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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=924">FML-15-1016 Employee Breached a Contamination Barrier Without Proper Work Controls</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>When working near Contamination Areas, it is imperative to remember that the rope equates to an invisible plane that you are not to cross unless RadCon has been notified, you are properly trained and wearing the appropriate Personal Protective Equipment (PPE). </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Around 9:00 am on Friday, October 16, 2015, an employee was discovered working in a posted contamination area in Hall C without proper work controls. The employee reached over the RadCon rope into the contamination area to work on the electrical outlet located inside the barrier. A RadCon technician spotted him and immediately asked him to stop working. The technician frisked the employee and his equipment and it was determined that both were not contaminated, nor was there a spread of contamination. The RadCon technician verified that the employee had RadWorker II, and the employee donned the appropriate PPE and placed the socket cover back on the receptacle to ensure that the receptacle was in a safe state. The employee then frisked himself to ensure that both he and his tools were not contaminated and then he left the Hall.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause: Human error- Although properly trained the employee failed to read and comply with the sign prior to reaching over the barrier rope. The area was roped off with a magenta rope and had a sign hanging which indicated that this area as a ¿Contamination Area.¿ The sign also stated RWP required for entry.
Contributing Causes:
Work Planning was less than adequate and did not include a pre-job walk down of the job. The scope of work and the plan to complete this ¿routine¿ work did not match. Job walk down was LTA- Brief interaction with the Hall Leader did not detail the work. Both the requester and the technician parties made incorrect assumptions about how the work is performed.
The Facility Work Request was a generic entry. The person entering the work request, thought that the work would be done in areas which would not require entry into a contamination area. The person performing the work was requested to fix the phases at each individual electrical outlet within the hall without any mention of any being in a contaminated area.
Communication was LTA. The customer and worker did not talk through the job. They missed the opportunity to discuss how the work would get done and what hazards may have been associated with completing the job.
The employee is RadWorker II trained, and does not have the need to use this training on a regular basis. Just like other skills, if you do not use them, you may lose the knowledge or skill. Lack of regular use of this training may have contributed to his oversight.
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Employee¿s RadWorker I and II were revoked by management. The employee will need to re-take his training. Until his training can be re-taken, he must be escorted in all appropriate areas.
2. Tool Box meeting to reiterate the contamination area and that you are not permitted to cross the invisible plane.
3. ISM Poster ¿ Explain what a Contamination Area is, the requirements for entry and what you should do if you are unsure about the requirements for entry.
4. Share Lessons Learned and Notable Event with all RadWorker I trained individuals.
5. Hold a Toolbox meeting to reiterate the importance of completing a detailed walk-down of the area prior to the start of the work. ( *If not offered by the requester, the worker should request the walk-down from the requester prior to completing the work) </pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>See actions listed above. </pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">12/1/2015 10:50:35 AM by Johnson, Tina</h5>
<pre>Please read and share this lessons learned within your work groups.
**SME read and approved for distribution.</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">924</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-924</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Caution</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">12/1/2015 10:48:18 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">12/1/2015 10:50:35 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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<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>Radiation - Ionizing</li>
<li>Radiologically Contaminated Area</li>
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<legend>Skills</legend>
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<li>SAF801P: Radiation Worker I Knowledge--Implementation</li>
<li>SAF801C: Radiation Worker I Knowledge--Information</li>
<li>SAF801T: Radiation Worker I Knowledge--Assessment</li>
<li>SAF802: Rad Worker II Radiological Knowledge</li>
<li>SAF801kd: General Access RWP</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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