[Hallb-engineering] Fwd: Lesson Learned "ENG-16-0726- Breach of a Radiological Area (Contamination and Radiation Area)"

[Douglas Tilles]

FYI

----- Forwarded Message -----
From: "Tina Johnson" <cjohnson at jlab.org>
To: "Tina Johnson" <cjohnson at jlab.org>
Sent: Thursday, October 20, 2016 11:00:20 AM
Subject: Lesson Learned "ENG-16-0726- Breach of a Radiological Area (Contamination and Radiation Area)"

Jefferson Lab Lessons Learned : Print Lesson 
	ENG-16-0726- Breach of a Radiological Area (Contamination and Radiation Area) 
	
Statement of Lessons Learned 
Employees that have conducted their work in the same manner for a long period of time should consider having another work group observe their work to ensure they are following the most current procedures and good work practices.

When working in areas that are both Radiation Areas and Contamination Areas, remember the rule of radiation boundaries.  You must honor and respect those boundaries at all times. 
Discussion of Activities 
An EES Associate Coordinator (AC) entered building 95 (hall C beam dump building) and encroached upon the Radiation Area/Contamination Area boundary within the building.  The AC moved the radiological boundary in order to position the legs of the ladder and then leaned the ladder against a tank, resulting in the ladder crossing the roped boundary. The AC climbed the ladder, placing himself within the posted area, removed a component from the system within the area, and removed it from the building.  The AC was not signed in on the RWP for entry to the roped area, did not receive a radiological briefing, and wore no PPE.

A Radcon technician (RCT) arrived as the EES AC was leaving the building.  Noticing the removed component, the RCT questioned the AC, determined that there had been an infraction of the radiological area, performed surveys on all items and areas affected by the breach, and denied the AC further entry.  RadCon management and JLab reporting officer were notified. 
Analysis 
Root Cause:  	
Communication of expectations from management/supervision to work teams less than adequate. 

Contributing Causes:
1. Prejob walkdown was not performed or was inadequate (did not identify boundary issue).
2. Prejob briefing/communications with RadCon was inadequate (no work details discussed).
3. Recent communication efforts stemming from similar event did not prevent this event. 
Recommended Actions 
1.  Employee�s RadWorker I and RadWorker II training was revoked and his supervisor(s) were notified of the same.

2.  Hold documented briefing session (department wide) to stress expectations of supervisors and work leads, importance of following work planning standards, admin controls, etc. (prejob reviews, walkdowns, etc).

3.  Counsel worker on importance of identifying and complying with all EHS issues and proper interactions with SME/EHS reps based on nature of work.

4.  Conduct advanced RW training for population of workers who routinely work in 91/95. [continuous improvement action]

5.  Issue site-wide communications regarding extent of boundaries in a JLab weekly brief.

6.  Evaluate work preparation/planning, execution, etc. within EES.  Consider tools such as Management Self-Assessments, Work Observations, etc.  Suggest obtaining assistance from QA/CI to tailor the approach to fit the conditions. [continuous improvement action]  

7. Evaluate the feasibility of installing an engineered system for accessing the upper portions of the expansion tanks in buildings 91 and 95.  If feasible, develop estimate of project cost, present to Acc. Division as safety improvement project. [continuous improvement action] 
JLab Preventive Measures 
See above mentioned corrective actions. 
Comments 
10/20/2016 9:29:10 AM by Johnson, Tina 
SME review and approved.  

Please review and discuss within your work groups. 
	
Summary 	Lesson ID: 	974 
	Status: 	OK 
	Doc ID: 	2016-JLAB-974 
	Priority: 	Info 
	Safety Related: 	NO 
	Originator: 	Johnson, Tina 
	Issued: 	10/17/2016 11:49:48 AM 
	Approved By: 	Johnson, Tina 
	Approved On: 	10/20/2016 9:29:10 AM 
	Source: 	TJNAF NE 
	Location: 	TJNAF 
	Cost Savings: 	
	Contact: 	Keith Welch 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	8 times Attachments 


Hazard Issues 

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

    * SAF801P: Radiation Worker I Knowledge--Implementation 
    * SAF801C: Radiation Worker I Knowledge--Information 
    * SAF801T: Radiation Worker I Knowledge--Assessment 
    * SAF802: Rad Worker II Radiological Knowledge 
    * SAF801kd: General Access RWP 
Distribution/Notification 

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




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