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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=799">Loose Bolts on Container Closure - URS | CH2M Oak Ridge LLC</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.
Verifier is to be present to verify work completion. Assuming activities were completed can lead to failure.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>In October, 2013, twelve B-25 boxes were shipped to an off-site waste facility. Upon arrival it was discovered that one of the boxes had five missing and several loose bolts.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The particular container was scheduled to be closed on September 5, 2013. The Waste Packaging Specialist (WPS), responsible for ensuring that the closure was conducted in accordance with manufacturer’s instructions and verifying that the instructions had been followed by documenting the procedure, was not present during closure operations. The closure activities were not completed during the scheduled shift; however the WPS assumed that the container had been closed according to the daily task schedule. The WPS documented that the container had been properly closed without verifying the work. Failure to use a "Questioning Attitude" and get "Feedback" resulted in the container being released for shipment prior to completing the closure procedure.</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.
• Developed an additional independent bolt torque verification step within the procedure.
• Brief all Waste Packaging Specialist that their presence is expected at all container closures.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">3/3/2014 9:06:44 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in
•SAF305: DOT HAZARDOUS MATERIALS SHIPPING Training</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">799</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-799</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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<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">3/3/2014 9:04:38 AM</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">3/3/2014 9:06:44 AM</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">ORNL</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">Paul Scott, Transportation Program Manager, 865-241-8895, URS | CH2M Oak Ridge LLC</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">3 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=2841">M:\wcd\LessonsLearned\DOEOEC\DOE Lessons Learned - WorkProcess7.pdf</a></li>
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<legend>Hazard Issues</legend>
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<li>Other: Work Planning and Communication</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF305: DOT HAZARDOUS MATERIALS SHIPPING</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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