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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=825">ENG-14-0504 Lock, Tag Try (LTT) Procedure Violation</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Follow LTT procedures explicitly. If unable to follow the procedure, stop, reevaluate and consult with your supervisor before proceeding.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Early Sunday morning, 5/04/2014 a work team was investigating operations problem with Expander #1 in the CTF building. When working on this particular piece of equipment, there is a LTT procedure (attached) that requires employees to complete specific steps in order to "safe" the belt and pulley area from unexpected release of stored energy. The employee had secured the power source, the pressure and equalization valve. Once the covers were removed, the employee did not insert the “locking bar” into the flywheel as specified in the procedure. While trying to troubleshoot the issue, the employee attempted to move the flywheel and was not able to move the wheel. He then removed several components of the engine during his initial inspection of the machine. The employee was instructed that another team would be in shortly to remove the U-tube and begin warming the machine. The employee left to acquire safety equipment for the U-tube procedure. The employee left the room without placing the locking bar into the flywheel, the final step to safe the machine before work begins. The pin immobilizes the pulleys and belt while work is ongoing. No equivalent mitigations were employed in lieu of the locking bar (i.e. setting up a keep out zone with ropes.) </pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause: Procedures followed incorrectly - Failure to follow prescribed LTT procedures for Expander Engine #1
Contributing Causes:
1. Procedures Needs Improvement - Current LTT procedure does not prescribe alternative LTT options during system repair on the flywheel. Desktop procedure failed to address all situations that it should have or reasonably should have been expected to occur during completion of the procedure.
2. Work Planning Needs Improvement – When encountering a situation that’s not covered in a procedure an employee should stop and re-evaluate the work and if necessary call his/her supervisor for guidance on how to proceed safely. An employee is also empowered to implement an equivalent safety mitigation.
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Develop an OSP for expansion engines that details proper LTT and training for safe repairs.
2. Hold toolbox meeting with equipment technicians to discuss LTT procedures.
3. Train the technicians and review possible scenarios to ensure there is a clear understanding of the new OSP. *If the employees are unable to follow the procedure as written, empower them to make changes and consult with their management so that the OSP can get updated as soon as reasonable
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<h2>Comments</h2>
<h5 style="white-space:nowrap">6/6/2014 11:16:10 AM by Johnson, Tina</h5>
<pre>SME approved. Please share with your work group during your next Tool Box Meeting.</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">825</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>
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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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<td class="label" nowrap>Issued:</td>
<td class="dataval">6/6/2014 11:03:58 AM</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">6/6/2014 11:16:10 AM</td>
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<td class="label">Source:</td>
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<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/FINAL%20ENG-14-0504.pdf" target="_blank">TJNAF NE</a>
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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">Henry Robertson</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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<legend>Hazard Issues</legend>
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<li>Other: Lock, Tag and Try (Potential Stored Energy)</li>
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<legend>Skills</legend>
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<li>SAF104: LOCK, TAG, AND TRY</li>
<li>SAF104A: LOCK & TAG PART I</li>
<li>SAF101: Work Planning and Control Familiarization </li>
<li>GEN007: J-1 Visa Requirements</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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