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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1198">Don't Get Caught Unaware of Hazards, Plan Ahead ? Brookhaven National Laboratory (BNL)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Use the Work Planning & Control Process to identify all potential hazards related to assigned work, not just the primary equipment hazards. Two BNL employees received minor electric shocks during a cryogenic transfer because they did not follow the appropriate work planning process, thus did not properly identify all potential secondary hazards and risks. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On October 21, 2021, two cryogenic technicians initiated the transfer of liquid helium into a magnet. The helium was contained in 250-liter dewars connected to a transfer line by means of an intermediate elbow-shaped piece (called dewar stab). Once connected, an electric pressure-building heater vaporizes the helium creating the pressure required to push the liquid through the transfer piping into the magnet. The dewar is placed on an electronic scale to monitor the helium level.
The first technician initiated the transfer by inserting the dewar stab into the dewar and, as the two parts made contact, he received a mild electric shock. The second, more experienced technician, dismissed the reported shock as he was in contact with the same dewar and felt no sensation.
The second technician then proceeded with the next step, which required the connection of a flexible transfer line to the stab. While holding the transfer line in one hand, the second technician reached for the stab with the other hand, and immediately felt a mild shock. Following this second shock, a decision was made to replace the dewar with a secondary unit.
The cryogenic transfer was successfully completed, and the technicians preserved the scene pending further investigation. They then reported the event to their supervisor and were instructed to report to the Laboratory's Occupational Medicine Clinic (OMC) to be evaluated.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The event investigation determined the following:
- The Work Planning & Control Process was not effectively implemented. The work was being performed as "worker-planned" work, however associated tasks met the requirements of "prescribed" work, requiring the use of the documented procedure "OPM 7.1.86 Cryogenic Systems for AGS Cold Snake, Section 5.4."
- The technicians and their supervisor had less-than-adequate knowledge of Electrical Safety requirements. The dewar heater and electronic scale were plugged into an extension cord equipped with ground-fault circuit interrupter (GFCI). Prior to use, the GFCI was not tested, as required, to ensure it was operating properly. (During the investigation it was determined to be defective.)
- The technicians and their supervisor had less-than-adequate knowledge of Electrical Safety Requirements. The cord, the dewar heater, and the scale were not Nationally Recognized Testing Laboratory (NRTL)-listed nor approved for use at BNL.
- The technicians and their supervisor had less-than-adequate knowledge of Event Response Requirements. Neither the initial shock event nor the secondary event was reported per requirements.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>- Revise procedures to correctly describe the process for filling the magnet, improve the hazard analysis, and other related procedures, as well as update Work Planning and Control for Operations procedure to be consistent with institutional requirements. Retrain the group on the revised procedure.
- Environment, Safety, and Health (ESH) Management is to provide new "Work Planning & Control Awareness training" to Division Managers, scientific, engineering, and technical staff.
- Inform department staff how to access information to identify, classify, and report a nonconformance according to the Events/Issues Management Subject Area.
- Give in-person dewar operations refresher training to the group.
- Develop a process to improve the department?s method for tracking and training to improve identification of work covered by documented procedures.
- Conduct a Corrective Action Effectiveness Review on all actions. Present the results to the BNL Institutional Risk Management Committee (IRMC).
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">12/2/2022 1:10:12 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in:
SAF912: CHEMICAL SAFETY TRAINING
ESC001: Basic Electrical Safety (for Electrical Workers)</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1198</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-1198</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">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">12/2/2022 12:59:37 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">12/2/2022 1:10:12 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">Raymond Fliller, (631) 344-2356, rfliller@bnl.gov</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">396</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=6766">OPEXShare BNL - Electric Shock from Dewar.pdf</a></li>
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<hr>
</fieldset>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Cryogenic Material - Gas or Liquid</li>
<li>Electricity</li>
<li>Gas Cylinders</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF912: CHEMICAL SAFETY TRAINING</li>
<li>ESC001: Basic Electrical Safety (for Electrical Workers)</li>
</ul>
</fieldset>
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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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