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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=902">Loss of Control of Unsupported Cover Plate</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>1. Thorough work planning and coordination with other works groups is the best defense against unwanted events.
2. Careful visual inspection of the items which you are working on is ideal. If possible compare the set-ups to one another which should make visual differences. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>At approximately 8:45am in the morning of August 21st, 2015, while an installation crew was removing sand shielding inside of a penetration in preparation of running new water lines in the Injector Test Cave of the Test Lab, a penetration ceiling plate with attached conduit fell through the penetration without falling completely to the floor below.
A previously installed PVC water line was determined to be insufficient for the project and was scheduled to be partially removed while new copper piping was to be run inside the remaining PVC tubing (see figures 1 & 2.) The PVC tubing was cut at the top of the penetration and at the bottom of the penetration to allow stabbing new copper lines through the old PVC tubing.
However, when the size of the copper tubing was changed from 1-1/4” to 1-1/2” the decision was made to remove the remaining PVC tubing and install the 1-1/2” pipe in its place. Since the penetration was filled with sand shielding, the sand needed to be removed from the penetration before work could continue.
A vacuum cleaner was utilized to remove the sand from the penetration from on top of the Injector Test Cave. It was noted that the sand seemed hard and compacted within the penetration and after ½ the sand was removed, the ceiling plate, conduit, and a short section of wave-guide tube dropped approximately 3 feet before being entangled in the vacuum hose, stopping just below the penetration opening in the ceiling below (see figures 3 & 4.)
Other personnel (Installation crew, Survey & Alignment crew, and Injector workers) working in the Injector Test Cave area at the time were not directly under the plate but were located as close as 10-15 feet away. No one came in contact with the dangling objects nor were there any reported injuries as a result of the event.
Within minutes of the event a second installation crew member donned a hard hat, climbed the ladder inside the cave and safely dislodged the dangling plate, wave-guide and conduit.
It was noted that one of the two Unistrut sections that supported the two ceiling plates from on top of the Test Cave was missing. Upon further investigation it was noted that this piece had been removed at an indeterminate time in the past, possibly during the installation of either the conduit or PVC tubing.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>From the pre-job photos, it was noted that the PVC tubing ran along the top of the Injector Test Cave, turned 90 degrees into the penetration and then turned 90 degrees upon exiting the penetration and was supported by a system of anchor points inside the Test Cave. Once these supports for the PVC were removed combined with the previous removal of the plate support (Unistrut), and disturbance of the compacted sand shielding, the weight of the plate, wave-guide, conduit and remaining sand caused the ceiling cover plate to dislodge from the ceiling.
Extent of Conditions:
On top of the Test Cave, there were three cover plates with or without conduit or wave-guide installed, including the one being modified. All plates and their supports were evaluated to see if this event could be repeated at either of the remaining plates. While the supports from above the cave were still intact for the other plates, it was noted that the removal of the supports from above the Test Cave could cause a potential repeat of the event.
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. The work area within the Test Cave was cleared of personnel during the removal of dangling ceiling plate, conduit and wave-guide.
2. The work area within the Test Cave remained clear while the rest of the sand was removed from the penetration above. It was taped off to ensure, employees not directly working on this project remained out of the area.
3. The work areas were cleaned up before any further work continued.
4. A wooden board was placed over the open penetration while a path forward was being developed by Installation Management, Survey & Alignment Management and the Accelerator Division Safety Officer with Environmental Health and Safety Deputy Associate Director and the Reporting Officer.
5. After the path forward was developed, additional supports were installed under each remaining penetration ceiling plate and anchored into the ceiling with bolts to prevent accidental release of the plates by unbolting the supports located above the Test Cave.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>- See actions.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">8/25/2015 10:19:42 AM by Johnson, Tina</h5>
<pre>See attached note.</pre>
<h5 style="white-space:nowrap">8/25/2015 10:19:31 AM by Johnson, Tina</h5>
<pre>Please share this lesson learned within your work groups. Great example of stopping and re-assessing the work prior to continuing. </pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">902</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-902</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">8/25/2015 10:17:51 AM</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">8/25/2015 10:19:42 AM</td>
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<td class="label">Source:</td>
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TATL
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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">Harry Fanning</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">1 times</td>
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<legend>Attachments</legend>
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<legend>Hazard Issues</legend>
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<li>Other: Work Planning and Personnel Protective Equipment </li>
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<legend>Skills</legend>
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<li>SAF101: Work Planning and Control Familiarization </li>
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<legend>Distribution/Notification</legend>
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<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</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>.