[Hallb-engineering] Fwd: Lesson Learned "ACC-16-1003- Employee Failed to Properly Post a High Radiation Area and a Radiation Area"

[Douglas Tilles]

FYI

----- Forwarded Message -----
From: "Tina Johnson" <cjohnson at jlab.org>
To: "Tina Johnson" <cjohnson at jlab.org>
Sent: Friday, January 6, 2017 11:00:14 AM
Subject: Lesson Learned "ACC-16-1003- Employee Failed to Properly Post a High Radiation Area and a Radiation Area"

Jefferson Lab Lessons Learned : Print Lesson 
	ACC-16-1003- Employee Failed to Properly Post a High Radiation Area and a Radiation Area 
	
Statement of Lessons Learned 
1. Unique programs involving delegation of key functions outside primary program ownership should undergo periodic formal reviews to ensure scope of the delegated functions and skill set inventory remain well matched.

2. Subject matter experts (SMEs) should either conduct or provide close oversight of on-the-job training on safety-significant tasks. 
Discussion of Activities 
During a Controlled Access, an employee in the South Linac came upon a radiological area and questioned the posting.  The worker informed the Operability Manager who then contacted RadCon.  RadCon investigated the South Linac, and determined that a high radiation area and radiation area were not appropriately posted as required under 10 CFR 835.  The condition was immediately corrected. 
Analysis 
Root cause:
Complex system; knowledge-based decision required.  Given the current scope and complexity of radiological conditions, performance expectations for ARMs may exceed the level of resources available to maintain an error-free program of the present depth and breadth.

Contributing Causes:
Understanding Needs Improvement (NI): Instruction needs improvement/continuing training needs improvement.  Details of beamline/shielding configuration not covered specifically in training. Requirements for posting not understood. 

Standards, Policies or Admin Controls NI: Confusing or Incomplete. The use of �keep out� zone posting is not consistent in all areas and was incorrectly applied following a complete survey. 
Recommended Actions 
1. Conduct a thorough review of the scope of the ARM program. The review should include (1) benchmarking the scope of the program against similar DOE facilities, (2) interviews or surveys of ARMs to identify vulnerabilities, (3) practices such as pre-posted areas, "walk-through" postings, use of escorted accesses, etc. and (4) discussions with Operations management to evaluate feasibility of potential changes. 

2. Revise/update ARM training.  The scope of the revision should cover the classroom training, the job performance measures, and OJT signoff process.  In particular, improve the details of expected process knowledge of the radiological conditions on the area familiarization documents.  Evaluate the need for retraining on practical elements.  Evaluate annual refresher training. Changes need to be harmonized with whatever program scope changes are made based on the ARM program review.

3. Evaluate the posting of �keep out� areas. If this practice is retained, ensure that the postings and protocols for establishing them are consistent and their basis is documented. 

4. RadCon should establish a schedule for management self-assessments to specifically evaluate the ARMs program on a periodic basis. 
JLab Preventive Measures 
See above corrective actions. 
Comments 
1/6/2017 9:41:04 AM by Johnson, Tina 
Please review and share within your work groups.  SME review and approval. 
	
Summary 	Lesson ID: 	982 
	Status: 	OK 
	Doc ID: 	
	Priority: 	Info 
	Safety Related: 	NO 
	Originator: 	Johnson, Tina 
	Issued: 	12/19/2016 10:24:55 AM 
	Approved By: 	Johnson, Tina 
	Approved On: 	1/6/2017 9:41:04 AM 
	Source: 	TJNAF NE 
	Location: 	TJNAF 
	Cost Savings: 	
	Contact: 	Harry Fanning 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	39 times Attachments 


Hazard Issues 

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

    * SAF899: RADIATION CONTROL TECHNOLOGIST 
    * MCC110: OPERATOR SCREENS 
    * MCC111: GENERAL TOOL SCREEN 
    * MCC112: LOG BOOKS AND LOG ENTRIES 
    * MCC113: Introduction to the CEBAF Accelerator Technology 
    * MCC114: BEAM OPERATIONS BASICS 
    * MCC-337: ALARA and Radiation Control 
    * MCC-636: CARM Reset 
Distribution/Notification 

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




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