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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=895">Lessons Learned from Unexpected Radiological Exposures are Relevant to other Work Areas - UT-Battelle, LLC/Oak Ridge 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.
When a radiological event occurred at Oak Ridge National Laboratory (ORNL), they realized a broader context of the situation could be translated to other work situations.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On August 25, 2014, facility personnel were shearing and packaging uranium material in an enclosure located in a posted contamination area. Four separate batches of material were successfully processed without incident. While processing the fifth batch, an unexpected airborne release occurred which triggered a Continuous Air Monitor (CAM) alarm. The uncertainty over the cause of the CAM alarm and the concern that the material needed to be secured before it could be left contributed to a delayed evacuation response and subsequent radiological exposure for workers in the area.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The delay in the evacuation response to the CAM alarms resulted in worker exposure. If you hear an alarm it means a criticality safety feature has been breached. Leave the area immediately. Don’t delay an evacuation to determine the reason for an alarm.
Due to the sensitive nature of the material only the general composition was made available to workers. It was therefore assumed that there was no possibility for airborne contamination and only minor possibility of surface contamination.
Radiological safety requirements conflicted with the area’s security requirements. This conflict was not recognized by work planners or workers. The conflict could have been resolved by creating an evacuation plan that required sealing the area doors upon exit.
Surface contamination had been discovered in unexpected locations during the first batch operation prompting a change in the Radiological Work Permit limits. This however, did not trigger concern about why contamination was spreading. A questioning attitude at this point could have precluded this event from happening.
A search of the Oakridge Lessons Learned database was not performed even though it is required in the work plan process. There were entries, indicating similar circumstances that had occurred at other National Laboratories within the past few years.
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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.
Too often, it is not high-hazard work that results in injuries, but routine tasks conducted based on inaccurate assumptions. Managers and staff must take the time to understand all potential hazards of the work task so that controls are in place to allow the work to be performed safely.
Treat all alarms as real. It is also helpful to conduct local drills to practice how to respond to emergency conditions. If steps are required to place a job into a safe or secure condition, make sure those steps have been identified ahead of time and are endorsed by facility management. Leave as soon as those steps have been taken.
Resolve conflicting requirements during work planning. Identify all requirements and ensure that conflicts are resolved and the work plan is adjusted prior to commencement of work.
Active use of the lessons learned systems is required when planning a task. A simple word search of the lessons learned databases when planning a new task can provide valuable information.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab’s ES&H Manual Chapter 3510 Emergency Response Activities describes management's responsibilities, processes, resources, and implementation strategies for dealing with emergency situations. It is recognized that vigilance and preparation efforts help to ensure the safety of everyone during an actual event.
Drills and exercises, to rehearse anticipated emergency scenarios, are periodically conducted at Jefferson Lab. They are designed to provide training, reduce confusion, and verify the adequacy of emergency response activities and equipment. Often these exercises involve external emergency organizations (such as the Newport News Fire Department) in order to familiarize them with the Jefferson Lab facility.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">6/23/2015 9:25:58 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those trained in MCC Emergency Response protocols and those with Rad Worker 1 training.</pre>
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<legend>Summary</legend>
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<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">895</td>
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<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
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<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2015-JLAB-895</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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<tr class="row">
<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">6/23/2015 9:16:10 AM</td>
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<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">6/23/2015 9:25:58 AM</td>
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<td class="label">Source:</td>
<td class="dataval">
DOECRD
</td>
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<td class="label" nowrap>Location:</td>
<td class="dataval">ORNL</td>
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<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
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<tr class="row">
<td class="label" nowrap>Contact:</td>
<td class="dataval">Teresa Cochran, cochrantj@ornl.gov</td>
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<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
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<tr class="row">
<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
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<tr class="row">
<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=3863">DOE - Alarms.pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Emergency Preparedness</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF801C: Radiation Worker I Knowledge--Information</li>
<li>MCC-702.04: MCC Emergency Response</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>
</ul>
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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>.