<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 "Confirm the Initial Configuration Settings of Safety Monitoring Systems ¿ 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=1179" 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=1179">Confirm the Initial Configuration Settings of Safety Monitoring Systems ¿ 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>Confirm and accurately documented the initial configuration settings of safety monitoring systems. Recently, at BNL's National Synchrotron Light Source II (NSLS-II), an oxygen deficiency monitor failed to alarm during a low-flow condition because the low-flow settings had not been properly initiated during initial set-up of the system. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>There are five (5) locations in the NSLS-II where liquid cryogens are used and/or stored. Due to the potential for release, oxygen deficiency monitors were installed in these areas. The systems operate by sampling the air within the work areas and measuring the oxygen concentrations in the sampled air stream. In the event of a low oxygen concentration condition, these systems are to provide visual and audible warnings to personnel in the area. These monitors are inspected on a regular basis.
On September 10, 2021, during a certification inspection test one of the monitors was found to have a tube pinched in the containment door (See Photo 1). When it occurred, this should have caused a low-air-flow alarm to activate, however this never happened.
<img src=" https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6466" width="250px">
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The analysis of the event found that when the monitor was initially installed, the setting which allows the monitor to detect a low-flow condition and trigger the alarm, had not been enabled, nor had this function ever been tested to determine adequacy.
It was determined that at some point during a prior maintenance process, one of the system's four tubes suffered the pinch. Only because the certification inspection test required a detailed inspection of the system was the pinched tubing discovered and the setting corrected.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Enable the low flow alarm settings and verify during subsequent maintenance or certification testing.
2. Prepare a document that shows the monitor system settings to ensure they are configured correctly. Place the document under configuration control in the Document Control Center.
3. Generate a procedure for configuration setup and maintenance so every time one of the devices is configured or maintained the settings will be verified using the procedure.
4. Include channel flow information for every monitor in the area. Include alarms that will sound and alert when the gas flow in any of the channels is in warning or alarm state.
5. Include a test in the procedure document to actuate the low-flow alarm by creating a low-flow condition on each channel. Include verification on the inspection form.
6. Dress the tubing with tie wraps to reduce the possibility of tubing being pinched between the door and the body during maintenance
</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">6/28/2022 3:14:56 PM by Bailey, Mary Jo</h5>
<pre>submitted to those current in SAF103: Oxygen Deficiency Hazard</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">1179</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">2022-JLAB-1179</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">6/28/2022 3:02:27 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">6/28/2022 3:14:56 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">Scott Buda, (631) 344-5431, sbuda@bnl.gov</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">1134</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=6466">Photo 1 - LL1179.jpg</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=6467">BNL - Pinched Hose - ODH.pdf</a></li>
</ul>
<hr>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Air Contaminants - Hazardous</li>
<li>Gas Cylinders</li>
<li>Pinch Points</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF103: Oxygen Deficiency Hazard</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 "Confirm the Initial Configuration Settings of Safety Monitoring Systems ¿ 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>