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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=789">Damage to Personnel Protection System Door Switches Caused by Over-Use – Brookhaven National Laboratory </a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>For a copy of the original report, see Attachments on Lessons Learned page.
While preparing a restart commissioning, the accelerator’s Personnel Protection System (PPS) was tripped. Upon investigation it was discovered that two door switches were stuck in the "door closed" position. Commissioning was halted until the cause of the failure was identified and corrected. There was no personnel radiation exposure or injury. An investigation was immediately initiated.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On January 19, 2014, a worker inadvertently depressed the "access permit" button located on the gate between Pentants 2 and 3. This resulted in the trip of the Pentant 2 security system. During the subsequent reset of the systems, it was discovered that Chain A’s door switches were stuck in the "door closed" position. This finding indicated that the Chain A door was compromised. The decision was made to keep the facility shutdown until the cause of the failed switches could be evaluated and corrected.
PPS trips, resulting from the door’s switches disengaging during operations, had been problematic in the past and the practice of “forcefully” closing the doors was considered standard practice. During the investigation it was discovered that shims had been added to the door to ensure switch engagement. However, due to repeated “forceful” closing, the shims had damaged the mechanical actuators for the switches.
Note: The system design includes dual controls on the magnetic lock for this door. Thus, the safety function of the PPS system was not compromised.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre></pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Below are the consequences of the above event. They are provided for information and discussion purposes only.
• Repair the mechanical actuators for the Injector Service Area to P2 access door.
• Inspect all PPS interlocked access doors required during Booster Commissioning to ensure switches are functioning properly.
• Inspect and repair any defective/damaged door switch used by the PPS including shims or improper installation.
• The Mechanical Engineering group will inspect all door switches to ensure they are not damaged.
• The Mechanical Engineering group will evaluate each door switch installation and if deemed necessary, propose improvements for the switch mounting configuration in the interest of improving switch operation and decreasing the likelihood of premature switch failure in future.
• The Mechanical Engineering group will recommend changes and establish a committee to review and concur on recommendations.
• The changes to the door switch installations will be reviewed by the Interlock Coordination Group and the Radiation Safety Committee for approval.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">1/30/2014 1:41:32 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with current •SAF132: TUNNEL WORKER SAFETY ORIENTATION Training</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">789</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-789</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">YES</td>
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<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<td class="label" nowrap>Issued:</td>
<td class="dataval">1/30/2014 1:23:50 PM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">1/30/2014 1:41:32 PM</td>
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<td class="label">Source:</td>
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OTHER
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<td class="label" nowrap>Location:</td>
<td class="dataval">BNL</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">Erik Johnson, Photon Sciences Deputy Associate Director, Brookhaven National Laboratory (631)344-5431</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=2721">M:\wcd\LessonsLearned\ORPS\01-24-14_Notification_ORPS.pdf</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>SAF132: TUNNEL WORKER SAFETY ORIENTATION</li>
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<legend>Distribution/Notification</legend>
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<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
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