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<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">:-moz-focusring {
outline: none;
}
body {
color: #5b6065;
font-family: Arial;
font-size: 16px;
padding: 0 !important;
}
fieldset {
margin-bottom: 1em;
border: 1px solid;
padding: 0.5em;
}
legend {
font-size: inherit;
margin: 0;
width: auto;
color: inherit;
font-weight : bold;
}
thead, tbody, tfoot {
border-color: #5b6065;
}
a, .ui-widget-content a, a:hover, .ui-widget-content a:hover, .ui-autocomplete.app-autocomplete .ui-menu-item .ui-menu-item-wrapper {
color: #ac172b;
}
.ui-widget-content {
color: inherit;
font: inherit;
}
p {
margin: 0 0 20px;
}
.h2, h2 {
font-size: 20px;
margin: 0;
padding-bottom: 20px;
}
h3 {
font-size: 1.2em;
line-height: 1.3em;
margin-bottom: 0.667em;
margin-top: 0.667em;
}
.page-wrapper {
overflow: inherit;
background: #f4f4f5 none repeat scroll 0 0;
padding-top: 160px;
}
.container {
background: #fff none repeat scroll 0 0;
position: relative;
width: 1315px;
}
ul.menu {
list-style: outside none none;
margin: 0;
padding: 0;
}
ul.menu li {
list-style: outside none none;
margin: 0;
padding: 0;
}
input[type="image"] {
border: 0 none !important;
padding: 0 !important;
}
input.form-text {
background: #e4e4e4 none repeat scroll 0 0;
border: medium none;
color: #6d6a6a;
padding: 5px 10px;
}
input.form-submit {
background-color: #ad172b;
border: medium none;
color: #fff;
font-size: 20px;
padding: 6px 20px;
text-transform: uppercase;
}
.for-mobile, .mobileNav {
display: none;
}
/* header */
.page-wrapper > header {
background: #fff none repeat scroll 0 0;
left: 0;
min-height: 160px;
position: fixed;
top: 0;
width: 100%;
z-index: 100;
}
.page-wrapper > header::before {
background: #fff none repeat scroll 0 0;
content: "";
height: 100px;
position: absolute;
top: -100px;
width: 100%;
}
.page-wrapper > header .container {
width: 90%;
}
.page-wrapper > header .top-menu ul.menu li.last a.right {
float: none;
}
.page-wrapper.smaller-header > header {
min-height: auto;
}
a.logo {
margin: 0;
padding: 33px 0;
padding-top: 33px;
transition: all 0.3s ease 0s;
}
.logo img {
height: 75px;
transition: all 0.3s ease 0s;
position: relative;
z-index: 100;
}
@media screen and (max-width: 750px) {
#DevelopmentHeaderNote {
font-size: 10px !important;
}
}
.top-right {
float: right;
padding: 23px 0 30px;
transition: all 0.3s ease 0s;
width: 260px;
}
.top-right * {
margin: 0;
}
.primary-nav {
float: right;
padding: 55px 40px 0 0;
transition: all 0.3s ease 0s;
}
.region.region-navigation {
float: right;
width: 100%;
}
.region.region-top-right > div {
float: right;
}
.top-menu {
height: 26px;
opacity: 1;
text-align: right;
transition: all 0.3s ease 0s;
visibility: visible;
}
.top-menu .menu > li.first {
margin: 0;
padding: 0;
}
.top-menu .menu > li.first::after {
display: none;
}
.top-menu .menu > li::after {
background: #404145 none repeat scroll 0 0;
content: "";
height: 20px;
left: 0;
position: absolute;
top: 2px;
width: 1px;
}
.top-menu .menu > li.signout a {
color: #ac172b;
}
.top-menu .menu > li a {
color: #404145;
font-size: 18px;
padding: 0;
text-transform: uppercase;
}
.top-menu .menu .leaf {
white-space: nowrap;
}
.main-menu ul.menu {
float: right;
}
.main-menu ul.menu li {
float: left;
padding-left: 40px;
position: relative;
}
.main-menu li > a {
color: #404145;
font-family: Arial;
font-size: 20px;
font-weight: 500;
text-transform: uppercase;
}
.top-right #HeaderSearchForm {
padding-bottom: 7px;
padding-right: 37px;
padding-top: 5px;
position: relative;
}
.top-right #HeaderSearchForm .views-exposed-form div {
padding: 0;
}
.top-right #HeaderSearchForm label {
display: none;
}
.top-right #HeaderSearchForm .views-exposed-form input.form-text {
width: 100%;
}
.top-right #HeaderSearchForm .views-submit-button {
float: left;
padding: 0;
position: absolute;
right: 0;
top: 8px;
}
.top-right #HeaderSearchForm .views-submit-button input {
background-color: transparent;
background-image: url("../images/search-icon.jpg");
background-position: center center;
background-repeat: no-repeat;
background-size: auto 100%;
border: medium none;
display: block;
font-size: 0;
height: 25px;
line-height: 0;
padding: 0;
text-indent: -999px;
width: 34px;
}
.usde-logo {
height: 31px;
opacity: 1;
text-align: right;
transition: all 0.3s ease 0s;
visibility: visible;
}
.usde-logo a img {
width: 122px;
}
.smaller-header .top-right {
padding: 12px 0;
transition: all 0.3s ease 0s;
width: 360px;
}
.smaller-header .top-menu {
height: 0;
opacity: 0;
transition: all 0.3s ease 0s;
visibility: hidden;
}
.smaller-header .usde-logo {
height: 0;
opacity: 0;
transition: all 0.3s ease 0s;
visibility: hidden;
}
.smaller-header a.logo {
padding: 10px 0;
transition: all 0.3s ease 0s;
}
.smaller-header .logo img {
height: 55px;
transition: all 0.3s ease 0s;
}
.smaller-header .primary-nav {
padding-top: 24px;
transition: all 0.3s ease 0s;
}
/* end of header */
/* sidebar */
.side.sidebar-left::after {
width: 185px;
height: 100%;
background-color: #e4e4e4;
content: "";
left: 0;
position: absolute;
top: 0;
}
.side.sidebar-left {
float: none;
position: absolute;
bottom: 0;
top: 0;
width: 185px;
}
.side.sidebar-left .block {
position: relative;
z-index: 1;
padding: 20px;
padding-bottom: 40px;
}
.primary-menu-style hr {
margin-left: -1em;
margin-right: -1em;
}
.primary-menu-style ul {
list-style: outside none none;
margin: 0;
padding: 0;
}
.primary-menu-style ul li {
padding-bottom: 0.5em;
font-size: smaller;
}
.primary-menu-style ul li a {
color: #5b6065;
display: inline;
padding: 0;
}
.primary-menu-style ul.menu li.headTitle {
font-weight: bold;
margin-left: -1em;
margin-right: -1em;
margin-bottom: 0.5em;
padding-bottom: 0.5em;
border-bottom: solid;
border-bottom-color: #9B1120;
border-bottom-width: 1px;
}
.primary-menu-style ul.menu li.title {
font-weight: bold;
margin-left: -1em;
}
ul.menu hr.menu-hr {
background-color: #9B1120;
height: 1px;
margin: 0.25em -1em;
}
.primary-menu-style input {
width: 100%;
}
aside.sidebar-left.side .menuCloseDiv {
position: absolute;
right: 5px;
top: 5px;
cursor: pointer;
}
aside.sidebar-left.side .mobileMenuCloseDiv {
display: none;
}
aside.sidebar-left.side.minimized {
display: none;
}
.mainMenuSelectorBars {
display: none;
cursor: pointer;
}
.mainMenuSelectorBars.minimized {
display: inline;
}
.mobileMainMenuSelectorBars {
cursor: pointer;
display: none;
}
/* end sidebar */
/* footer */
.footer {
background-image: none;
padding: 1em;
background-color: #5b6064;
position: relative;
bottom: 0;
color: #fff;
overflow: hidden;
}
.footer .container {
background-color: transparent;
}
.footer .container::before {
background-color: #5b6064; /* or should it be: #22292f; */
height: auto;
background-color: #22292f;
content: "";
left: 100%;
margin-left: -450px;
position: absolute;
top: 0;
width: 5000px;
z-index: 0;
}
.block_footer ul li a {
color: #fff;
font-size: 12px;
text-transform: uppercase;
}
.block_footer_left {
float: left;
padding-left: 40px;
}
.block_footer_right {
float: right;
padding-right: 40px;
}
/* end footer */
/* main content */
section.one-sidebar {
float: none;
}
.main-container-wrapper {
background: #f4f4f5 none repeat scroll 0 0;
position: relative;
}
.main-container.container::before {
background-image: linear-gradient(to right, rgb(244, 244, 245) 0%, rgb(209, 210, 211) 100%);
content: "";
display: block;
height: 100%;
position: absolute;
left: -80px;
top: 0;
width: 80px;
z-index: 1;
}
.main-container.container::after {
background-image: linear-gradient(to right, rgb(209, 210, 211) 0%, rgb(244, 244, 245) 100%);
content: "";
display: block;
height: 100%;
position: absolute;
right: auto; /* orig: -80px; */
top: 0;
width: 80px;
z-index: -1;
}
h1.page-header {
border-bottom: 2px solid #a29f9f;
color: #ad172b;
font-family: Arial;
font-size: 25px;
margin: 0 0 20px;
padding-bottom: 10px;
text-transform: uppercase;
}
section.one-sidebar.left-side > .row-inner .region.region-content {
padding: 0 1em 1em 0;
}
section.one-sidebar.left-side > .row-inner {
padding-left: 200px;
}
section.no-sidebars > .row-inner {
padding: 0 1em 1em 1em;
}
/* end of main content */
/* responsive rules */
@media screen and (max-width: 1515px) {
img {
height: auto;
max-width: 100%;
}
}
@media screen and (min-width: 667px) and (max-width: 1315px) {
.container {
width: 100%;
}
.primary-nav {
padding-right: 10px;
}
.logo img {
height: auto;
max-width: 200px;
}
.page-wrapper > header .container {
width: 98%;
}
.smaller-header .top-right {
width: 260px;
}
}
@media screen and (max-width: 960px) {
a.logo {
padding: 0;
}
.block.block-block.usde-logo {
position: absolute;
right: 10px;
top: 30px;
}
.usde-logo a img {
height: auto;
width: 80px;
}
.page-wrapper > header {
min-height: 110px;
position: inherit;
}
.top-right {
padding: 0;
width: 100%;
}
.top-menu {
position: absolute;
right: 10px;
top: 8px;
}
.top-menu .menu>li::after {
height: 10px;
top: 7px;
}
.top-menu .menu>li a {
font-size: 12px;
}
.navbar-header {
min-height: auto;
padding: 15px 10px 0;
position: relative;
width: 100%;
}
button.navbar-toggle {
bottom: -26px;
display: block !important;
height: auto !important;
left: auto !important;
margin: 0 !important;
opacity: 1 !important;
padding: 0 !important;
position: absolute;
right: 15px;
top: auto !important;
width: auto !important;
z-index: 100;
}
button.navbar-toggle span {
background-color: #ac172b;
}
.region.region-top-right #HeaderSearchBlock {
padding-right: 50px;
position: relative;
}
.primary-nav {
display: none;
padding: 0;
width: 100%;
}
.primary-nav.mobileNav {
padding: 0;
width: 100%;
}
.mobileNav {
background: #e4e4e4 none repeat scroll 0 0;
}
.mobileNav li {
border-bottom: 1px solid #32373d;
float: left;
padding: 0;
position: relative;
width: 100%;
}
.mobileNav li a {
color: #404145;
display: block;
padding: 10px;
text-align: center;
text-transform: uppercase;
}
.mobileNav li a.active,
.mobileNav li a:hover {
background: #ad172b none repeat scroll 0 0;
color: #fff;
}
.primary-nav.mobileNav {
float: none;
transition: none;
}
.mobileNav .main-menu ul.menu {
float: none;
}
.mobileNav .main-menu ul.menu li {
padding-left: 0;
}
.mobileNav .main-menu li > a {
font-size: inherit;
}
.page-wrapper {
padding-top: 0px;
}
}
@media screen and (min-width: 667px) and (max-width: 960px) {
.smaller-header .top-right {
position: absolute;
right: 0;
top: 15px;
}
.smaller-header button.navbar-toggle {
bottom: 36px !important;
}
}
@media screen and (max-width: 667px) {
.container {
width: 100%;
}
.main-container.container {
min-height: auto !important;
}
.block_footer {
padding: 20px;
width: 100%;
}
.block_footer_left {
padding: 0 0 0 20px;
}
.page-wrapper > header .container {
width: 100%;
}
.logo img {
height: auto;
max-width: 175px;
}
.for-mobile {
display: block;
}
.for-mobile.more-menu-options-wrap {
padding: 10px;
text-align: right;
}
.closen1, .closen {
color: #ac172b;
cursor: pointer;
position: absolute;
right: 10px;
top: 10px;
z-index: 11;
}
section.one-sidebar {
float: left;
}
.one-sidebar.left-side {
width: 100%;
}
.side.sidebar-left {
background: #e4e4e4 none repeat scroll 0 0;
width: 100%;
position: relative;
}
.primary-nav {
display: none;
padding: 0;
width: 100%;
}
section.one-sidebar.left-side > .row-inner {
padding: 20px;
padding-left: 10px;
}
.side.sidebar-left::after {
display: none;
}
.sidebar-left {
display: none;
}
.region.region-top-right #HeaderSearchBlock {
width: 100%;
}
#HeaderSearchBlock form {
padding: 5px 80px 0 15px;
width: 100%;
}
.more-menu-options {
color: #ad172b;
cursor: pointer;
}
aside.sidebar-left.side .menuCloseDiv {
display: none;
}
aside.sidebar-left.side .mobileMenuCloseDiv {
cursor: pointer;
display: inline;
position: absolute;
right: 5px;
top: 5px;
}
.mainMenuSelectorBars.minimized {
display: none;
}
.mobileMainMenuSelectorBars {
display: inline;
}
aside.side.sidebar-left.showMobileMenu::after {
display: block;
}
aside.sidebar-left.showMobileMenu {
display: block;
}
aside.side.sidebar-left.showMobileMenu.minimized::after {
display: block;
}
aside.sidebar-left.showMobileMenu.minimized {
display: block;
}
}
/* end of responsive rules */
/* MIS styles */
label {
display: inline-block;
}
label {
font-weight: normal;
}
label:empty {
display: none !important;
}
pre {
background-color: inherit;
color: inherit;
border: none;
font: inherit;
padding: 0;
margin: 0;
white-space: pre-wrap;
overflow-wrap: break-word;
}
input[type="submit"]:not(.btn), input[type="button"]:not(.btn), input[type="reset"]:not(.btn), button:not(.btn) {
height: initial;
}
input[type="file"]:focus, input[type="checkbox"]:focus, input[type="radio"]:focus {
outline-offset: 0;
}
hr {
background: none repeat scroll 0 0 #BABABA;
border: medium none;
height: 5px;
margin: 0;
padding: 0;
}
.clear {
clear: both;
}
.invisibleContent {
visibility: hidden;
display: none;
}
#InvisibleContent {
visibility: hidden;
display: none;
}
#FeedbackDialog {
position: relative;
}
#FeedbackDialog .dialogContent {
position: absolute;
top: 2em;
bottom: 2em;
left: 0;
right: 0;
padding: 1em;
}
#FeedbackDialog textarea {
width: 100%;
height: 100%;
}
#FeedbackDialog .buttonContent {
position: absolute;
bottom: 0;
left: 0;
right: 0;
height: 2em;
}
#FeedbackDialog .buttonContent button {
margin: 0 1em;
}
#FeedbackDialog .buttonContent .feedbackCancel {
float: right;
}
#DevelopmentHeaderNote {
font-size: small;
margin-right: 1em;
padding: 0.5em;
}
/* end main body */
/* flash notices */
.error, .notice, .warning {
border: 1px solid #bbb;
padding: 1em;
font-weight: bold;
text-align: center;
margin-bottom: 1em;
}
.error {
color: #D8000C;
background-color: #FFBABA;
}
.error, .warning {
background-repeat: no-repeat; /* to override system.allcombined */
background-position: calc(100% - 10px) 5px;
}
.warning {
color: #a39709;
background-color: #FF8;
}
.notice {
color: #4F8A10;
background-color: #DFF2BF;
}
/* end flash notice*/
/* bootstrap overrides */
@media print {
a[href]::after {
content: "" !important;
}
}
/* end bootstrap overrides */
/* in app login page styles */
#login {
padding-top: 1em;
text-align: center;
}
#login .greeting {
font-weight: bold;
font-size: 16px;
}
#login_form {
width: 400px;
text-align: left;
margin: 1em auto;
border: 1px solid #4A637B;
}
#login_form .prop {
border-bottom: 0;
padding: 0 10px;
}
#login_form #action_buttons {
padding: 10px;
}
#login_form h2 {
margin: 0;
border: 0;
padding: 5px 10px;
font-size: 14px;
background-color: #000;
color: #fff;
margin-bottom: 1em;
}
#login_dialog {
margin: 1em auto;
width: 235px;
}
#login_dialog .input input {
width: 100%;
}
/* end in app login page styles */
/* mis forms styles */
.prop {
overflow: auto;
padding: 1em 0;
page-break-inside: avoid;
}
.prop_label {
font-weight: bold;
}
.prop .label {
color: inherit;
font-size: 100%;
text-align: inherit;
padding: 0;
}
.show .prop {
padding: 0 0 1em 0;
}
.form {
padding: 1em;
}
.title {
font-weight: bold;
}
.actions, #action_buttons {
padding: 1em 0;
}
.actions:empty, #action_buttons:empty {
display: none;
}
.name {
clear: both;
float: left;
height: 100%;
padding-right: 5px;
text-align: right;
width: 15%;
font-weight: bold;
}
.value {
float: none;
}
.prop .value {
float: left;
width: 80%;
}
.prop .prop .name {
width: 10%;
}
.form .fields .prop .value .errormsg {
display: inline;
position: relative;
}
#content-body .prop {
border-bottom: 0;
}
.textAreaError .errormsg {
top: -7px;
}
.field_with_errors > input, .field_with_errors > textarea, .field_with_errors > select, .field_with_errors > .poa, .field_with_errors > .personList, .field_with_errors > .radio_buttons, .input_error > .radio_buttons, .field_with_errors > .check_boxes, .input_error > .check_boxes, .field_with_errors > .select2-container {
outline: 1px solid #f00;
margin: 1px;
}
.input_error .radio_option .field_with_errors input, .input_error .radio_button_option .field_with_errors input, .input_error .check_box_option .field_with_errors input {
outline: none; /* to stop the double highlight that would be caused by the above rule */
}
.input_error .radio_option .field_with_errors, .input_error .radio_button_option .field_with_errors, .input_error .check_box_option .field_with_errors {
display: inline-block;
}
.personList {
display: inline-block;
}
.note {
font-style: italic;
padding: 10px;
}
*[disabled] {
background-color: #EEE !important;
color: #545454 !important;
}
input[type=submit]:not(.btn), input[type=button]:not(.btn), input[type=reset]:not(.btn), button:not(.btn), a.btn_link:not(.btn), a.btn_link:link:not(.btn), a.btn_link:visited:not(.btn), a.btn_link:active:not(.btn) {
background-color: #B1C3D8;
border: 1px solid #4A637B;
color: #000000;
font-family: Tahoma,Arial,Helvetica,sans-serif;
overflow: visible;
padding: 2px 8px;
text-align: center;
text-decoration: none;
vertical-align: middle;
line-height: normal;
}
input[type=submit]:hover:not(.btn), input[type=button]:hover:not(.btn), input[type=reset]:hover:not(.btn), button:hover:not(.btn), a.btn_link:hover:not(.btn) {
background-color: #19355E;
border: 1px solid #19355E;
color: #FFF;
}
input, select, textarea {
background-color: #E7EFFC;
border: 1px solid #19355E;
padding-bottom: 2px;
}
input.dirty, select.dirty, textarea.dirty {
outline: 2px solid yellow;
margin: 2px;
}
.required {
color: #D8000C;
}
.field_error {
color: #D8000C;
}
.poa {
display: flex;
align-items: center;
}
.prop .poa .prop {
padding-top: 0;
padding-bottom: 0;
}
.poa .prop {
display: inline;
float: left;
}
.poa .spacer {
display: inline;
padding: 0 10px;
}
.prop .poa .spacer {
padding-top: 1.5em;
}
.poa .spacer > br {
display: none;
}
.radio_buttons, .check_boxes {
display: inline-block;
}
.radio_buttons .radio_option {
display: inline-block;
position: relative;
}
.radio_buttons .radio_option, .radio_buttons .radio_button_option, .check_boxes .check_box_option {
background-color: #E7EFFC;
padding: 3px 5px;
white-space: nowrap;
overflow: hidden;
vertical-align: top;
}
.radio_buttons .radio_option:not(:first-of-type){
padding-left: 1em;
}
.radio_buttons.disabled .radio_option, .radio_buttons.readonly .radio_option, .radio_buttons.readonly .radio_button_option, .check_boxes.readonly .check_box_option {
background-color: #EEE;
}
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line-height: 20px;
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pre {font-family: Helvetica;} fieldset {border: solid thin black;}</style><base href="https://misportal.jlab.org"><div align="left">
<h1 class="lesson_title">ACC-23-1215: Near Miss in Main Cleanroom Drying Bay 4 (Management Concern)</h1>
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<h3>Statement of Lessons Learned</h3>
<pre>Two (2) of four (4) clamps, on a Back-Tek rolling cart, disengage causing a C100 cavity to pivot uncontrollably. 

<img src="https://misportal.jlab.org/ll/lessons/1201/show_attachment_content?attachment_id=7147" width="500px"></pre>
<h3>Discussion of Activities</h3>
<pre>On December 15, 2023, after undergoing a high-pressure-rinse, a C100 cavity was loaded onto a on a Back-Tek. During this operation, while the cavity was being rotated from a vertical to a horizontal orientation, two top toggle clamps opened resulting in the cavity pivoting downward uncontrollably. The two bottom clamps stayed intact preventing the load from falling to the floor. No injuries occurred during this event and there was no serious damage to the equipment other than a broken "speed handle" on the Back-Tek.</pre>
<h3>Analysis</h3>
<pre>The two clamps that failed were found to be too loose in their hasp-loop. Additionally, the clamps were only secured to the fixture with bolts; no application of lock-washers was required. This resulted in the washers backing-out of their orientation, loosening the clamps' attachment to the fixture. 

The fixture clamps receive no preventive maintenance inspection or evaluation to verify their continued fitness-for-use. The only trigger for maintenance or operational adjustment considered at the discretion of the operator/technician. 

The workers manipulating the C100 cavity, were not those who installed the cavity onto the Back-Tek. Workers often take possession of mounted components from others under the assumption that skills are common to all. A comprehensive evaluation or verification of the clamp setup was not required in the procedures. All persons involved in handling the C100 cavity leading up to the event were considered "competent" on the use of the Back-Tech procedures leadership. There is no record of what is required to reach a level of "competence." 

There was no requirement for properly adjusting the clamping device nor was the task of clamp adjustment/fitting identified as a critical task. The procedure provided insufficient detail on the critical parameters and conditions for safe operation. Due to the nature of the clamping devices on the Back-Tech fixtures, determination as to whether the clamp was "sufficiently" tight was based on the technician's interpretation. This introduced the potential for a high standard deviation in the clamp's setup. 

The content of "on the job" training to achieve competence on the Back-Tech loading and operation procedure was not documented. This introduces the probability that the curriculum varies based on the trainer/technician.</pre>
<h3>Recommended Actions</h3>
<pre>Immediately inspect the condition of all Back-Tech Fixture Clamps, replace as required.

Replace/retrofit the installation fasteners (threaded bolts) with bolts sized appropriately for the threaded holes in fixture and clamp plate, and include the addition of lock washers to the installation scheme. Use a thread locker such as Loctite on the threaded bolts.

Develop and deliver the specific training for the use of the fixture clamps. As the appropriate fit of the clamps can only be gauged through sensory feedback, the training must include demonstration of both acceptable and unacceptable operation, as well as a concise "pre-flight" check/inspection of the condition of the clamp prior to loading. Training is to be provided as a "corrective one-off" for existing Cleanroom Technicians and as part of initial Cleanroom Proficiencies Training to new technicians.

Revise the Cleanroom procedure to require the use of and specify the appropriate bolts, lock washers and thread locker for the clamp installation going forward. Address the proper use of the fixture clamps as a critical step and reinforce require that workers receive required training on what constitutes both "good" and "bad" conditions and adjustment results.

Develop and implement a preventive inspection routine that includes the evaluation and assures the continued fitness-for-use of the Back-Tech fixture clamps. Evaluation must include an assessment of the integrity of the clamps' installation and operating mechanisms prior to use.</pre>
<h3>JLab Preventative Measures</h3>
<pre></pre>
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<legend class="header_color">Summary</legend>
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<tr>
<td class="bold nowrap">Lesson ID:</td>
<td>1221</td>
</tr>
<tr>
<td class="bold nowrap">Status:</td>
<td>OK</td>
</tr>
<tr>
<td class="bold nowrap">Doc ID:</td>
<td class="nowrap">2024-JLAB-1221</td>
</tr>
<tr>
<td class="bold nowrap">Priority:</td>
<td class="nowrap">Caution</td>
</tr>
<tr>
<td class="bold nowrap">Safety Related:</td>
<td class="nowrap">YES</td>
</tr>
<tr>
<td class="bold nowrap">Originator:</td>
<td class="nowrap">Mary Jo Bailey (mbailey)</td>
</tr>
<tr>
<td class="bold nowrap">Issued:</td>
<td class="nowrap">1/9/2024 3:54 pm</td>
</tr>
<tr>
<td class="bold nowrap">Approved By:</td>
<td class="nowrap">Mary Jo Bailey (mbailey)</td>
</tr>
<tr>
<td class="bold nowrap">Approved On:</td>
<td class="nowrap">2/23/2024 8:02 am</td>
</tr>
<tr>
<td class="bold nowrap">Source:</td>
<td class="nowrap">
<a target="_blank" href="https://misportal.jlab.org/railsForms/notable_events/168072/edit">TJNAF NE</a>
</td>
</tr>
<tr>
<td class="bold nowrap">Location:</td>
<td class="nowrap">TJNAF</td>
</tr>
<tr>
<td class="bold nowrap">Cost Savings:</td>
<td class="nowrap"></td>
</tr>
<tr>
<td class="bold nowrap">Contact:</td>
<td>Kirk Davis, Accelerator Engineer-Instruments & Measurements, (KDavis@JLab.org</td>
</tr>
<tr>
<td class="bold nowrap">Queued Emails:</td>
<td>126</td>
</tr>
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<td>0</td>
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<td class="bold nowrap">Viewings:</td>
<td>6 times</td>
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<td><img width="75" class="stars" src="/ll/assets/stars-3-fecf1c4baf025fed9e768b523fd13808e34c7b7a1babac2a83bade0ec1ea73ca.png" /></td>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/lessons/1221/show_attachment_content?attachment_id=7147">ACC-23-1215 Example.jpg</a></li>
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Other: Situational Awareness
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<li>
Ergonomics - Lifting, Carrying, Repetitive Motion
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<li>
Material Handling Equipment
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