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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=905">FML-15-0610 Exposure to Silica Above the TLV Limits</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>1. It is best to complete a bulk sample when planning to perform work where silica hazards are present, on items/equipment that were not installed by Jefferson Lab and therefore we are not certain of its make-up.
2. When working with silica in a quarantined area it is best to use local exhaust ventilation on cutting tools and jackhammers.
3. It is always best when planning your work to eliminate the higher hazards by using an alternative method to get the work done. This process should involve all invested parties and the appropriate subject matter experts to ensure that the elimination of one hazard does not create a higher risk hazard.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On June 10, Thomas Jefferson National Accelerator Facility (TJNAF) was informed by a subcontractor that personal air samples collected during a concrete wall demo activity exceeded the ACGIH Threshold Limit Value for respirable crystalline silica. The work was immediately suspended by the contractor, and remained on hold until
a revised demo and exposure control plan was approved by the Lab.
Information and statements from the demolition subcontractor between June 10-17 indicated that full face respirators were worn by their workers, as required by the Laboratory approved work plan; however, upon subsequent receipt of the Industrial Hygiene field notes on 06/18/2015, it was documented that the subcontractors
were only wearing half face respirators. Jefferson Lab held a meeting with the contractor on 06/19/2015, and confirmed that the workers were only wearing half face respirators. Neither full face or a half face respirator would have provided adequate protection for the concentrations of respirable crystalline silica measured, but the level of protection provided by the respirators worn (OSHA assigned protection factor) was less than originally thought or specified.
Engineering controls were identified in the approved work plan (Activity Hazard Analysis), and included wet saw cutting, wet jack hammering, and HEPA filtered general exhaust ventilation. The subcontractor¿s utilization of those engineering controls, and HEPA filtered vacuuming were reflected in the field notes recorded by an Industrial Hygiene subcontractor at the time of the exposure monitoring.
This concrete demo work is associated with the renovation of the Injector Test Cave inside the Test Lab. Sampling results revealed percentages of crystalline silica up to 80% in the in the concrete being removed. The subcontractor has ruled out further use of a pneumatic jackhammer, as this technique seems to be more
problematic to control worker exposures, even when water is applied for dust suppression.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Engineering controls were LTA. Once sampling results were reviewed it was determined that engineered controls such as the general exhaust ventilation, HEPA vacuum, water for dust suppression, etc. were not sufficiently effective at managing the airborne dust hazard for the demolition techniques used.
Contributing Causes:
1. Previous sample data from similar work inside the same building (Test Lab, 1960¿s era NASA Space Radiation Effects Lab) was not readily available to the responsible parties when reviewing the work plan. IH personnel used previous lessons learned and the silica data that was available from silica events in other Laboratory buildings however, the engineered controls and PPE were LTA under this work evolution. Only upon conducting this investigation was it noted that there
were historical samples that contained similar amounts of silica; however they were not in the IH database.
2. Contractors failed to follow the approved Safety Plan and associated AHA when completing this demo. Although the Safety Plan documentation stated a full face respirator was required for this work, contractor wore a half face respirator. This change would not have prevented the over exposure; however it was a deviation from their approved Safety Plan.
3. The workers were not silica trained as per contract and their approved Safety Plan
4. Supervision of work LTA- SOTR observed the work when it first started however, the SOTR and the subcontractor supervisor failed to recognize that the PPE worn by the workers was not what was identified and approved in the Safety Plan.</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Adjust the existing AHA to ensure that the results
of the bulk sample are used in the development of the new AHA and include additional engineering controls or alternate methods of removal that will limit silica dust production. The amended AHA will be reviewed by the Industrial Hygienist prior to receiving the approval to restart demo activities and contract employees must review and sign prior to restart.
2. AHA will list the specific type of required PPE and engineering controls, and will no longer reference another document.
3. Gen 133 (AHA Preparation) training will be updated to reflect the new requirement to have the personal protective equipment listed in the AHA.
4. Subcontractors must complete Site Specific Silica Training prior to starting the work.
5. Develop a SOTR training database that captures required JLab training for subcontractors. This report will then be used by the SOTR to validate training prior to the start of their work.
6. Deliver letter to the subcontractor which will include a fine for not following approved work plan.
7. The Health and Safety Group is currently developing a ¿Demolition Decision Tree Diagram.¿ They will adjust the diagram to include pulling a bulk sample
of concrete to be demolished prior to the start of work.
8. FM&L will conduct a SOTR meeting to discuss this event which will raise awareness.
9. FM&L will conduct a SOTR meeting and review the various types of respirators that we may see in the field.
10. Revise ES&H Manual Chapter 6883 to identify criteria/thresholds that would require inserting a formal hold point in a work plan to allow analysis of monitoring to verify controls are adequate.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>See Corrective actions. </pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">9/18/2015 10:17:33 AM by Johnson, Tina</h5>
<pre>Please share within your work group. </pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">905</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-905</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">9/18/2015 9:59:02 AM</td>
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<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Johnson, Tina</td>
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<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">9/18/2015 10:17:33 AM</td>
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<td class="label">Source:</td>
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TJNAF NE
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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">Bob Sperlazza</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>
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<legend>Hazard Issues</legend>
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<li>Silica</li>
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<legend>Skills</legend>
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<li>GEN020: SOTR QUALIFICATION </li>
<li>SAF138: Silica Safety</li>
<li>GEN133: Conduct effective Activity Hazards Analysis</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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