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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=972">ACC-16-0714- LERF Brought to Beam Permit Without Requisite Authorized Personnel on Site</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>When operational paradigms are changed, ensure supporting and governing documents are also updated to reflect changed conditions to reduce risk of compliance violation.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On July 14th and 15th, 2016, the Low Energy Recirculator Facility (LERF) was placed into Beam Permit without a "Free Electron Laser (FEL) Operator"/LERF Operator on watch. This activity constituted a violation of Administrative Control 6 of Table 1-3 of the current revision of the Accelerator Safety Envelope (ASE.) This violation was a procedural violation of the ASE but personnel and machine safety were not compromised at any time.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause: A3B1C06 - Wrong Action was selected based on similarity with other actions. OPS did not follow the LERF procedures (LOD and ASE) the way they were written based on flawed assumed equivalency to CEBAF procedures (AOD and ASE) which would allow them to run with reduced staffing during certain low energy (<1MeV) related tasks. The LERF Operation Directives clearly state minimum staffing requirements for the LERF activities event though the ASE is out dated.
Contributing Causes:
A4B3C05 - Insufficient Number of Trained or Experienced Workers Assigned to Task.
While the worker assigned to the activities had previous experience and authorization during the FEL era, that authorization had been revoked at the beginning of the LERF activities. New authorization as LERF Operator required completion of an extensive training catalog which the individual in question had never taken. An improper assumption by acting management of equivalence was made based on past authorization and duties (FEL Operator ≠ LERF Operator).
A4B2C06 - Means not Provided to Assure Procedures are Up-to-Date.
A5B2C07 - Facts Wrong/Requirements Not Correct.
The ASE had not been updated to reflect changes made with governing documents from FEL to LERF operations which caused confusion during minimum staffing requirements.
The ASE is inconsistent between FEL and CEBAF minimum staffing requirements ("FEL Operator" vs. "Authorized Personnel") which caused confusion during decision making for staffing during shift operations.
AOD is consistent with all ASE staffing requirements for CEBAF. FELODS has been rewritten to align the LOD more with AOD standards. However, the LOD is not consistent with all AOD minimum staffing requirements for machine related tasks (equal to/below 1MeV) lending confusion with OPS driven staffing requirements.
A4B5C11 - Changes not Adequately Communicated.
Previous operational paradigm is hard to shake and new roles and responsibilities are not clear to all invested parties. Unofficial verbal communications were LTA as only a subset of effected parties were informed of changes, leaving others out of the loop.
No formal transition from FEL to LERF operations which highlights the major changes to the LERF Operators vs. former FEL Operators.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Extent of condition: Check procedures for CEBAF operations to ensure that there are no loop holes in minimum staffing requirements.
2. FSAD and ASE need to be updated to align LERF safety envelopes to be the same as CEBAF safety envelopes. Current wording in the ASE refer to "FEL Operator" for the FEL facility vs. "authorized personnel" in the CEBAF machine for minimum staffing requirements. "FEL" references should be removed from the ASE and FSAD during their next triennial review and update.
3. Ensure all "FEL Operator" references and qualification postings are removed from MCC and LERF Control Rooms and their governing procedures.
4. Formal letter to all former FEL staff that "FEL Operator": and "Duty Officer" qualifications have been revoked. New list of qualified LERF Operators should accompany this letter to ease confusion about who is qualified to act as a LERF Operator.
5. Update LOD to be more specific about minimum staffing requirements at different conditions and operating levels, which is more in line with AOD guidance.
6. Letter to TJSO from Lab Management stating the violation and steps for path forward.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">10/3/2016 2:09:26 PM by Johnson, Tina</h5>
<pre>SME review and approval. Please share within your groups.</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">972</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-972</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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<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">9/28/2016 3:39:43 PM</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">10/3/2016 2:09:26 PM</td>
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<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/final%20ACC-16-0714.pdf" target="_blank">TJNAF NE</a>
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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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<tr class="row">
<td class="label" nowrap>Contact:</td>
<td class="dataval">Harry Fanning</td>
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<tr class="row">
<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">10 times</td>
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<legend>Hazard Issues</legend>
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<li>Other: LERF Operations</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>MCC103: MCC Operations Manual</li>
<li>MCC110: OPERATOR SCREENS</li>
<li>MCC111: GENERAL TOOL SCREEN</li>
<li>MCC-706.05 : ORFP & Optics for Fall 2015 Run</li>
<li>MCC-706.11: LERF Introduction</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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