Ungrounded Short Discovery in Process Technology HTX Series Heater

An arc that resulted from the inadvertent contact between a ratchet and the casing outlet box (part of a Process Technology HTX Series immersion heater assembly) led to the discovery of uncontrolled hazardous energy. The immersion heater was used to maintain sump temperatures on a Sludge Stabilization Chemical Scrubber tank. The investigation has...

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Employee Injured Operating a Handheld Drill

A construction carpenter was preparing 2x4 boards to be installed at the new Central Facilities Area Live Fire Shoot House. This preparation consisted of drilling a series of holes in each board. As the carpenter was performing this action the drill bit got tangled in one of his cut resistant gloves, and pulled his finger into the spinning drill bi...

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Overhead Object Falls from Bridge Crane Striking Worker Below

Performing overhead/elevated work requires that all personnel working in the immediate vicinity be briefed on all work evolutions taking place in the area, that tools and materials used for overhead work are properly secured, and workers remain vigilant of the overhead hazards. Two individual work crews were performing maintenance on an overhead cr...

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Supervisor Dies When Struck by Falling Clothing Bales

A supervisor at a used clothing processing facility died when she was struck by falling bales of used clothing. On the day of the incident, a forklift operator was stacking bales of used clothing in a storage area against beside other stacks of bales. As the victim was walking by the new bales that were stacked six high, four bales fell from the t...

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Situation Awareness - Preventing Injuries, Accidents, and Property Damage

Situation awareness was the common factor leading to vehicle accidents, personnel injuries, and property damage. The majority of the vehicle accidents were due to a lack of situational awareness by vehicle operators. The majority of the personnel injuries were due to situational awareness- employees not watching what they were doing or poor decisio...

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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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Inadequate Freeze Protection Leads to Piping Failures

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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Lessons from Hydrogen Fire and Explosion in Unattended Experiment at PNNL

On September 30, 2018, a fire and minor explosion occurred in a laboratory in Pacific Northwest National Laboratory's Physical Sciences Laboratory building. While damage to the experimental equipment was significant, the damage to the lab itself was minimal. Over the course of an investigation and causal analysis, much was learned.
PNNL managemen...

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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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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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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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Mechanical Door Failure Operating Experience Prevents Possible Injury

After receiving and sharing OE-3-2014-03, "Mechanical Door Failures," in March of 2015, measures were put into place at the Idaho National Laboratory to ensure that employees were not in the direct line of fire in case of door failure. On October 26th, 2015 the measures prevented personnel from being injured when a overhead door sprocket came loo...

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

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.

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