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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=791">ENG-13-1218 - Loss of PSS Configuration Management on Box Supply </a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>1. Personnel Safety System (PSS) training/awareness for groups that have interactions with this system should be more robust.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On December 18, 2013 around 2:00 pm while trying to diagnose why the North Linac would not got into sweep mode PSS discovered that a PSS connection to the DOG1E Box Power Supply was removed and a test box connected to the supply. The test box can simulate PSS permits, enabling the supply to turn on without connection to the PSS. The employee stated that he had the box power supply locked out while performing the maintenance to this supply, per his supervisor's verbal instructions. Unfortunately, during his recollection of those instructions, the worker did not remember that he should not disconnect the PSS wires, as this area has already been previously certified. </pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause: Unclear instructions; not understood by the worker
Contributing Cause(s):
1. Didn't stop work when unsure of indicator and how to proceed;
2. PSS Connector cable not well labelled and not in field of vision;
3. Employee was not trained in PSS general familiarity;
4. Written procedural instructions do not address PSS connections.</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Field train DC Power group, and affected other on revised EESDC-01-005 procedure to include reviewing scenarios and answering technical questions.
2. Clearly label, identify or segregate RF power supplies.
3. Schedule and provide general familiarization training of PSS indicator and scenarios for technical workers.
4. Develop PSS awareness poster material for appropriate site locations.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">2/6/2014 2:27:53 PM by Johnson, Tina</h5>
<pre>Approved. Please share this event and associated Lesson Learned within your work groups.</pre>
<h5 style="white-space:nowrap">2/6/2014 2:27:05 PM by Johnson, Tina</h5>
<pre>Approval received. Please share this event and associated Lesson Learned 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">791</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-791</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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<td class="label" nowrap>Issued:</td>
<td class="dataval">2/6/2014 11:47:23 AM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Johnson, Tina</td>
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<td class="label" nowrap>Approved On:</td>
<td class="dataval">2/6/2014 2:27:53 PM</td>
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<td class="label">Source:</td>
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<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/ENG-13-1218%20FInal.pdf" target="_blank">TJNAF NE</a>
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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">Steve Smith</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">8 times</td>
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<legend>Hazard Issues</legend>
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<li>Other: Personnel Safety Systems (PSS)</li>
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<legend>Skills</legend>
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<li>EN-028: Broad understanding of engineered personnel and equipment protection codes, methodologies, requirements and standards</li>
<li>EN-036: Understanding of design, construction, installation and maintenance of high reliability personnel and equipment protection systems</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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