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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=980">ACC-15-1028- Low Energy Recirculator Facility Left in Beam Permit without Proper Pass-Down to Authorized Personnel in Charge</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>When resources are limited, and more objectives are added to an established plan, reevaluate resource management to allow for single project success or compensate: all objectives to avoid potential programmatic issue development due to not enough resources for all objectives.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On October 28th, 2015 the Low Energy Recirculator Facility (LERF) was left unattended overnight by LERF Operator #1 while the LERF was in Beam Permit and without proper turnover to the Continuous Electron Beam Accelerator Facility (CEBAF) Operations staff.
Due to the nature of work being conducted during Hot Check-Out (HCO) of the LERF as well as extenuating circumstances described in the following paragraph, there was never any danger to personnel or to facilities on or off site at Jefferson Lab.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause:
A4B2C03 - Insufficient manpower to support identifid goal/objective: LERF Operator #1 was tasked to initiate LERF resuscitation with limited resources and manpower. As a result, LERF Operator #1 performed as Subject Matter Expert (SME) for the Drive Laser Pulse
Controller (DLPC) system, as the LERF Operator for Day Shift, LERF Operator trainer for CEBAF trained Operators, LERF Run Coordinator to oversee program planning as well as their primary task of LERF Operations Coordinator.
Due to simultaneous CEBAF operational goals which took precedence over LERF operational goals, needed CEBAF/LERF Operators were not readily available. LERF Operator #1 was spending multiple hours on site acting as LERF Run Coordinator and LERF Operations Coordinator to reach
and communicate LERF objectives.
Contributing Causes:
A3B1C03 - Incorrect Peiformance due to Mental Lapse: LERF Operator #1 knew the proper steps to pass down information to CEBAF Operators for them to take over as LERF Hot-Standby Operator and to reduce the LERF PSS state to below Beam Permit.
However, due to being assigned too many administrative duties due in part to limited resource
allocation, LERF Operator #1 missed those steps due to a mental lapse.
A5B1C04 - Deficiencies in User Aids (charts, etc.)
PSS Status Displays go to sleep after a period of inactivity to save the screens from bum in. lnformation from these screens is accessed via the Safety System Operator (SSO) during machine accesses or status inquiries but do not stay visible throughout the shift. lnteraction by humans is
needed to understand irregularities in machine status.
A4B4C07 - Too Many Concurrent Tasks Assigned to Worker
LERF Operator #1 was assigned too many concurrent jobs both administrative and task oriented which contributed to job performance errors.
A4B4C05 - Emphasis on Schedule Exceeded Emphasis on Methods/Doing a good job
With limited resources available for achieving both LERF and CEBAF objectives, planning and resource management was LTA to ensure all objectives were met. LERF objectives could have been met if CEBAF objectives did not overlap within the overall schedule. When both objectives
overlapped, resources were diverted to one over the other, making the other's mission more likely to develop programmatic issues. Certain personnel had to cover two and three jobs which lead to errors. A quick completion for one objective (LERF Operations) became more important versus its
successful completion in order to ensure a higher priority objective (CEBAF Operations) could be met.
A5B4C01 - Communication Between Workgroups LTA
The LERF Run Coordinator failed to define the shift plan to include prolonged Beam Permit operational activities for the Day and Swing shifts, which was out of the "norm" for the week's activities at the LERF. Short duration Beam Permit requests had been made by LERF Operators and
granted by CEBAF Operators during Day shifts, but were not recorded in the daily shift plans either.</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Extent of condition:
1. Check Operational procedures to verify the extent of the failure. Check operational systems to ensure there is/was no danger to personnel due to the procedural lapse.
2. Conduct an operational review of the LERF to promote better communications between the LERF, CEBAF machine operations staff and stakeholders. The review should investigate effectiveness of shift turnovers; running of LERF and CEBAF machines with limited resources and with current staffing projections; PSS controls and hand-offs between LERF and CEBAF staff; and LERF Run Coordinator communication of LERF status and run plans to CEBAF Operations and stakeholders in morning meetings and PD Shift Plans.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>See above corrective actions</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">12/16/2016 10:01:35 AM by Johnson, Tina</h5>
<pre>SME approved. Please review and discuss within your work 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">980</td>
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<tr class="row">
<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"></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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<tr class="row">
<td class="label" nowrap>Originator:</td>
<td class="dataval">Johnson, Tina</td>
</tr>
<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">12/14/2016 3:55:06 PM</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Johnson, Tina</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">12/16/2016 10:01:35 AM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/ACC-15-1028_LERF_Left_in_Beam_Permit_wo_Proper-Passdown.pdf" target="_blank">TJNAF NE</a>
</td>
</tr>
<tr class="row">
<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">6 times</td>
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<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=4618">ACC-15-1028_LERF_Left_in_Beam_Permit_wo_Proper-Passdown.pdf</a></li>
</ul>
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</fieldset>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Other: LOD, AOD, LERF </li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF115O: LERF Laser Operator Training</li>
<li>SAF115U1: LERF TRAINING FOR USERS -LAB 1</li>
<li>SAF115U2: LERF TRAINING FOR USERS - LAB 2</li>
<li>SAF115U3: LERF TRAINING FOR USERS - LAB 3</li>
<li>SAF115U3A: LERF TRAINING FOR USERS - LAB 3A</li>
<li>SAF115U4: LERF TRAINING FOR USERS - LAB 4</li>
<li>SAF115U5: LERF TRAINING FOR USERS - LAB 5</li>
<li>SAF115U6: LERF TRAINING FOR USERS - LAB 6</li>
<li>SAF115GTS: LASER OPERATOR - GUN TEST STAND</li>
<li>MCC103: MCC Operations Manual</li>
<li>MCC110: OPERATOR SCREENS</li>
<li>MCC-309: FSAD</li>
<li>MCC-310: AOD</li>
<li>MCC-311: MOM</li>
<li>MCC-320: Control Room Supervision</li>
<li>MCC-321: Program Control</li>
<li>MCC-322: Control Room Efficiency</li>
<li>MCC-332: ASE and Operational Parameters</li>
<li>MCC-341: Beam Restoration, Setup and Configuration</li>
<li>MCC-702.19: Operations Safety</li>
<li>MCC-706.11: LERF Introduction</li>
<li>MCC-502: LERF Operational Directives (LOD)</li>
<li>MCC-503: LERF Accelerator Safety Envelope</li>
<li>MCC-509: LERF Machine Protection</li>
<li>MCC-510: LERF Gun Operation</li>
<li>MCC-511: LERF Mini-Phase</li>
<li>MCC-512 : LERF Arc 1 Setup</li>
<li>MCC-513: LERF Back Leg Straights</li>
<li>MCC-514 : LERF Arc 2 Setup</li>
<li>MCC-515: LERF Phase/Pathlength for Recirculation and 10 MeV Dump</li>
<li>MCC-516: LERF BLM Setup</li>
<li>MCC-517: LERF CW Beam Operations</li>
<li>MCC-518 : LERF Operational Recovery and Troubleshooting</li>
<li>MCC-519: LERF Optics</li>
<li>MCC-520: LERF FSD Tree</li>
<li>MCC-521: LERF Diagnostic Tools</li>
<li>MCC-551: LERF Laser Optics</li>
<li>MCC-552: LERF Lasing Optimization</li>
<li>MCC-560: LERF Advanced Injector Setup</li>
<li>MCC-561: LERF Advanced Electron Beam Troubleshooting</li>
<li>MCC-562: LERF Advanced Laser Troubleshooting</li>
</ul>
</fieldset>
<fieldset>
<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>.