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04/19/2018

Suspect Bolt Modified by Manufacturer to Meet ASTM Requirements

An alert receiving inspector was inspecting an order of incoming bolts when his questioning attitude made him take note that the ASTM A320 Grade L7M bolts had both raised and indented letters indicating the grade. The "L7" was raised and the "M" was engraved. The manufacturer was notified and stated that the bolts had been modified to meet L7M and...

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04/19/2018

Transfer of Responsibilities/Authorities for Safety Significant Roles

Initiate an orderly transfer of responsibilities for safety-significant roles. Without establishing an orderly transfer of responsibilities newly appointed individuals may fail to understand and fulfill all role responsibilities. When staff or facility changes occur, incomplete transfer of role responsibilities has led to lapses in oversight and...

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04/18/2018

PNNL Staff Member Shoots Nail Through Hand While Building House

A PNNL staff member recently shared a story about building a house on evenings and weekends while also working full-time for a Hanford contractor. He says he made several poor decisions that led to him shooting a three-inch nail into his hand with a nail gun, and is sharing his story so others might think twice before making a decision that causes...

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04/17/2018

Schneider Electric Recalls Square D Safety Switches Due to Electrical Shock Hazard

This recall involves Square D brand General Duty 30 & 60A, 120/240-volt, 2-phase and 3-phase NEMA 3R safety switches. The switches are a dark gray metal box with a black handle on the side that can be moved to an "ON" or "OFF" position. Consumers should immediately inspect installed safety switches by moving the handle to the "OFF" position. The po...

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04/27/2015

Two Workers Electrocuted when Boom Crane Contacts 7,200 Volt Overhead Power Line

On the day of the incident, a material handler rigged a propane tank with a metal chain so that it could be lifted by the crane. The tank was located at the end of a row of 320-gallon capacity tanks adjacent to a fence marking the yards boundary. Just beyond the fence, a 3-phase 7,200 volt overhead power distribution line, crossed over into the yar...

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05/12/2015

Employee Ignores Peer Pressure and Reports Safety Concern

An employee performed a safety intervention with a co-worker who crossed a lockout/tagout boundary without complying with the required hazardous energy control process. The co-worker resisted the safety intervention and encouraged the employee to ignore their concern. Disregarding the peer pressure, the employee notified management and a stop wor...

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01/09/2017

Evaluating the Use of Sit to Stand Workstations

As a result of an article published in April 2015 by the U.S. Department of Energy Office of Environment, Health, Safety & Security titled "Health Hazards of Prolonged Sitting," an increased installation of Sit to Stand Workstations occurred at Nevada National Security Site. To determine if or how users benefited from the installation of the Sit to...

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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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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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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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01/31/2018

Safe Conduct of Research: A Healthy Respect for What Can Go Wrong

Battelle's Safe Conduct of Research (SCoR) principles form the foundation of PNNL's safety culture. In the second in a series of videos examining the principles in action, PNNL Coastal Sciences Researcher Shon Zimmerman discusses how he maintains a "healthy respect for what can go wrong". Zimmerman got himself, another staff member, and the researc...

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01/15/2018

Critical Knowledge inSight: Beware of Complacency

In this video, William Gerstenmaier, NASA Associate Administrator for Human Exploration and Operations, discusses the dangers that complacency can cause on a mission or project. He discusses a specific example where water entered an astronaut's space helmet during a spacewalk and caused a dangerous situation. The same problem with water in the helm...

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01/23/2018

Identified Suspect/Counterfeit Bolts on Ratchet Tie Downs

Acting on a Department of Energy Operating Experience Level 3 Document on Suspect/Counterfeit Items and an OPEXSHARE report, URS / CH2M Oak Ridge conducted site-wide surveillances specifically designed to identify any suspect bolts associated with the use of ratchet straps. During surveillances, four legacy ratchet tie downs were discovered at the...

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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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