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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=914">Hierarchy Required for Overlapping Work Control Documents - CNS Y-12 Production Site</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 multiple work control documents are required a hierarchy of order must be established and understood by all employees. In this case it was agreed that one document would control the work process and that all changes to it would be documented by revision or field change, with the remaining documents being subordinate.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>In March 2015 a Hazard Assessment/Work Instruction (HA/WI) and a Demolition Plan were written and approved the demolition of a building. Legacy mercury was discovered in the piping system of the building and Occupational Safety and Health Administration (OSHA) require that cleanup operations, be performed by a government body.
In accordance with the HAZWOPER requirements, a Site Safety Health Officer (SSHO) was appointed to the project. In addition, a Health and Safety Plan (HASP) was written to cover the demolition and abatement of the mercury
The removal method consisted of raking the residual mercury from the invert of the pipe section while catching any dripping fluids until the dripping stopped and subsequently cutting and capping the pipe sections. The planned work steps in the HA/WI as well as the HASP, included provisions for use of a glove bag.
Early in the performance of the HAZWOPER scope workers identified that the glove bag debris collection method, initially described in the work documents, was not adequate to control mercury due to its weight.
Workers paused the work and contacted the Site Safety Health Officer (SSHO) who approved an alternative method of capturing the residual mercury in a bucket. Neither the HA/WI nor the HASP work documents were modified to incorporate these changes.
At this point workers had removed approximately 70 of 80 total sections of pipe totaling approximately 250 linear feet. As the next piping section cut was being sawn, a larger than expected amount of residual mercury flowed from the cut and fell to the scaffolding and surrounding ground causing the mercury to be distributed throughout the work area. Workers were able to mitigate the spill and capture some of the mercury. Later that night the crew was remobilized and cleaned the remaining area to the satisfaction of the Envionmental Safety Health representatives.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>Multiple work control documents, i.e., HA/WI and HASP as well as the SSHOҳ authority to make field implementation decisions contributed to work site confusion. Uncertainty existed as to which document controlled the work process and whether the SSHOҳ authority allowed modification of the removal method.
When deficiency in the removal method occurred changes were made without modifying the work documents to reflect the changes. If the established protocol for HA/WI changes had been followed, then the probability of an appropriate, documented approach to the demolition process would have existed that in all probability would have instituted controls that would have prevented the mercury spill.
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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.
Examine work scopes in which multiple governing documents exist. Eliminate duplication and redundancy if possible.
If overlapping work control documents must be used, check to determine if gaps or overlaps exist in them.
If overlapping work control documents exist, specify the hierarchy.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>In accordance with ES&H Manual Chapter 3210 Work Planning, Control, and Authorization Process, when two or more work control documents are required the work supervisors is to review the work and the documents, and determine if an overarching document needs to be initiated to provide adequate control of the work.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">10/13/2015 3:26:41 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with the following training:
SAF117: EH&S MANAGEMENT TRAINING</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">914</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-914</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">10/13/2015 3:24:27 PM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<td class="label" nowrap>Approved On:</td>
<td class="dataval">10/13/2015 3:26:41 PM</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">Floyd Smith, fsf, 865.576.9040</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>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=4122">DOE - MultipleDocs.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>
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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>.