<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html>
<head>
<title>Jefferson Lab Lessons Learned : Print Lesson</title>
<base href='https://misportal.jlab.org/ll/'>
<!--[if IE]>
<style type="text/css">
#page_content input[type=checkbox], #page_content input[type=radio] {
background-color: transparent;
border: 0;
}
</style>
<![endif]-->
</head>
<body>
<div id="doc3" class="yui-t7">
<div class='round' id='pageMessages'>
<!-- -->
</div>
<div id="lesson" class="yui-gc">
<style type="text/css">
pre {
white-space: -moz-pre-wrap;
white-space: -pre-wrap;
white-space: -o-pre-wrap;
white-space: pre-wrap;
word-wrap: break-word;
overflow: hidden;
margin-left: 10px;
}
</style>
<div id="topbar">
<div id="lesson_title">
<table width="100%">
<tr>
<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=805">Discovery of Uncontrolled Hazardous Energy Source during Air Compressor Planned Maintenance - Advanced Mixed Waste Treatment Facility</a></td>
</tr>
</table>
</div>
</div>
<table width="100%">
<tr>
<td valign="top" width="100%">
<div id="maintextcol" class="yui-u first">
<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>For a copy of the original report, see Attachments on Lessons Learned page.
It is essential to anticipate operational trends and incorporate information into hazard mitigation processes. In this instance a questioning attitude resulted in a positive outcome. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On 03/20/2014 at 0956, during planned quarterly maintenance on an air compressor, it was discovered that air pressure, deemed to be a hazard, had not been totally bled off. The work included visual inspection, cleaning, and lubrication of various internal and external components. The compressor unit was locked out prior to execution of the maintenance citing mechanical energy and pneumatic air pressure as the hazards.
The pneumatic air pressure hazard was mitigated by locking out the compressor’s air discharge gate valve, and opening two air drain discharge valves (low pressure and high pressure drain paths). These drain valves were also locked open to preclude re-accumulation of air pressure.
Following the pre-job briefing, a Maintenance Technician prepared the lockout/tagout. The lockout was then authorized and correctly installed, and the “safe to work” check was satisfactorily completed.
When disconnecting the condensate drain tubing, it was observed that rust buildup was more than normal. Anticipating blockage within the air system and a potential for inadequate initial bleed off, the pressure relief valve was manually lifted, at which time additional air was observed to be relieved.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Anticipating that corrosion blockage could prevent air from adequately bleeding off the decision to manually lift the air pressure relief valve was agreed upon. When the relief valve was opened, air was relieved indicating an inadequate initial bleed off due to rust blockage in the drain tubing. </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.
1. Work was stopped.
2. Compressor was placed in a safe configuration.
3. Drain tubing was reinstalled.
4. A fact finding was conducted.
</pre>
</div>
<div id="comments_div">
<a name="comments"></a>
<h2>Comments</h2>
<h5 style="white-space:nowrap">3/27/2014 11:18:00 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in the following training
•SAF104: LOCK, TAG, AND TRY
•SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS
</pre>
</div>
</td>
<td valign="top">
<div class="yui-u">
<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">805</td>
</tr>
<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
</tr>
<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2014-JLAB-805</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Info</td>
</tr>
<tr class="row">
<td class="label" nowrap>Safety Related:</td>
<td class="dataval">YES</td>
</tr>
<tr class="row">
<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">3/27/2014 11:13:01 AM</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">3/27/2014 11:18:00 AM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
OTHER
</td>
</tr>
<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">OTHER</td>
</tr>
<tr class="row">
<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
</tr>
<tr class="row">
<td class="label" nowrap>Contact:</td>
<td class="dataval">Theodore Griffith, Plant Shift Manager (208)557-7279</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
</tr>
<tr class="row">
<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
</tr>
<tr class="row">
<td class="label" nowrap>Viewings:</td>
<td class="dataval">3 times</td>
</tr>
</table>
</fieldset>
<fieldset>
<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=2900">Air Compressor.pdf</a></li>
</ul>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Pressure Systems</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF104: LOCK, TAG, AND TRY</li>
<li>SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS</li>
</ul>
</fieldset>
<fieldset>
<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>
</ul>
</fieldset>
<!--
<fieldset>
<legend>Applicable Orgs</legend>
<ul class="lesson_attribute_listing">
</ul>
</fieldset>
-->
</div>
</td>
</tr>
</table>
<script language="javascript">
var commentTextarea = document.getElementById("commentForm:commentText");
if (commentTextarea){
var validationErrorFound = commentTextarea.parentNode.innerHTML.indexOf("Validation Error: Value is required.") > -1;
if (validationErrorFound){
// add hash if necessary
if (window.location.hash == null || window.location.hash == "" || window.location.hash == "#"){
window.location.hash = "#comments";
}
}
else {
//JSF likes to hold on to the values entered into the form...so blank them out
commentTextarea.value = "";
commentTextarea.form.elements["commentForm:commentType"].selectedIndex = 0;
var numStars = commentTextarea.form.elements["commentForm:stars"].length;
for (var ii=0; ii<numStars; ii++){
commentTextarea.form.elements["commentForm:stars"][ii].checked = false;
}
}
}
</script>
</script>
</div>
<br>
<br>
</div>
</body>
</html>