<html xmlns:v="urn:schemas-microsoft-com:vml" xmlns:o="urn:schemas-microsoft-com:office:office" xmlns:w="urn:schemas-microsoft-com:office:word" xmlns:m="http://schemas.microsoft.com/office/2004/12/omml" xmlns="http://www.w3.org/TR/REC-html40">
<head>
<!--[if !mso]><style>v\:* {behavior:url(#default#VML);}
o\:* {behavior:url(#default#VML);}
w\:* {behavior:url(#default#VML);}
.shape {behavior:url(#default#VML);}
</style><![endif]--><title>Lesson Learned "Misinterpretation of Work Plan Leads to Exposed Hazard of a Heater Unit - Brookhaven National Laboratory (BNL)"</title><style><!--
/* Font Definitions */
@font-face
{font-family:Helvetica;
panose-1:0 0 0 0 0 0 0 0 0 0;}
@font-face
{font-family:Wingdings;
panose-1:5 0 0 0 0 0 0 0 0 0;}
@font-face
{font-family:"Cambria Math";
panose-1:2 4 5 3 5 4 6 3 2 4;}
@font-face
{font-family:Calibri;
panose-1:2 15 5 2 2 2 4 3 2 4;}
/* Style Definitions */
p.MsoNormal, li.MsoNormal, div.MsoNormal
{margin:0in;
margin-bottom:.0001pt;
font-size:11.0pt;
font-family:"Calibri",sans-serif;}
h1
{mso-style-priority:9;
mso-style-link:"Heading 1 Char";
margin:0in;
margin-bottom:.0001pt;
line-height:125%;
font-size:19.5pt;
font-family:Helvetica;
color:#202020;
font-weight:bold;}
h2
{mso-style-priority:9;
mso-style-link:"Heading 2 Char";
margin:0in;
margin-bottom:.0001pt;
line-height:125%;
font-size:16.5pt;
font-family:Helvetica;
color:#202020;
font-weight:bold;}
h3
{mso-style-priority:9;
mso-style-link:"Heading 3 Char";
margin:0in;
margin-bottom:.0001pt;
line-height:125%;
font-size:15.0pt;
font-family:Helvetica;
color:#202020;
font-weight:bold;}
h4
{mso-style-priority:9;
mso-style-link:"Heading 4 Char";
margin:0in;
margin-bottom:.0001pt;
line-height:125%;
font-size:13.5pt;
font-family:Helvetica;
color:#202020;
font-weight:bold;}
h5
{mso-style-priority:9;
mso-style-link:"Heading 5 Char";
margin:0in;
margin-bottom:.0001pt;
font-size:10.0pt;
font-family:"Calibri",sans-serif;
font-weight:bold;}
h6
{mso-style-priority:9;
mso-style-link:"Heading 6 Char";
margin:0in;
margin-bottom:.0001pt;
font-size:7.5pt;
font-family:"Calibri",sans-serif;
font-weight:bold;}
p.MsoHeader, li.MsoHeader, div.MsoHeader
{mso-style-priority:99;
mso-style-link:"Header Char";
margin:0in;
margin-bottom:.0001pt;
font-size:11.0pt;
font-family:"Calibri",sans-serif;}
p.MsoFooter, li.MsoFooter, div.MsoFooter
{mso-style-priority:99;
mso-style-link:"Footer Char";
margin:0in;
margin-bottom:.0001pt;
font-size:11.0pt;
font-family:"Calibri",sans-serif;}
a:link, span.MsoHyperlink
{mso-style-priority:99;
color:blue;
text-decoration:underline;}
a:visited, span.MsoHyperlinkFollowed
{mso-style-priority:99;
color:purple;
text-decoration:underline;}
p.msonormal0, li.msonormal0, div.msonormal0
{mso-style-name:msonormal;
margin-top:7.5pt;
margin-right:0in;
margin-bottom:7.5pt;
margin-left:0in;
font-size:11.0pt;
font-family:"Calibri",sans-serif;}
span.Heading1Char
{mso-style-name:"Heading 1 Char";
mso-style-priority:9;
mso-style-link:"Heading 1";
font-family:"Calibri Light",sans-serif;
color:#2F5496;}
span.Heading2Char
{mso-style-name:"Heading 2 Char";
mso-style-priority:9;
mso-style-link:"Heading 2";
font-family:"Calibri Light",sans-serif;
color:#2F5496;}
span.Heading3Char
{mso-style-name:"Heading 3 Char";
mso-style-priority:9;
mso-style-link:"Heading 3";
font-family:"Calibri Light",sans-serif;
color:#1F3763;}
span.Heading4Char
{mso-style-name:"Heading 4 Char";
mso-style-priority:9;
mso-style-link:"Heading 4";
font-family:"Calibri Light",sans-serif;
color:#2F5496;
font-style:italic;}
span.Heading5Char
{mso-style-name:"Heading 5 Char";
mso-style-priority:9;
mso-style-link:"Heading 5";
font-family:"Calibri Light",sans-serif;
color:#2F5496;}
span.Heading6Char
{mso-style-name:"Heading 6 Char";
mso-style-priority:9;
mso-style-link:"Heading 6";
font-family:"Calibri Light",sans-serif;
color:#1F3763;}
p.readmsgbody, li.readmsgbody, div.readmsgbody
{mso-style-name:readmsgbody;
mso-margin-top-alt:auto;
margin-right:0in;
mso-margin-bottom-alt:auto;
margin-left:0in;
font-size:11.0pt;
font-family:"Calibri",sans-serif;}
p.externalclass, li.externalclass, div.externalclass
{mso-style-name:externalclass;
mso-margin-top-alt:auto;
margin-right:0in;
mso-margin-bottom-alt:auto;
margin-left:0in;
font-size:11.0pt;
font-family:"Calibri",sans-serif;}
p.mcnimage, li.mcnimage, div.mcnimage
{mso-style-name:mcnimage;
mso-margin-top-alt:auto;
margin-right:0in;
mso-margin-bottom-alt:auto;
margin-left:0in;
font-size:11.0pt;
font-family:"Calibri",sans-serif;}
p.mcnretinaimage, li.mcnretinaimage, div.mcnretinaimage
{mso-style-name:mcnretinaimage;
mso-margin-top-alt:auto;
margin-right:0in;
mso-margin-bottom-alt:auto;
margin-left:0in;
font-size:11.0pt;
font-family:"Calibri",sans-serif;}
p.mcntextcontent, li.mcntextcontent, div.mcntextcontent
{mso-style-name:mcntextcontent;
mso-margin-top-alt:auto;
margin-right:0in;
mso-margin-bottom-alt:auto;
margin-left:0in;
font-size:11.0pt;
font-family:"Calibri",sans-serif;}
p.mcnpreviewtext, li.mcnpreviewtext, div.mcnpreviewtext
{mso-style-name:mcnpreviewtext;
mso-margin-top-alt:auto;
margin-right:0in;
mso-margin-bottom-alt:auto;
margin-left:0in;
font-size:11.0pt;
font-family:"Calibri",sans-serif;
display:none;}
p.templatecontainer, li.templatecontainer, div.templatecontainer
{mso-style-name:templatecontainer;
mso-margin-top-alt:auto;
margin-right:0in;
mso-margin-bottom-alt:auto;
margin-left:0in;
font-size:11.0pt;
font-family:"Calibri",sans-serif;}
p.mcntextcontent1, li.mcntextcontent1, div.mcntextcontent1
{mso-style-name:mcntextcontent1;
margin-top:7.5pt;
margin-right:0in;
margin-bottom:7.5pt;
margin-left:0in;
line-height:150%;
font-size:9.0pt;
font-family:Helvetica;
color:#656565;}
p.mcntextcontent2, li.mcntextcontent2, div.mcntextcontent2
{mso-style-name:mcntextcontent2;
margin-top:7.5pt;
margin-right:0in;
margin-bottom:7.5pt;
margin-left:0in;
line-height:150%;
font-size:12.0pt;
font-family:Helvetica;
color:#202020;}
p.mcntextcontent3, li.mcntextcontent3, div.mcntextcontent3
{mso-style-name:mcntextcontent3;
margin-top:7.5pt;
margin-right:0in;
margin-bottom:7.5pt;
margin-left:0in;
line-height:150%;
font-size:12.0pt;
font-family:Helvetica;
color:#202020;}
p.mcntextcontent4, li.mcntextcontent4, div.mcntextcontent4
{mso-style-name:mcntextcontent4;
margin-top:7.5pt;
margin-right:0in;
margin-bottom:7.5pt;
margin-left:0in;
line-height:150%;
font-size:12.0pt;
font-family:Helvetica;
color:#202020;}
p.mcntextcontent5, li.mcntextcontent5, div.mcntextcontent5
{mso-style-name:mcntextcontent5;
margin-top:7.5pt;
margin-right:0in;
margin-bottom:7.5pt;
margin-left:0in;
text-align:center;
line-height:150%;
font-size:9.0pt;
font-family:Helvetica;
color:#656565;}
span.org
{mso-style-name:org;}
span.locality
{mso-style-name:locality;}
span.region
{mso-style-name:region;}
span.postal-code
{mso-style-name:postal-code;}
span.EmailStyle43
{mso-style-type:personal-reply;
font-family:"Calibri",sans-serif;
color:windowtext;}
span.HeaderChar
{mso-style-name:"Header Char";
mso-style-priority:99;
mso-style-link:Header;
font-family:"Calibri",sans-serif;}
span.FooterChar
{mso-style-name:"Footer Char";
mso-style-priority:99;
mso-style-link:Footer;
font-family:"Calibri",sans-serif;}
.MsoChpDefault
{mso-style-type:export-only;
font-size:10.0pt;}
/* Page Definitions */
@page WordSection1
{size:8.5in 11.0in;
margin:1.0in 1.0in 1.0in 1.0in;}
div.WordSection1
{page:WordSection1;}
/* List Definitions */
@list l0
{mso-list-id:140394945;
mso-list-template-ids:1951436290;}
@list l0:level1
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Symbol;}
@list l0:level2
{mso-level-number-format:bullet;
mso-level-text:o;
mso-level-tab-stop:1.0in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:"Courier New";
mso-bidi-font-family:"Times New Roman";}
@list l0:level3
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:1.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l0:level4
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:2.0in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l0:level5
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:2.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l0:level6
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:3.0in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l0:level7
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:3.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l0:level8
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:4.0in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l0:level9
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:4.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l1
{mso-list-id:198981324;
mso-list-template-ids:-1181181246;}
@list l1:level1
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Symbol;}
@list l1:level2
{mso-level-number-format:bullet;
mso-level-text:o;
mso-level-tab-stop:1.0in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:"Courier New";
mso-bidi-font-family:"Times New Roman";}
@list l1:level3
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:1.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l1:level4
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:2.0in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l1:level5
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:2.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l1:level6
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:3.0in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l1:level7
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:3.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l1:level8
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:4.0in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l1:level9
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:4.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l2
{mso-list-id:1383752591;
mso-list-template-ids:1902034278;}
@list l2:level1
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Symbol;}
@list l2:level2
{mso-level-number-format:bullet;
mso-level-text:o;
mso-level-tab-stop:1.0in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:"Courier New";
mso-bidi-font-family:"Times New Roman";}
@list l2:level3
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:1.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l2:level4
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:2.0in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l2:level5
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:2.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l2:level6
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:3.0in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l2:level7
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:3.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l2:level8
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:4.0in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
@list l2:level9
{mso-level-number-format:bullet;
mso-level-text:¿;
mso-level-tab-stop:4.5in;
mso-level-number-position:left;
text-indent:-.25in;
mso-ansi-font-size:10.0pt;
font-family:Wingdings;}
ol
{margin-bottom:0in;}
ul
{margin-bottom:0in;}
--></style><!--[if gte mso 9]><xml>
<o:shapedefaults v:ext="edit" spidmax="2049" />
</xml><![endif]--><!--[if gte mso 9]><xml>
<o:shapelayout v:ext="edit">
<o:idmap v:ext="edit" data="1" />
</o:shapelayout></xml><![endif]-->
</head>
<body bgcolor="#FAFAFA" lang="EN-US" link="blue" vlink="purple">
<div class="WordSection1">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%;background:#FAFAFA;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%" id="bodyTable">
<tr>
<td width="100%" valign="top" style="width:100.0%;padding:0in 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%" id="bodyCell">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="background:#FAFAFA;padding:6.75pt 0in 6.75pt 0in;background:cover;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%;background-size: cover;background-position-x:50%;background-position-y:50%" id="templatePreheader">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="600" style="width:6.25in;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td width="600" valign="top" style="width:6.25in;padding:0in 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" style="max-width:6.25in;border-collapse:collapse;min-width: 100%;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%;border-collapse:collapse;max-width:100%;min-width: 100%;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:6.75pt 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%;word-break:break-word">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" align="left" width="100%" style="width:100.0%;border-collapse:collapse;margin-left:-2.25pt;margin-right:-2.25pt">
<tr>
<td width="600" valign="top" style="width:6.25in;padding:0in 0in 0in 0in">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" align="left" width="100%" style="width:100.0%;border-collapse:collapse">
<tr>
<td valign="top" style="padding:0in 13.5pt 6.75pt 13.5pt">
<p class="MsoNormal" align="center" style="text-align:center;line-height:150%">
<span style="font-size:9.0pt;line-height:150%;font-family:Helvetica;color:#656565">
<a href="https://misportal.jlab.org/ll/index.jsf?function=print&lessonId=1149" target="_blank">
<span style="color:#656565">View this email in your browser</span>
</a>
</span>
</p>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</div>
</td>
</tr>
<tr>
<td valign="top" style="background:white;padding:6.75pt 0in 0in 0in;background:cover;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%;background-size: cover;background-position-x:50%;background-position-y:50%" id="templateHeader">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="600" style="width:6.25in;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td width="600" valign="top" style="width:6.25in;padding:0in 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" style="max-width:6.25in;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in;min-width: 100%;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in;min-width: 100%;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" align="left" width="100%" style="width:100.0%;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in">
<p class="MsoNormal" align="center" style="text-align:center">
<img border="0" width="600" style="width:6.25in" id="_x0000_i1027" src="https://www.jlab.org/ehs/images/LessonsLearnedgraphic.jpg" alt="Lessons Learned">
</p>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</div>
</td>
</tr>
<tr>
<td valign="top" align="center" style="background:white;padding:6.75pt 0in 6.75pt 0in;background:cover;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%;background-size: cover;background-position-x:50%;background-position-y:50%;border-top:3px solid #AB162B;" id="templateBody">
<style type="text/css">/* The header styles define the strapline across the top of the main page */
#header {
border-top: 1px solid;
border-bottom: 1px solid;
margin-bottom: 2px;
height: 3.0em;
background-color: #D4BFA9;
width: 100%;
font-family: sans-serif;
}
#header .strapline {
float: right;
margin-right: 2em;
margin-left: 0.5em;
}
#header .appname {
float: left;
font-size: 2.0em;
font-family: sans-serif;
color: white;
margin-left: 0.1em;
margin-top 0.5em;
}
#header a {color: white; font-weight: normal; text-decoration: none; }
#header a:visited {color: white; font-weight: normal; text-decoration: none; }
.readme {
color: red;
}
.success {color:green;}
.failure {color:red;}
#navsite h5 {
display: none;
}
#navsite ul {
padding: 3px 0;
margin-left: 0;
border-bottom: 1px solid #778;
font: bold 12px Verdana, sans-serif;
}
#navsite ul li {
list-style: none;
margin: 0;
display: inline;
}
#navsite ul li a {
padding: 3px 0.5em;
margin-left: 3px;
border: 1px solid #778;
border-bottom: none;
background: #DDE;
text-decoration: none;
}
#navsite ul li a:link {
color: #448;
}
#navsite ul li a:visited {
color: #667;
}
#navsite ul li a:link:hover, #navsite ul li a:visited:hover {
color: #000;
background: #AAE;
border-color: #227;
}
#navsite ul li a#current {
background: white;
border-bottom: 1px solid white;
}
h2 {
font-size: 116%;
font-weight: bold;
margin-top: 15px;
}
img {
border:0px;
}
.imgbutton{
border:0px;
}
.grouping_separator {
font-weight: bold;
font-size: 1.5em;
}
div#lesson_title
{
margin-top: 5px;
min-height: 25px;
font-size: 108%;
background-color: #eee;
padding: 5px;
}
#preapproval
{
font-size: 108%;
font-weight: normal;
color: #ca0000;
margin-right: 20px;
}
#lesson_title a
{
font-size: 125%;
color: black;
display: inline;
font-weight: bold;
white-space: wrap;
}
#lesson_title div{
float:right;
display: inline;
padding: 0;
}
div.yui-gc{
margin-top: 2px;
margin-left: 4px;
}
div.buttonbar
{
padding-left: 5px;
padding-right: 15px;
margin-right: 5px;
text-align: right;
}
fieldset {
border: 1px solid #000000;
}
legend {
margin: .5em .5em;
margin-bottom: .2em;
padding: .2em;
font-size: 1.1em;
font-weight: bold;
color: #9B1120;
border: 0px solid #000000;
}
td.label {
text-align: left;
vertical-align: middle;
padding-right: 1em;
font-weight: bold;
}
td.dataval {
width: auto;
text-align: left;
vertical-align: middle;
}
input.checkboxes {
width: auto;
margin: 3px;
font-weight: bold;
background-color: #F5F5F5;
}
input.radiobuttons {
margin: .2em .5em;
}
.radioLabel label {
font-weight:normal;
}
.help {
cursor: help;
}
.help_optional, .help_required {
border-bottom: 1px dotted #333;
cursor: help;
}
dt {
padding: .5em 0;
font-weight: bold;
}
dd {
margin: 0;
margin-right: 0.5em;
padding-left: 1em;
}
dd pre{
font-family: Arial;
font-size: 93%;
}
dd.description{
width: 40em;
font-weight: light;
font-size 60%;
margin-bottom: 4px;
padding-left: 1em;
color: darkgray;
/*float:right;*/
}
/*
#comments_div{
background-color: #F0F0F0;
margin-top: 1em;
}
*/
#hazard_checklist td {
padding : 2px 5px;
}
.color_header {
display: block;
background-color: #6EC8DD;
}
.safety_header {
display: block;
background-color: #FFFFCC;
}
div.spacer {
background-color: transparent;
margin: 0.5em;
padding: 0;
}
.editlink select{
font-weight: bold;
color: #ca0000;
}
.review_icon{
vertical-align: middle;
}
ul {
list-style: disc inside;
marker-offset: auto;
margin-left: 1.5em;
padding-left: 0;
}
ul ul{
list-style: circle inside;
marker-offset: auto;
margin-left: 1.5em;
padding-left: 0;
}
ol {
list-style: decimal outside;
marker-offset: auto;
margin-left: 1.5em;
padding-left: 0;
}
ol ol{
list-style: decimal outside;
marker-offset: auto;
margin-left: 1.5em;
padding-left: 0;
}
.lesson_attribute_listing {
padding:0;
margin-top:0;
margin-bottom:0;
}
span.zone_heading {
margin-left: -0.5em;
font-weight: bolder;
}
iframe {
border: 0px;
background-color: #F4F4F4;
width: 16em;
height: auto;
scrolling: no;
marginwidth: 0;
marginheight: 0;
}
a.ttip {
text-decoration:underline;
}
div.ttip {
width:12em;
margin:0;
padding:0;
overflow: visible;
}
table#lesson_entry {
width: 800px;
}
table#lesson_entry td {
padding-top: 5px;
}
.radioLabel {
font-weight: bold;
}
.required {
font-weight: bold;
color: red;
}
#lesson h1, #lesson h2, #lesson h3, #lesson h4 {
color: #9B1120
}
#overDiv {
border: solid thin black;
} #lesson_info{display: none;}</style><base href="https://misportal.jlab.org/ll/">
<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>
<div id="topbar">
<div id="lesson_title">
<table width="100%">
<tr>
<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1149">Misinterpretation of Work Plan Leads to Exposed Hazard of a Heater Unit - Brookhaven National Laboratory (BNL)</a></td>
</tr>
</table>
</div>
</div>
<table width="100%">
<tr>
<td valign="top">
<div id="maintextcol" class="yui-u first">
<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Engage in detailed work briefings so that task specific factors can be fully understood by assigned worker. Assumptions of understanding can create communication gaps. In this instance a heater unit was left in an unguarded / unsafe state. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>The initial work plan was to paint a heater unit's cover. The work plan was generated in accordance with the Work Planning and Control for Experiments and Operations Subject Area and the Facilities and Operations (F&O) Work Planning and Control System procedure. The worker assigned was instructed not to remove any panel connected to an electrical device (i.e. the heater cover). When the worker requested that the cover be removed, the paint shop supervisor rescoped the work and requested a modification to include electrical craft support.
The revised work scope was reviewed by the electrical supervisor and a pre-job briefing was given to the electrician selected to remove the cover. The electrician assessed the task, donned appropriate personal protective equipment (PPE), turned the heater thermostat off (a good work practice), and removed the four screws of the cover.
Neither worker recognized that the work scope failed to identify the newly exposed hazards that needed to be mitigated after the heater's cover was removed. This left the worker, who was to paint the cover, exposed to the heater's fan blades and exposed electrical wiring.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Poor communication between the electrician and electrical supervisor created an interpretation gap whereby the worker did not understand the supervisor's expectations. The work scope did not consider that while the cover was off other workers would be exposed to the heater's fan blades and exposed electrical conductors.
The work planning risk perception did not align with Lab management's expectation that every hazard is to be evaluated, for every task, every time, by everybody.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>- Conduct work briefings by engaging the worker in a two-way dialogue for assurance of understanding.
- Walk down the job site with worker when the worker does not demonstrate full alignment or understanding of the work scope instructions.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
</div>
<div id="comments_div">
<a name="comments"></a>
<button onclick="sendLogin(document.location.href + '#comments')">Add Comment</button>
<h2>Comments</h2>
<h5 style="white-space:nowrap">6/29/2021 2:04:40 PM by Bailey, Mary Jo</h5>
<pre>submitted to those current in
_Basic Electrical Safety (for Electrical Workers)
SAF307: Ladder Safety
</pre>
</div>
</td>
<td valign="top">
<div class="yui-u" id="lesson_info">
<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1149</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">2021-JLAB-1149</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Caution</td>
</tr>
<tr class="row">
<td class="label" nowrap>Safety Related:</td>
<td class="dataval">YES</td>
</tr>
<tr class="row">
<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">6/29/2021 1:58:54 PM</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">6/29/2021 2:04:40 PM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
DOECRD
</td>
</tr>
<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">BNL</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">Contact: Thomas Baldwin, 631-344-4556, baldwint@bnl.gov</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">485</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">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6005">BNL - Heater Unit Hazards Exposed.pdf</a></li>
</ul>
<hr>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Electricity</li>
<li>Lock, Tag, Try</li>
<li>Sharp Edges</li>
<li>Other: Poor Work Planning and Communication </li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF307: Ladder Safety</li>
<li>ESC001: Basic Electrical Safety (for Electrical Workers)</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>
</div>
<br>
<br>
</div>
<br><p>Do you have a lesson learned you would like to contribute? Contact a <a href="mailto:mbailey@jlab.org,sjsmith@jlab.org">Lesson Learned Coordinator</a>.</p>
</td>
</tr>
<tr>
<td valign="top" style="border:none;border-bottom:solid #EAEAEA 1.5pt;background:white;padding:0in 0in 6.75pt 0in;background:cover;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%;background-size: cover;background-position-x:50%;background-position-y:50%" id="templateColumns">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" style="max-width:6.25in;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="600" style="width:6.25in;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td width="200" valign="top" style="width:150.0pt;padding:0in 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" align="left" width="200" style="width:150.0pt;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in;min-width: 100%;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 13.5pt 13.5pt 13.5pt;border-radius: 0px;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%;background:#AB162B;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td style="padding:11.25pt 11.25pt 11.25pt 11.25pt;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<p class="MsoNormal" align="center" style="text-align:center">
<span style="font-size:12.0pt;font-family:"Arial",sans-serif">
<a href="mailto:mbailey@jlab.org?subject=Lesson Learned "Misinterpretation of Work Plan Leads to Exposed Hazard of a Heater Unit - Brookhaven National Laboratory (BNL)"" target="_blank" title="CONTACT">
<span style="color:white;letter-spacing:.75pt;text-decoration:none">CONTACT</span>
</a>
</span>
</p>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
<td width="200" valign="top" style="width:150.0pt;padding:0in 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" align="left" width="200" style="width:150.0pt;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in"></td>
</tr>
</table>
</td>
<td width="200" valign="top" style="width:150.0pt;padding:0in 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" align="left" width="200" style="width:150.0pt;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in;min-width: 100%;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 13.5pt 13.5pt 13.5pt;border-radius: 0px;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%;background:#AB162B;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td style="padding:11.25pt 11.25pt 11.25pt 11.25pt;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<p class="MsoNormal" align="center" style="text-align:center">
<span style="font-size:12.0pt;font-family:"Arial",sans-serif">
<a href="https://www.jlab.org/ehs/" target="_blank" title="ESH&Q WEB">
<span style="color:white;letter-spacing:.75pt;text-decoration:none">ESH&Q WEB</span>
</a>
</span>
</p>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</div>
</td>
</tr>
<tr>
<td valign="top" style="background:#FAFAFA;padding:6.75pt 0in 6.75pt 0in;background:cover;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%;background-size: cover;background-position-x:50%;background-position-y:50%" id="templateFooter">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="600" style="width:6.25in;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td width="600" valign="top" style="width:6.25in;padding:0in 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" style="max-width:6.25in;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in;min-width: 100%;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:6.75pt 0in 0in 0in;max-width:100%;min-width: 100%;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" align="left" width="100%" style="width:100.0%;border-collapse:collapse;margin-left:-2.25pt;margin-right:-2.25pt;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%;word-break:break-word">
<tr>
<td width="600" valign="top" style="width:6.25in;padding:0in 0in 0in 0in">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" align="left" width="100%" style="width:100.0%;border-collapse:collapse">
<tr>
<td valign="top" style="padding:0in 13.5pt 6.75pt 13.5pt">
<p class="MsoNormal" align="center" style="text-align:center;line-height:150%">
<em>
<span style="font-size:9.0pt;line-height:150%;font-family:Helvetica;color:#656565">Copyright © 2019 Jefferson Lab, All rights reserved.</span>
</em>
<span style="font-size:9.0pt;line-height:150%;font-family:Helvetica;color:#656565">
<br>You are receiving this email because you are a member of an auto-generated email distribution list. You can only unsubscribe from these emails by using the link below. Contact the Jefferson Lab Computer Center Help Desk with questions regarding your subscription. Thank you.
<br><br>
<strong><span style="font-family:Helvetica">Our mailing address is:</span></strong>
</span>
</p>
<div>
<p class="MsoNormal" align="center" style="text-align:center;line-height:150%">
<span class="org"><span style="font-size:9.0pt;line-height:150%;font-family:Helvetica;color:#656565">Jefferson Lab</span></span>
<span style="font-size:9.0pt;line-height:150%;font-family:Helvetica;color:#656565"></span>
</p>
<div>
<div>
<p class="MsoNormal" align="center" style="text-align:center;line-height:150%">
<span style="font-size:9.0pt;line-height:150%;font-family:Helvetica;color:#656565">12000 Jefferson Avenue</span>
</p>
</div>
<p class="MsoNormal" align="center" style="text-align:center;line-height:150%">
<span class="locality"><span style="font-size:9.0pt;line-height:150%;font-family:Helvetica;color:#656565">Newport News</span></span><span style="font-size:9.0pt;line-height:150%;font-family:Helvetica;color:#656565">, </span><span class="region"><span style="font-size:9.0pt;line-height:150%;font-family:Helvetica;color:#656565">VA</span></span> <span class="postal-code"><span style="font-size:9.0pt;line-height:150%;font-family:Helvetica;color:#656565">23606</span></span>
</p>
</div>
</div>
<p class="MsoNormal" align="center" style="margin-bottom:12.0pt;text-align:center;line-height:150%">
<span style="font-size:9.0pt;line-height:150%;font-family:Helvetica;color:#656565">
<br><br>
Want to change how you receive these emails?
<br>
You can
<a href="https://mailman.jlab.org/mailman/listinfo/lessonslearned">
<span style="color:#656565">update your preferences</span>
</a>
or
<a href="https://mailman.jlab.org/mailman/listinfo/lessonslearned">
<span style="color:#656565">unsubscribe from this list</span>
</a>.
</span>
</p>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</div>
</div>
</body>
</html>