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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=882">Low-Pressure Natural Gas System Requires Lockout/Tagout - Pacific Northwest National Laboratory </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 service request to “replace and repair” a natural gas meter was generated in mid-January, however work did not commence until July. A pre-job briefing and site walk down with the assigned work team took place in March; but, by the time work commended the team leader and another team member had changed. No follow-up briefing or walk down was held. When work commenced workers found two meters at the site. This caused confusion and resulted in the wrong valve being closed and an unexpected shutdown of a boiler in an adjacent facility.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>The elapsed time between work request initiation, pre-job briefing and walk down, and actual work start-up, plus changes in team members, contributed to confusion as to which meter was to be replace and the appropriate power isolation requirements. Capturing all pertinent information in the initial work documents and holding a more relevant pre-job briefing could have helped to clarify LOTO requirements for the natural gas meter work.
In reviewing the situation, the work center manager recognized the confusion about the meters. He also found that LOTO requirements apply to all natural gas systems, but had been overlooked in this situation due to the low pressure in the system.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>Workers correctly configured the system and isolated the meter by closing two valves, but did not perform a lockout/tagout, believing it unnecessary for such a low-pressure system.
Important information about LOTO requirements, coordination with other site contractors, and valve replacement sequencing needed by the workers and team leader was not recorded in the appropriate sections of the service request.
Confusion about the sequence of work on the day work started prompted a review that determined a lockout/tagout (LOTO) was not performed.
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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.
• Prior to preparing work documents fully understanding the related system functionality and safety requirements.
• Outline the scope of work in exact detail and explain the safely requirements.
• Understand LOTO requirements and confirm exactly how to complete the work safely.
• Provide written LOTO instructions in the work documents.
• Ensure workers are clear about the scope of work and are familiar with the configuration and operation of related equipment and systems.
• Walk down jobs prior to work start-up and re-emphasize the work scope and other details in a pre-job briefing.
• Before commencement of work, verify that service requests are up-to-date and accurate.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">4/20/2015 9:45:31 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those with LTT Training and Pressure Systems Safety.</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">882</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-882</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">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">4/20/2015 9:36:09 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">4/20/2015 9:45:31 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">PNWL</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">Patti Ammonet, Lessons Learned/Operating Experience Program Manager (509)375-2275</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>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=3800">DOE - Yellow - LOTO.pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Pressure Systems</li>
<li>Other: Work Planning and Communication</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF104: LOCK, TAG, AND TRY</li>
<li>SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS</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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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>.