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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=839">Inadequate Safety Review for a Fire-Seal Replacement Project Leads to Technical Safety Violation - B&W Pantex</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.
A technical safety violation was declared at B&W Pantex for failure to ensure that design features met safety requirements. The violation occurred because 53 of 2,334, newly installed fire penetration seals, did not meet the two-hour fire-rating as described.
Walk-downs of the project identified the following installation issues:
- Installations did not match the design
- Insufficient amount of fire stop material was used
- Holes in fire seal material exposed mineral wool
- Unsealed through-penetrations
- Incorrect design installed for the penetration conditions
- Mineral wool not installed per design
- Wrong seal installed
- Paperwork/record discrepancies
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>The project plan for the work was developed based on available time and resources. The original installation specification,required independent verification signatures for every step of the project; however, limited resources resulted in this step-by-step verification being replaced by a single verification signature at the end. However, once installed, the critical attributes of the penetration seals were hidden; making a single, final inspection, inadequate. The trade-off between quality and schedule/resources made it increasingly difficult for personnel to adequately incorporate the required level of review. Had either the time constraints or the available resources been addressed, it would have decreased the likelihood of errors.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The importance of step-by-step verification and reviews was not clearly defined from the beginning, thus leaving these open to editing. Acceptance requirements and failure modes were also not thoroughly defined. Thus personnel did not fully understand their roles and responsibilities and expectations for execution. Personnel made assumptions regarding the time allowed to complete the work and the required resources.
The most critical causal factors of the safety violation stemmed from the fact that verification and acceptance validations did not have the rigor necessary to ensure that the design met safety requirements prior to acceptance. Personnel made assumptions that the work was being done correctly and that other reviews and validations were sufficient to identify discrepancies.
In addition, personnel did not understand the requirements for completing the paperwork/ records which documented the seal installations. These errors and assumptions are symptoms of a more significant underlying cause which is attributed to an independent verification process which included System Engineers who did not fully understanding the significance of their roles, responsibilities, and expectations for verification and acceptance requirements. A significant underlying cause of this condition is the lack of training for subcontractors, Project Managers (PMs), Project Subcontract Technical Representatives (PSTRs), Maintenance Supervisors, and System Engineers.
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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.
1. When conducting a review understand your role and responsibilities do not make assumptions based on others acceptance.
2. Clearly define final acceptance requirements in the design phase.
3. Realistically evaluate time and staffing/resource allocation.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">8/1/2014 10:24:34 AM by Bailey, Mary Jo</h5>
<pre>submitted to those current in:
SAF101: Work Planning and Control Familiarization</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">839</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-839</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">8/1/2014 10:14:47 AM</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">8/1/2014 10:24:34 AM</td>
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<td class="label">Source:</td>
<td class="dataval">
DOECRD
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<td class="label" nowrap>Location:</td>
<td class="dataval">OTHER</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">Minton, Lauri / (806) 477-3556</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>
<a name="attachments"></a>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=3200">FireMaterialReview.pdf</a></li>
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<legend>Hazard Issues</legend>
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<li>Other: Safety Document Review</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF101: Work Planning and Control Familiarization </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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