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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=820">Magnet Work Required Low-Conductivity Cooling Water (LCW) Valve Shutoff which adversely affected Other Systems</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Scheduled work, to be performed on a magnet, required that an LCW valve be turned off. The magnet work was recorded in the “Hot Checkout” work control system; however, the valve shut-off was not mentioned. This particular LCW valve affected several other magnets and systems that, if engaged, could have led to an overload trip or overheat of another magnet.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On April 24, 2014 it was discovered that a LCW valve had been turned to the “off” position as a result of a small leak which affected work being done on a magnet. The shut off was intended to affect only one magnet; however because of the system’s configuration it actually affected several, both above and below the one being work on. The work task was recorded in the “Hot Checkout” system as magnet work only and neglected to record the valve shutoff.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Jefferson Lab has been undergoing a facility upgrade that has affected all systems of the organization. To organize and communicate task status a work control program was instituted known as “Hot Checkout.” It is utilized by all departments to determine the machines status in a variety of areas. Recently, during a walk-down of the machine, a LCW valve was turned off to allow for a leak repair affecting a magnet. A review of the “Hot Checkout” system revealed that an associated magnet had been scheduled for work, but there was no entry regarding the LCW valve.
The LCW that was shut off affected several magnets, not just the one denoted. If any of these had been powered up when the valve was “off” best case an alarm would notify the machine operators to shut the power off; worst case a fire would result.
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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.
Physical walk-downs of the machine, prior to start-up. Walk-downs have proven to be a valuable tool. Over the years a variety of situations have been discovered that, if left unmitigated, would have led to negative results.
Training in the “Hot Checkout” system. Work planners need to be aware of how work may affect interrelated systems and provide accurate records. Changes to the plan during work, also needs to be recorded accurately so others are aware and can plan accordingly.
System Owner Communication. Workers need to be aware of how their actions affect other systems up and down stream. Effective lines of communication between workers and system owners are needed to ensure that appropriate mitigation is instituted.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">5/12/2014 2:48:52 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with current SAF117: EH&S MANAGEMENT TRAINING</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">820</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-820</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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<td class="label" nowrap>Issued:</td>
<td class="dataval">5/12/2014 2:46:03 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">5/12/2014 2:48:52 PM</td>
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<td class="label">Source:</td>
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OTHER
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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">Neil Wilson, Engineering Division, (757)269-7265</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>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=3040">LCW Shutoff Pic 1.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>
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<li>SAF117: EH&S MANAGEMENT TRAINING</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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