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              <td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1189">PHY-22-0825: Improper Fall Protection Used in Test Lab Hi Bay</a></td>
              
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                    <h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
                    <pre>On August 25, 2022, a work team was observed using a JLG scissor lift (see Photo 1 for an example) to access an elevated work platform without using appropriate fall protection.  The setup was found non-compliant with OSHA requirements.  When requested the work team was unable to produce the required Work Planning, Control, and Authorization (WPC&A) documentation for the task.  The Division?s Safety Officer suspended the work until a WPC&A Task Hazard Analysis and Operational Safety Procedure could be developed which required input from material handling and fall protection Subject Matter Experts. No injuries were sustained as a result of this event.

             <img src=" https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6686" width="400px"></pre>
                  
                    <h2 style="white-space:nowrap">Discussion of Activities</h2>
                    <pre>Prior to initiation of work, Jefferson Lab's Material Handling Manager (MHM) provided a pre-job meeting with members of the work team to discuss the use of the overhead crane that would be used to lift the Cryogenics Control Reservoir (CCR) into its cradle on a platform built above the CLEO magnet.  The platform?s elevation was approximately 18-20 feet above the flooring.  The crane lift was classified and managed as "Ordinary," which, according to ES&H Manual Chapter 6141 Appendix T1 Hoisting and Rigging Operations (Including Planning a Lift), and by reference, DOE STD 1090-2011, did not require a written "Lift Plan."  The MHM remained at the lift site and continued to observe the lift in progress. 

While work proceeded, the MHM witnessed members of the work team position a JLG scissor lift to within approximately 8-10 inches of the platform.  They then proceeded to gain access to the platform by crawling through both the scissor lift?s and the platform?s guardrails.  This activity had not been discussed in the pre-job briefing so the MHM contacted an ESH representative to assess the situation. 

During the subsequent discussion it was determined that the work team did not have the required WPC&A (formal Task Hazard Analysis or Operational Safety Procedure).  The work team members felt that the work was considered "routine" as the crane lift was considered ?Ordinary.? Their Division Safety Officer was contacted and suspended work until the required WPC&A could be developed.
</pre>
                  
                    <h2 style="white-space:nowrap">Analysis</h2>
                    <pre>The work team did not have an acceptable understanding of appropriate behaviors regarding the use of the JLG scissor lift. There was no supervisory oversight at the work site, nor was there evidence that the WPC&A process was completed prior to the event to mitigate task hazards. 

The primary task was considered the crane lift.  This reduced the vigilance surrounding associated tasks such as the use of the JLG scissor lift. 

The cluttered state of the area contributed to the orientation of the JLG scissor lift.  This resulted in the more hazardous entry/egress method through the guardrails. 
</pre>
                  
                    <h2 style="white-space:nowrap">Recommended Actions</h2>
                    <pre>Targeted retraining on the Work Planning, Control, and Authorization process, requirements and procedures will be provided to all Hall Coordinators.

An educational training program will be developed to strengthen the competencies and enforce ownership of the responsibilities and accountability for worker safety on the part of the front-line supervisor.

The training curriculum of SAF302 Aerial Work Platforms will be reviewed and revised to strengthen its coverage of situations when exiting/accessing a scissor lift at elevation may be necessary. A "targeted" communication will be sent out to all qualified Aerial Lift operators summarizing the revised content.

Placarding/signage will be applied to all scissor lifts that addresses Jefferson Lab requirements.   

</pre>     

        <h2 style="white-space:nowrap">JLab Preventive Measures</h2>
        <pre></pre>
        
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          <h2>Comments</h2>
          
            <h5 style="white-space:nowrap">10/13/2022 2:55:19 PM by Bailey, Mary Jo</h5>
            <pre>Submitted to those current in:
SAF302: Aerial Platform/Manlift Operation
SAF202: Personal Fall Protection</pre>
          
        
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                    <fieldset>
                      <legend>Summary</legend>
                      <table>
                      <tr class="row">
                        <td class="label" nowrap>Lesson ID:</td>
                        <td class="dataval">1189</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-1189</td>
          </tr>
                      <tr class="row">
                        <td class="label" nowrap>Priority:</td>
                        <td class="dataval">Best Practice</td>
                      </tr>
                      <tr class="row"> 
                        <td class="label" nowrap>Safety Related:</td>
                        <td class="dataval">NO</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">9/6/2022 9:10:28 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">10/13/2022 2:55:19 PM</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">Cynthia (Thia) Keppel, Associate Director for Experimental Nuclear Physics, Keppel@jlab.org</td>
                      </tr>
                      <tr class="row">
            <td class="label" nowrap>Queued Emails:</td>
            <td class="dataval">338</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">3 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=6686">Photo 1 - LL1189.JPG</a></li>
              
              </ul>
            
            
                        <hr>
                      
                      
                    </fieldset>
                    
                    <fieldset>
                      <legend>Hazard Issues</legend>
                      <ul class="lesson_attribute_listing">
                      
                        <li>Material Handling Equipment</li>
                      
                        <li>Working at Elevations</li>
                      
                        <li>Aerial Work Platforms (Scissor/Aerial Lifts, Boom Trucks)</li>
                      
                        <li>Four Feet or More Above the Ground (other than ladder or scaffold).</li>
                      
                      </ul>
                    </fieldset>
                    
                    <fieldset>
          <legend>Skills</legend>
          <ul class="lesson_attribute_listing">
          
            <li>SAF302: Aerial Platform/Manlift Operation</li>
          
            <li>SAF202: Personal Fall Protection</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>
                    
                    <!-- 
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                      <ul class="lesson_attribute_listing">
                      
                      </ul>
                    </fieldset>
                     -->
                     
                  </div>
    </td>
  </tr>
  </table>

  
  

        
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        <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>
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