2017 Notable Event / Incident Investigation Worksheets

2017 Notable Event / Incident Investigation Worksheets

• FML-17-1012- Starter Fire Occurred in CHL1 C6 Motor Control Center
  Author: Steve Smith
  Date of Event: 10-12-2017
  * No specific lessons learned were identified during this investigation. Please read the report for further details.

• FML-17-1004- CHL Roof Conduit Pierced, Causing a Loss of Power to CHL1 4.5K Controls
  Author: Celia Whitlatch
  Date of Event: 10-04-2017
  1. Plan / coordinate future outages with Operations and Engineering to better utilize planned Accelerator down time.

• FML-17-0927- Breaker Failure Occurred Causing Emergency Power Outage
  Author: Paul Powers
  Date of Event: 09-27-2017
  1. A complete and accurate list of systems that run on emergency power breakers including the accurate list of personnel that will be contacted in the event of a power outage was not in place during the event outlined in this report.

• ENG-17-0725- Inadequate Fall Protection in Central Helium Liquifier (CHL)
  Author: Henry Robertson
  Date of Event: 07-25-2017
  1. When delegating work to your subordinates, it is imperative that your employees are fully aware of what is expected of them in their absence, specifically safety related hazards (fall protection, chemicals, etc.).
  2. When making changes to manual chapters be mindful of the possible adverse ripple effect that may occur with other chapters, processes and systems.

• FML-17-0707- Three Foot Long Abandoned Metal Pipe Burning with No Obvious Source
  Author: Paul Powers
  Date of Event: 07-07-2017
  1. When there is an emergency situation - outdoors, call 911 and get Emergency Services moving. Contact the Guard Post and alert them so that they can direct Emergency Services to your location.
  2. Do not bring hazardous materials(A hazardous material is any item or agent (biological, chemical, radiological, and/or physical), which has the potential to cause harm to humans, animals, or the environment, either by itself or through interaction with other factors) on DOE property, without consulting Industrial Hygiene.

• FML-17-0509- Unauthorized Personnel Transported a DOT Hazardous Material Shipment
  Author: Kris Burrows
  Date of Event: 05-09-2017
  1. It is imperative that you rely and utilize our Subject Matter Experts (SMEs) at all times , or make sure that you have adequate training when making such decisions.
  2. If there are differing professional opinions, it is vital that you stop, reassess the circumstances, identify the objectives and have a collaborative meeting among all involved including the appropriate subject matter experts to develop a new plan of action.
  3. Schedule pressure does not mean that one should become a "hero", bypassing rules and regulations in order to meet a deadline.

• ENG- 17-0419- Employee Falls and Injures their Leg which Results in Sutures
  Author: Nate Laerdure
  Date of Event: 04-19-2017
  1. Employees should maintain situational awareness at all times, especially when working in an area that has multiple congruent hazards.

• ES&H-17-0307- Failure to Secure a Credited Control (building 95 gate) while in "Beam Permit"
  Author: Keith Welch
  Date of Event: 03-07-2017
  1. Individual system owners may not anticipate effects of their modifications on the overall operation of a multi-component process. Project managers and geographic integrators should harmonize development of system-wide performance tests.
  2. Caution should be used when addressing multiple specific requirements such as ASE credited controls and regulatory compliance controls with the same mitigation (i.e. locked gates/doors). When the conditions for applying the control are not identical for the two requirements, and non-failsafe methods are used, the likelihood of error increases.

• ENG-17-0103- Electrical Spark and Power Loss Caused by Leak During Magnet Power Supply Cooling System Flush
  Author: Todd Kujawa
  Date of Event: 01-03-2017
  1. Best practice not followed when energizing a pressure system after maintenance work has been done: “Caution shall be exercised when energizing a system following maintenance work. The system shall be energized by personnel trained in the safe operation of the system. The integrity of all disassembled components shall be considered untested until an informal in-service leak test is performed.” [Pressure and Vacuum Systems Safety Supplement Part 8: Operation and Maintenance].
  2. Jefferson Lab investigates ‘events’ in order to implement corrective and preventive actions to avoid recurrence. To ensure an adequate investigation is performed, after assuring equipment is in a safe condition and hazards are mitigated, the affected area/equipment must be preserved. This may include cordoning off the area and taking preliminary photographs so that sufficient data is collected to ensure an accurate casual analysis is done.