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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1183">Unauthorized Energized Electrical Testing Performed During Equipment Installation and Commissioning ¿ Oak Ridge National Laboratory </a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>When work is evaluated and determined to involve a hazardous condition, involve appropriate subject matter experts to ensure controls are in place that mitigate the hazards, and supervise external contractors if required. In this lesson learned, staff, who did not regularly engage external contractors, did not realize they were supposed to reached out to their Environmental, Safety, Health and Quality (ESH&Q) Coordinator for support. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On November 9, 2021, UT-Battelle (UT-B) electricians discovered multiple non-Qualified Electrical Workers (QEWs), without appropriate personal protective equipment, had removed the outer panels on an energized radiation generating device (RGD). One of the workers near the open, energized electrical panel was a UT-B Radiological Control Technician and two of the workers were external contractors who were onsite conducting a Nationally Recognized Testing Laboratory (NRTL) field evaluation so as to complete the RGD installation. Per UT-B's Electrical Safety Program, external contract workers are not permitted to perform exposed energized electrical work; only UT-B QEWs can perform energized electrical measurements.
Later, it was also discovered that neither an Activity Hazard Analysis nor a pre-job briefing had been conducted prior to the start of work. While there were no environmental, health, or safety consequences from this activity, the potential existed for such consequences. The event highlights the lack of understanding of the need to oversee external performing work on ORNL campus and a confusion amongst research staff as to where the extent of responsibilities lies.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The Root Cause Analysis (RCA) identified the following (direct cause(DC), contributing causes (CC), and root cause (RC)):
- DC: The work control process for authorization of on-site subcontract work was not followed.
- CC1: The rigor of Technical Project Officer (TPO) training was not commensurate with the expectations of, and duties performed by individuals holding that role.
- CC2: There are no controls in place to ensure Activity Hazard Analyses (AHAs) and other work control documents be completed prior to subcontractors performing work on site.
- CC3: SBMS does not clearly link and flow down requirements from multiple locations into a comprehensive workflow; including SBMS procedures and subject areas, AHA forms, Procurement internal operating procedures, TPO SharePoint site, etc.
- RC: The process for acquiring on-site subcontract services was found to be insufficient to ensure that appropriate personnel are adequately engaged to identify and address hazards associated with the work
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. Deliver a presentation to all Technical Project Officers (TPO) highlighting this event and reinforcing the responsibilities for onsite external contractor work as it relates to:
- Understanding their scope of work - ensure the TPO has the proper knowledge and background to oversee the work.
- Clearly define management's expectations regarding the TPO role and extent of oversight.
- Describe how the TPO is to acquire additional support from other staff (i.e. SMEs) based on the scope/ hazards, and how to identify appropriate support staff members.
- Define the expectations for completing and documenting a detailed hazard analysis and pre-job briefing. Provide all TPOs with the pre-job briefing form and the Activity Hazard Analysis (AHA) Form
2. Establish TPO oversight expectations for external contractor activities.
3. Revise TPO training to incorporate improvements identified.
4. All TPOs are to retake the TPO training module within the next year.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">8/4/2022 1:44:11 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in GEN020: Technical Representative (TR) Training</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1183</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-1183</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">8/4/2022 1:34:44 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">8/4/2022 1:44:11 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">ORNL</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">Susan Hogle, Division Director, Radioisotope Science, hoglesl@ornl.gov </td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">325</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=6526">OPEXShare Oakridge - Unauthorized Energized Electrical Testing.pdf</a></li>
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<hr>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Electricity</li>
<li>Radiation - Ionizing</li>
<li>Stored Energy: Mechanical, Hydraulic, Pneumatic</li>
<li>Subcontracts</li>
</ul>
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<legend>Skills</legend>
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<li>GEN020: TR 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>
</ul>
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