New
12/13/2018

Communication Issues Following Personnel Contamination at an Offsite Work Location

After performing visual verification on waste materials at an Offsite Waste Generating Facility, two CHPRC Waste Acceptance personnel could not clear the Personnel Contamination Monitors upon exiting the Radiologically Controlled Area. Assumptions in communications and follow up response led to delays in follow-up personal surveys and conflicting...

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12/07/2018

Deeper Dive Detects Suspect Hardware

A refurbished electrical automatic transfer switch from a third-party supplier arrived without the wiring diagram or owner/maintenance manual. The engineer involved in this procurement communicated directly with the original equipment manufacturer. This resulted in the hardware being identified as a suspect/counterfeit item before it could be place...

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12/05/2018

Fluke Recalls Two-Pole Voltage Testers

Fluke Corporation has identified a safety issue affecting certain Fluke Two-Pole Voltage Testers. As a precautionary measure, Fluke has voluntarily recalled all of these products and provide affected customers with new and improved equivalent replacement products. A false negative may lead to electric shock or arc flash from subsequent user action...

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12/05/2018

Retractable Wall Stanchions - When Cones just Won't Work

During an emergency hazard cones were to be placed at the entry and exit points outside a Chemistry Room to divert pedestrian traffic. During an actual emergency pedestrians would have time to enter the potentially contaminated hallway while cones were being retrieved. Wall Mounted Retractable Stanchions were proposed to more quickly divert pedestr...

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06/19/2014

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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05/16/2018

Hackers, Scammers, and Skimmers! How to Fight Back Against Credit and Debit Card Fraud at Work and Home

Credit and debit card "skimming" and "shimming" are in the news often these days as thieves continue to get more sophisticated with equipment that steals your card numbers as you make point-of-sale purchases. Recently a PNNL staff member's personal debit card was compromised and another staff member's corporate card was charged for plane tickets an...

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05/29/2014

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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03/21/2017

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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10/27/2017

Safety Differently

Work has never been as safe as it seems today. But bureaucracy and compliance demands have mushroomed, including many imposed by organizations on themselves. And progress on safety has actually slowed to a crawl. Bureaucracy and compliance impose performance drag on our organizations, and rob us of precisely the sources of human insight, creativity...

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04/11/2018

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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09/07/2018

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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03/19/2018

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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03/15/2018

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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Best Practice
Inculdes Good Work Practices developed by the DOE Operating Experience Community.

DOE OPEX
DOE Corporate Operating Experience Program Documents: OE-1, OE-2, OE-3, Operating Experience Summaries, Suspect/Counterfeit/Defective Items, Data Collection Sheets, and ORPS Summaries/Final reports.

Just-In-Time Reports
Reports issued to communicate brief examples of problems and mistakes encountered in actual cases and to present points to be consider for avoiding similar occurrences.

Lessons Learned
Articles on identified program/mission specific lessons learned across the DOE complex and from external entities.

Product Recalls and Alerts
Information related to products that have been formally recalled either by a defined company or in conjunction with the consumer products safety commission.

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