issues 

    * Radiation - Ionizing 
    * Controlled Area 
    * Radiological Controlled Area 
Skills 

    * SAF801T: Radiation Worker I Knowledge--Assessment 
    * SAF802: Rad Worker II Radiological Knowledge 
    * SAF803: Comprehensive Knowledge for Assigned Radiation Monitors 
    * SAF803E: Knowledge for Assigned Radiation Monitors in Experimental Halls 
    * SAF803F: Knowledge for Assigned Radiation Monitors in FEL 
    * SAF899: RADIATION CONTROL TECHNOLOGIST 
    * SAF803V: Knowledge for Assigned Radiation Monitors in VTA 
    * SAF803kd: General Access RWP for ARMs 
    * SAF801kd.1: RWP FOR VTA 
    * SAF801kd.2: RWP 10S001HRAW1 
    * SAF803Ekd: Radiation Surveys During QWEAK 
Distribution/Notification 





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