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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=847">Failure to Meet Criticality Working Requirement due to Poor Turnover of Equipment - Idaho Treatment Group</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.
The Operations Department needed to ensure all technical requirements for operating a new system/equipment were properly implemented as part of the turnover from the Engineering Department. Failure to verify all requirements could have resulted in unsafe conditions. A Criticality Working Requirement (CWR) violation was identified because the HEM band saw cabinet ventilation and oil reservoir filters had not been replaced within the required periodicity. This resulted in a fact finding, the filing of an Occurrence Reporting and Processing System (ORPS) report, and a Corrective Action Report (CAR).
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Operations received the band saw from Engineering, as part of a facility modification. A Criticality Safety Evaluation was performed which determined that a CWR was necessary for the lubricating system for the saw. During the turnover , the operating procedure for the equipment was verified to contain the CWR and the time frame needed to be met. What was not verified was how the time frame was to be tracked and the preventive maintenance (PM) task completed. An Engineer reviewing the facility modification for close out recognized a PM needed to be performed on a quarterly basis to ensure the CWR was met. In determining when the PM should start it was recognized that the time requirements for the first performance had been exceeded. Operations had, by then, been operating the saw for approximately five months.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Operations had a procedure which identified the quarterly CWR, but did not implement a tracking method nor require personnel to verify completion of the CWR for continued use. The PM was never generated as part of the modification paperwork so no work order generated to ensure the requirement was met. Operations should have verified that any identified pre-start items on the Facility Modification Proposal are complete prior to commencing operation.</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. System status board updated with a tracking method of when the next performance of the CWR is required.
2. Procedure changed to ensure operators acknowledge the CWR has been completed as required.
3. PM task generated on a quarterly basis to address the maintenance needed to complete the CWR.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>This situation is avoided at Jefferson Lab due to the requirements outlined within "ES&H Manual Chapter 6121 Machine Tools," wherein it is recognized that machine tools are inherently risky, and that their use carries an unmitigated Risk Code 3. An Operational Safety Procedure (OSP) is required for each machine tool, and read by machine operators prior to use.
Jefferson Lab bases its Machine Tool Program on Occupational Safety and Health Administration (OSHA) regulations and American National Standards Institute (ANSI) standards. Operator's Manuals also provide valuable information and are used in preparation of OSPs and training.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">9/15/2014 9:10:40 AM by Bailey, Mary Jo</h5>
<pre>Submitted to Forklift Operators and those who perform Safety Observations. </pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">847</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-847</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Best Practice</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">Bailey, Mary Jo</td>
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<td class="label" nowrap>Issued:</td>
<td class="dataval">9/15/2014 8:59:34 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">9/15/2014 9:10:41 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">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">Rob Hamilton, 208-557-6314, Robert.hamilton@amwtp.inl.gov</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>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=3340">M:\wcd\LessonsLearned\Material Handling\DOE - MachineTools.pdf</a></li>
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<legend>Hazard Issues</legend>
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<li>Tools - Machine & Portable</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF502: FORKLIFT OPERATOR</li>
<li>SAF120kd: SAFETY OBSERVATION PROCEDURE</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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