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Lesson Learned "Avoiding Experience-Based Confirmation Bias During Lockout/Tagout and System Breaching - Hanford" View this email in your browser Avoiding Experience-Based Confirmation Bias During Lockout/Tagout and System Breaching - Hanford</div>
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<td valign="top" style="background:#FAFAFA;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%" id="templatePreheader">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="600" style="width:6.25in;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td width="600" valign="top" style="width:6.25in;padding:0in 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" style="max-width:6.25in;border-collapse:collapse;min-width: 100%;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%;border-collapse:collapse;max-width:100%;min-width: 100%;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:6.75pt 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%;word-break:break-word">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" align="left" width="100%" style="width:100.0%;border-collapse:collapse;margin-left:-2.25pt;margin-right:-2.25pt">
<tr>
<td width="600" valign="top" style="width:6.25in;padding:0in 0in 0in 0in">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" align="left" width="100%" style="width:100.0%;border-collapse:collapse">
<tr>
<td valign="top" style="padding:0in 13.5pt 6.75pt 13.5pt">
<p class="MsoNormal" align="center" style="text-align:center;line-height:150%">
<span style="font-size:9.0pt;line-height:150%;font-family:Helvetica;color:#656565">
<a href="https://misportal.jlab.org/ll/lessons/1285/print" target="_blank">
<span style="color:#656565">View this email in your browser</span>
</a>
</span>
</p>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</div>
</td>
</tr>
<tr>
<td valign="top" style="background:white;padding:6.75pt 0in 0in 0in;background:cover;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%;background-size: cover;background-position-x:50%;background-position-y:50%" id="templateHeader">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="600" style="width:6.25in;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td width="600" valign="top" style="width:6.25in;padding:0in 0in 0in 0in;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<div align="center">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" style="max-width:6.25in;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in;min-width: 100%;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in;min-width: 100%;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" align="left" width="100%" style="width:100.0%;border-collapse:collapse;-ms-text-size-adjust: 100%;-webkit-text-size-adjust: 100%">
<tr>
<td valign="top" style="padding:0in 0in 0in 0in">
<p class="MsoNormal" align="center" style="text-align:center">
<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">.appMessages {
padding-bottom: 3px;
background-color: #FFF;
}
.appMessages .alert {
font-size: x-small;
margin-bottom: 0;
padding: 5px 20px;
text-align: center;
}
.appMessages .alert:not(:first-child) {
margin-top: 3px;
}
.appMessages .msgDetail {
display: none;
border: solid thin;
margin-top: 0.5em;
padding: 0.5em;
}
:-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;
}
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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">Avoiding Experience-Based Confirmation Bias During Lockout/Tagout and System Breaching - Hanford</h1>
<div id="ViewLesson">
<div class="summary">
<h3>Summary</h3>
<div class="inline">
<div class="prop" id="prop_lesson_id"><label class="prop_label" for="lesson_id">Lesson ID</label><div class="input">1285
</div></div><div class="prop" id="prop_approval_status"><label class="prop_label" for="approval_status">Status</label><div class="input">OK
</div></div><div class="prop" id="prop_doc_id"><label class="prop_label" for="doc_id">Doc ID</label><div class="input">2026-JLAB-1285
</div></div><div class="prop" id="prop_priority"><label class="prop_label" for="priority">Priority</label><div class="input">Best Practice
</div></div><div class="prop" id="prop_safety_related"><label class="prop_label" for="safety_related">Safety Related</label><div class="input">YES
</div></div><div class="prop" id="prop_source"><label class="prop_label" for="source">Source</label><div class="input">DOE Corporate Reporting Databases
</div></div><div class="prop" id="prop_location"><label class="prop_label" for="location">Location</label><div class="input">Hanford
</div></div><div class="prop" id="prop_originator_person"><label class="prop_label" for="originator_person">Originator</label><div class="input">Mary Jo Bailey (mbailey)
</div></div><div class="prop" id="prop_issue_date"><label class="prop_label" for="issue_date">Issued</label><div class="input">1/13/2026 8:55 am
</div></div><div class="prop" id="prop_approver_person"><label class="prop_label" for="approver_person">Approved By</label><div class="input">Mary Jo Bailey (mbailey)
</div></div><div class="prop" id="prop_approval_date"><label class="prop_label" for="approval_date">Approved On</label><div class="input">1/13/2026 11:31 am
</div></div><div class="prop" id="prop_contact"><label class="prop_label" for="contact">Contact</label><div class="input">Jennifer Bilskis, Central Plateau Cleanup, jennifer_o_bilskis@rl.gov
</div></div><div class="prop" id="prop_queued_emails"><label class="prop_label" for="queued_emails">Queued Emails</label><div class="input">614
</div></div><div class="prop" id="prop_sent_emails"><label class="prop_label" for="sent_emails">Sent Emails</label><div class="input">0
</div></div><div class="prop" id="prop_viewings"><label class="prop_label" for="viewings">Viewings</label><div class="input">1 time
</div></div><div class="prop" id="prop_stars"><label class="prop_label" for="stars">Rating</label><div class="input"><img width="75" class="stars" src="/ll/assets/stars-4-557508b4dfb2fb8b0339a66775e14941dbc2c0cfe7cfa7f5c6a05215cefc036c.png" />
</div></div></div>
<div class="clear"></div>
</div>
<div class="llstatement">
<h3>Statement of Lessons Learned</h3>
<pre>Use critical thinking when assessing all forms of hazardous energy for Lockout/Tagout (LOTO) protocols, then evaluate the potential risk of each, including system breaches. Reliance on experience-based confirmation bias can lead to mishandled LOTO protocols and the misidentification of isolation boundaries. In this event, pipefitters were removing a section of a 12-inch raw water pipe when an unexpected hazardous energy release caused a valve body and attached section of PVC pipe to separate from the upstream line and shoot across the excavation area, resulting in the unplanned release of approximately 80,000-100,000 gallons of raw water. No injuries occurred, but the incident qualified as a near miss.

 <img src="https://misportal.jlab.org/ll/lessons/1201/show_attachment_content?attachment_id=7912
" width="600px"></pre>
</div>
<div class="activity_discussion">
<h3>Discussion of Activities</h3>
<pre>The event investigation revealed several failures stemming from experience-based confirmation bias, resulting in inadequate adherence to the protocols designed to prevent LOTO and system breaching.

Controlling Organization Administrator (COA) #1, recognized as the owner/expert on the system, prepared the LOTO authorization form for the isolation of a 12-inch raw water line, which was documented to fluctuate between 130 and 300 psig. COA#1 reviewed photos and referenced the work package as well as a drawing. A walkdown of the jobsite confirmed valve nomenclature; however, since the piping was buried, system configuration could not be validated. Based on experience, COA #1 elected to lockout valves downstream of the main isolation point. 

The authorization form was then submitted to COA #2, with the request for a Technical Review. After performing a walkdown of the area and reviewing the document, COA #2 signed the authorization form.

The COA#1 then waived the authorization form's compulsory independent project-specific action review, even though they had neither the authority nor the justification to do so.

Company-level performance standards then required a separate management review for any non-routine LOTO work activities. The management review process did not define clear responsibilities or expectations. As a result, the review was done without confirming whether the identified hazards, risks, consequences, and mitigation measures were adequate.</pre>
</div>
<div class="analysis">
<h3>Analysis</h3>
<pre>The work authorization form misidentified key isolation boundaries, which were insufficiently reviewed. This led to an incorrect LOTO boundary. 

Waiving of an essential independent review without proper authorization or justification allowed safety checks to be bypassed. The originator of the authorization form (i.e., COA #1) was considered the expert on the system; subsequent reviewers, out of respect, applied less rigor during their evaluations, which resulted in the failure to identify the flawed isolation boundary.</pre>
</div>
<div class="recommended_action">
<h3>Recommended Actions</h3>
<pre>Review Controls with Skepticism: Those reviewing LOTO documentation must approach each review with a critical mindset, carefully verifying all details and never assuming the Preparer's work is error-free. 

Obtain External Opinions: Encourage external experts or third-party reviews during critical decision-making processes or evaluations to contrast with internal biases. 

Adhere to a Structured Decision-Making Process: Use checklists and formal reviews to ensure all aspects of a situation are examined.</pre>
</div>
<div class="attachments">
<h3>Attachments</h3>
<ul>
<li><a target="_blank" href="https://misportal.jlab.org/ll/lessons/1285/show_attachment_content?attachment_id=7912">OPEX-Share - Hanford LOTO.jpg</a></li>
<li><a target="_blank" href="https://misportal.jlab.org/ll/lessons/1285/show_attachment_content?attachment_id=7913">OPEX-Share - Hanford LOTO.pdf</a></li>
</ul>
</div>
<div class="hazard_issues">
<h3>Hazard Issues</h3>
<ul>
<li>
Lock, Tag, Try
</li>
</ul>
</div>
<div class="skills">
<h3>Training Skills</h3>
<ul>
<li>SAF104: Lock, Tag, and Try</li>
<li>ESC007: Lockout/Tagout (LOTO)</li>
</ul>
</div>
<div class="work_functions">
<h3>Distribution/Notification</h3>
<ul>
<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
</ul>
</div>
</div>
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</div><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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