2022 NOTABLE EVENT / INCIDENT INVESTIGATIONS

PHY-23-1019 - A Rubber Hose Connection Burst While Tests Were Underway
Date of Event: October 19, 2022
Lead Investigator: Dan Gautier
Lesson Learned:

There is a strong possibility of a Latent Organizational Weakness concerning quantity of work and available resources. Specifically, "time pressure" is a consistent latent condition. Therefore, the lab as a whole will investigate whether time-pressure or oversubscribed resources is a problem and to what extent (breadth and depth) it exists.

Ensure all rails being used to transfer strings throughout the Lab are equipped with hand rails to assist in guiding the speed and maneuverability of the string, as well as ensuring the safe distancing of employees away from string wheel paths
During string movements, ensure that all team members have a clearly defined role to fulfill in order to encourage stronger focus amidst potential chaotic situations and changed environments.
Ensure that string movements have a formal pre-brief process with all groups involved in the move to ensure all participants have a clear understanding of their role.

Ensure that all planned moves involving RAM are identified during daily work planning meetings and reported timely to RadCon.
Ensure that RAM moves are being adequately and timely communicated with RadCon.

PHY-22-0825: Elevated Work in the Test Lab High Bay was Paused
Date of Event: August 24, 2022
Lead Investigator: Dan Gautier
Lesson Learned:

Follow the Work Planning, Control, and Authorization process, requirements and procedures to ensure worker safety.
The educational training program needs to be strengthened to ensure competencies and enforce ownership of the responsibilities and accountability for worker safety on the part of the front-line supervisor.
The training curriculum of SAF302 Aerial Work Platforms needs to be reviewed and revised to strengthen its coverage of situations when exiting/accessing a scissor lift at elevation may be necessary. A "targeted" communication will be sent out to all qualified Aerial Lift operators summarizing the revised content.

FML-22-0810: Employees Observed Working Without Proper Fall Protection
Date of Event: September 10, 2022
Lead Investigator: Dan Gautier
Lesson Learned:

Ensure the work planning system includes the work planning control and authorization process for all work activities, and not a replacement for it.
Classification of work as "urgent/emergency" is not a recognized exemption from using the formal work planning control and authorization process.

FML-22-0511: SRF Safety Shower Systems Failures
Date of Event: May 11, 2022
Lead Investigator: Dan Gautier
Lesson Learned:

Do not allow inventive solutions spill over into systems that do not require novel solutions. While unavoidable in the support of research applications, novel, homegrown solutions do not typically operate with the reliability required by life-safety control system..

CST-22-0414 Recent Emergency Communications Failures
Date of Event: April 14, 2022
Lead Investigator: Dan Gautier
Lesson Learned:

When emergency notification system(s) rely on human support, the rigor with which code modifications are analyzed and validated should be expanded. Employ HPI tools such as Peer Review, SME Consultation and Independent Review to validate functionality.
Program initiators need to remember that the amount of change to system’s coding, performed between “event-free” periods, is directly correlated to the level of potential system failure during an actual event. If changes have been made, results should be monitored accordingly to ensure reliability.

PHY-22-0328: Odor Detected in Test Lab High Bay Area
Date of Event: March 28, 2022
Lead Investigator: Dan Gautier
Lesson Learned:

The format of the High Bay Area’s Task List Form did not prompt the author to disclosure the potential for emissions/fumes. "Poor Ventilation" was only addressed in the context of a “confined space” hazard.
Prior to work, Task List entries are reviewed for ESH hazard by a single resource. Their role is to screen and seek input from other ESH SMEs, as needed.
Due to the configuration of the High Bay and the roped off boundary work area, the posted Task List was not readily visible to those searching the area for the source of the odor.

When entering an enclosed spaces be aware that disturbed dust and debris particles may become airborne, particularly where ventilation fans and mechanisms with moving parts operate.

FML-22-0302 Notice of Violation from Hampton Roads Sanitation District
Date of Event: March 2, 2022
Lead Investigator: Steve Smith
Lesson Learned:

Requirements for meter configuration and the associated calibration procedures were not adequately documented in a formal process. Prior to leaving the Lab, the individual responsible for the activities did not transfer the responsibility.

FML-22-0216: Employee Sprains Right Wrist While Loading a Property Truck
Date of Event: February 16, 2022
Lead Investigator: Dan Gautier
Lesson Learned:

The design of a truck's flat-bed ladder, specifically that it lacked handholds to aid ascent/descent provided less than optimal ergonomic stability of an individual during use.
Experience in the overall assigned task and past success with negotiating the climb and descent on the ladder contributed to confidence that the elevated risk created by the sub-optimal design was mitigated.

ESH-22-0203: Disconnected Circuit Board shocks Radiation Control Surveyor
Date of Event: February 3, 2022
Lead Investigator: Steve Smith
Lesson Learned:

Electrical safety training did not include steps to ensure that all stored energy be dissipated from equipment prior to disassembly, and after disassembly to store equipment in a static proof bag (as able) during transport.
An extent of condition review was performed to identify similar MDR-10 series power supplies which could be susceptible to a similar failure mode.

FML-22-0122: Employee Strains Back Muscles While Lifting Bags
Date of Event: January 22, 2022
Lead Investigator: Dan Gautier
Lesson Learned:

Develop and implement a structured Snow Removal Team Pre-Brief Meeting Agenda that will prompt effective two-way discussion between the snow removal team members and the supervisor. Include discussion regarding planned activities, changed conditions, and any associated risks stemming from these activities and conditions.
An ergonomic risk assessment, including the potential for injury when manually lifting an over 50lbs weight to specific heights, and a formal procedure to mitigate the risk, should be provided.