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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=966">Reoccurring Corrective Maintenance Can Indicate a Systemic Problem - Oak Ridge National Laboratory</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Repeated corrective maintenance, to a particular system, may indicate a systemic problem that is not being addressed by the repairs performed. Individual systems or mechanical operations often require corrective maintenance. Because repairs made during maintenance are often minor, they may not be identified as anything more than maintenance; masking the indication of a larger systemic problem. In this case an ozone gas generating system received multiple repairs during several regularly scheduled maintenance periods, each time the repair was thought to ¿fix¿ an apparent issue. In the end, failure to recognize and address the root causes behind the system¿s ozone build-up resulted in personnel being exposed to ozone above allowable limits.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>At ORNL¿s on-site sewage treatment plant, ozone is used as a final source of disinfection before treated wastewater is discharged into a local stream. This ozone is produced by a gas generating system and then bubbled through the tertiary effluent in a below-ground contact chamber. Over the course of several years, a number of events were noted regarding the ozone system. Each issue was addressed during a singular scheduled corrective maintenance activity. Issues included adjusting the production rate, replacing cracked piping in the system, or replacing air stones in the bubblers. At no point were these individual events tied together to indicate a systemic build-up of ozone without adequate destruction and gas exhaustion.
In the end, this build-up of ozone, coupled with a special treatment plant configuration used to perform maintenance at another location in the system, allowed ozone to back up through an overflow pipe into the basement where other maintenance activities occurred. This build-up of ozone in the basement resulted in personnel being exposed to above allowable limits when they entered the building to complete pre-job tasks. The exposed personnel were examined by ORNL¿s medical staff, and no acute or long term affects were noted.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>Inadequate evaluation of repairs done during scheduled maintenance led to build-up of ozone in a work area. There was no opportunity given to evaluate and correct the main ozone issue because repairs were identified as maintenance. They temporarily corrected a specific problem but did not provide an opportunity to evaluate the entire system.</pre>
<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.
ORNL plugged the overflow pathway and is in the process of installing an ozone destruct unit, increasing the capacity of the exhaust system.
In the future managers and maintenance personnel are to review past maintenance repairs to see if there is a common link pointing to a systemic problem.
Encourage all managers to develop a system for examining corrective maintenance activities to detect inter-related activities that may suggest a systemic problem.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>(Jefferson Lab¿s Subject Matter Expert has read and approved this lesson.)
Part of Jefferson Lab¿s Work Planning, Control and Authorization Process (outlined within ES&H Manual T1 Work Planning, Control, and Authorization Procedure ) defines the Lab¿s expectations relating to work process and control methods. This process incorporates the principles of Integrated Safety Management (ISM):
¿ Define the Scope of Work
¿ Analyze the Hazards
¿ Develop and Implementing Hazard Controls
¿ Perform Work Within Controls
¿ Provide Feedback and Continuous Improvement
When following the process, individuals review historical records related to equipment, areas, and similar activities prior to commencement of work. Upon completion of their assignment, they provide an activity summary, denoting actual events, to be used in the future by others.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">9/6/2016 2:29:32 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with Safety Observation Training</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">966</td>
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<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-966</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">9/6/2016 2:28:37 PM</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">9/6/2016 2:29:32 PM</td>
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<td class="label">Source:</td>
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DOECRD
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<td class="label" nowrap>Location:</td>
<td class="dataval">ORNL</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">Mike Watkins, 865-241-3341</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>Hazard Issues</legend>
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<li>Other: Work Planning and Communication,</li>
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<legend>Skills</legend>
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<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>
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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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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>.