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         <td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=885">ENG-14-1009- Unauthorized movement of contaminated item from outside contamination area</a></td>
        
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                 <h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
                 <pre>1. It is imperative that each employee review the hazards associated with their work area before beginning their work. This requires active and engaging conversations that encourage questions, especially when the workers change, the schedule changes, or decisions are made to accelerate or change task sequence.
2. Strict observance of contamination control boundaries must be observed. This applies not only to bodily entry of a contamination area, but also any manipulation of items within such an area.
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                 <h2 style="white-space:nowrap">Discussion of Activities</h2>
                 <pre>At about 12:00 on October 9, two Mechanical Installation (MSINST) technicians attempted to retrieve a flange sealing ring from within a posted contamination area (CA) without authorization and using inappropriate methods. One technician initiated the activity and the second joined in the effort a few minutes later. The goal was to bring the flange ring into proximity of the edge of the CA, because it was assumed this would expedite installation of the component on a beam pipe located just inside the CA. The technicians used a plumb bob and a tape measure to pull the component about ten feet along the floor up to the CA boundary. They did not discuss the activity with their supervision or RadCon, and did not wear PPE.</pre>
                
                 <h2 style="white-space:nowrap">Analysis</h2>
                 <pre>Root Cause:
A3B4C02 – Work Practices LTA: Deliberate Violation
Contributing Causes:
A4B4C08 – Supervisory Methods LTA: Frequent job or task shuffling
A5B4C01 – Verbal Communications LTA: Communication between work groups less than adequate
A4B4C05 – Supervisory Methods LTA: Emphasis on schedule exceeded emphasis on methods/doing a good job
A6B2C01 – Training Methods LTA: Practice or hands-on experience less than adequate
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                 <h2 style="white-space:nowrap">Recommended Actions</h2>
                 <pre>1. Retrain Mechanical Technicians in RW-1 and RW-II
2. Update Atlis and other work planning tools per the “Work Planning, Control and Authorization Flow Diagram” to identify the Lead on a complex or cross divisional jobs.
3. Enhance RWP briefing process to include standard materials that reinforce good practice.
4. Develop a refresher training module for work groups doing radiologically significant jobs.
5. Expand and complete the current effort to formalize a progressive disciplinary action plan for radiological infractions.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">5/13/2015 9:12:09 AM by Johnson, Tina</h5>
<pre>Please share this event and related Lessons Learned within your work group. SME has reviewed and approved content.</pre>
        
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                 <legend>Summary</legend>
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                 <td class="label" nowrap>Lesson ID:</td>
                 <td class="dataval">885</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-885</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">5/7/2015 3:53:11 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">5/13/2015 9:12:09 AM</td>
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                 <td class="label">Source:</td>
                 <td class="dataval">
                
                 <a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/final%20eng-14-1009.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">Keith Welch</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">277 times</td>
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                 <legend>Hazard Issues</legend>
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                 <li>Radiation - Ionizing</li>
                
                 <li>Sources-Prompt Radiation & Induced Radioactivity</li>
                
                 <li>Storage & Handling of Radioactive Materials</li>
                
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF800: GENERAL EMPLOYEE RADIATION KNOWLEDGE </li>
<li>SAF800T: GERT TEST</li>
<li>SAF801P: Radiation Worker I Knowledge--Implementation</li>
<li>SAF801C: Radiation Worker I Knowledge--Information</li>
<li>SAF801T: Radiation Worker I Knowledge--Assessment</li>
<li>SAF802: Rad Worker II Radiological Knowledge</li>
<li>SAF801kd: General Access RWP</li>
<li>SAF801kd.1: RWP FOR VTA</li>
<li>SAF801kd.2: RWP 10S001HRAW1</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>.