Mechanics Design Machine Guard to Protect Themselves during Fire Pump Adjustments

A fire pump adjustment requires two mechanics to simultaneously tighten a pair of hex nuts, one on either side of a rotating shaft, to ensure even distribution of the gland. However, to make the adjustment, the shaft must be in operation. There are no built-in safety guards on the pump to prevent mechanics from getting tools, or even body parts, fr...

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Subcontract Employee Engaged Fall Protection

At the Materials and Fuels Complex, a subcontract employee was placing floor decking on the second floor of the Research Collaboration Building when their retractable lanyard slightly locked up causing the employee to lose their balance. The employee fell approximately 4 feet through a gap in previously placed floor decking and was arrested by thei...

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Foam Tank Spill during Demolition Due to Inadequate Draining and Verification

Prior to size-reduction activities of a 1200-gallon firefighting foam tank, and based on the evidence available, it was determined that the tank was empty. During size-reduction activities, foamy liquid began running onto the ground.
Lessons Learned: Vessels open to atmosphere and marked "Empty" can still contain material. During the draining,...

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Security Concern Involving Foreign Nationals and Remote Computer Access Protocols

INL personnel allowed a Foreign National from a sensitive country to access an INL computer via a remote video conferencing and desktop sharing session through This access was given without a required and approved security plan in place. As a result, this incident was determined to meet the criteria for an Incident of Security Con...

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Freeze Protection Not Adequately Implemented Leads to Failure of Process Piping Components

The early onset of the cold weather without freeze protection fully installed led to freezing of the process system piping. This condition caused failures of numerous components such as valves, fittings, instrument sensing lines, etc. Furthermore, additional damage resulted from the loss of heater(s) main power during a lower temperature period....

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A Users Guide to Preventing Major Accidents

"A Users Guide to Preventing Major Accidents" presented at the 2014 Nuclear Facility Safety Programs Workshop, May 7, 2014 by Peter S. Winokur, Chairman Defense Nuclear Facilities Safety Board.
Lessons Learned:
Cost of safety is small compared to cost of accident
Nuclear events and accidents have disproportionately larger impacts on mission that...

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Oakland East Span Bay Bridge Lessons Learned

In the increasing need for larger and more complicated projects, a valuable amount of data is available in lessons learned from prior projects to support the execution of existing and planned projects. The 1989 Loma Prieta earthquake initiated the California Department of Transportation replacement or retrofitting of more than 2,000 bridges in the...

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The Safe Conduct of Research - Cobalt-60 Source Transfer

Battelle's Safe Conduct of Research (SCoR) principles form the foundation of PNNL's safety culture. In the third in a series of videos examining these principles in action, a PNNL project team tasked with the planning, procurement, and receipt of a highly radioactive source of Cobalt-60 shares how the SCoR principles inform their work.
From maint...

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INL Forklift Lessons Learned Video

Recently INL experienced multiple forklift events at different facilities with in a weeks time frame. This video discusses those events and the initial lessons learned from them.

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Peer to Peer Accountability / Teamwork: Heat Stress

Video demonstrating teamwork and worker understanding when dealing with Heat Stress on the job

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Vehicle Security Barrier Accident

This video summarizes an accident that occurred when a delivery truck driver was struck in the back of the leg by a descending active vehicle barrier which caused significant injury to the drivers lower leg. The Security Police Officer, who was processing the driver through the Vehicle Monitoring Facility, lowered the barrier without first verifyin...

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Review of Operating Experience Results in Process Improvement

In preparation for an upcoming core internals change out outage at the Advanced Test Reactor, a team of personnel reviewed past core internal change out reports for information to improve performance. During this review, it was noted that the tool used for removing the right hand beryllium blocks was very difficult to set up and operate. In Additi...

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