[Hallb-engineering] Fwd: Lesson Learned "Lockout/Tagout Device Condition Transient Reactor Test Facility (TREAT)"

[Douglas Tilles]

FYI

----- Forwarded Message -----
From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Friday, September 2, 2016 11:00:15 AM
Subject: Lesson Learned "Lockout/Tagout Device Condition Transient Reactor Test Facility (TREAT)"

Jefferson Lab Lessons Learned : Print Lesson 
	Lockout/Tagout Device Condition Transient Reactor Test Facility (TREAT) 
	
Statement of Lessons Learned 
On January 14, 2016, a TREAT Facility Representative questioned the adequacy of a locking device along with its ability to prevent operation of the associated 120v breaker due to slight play in the lockout configuration.  It was theorized that a reasonable scenario could result in a condition that would allow the breaker to be shut with the locking device in place.  

The investigation resulting from this theory showed that when fully closed the locking device did prevent operation of the breaker. 
Discussion of Activities 
The locking device was from different manufacturer than those authorized.  It looked similar but did not have the same physical dimensions or operability functions. 
Analysis 
All Authorized Workers on the LO/TO confirmed that when the locking device was initially installed all had verified the installation and adequacy of the device; and that even though the system had been locked out it was in its normal configuration as work had not started. 
Recommended Actions 
Below are the consequences of the above event.  They are provided for information and discussion purposes only. 

The Operations Manager contacted the Facility Area Supervisor to confirm that no work was being performed under the LO/TO in question and removed any effected work from the approved Plan of the Day.  

An inspection of all installed LO/TOs was performed to ensure no other devices exhibited the same issue.

All similar locking devices were checked to ensure they provided full locking capability.  The failed locking device, while of the same design, was from a different manufacturer and had a slightly smaller diameter shackle which allowed the clearance to shut the breaker.

The workers removed their personal locks from the suspect locking device and replaced it with one that clearly prevented operation of the breaker. 
JLab Preventive Measures 
(Jefferson Lab�s Subject Matter Expert has read and approved this lesson.)

In accordance with Jefferson Lab�s ES&H Manual Chapter 6110 Lock, Tag, Try Program only approve and authorized locks and tags are to be used for locking out of systems.  Samples of pproved locks and Tags can be found at https://www.jlab.org/ehs/ehsmanual/Glossary.htm#LTTDef .  

Contact Todd Kujawa, Electrical Safety Engineer at x7006 if you have questions regarding the adequacy of a lock, or you see an unapproved lock on a system. 
Comments 
9/2/2016 9:17:29 AM by Bailey, Mary Jo 
Submitted to those with SAF603A: ELECTRICAL SAFETY AWARENESS 
	
Summary 	Lesson ID: 	963 
	Status: 	OK 
	Doc ID: 	2016-JLAB-963 
	Priority: 	Best Practice 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	9/2/2016 9:13:38 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	9/2/2016 9:17:29 AM 
	Source: 	DOECRD 
	Location: 	INL 
	Cost Savings: 	
	Contact: 	L. Kinghorn/ 208-533-889 TREAT at Idaho National Laboratory 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	1 times Attachments 

    * DOE - LTT1.pdf 
    * ES&H Manual Chapter 6110 Appendix T1 Lock, Tag, Try (LTT) Procedure 

Hazard Issues 

    * Lock, Tag, Try 
Skills 

    * SAF603A: ELECTRICAL SAFETY AWARENESS 
Distribution/Notification 

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




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