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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=788">FML-13-1216 -Contractor Violated the RadCon Posting to Access the top of The VTA </a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>It is imperative that employees and contractors obey all signage. If the signage is questionable, contact the appropriate personnel, SOTR or other JLab personnel, to verify the purpose of the signage.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On December 16, 2013 around ~7:30 am a contractor was found on top of the VTA Control Room by VTA employee. The Contractor had removed the Radiologically Controlled Area (RCA) sign that was hanging on the fixed ladder and proceeded to climb the ladder to gain access to the top of the VTA. The signage was attached to the ladder by a magenta and yellow bungee cord, and this area is known to all as a RCA. The contractor stated that he did not pay attention to verbiage on the sign and also incorrectly assumed the sign was temporary as it was attached via bungee cord.
This area was posted on Friday, December 13, 2013, as they were scheduled to begin testing a cavity with a 1w amplifier over the weekend. The contractors performed a walk-through of the site on Friday, however, they failed to take a look at this particular area.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause:
Less Than Adequate (LTA) Walk through/Pre-Job Briefing: Although the Contractors participated in a walk-through, the walk-through did not cover the entire affected area. This walk-through was performed on Friday, therefore there was a bit of a time lapse which may have contributed to these unwanted results.
Contributing Causes:
Failure to follow established RadCon procedures: The Contractor failed to follow the appropriate procedure for accessing RCA areas.
Failure to Recognize Safety Signage and Potential Hazard- Contractor was GERT trained and he incorrectly assumed that the signage was not valid and had been placed on the ladder as a “temporary means of getting the sign out of the way” while completing another task.
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Facilities management will work with RadCon to attach an OSHA approved ladder guard with locks to the ladder. The signage on the ladder with be a flip sign which will only be managed by VTA operators and RadCon only. Facilities Management work order 41848
2. Have the contractor re-take GERT training to raise awareness before additional on-site work.
3. Hold a Toolbox meeting with the involved lower tier subcontractor to address the importance of conducting a through walk-through and pre-job brief, encouraging that the walk-through and pre-job briefs be done the same day the work is to begin (Not to exceed a 24 hour period).
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<h2>Comments</h2>
<h5 style="white-space:nowrap">1/24/2014 4:40:59 PM by Johnson, Tina</h5>
<pre>SME review and Approval. Please share within your work groups.</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">788</td>
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<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
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<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2014-JLAB-788</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Info</td>
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<td class="label" nowrap>Safety Related:</td>
<td class="dataval">NO</td>
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<td class="label" nowrap>Originator:</td>
<td class="dataval">Johnson, Tina</td>
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<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">1/24/2014 3:38:00 PM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Lawrence, Bobby</td>
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<td class="label" nowrap>Approved On:</td>
<td class="dataval">1/24/2014 4:40:59 PM</td>
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<td class="label">Source:</td>
<td class="dataval">
TJNAF NE
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<td class="label" nowrap>Location:</td>
<td class="dataval">TJNAF</td>
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<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
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<td class="label" nowrap>Contact:</td>
<td class="dataval">Tina Johnson</td>
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<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
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<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
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<td class="label" nowrap>Viewings:</td>
<td class="dataval">7 times</td>
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<legend>Attachments</legend>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=2700">photo.JPG</a></li>
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<legend>Hazard Issues</legend>
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<li>Radiation - Ionizing</li>
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<legend>Skills</legend>
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<li>SAF800: GENERAL EMPLOYEE RADIATION KNOWLEDGE </li>
<li>SAF800T: GERT TEST</li>
<li>SAF801C: Radiation Worker I Knowledge--Information</li>
<li>SAF801kd: General Access RWP</li>
<li>SAF801kd.1: RWP FOR VTA</li>
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<legend>Distribution/Notification</legend>
<ul class="lesson_attribute_listing">
<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
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