<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html>
<head>
<title>Jefferson Lab Lessons Learned : Print Lesson</title>
<base href='https://misportal.jlab.org/ll/'>
<!--[if IE]>
<style type="text/css">
#page_content input[type=checkbox], #page_content input[type=radio] {
background-color: transparent;
border: 0;
}
</style>
<![endif]-->
</head>
<body>
<div id="doc3" class="yui-t7">
<div class='round' id='pageMessages'>
<!-- -->
</div>
<div id="lesson" class="yui-gc">
<style type="text/css">
pre {
white-space: -moz-pre-wrap;
white-space: -pre-wrap;
white-space: -o-pre-wrap;
white-space: pre-wrap;
word-wrap: break-word;
overflow: hidden;
margin-left: 10px;
}
</style>
<script languange="javascript">
function showAttachmentOptions(ele) {
var type=ele.options[ele.selectedIndex].value;
switch (type) {
case 'FILE': document.getElementById('urlAttachment').style.display='none';
document.getElementById('fileAttachment').style.display='inline';
break;
case 'URL': document.getElementById('fileAttachment').style.display='none';
document.getElementById('urlAttachment').style.display='inline';
break;
default: document.getElementById('fileAttachment').style.display='none';
document.getElementById('urlAttachment').style.display='none';
break;
}
}
</script>
<div id="topbar">
<div id="lesson_title">
<table width="100%">
<tr>
<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1022">FML-17-0707- Three Foot Long Abandoned Metal Pipe Burning with No Obvious Source</a></td>
</tr>
</table>
</div>
</div>
<table width="100%">
<tr>
<td valign="top" width="100%">
<div id="maintextcol" class="yui-u first">
<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>1. When there is an emergency situation - When outdoors, call 911 and get Emergency Services moving. Contact the Guard Post and alert them so that they can direct Emergency Services to your
location.
2. Do not bring hazardous materials on DOE property, without consulting Industrial Hygiene.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On Friday, July 7, 2017, Jefferson Lab ESH&Q staff discovered a pipe emitting smoke and flames in a wooded area behind the Residence Facility on SURA property. The pipe was discovered during a regular weekly environmental walk through. The Industrial Safety employee called the Fire Protection
Engineer who responded to the scene. Upon arrival, the pipe was found smoking but the flame had self-extinguished. The Fire Protection Engineer visually inspected the pipe. The surrounding area was covered with dried leaves and other combustibles. Using a thermal scanning tool the pipe was observed to be cool. The desire to analyze the pipe contents was discussed. Because of the
proximity of the pipe to combustibles it was decided to relocate the pipe to the Central Material Storage Area (CMSA), a secure gravel area. The pipe was isolated in an area that would not allow the flames to travel.
Around noon, the pipe was observed on fire and the Fire Department was called for advice. Upon hearing the details, the Fire Department suggested that they should respond. By the time they arrivedthe flames had again self-extinguished. The Fire Department contacted their Hazardous Materials specialists and instructed FM&L personnel to acquire the supplies to secure the pipe. The NNFD secured the pipe in dry cement and covered it in plastic; FM&L staff secured the area. As a
precautionary measure, the ESH&Q Director advised employees not to enter the CMSA for the remainder of the day or contact the Security Guards for information on the hazard if they had to enter the CMSA. The U.S. Army Corps of Engineers (USACE) was notified and are expected onsite in the near future to evaluate and take responsibility for disposal of the pipe and determine extent of condition.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause (Event 1):Failure to Recognize Potential Extent of Hazard. Failure to recognize the burning pipe as a potentially hazardous material or danger. When the Environmental Engineer (EE) and the Safety Engineer (SE) approached the pipe, their immediate response did not include calling 911, according to their SAF100.
Contributing cause(s) (Event 1):
Discovery of burning pipe without an obvious source on SURA Property
A. Reluctance of JLab personnel to activate pull stations or call 911
B. Failure to recognize Fire as an Emergency/Hazardous Material Incident
C. Emergency Response Protocol is not clear regarding outdoor events
Root Cause (Event 2):
Moved an unknown hazardous material. There was too much emphasis on controlling/correcting the unusual situation which overshadowed emphasis on diagnosing potential hazard.
Event No. 2 Decision to move the pipe following the first ignition to a secure location (CMSA- gravel
area)
A. Lack of questioning attitude before taking action
Contributing Cause(s) (Event 2):
Decision to move the pipe following the first ignition to a secure location (CMSA- gravel
area)
A. Lack of questioning attitude before taking action
Root Cause (Event 3):
Failure to Recognize Potential Hazard (smoke exposure from pipe with no apparent
ignition or fuel source). While the pipe was on fire and smoking multiple people videotaped and took
pictures of the fire and were in close proximity while taking photos and videos (see attached)
exposing themselves to potentially dangerous fumes. This occurred both in the woods and in the
CMSA.
Contributing Cause (Event 3):
Taking pictures and video of the pipe while burning/smoking. Potentially exposing them
to unknown substance
A. Emphasis on recording unusual event overshadowed concern for individuals own safety.
B. Emergency Response protocol not clear
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Remind staff on the emergency response procedures with an emphasis on things like recognizing a situation that they can't control, activating a pull station, making a 911 call and securing an area, and not placing themselves in a potentially harmful situation in order to videotape or take pictures.
2.Develop a Tool Box Talk that incorporates the lessons learned from the event, including activating a pull station, calling 911, recognizing a hazard, exercising a stop work and practicing conservative behavior (not touching unknown substance, have a questioning attitude). Give examples of good responses and not so good response. Be sure to emphasize that when acting on these potential hazards, there should be no fear of retribution.
3.Communicate through the Weekly Briefs that unknown hazardous materials are not to be handled.
4. Share the lessons learned from this event with Facilities Management and Logistic's SOTRs, line managers and supervisors, emphasizing that a "deliberate" response, over an "immediate" response is expected of Facilities personnel.
5. Associate Director's shall hold small group meetings with their organization (line management) using the developed "Tool Box Talk".
6. Conduct a series of drills over the course of one year that involve multiple inhabited buildings and obvious hazards such as smoke, fire, smell, or unknown package hazard. These drills shall be coordinated with the emergency manager.
7. Evaluate the need to review and revise the Emergency Management flow chart to include emergencies that occur outside.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>See the corrective actions that were identified above.</pre>
</div>
<div id="comments_div">
<a name="comments"></a>
<h2>Comments</h2>
<h5 style="white-space:nowrap">9/1/2017 10:00:16 AM by Johnson, Tina</h5>
<pre>This event and lessons learns effects everyone at the Lab. Please take a moment to review your emergency response procedures and discuss within your work areas.
* SME review and approval was received. </pre>
</div>
</td>
<td valign="top">
<div class="yui-u">
<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1022</td>
</tr>
<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
</tr>
<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2017-JLAB-1022</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Info</td>
</tr>
<tr class="row">
<td class="label" nowrap>Safety Related:</td>
<td class="dataval">NO</td>
</tr>
<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">9/1/2017 9:52:36 AM</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">9/1/2017 10:00:16 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/FML-17-0707%20web%20version.pdf" target="_blank">TJNAF NE</a>
</td>
</tr>
<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">TJNAF</td>
</tr>
<tr class="row">
<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
</tr>
<tr class="row">
<td class="label" nowrap>Contact:</td>
<td class="dataval">Paul Powers</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">234</td>
</tr>
<tr class="row">
<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
</tr>
<tr class="row">
<td class="label" nowrap>Viewings:</td>
<td class="dataval">1 times</td>
</tr>
</table>
</fieldset>
<fieldset>
<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
</ul>
<hr>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Other: fires, emergency responses</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF108: FIRE SAFETY</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>
</fieldset>
<!--
<fieldset>
<legend>Applicable Orgs</legend>
<ul class="lesson_attribute_listing">
</ul>
</fieldset>
-->
</div>
</td>
</tr>
</table>
<script language="javascript">
var commentTextarea = document.getElementById("commentForm:commentText");
if (commentTextarea){
var validationErrorFound = commentTextarea.parentNode.innerHTML.indexOf("Validation Error: Value is required.") > -1;
if (validationErrorFound){
// add hash if necessary
if (window.location.hash == null || window.location.hash == "" || window.location.hash == "#"){
window.location.hash = "#comments";
}
}
else {
//JSF likes to hold on to the values entered into the form...so blank them out
commentTextarea.value = "";
commentTextarea.form.elements["commentForm:commentType"].selectedIndex = 0;
var numStars = commentTextarea.form.elements["commentForm:stars"].length;
for (var ii=0; ii<numStars; ii++){
commentTextarea.form.elements["commentForm:stars"][ii].checked = false;
}
}
}
</script>
</script>
</div>
<br>
<br>
</div>
</body>
</html>
<br>
<br>
Do you have a lesson learned you would like to contribute? Contact the <a href="mailto:cjohnson@jlab.org,sjsmith@jlab.org,mbailey@jlab.org">Lesson Learned Coordinator</a>.