Type: Lessons Learned
Publisher: Pacific Northwest National Laboratory (Richland WA), Richland, WA (PNNL)
Published As: Public
The PM had been in a hurry while troubleshooting as he had a flight to catch. He wanted the system to be operational before he left so it could be used by other staff who would continue to test the system in his absence.
In this Lessons Learned article, you'll read about how time pressure, a lack of hazard recognition and established controls, and communication challenges combined with a system that was not yet fully operational to lead to this event.
You must be logged in to open the attachment.Download Article