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valign="top">Lesson Learned "PHY-19-0607 Student Was Exposed to Laser While Wearing Protective Eyewear- No Injuries"</td>
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valign="top"><strong><span
style="font-size: 18px">INTERNAL MEMO</span></strong></td>
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valign="top"><span style="font-size: 14px">
<strong>September 25, 2019</strong><br>
<strong>Sent on behalf of ESH&Q</strong><br>
<strong>SUBJECT:</strong> Lesson Learned "PHY-19-0607 Student Was Exposed to Laser While Wearing Protective Eyewear- No Injuries"<br>
<strong>CONTACT:</strong> cjohnson@jlab.org
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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1117">PHY-19-0607 Student Was Exposed to Laser While Wearing Protective Eyewear- No Injuries</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>1. It is imperative that before working on equipment there is verification that it has been de-energized.
2. If something does not look or feel right, be sure to stop and ask questions to gain clarity and a better understanding as to what the expected status should be.
3. Perform a task review with the current procedure to ensure that the scope of work is covered by the existing procedure.
4. When working with others roles, responsibilities, and actions need to be discussed and clearly understood before starting the task and at critical steps.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On June 7, 2019, a William and Mary Graduate student, working in EEL Lab 102A, realized the while inspecting a laser fiber using a fiber inspection scope, that the 30W laser was still energized. Fortunately the student was wearing protective eye wear, which is required when you make an entry into this lab. He did not feel any adverse effects from the exposure. The student was unable to report the event to their supervisor that day and proceeded to report the event to his supervisor Monday afternoon. The student was then referred to Occupational Medicine for evaluation. Dr. Chandler determined that the student was not injured as a result of the exposure. Following the event, lasers operations in 102A have been suspended.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>JON 1 Lab Management needs to improve recognition that laser light is a form of hazardous energy. Concepts and practices incorporated in the Lock-Tag-Try program such as the need to personally verify that the laser is off, as well as use of secondary methods for this verification should be included in the laser safety program in some fashion.
Root Cause: Management did not provide adequate expectations that each individual has responsibility to ensure that the hazard (laser light) is controlled to prevent potential exposure.
JON 2: Lab Management needs to establish a clearly defined process to periodically refresh laser system specific training supported by objective records.
Contributing causes: The hazards of performing laser fiber inspections are not adequately covered in existing policies and the laser lab procedures. A more complete hazard assessment would have brought attention this issue.
JON 3 Lab Management needs to develop and implement specific policies and practices on laser fiber inspection.
Contributing cause: The hazards of performing laser fiber inspections are not adequately covered in existing policies and the laser lab procedures. A more complete hazard assessment would have brought attention this issue.
JON 4-Lab Management needs to address the means to enhance communication between people working together with laser systems. This can be addressed in both laser safety training and via the student mentoring program.
Contributing Causes: Less than adequate communication between individuals working in the laser lab on the tasks to be conducted and the state of equipment. This led to one student assuming the other had turned off the laser.
JON 5: Lab Management should determine if an employee should be required to take Laser Safety Orientation training (SAF114O) at a periodic interval rather just once (which is the current practice).
Additional Conclusion related to this event: Training less than adequate LTA- Laser Safety Orientation (SAF114O) training is only required once in a person's JLab career. Although this is a general training, the LSO covers lessons learned, the importance of personal protective equipment, and other pertinent information. Student 1 had taken that training in 2013 and Student 2 had taken it in 2017. This time lapse may have contributed to the student's lack of general hazard awareness associated with working with this laser. </pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Conduct a team activity that evaluates the laser system requirements, hazardous energy control (lock, tag and try (LTT)) requirements. Ensure the team identifies and addresses all laser hazards and the specific LTT requirements for lasers.
2. Update laser system specific training to include expiration dates that are linked to their respective LOSP expiration date. Ensure this training incorporates a mentoring portion and includes recordkeeping.
3. Enter all laser system specific training into LMS database for tracking purposes.
4. Update Laser manual chapter to address appropriate procedures for laser fiber inspection.
5. Notify labwide LSS's about the updates to the Laser Safety Program Manual chapter, LTT, etc).
6. Update LOSPs to include importance of verbal communication within your work place to include repeat backs. ( Ensure these documents also stress the importance of reporting near-misses even if there is not apparent injury).
7. Work with the Laser Subject Matter Expert to Develop and Implement a expiration cycle for SAF114O. (Suggested 4 years).
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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">9/25/2019 7:34:32 AM by Johnson, Tina</h5>
<pre>There were some IT issues and this lessons learned must be resent.- Please review and share these lessons learned within your work groups. Focus on never assuming your responsibilities but understanding them each time you work with someone else.
</pre>
<h5 style="white-space:nowrap">9/16/2019 12:31:39 PM by Johnson, Tina</h5>
<pre>SME review and approval received. Please review and share these lessons learned within your work groups. Focus on never assuming your responsibilities but understanding them each time you work with someone else. </pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1117</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">2019-JLAB-1117</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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<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">9/16/2019 12:16:18 PM</td>
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<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Johnson, Tina</td>
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<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">9/25/2019 7:34:32 AM</td>
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<td class="label">Source:</td>
<td class="dataval">
<a href="https://www.jlab.org/eshq/notableevents" 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">Dave Gaskell</td>
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<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">353</td>
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<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">2</td>
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<td class="label" nowrap>Viewings:</td>
<td class="dataval">19 times</td>
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<legend>Hazard Issues</legend>
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<li>Lasers Class 3B or 4 (Ultraviolet, Infrared, and Visible Light)</li>
<li>Other: Student User</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF114O: LASER SAFETY ORIENTATION</li>
<li>SAF115DLE: SAF115 DRIVE LASER ENCLOSURE</li>
<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: Properly lock up the Gun Test Stand and run it for experiments</li>
<li>SAF115GTS-1: Properly set up and align the Gun Test Stand</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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