[Hallb-engineering] Fwd: Lesson Learned "Metal Halide Bulb Fails, Shatters Outer Glass Envelope, Hot Glass Shard Chars Wood Crate - Fermi National Accelerator Laboratory"

[Douglas Tilles]

FYI

----- Forwarded Message -----
From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Wednesday, January 4, 2017 11:00:09 AM
Subject: Lesson Learned "Metal Halide Bulb Fails, Shatters Outer Glass Envelope, Hot Glass Shard Chars Wood Crate - Fermi National Accelerator Laboratory"

Jefferson Lab Lessons Learned : Print Lesson 
	Metal Halide Bulb Fails, Shatters Outer Glass Envelope, Hot Glass Shard Chars Wood Crate - Fermi National Accelerator Laboratory 
	
Statement of Lessons Learned 
Lighting fixtures and replacement bulbs should be evaluated for the application. Open (unprotected) fixtures should be lamped with bulbs that have provisions to contain shards if a bulb fails so as not to cause further property or personnel damage. 
Discussion of Activities 
The morning of September 8, 2015, technicians arrived at the D0 Assembly Building (DAB) and switched on the high bay lighting.  Approximately 40 minutes later they heard a buzzing noise and then a "pop," and then glass rained down to the floor (approximately 60 feet). The technicians went to investigate and noticed that a metal halide bulb had failed and shattered its outer glass envelope. The high bay lighting fixture was a non-protected (no grill or deflector) fixture. The technicians later noticed a smell of burning wood. When they investigated, they found that a piece of the hot glass had fallen on a wood pallet causing a dime sized char mark. (Photos included in attachment.)

On December 12, 2015 a second metal halide 1000W lamp failed in the same manner, again at DAB.  Both lamp failures occurred over the deep pit area.  This area had been designated  a "no maintenance zone" since 2010, as there was no safe way to replace the lamps.

On December 27, 2016 a third metal halide 1000W lamp failed and rained glass down in the  Proton Assembly Building area where Type "E" lamps in open fixtures remain. 
Analysis 
The high bay lighting fixture is a non-protected (no grill or deflector) fixture, containing a 1000 Watt (W) MH lamp.  The 2015 incident investigation revealed that the Type "E" MH lamp being used in the DAB area was meant for use in an enclosed fixture that would contain the glass and quartz shards that would result from a non-passive lamp failure.  Corrective actions  were implemented in this area at the time.

However, the Type "E" MH lamps remained in the Proton Assembly Building Area . 
Recommended Actions 
(Provided for Discussion Purposes)

The situation will now be mitigated by either restricting access and removing combustibles from a fall zone below, or de-energizing the non-mitigated fixtures until lamp replacement is complete.

OSHA has a Technical Information Bulletin (See Attached) discussing the failure of these lamps and that there are special bulbs for the open fixture applications. 
JLab Preventive Measures 
Jefferson Lab has a robust "Extent of Condition" program to identify hazardous conditions and mitigate them over the entire site.  This program is integrated within the Notable Events Investigation and Reporting process and uses the Corrective Action Tracking System to ensure completion.

Lesson Learned notifications are also provided in order to increase awareness of hazardous situation and the mitigation activities applied by others in order to decrease similar occurrences here at Jefferson Lab. 
Comments 
1/4/2017 9:54:53 AM by Bailey, Mary Jo 
Submitted to those with the following training:
SAF104: LOCK, TAG, AND TRY
SAF115O: LERF Laser Operator Training
SAF120kd: SAFETY OBSERVATION PROGRAM 
	
Summary 	Lesson ID: 	985 
	Status: 	OK 
	Doc ID: 	2017-JLAB-985 
	Priority: 	Info 
	Safety Related: 	NO 
	Originator: 	Bailey, Mary Jo 
	Issued: 	1/4/2017 9:22:21 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	1/4/2017 9:54:53 AM 
	Source: 	DOECRD 
	Location: 	Fermilab 
	Cost Savings: 	
	Contact: 	Angela Aparicio, FNAL, 630-840-3701 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	1 times Attachments 

    * DOE - Bulb Replacement Pic.pdf 
    * DOE - Bulb Replacement Bulletin.pdf 
    * DOE - Bulb Replacement.pdf 

Hazard Issues 

    * Electricity 
    * Sharp Edges 
Skills 

    * SAF104: LOCK, TAG, AND TRY 
    * SAF115O: LERF Laser Operator Training 
    * SAF120kd: SAFETY OBSERVATION PROGRAM Read (http://www.jlab.org/ehs/ehsmanual/manual/3700.html) Then Contact Bob May ext.7632 to arrange practical 
Distribution/Notification 

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




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