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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1157">FML-21-0825 Unsecured Gate Results in an Accelerator Safety Envelope (ASE) Violation</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>An outdoor credited control area, surrounded by a chain-link fence secured with a chain and lock, was accessed inappropriately twice in as many days, and the area was later found unsecured during a routine inspection. Access controls that allowed entry into the area were found to be less than adequate. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On August 9 there was intermittent low duty factor pulsed beam running in the accelerator tunnel. A Facilities, Management and Logistics (FM&L) staff member was granted access, against protocols, to an above ground outdoor credited controlled area by Accelerator Operations when they allowed the access key to be checked out. The FM&L staff member then entered the area to perform routine maintenance on an air-handling unit.
On August 10th Accelerator Operations again granted access to the area by checking out the key, this time to an Environment, Safety & Health (ES&H) staff member who entered for a dosimeter exchange. There was no beam running, but the person did not have a Self-Reporting Pocket Dosimeter as required for the credited controlled area.
On Aug. 25, 2021, while performing a routine inspection a Radiation Control technician found the gate to the area had not been adequately secured.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The outdoor controlled area limited access by a chain-link fence secured with a chain and padlock requiring a key (See Photo 1). Access to the area is prohibited while beam is being delivered. Control included the key being checked out at Accelerator Operations. A Self-Reporting Pocket Dosimeter, checked out by the Radiation Control Group, was also to be worn at any time while in the area, to confirm only background dose is received.
<img src="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6124" width="250px">
In the first case, Accelerator Operations issued the key to the padlock while beam was running, thus allowing access against protocols. In the second case, no beam was on but not obtaining a Self-Reporting Pocket Dosimeter violated the integrity of the Accelerator Safety Envelope (ASE) as well as the requirements of the area's Radiation Work Permit (RWP).
Failure to properly secure the gate after exiting, also defeated the integrity of the ASE during subsequent beam operations.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>The ASE infractions are being reviewed by the Safety Configuration Management Board (SCMB) through ASE violation procedure.
Potential radiation exposure was verified for those who entered the area while the beam was running. Monitoring records indicate radiation levels during this period did not exceed background.
It was determined that the checkout procedure for the key was insufficient to ensure integrity of the credited control. The procedure is to be updated to include verification that the beam is off before allowing access, and verification by an impartial individual that the area is secure after access.
Other CEBAF accelerator gate or access areas that do not have personnel safety system interlocks were inspected and validated that controls are in place. These controls include a two-lock configuration. Other fenced area access controls were verified as bolted in place with radiation control locks and postings in expected configuration.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>See above.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">10/5/2021 10:06:59 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in SAF800T: Knowledge of radiation hazards at JLab encountered by the general employee.</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1157</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-1157</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">10/5/2021 9:12:47 AM</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">10/5/2021 10:06:59 AM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
TJNAF NE
</td>
</tr>
<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">TJNAF</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">Harry Fanning, Accelerator Division Safety Officer, Fanning@jlab.org</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">133</td>
</tr>
<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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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6124">Photo 1 - FML-21-0825.jpg</a></li>
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<hr>
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<legend>Hazard Issues</legend>
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<li>Radiation - Ionizing</li>
<li>Controlled Area</li>
</ul>
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<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF800T: Knowledge of radiation hazards at JLab encounted by the general employee population acquired by exam</li>
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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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