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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=878">Subcontractor Failed to Follow Lock/Tag/Try Procedures</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>1. Upon contract award, reiterate to the contractors that they are only permitted to take direction from their Subcontracting Officer (SO) and Safety Officer Technical Representative (SOTR).
2. It is imperative that contractors follow their approved procedures at all times while on-site.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On January 7, 2015 during a joint DOE walk through of the UIM project, a lock/tag/try (LTT) violation was identified. An electrical subcontractor was using a group lock box for work being performed inside of an outdoor electrical switch cabinet. The transformer that feeds this electrical cabinet was controlled by a Supervisor's lock and tag, and the key to that lock was within the group lock box. At the time of the observation, one of the two workers working inside the switch cabinet did not have their lock on the group lock box. It was also noted that the subcontractor's lock-out/tag-out log book did not have an entry recording the work activity on this day.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause: Forman oversight was less than adequate. The contractor’s foreman failed to provide proper oversight to their apprentice.
Direct Cause: Contractor failed to follow their Lock, Tag and Try procedures (placement of his lock at the new location) and best management practices (updating the log book entry in real time).
Contributing Causes:
Contractors were questioned by a Lab employee, who was not the SOTR, about their schedule. The contractors interpreted this communication as implied urgency to complete the T-6 job and restore normal operations. The Contractors response to this inquiry was to re-assign a Unisub worker to the T-6 location.
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Have the contractor conduct a Safety Stand-down meeting to review their Lockout-Tagout Procedure.
2. Prior to the start of each work day, the Superintendent or the Site Safety & Health Officer will conduct an audit of the lockout lockbox comparing that with the workers at the work location, and initial the lockout log book as verification that all workers are in compliance with our program.
3. Jefferson Lab Safety Representative will conduct on-the- spot checks at the various York River locations to ensure LTT procedures are being followed and document the checks via the safety observation program.
4. All Hands Meeting with SOTRS to review this event and reiterate the importance of reminding our contractors that they should only take directions from their SOTR.
5. Review the use of the log book as a best management practice. If determined that it is necessary, the contractor should update their procedure, get JLab approval and provide training on the updated procedure.
6. Procurement should provide a letter to the subcontractor informing them that direction only comes from SOTR and if subs get input from others, they should refer them to the to the SOTR.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>See above.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">3/5/2015 1:26:52 PM by Johnson, Tina</h5>
<pre>SME reviewed and approved. Please share these lessons learned within your work group. </pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">878</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">2015-JLAB-878</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">3/5/2015 12:40:06 PM</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">3/5/2015 1:26:52 PM</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%20fml%2015%200107.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>
<td class="dataval"></td>
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<td class="label" nowrap>Contact:</td>
<td class="dataval">Bob Sperlazza</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">5 times</td>
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<legend>Attachments</legend>
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<legend>Hazard Issues</legend>
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<li>Electricity</li>
<li>Other: Lock, Tag and Try Procedure Violation</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF603: SAF603A FPA-70E BASIC ELECTRICAL TRAINING</li>
<li>SAF608B: PULSED POWER SAFETY</li>
<li>SAF603A: ELECTRICAL SAFETY AWARENESS</li>
<li>SAF603N: NFPA-70E BASIC ELECTRICAL SAFETY</li>
<li>SAF604: HIGH VOLTAGE IN R&D</li>
<li>SAF603S: NFPA-70E for Supervisors</li>
<li>SAF603M: NFPA-70E for Managers</li>
<li>SAF603N1: ARC FLASH:LIVE to TELL! (ELE016EFV)</li>
<li>SAF603N2: Electrical Safety:Beware of the Bite (ELE5EFV)</li>
<li>SAF603N3: Electrical Safety for the Qualified Worker (ELECEFV)</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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Do you have a lesson learned you would like to contribute? Contact the <a href="mailto:cjohnson@jlab.org,sjsmith@jlab.org,mbailey@jlab.org">Lesson Learned Coordinator</a>.