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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1039">TSR/SAC Violation Due to Inadequate Transfer Path Walkdown - Savannah River Remediation (SRR)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Specific Administrative Control (SAC) 5.8.2.20 requires that a pre-job walkdown of the transfer path be performed prior to a liquid waste transfer to identify any in-progress excavation work having the potential to breach the transfer line core pipe. Excavation work is to be discontinued during the transfer. In this case, the pre-job walkdown was not performed due to inadequate communications between operations personnel and the failure to verify completion of procedure steps on the part of the driver.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On May 20, 2017, excavation was being performed at the east side of the Low Point Pump Pit (LPPP) over the transfer lines to the Salt Waste Processing Facility (SWPF). In violation of DWPF Technical Safety Requirement (TSR) Specific Administrative Control (SAC) 5.8.2.20, a waste transfer was initiated and completed without notifying the excavation workers. It was later determined that an evaluation of the transfer path had been previously performed, with the conclusion that there were no potential radiological consequences to excavation workers from any liquid waste transfers due to the soil coverage.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>An apparent cause analysis (ACA) was conducted that determined that standards regarding operator performance for procedure steps had not been reinforced by shift management. In this case, the operator had not completed the procedural step as written.
In discussing the issue, it was determined that when the Chemical Process Cell (CPC) Operator returned from lunch, the Melter Operator informed him that the transfer from the RCT to the LPPPRWT was to be performed soon. The CPC Operator asked the Melter Operator who had performed the walkdown of the transfer path. The Melter Operator responded by saying, "Operator "A" has the LPPP watch". The CPC Operator assumed, based on that response, that the LPPP Operator performed the transfer path walkdown. However, the CPC Operator did not verify this to be factual, and filled in/signed off the transfer path walkdown step of the transfer procedure (SW4-15.17-4.31). The miscommunication between the DWPF Control Room Operators (CROs) that the transfer line walkdown was complete prior to initiating the transfer from the RCT in 221-S to the LPPPRWT led to this TSR/SAC violation.
During the issue investigation, it was discovered that no pre-job briefing had been performed prior to initiating the transfer. As a minimum, an undocumented pre-job briefing is required for all transfer evolutions.
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>- When a procedure step requires a "verification," the procedure user is responsible for personally ensuring the verification has been completed prior to signing the step. The CPC Operator did not establish the accuracy of the claim that a transfer path walkdown.
- It is the responsibility of shift management to ensure that prerequisites for radioactive waste transfers are completed prior to initiation of the transfer. Facility conditions can and do change quickly so any directions (shift orders, emails, etc.) from line management need to be verified prior to acting upon them.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab's ES&H Manual Chapter Appendix T1 Work Planning, Control, and Authorization Procedure provides direction for safe work planning. It is the Lead Worker's responsibility to perform a pre-job briefing prior to work.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">12/22/2017 12:50:36 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with SAF120kd: SAFETY OBSERVATION PROGRAM </pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1039</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">2017-JLAB-1039</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">YES</td>
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<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<td class="label" nowrap>Issued:</td>
<td class="dataval">12/22/2017 12:49:53 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">12/22/2017 12:50:36 PM</td>
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<td class="label">Source:</td>
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DOECRD
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<td class="label" nowrap>Location:</td>
<td class="dataval">SRNS</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">David Griffith, SRR DWPF Shift Manager, (803) 208-6229</td>
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<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">201</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>Waste Generation</li>
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<legend>Skills</legend>
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<li>SAF120kd: SAFETY OBSERVATION PROGRAM Read (http://www.jlab.org/ehs/ehsmanual/manual/3700.html) Then Contact Bob May ext.7632 to arrange practical</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:cjohnson@jlab.org,sjsmith@jlab.org,mbailey@jlab.org">Lesson Learned Coordinator</a>.