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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">.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;
}
#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 .field_with_errors {
display: inline-block;
}
.personList {
display: inline-block;
}
.note {
font-style: italic;
padding: 10px;
}
*[disabled], .select2-container.select2-container-disabled .select2-choice {
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;
}
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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">Preventing ASE Violations: Lessons from Unsecured Personnel Protection System (PPS) Enclosures - Brookhaven National Laboratory (BNL)</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">1287
</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-1287
</div></div><div class="prop" id="prop_priority"><label class="prop_label" for="priority">Priority</label><div class="input">Caution
</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">BNL
</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)
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</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">1/21/2026 12:27 pm
</div></div><div class="prop" id="prop_contact"><label class="prop_label" for="contact">Contact</label><div class="input">Preventing ASE Violations: Lessons from Unsecured Personnel Protection System (PPS) Enclosures
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</div></div></div>
<div class="clear"></div>
</div>
<div class="llstatement">
<h3>Statement of Lessons Learned</h3>
<pre>//See "OPEX-Share - BNL ASE Violation - JLab position" attached for TJNAF's preventive measures.//

In accordance with the National Synchrotron Light Source II (NSLS-II) Accelerator Safety Envelope (ASE) prior to a new run cycle, all systems, including Personnel Protection Systems (PSS), are to undergo multiple approved configuration verifications. In this event, pre-start verification checklists confirmed that all PPS control panels were properly padlocked; however, during non-routine operations, two padlocks were found unlocked. This resulted in an NSLS-II ASE violation.

 <img src="https://misportal.jlab.org/ll/lessons/1201/show_attachment_content?attachment_id=7935
" width="600px"></pre>
</div>
<div class="activity_discussion">
<h3>Discussion of Activities</h3>
<pre>NSLS-II workers are able to access PPS cabinets during NSLS-II operations for non-routine tasks such as resetting system faults, troubleshooting issues, or verifying operability. It is assumed that after completion of the task, the assigned worker would then fully engage the padlock. 

Pre-start beamline enabling checklists, completed on May 8 and May 9, confirmed that all PPS control panels were padlocked. 

On May 12, 2025, an NSLS-II floor coordinator discovered that a PPS control panel's padlock was improperly engaged; the padlock's shackle had been inserted through the cabinet locking hasp; however, it had not been engaged as required. The next day, a similar condition was discovered on another PPS control panel.

During the investigation, staff provided conflicting accounts of events. In the first instance, a beamline scientist stated that an operations worker had unlocked the PSS control panel to resolve an issue. The operations worker stated that they did not open the PSS control panel at all. The cause of the second unlocked PSS control panel could not be determined.</pre>
</div>
<div class="analysis">
<h3>Analysis</h3>
<pre>The primary factors for the event included:
- An unsecured PPS control panel represents a breakdown in a credited safety control configuration, which could result in a hazard exposure. 
- Visually checking that a padlock is present is no substitute for physical verification of engagement. 
- Work control documents for non-routine resets, troubleshooting, or operational adjustments did not include a procedure for accessing PPS control panels. 

The investigation also identified several contributing factors:
- Other than the Pre-Start Verification Protocols, there was no requirement to verify that PPS control panels were locked after non-routine access.
- Existing verification checklists only apply to routine activities and do not cover non-routine conditions that may present
- Additional configuration concerns requiring intervention may have contributed to the padlocks not being fully engaged.</pre>
</div>
<div class="recommended_action">
<h3>Recommended Actions</h3>
<pre>1. Configuration controls will be strengthened by: 
- Requiring documentation of access requirements, 
- Upgrading locking hardware, 
- Reducing the need for PSS control panel access, 
- Centralizing key controls, and 
- Reinforcing configuration management expectations through targeted communication and training.
2. An NSLS-II access procedure will be provided and will define responsibilities for :
- PSS control panels access logs requiring worker and verifier signatures, time and date of access, and re-securing of panels.
- Key lock alarms will be considered to ensure PSS control panels cannot be inadvertently left unlocked.
3. PPS control panel keys will be centralized and will require a formal sign-out system for accountability.
4. Increase configuration management awareness through weekly All-Hands messaging and by assigning Beamline 101 training to all personnel with PPS enclosure access.</pre>
</div>
<div class="attachments">
<h3>Attachments</h3>
<ul>
<li><a target="_blank" href="https://misportal.jlab.org/ll/lessons/1287/show_attachment_content?attachment_id=7933">OPEX-Share - BNL ASE Violation - JLab position.pdf</a></li>
<li><a target="_blank" href="https://misportal.jlab.org/ll/lessons/1287/show_attachment_content?attachment_id=7934">OPEX-Share - BNL ASE Violation.pdf</a></li>
<li><a target="_blank" href="/ll/lessons/1287/show_attachment_content?attachment_id=7935">OPEX-Share - BNL ASE Violation Photo.jpg</a></li>
</ul>
</div>
<div class="hazard_issues">
<h3>Hazard Issues</h3>
<ul>
<li>
Other: Work Planning and Communication
</li>
<li>
Lock, Tag, Try
</li>
</ul>
</div>
<div class="skills">
<h3>Training Skills</h3>
<ul>
<li>SAF132kd: ISMS ACCELERATOR SAFETY DOCUMENT</li>
<li>SAF701E: Accelerator Safety Controls</li>
<li>SAF801.ASE: Vertical Test Area Accelerator Safety Envelope (VTA ASE)</li>
<li>SAF808.ASE: Cryomodule Test Facility Accelerator Safety Envelope (CMTF ASE)</li>
<li>MCC-503: LERF Accelerator Safety Envelope</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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