Notable Events / Lessons Learned
2012 Notable Event / Incident Investigation Worksheets
- ACC-12-0324 - Unposted Radiological Area Near-Miss
Author: Gina Roemer
Date of Event: 03-24-2012
1. Communication of valuable knowledge obtained from a similar past event was not shared with the new ARMS.
- ACC-12-0302 - CEBAF Center F- Wing Doorway Fall
Author: Todd Kujawa
Date of Event: 03-02-2012
1. None were determined for this particular event.
- FML-12-0223 - EWB Solenoid Valve Failure
Author: Richard Jacobsen
Date of Event: 02-23-2012
1. When more than 1 subcontractor is involved in a project, it is necessary to have a meeting with all the contractors at one time so that all parties are informed of the necessary steps and time lines needed to complete the task.
2. Ensure that all contractors are completely aware of the steps and time necessary to complete their portion of the project by having them repeat back instructions to verify that they understood the directions.
3. Always check and follow the manufacturer's recommendations.
- TEDF-12-0217 - Fall From the Hydromobile Ladder
Author: Keith Royston
Date of Event: 02-17-2012
1. Be mindful of environmental changes that affect your work area. Be sure to stop your work and reassess your work environment before your restart your work.
- FEL-12-0214 - Access Allowed into FEL Vault under Laser-Bypass mode without proper Training and PPE
Author: Harry Fanning
Date of Event: 02-14-2012
1. Better communication is needed to all parties involved with an access into exclusion zones especially during infrequently run and/or specialized access procedures.
2. When performing tasks which utilize human interface as administrative safeguards, distractions should be held to a minimum to avoid human error.
- ENG-12-0208 - Right Arm Injury During Equipment Move
Author: Andrew Kimber/ Henry Robertson
Date of Event: 02-08-2012
1. Planning work activities in crowded situations should include participation from all groups that are expected to be in close proximity to the ongoing effort. This should include discussion of special space requirements and potential hazards.
- ACC-12-0202 - Unauthorized Access to the North and South Linac Service Buildings
Author: Steve Suhring
Date of Event: 02-02-2012
1. Consider using Radiation Control Department (RCD) postings when roll -up doors provide a point of entry that is not normally available.
- ENG-12-0120 - Finger Cut on Band Saw
Author: Henry Robertson
Date of Event: 01-20-2012
1. Pre-task planning plays a vital role in site safety.
- FML-12-0110 - Laceration to the Left Shin
Author: Richard Jacobsen
Date of Event: 01-10-2012
1. This incident reminds us to be on the lookout for potential injury sources at all times at work. Small things that have been in existence for years and not detected can become a hazard.
- ACC-12-0104 - Splinter in Finger
Author: Brian Carpenter
Date of Event: 01-04-2012
1. Be aware that when environmental conditions change during the course of performing work, there is a corresponding need to reassess the PPE requirements.
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