- ACC-16-1215- Unexpected Energy Discovery - No Injuries
Author: Harry Fanning
Date of Event: 12-15-2016
1. When changes are proposed or made to exiting systems, always check work to ensure that unintended hazards are not introduced or system, functionality is not lost.
- PHY-16-1206- Fractured Foot While Assisting with Lift in Hall B
Author: Ed Folts
Date of Event: 12-06-2016
1. Even if you have completed the same task multiple times you should always reevaluate your set-up, if not sure ask for an extra set of eyes before completing the task. This includes questioning the worst case scenario with co-workers that may perform similar tasks.
2. Ask questions when planning your work. This communication method gives other the opportunity to provide valuable nuggets of information.
- FML-16-1130-Refrigerant Detection System Disabled Following Discovery of a small Leak -Interim Mitigations were Less Than Adequate (LTA)
Author: Bob Sperlaaza
Date of Event: 11-30-2016
1. When planning our work, we should always prepare and mitigate for the worst case scenario. This will ensure that we have all the proper mitigations in place before we proceed.
2. Communication is the key. When a change in conditions occur, consult with all invested parties. This will ensure that all potential scenarios are covered and that invested parties are notified of the change in conditions. Consider a checklist when applicable or if notifications involve multiple groups.
- ACC-16-1003- Employee Failed to Properly Post a High Radiation Area and a Radiation Area
Author: Harry Fanning
Date of Event: 10-03-2016
1. Unique programs involving delegation of key functions outside primary program ownership should undergo periodic formal reviews to ensure scope of the delegated functions and skill set inventory remain well matched.
2. Subject matter experts (SMEs) should either conduct or provide close oversight of on-the-job training on safety-significant tasks.
- ENG-16-0829- Employee Shocked While Using a JLG Manlift- No Injuries
Author: Tina Johnson
Date of Event: 08-29-2016
1. Improper use of GFCI protection may lead to a lessened level of protection from an electrical shock. It was later determined that the wall outlet used to power the JLG 120 volt cord was not powered from a gfci protected circuit.If the JLG manlift was plugged into a GFCI protected receptacle initially, then the employee would have benefitted from both let-go protection and protection against fibrillation because of the 4-6 milli-amp trip limit on a class A GFCI.
2. Technicians need to know whether their test tool has a low input impedance or a high input impedance. Technicians also need to understand the advantages and disadvantages of each.
- ENG-16-0817- Minor Electric Shock from Milwaukee Heat Tool – Model 1400- No Injuries
Author: Todd Kujawa
Date of Event: 08-17-2016
1. Electric shock events, of any magnitude, occurring at Jefferson Lab must be reported followed by an immediate visit with Occupational Medicine.
2. When a tool is known or suspected to be defective, it must be tagged and taken out of service immediately.
- ENG-16-0726- Breach of a Radiological Area (Contamination and Radiation Area)
Author: Ken Baggett/ Keith Welch
Date of Event: 07-26-2016
1. Employees that have condcuted their work in the same manner for a long period of time should consider having another work group observe their work to ensure they are following the most current procedures and good work practices.
- ENG-16-0726- Shock Incident at the ARC1 Box Power Supply in the LERF- No Injuries
Author: Todd Kujawa
Date of Event: 07-26-2016
1. When an unexpected result/scenario is encountered; take time to stop the work and re-analyze the path forward.
2. When performing a design/operational review, made up of different components, make sure the system is reviewed as a whole.
- ACC-16-0714- LERF Brought to Beam Permit Without Requisite Authorized Personnel on Site
Author: Harry Fanning
Date of Event: 07-14-2016
1. When operational paradigms are changed, ensure supporting and governing documents are also updated to reflect changed conditions or reduce risk of compliance violation.
- FM&L-16-0623- HRSD Notice of Deficiency for Late Submittal
Author: Bob Sperlazza
Date of Event: 06-23-2016
1. Never assume that we will receive a pardon for sumitting a late report even if a pardon was granted the previous year.
- PHY-16-0531-Propane Torch Caught Fire Around Bottle Neck, Requiring Use of Fire Extinguisher
Author: Ed Folts
Date of Event: 05-31-2016
1. Although you may be semi familiar with a piece equipment (use it at home from time to time), you should consider investing a few extra minutes into re-familiarizing yourself with that equipment and recommended uses of the equipment before using it.
- PHY-16-0516- Brief Exposure to Pungent Odor(oil vapor), Results in Days Away
Author: Tina Johnson
Date of Event: 05-16-2016
1. Small tidbits of historical information about equipment and material used during a build may be helpful to others. Try to share this type of information with others.
- ES&H-16-0311- Radiation Area not Identified or Posted During Survey
Author: Keith Welch
Date of Event: 03-11-2016
1. When performing routine work, it is always best to revert back to the procedure to ensure that you are following every step as if you were a new employee.
- ACC-16-0308- Less than Adequate Posting of a Radiation Area Upon Completion of a Full Survey
Author: Harry Fanning
Date of Event: 03/08/2016
1. When performing a task and are interrupted, it is best to reassess the task before continuing to ensure all aspects will be completed properly.
- ACC-16-0303- Shoulder Injury During Disassembly Task- Require Surgical Repair
Author: Harry Fanning
Date of Event: 03/03/2016
1. To promote an atmosphere of inclusiveness and enhance overall employee engagement, and to encourage continued feedback within the organization, it is important to close the loop with personnel so they know their feedback is being handled, even if progress is slow.
2. Always stop and reassess scope creep to ensure all hazards are mitigated before continuing.
3. Always review tool usage during job specific hazard analysis to ensure worker safety. Ensure the right tool is on hand at the time of task performance and reassess hazards for any tool substitution before continuing work.
- ENG-16-0223- Tennis Elbow After Buffing Activities
Author: Tina Johnson
Date of Event: 02-23-2016
1. When in doubt, always report unexpected soreness, tightness or any other bodily reaction that may be attributed to your recent work activites to Occupational Medicine.
2. Case Management,Occupational Medicine oversight, is a great tool that can help assure that you remain helathy and return home in the same conditions as you arrived to work in.
3. Ergonomic hazards need to be identofoed in the planning stage to reduce the potential for injuries.
- PHY-16-0208- Lower Lumbar Strain While Moving a Rigging Attachment
Author: Ed Folts
Date of Event: 02-08-2016
1. Never assume the weight of infrequently used items, when in doubt have the items weighted and labeled so that you are aware and can be prepared for the lift.
- CIO-16-0201- Employee Received a Dog Bite While Attending an Off-Site Meeting
Author: Tina Johnson
Date of Event: 02-01-2016
1. If ever bitten by an animal, be sure to get the owner's name, address and telephone number as a precautionary measure.
- ES&H-16-0119 - Hampton Roads Sanitation District (HRSD)- Notice of Violation (NOV)
Author: Bill Rainey
Date of Event: 01-19-2016
1. There were no lessons learned developed as a result of this investigation.
- ENG-16-0104 - Employee Injuries Left Shoulder While descending a Ladder
Author: Paul Collins
Date of Event: 01-04-2016
1. Even when a task seems simple, maintain your situational awareness until that task is completed.
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