[Hallb-engineering] Fwd: Lesson Learned "Attention to Detail by Craftsmen Leads to Discovery of Electrical Hazard at EMS - Pacific Northwest National Laboratory"

Douglas Tilles tilles at jlab.org
Thu Jan 12 13:20:23 EST 2017

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From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Thursday, January 12, 2017 1:00:22 PM
Subject: Lesson Learned "Attention to Detail by Craftsmen Leads to Discovery of Electrical Hazard at EMS - Pacific Northwest National Laboratory"

Jefferson Lab Lessons Learned : Print Lesson 
	Attention to Detail by Craftsmen Leads to Discovery of Electrical Hazard at EMS - Pacific Northwest National Laboratory 
Statement of Lessons Learned 
A veteran craftsman provided a powerful example of PNNL's strong culture of safety to his colleague by avoiding making assumptions about the risks inside the heat pump panel. By questioning an unexpected situation, the craftsmen avoided a potentially hazardous situation and serious consequences to the equipment and their safety. 
Discussion of Activities 
Two PNNL craftsmen, one a long-time PNNL journeyman, the other relatively new, were performing preventive maintenance on a heat pump in a mechanical room.  The veteran opened the initial panel on the pump, and saw exposed electrical equipment.  He knew that a second, internal panel should have been in place so immediately replaced the outer panel, stopped work, and notified his supervisor. 
To access the interior of the heat pump, the workers had to remove an outer rear panel to expose a second interior panel where the energized electrical conductors are. When the veteran worker removed the outer panel, he recognized that the inner panel door was not in place and that the electrical equipment that would normally be behind the inner panel was exposed. Knowing that this was an unexpected discovery, the worker replaced the outer panel, stopped work, and notified his supervisor. 

The veteran craftsman says he has benefited from the years of mentoring and training received while at PNNL and passes the following message on to others. "I have received constant reminders from my managers, peers, and instructors to always think about safety first, both at work and at home.  I work to pass on these preventive measures by instilling safety practices in those working with me."

The newer journeyman says he counts on his veteran colleague to provide guidance on expectations at PNNL. "Riding along with (a veteran craftsman) every day and being able to ask questions when issues come up has taught me a lot about what we can and cannot do," he says. "It is hard coming from the private sector, where some of these regulations do not apply. " 

This event is a textbook example of the value of having a questioning attitude and following training before a negative event occurs. 
Recommended Actions 
/These are provided for discussion purposes./

After this event, a team of electricians locked out the heat pump to investigate the missing interior electrical panel. They discovered the interior panel had fallen off due to vibrations inside the unit. Other heat pump units are being inspected to assure similar problems are not occurring.

All of us have regular opportunities to demonstrate safe behavior and a questioning attitude, and to watch out for each other on the job. 

Provide guidance to junior staff members. When working alongside staff members who have less experience, provide guidance and set a good example. Recognize that some staff members come from industry where the safety culture may not be as rigorous. 

Question unexpected discoveries. Try and use common sense, says the newer journeyman. If what you are doing does not look or feel right, stop  and let your supervisor know. 

Slow and steady wins the race. Adopt a disciplined approach to performing your tasks, think through the work as you go, watching for anything unexpected. 
JLab Preventive Measures 
At Jefferson Lab "Suspend Work" occurs when a hazard issue is discovered or anticipated that may endanger individuals, equipment, or the environment if the activity continues. Work is suspended until mitigation measures are implemented or a new, safer, work plan is developed.  To prevent injury or damage, utilize the process steps outlined in "ES&H Manual Chapter 3330 Appendix T1 Suspend Work for Safety" when additional consideration for a situation is desired. 
1/12/2017 11:58:41 AM by Bailey, Mary Jo 
Submitted to those with Electrical Safety Awareness and SOTR Qualifications 
Summary 	Lesson ID: 	987 
	Status: 	OK 
	Doc ID: 	2017-JLAB-987 
	Priority: 	Best Practice 
	Safety Related: 	NO 
	Originator: 	Bailey, Mary Jo 
	Issued: 	1/12/2017 11:53:08 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	1/12/2017 11:58:41 AM 
	Source: 	DOECRD 
	Location: 	PNWL 
	Cost Savings: 	
	Contact: 	Patti Ammonet Lessons Learned/Operating Experience Program Manager, (509)375-2275 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	1 times Attachments 

    * DOE - AttntoDetail.pdf 
    * ES&H Manual Chapter 3330 Appendix T1 Suspend Work for Safety 

Hazard Issues 

    * Other: Work Planning and Communication, 


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

Do you have a lesson learned you would like to contribute? Contact the Lesson Learned Coordinator .

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