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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=957">Recognize and Respond to Changed Conditions - Roll-up Door Falls during Maintenance Work - Lawrence Livermore National Security, LLC</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>The work plan for replacement of a roll-up door motor recognized that there was a remote possibility that the door would suffer an uncontrolled fall. In response, workers cordoned off an appropriate workspace to protect personnel, however they did not consider equipment safety. When the door jammed the hazard went from "remote" to "probable" but the work plan was not adjusted to protect equipment. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>At the time of the occurrence the motor had been replaced and the subcontractor was testing the setting for fully-open and fully-closed operation. During the test the fully-open limit was set too high and the bottom rail of the door jammed at a height greater than ten feet. This introduced a changed condition to the work plan.
Fortunately, the original work plan had identified the possibility that the door could fall, so workers had already cordoned off the area to prevent unauthorized personnel from entering. Subcontractor personnel recognized the danger and, to avoid injury, they immediately evacuated the area while the jam was cleared. The door then fell, in an uncontrolled manner, 10-feet to the floor.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>The door jammed because the counterbalance assembly (springs) failed due to fatigue. This resulted in the key stock shearing where the drive shaft and sprocket joined. When the jam was cleared there was nothing in placed to prevent the door from falling.
Note: At more than 10-feet above the floor, the door presented a falling object hazard with considerable potential energy. While personnel and property outside the exclusion area were adequately protected, the door and its hardware were not.
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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.
Personnel should recognize that performance anomalies or malfunctions (the door jamming) signal a changed condition. When a condition changes it is prudent to:
Step 1: Stop/pause work,
Step 2: Bring the device or system to a safe configuration,
Step 3: Assess for causes and potential hazards, and
Step 4: Eliminate/mitigate the hazard(s) through implementation of appropriate work controls.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>No work at Jefferson Lab is completely without risk; therefore, all work requires forethought, planning, and authorization. Identification of work hazards and understanding their risks is an essential part of work planning. ES&H Manual Chapter 3210 Work Planning, Control, and Authorization Process defines Jefferson Lab's work planning, control, and authorization process. This process is commensurate with the laboratory's commitment to achieve the highest standards of safety and quality.
All individuals at Jefferson Lab have the responsibility, and authority, to stop work when conditions change or appear to pose a hazard. ES&H Manual Chapter 3330 Stop Work and Re-Start for Safety Program is used to evaluate work conditions when anomalies or malfunctions develop during "in-process" work.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">8/8/2016 9:51:36 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in SAF120kd: SAFETY OBSERVATION PROGRAM </pre>
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<legend>Summary</legend>
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<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">957</td>
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<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
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<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2016-JLAB-957</td>
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<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Best Practice</td>
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<tr class="row">
<td class="label" nowrap>Safety Related:</td>
<td class="dataval">YES</td>
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<tr class="row">
<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">8/8/2016 9:43:48 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">8/8/2016 9:51:36 AM</td>
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<td class="label">Source:</td>
<td class="dataval">
DOECRD
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<tr class="row">
<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">Paul Diniz, LLNL Roll-up Door SME (diniz1@llnl.gov, 925-423-7827)</td>
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<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
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<tr class="row">
<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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<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=4503">DOE - Roll-up Door.pdf</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4504">ES&H Manual Chapter 3210 Work Planning, Control, and Authorization Process</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4505">ES&H Manual Chapter 3330 Stop Work and Re-Start for Safety Program</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>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>
</ul>
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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>.