2021 NOTABLE EVENT / INCIDENT INVESTIGATIONS

<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/FML-21-0825.pdf">FML-21-0825- Unsecured Gate Results In An Accelerator Safety Envelope Violation</a> 
Date of Event: August 9 & 10, 2021 
Lead Investigator: Daniel Caldwell 
Lesson Learned:
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<li>Follow all posted Radiation Control signs on gates and barriers, review the RWP before entry and wear supplemental dosimetry whenever required.</li>
<li>Safety significant administrative controls require rigorous protocols and strict adherence to procedure.</li>
<li>Engineered controls or fail-safe processes should be used whenever feasible for credited controls.</li>
</ol>

<a href="https://misportal.jlab.org/railsForms/notable_events/122864">ACC-21-0818 Waste Acid Production</a> 
Date of Event: August 18, 2021 
Lead Investigator: Daniel Caldwell 
Lesson Learned:
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<li>Accelerator Division and ES&H reviewed all Superconducting Radiofrequency (SRF) work processes involving RAM and are to develop procedures for handling waste acid to ensure appropriate disposal selection. </li>
<li>The facility that receives and incinerates Jefferson Lab waste acid was notified of the potential that past shipments may have contained mixed waste.</li>
<li>Both batches of acid waste on site were segregated, precautionarily labeled and analyzed. Based on our release protocols, these batches would meet release criteria as indistinguishable from background (IFB). Based on sample activity to dose rate ratios, it is estimated the activity in previous waste batches (perhaps half, on average) would not have met IFB criteria and should have been designated radioactive. </li>
</ol>

<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/ACC-21-0809.pdf">ACC-21-0809- Employee Received 120 Volt Shock While Unplugging Equipment</a> 
Date of Event: August 9, 2021 
Lead Investigator: Daniel Gautier 
Lesson Learned:
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<li>It is poor practice to place unprotected (non-weather or water tight)electrical connections near areas subject to water or condensation sources. While not explicitly required by National Electric Code; design engineers, installation technicians and electrical inspectors should recognize the additional hazards surrounding an electrical install and use best practices to protect the workers.</li>
<li>Never touch energized electrical devices if you see or suspect water or other liquids might be present and form a conducting path.</li>
</ol>

<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/PHY-21-0721.pdf">PHY-21-0721- Student Receives two 120V Shocks -No injury</a> 
Date of Event: July 21, 2021 
Lead Investigator: Steve Smith 
Lesson Learned:
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<li>A student received two 120V shocks because a Cannon-plug lock-ring was installed incorrectly by the manufacturer and did not "lock" the plug into place. Instead the lock-ring could rotate and the "hot" channel could be inserted into the "ground" channel and energize the crate. The discovered defects were not visible at the time of the incident.</li>
</ol>

<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/FML-21-0623.pdf">FML-21-0623- Security Guard Lower Back Pain/ Days Away</a> 
Date of Event: June 23, 2021 
Lead Investigator: Steve Smith 
Lesson Learned:
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<li>There were no lessons learned identified during this investigation</li>
</ol>

<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/FML-21-0302.pdf">FML-21-0302 Right Arm and Shoulder Soreness DART Case</a> 
Date of Event: March 02, 2021 
Lead Investigator: Steve Smith 
Lessons Learned:
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<li>Consider the potential for changed conditions, i.e., multiple lifts of equipment from floor to shoulder height, in work planning.</li>
<li>Perform stretching and warm-up activities prior to lifting heavy objects.</li>
</ol>

<a href="/sites/default/files/ENG-21-0125.pdf">ENG-21-0125- Repetitive Work Injury to Employee</a> 
Date of Event: January 25, 2021 
Lead Investigator: Steve Smith 
Lesson Learned:
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 <li>Any change in the type or usage of machinery, tools, or even standard office equipment that involves repetitive motion requires a thoughtful evaluation of the ergonomic impact by the employee and supervisor. Adjustments in work or the use of additional controls may be required to prevent repetitive motion injury. Consult Occupational Medicine if you need assistance in evaluating ergonomics.</li>
 <li>Early reporting of discomfort can lead to effective case management and the development of a preventative plan that includes the even distribution of tasks within your workgroup</li>
 <li>COVID-19 safety controls can have unintended consequences and should trigger reassessment of work practices by employees and supervisors.</li>
</ol>

<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/ENG-20-1215.pdf">ENG-20-1215- Heat Exchanger Tube Bundle Procurement</a> 
Date of Event: January 14, 2021 
Lead Investigator: Daniel Caldwell 
Lesson Learned:
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<li>Full payment was made for a high value item that was not properly inspected prior to acceptance. Investigation revealed that the Lab's tangible material receipt and payment procedures allow payment prior to completion of a comprehensive, complete inspection. </li>
</ol>

<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/ENG-20-1014.pdf">ENG-20-1014- Failure to Identify and Apply LO/TO on Potential Energy Source</a> 
Date of Event: October 14, 2020 
Lead Investigator: Ken Baggett 
Lesson Learned:
<ol style="padding-top: 0px; margin-top: 0px;">
<li> Improve effectiveness of work planning and integration for jobs with pre-mitigated risk codes >/=3 and implement temporary improvements to task list systems that ensure proper alignment and effective use of ES&H Manual required work control documents per 3210 T1 Section 4.2. </li>
</ol>