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valign="top">Lesson Learned "Pre-Signing Verification Documents Led to Program Suspension - Brookhaven National Laboratory (BNL)"</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>January 30, 2020</strong><br>
<strong>Sent on behalf of ESH&Q</strong><br>
<strong>SUBJECT:</strong> Lesson Learned "Pre-Signing Verification Documents Led to Program Suspension - Brookhaven National Laboratory (BNL)"<br>
<strong>CONTACT:</strong> mbailey@jlab.org
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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1124">Pre-Signing Verification Documents Led to Program Suspension - Brookhaven National Laboratory (BNL)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Task verification forms were completed prior to the performance of waste management task(s). Pre-signing the task verification forms, without verifying the conditions or based on assumptions, resulted in procedure requirements being missed. Failure to follow the prescribed processes resulted in safety issues, loss of program credibility, certification, accreditation, authority to operate, and could lead to loss of funding.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Waste management technicians were observed adding solidifying agent to a stack drain waste container. According to the associated, pre-signed verification documents, the technicians added less of the solidifying agent than was indicated. (The amount of agent added was appropriate per governing procedure calculations, but not consistent with pre-verified paperwork.) </pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Steps for waste containment verification, as specified in the procedure, were not sequentially followed, i.e. Radioactive Waste Acceptance documents were completed and signed prior to waste packaging. Thus the verification signature did not verify actual solidification activities, required inspections, or adequate container closure. Pre-signing the document led to a procedural nonconformance and resulted in suspension of future low-level radioactive waste shipments from BNL to the Nevada National Security Site.
BNL establishes procedures for the protection of people, facilities, and the environment. Waste management procedures also align with requirements in order to retain certain certifications as established by the DOE-EM Nevada Program. Pre-signing verification forms prior to performing work activities negates an important step in the process and could lead to adverse consequences if the activities performed are inadequate.</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. A causal analysis of the nonconformance was conducted and an extent of condition review to identify previous occurrences or issues during solidification of liquid stack drain waste.
2. A Laboratory-wide article was published emphasizing that everyone is personally responsible for ensuring safe operations which is accomplished through adherence to established procedures and processes. Managers are encouraged to use this lesson to communicate laboratory expectations when completing processes/procedures and associated documentation.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab promotes the use of Human Performance Improvement tools. These allow workers to maintain positive control of a work situation. These tools give the employee more time to think about the task, what is expected to happen, what are the constraints, and what to do when things do not go as expected. When there is a difference between an expected condition and actual condition STOP contact your supervisor get resolution before proceeding.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">1/30/2020 1:16:59 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with GEN500: Human Performance Improvement Orientation</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1124</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">2020-JLAB-1124</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">YES</td>
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<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">1/30/2020 9:14:55 AM</td>
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<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">1/30/2020 1:16:59 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">BNL</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">Contact: Steven Stein, (631) 344-5694</td>
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<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">452</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">3 times</td>
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<legend>Attachments</legend>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=5684">Waste Container.pdf</a></li>
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<legend>Hazard Issues</legend>
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<li>Other: Work Planning and Communication</li>
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<legend>Skills</legend>
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<li>GEN500: Human Performance Improvement Orientation</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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