2023 NOTABLE EVENT / INCIDENT INVESTIGATIONS

 

ACC-23-1220: Failure to Comply with Posted Signage Results in Near Miss (Management Concern)
Date of Event: December 20, 2023
Lead Investigator: Rick Adrover
Lesson Learned:

  1. A policy, defining when it is acceptable to use general ATLis entries for work planning will be established along with additional expectations for ePAS use. Policy is to include levels of task review before work is performed.
  2. The pre-job checklist is to be revised to clearly define topic categories to be covered.
  3. A review of all standing, general ATLis entries are to be reviewed. Determine if they adequately define the work and identify all hazards.

ACC-23-1215: Near Miss in Main Cleanroom Drying Bay 4 (Management Concern)
Date of Event: December 15, 2023
Lead Investigator: Dan Gautier
Lesson Learned:

  1. Immediately inspect the condition of all Back-Tech Fixture Clamps, replace as required.
  2. Replace/retrofit the installation fasteners (threaded bolts) with bolts sized appropriately for the threaded holes in fixture and clamp plate, and include the addition of lock washers to the installation scheme. Use a thread locker such as Loctite on the threaded bolts.
  3. Develop and deliver the specific training for the use of the fixture clamps. As the appropriate fit of the clamps can only be gauged through sensory feedback, the training must include demonstration of both acceptable and unacceptable operation, as well as a concise "pre-flight" check/inspection of the condition of the clamp prior to loading. Training is to be provided as a "corrective one-off" for existing Cleanroom Technicians and as part of initial Cleanroom Proficiencies Training to new technicians.
  4. Revise the Cleanroom procedure to require the use of and specify the appropriate bolts, lock washers and thread locker for the clamp installation going forward. Address the proper use of the fixture clamps as a critical step and reinforce require that workers receive required training on what constitutes both "good" and "bad" conditions and adjustment results.
  5. Develop and implement a preventive inspection routine that includes the evaluation and assures the continued fitness-for-use of the Back-Tech fixture clamps. Evaluation must include an assessment of the integrity of the clamps' installation and operating mechanisms prior to use.

ENG-23-1208: LERF Vault Helium Leak (Management Concern)
Date of Event: December 8, 2023
Lead Investigator: Rick Adrover
Lesson Learned:

  1. Immediate action was to shut the valve and stop the helium loss.
  2. Conduct a review of the warmup and disconnect procedures, particularly where the cryogenics group interfaces with cryogen users, to ensure systems are in a continuous condition to support subsequent work without a loss of helium.
  3. Revise the warmup and the disconnect procedure to include the steps for positioning and controlling all valves to prevent helium loss.

FML-23-1201 - Service Subcontractor Punctures Finger During Routine Work
Date of Event: December 1, 2023
Lead Investigator: Shauna Cannella
Lesson Learned:

  1. Management, both the Technical Representative and Subcontractor, will express to workers the importance of using appropriate personal protective equipment (PPE) or other tools to grasp objects embedded in carpeting.
  2. The Technical Representative responsible for the subcontract, will conduct a hazard analysis of the tasks performed by workers and ensure appropriate controls (e.g.: appropriate personal protective equipment (PPE)) are develop and available for use during these tasks.
  3. The Technical Representative responsible for the subcontract, will conduct an extent of condition review to determine how prevalent it is for workers to use minimal protection when retrieving sharp items, to determine if this is an organizational deficiency.
  4. Appropriate personal protective equipment (PPE) and other tools are to be made readily available, at the point of use, to the worker.

PHY-23-1102: Hall A Beam Dump Filter Housing Unit Leak (Management Concern)
Date of Event: November 2, 2023
Lead Investigator: Priscilla Moseley
Lesson Learned:

  1. Reaction plans are to be developed and implemented in order to address subsequent leak events in the LCW system.
  2. An assessment of the use frequency and duration of the existing Tritium Monitoring and Disposal Units (TMDU), supporting the Beam Dump LCW systems, will be conducted to determine whether the operating parameters are in accordance with As Low as Reasonably Achievable (ALARA) principles.
  3. Cameras are to be installed in the interior of beam dump buildings to improve remote response, assessment and verification of interior conditions.
  4. Notification procedures for the LCW System will be developed to address and clarify protocols by which critical monitoring system alarms are transmitted, to whom, and any required actions.
  5. A viable supplier for pre-filter housing parts, considered operationally critical, vulnerable, or susceptible to failure, is to be contacted and an appropriate inventory of spare parts secured.
  6. A Failure Modes and Effects Analysis will be conducted to identify and prioritize improvements in the design and management of the Beam Dump Cooling LCW system.

ENG-23-1002 - Employee Injures Back While Driving Forklift
Date of Event: October 2, 2023
Lead Investigator: Dan Gautier
Lesson Learned:

  1. The employee immediately placed an orange safety cone on top of the pothole to warn others and submitted a work-order to Facilities Management to have the pothole filled. The following morning ES&H surveyed the area and Facilities Management filled the pothole.
  2. A comprehensive assessment of the Lab's roadway system is to be conducted to determine repair-prioritization. Repairs will then be performed in a timely manner to areas identified as high-priority and in a manner commensurate with reducing the consequence (injury from impact) of human error (i.e. driving over broken areas of road or potholes).
  3. A revised roadway maintenance regimen is to be developed that will address a proactive inspection frequency and method, condition categorization, repair prioritization, and program effectiveness evaluation for the Lab's roadways that do not adhering to established civil engineering practices regarding asphalt road systems.
  4. A proposal is to be provided to identify the resources needed to renovate the current roadways to achieve the level of current civil engineering practices regarding asphalt road systems. This will include an execution plan that would accommodate any constraints required by the CEBAF operations.
  5. An analysis of the feasibility of using pneumatic tires on forklifts, that have significant outdoor service; or recommendation of other changes to better absorb shocks from the roadway and protect the operator is to be developed.

ACC-23-0926- Employee Injures Finger Requiring Sutures
Date of Event:September 26, 2023
Lead Investigator: Dan Gautier
Lesson Learned:

  1. The group is to reevaluate planned task. Reconfirm that work is only to proceed when the scope, provided resources, and planned controls are confirmed to be correct. When unexpected or changed conditions are encountered, the expectation is to pause and adjust plans and confirm resource before proceeding.
  2. The group is to be provided gloves (PPE) that will afford some degree of protection from cuts, contusions and abrasions while still allowing as much sensory feel and dexterity as possible for use in situations requiring imprecise physical actions.
  3. Reconfirm that all members of the group have ready access to emergency contact information. (Jefferson Lab offers all employees laminated Integrated Safety Management Cards, which can be attached to the same device that carries their employee badge. The ISM Card contains important contact information, including the phone number for Occupational Medicine.)
  4. An evaluation will be conducted to determine the feasibility to implement an infrastructure (racks) upgrade that would appropriately accommodate the management of network computing components instead of utilizing legacy racks that are not designed for this purpose.

ACC23-0809 Injector Support Bldg. Breaker Incident
Date of Event:August 08, 2023
Lead Investigator: Dan Gautier
Lesson Learned:

  1. Jefferson Lab's Electrical Safety Committee and its ES&H Authority Having Jurisdiction for Electrical Safety will address the lab's policy on the maintenance of molded case circuit breakers.
  2. The Qualified Electrical Worker training curriculum will be updated to include content describing the effects of reduced sensory/motor skills associated with the use of various forms of electrical/arc-flash PPE.

CIO 23-0706MC Repeater Replacement Impacted Hall A, B, and C's Public Safety Band
Date of Event:July 06, 2023
Lead Investigator: Dan Gautier
Lesson Learned:

  1. Work was suspended in the effected halls until testing of the "Simplex" mode was verified by Emergency Services.
  2. The network of repeaters were classified as a life-safety system having a strict maintenance of configuration control established for the equipment/system.
  3. The remaining repeaters, across the site, were surveyed to ensure adequate radio support. Those that did not were scheduled for replacement with units compatible with Hall A, B, and C repeater(s).

ESH-23-0616 Tornado Warning Was Delayed Due to Mixed Interpretation and Messages (Management Concern)
Date of Event: June 16, 2023
Lead Investigator: Dan Gautier
Lesson Learned:

  1. Update procedure(s) to define who has the authority to revise the geographic zone(s). Verify annually that the zone(s) set up in the software are aligned with the zones(s) documented in the Tornado Notification Procedure.
  2. The current monthly tornado siren drills do not test the upstream functionality of the system. Update the protocols to ensure the system's consistent ability to effectively receive, process, and activate the tornado siren. Verify through some form of periodic testing procedure.
  3. Revise the Tornado Notification Procedure to include decision-making responsibilities for any scenario in which the flow of information or automated activation of warnings may malfunctioned or be otherwise inconsistent with a human's assessment of weather conditions.
  4. Implement a policy that requires all qualifying meetings, to begin with a safety brief that covers the actions to take in the event of specific emergencies (fire/evacuation, tornado warning).

ENG-23-0609 Non-Ionizing RF Radiation Exposure Exceeding the 20CFR851 Limit
Date of Event: June 9, 2023
Lead Investigator: Dan Gautier
Lesson Learned:

  1. Power was secured to the test stand and the unit was locked and tagged out during the investigation..
  2. The resiliency of the 13kW Klystron Test Stand system is to be increased via the application of more robust (or engineered) controls such as sensory warning devices (beacons/alarms) or interlocks.
  3. Contrary to the tendency in tool-box meetings to discuss work at a "skill-of-the-trade" level, the pre-brief meetings should be conducted with more rigor and with a greater focus on hazard awareness and mitigation. The supervisor developed a more robust pre-brief or toolbox meeting agenda/checklist template so important topics related to safety are provided to workers no matter their skill level.

ENG-23-0504 Employee Applied a LOTO Lock without the Proper Training
Date of Event: May 04, 2023
Lead Investigator: Dan Gautier
Lesson Learned:

  1. The MMG supervisor participated in the next Supervisory Academy to gain an increased understanding of the responsibilities and actions associated with ensuring work-team safety and the HPI tools available to facilitate that objective.
  2. The MMG supervisor developed and adopted the use of a Pre-Job Brief Checklist. The checklist provides a forcing function to ensure no details are missed because of assumptions and provides a verification of critical conditions to support a safe work plan.
  3. A documented process was developed that requires an administrative supervisor and a working supervisor to perform a review of the subject employee's Job Task Analysis to ensure any gaps in skill/qualification requirements associated with the temporary assignment are filled.

FML-23-0516 Employee Discovered Hazardous Energy While Conducting Work in Hall A
Date of Event: May 16, 2023
Lead Investigator: Dan Gautier
Lesson Learned:

  1. The supervisor was scheduled to participate in the Supervisory Academy training to provide an increased understanding of the responsibilities and behaviors to enforce compliance with procedures for teams who perform hazardous work.
  2. A Hazardous Energy Control Restart Process was initiated lab-wide to increase awareness that the potential for hazard energy is present even if all steps of a safety procedure are followed.

COO-23-0426 Unexpected Discovery of Hazardous Energy While Plugging in a Laptop
Date of Event: April 26, 2023
Lead Investigator: Dan Gautier
Lesson Learned:

  1. ESH Annual Orientation (SAF100) Training is to be updated to include failure modes associated with common electrical hazards that employees may encounter during the day.
  2. Inspection of electrical outlets will be included in the Safety Wardens' monthly inspection routine.
  3. An Extent of Condition inspection was performed on the floor receptacles throughout the site.

ESH-23-0414 Left Shoulder Strain Resulting in a DART Case
Date of Event: April 14, 2023
Lead Investigator: Dan Gautier
Lesson Learned:

  1. Developed an ergonomically appropriate procedure that allows the worker to perform a radiation survey without undue risk of injury.
  2. Established guidelines for workers to use to evaluate work governing the handling/manipulation of materials and equipment. The guidelines should be sufficiently broad to allow for application across a wide variety of situations and still allow for RCT in-field discretion and provide clear guidance on how a worker is to avoid undue risk of injury.

ACC-23-0407: Finger Injury resulting in DART Case
Date of Event: April 07, 2023
Lead Investigator: Daniel Caldwell
Lesson Learned:

  1. A toolbox talk will be created that covers how to select the proper tools for performing manual tasks; and how to determine the appropriate PPE for hand safety.

ACC-23-0321-Minor Chemical Exposure to an Employee's Forearm
Date of Event: March 21, 2023
Lead Investigator: Steve Smith
Lesson Learned:

  1. Provided new guidelines in applicable procedures, training and work practices to convey that all HF and H2SO4 equipment is to be assumed contaminated at all times.
  2. Determined consistent Personal Protective Equipment requirements for all chemical areas and within any modified work practices such as in the specific Operational Safety Procedure, including that lab coats are to be worn regardless of cleaning status.
  3. To ensure there would be no contamination going forward the requirement will be added to wash down fume hoods with water, dry with chemwipes, then re-wet and test surfaces, and log results..

ESH-23-0120-Discovery of A Condition Denoting Radiological Area Outside of Posted Area
Date of Event: January 20, 2023
Lead Investigator: Steve Smith
Lesson Learned:

  1. Institute secondary review of survey forms prior to allowing access to beam enclosures
  2. Re-train accelerator crew chiefs in survey review criteria and thresholds, to ensure reviews include compliance with regulatory requirements.
  3. Investigate implementation of automated tools (software) to capture real time survey data, including QA checks and flags.