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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=903">Inadequate Procedure, Data Documentation and Training lead to Technical Safety Requirment Violation ¿ Mission Support Alliance, Hanford Fire Department (HFD)</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.
Hanford Fire Department (HFD) personnel missed a step during a fire system maintenance test, contributing to a Technical Safety Requirement (TSR) violation at a Hanford nuclear facility.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>HFD personnel only received general training for fire systems testing. This did not inlcude the associated technical details for the actual systems tested. The procedure used provided instructions and data collection requirements for abnormal result reporting. In addition no training on Conduct of Operations (CONOPS) or Human Performance Improvement (HPI) was provided which prepares firefighter to conduct testing in a manner that meets the rigorous requirements of nuclear facility operation.
The event analysis discovered that the testing procedures steps contained sequencing errors and did not align with the associated data sheets, and the data was not maintained with adequate configuration control. Lack of field validation was also identified as a key element that contributed to the procedure inadequacies.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>Problems with personnel training, procedure, data sheet development and control, and field supervision contributed to the violation. Also, management assessments had not identified these conditions for several years.
The HFD supervisor was not in the field during the performance of the test. Testing being a routine activity would generally not require a great deal of supervision, however, in light of the procedure and training problems described above, the presence of an experienced supervisor could have been effective in reducing the potential for errors.
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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.
Write procedures so they can be performed in sequence. This testing procedure was arranged in a manner that required the performer to skip sections, and perform tasks out of order. In addition, the procedure contained instructions for more than one type of test. This required the performer to choose appropriate section(s) while ignoring others. Procedures that require interpretation, skipping of steps, or other optional approaches, do not provide assurance that the performer will act in a manner that satisfies requirements.
Implement proper Data Sheets Configuration Control. In this instance 209 Data Sheets had accumulated over a period of time. Without proper configuration control, the Data Sheet to Procedure alignment had deteriorated. Lack of alignment caused confusion as to where data was being recorded, what data to record, and which steps needed to be performed.
Properly train personnel to perform testing. Firefighters received system familiarization training. This did not cover equipment specific information that were encountered on the Hanford Site. In addition, neither Conduct of Operations principles nor HPI techniques are taught. Without proper training, personnel were unable to recognize abnormal conditions, and unaware of mistakes that cause inaccurate results.
Provide periodic field supervision to identify problems and provide training / mentoring for personnel to improve organizational performance. The Firefighters assigned to conduct this test were generally the most junior in the department and needed additional supervisory participation, particularly in light of the current training deficit cited above.
Perform a thorough, in-depth management assessment to ensure that performance standards are in place and are being effectively implemented. Assessments provide an opportunity for early detection of problems so they can be corrected before they create significant complications.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab training modules undergo a robust review and approval process prior to acceptance. Once approved training plans and content are reviewed for accuracy on a periodic basis (generally every three years).
Jefferson Lab has a robust assessment program which has been verified to ensure compliance with requirements. Assessments are scheduled and monitored by an impartial party to ensure adequacy.
Jefferson Lab¿s Safety Observation Program provides a process where all managers regularly visit work areas; observe work behavior and conditions; and discuss job performance with individuals. The framework helps resolve safety issues and concerns; recognizes and acknowledges safe work practices; and gains employee commitment to correct work practices.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">9/8/2015 10:22:48 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in:
SAF117: EH&S MANAGEMENT TRAINING
QA01kd: BASIC ASSESSMENT
SAF120kd: SAFETY OBSERVATION PROGRAM </pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">903</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-903</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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<td class="label" nowrap>Issued:</td>
<td class="dataval">9/8/2015 10:16:18 AM</td>
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<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">9/8/2015 10:22:48 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">OTHER</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">G. A Whitney 509-372-2166</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">1 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=4002">DOE - Lost Test Step.pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Other: Training</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF117: EH&S MANAGEMENT TRAINING</li>
<li>QA01kd: BASIC ASSESSMENT</li>
<li>SAF120kd: SAFETY OBSERVATION PROGRAM Read (http://www.jlab.org/ehs/ehsmanual/manual/3700.html) Then Contact Bob May ext.7632 to arrange practical</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:mbailey@jlab.org,sjsmith@jlab.org,cjohnson@jlab.org">Lesson Learned Coordinator</a>.