Type: Lessons Learned
Publisher: U. S. Department of Energy, Office of Fossil Energy
Published As: Public
Some of the same deficiencies that had contributed to two worker fatalities were once again found to be present, despite having been reported as corrected less than two years before. This sobering realization continues to challenge SPR management to provide more effective and sustainable controls.
Lessons Learned: Independent corrective action effectiveness reviews must be conducted of all corrective actions from previous accident/incident reports to measure their current effectiveness regarding oversight, training, stop work, and lessons learned.
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