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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=979">Use Administrative and Engineered Controls to Minimize the Possibility of Using the Wrong Unit</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Wherever multiple, identical (or similar) units are installed, administrative and engineered controls should be considered to minimize the possibility of inadvertent operation of the wrong unit. Use all available indicators to cross-check that intended operations are safe. Time constraints during an operation can impair decision-making. Keep safety first, then quality, and leave schedule for last.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Due to resource sharing and time constraints placed on an employee performing a sequence of routine back to back tasks, the employee became distracted. After the first job was completed, the employee left to ask the group waiting for the shared resource if the employee had time to perform the second job which involved similar tasks on a different but similar system. When told they had 30 minutes before the shared resource was needed by the group, the employee came back and started to perform the next set of routine tasks on the next system.
However, midway through the task sequences, the employee noticed a few visual clues that they were on the wrong system and began to back out of the sequence of performed tasks when a second employee (who was overseeing the operations in the area) stopped to question the actions of the first employee. The first employee stated they understood they were on the wrong system, and were in the process of putting the system back in order.
The second employee checked the electronic read backs for status of the effected system and found there was only a minor fluctuation of the effected system, but otherwise none the worse for wear.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>The employee went to the wrong system because they had become distracted due to the interface with the group needing the shared resource between jobs and worrying about time constraints to perform the job.
An analysis of the hazards showed the most likely consequences of performing the sequence of tasks on the wrong system would not have involve any safety issues. However, performing the tasks on the wrong system would have effected plant quality as the actions would have certainly lead to contamination being introduced to the system and liquid helium would have been wasted as it slowly boiled off.
If the system had become contaminated, a shutdown of the effected facility would have been necessary to clean up all effected systems within the facility and generated unnecessary downtime.
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. The effected facility¿s management will review this event with all employees who perform similar jobs or activities within the facility.
2. The effected facility¿s management will install conspicuous labels which are more visible for employees so they are less likely to be confused on which system they are performing tasks.
3. The effected facility¿s management will investigate the installation of localized go/no-go indicators which are easily visible to employees who carry out tasks on these systems.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">12/6/2016 12:55:09 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with Hall Safety Training.</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">979</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">2016-JLAB-979</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Best Practice</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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<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">12/6/2016 12:54:29 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">12/6/2016 12:55:09 PM</td>
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<td class="label">Source:</td>
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TJNAF Other
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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">Harry Fanning, Accelerator Division Safety Officer </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>Hazard Issues</legend>
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<li>Other: Work Planning and Communication,</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF104: LOCK, TAG, AND TRY</li>
<li>SAF110: HALL A SAFETY KNOWLEDGE</li>
<li>SAF111: HALL B SAFETY AWARENESS</li>
<li>SAF112: HALL C SAFETY AWARENESS</li>
<li>SAF113: Hall D Safety</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>.