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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=797">Hazardous Material Shipped before Required Preparations were Complete – Pacific Northwest 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.
Complex operations, involving multiple people with different roles and authorizations, require that everyone clearly understand their responsibility. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>After hazardous material had been properly loaded into a 9977 Type B radioactive material package, the trained Hazardous Materials Transportation Officer (HMTO) left the area to obtain peer review and get the required labels. Before he returned, a teamster arrived to pick up the shipment. A researcher, believing the shipment was ready to go, approved the transport. Thus the shipment arrived at its destination without its required documents, labeling, or a cover as required by the safety analysis. </pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The researcher, who had coordinated the transfer of the material, was familiar with the preparation process, but had only worked with one 9977 shipment before, and was not heavily involved in the packaging process of this particular shipment. She did coordinate with others, including the sealed source custodian, the material balance area custodian, the cognizant space manager, the radiation protection technologist, and the HMTO. However, she did not realize that the HMTO was the only one authorized to release the package for transport.
The shipping process involved multiple steps and staff members. The researcher did not recall details of a conversation with the HMTO and mistakenly believed the 9977 was ready for transport. Because the team members’ roles and responsibilities were not clearly defined and communicated before the operation started, most were unaware of who was authorized to release the shipment.
Shipping procedures do require the HMTO hold a pre-job briefing when any member is new to the process, but one was not held in this case.
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<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.
* Know your role and authority level. When complex tasks involve multiple people and interfaces, be clear, not only on your job but also on the roles, responsibilities, authorities and accountabilities of others involved in the task. Perform your duties as you have been trained and authorized to do. Do not go beyond your authority.
* A pre-job briefing is a good practice. When you are responsible for a task that involves multiple roles, handoffs, functions and SMEs, consider holding a short pre-job briefing to review the steps and confirm individual responsibility for each step. The goal is clear communication among all participants regarding successful completion of the project.
* Recognize process complexities. Recognize the many details, authorizations and requirements necessary for completing the job and proceed cautiously, making sure you or others are not out of step. Maintain a questioning attitude and encourage it in others if uncertainty arises.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">2/27/2014 3:45:41 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in •SAF305: DOT HAZARDOUS MATERIALS SHIPPING
•SAF906: Hazardous Waste Mgt & Handling
•SAF305A: IATA Dangerous Good Shipping--Air
Training</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">797</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-797</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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<tr class="row">
<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">2/27/2014 3:44:57 PM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<td class="label" nowrap>Approved On:</td>
<td class="dataval">2/27/2014 3:45:41 PM</td>
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<td class="label">Source:</td>
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DOECRD
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<td class="label" nowrap>Location:</td>
<td class="dataval">PNWL</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">Patti Ammonet (509)375-2275</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">2 times</td>
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<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=2800">M:\wcd\LessonsLearned\DOEOEC\DOE Lessons Learned - Hazardous Material.pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Hazardous Material</li>
<li>Transport or Shipping - On or Off Site</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF305: DOT HAZARDOUS MATERIALS SHIPPING</li>
<li>SAF906: Hazardous Waste Mgt & Handling</li>
<li>SAF305A: IATA Dangerous Good Shipping--Air</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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