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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1155">Assessment Discovers Unsafe Equipment Configuration - Pacific Northwest National Laboratory (PNNL)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>In 2010 an electrical inspection at Pacific Northwest National Laboratory (PNNL) determined that a furnace's heating elements presented an electrical hazard with shock potential if the furnace was turned on while staff were working in it. To mitigate the hazard a label was affixed to the front of the furnace that instructed users to turn off the furnace before opening the door.
In 2015 use of the lab, where the furnace was located, came to an end. The furnace was left, turned off but functional, in the area. In 2017, an Electrical Safety assessment of the lab determined the label affixed to the front of the furnace was not sufficiently to mitigate the hazard, so it was replaced with a new label that directed users to unplug the furnace before opening the door to avoid a potential shock from exposed electrical elements.
Years later, during a 2021 Electrical Safety assessment of the area, the furnace was found plugged in with the door open, which was the state that had been determined to expose users to an electrical shock hazard.
</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>In 2010 a circa 1978 Lindberg Tube Furnace (electric heating device used to conduct syntheses and purifications of inorganic compounds), underwent an electrical inspection. The PNNL Electrical Authority Having Jurisdiction (AHJ) at the time determined that the furnace's heating elements presented an exposed energized electrical hazard with shock potential if the furnace was turned on while staff were working in it. To mitigate this hazard a label was affixed to the front of the furnace that instructed the user to turn off the furnace before opening the door to avoid shock exposure from energized electrical elements.
In 2015 the project assigned to the lab came to an end. The area was, from then on, primarily used for storage only being accessed to add or remove equipment, for routine radiological surveys, and Integrated Operations System assessments.
In January 2017, an Electrical Safety assessment of the area determined that the label affixed to the front of the furnace did not sufficiently mitigate the hazard so it was replaced with a new label that directed a user to unplug the furnace before opening the door to avoid shock exposure from the electrical elements.
Years later, during a February 2021 area assessment, the furnace was found plugged in with the door open in total disregard of the warning label.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Identifying and correcting the label suggests that the furnace had been left in a safe configuration.
Interviews with staff and assessment records suggests that the furnace had likely been put in an unsafe configuration sometime after the December 2017 assessment.
The Cognizant Space Managers (CSM) assigned to oversee activities and identify associated hazards in the area had determined that since the area was inactive it was low risk. This determination most likely caused the CSM and others who had access to the area, to overlook the warning label on the furnace.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>CSMs were reminded that they are responsible for hazard identification, mitigation, correction and reporting deficiencies found in their assigned areas. CSMs are to conduct thorough assessments that assure hazards are identified and mitigation continually provides the protection assumed, regardless of the area's actively status. The most successful CSMs keep safety in the forefront of their mind whenever they enter an assigned workspace. They are to maintain a questioning attitude when conducting routine assessments, no matter what type of activity (or lack thereof) occurs in the workspace. Complacency, while performing routine assessments, can result in overlooking a hazard or ignoring a failure in an existing mitigation.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">9/16/2021 1:03:38 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with current SAF901: Safety Warden Training</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1155</td>
</tr>
<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
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<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2021-JLAB-1155</td>
</tr>
<tr class="row">
<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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<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">9/16/2021 12:32:14 PM</td>
</tr>
<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">9/16/2021 1:03:38 PM</td>
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<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">PNNL</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">Laura Valett, Operating Experience / Lessons Learned Program Manager, laura.valett@pnnl.gov or 509-372-4959</td>
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<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">199</td>
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<td class="dataval">0</td>
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<td class="dataval">1 times</td>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6084">PNNL - Updating Safety Configurations.pdf</a></li>
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<li>Electricity</li>
<li>Other: Maintenance/Calibration</li>
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<legend>Skills</legend>
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<li>SAF901: Safety Warden Training</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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