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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=794">PHY-14-0107Loss of RAM in Physics Storage Building</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>When planning your work, consider the equipment and location of that equipment which may be needed to complete your task in the most safe and effective manner. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On January 2, 2014 the Physics employee had contacted the RadCon Tech I about their upcoming plan to disassemble a radioactive pump. The Physics employee would be performing the required work in the Radiologically Controlled/Radioactive Material posted area of the Physics storage building (Hall C section). The work was discussed and there was a plan to move forward.
On January 8, 2014 around 10:30-11:00 am two RadCon Technicians were walking through the Physics storage Building and noticed 2 filters on the work table located approximately 8 feet or so from the Posted RCA/RMA storage within the building. Both filters read above back ground.
Filter A: .015mR/hr
Filter B: .009mR/hr.
After this discovery, RadCon met with the Physics employee to discuss their findings and they also reported their findings to the RadCon Manager.
The Employee stated that she went to the un-posted work bench to use the vice to begin the dis-assembly process of the pump. When complete she moved the items back to the posted area with the exception of the (2) filters.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause:
Human Performance LTA: Employee needed to use a tool outside the designated RCA/RMA work area. The Employee temporarily moved the pump to begin the dis-assembly process. After doing this, the employee inadvertently left 2 activated filters on a workbench outside the designated work area. (Step omitted due to mental lapse)
Contributing Causes:
Work Planning was LTA: The employee was re-tasked in the middle of performing the pump disassembly. Too much time lapsed between original RadCon consultation and when the employee actually began the work because she had been re-assigned to another task. (Job tasking did not identify potential task interruptions)
Work Planning was LTA: In an effort to save the Lab money, the employee was (piece- mealing) a piece of equipment to make a non-radioactive pump. These effort s are commendable however, they can complicate a task at times and should be considered during the work planning phase.( Did not identify special circumstance surrounding this task)
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Run “Weekly Brief ”article on the recent“ Loss of RAM events.
2. Have the Employee/Supervisor conduct a tool box meeting to discuss lessons learned from all the recent “Loss of RAM” events.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">2/19/2014 9:43:59 AM by Johnson, Tina</h5>
<pre>SME review and approval. Please share this event with 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">794</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"></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">2/17/2014 4:42:04 PM</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">2/19/2014 9:44:00 AM</td>
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<td class="label">Source:</td>
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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>
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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">83 times</td>
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<legend>Attachments</legend>
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<legend>Hazard Issues</legend>
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<li>Radiation - Ionizing</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF800: GENERAL EMPLOYEE RADIATION KNOWLEDGE </li>
<li>SAF800T: GERT TEST</li>
<li>SAF801P: Radiation Worker I Knowledge--Implementation</li>
<li>SAF801C: Radiation Worker I Knowledge--Information</li>
<li>SAF801T: Radiation Worker I Knowledge--Assessment</li>
<li>SAF802: Rad Worker II Radiological Knowledge</li>
<li>SAF801kd: General Access RWP</li>
<li>SAF801kd.1: RWP FOR VTA</li>
<li>SAF801kd.2: RWP 10S001HRAW1</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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