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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1158">FML-21-0720 ARC Building HVAC Suspend Work for Lockout/Tagout (LOTO</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Two subcontract employees (one lead, one in-training) were tasked to replace a building's Main Hood Exhaust Fan 1 (of 2). During their work, concerns arose as to whether the lock-out/tag-out (LOTO) applied to the equipment was adequate. Though two locks had been applied to the hasp on the local disconnect switch, both locks were keyed to the same key which was in the exclusive possession of the lead worker. The trainee did not have a key. It was also determined that there was a secondary energy source (potential impeller "wind-milling") that had not been adequately controlled. Work was suspended for further review.
<img src=" https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6144" width="400px"> </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On July 20th, 2021, a pre-job briefing was provided to two subcontract employees by TJNAF's Technical Representative (TR). The briefing included energy shutdown, LOTO, and restart protocols. The subcontractor also had an approved activity hazard analysis on file.
Later that day, during an unrelated safety walk-through, several issues of concern were noticed in the work area. These included the door to the building/s electrical room was found wired open, and the roof-hatch had been left open with no one around. These led the inspector to initiate a questioning attitude. The inspector found the lead worker and trainee and asked why the door and hatch had been left open. As the discussion continued the inspector asked to observe any other hazard mitigations applied.
During this observation it was discovered that the LOTO protocols were inadequate. Even though two locks had been applied, the lead worker confirmed that both locks could be opened with the single key in his sole possession. This is contrary to the LOTO requirements that each worker exposed to a hazard apply their own lock and/or tag, under their control during the exposure. It was also determined that the manufacture provided a warning and mitigation techniques to prevent unwanted impeller rotation ("wind milling"). These techniques had not been applied adequately.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Current HVAC equipment protocols for LOTO and for mitigation of multiple energy sources were not adequately analyzed. The subcontractor had a current hazardous energy control program, on file, which included equipment-specific LOTO procedures. The program had been reviewed and approved prior to contract award. Since that time OSHA 1910.147 and NFPA 70(E) LOTO requirements (and thus TJNAF requirements) had been revised. Not all TJNAF's subcontractor's safety/hazard-analysis programs had been re-reviewed and updated to reflect the new requirements.
Lessons learned were not adequately assimilated. A similar event occurred at TJNAF in 2012 when a subcontract employee actually suffered a serious hand injury while attempting to stop the rotation of a pulley/belt drive with his hand. The notable event investigation determined the direct cause of the event to be the worker/s impatience to start assigned task, instead of the inadequate LOTO/multiple energy source control protocols in effect.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>A comprehensive review of all subcontractor's hazardous energy control programs will be performed to ensure compliance with both OSHA 1910.147 and NFPA 70E 2015.
Affected employees who have not yet received the updated training are to be provided the training to ensure compliance with current hazardous energy mitigation techniques.
</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">10/25/2021 3:16:11 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in ESC007: Lockout/Tagout (LOTO)</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1158</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-1158</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">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">10/25/2021 3:04:54 PM</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">10/25/2021 3:16:11 PM</td>
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<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
TJNAF NE
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<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">TJNAF</td>
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<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">Rusty Sprouse, Facilities, Maintenance & Logistics Manager, (Sprouse@JLab.org)</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">359</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">1 times</td>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Lock, Tag, Try</li>
<li>Stored Energy: Mechanical, Hydraulic, Pneumatic</li>
<li>Subcontracts</li>
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<legend>Skills</legend>
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<li>ESC007: Lockout/Tagout (LOTO)</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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