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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=988">FML-16-1130 Refrigerant Detections System Disabled Following Discovery of a small leak- Interim Mitigations were Less than adequate (LTA)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>1. When planning our work, we should always prepare and mitigate for the worst case scenario. This will ensure that we have all the proper mitigations in place before we proceed.
2. Communication is the key. When a change in conditions occur, consult with all invested parties. This will ensure that all potential scenarios are covered and that invested parties are notified of the change in conditions. Consider a checklist when applicable or if notifications involve multiple groups.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On November 29, 2016 an IH employee and Safety employee were in the CUP building (Building 60) to inspect the eye wash station. While walking through the building they noticed that the refrigerant alarm was not on. The IH employee emailed the FM Mechanical Manager and asked when the system would be returned to service. The FM Mechanical Manager replied that the monitoring system was off due to a slow refrigerant leak however the building refrigerant exhaust ventilation was manually activated and rollup doors partially open. The IH employee then replied to the FM Mechanical Manager and cc¿d ESH Department line management stating that other means of hazard control needed to be in place (e.g. signs, PPE). Line management informed their supervisor and the Reporting Officer. </pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause:
Work Organization and Planning was LTA- When the conditions of the building changed (fixed monitoring system continued to alarm following several failed attempts to find a leak using a hand-held device), they failed to recognize and properly mitigate the hazards associated with this building as a result of the refrigerant leak to include a potential catastrophic event. Initial mitigations were rationalized for a small refrigerant leak only: roll-up doors were locked open, exhaust fan and air intake fans were turned on; and did not account for the potential catastrophic failure that may have occurred.
Employees did not contact all invested parties when the change occurred. Employees were not aware that they should communicate changes with Industrial Hygiene, per the draft OSP. could have given guidance as to how to properly proceed with mitigating all potential hazards until the system could have been restored.
As a result, entrants were able to access the building with no visual clues, there were no personnel door locks, or hazard communication signage stating that the alarm had been turned off and who to contact if entry into this building was needed. Briefing to potential building entrants were informal at best and did not account for ¿others¿ that may have needed access to this building for a variety of reasons.
Contributing Causes:
Verbal Communication LTA among work groups. The change in conditions was not effectively communicated to all invested parties. Management was unaware that the refrigerant system alarms was no longer on, that the refrigerant leak detection system was offline, and that the employees believed that they system may be defective in nature.
Written Communication not used- There is no approved procedure (OSP) for handling refrigerant leaks. Employees were working from an old DRAFT version of an OSP. The OSP approval process will give SME¿s the opportunity to review and provide valuable input for employees. This had not occurred when this event occurred.
Written Communication content LTA- Draft procedure (OSP) did not cover all scenarios that may occur in the event of a leak. Employee did not have a procedure on how to handle communication if/when a fixed alarm system must be turned off for any reason. Also, the draft procedure did not cover appropriate mitigation efforts in the event of a leak, which would include the use of hand held meters, and PPE as needed.
Supervisory Methods LTA- Emphasis on schedule and job shuffling. Employees were faced with mixed priorities as they were trying to balance the Test Lab basement work and the CUP building work during the same time. Both systems must remain on for commissioning activities.
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Put up signs on the building to ensure entry is made with hand-held refrigerant monitor or SCBA until leak is repaired and monitoring system returned to operation.
2. Install locks to the personnel doors to ensure only authorized personnel are able to enter the building.
3. Send the fixed alarm off-site for evaluation.
4. Update and finalize the OSP for entries into these specific areas. Be sure to include lesson learned from previous incidents. The OSP should also include communication procedures in the event of a leak and the need to turn off any early detection system and cover the use of a hand held meter.
5. Install hazard communication signs on CUP entry doors to inform entrants of the presence of refrigeration machinery/Freon and response required in case of an alarm.
6. Once the OSP is updated with the new steps to cover lessons learned and additional steps, review with FM&L staff that will be required to work in building with refrigerant systems.
7.Ensure all parties responsible for entering these areas have the appropriate SCBA training.
8. Applicable Lessons Learned from recent Notable Events will be shared to supervisors during supervisor training.</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">1/23/2017 11:27:09 AM by Johnson, Tina</h5>
<pre>SME reviewed and approved. Please share the identified Lessons Learned within your work groups.
Thank you!</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">988</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">2017-JLAB-988</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Caution</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">1/18/2017 2:49:32 PM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Johnson, Tina</td>
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<td class="label" nowrap>Approved On:</td>
<td class="dataval">1/23/2017 11:27:09 AM</td>
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<td class="label">Source:</td>
<td class="dataval">
<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/FINAL%20FML-16-1130.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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<td class="label" nowrap>Contact:</td>
<td class="dataval">Bob Sperlazza</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">12 times</td>
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<legend>Hazard Issues</legend>
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<li>Air Contaminants - Hazardous</li>
<li>Environmental</li>
<li>Other: Refrigerant</li>
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<legend>Skills</legend>
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<li>SAF109: SELF CONTAINED BREATHING APPAR (SCBA)</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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