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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1180">Incidents Occurred while Moving Radiological Safety Instruments Without Recognizing Proper Controls - Nevada National Security Site (NNSS)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>When moving equipment, make sure you know the weight and center of gravity. Two separate incidents occurred on the same day at the Nevada National Security Site (NNSS) while moving several Tennelec Series 5 Radiological Safety Instrument units.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Incident #1: A Tennelec Series 5 unit was being relocated to another building. The two-person work crew had positioned themselves on either side. While rolling it out of the building the front wheels of the cart contacted a metal plate on the floor and the unit tipped forward onto the plate. The work crew continue with the move but once completed they stopped, made appropriate notifications, and scheduled a critique. No one was injured, but the unit was damaged.
Incident #2: Two Tennelec Series 5 units slated to be excessed, were being loaded into a transport vehicle using a powered industrial truck. The first unit was loaded successfully by lifting from the bottom/back. The second unit was lifted from bottom/side and tipped over once lifted a few inches off the ground. No one was injured; however, the unit was damaged. The work crew paused work, discussed the incident, but then continued because no one was injured and the unit was being excess anyway.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Similarities of each event:
When purchased, all the Tennelec Series 5s were equiped with, and attached to, carts with caster wheels recommended by the manufacture. (See Photo 1). Each of these units weighed ~835 lbs. The majority of the units' weight is located at the top/rear due to the position of a lead shielding plate, which is obstructed from view because it is covered with plastic to prevent inadvertent contact. The overall configuration results in the units having a high center of gravity making them less stable during movement.
<img src=" https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6486" width="250px">
Neither crew was aware that the units, while attached to their carts, were less than stable during movement because the center of gravity was higher.
Neither unit had any markings, labels, or warnings alerting work crews to any hazards nor providing instructions for mitigation.
Work crew were not provided the hazards listed in the manufacturer's owners manual, which were:
1. The heavy lead shielding plate, hidden by protective plastic, was supposed to be removed prior to moving the unit.
2. There were limitations when moving the units when attached to the carts. Because they were top-heavy movement was to be restricted.
Neither work crew recognized the need to stop work and make notifications when the incident occurred.
Unique to each event:
Incident #1:
1. A generic facility procedure was used. This did not address the specific hazards of the units.
2. Task complacency was exhibited by the supervisor of the work crews as several other Tennelec Series 5 units had been moved earlier without incident. However, this time a new work crew was assigned, and they had not performed the operation before.
Incident #2:
1. No work control document was used. The work crew believed that skill of the worker was adequate to perform the operation.
2. The work crew believed the units weighed somewhat over 300 lbs. (The actual weight was ~835 lbs.)
3. The work crew had a more cavalier attitude regarding the assignment because the units were being excessed.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Supervisors are to ensure work control documents have sufficient detail to safely perform operations and mitigate potential hazards.
2. Supervisors are to ensure work crews understand the requirement to stop work when unexpected conditions are encountered.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">6/30/2022 2:28:56 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in:
SAF136: Lead Worker
SAF502: Forklift Operator
MED05: Safe Lifting (Ergonomics)</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1180</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-1180</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">6/30/2022 2:01:39 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">6/30/2022 2:28:56 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">NNSS</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">Douglas Frenette, 702-295-0620 frenetde@nv.doe.gov Radioactive Waste Operations</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">481</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>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6486">Photo 1 - LL1180.jpg</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=6487">NNSS - Top Heavy Load.pdf</a></li>
</ul>
<hr>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Ergonomics - Lifting, Carrying, Repetitive Motion</li>
<li>Hazardous Metals</li>
<li>Material Handling Equipment</li>
<li>Lead Work (not bricks)</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF136: Lead Worker</li>
<li>SAF502: Forklift Operator</li>
<li>MED05: Safe Lifting (Ergonomics)</li>
</ul>
</fieldset>
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<legend>Distribution/Notification</legend>
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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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