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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=900">Understanding the Importance of Hold Points - Lawrence Livermore National Laboratory (LLNL)</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.
LLNL’s procedures and work instructions call out "hold points" to initiate a pause in work to verify that work completed is sufficient to allow initiation of the next operation.
Common contributors to hold point errors are:
1. Timing is not adequately defined or understood,
2. Trigger(s) are not adequately defined or understood, and
3. Actions/conditions that must exist to release the hold are not adequately defined or understood.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>LLNL recently experienced tow events in which written instructions for performing radiological work were not followed. In each event the work document contained hold points intended to limit activities when levels of radiological conditions were discovered .
In one event, a health safety technologist found fume hood contamination above the 10,000 counts per minute alpha which triggered a hold point and notifications. The health physicist confirmed the levels, marked the opening with barrier tape, and both personnel reported the condition to program management. The health safety technologist, the responsible individual, and the authorizing individual/program manager evaluated the fume hood and discussed the potential risk of leaving the contaminant over the weekend. Concerns that it could migrate out of the fume hood, were discussed and a decontamination gel was applied to the area. Nobody discussed whether this action was allowed or consistent with any work document It was later determined that this action possibly dispersed the contaminant to the floor and, as a result, outside this laboratory (shoe monitoring was not a requirement for exiting this lab).
In a second event, a light fixture inside a glovebox needed to be realigned. A health physicist, health safety technologists, and several material handlers developed the work permit. All were familiar with the expected radiological conditions because similar work had been performed recently. Hold point values were determined and placed in the work permit. That afternoon, the workers, health safety technologists and health physicist involved in the work permit development attended a pre-job briefing that discussed the hold points, their values, and the responses to them (stop work and contact the health physicist). The work was conducted within an hour or so of the pre-job briefing, and the health safety technologist survey data indicated that a hold point value was exceeded. However, the participating personnel failed to remember the stated hold point values. After the work was done, the senior material handlers visited the health physicist and mentioned the contamination levels discovered during the work. The health physicist reminded them of the specified hold point values, and a causal analysis was initiated.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>A hold point is used to initiate a pause in work activities to obtain additional necessary information and/or appropriate approvals prior to proceeding. Holds may be used to validate pre-planning expectations, revise hazard assessments, or modify work control documents covering the work.
For the first event, personnel assumed that when the Responsible Individual, health safety technologist and authorizing individual/program manager participated in the discussion evaluating the fume hood, the discussion included everything the personnel needed to authorize release of the hold point. The decontamination gel was applied as a result of this and the absence of any voiced objections to its use. The improper decontamination and the resulting spread of contamination led to a review and corrective actions which impacted operations for weeks.
The second event’s investigation revealed that the intent of the hold point was clear and properly understood by the individuals involved. However, the hold point trigger value was not remembered when needed and the work was completed without interruption. The event resulted in a work delay on this project.
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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.
When writing work control documents, be sure that hold points are clearly stated and understood.
-When conducting work, ensure that you understand the hold points, authorizations and limitations in work control documents and comply with them.
-Prior to starting the work, establish clear protocols for authorizing the resumption of work after reaching a hold point and following an upset condition, including
• Specifics that constitute approval/concurrence for resumption of work,
• Communication of the authorizations, limitations, and qualifications for the resumption of work, and
• Criteria that must be met for releasing a hold and returning to normal operating conditions.
-If a hold point is triggered and resumption protocols specific to that situation or condition are not clear or provided, pause/stop work so the necessary work resumption protocols and plans can be implemented.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab has a variety of systems, programs, and procedures to document and verify work task steps. These include periodic verification and adequacy checks. work supervisors are responsible to ensure that everyone understands the appropriate task progression.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">8/10/2015 11:00:47 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in •SAF117: EH&S MANAGEMENT TRAINING
•SAF101: Work Planning and Control Familiarization
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">900</td>
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<tr class="row">
<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-900</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">YES</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">8/10/2015 10:56:47 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">8/10/2015 11:00:47 AM</td>
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<td class="label">Source:</td>
<td class="dataval">
DOECRD
</td>
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<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">LANL</td>
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<tr class="row">
<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">Jeff Horning, horning1@llnl.gov, 925-424-5393</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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<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=3944">M:\wcd\LessonsLearned\Work Control\DOE - Hold Points.pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Other: Work Planning and Communication</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF117: EH&S MANAGEMENT TRAINING</li>
<li>SAF101: Work Planning and Control Familiarization </li>
</ul>
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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>.