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valign="top">Lesson Learned "ACC-19-0828 Subcontractor Slipped and Chipped Their Tooth "</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>November 15, 2019</strong><br>
<strong>Sent on behalf of ESH&Q</strong><br>
<strong>SUBJECT:</strong> Lesson Learned "ACC-19-0828 Subcontractor Slipped and Chipped Their Tooth "<br>
<strong>CONTACT:</strong> cjohnson@jlab.org
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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1122">ACC-19-0828 Subcontractor Slipped and Chipped Their Tooth </a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Never under estimate or dismiss a potential hazard. It is imperative that we attempt to evaluate our daily rituals with the intention of unmasking potential hazards and preventing accidents. Using fellow workmates or Subject Matter Experts (SMEs) to evaluate a workspace is an underutilized tool and could prove useful in effective change management. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Contract Staff slipped on mat in the clean room water side and hit their front tooth and chipped it. </pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Judgement of Need:
Management should educate employees to the importance of considering the ergonomic aspects of the work during the work planning phase.
Root Cause:
A1B5C01- Ergonomics LTA (Ergonomics is defined as the science that seeks to adapt work or working conditions to suit the worker. The design should include provisions for eliminating problems encountered by personnel performing tasks. This may also include problems resulting from Physical or Environmental factors.)
The perforated ergonomic mats are in place to reduce back, leg and feet issues caused by standing in place for long durations, as well as to relocate soapy water from the top of the mats to the floor to prevent slips. However, the mats tend to migrate over time due to personnel turning in place and walking over the mats to relocate parts from the flow hoods to drying racks and vice/versa.
Contributing Cause(s):
A3B3C04 - Less Than Adequate review based on assumption that process will not change (Individual believed that no variability existed in the process and overlooked the fact that a change has occurred leading to differing results than normally realized.)
A4B5C05 - System interactions not considered (Changes to processes or physical systems caused interactions with other processes or physical systems that had were not identified prior to implementation.)</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Immediate Corrective actions:
1. Supervisor held a safety minute and area walk-through to discuss all of the potential hazards in the area with their workforce.
2. Anti fatigue mats were adjusted to line up without a gap in between them.
Corrective Actions:
1. SRF chemical work center Supervisir needs to evaluate aligning the ergonomic mats on a periodic basis (like every Monday morning) to ensure mats are properly placed. Check lists could be used, OSP could be changed to reflect new expectations, etc.
2. SRF management needs to investigate ergonomic mat usage in chemical use areas to ensure mats are of correct size and material. This should include the possibility of using interlocked ergonomic mats.
Extent of Condition:
Division Safety Officers to evaluate other areas (chemical) with mat (chemical) usage to ensure mats are appropriate size and do not present similar trips hazards from sliding.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>See noted corrective actions</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">11/15/2019 8:43:18 AM by Johnson, Tina</h5>
<pre>The SME has reviewed and approved. Please review this Lessons Learned within your work groups. Ensure that you are focusing on your work areas and especially overlooking potential hazards that you may not recognize because you have worked in that area for so long.
</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1122</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-1122</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Caution</td>
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<tr class="row">
<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">11/15/2019 7:50:19 AM</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">11/15/2019 8:43:18 AM</td>
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<td class="label">Source:</td>
<td class="dataval">
TJNAF NE
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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">Harry Fanning</td>
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<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">1682</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">1 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=5664">ACC-19-0828 Chipped Tooth-final.pdf</a></li>
</ul>
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</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Chemicals</li>
<li>Ergonomics - Lifting, Carrying, Repetitive Motion</li>
<li>Other: Situational Awareness</li>
</ul>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF100: ES&H ORIENTATION</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>
</ul>
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