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					                                                                                                                                            LL Initial Review

                                  Bungee
              Item #     Date                               2012-BNL-Bungee-0001)                              OQBP LLC (ERV, JFM) Initial Review Comments      Date   MSLLC or MPLLC Initial Review Comments   Date   MS/MP (Area) Initial Review Status
                                  1. Enhanced Camera System Improves Efficiency of Remote D&D
                                  Activities(Source: User Submitted - ID: PMLL-2010-BNL-ARRA BGRR-0001)

                1      12-Jan-11 Decisions on remote camera system quality and placement need to
                                  consider the benefits provided by close-up views of remotely operated
                                  equipment. Enhanced monitor quality can help quickly diagnose
                                  equipment problems and also improve efficiency of equipment
                                  operations.
                                  2. Remote Monitoring Enhances Effectiveness of BGRR Radiological
                                  Protection(Source: User Submitted - ID: PMLL-2010-BNL-ARRA BGRR-0002)
                2      12-Jan-11 The use of commercially available telemetry systems for remote
                                  monitoring of worker radiological dose, when coupled with a camera
                                  system, can significantly improve a project's radiological oversight
                                  and ALARA performance.
                                  3. Contractual Performance Based Incentives (PBI) Alignment(Source: User
                                  Submitted - ID: PMLL-2010-WIPP-WIPP ARRA Project-0001)
                3      12-Jan-11 Generator sites priorities were modified to ensure acceleration targets
                                  could be achieved. Determine target PBIs collectively when
                                  considering multiple sites and multiple contract incentives. Alignment
                                  of target PBIs was not completed before waste acceleration program
                                 4. Innovative Acquisition Strategy Leads to Significant Efficiencies and
                4      12-Jan-11 Savings(Source: User Submitted - ID: PMLL-2010-LANL-TA-21 D&D-0001)
                                  Innovative acquisition strategy leads to significant efficiences and
                                  savings
                                  5. Six Sigma Process Improvement Projects for Drilling IDW(Source: User
                                  Submitted - ID: PMLL-2010-LANL-GW Wells-0002)
                                 Conduct initial review of project risks as early as possible during
                5      12-Jan-11 project planning. High risk activities should be identified early and
                                 mitigated during project planning, before the PMB is submitted. The
                                 risk identified was slow completion of waste disposition. The risk
                                 mitigation was to initiate a six sigma process improvement project at
                                 the beginning of the well installation project to address this problem
                                  6. Communications - Incorporated All Stakeholders in Project Progress
                                  (EAC, REAs) and Oversight(Source: User Submitted - ID: PMLL-2010-
                6      12-Jan-11 Best Practice: Establish and maintain meaningful stakeholde
                                  interactions. Coordinate and communicate often. Continually monitor
                                  contractor EAC and challenge assumptions. Maintain vigilance in field
                                  7. Close Coordination Allows Shipping Success and Accelerated
                                  Schedule(Source: User Submitted - ID: PMLL-2010-NTS-NTS RA Project-
                                 Significant inspection and certification criteria area required for
                7      12-Jan-11 transportation and disposal of radioactive waste. Because of the
                                 radioactive contamination the building debris was required to be
                                 packaged in intermodals and transported to Area 5 for disposal.
                                 Similar work on a previous site earlier in the year provided valuable
                                 lessons on how to develop the work package and waste profile and
                                  8. NTS Text Cell C Radiological Piping Demolition(Source: User Submitted -
                                  ID: PMLL-2010-NTS-NTS RA Project-0002)
                8      12-Jan-11 Through the use of detailed step-by-step planning and worker
                                  involvement, the demolition of a large amount of contaminated piping
                                  and tanks was accomplished without a safety incident, ahead of
                                  schedule, and without the spread of radioactive contamination.
                                  9. Compact Fluorescent Lamps Used in Power Cart Light Stringers Result In
                                  Transformer Failures(Source: User Submitted - ID: PMLL-2010-OR-K-27 Pre-
                                  Demo Project-0001)
                                  Engineering personnel need to evaluate the use of Compact
                9      12-Jan-11 Fluorescent Lamps (CFL) used in construction light stringers. The
                                  CFL's produce additive harmonic currents on the transformer neutral
                                  and circulating harmonic currents in the delta primary winding of the
                                  transformer. This can lead to transformer overheating (resulting in the
                                  shortening of transformer life), or acute transformer failure
                                 10. BCWS Not Allotted for New Employee Site Orientation (beyond the
                10     12-Jan-11 training period)(Source: User Submitted - ID: PMLL-2010-PA-C-410-0001)
Fermi National Accelerator Laboratory Confidential                                                                                             5/3/2013                                                                                                     Page 1
                                                                                                                                           LL Initial Review

              Item # 12-Jan-11
                10     Date                                2012-BNL-Bungee-0001)                              OQBP LLC (ERV, JFM) Initial Review Comments      Date   MSLLC or MPLLC Initial Review Comments   Date   MS/MP (Area) Initial Review Status
                                  When creating the baseline schedule, budgeted cost of work
                                  scheduled (BCWS) was not allotted for "site orientation" of new
                                  11. U-233 Rendered Fissile Waste Packages Non-Compliant for
                                  Transportation(Source: User Submitted - ID: PMLL-2010-PO-ARRA
                                  Portsmouth RA Project-0001)
                                  Early involvement of specialists from the different disciplines can help
                11    12-Jan-11 identify potential issues and mitigate noncompliances. A complete
                                  data set based on either process knowledge or data of known quality
                                  must be provided to the specialists to assess the waste. Each project
                                  or activity generating waste must identify the necessary specialists
                                  early in the process to identify applicable regulatory and receiving site
                                12. Demolition of Pipe Results in Oil Spill(Source: User Submitted - ID:
                12    12-Jan-11 PMLL-2010-PA-ARRA Portsmouth RA Project-0002)
                                  Not analyzing unique work hazards can lead to unexpected liquids
                                  being released from systems during demolition.
                                  13. Timely and Effective Communication(Source: User Submitted - ID:
                                  PMLL-2010-RL-ARRA All Projects-0001)
                                  We improved communications between DOE and contractors,
                13    12-Jan-11 integrated project teams, and stakeholders through the
                                  implementation of an ARRA Project Team, Project Data Management
                                  System (PDMS) intranet site, and regular scheduled presentations by
                                  DOE and Contractor managers to external stakeholders (state,
                                  14. Organizational Separation of ARRA from Base(Source: User Submitted -
                                  ID: PMLL-2010-RL-ARRA All Projects-0002)
                14    12-Jan-11 Separation of organizations supporting ARRA from those supporting
                                  Base projects has resulted in more effective and efficient ARRA
                                  project implementation.
                                  15. Training Programs Specific to ARRA Work Were Necessary to Rapidly
                                  Instill The Princples of Integrated Safety Management in Newly-Hired ARR
                                  Works(Source: User Submitted - ID: PMLL-2010-SR-TRU & Solid Waste-
                15    12-Jan-11 Training programs specific to ARRA work were necessary to rapidly
                                  instill the principles of Integrated Safety Management in newly-hired
                                  ARRA workers. Additionally, programs were established for both
                                  management and line workers to actively observe and correct unsafe
                                16. Equipment Procurement(Source: User Submitted - ID: PMLL-2010-SR-
                16    12-Jan-11 ARRA Liquid Waste-0002)
                                  Clearly define the ARRA terms and conditions for equipment
                                  procurements to ensure qualified vendores are able to competitively
                                  17. Use of Cross-Functional Team to Screen Candidates and Perform Job
                                  Candidate(Source: User Submitted - ID: PMLL-2010-WV-WVDP-0001)
                17    12-Jan-11 Use of a cross-functional team to screen candidates and perform job
                                  candidate interviews was more effective than using traditional
                                  screening and hiring processes. Also use of the structured
                                  behaviorally based system of interviewing resulted in a better product
                                  18. Use of Union Mentors in the Initial Classroom Training of ARRA
                                  Employees(Source: User Submitted - ID: PMLL-2010-WV-WVDP-0002)
                                  Union Mentors should be included in initial classroom training for new
                18    12-Jan-11 ARRA employees. These mentors can answer questions the trainees
                                  have and help acclimate the new hires to the site. These mentors can
                                  also help transition the ARRA employees to the siteҳ safety culture
                                  and accelerated the On-the-job training process, allowing the ARRA
                                  1. BLUE - Importance of Operational Process Knowledge in D&D(Source:
                                  User Submitted - ID: 2010B-LL-LATA-0098)
                19    21-Jan-11 When conducting D&D operations in buildings that have been shut
                                  down for several years, it is important to learn as much as possible
                                  about how the system(s) within the building were operated.
                                  2. GREEN - Alternative Work Schedule May Lead to Cost Efficiencies
                                  (Source: User Submitted - ID: G-2010-OR-BWY12-0703)
                20    21-Jan-11 Implementation of an alternative work schedule (Monday-Thursday 10
                                  hrs/day) at Y-12 creates cost efficiencies in multiple organizations by
                                  eliminating one day's worth of non-value added overhead costs.


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                                                                                                                                            LL Initial Review


              Item #     Date                              2012-BNL-Bungee-0001)                               OQBP LLC (ERV, JFM) Initial Review Comments      Date   MSLLC or MPLLC Initial Review Comments   Date   MS/MP (Area) Initial Review Status
                                 3. GREEN - Lean Implementation Methods Results in Identification of
                                 Operational Efficiencies in Container Refurbishment (Source: User
                21     21-Jan-11 Submitted - ID: G-2010-OR-BWY12-0704)
                                  Periodic review of implementation methods using lean and six sigma
                                  techniques may provide opportunities for achieving operating cost
                                  4. YELLOW - Tornado Door Event - Unidentified Hazard(Source: User
                                  Submitted - ID: 2011-EM-CBFO-WTS-WIPP-LL-2011-01)
                                 A subcontractor received minor injuries, when a tornado door in the
                                 work area was activated creating a pinch point. Lessons Learned: 1)
                22     21-Jan-11 Job Hazard Analysis (JHA) should be job specific. 2) Detailed work
                                 instructions, pre-job walk downs, and hazard recognition
                                 requirements, must be clearly communicated to personnel through
                                 training, management involvement, and procedures. 3) Personnel
                                 must be aware of their roles and responsibilities during
                                  1. YELLOW - Electrical Deactivation(Source: User Submitted - ID: 2010-
                                  ORNL-SEC-0001)
                                  Although buildings scheduled for demolition have been classified as
                                  cold and dark, workers must understand that cold and dark does not
                23     8-Feb-11   mean safe with all hazards removed. Because chemical, radiological,
                                  electrical, mechanical and residual liquid hazards may remain in a
                                  facility, continued hazard analyses must be performed as work
                                  progresses. In this incident, de-energizing at the distribution panels
                                  only is not adequate. Unknown sources may come through the slab or
                                  2. BLUE - Improper Transport of Hazardous Chemical Sample in Personal
                                  Luggage(Source: User Submitted - ID: 2011-ANL-001)
                24     8-Feb-11   General users of a DOE user facility must remain aware of hazardous
                                  material transportation requirements when arranging for samples to
                                  be transported to and from a user facility.
                                  3. BLUE - Plan the Work and Work the Plan(Source: User Submitted - ID:
                                  2011-EM-SEC-0002)
                25     8-Feb-11   Successful work execution comes from effective work planning,
                                  integrating all five ISMS Core Functions and performing the work as
                                  approved. Changes to the plan (work package) need to be carefully
                                  reviewed and approved before incorporating, modifying or
                                  4. YELLOW - Software Unit Conversion Error and Use of Default Data
                                  Results in Misclassification of Waste(Source: User Submitted - ID: Y-2011-
                26     8-Feb-11   Testing of software applications must be performed in accordance
                                  with sound Software Quality Assurance requirements to ensure the
                                  output results of the application are in accordance with the system
                                  design requirements and expectations.
                                  1. YELLOW - Defective Miller Ultra Fall Protection Harness Locking
                                  Mechanism(Source: User Submitted - ID: 2011-RL-HNF-0003)
                                  A recent inspection of Miller fall protection harnesses at the Hanford
                27     9-Feb-11   Site identified two units that were manufactured with a "green" plastic
                                  component in the locking mechanism that was cracked. The cracked
                                  plastic component prevents the latch from staying in a closed
                                  position. All harnesses should be inspected and removed from service
                                  regardless of the condition of the harness or the plastic component
                                  2. GREEN - Workforce Skill-Level Diversification May Lead to Cost
                28     9-Feb-11   Efficiencies (Source: User Submitted - ID: G-2010-OR-BWY12-0705)
                                  Work force experience and skill-level diversification may significantly
                                  reduce operating costs, while enhancing resource sustainability.
                                  3. GREEN - Use of Local Analytical Capabilities in lieu of Remote
                29     9-Feb-11   Capabilities (Source: User Submitted - ID: G-2010-OR-BWY12-1203)
                                  Questioning past operational methods based on current capabilities
                                  and requirements lead to cost-efficiencies.
                                  4. GREEN - Early Tenant Move Out from Facilities Scheduled for Demolition
                30     9-Feb-11   Can Result in Cost Efficiencies (Source: User Submitted - ID: G-2010-OR-
                                  Placing a building in a "cold and dark" condition ahead of the
                                  demolition schedule can lead to cost efficiencies.


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                                                                                                                                           LL Initial Review
              Item #     Date                               2012-BNL-Bungee-0001)                             OQBP LLC (ERV, JFM) Initial Review Comments      Date   MSLLC or MPLLC Initial Review Comments   Date   MS/MP (Area) Initial Review Status
                                  5. GREEN - Review of Cross-Training Opportunities for Potential Cost
                                  Efficiencies (Source: User Submitted - ID: G-2010-OR-BWY12-1202)
                31     9-Feb-11   Challenging past labor practices and cross-training employees results
                                  in increased productivity by reducing "down time" experienced by
                                  Assembly personnel.
                                  6. YELLOW - Potentially Inadequate Safety Analysis - Positive Unreviewed
                                  Safety Question: Discovery of Undesorbed Sodium Flouride Traps in the K-
                                  25 and K-27 Facilities(Source: User Submitted - ID: Y-2011-OR-BJCK25-
                                  Determination of the quantities of uranium or other radioactive
                32     9-Feb-11   materials in a nuclear facility should be based on direct
                                  measurements/readings where possible. While historical documents,
                                  process knowledge, and procedures that were in place at the time of
                                  facility shutdown can be valuable resources, they are not always an
                                  accurate indication of the condition in which a facility was left.
                                  7. GREEN - Protection of the Geomembrane Tie-In Between Cells -
                                  ARRA(Source: User Submitted - ID: G-2011-OR-BJCEMWMF-0101)
                33     9-Feb-11   Extra care and effort should be made to protect the leading edge of
                                  geomembrane tie-ins. Doing so would expedite the installation of
                                  additional geomembranes should additional cell construction be
                                  8. GREEN - Requirement for Pre-shipment Material Inspection at Supplier's
                                  Facility - ARRA(Source: User Submitted - ID: G-2011-OR-BJCEMWMF-0102)
                34     9-Feb-11   In some cases, a pre-shipment material inspection, for major
                                  equipment, should be performed at the Supplier's facility in order to
                                  detect and correct any nonconforming conditions prior to delivery.
                                  9. GREEN - Pre-Construction Preparation and Stockpiling of Low
                                  Permeability Soil - ARRA(Source: User Submitted - ID: G-2011-OR-
                35     9-Feb-11   The production and placement of bentonite amended low permeability
                                  clay should be completed by late summer or early fall to avoid adverse
                                  weather conditions and subsequent schedule impacts during the
                                  deployment of geosynthetics.
                                  1. YELLOW - Improper Disposal of Sharp Objects Creates Personnel Safety
                                  Problems(Source: User Submitted - ID: LL-2010-LLNL-09)
                                  Each of us has a fundamental responsibility to ensure that our actions
                36     10-Feb-11 do not degrade the safety of other personnel or the work environment.
                                  When disposing of items, take into account the hazards they present
                                  in their current condition and the potential hazards they can create if
                                  their condition changes (i.e., an intact item breaks).
                                  2. GREEN - Safety Glasses Prevent Possible Eye Injury(Source: User
                                  Submitted - ID: LL-2010-LLNL-10)
                37     10-Feb-11 Wearing appropriate personal protective equipment (PPE) is an
                                  essential and sometimes critical part of safety. It is usually the last,
                                  and sometimes the only barrier between a hazard and possible injury.
                                  3. YELLOW - Supercompaction of Pressurized Cylinder Results in Near
                                  Miss(Source: User Submitted - ID: 2011-ID-AMWTP-0004)
                                 Thorough examination of packaged waste is key to identifying
                                 prohibited items in boxlines (troughs where transuranic waste is
                                 remotely dumped out of boxes, sorted, segregated, and packaged into
                38     10-Feb-11 "silver" drums destined for supercompaction). If a prohibited item
                                 enters the supercompactor, the possibility of a failure of engineered
                                 controls increases the likelihood of a release of hazardous
                                 material/contamination. Two visual examination operators missed the
                                 identification of a fire extinguisher that was subsequently compacted
                                 and depressurized in the supercompactor. This resulted in a root
                                  4. BLUE - Error Reduction was Less than Effective Due to Less than
                                  Adequate Communication and Implementation of Expectations(Source:
                                  User Submitted - ID: 2010-RL-HNF-0064)
                                  The combination of a highly qualified work force and the lack of
                39     10-Feb-11 clearly communicated management expectations may result in work
                                  teams that do not exercise a questioning attitude or conservative
                                  decision making in the performance of their work. When coupled with
                                  a corrective action management process that is not fully understood
                                  by the work force, the end result is an inability to effectively correct
                                  previous events and continuously improve performance.
Fermi National Accelerator Laboratory Confidential                                                                                            5/3/2013                                                                                                     Page 4
                                                                                                                                            LL Initial Review
              Item #     Date                                2012-BNL-Bungee-0001)                             OQBP LLC (ERV, JFM) Initial Review Comments      Date   MSLLC or MPLLC Initial Review Comments   Date   MS/MP (Area) Initial Review Status
                                   5. BLUE - Energized Electrical Conductor Cut at U Canyon(Source: User
                                   Submitted - ID: 2011-RL-HNF-0001)
                                 The entire work team, composed of the workers, subject matter
                                 experts (SME), and supervisors, are individually responsible for
                40     10-Feb-11 reading and understanding the work scope, hazards, and controls, and
                                 performing work steps, as written. Management must be particularly
                                 vigilant when roles overlap, potentially bypassing the peer review
                                 process that normally occurs during work authorization. A
                                 questioning attitude is a highly valuable barrier that, when used
                                   6. GREEN - Replacing Existing Windows on Heavy Equipment with an
                                   Improved Material Provides a Safer Environment for Operators(Source:
                                   User Submitted - ID: G-2011-OR-BJCEMWMF-0201)
                41     10-Feb-11 Pushing demolition debris that includes miscellaneous metal waste                                                                                                                                   Awaiting OQBP Review
                                   with bull dozers is extremely hard on heavy equipment and may be
                                   hazardous to the equipment operators. Replacing existing windows on
                                   heavy equipment with an improved material can provide a safer
                                   7. GREEN - Single Shell Tank Dome Cut Removal Operation(Source: User
                                   Submitted - ID: 2011-RL-HNF-0006)
                                   Garnet-entrained water was used as an effective and radiological-risk
                42     10-Feb-11 minimizing method to cut a large hole through reinforced structural
                                   concrete in the top of a Hanford Site single shell tank. Good work
                                   planning, numerous mock ups, and sound work practices were noted
                                   as part of the 241-C-107 tank dome cut.
                                   8. BLUE - E-85 Fuel and Cold Temperatures(Source: User Submitted - ID:
                                   2011-ID-AMWTP-0001)
                                   In order to avoid starting/stalling problems, flex fuel vehicle operators
                43     10-Feb-11 should verify that ethanol fueling stations have converted to a winter
                                   blend of ethanol (E-70) in areas where temperatures routinely drop
                                   below 32 degrees F prior to fueling. They should also be aware that
                                   the E-70 fuel may not completely alleviate cold weather problems
                                   associated with ethanol fuel use during sustained periods of very cold
                                   1. YELLOW - Fall Protection - X-700 Roof(Source: User Submitted - ID: Y-
                                   2010-WEMSPORTS-001)
                44     16-Feb-11 Personnel must maintain focus and attention to detail on their
                                   individual roles and responsibilities, and not the most pressing
                                   priorities of the work at any given time.
                                 2. YELLOW - Asbestos Training - X-700 Roof Project(Source: User
                45     16-Feb-11 Submitted - ID: Y-2010-WEMSPORTS-002)
                                   Task Managers must assure that all personnel working on a project
                                   have the proper training to perform their assigned duties.
                                 3. BLUE - Hydraulic Oil Spill (Source: User Submitted - ID: L-2009-OR-
                46     16-Feb-11 Advance preparation for quick and effective hydraulic oil spill
                                   response reduces impact to the environment.
                                   4. YELLOW - Pre-Use Inspection Uncovers Defect in Overhead Crane Wire
                                   Rope(Source: User Submitted - ID: CWI-ICP-2011-0001)
                47     16-Feb-11 Always perform a thorough visual pre-use inspection of crane
                                   components and hoist ropes before each use. A pre-inspection of the
                                   multi-hoist crane found a distortion in the crane's hoist rope.
                                   5. YELLOW - Beware of Legacy Energized Electrical Wiring (Source: User
                                   Submitted - ID: 2011-BNL-F&O-0001)
                48     16-Feb-11 Energized electrical conductors may be present in any service areas
                                   hidden from casual view. Never reach into an area that that has not
                                   been verified as safe.
                                   1. GREEN - Lessons Learned from Joint DOE/Contractor Annual ISMS
                                   Reviews(Source: User Submitted - ID: 2011-OH-WVES-001)
                49     17-Feb-11 Joint DOE/Contractor conduct of annual Integrated Safety
                                   Management System reviews in support of the integrated safety
                                   management system (ISMS) declaration is an effective and productive
                                 2. YELLOW - Incomplete Radiological Characterization Results in Exceeding
                                 Allowances during Waste Transport (Source: User Submitted - ID: 2011-
                50     17-Feb-11 BNL-DJ-0001)
                                   It is important to consider the potential presence of hard-to-detect
                                   (e.g., pure beta-emitting) radionuclides in characterization of
Fermi National Accelerator Laboratory Confidential                                                                                             5/3/2013                                                                                                     Page 5
                                                                                                                                             LL Initial Review
              Item #     Date                              2012-BNL-Bungee-0001)                                OQBP LLC (ERV, JFM) Initial Review Comments      Date   MSLLC or MPLLC Initial Review Comments   Date   MS/MP (Area) Initial Review Status
                                 3. BLUE - Pre-existing Crack Results in Chain Hoist Failure(Source: User
                51     17-Feb-11 Submitted - ID: B-2011-LPPORTS-0201 )
                                   Pre-existing anomalies in rental equipment can lead to failures on the
                                   jobsite.
                                   1. YELLOW - Independent Verification Not Performed on Fissile Tracking
                                   System Data Entry Results in TSR Violation and Supercompaction of a
                                   Container without a Valid Radioassay Result(Source: User Submitted - ID:
                                   Ensure there is a clear understanding of a Technical Safety
                52     24-Feb-11 Requirement (TSR) prior to performing any steps associated with the
                                   TSR. A TSR specified Independent Verification of container data entry
                                   into the Fissile Tracking System (FTS) was not performed during a
                                   manual data entry activity into the FTS. This missed Independent
                                   Verification resulted in a drum being supercompacted with the wrong
                                   radioassay data. This resulted in a TSR violation, the filing of an ORPS
                                   2. YELLOW - Activated Circuit Board Requires Disposal as Mixed
                                   Waste(Source: User Submitted - ID: TJNAF-339-02-17-2011)
                                 When preparing low-level radioactive waste for shipment and
                                 disposal, equipment containing electronic components and circuit
                                 boards should be disassembled and such components should be
                                 individually surveyed for release. Boards found to be
                53     24-Feb-11 activated/contaminated should be set aside for possible repair, reuse
                                 or storage for decay. The inadvertent inclusion of circuit boards along
                                 with activated metal led to the creation of a waste that the disposal
                                 firm classified as mixed waste. The disposal firm's waste acceptance
                                 guidelines require that such waste be approved in advance and
                                 segregated in packaging. Circuit boards, when discarded, are
                                 presumed to be hazardous waste (per the TCLP test) due to the
                                 presence of lead solder (except as noted below in "Anal ysis"). Unless
                                   1. Backhoe Struck Buried Electrical Conduit; 2nd Occurrence in 2
                                   months(Source: User Submitted - ID: PMLL-2010-SRS-SWPF-0001)
                54     24-Feb-11 Over a two-month period, the Project (SWPF) experienced two
                                   separate incidents involving the unexpected contact of electrical
                                   conduit while conducting excavations. If the corrective actions from
                                   the first event had been fully implemented, this second event could
                                   1. BLUE - Change Conditions Prompt Questioning Attitude (Source: User
                                   Submitted - ID: 2011-EM-SEC-003)
                55     25-Feb-11 Execution of work does not always go as planned. When conditions
                                   change, employees are trained to stop and ask questions. This is a
                                   critical yet positive attribute of a strong work control process.
                                   2. BLUE - Respirator Inspection (Source: User Submitted - ID: 2011-EM-SEC-
                                 Proper inspection of respirators is essential to ensure adequate
                                 protection of workers. Good inspection practices begin with adequate
                                 training followed by thorough implementation of those practices.
                56     25-Feb-11 Training should cover the manufacturer's inspection guidelines and
                                 should be provided upon issuance and whenever changes to the
                                 respirator or type of respirator occur. Inspections should always
                                 include positive/negative seal tests but should also include inspection
                                 of individual respirator components. When defective respirators or
                                 respirator components are discovered, they should be removed with
                                   3. YELLOW - Vendor Troubleshoots Power Distribution Console without
                                   Required PNNL Permit or Training(Source: User Submitted - ID: 2011-LL-
                                 DOE Contractor electrical safety program requirements may differ
                                 from procedures used by vendors to start up and commission new
                57     25-Feb-11 equipment. Technical administrators (TA) and safety and health (S&H)
                                 representatives play a vital role in making sure vendors who work on-
                                 site are aware of and comply with host requirements that are
                                 applicable to the work scope. The TA and S&H reps role involves
                                 communicating with the vendor throughout the planning stage and as
                                   4. YELLOW - Energized Electrical Equipment Left Unattended in Lab Causes
                                   Concern(Source: User Submitted - ID: 2011-LL-PNNL-0002)
                                   Oversights during the process of ordering, fabricating, approving, and
                58     25-Feb-11 securing electrical equipment (as well as in communicating walk-
                                   through observations) contributed to an uncontrolled electrical
                                   hazard. Maintaining personal accountability and practicing clear
                                   communications are important elements in preserving a safe
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                                                                                                                                          LL Initial Review




              Item #     Date                             2012-BNL-Bungee-0001)                              OQBP LLC (ERV, JFM) Initial Review Comments      Date   MSLLC or MPLLC Initial Review Comments   Date   MS/MP (Area) Initial Review Status
                                  5. GREEN - Conduct of Operations Process Improvements through
                                  Mentoring(Source: User Submitted - ID: G-2011-OR-BJCSSI-0202)
                                  Mentoring is an effective method of effecting a strong Conduct of
                59     25-Feb-11 Operations (ConOps) culture. In this context, ConOps refers to not
                                  only the requirements of DOE O 422.1, Conduct of Operations, but
                                  also rigor and formality of operations, attention to detail, quality of
                                  work, documentation, and the principles and functions of Integrated
                                  6. YELLOW - Ambiguous Safety Documents Enables Unexpected Urgent
                                  Safety Decision(Source: User Submitted - ID: 2010-PTX-LL-0703)
                                 Control priorities at Program, TSR and Specific Administrative Control
                                 (SAC) interfaces, like urgent or emergency decision points must be
                60     25-Feb-11 clearly detailed during control development and implementation.
                                 Ambiguities or errors at these control interfaces, whether discovered
                                 by events or assessments, should be included in future assessments
                                 of the interfacing controls. Personnel need to consistently assure that
                                 Safety Significant Control items are protected during Severe Weather.
                                 Assure that personnel understand the requirement to make necessary
                                  1. YELLOW - Natural Gas Line Severed During Excavation Activity (Source:
                                  User Submitted - ID: 2011-UTB-ORNL-0007)
                                  Planning, permitting and conduct of excavation operations are subject
                61     1-Mar-11 to a wide range of hazards that must be effectively identified and for
                                  which controls must be developed. Procedures must effectively
                                  identify guidelines and requirements for excavation job hazard
                                  evaluation, determination of adequate controls, and safety margins.
                                  Training and on-the-job experiences should not be overlooked when
                                  2. YELLOW - Assessing Changing Conditions due to HAZWOPER
                                  Remediation Activities (ARRA)(Source: User Submitted - ID: Y-2011-OR-
                                  Hazardous Waste Operations and Emergency Response (HAZWOPER)
                62     1-Mar-11 activities resulting in removal of material and waste during
                                  remediation and changes to the landscape and facility footprint as
                                  work progresses, require ongoing routine assessment and evaluation
                                  of the hazard impact, controls, and assumptions for completion of
                                  remaining work to promote safe and successful completion of all
                                  1. Over-Reliance on 'Fixatives' for Contamination Control(Source: User
                                  Submitted - ID: PMLL-2011-SPRU-H2-0001)
                                  Evaluate contamination control techniques used before and during
                63     1-Mar-11   demolition to assure they are adequate to prevent the spread of
                                  contamination. An over reliance on the application and effectiveness
                                  of 'Fixatives' to control the spread of contamination may not be
                                  sufficient. This practice led to the uncontrolled release of radioactive
                                  contaminants to areas outside of the Separations Process Research
                                  1. YELLOW - Become Familiar with the Vehicle You Are Driving before
                                  Operating It(Source: User Submitted - ID: LL-2011-LLNL-02)
                                  The driver has ultimate responsibility for controlling the vehicle while
                64     2-Mar-11 it is in operation. Under normal circumstances, a driver commits five
                                  errors per hour. You can reduce the risk and impacts of potential
                                  errors by making sure you are familiar with the vehicle's built-in
                                  controls and safety features before you operate it.
                                  2. YELLOW - Subcontractor Employee Injury - Do Not Allow Previous
                                  Success to Decrease Focus on Task at Hand (ARRA)(Source: User Submitted
                                  - ID: 2011-SR-SRNS-0001)
                65     2-Mar-11 Personnel should not allow previous successful operations with a
                                  particular method or tool to decrease their awareness or focus on the
                                  task at hand. They should not allow themselves to become so
                                  comfortable with the task that the real hazards associated with it end
                                  up being perceived to be diminished or unlikely.




Fermi National Accelerator Laboratory Confidential                                                                                           5/3/2013                                                                                                     Page 7
                                                                                                                                          LL Initial Review

              Item #     Date                               2012-BNL-Bungee-0001)                            OQBP LLC (ERV, JFM) Initial Review Comments      Date   MSLLC or MPLLC Initial Review Comments   Date   MS/MP (Area) Initial Review Status
                                  3. YELLOW - Legacy Contamination Found at 420-2D Decommissioned Pad -
                                   Emphasizes Being Cognizant of Traceability of Actions for Impact on
                                  Future Activities (ARRA)(Source: User Submitted - ID: 2011-SR-SRNS-0002)
                                  Personnel performing decommissioning-related activities need to be
                                  cognizant of the traceability of their actions for future area closure
                66     2-Mar-11   related activities. Personnel performing area closure activities need to
                                  also be cognizant that existing visible conditions and postings (or lack
                                  there of) do not necessarily provide all of the information necessary to
                                  address potential hazards during activities that disturb the soil or
                                  ground covering. Reviews of previous work should be conducted to
                                  ensure adequate understanding for potential hazards that may be
                                  found as the soil or other ground covering is disturbed and removed.
                                  4. BLUE - PVC Insulation Plasticizer Green Residue Issue - Includes
                                  Recommendations for Preventive and Corrective Maintenance of Electrical
                                  Equipment(Source: User Submitted - ID: 2011-SR-SRNS-0003)
                                  This Lessons Learned recommends that electrical wiring,
                                  terminations, and components be visually inspected for a weeping
                67     2-Mar-11   green-colored residue during each routine inspection and during
                                  normal preventive and corrective maintenance of electrical equipment.
                                  The green sticky residue, sometimes referred to as "green goo", can
                                  cause problems with electrical components by preventing operation of
                                  contacts, and under certain rare conditions, may result in electrical
                                  arc tracking. The green substance can also be an indicator that wiring
                                  insulation has deteriorated and may be brittle or subject to cracking if
                                  5. YELLOW - DOE Type B Accident Investigation Board Report, Employee
                                  Puncture Wound at the F-TRU Waste Remediation Facility(Source: User
                                  Submitted - ID: 2011-SR-SRNS-0004)
                68     2-Mar-11 This report documents the results of the Type B Accident
                                  Investigation Board investigation of the June 14, 2010, employee
                                  puncture wound at the Department of Energy (DOE) Savannah River
                                  Site (SRS) F-TRU Waste Facility located in the F Canyon facility.
                                  6. BLUE - Unregistered Radiation Generating Device in H Tank Farm -
                                  Ensure Appropriate Procedures Are Referenced and Followed for Purchase
                                  Requisition Process(Source: User Submitted - ID: 2011-SR-SRR-0001)
                69     2-Mar-11 During the procurement of a Radiation Generating Device (RGD),
                                  personnel should ensure the appropriate procedures are referenced
                                  and followed in the preparation, review, approval, and control of
                                  purchase requisitions for the Savannah River Site (SRS).
                                  7. BLUE - Pad 16 Contamination Lessons Learned - Understanding Internal
                                  Drum Integrity with Liquids(Source: User Submitted - ID: 2011-SR-SRNS-
                                  On July 26, 2010, a spill occurred on TRU Pad 16 at the Savannah
                                  River Site (SRS) when a TRU waste container (an 85-gallon overpack)
                                  was being moved off a pallet manually. During the movement, water
                                  was noticed coming from the bottom of the overpack. Personnel took
                                  the appropriate actions and exited the pad. This event highlights a
                70     2-Mar-11
                                  failure mode that had not been experienced in previous container
                                  movements, which is the corrosion of a container from the inside,
                                  creating weak spots and the potential for leaks during routine
                                  container movement. Inspection of the outside of the container cannot
                                  be relied on to reveal evidence of this phenomenon. Note: The failure
                                  mode described above is based on the best physical evidence
                                  currently available, and analysis of that information by the Savannah
                                  River National Laboratory (SRNL). If new information emerges from
                                  8. YELLOW - Technical Safety Requirements Implementation(Source: User
                                  Submitted - ID: 2011-ID-AMWTP-0003)
                                  Perform an extensive review when incorporating revised Technical
                                  Safety Requirements (TSR) into procedures and software. A Specific
                71     2-Mar-11   Administrative Control (SAC) was implemented to specify independent
                                  verification for manual data entries into the Fissile Tracking System
                                  (FTS). Neither the procedure nor the software was evaluated
                                  sufficiently to ensure consistent and compliant application of the
                                  independent verification. This eventually resulted in a TSR violation

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              Item #     Date                              2012-BNL-Bungee-0001)                                 OQBP LLC (ERV, JFM) Initial Review Comments      Date   MSLLC or MPLLC Initial Review Comments   Date   MS/MP (Area) Initial Review Status
                                  1. Appropriate Acquisition Strategy(Source: User Submitted - ID: PMLL-
                                  2011-NNSS-RFS-388)
                72     3-Mar-11 The selection of an acquisition strategy that is appropriate for current
                                  market conditions, funding constraints, and project scope can result
                                  in more competitive bidding and lower bid prices.
                                  1. YELLOW - Job Planning Must Identify Hazards Mitigated by Seasonal
                                  Work (Source: User Submitted - ID: Y-2010-OR-BWY12-0801)
                73     4-Mar-11 When planning and scheduling outdoor work for performance during
                                  cold winter months, the ambient temperature must be identified as a
                                  mitigating or controlling factor if the activity has the potential for heat
                                  2. YELLOW - Inadequate LOTO of Chemical Line (Source: User Submitted -
                                  ID: Y-2010-OR-BWY12-1204)
                                  When preparing and executing a Lockout/Tagout (LOTO), it is
                74     4-Mar-11 imperative that positive isolation points are chosen and secured to
                                  ensure effective isolation from hazardous energy sources or
                                  materials. When the LOTO involves isolation of a liquid or process
                                  system, all inlets and outlets associated with the work location must
                                  1. Ineffective Work Control Practices(Source: User Submitted - ID: PMLL-
                                  2011-SPRU-ARRA-H2-0003)
                                  Implement work control processes that ensure the work is reviewed
                                  by the appropriate subject matter expert (SME) before proceeding.
                75     7-Mar-11   Work activities that are conducted without being adequately reviewed
                                  by SMEs and/or discussed with workers prior to the work execution
                                  can lead to unexpected results. The removal and size reduction of
                                  contaminated equipment during demolition activities which led to a
                                  contamination event outside the boundaries of the Separations
                                  Process Research Unit (SPRU) project was partially due to not
                                  2. Insufficient Period for Field Observations could Impact ISMS Verification
                                  Results(Source: User Submitted - ID: PMLL-2011-SPRU-ARRA-H2-0007)
                                  Devote sufficient time to field observations during Phase II ISMS
                76     7-Mar-11 reviews. A condensed period of 5 days for field observations,
                                  interviews and inquiry, and report writing may not be adequate to
                                  obtain the best result. Team members reported that evening hours,
                                  especially late in the week, were required to complete the report and
                                  that this aggressive time frame impacted their ability to conduct a
                                  3. Perceived Schedule Pressure affects Worker Involvement(Source: User
                                  Submitted - ID: PMLL-2011-SPRU-ARRA-H2-0002)
                                  Encourage an atmosphere of open communication and acceptance of
                77     7-Mar-11 employee feedback regarding work processes and safety concerns.
                                  Perceived schedule pressure by workers caused a reluctance to bring
                                  up issues that might slow progress. This resulted in lost opportunities
                                  to control the spread of contamination to offsite areas during
                                  4. Need for a Strong Conduct of Operations Program(Source: User
                                  Submitted - ID: PMLL-2011-SPRU-ARRA-H2-0004)
                                  Encourage a strong conduct of operations (CONOPs) work
                                  environment. Transient construction workers cannot be expected to
                78     7-Mar-11   exhibit rigorous safety culture behaviors without clear expectations
                                  and constant supervision by managers with strong CONOPs
                                  backgrounds. Clear and comprehensive work planning, radiological
                                  controls, adherence to work planning documents as written (e.g. hold
                                  points), and safety focused supervision are necessary to ensure work
                                  activities are conducted safely to prevent the spread of contamination
                                  5. Need for Effective Management Oversight(Source: User Submitted - ID:
                                  PMLL-2011-SPRU-ARRA-H2-0006)
                79     7-Mar-11 Provide effective and independent oversight during management
                                  activities. Contractor self assessments and DOE assessments need to
                                  be thorough and critical. Recent assessments of the Radiological
                                  Protection Program did not identify significant weaknesses prior to




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                                                                                                                                                       LL Initial Review




              Item #     Date                                  2012-BNL-Bungee-0001)                                  OQBP LLC (ERV, JFM) Initial Review Comments                Date                 MSLLC or MPLLC Initial Review Comments                 Date      MS/MP (Area) Initial Review Status
                                   6. Excessive Flexibility in Work Planning Documents can be
                                   Detrimental(Source: User Submitted - ID: PMLL-2011-SPRU-ARRA-H2-0005)
                                   Discourage the frequent use of terminology such as ӡs required,Ԡӡs
                                   needed,Ԡand ӡs necessaryԠin work control documents. Excessive
                80     7-Mar-11    flexibility incorporated into work documents can cause an over-
                                   reliance in individual decision making instead of providing the
                                   necessary detail to ensure steps are accomplished as planned. This
                                   contributed to the unplanned off-site release of radiological
                                   contamination due to releasing work too far in advance with no
                                   subsequent discussion in the Plan of the Day meeting regarding the
                                   1. Managers Adapt Readiness to New Business Needs at PNNL(Source:          Sending to Bruce Chrisman to determine who this should                       I accept this as a 2. ie FYI.
                                   User Submitted - ID: PMLL-2011-SC-PNNL-PSC-0003)                           receive this within Business Operations or another D/S/C.
                                   The term "readiness" is not new at PNNL, but it is being adapted by
                                   some managers for timely start-up and completion of projects
                                   involving facilities and infrastructure, assets and equipment, and
               81a     9-Mar-11    materials and specimens. Several managers have shared their                                                                                 27-Mar-11                                                                   27-Mar-11    Operations          FYI Only
                                   experiences in using the readiness process to help them start
                                   research facility operations safely and efficiently, minimize delays and
                                   added costs, complete projects on schedule, and maximize customer
                                   confidence. PNNL managers explain how using readiness helps
                                   reduce the risk of error in projects, fulfill contracts, meet schedules,
                                   1. Managers Adapt Readiness to New Business Needs at PNNL(Source:          Also, sending this to Dean Hoffer for review for applicability             I called the contact person for the lessons learned (Patti
                                   User Submitted - ID: PMLL-2011-SC-PNNL-PSC-0003)                           versus Project Management processes.                                       Ammonet - PNNL) to get more detail then what was in the
                                   The term "readiness" is not new at PNNL, but it is being adapted by                                                                                   lesson learned email to better understand the item. Patti
                                   some managers for timely start-up and completion of projects                                                                                          then referred me to the person that is responsible for the
                                   involving facilities and infrastructure, assets and equipment, and                                                                                    Readiness Process at PNNL (Nick Regoli) to explain the process
                                   materials and specimens. Several managers have shared their
                                                                                                                                                                                         further. What I learned from Patti and Nick is that the process
                                   experiences in using the readiness process to help them start
                                   research facility operations safely and efficiently, minimize delays and
                                                                                                                                                                                         helps the project and the end user to identify early in the
                                   added costs, complete projects on schedule, and maximize customer                                                                                     project on what deliverables are required by the end user, so
                                   confidence. PNNL managers explain how using readiness helps                                                                                           project ensures those deliverables are achieved. This process
                                   reduce the risk of error in projects, fulfill contracts, meet schedules,                                                                              appears to be use on civil projects and equivalent to the GPPs
                                   and assure a smooth transition to project turnover and operation.                                                                                     and AIPs. I believe in the 413,3 projects the principals of the
               81b     9-Mar-11                                                                                                                                                27-Mar-11                                                                   11-Apr-11   Project Mgmt         FYI Only
                                                                                                                                                                                         readiness process is part of the process. I cannot comment
                                                                                                                                                                                         on if the readiness principles are applied to the GPP and AIP
                                                                                                                                                                                         type projects, which FESS would address.

                                                                                                                                                                                           As for OPMO this Lesson Learned is accepted as an FYI.

                                                                                                                                                                                           COO response for FESS:
                                                                                                                                                                                           I agree with Dean, this is simply and FYI. No actions needed.




                                   1. YELLOW - Laceration to Wrist When Worker Cuts Metal Coiled Duct         Reject? – This looks like a failure to perform complete                      RColl Comments: Agree
                                   Work(Source: User Submitted - ID: 2011-ANL-003)                            planning and education of the employee. Thus, I see this as a
                82     10-Mar-11 Injuries can happen when workers are performing skill-of-the-worker          management issue. Also, Fermilab’s procedures already            27-Mar-11                                                                   28-Mar-11       ES&H         Rejected-Close
                                   activities involving cutting metal.                                        require the job be analyzed and understood before starting.


                                   2. GREEN - Timely Notification Of Receipt Inspection Issues By LLNL        Sending to Billy Arnold to verify Fermilab’s procedures would              Accept as an "FYI";
                                   Personnel Improves 9975 Container Procurement Process(Source: User         cover this.                                                                The lesson is accepted for use as a reminder and distributed
                                   Submitted - ID: 2011-SR-SRNS-0006)                                                                                                                    that way; no further action is required, except for the
                                                                                                                                                                                         receiving party to read it.
                                                                                                                                                                                         Fermilab has procedures in place to inspect packages upon
                                                                                                                                                                                         receipt used to transport hazardous materials and special
                                                                                                                                                                                         waste. The Hazard Control Technology Team Packaging
Fermi National Accelerator Laboratory Confidential                                                                                                         5/3/2013                      Acceptance Inspection Form is used for this purpose. Fermi                                                         Page 10
                                                                                                                                                                                         will accept the lesson as an FYI and it will be distributed to
                83     10-Mar-11                                                                                                                                               27-Mar-11 Hazard Control Technology Team Personnel as a reminder.           28-Mar-11       ES&H             FYI Only
                                                                                                                                                 LL Initial Review




                                                                                                         Sending to Billy Arnold to verify Fermilab’s procedures would             Accept as an "FYI";
                                                                                                         cover this.                                                               The lesson is accepted for use as a reminder and distributed
              Item #     Date                           2012-BNL-Bungee-0001)                                    OQBP LLC (ERV, JFM) Initial Review Comments                Date             MSLLC or action Initial Review Comments
                                                                                                                                                                                   that way; no furtherMPLLC is required, except for the              Date      MS/MP (Area) Initial Review Status
                                 During receipt inspection of the first shipment of new, unused 9975                                                                               receiving party to read it.
                                 containers, Lawrence Livermore National Laboratory (LLNL) personnel                                                                               Fermilab has procedures in place to inspect packages upon
                                 identified three issues that affected container quality: -Difficulty                                                                              receipt used to transport hazardous materials and special
                                 identifying the scribe line on the 9975 containment vessel weldment -
                                                                                                                                                                                   waste. The Hazard Control Technology Team Packaging
                                 Excessive scratches and gouges on the underside of the aluminum
                                 Shielding Lid -Excessive lubricant on the drum closure bolts.
                                                                                                                                                                                   Acceptance Inspection Form is used for this purpose. Fermi
                                 LLNL personnel immediately notified the 9975 Design Agency and the                                                                                will accept the lesson as an FYI and it will be distributed to
                83     10-Mar-11 Procurement Agent of the discrepant conditions. The Design Agency                                                                       27-Mar-11 Hazard Control Technology Team Personnel as a reminder.          28-Mar-11       ES&H             FYI Only
                                 and the Procurement Agent dispatched personnel to LLNL to
                                 determine corrective actions. Because of the immediate notification,
                                 the Procurement Agent was able to put a QA hold on unshipped and in-
                                 process components in order for corrective actions to be developed
                                 and implemented by the supplier to prevent similar issues. The
                                 affected containers at LLNL will be reworked to correct noted
                                 deficiencies. Key Lessons Learned: -Timely receipt inspection along
                                 with identification and correction of deficiencies reduces the
                                 probability of future operational problems. -Timely notification of
                                 procurement problems allows corrections to be made to in-process
                                 components and results in a better product.




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              Item #     Date                              2012-BNL-Bungee-0001)                                    OQBP LLC (ERV, JFM) Initial Review Comments                   Date               MSLLC or MPLLC Initial Review Comments                  Date      MS/MP (Area) Initial Review Status
                                  3. YELLOW - Technical Safety Requirement (TSR) Violation: Staging of      Recommend this is used as a reminder by sending this as an                    RColl Comments: Sent to SSOs and task manager/construction
                                  Transient Combustibles(Source: User Submitted - ID: Y-2011-OR-BJCWD-      FYI to SSOs and Task Managers since Fermilab’s procedures                     coordinators as an FYI and internal distribution.
                                  0301)                                                                     already cover area walk-downs and JHA reviews prior to                        Note - Needed to recheck emails; 2 different responses.
                                 Additional rigor is needed when work is being performed by other           commencing work.                                                              29-Mar-11: RColl Comments: Rejected. This is a series of
                                 prime contractors to ensure implementation of Documented Safety                                                                                          mistakes that violated established procedures and was also a
                84     10-Mar-11 Analysis (DSA) requirements.                                                                                                                   27-Mar-11                                                                  28-Mar-11       ES&H             FYI Only
                                                                                                                                                                                          break in communications. Our HA system requires that the
                                                                                                                                                                                          workers of all subcontractors read and sign the HA.
                                                                                                                                                                                          After review with Rafael, verbal agreement to use as FYI.



                                  1. YELLOW - Mechanical Failure of Gantry Crane Hoist Brake(Source: User   Reject – This lesson does not point out how anything can be                     RColl Comments- Agree
                                  Submitted - ID: 2011-ID-AMWTP-0006)                                       avoided nor what changes can be done. Part of the
                                 Performing pre-operational checks on hoisting equipment is an              investigation is still underway.
                                 essential task, but does not always assure safe operation of
                                 equipment. Hoisting equipment can fail unexpectedly, resulting in
                                 possible injury to personnel or equipment. A gantry crane brake
                85     16-Mar-11 system failed unexpectedly during radiological surveying of a payload                                                                          25-Mar-11                                                                  29-Mar-11       ES&H         Rejected-Close
                                 assembly. No personnel were injured, but the payload impacted the
                                 survey equipment and severely damaged the stainless steel table the
                                 equipment was located on. The crane had undergone annual and pre-
                                 use inspections as required and no abnormalities were detected. The
                                 crane was placed out of service until cause of the failure could be
                                 determined.

                                 2. BLUE - Solving One Problem Can Lead to Another Problem (Source: User Reject – Fermilab training, procedures and expectations                            RColl Comments: Rejected. We have systems in place to
                                 Submitted - ID: L-2009-OR-BWY12-0805)                                   already require this.                                                              prevent this.
                86     16-Mar-11 When resolving one problem, a different problem may be created          Could be used as an FYI for a reminder.                                25-Mar-11                                                                  29-Mar-11       ES&H         Rejected-Close
                                  which may have serious impact on the equipment / facility and need to
                                  be thoroughly analyzed.
                                  3. BLUE - Failure to Accept Mistakes Prohibits Learning and Continuous    Reject – Fermilab training, procedures and expectations                       RColl Comments: Rejected. This has to do with work ethics
                                  Improvement(Source: User Submitted - ID: INL-BEA-ID-2011-665)             already require this.                                                         and attention to detail. Continuous improvement for a person
                                                                                                            Could be used as an FYI for a reminder.                                       is a commitment each and every one of us needs to embrace.
                                 Organizations can effectively learn from their mistakes when                                                                                             That is the difference between a good employee and a
                                 management and employees accept that mistakes have been made                                                                                             mediocre employee. Thus the phrase “accident prone”
                87     16-Mar-11 and that opportunities for improvement exist. If personnel begin by                                                                            25-Mar-11 because people may tend NOT to learn from their own              29-Mar-11       ES&H         Rejected-Close
                                 denying an error has occurred, they miss out on taking full advantage
                                                                                                                                                                                          mistakes.
                                 of opportunities to learn and improve. However, by identifying
                                 problems with procedures, processes, and programs in addition to
                                 recognizing human errors, an organization can move away from
                                 placing blame and move toward understanding, learning, and
                                 improving.
                                  4. GREEN - Unexpected Elevated Dose Rate during Warm-Up of RTR-           Sending to Don Cossairt in order to verify Fermilab systems                     We reject. We already have systems in place that have served
                                  1001(Source: User Submitted - ID: 2011-ID-AMWTP-0007)                     would cover this or verify even if this exact situation could not               us well in addressing the hazards of radiography sources.
                                 Vigilant radiological survey practices can result in mitigation of a       happen that something like it would not; thus, this would this
                                 potentially significant risk. During radiation surveys of the shielding    even apply to Fermilab.
                88     16-Mar-11 for Real Time Radiography (RTR)-1001 following a maintenance                                                                                   25-Mar-11                                                                  25-Mar-11       ES&H         Rejected-Close
                                 activity which adjusted some of the shielding an unexpected reading
                                 of 900 mr/hr @ 30 cm. was discovered streaming through the roof of
                                 the RTR near the RTR ventilation ducting.

                                  5. BLUE - Hydrostatic Test Pressure Determination (Source: User      Reject? – Fermilab Engineering Manual, training, procedures                          RColl Comments: Belongs to the Engineering LLC. Send this to
                                  Submitted - ID: IB-11-010)                                           and expectations already seem to require this. However, I                            the Chair of the Mechanical Safety Subcommittee which is
                                 When performing ASME Code calculations, all applicable Code           would recommend a engineering or safety committee review                             more Engineering than Safety.
                                 requirements, material limitations, and system design conditions must this. I am not sure who to send this to for review.                                  Need to find out who should get this
                89     16-Mar-11 be thoroughly understood and applied to ensure results are accurate Also, could be used as an FYI for a reminder.                              25-Mar-11                                                                  25-Mar-11       ES&H       Awaiting SME Review
                                  and meet the intent of the Code.
                                                                                                                                                                                            06/17/11 - Meet with Bob Grant; his review was to go back to
                                                                                                                                                                                            ES&H suggestion of sending to the Mechanical Safety
                                                                                                                                                                                            Subcommittee.



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              Item #     Date                               2012-BNL-Bungee-0001)                                    OQBP LLC (ERV, JFM) Initial Review Comments                  Date               MSLLC or MPLLC Initial Review Comments                      Date      MS/MP (Area) Initial Review Status
                                   1. YELLOW - Avoid Accidents by Performing Safety Checks on Hydraulic      Rejected? – Sending on to verify Fermilab systems with                       RColl Comments: We have a strong preventive maintenance
                                   Liftgates(Source: User Submitted - ID: 2011-LL-PNNL-0005)                 Transportation would require checks of the tailgate systems                  program that takes care of problems like this. However, this is
                                                                                                             and to verify the normal operation instructions or training                  in the operations area and I would suggest to forward to BSS
                                 Inspect hydraulic liftgates on trucks daily prior to operating the          includes verifying condition of equipment before use.                        for evaluation by their transportation people as this falls in
                                 vehicle and using them for loading or unloading. Use the suggested          Could be used as an FYI for a reminder, even if things are                   their area of responsibility regarding licensing and use of
                90     17-Mar-11 Pre-operation Liftgate-Checklist to look for potential problems and                                                                            17-Mar-11                                                                      25-Mar-11       ES&H             FYI Only
                                                                                                             properly done.                                                               vehicles at Fermilab. Part of the responsibility of a driver is to
                                 equipment failures. Always obey posted warning and caution signs.
                                                                                                                                                                                          verify the condition of his vehicle. We do not have a FESHM
                                                                                                                                                                                          chapter discussing transportation. In the meantime I will
                                                                                                                                                                                          disseminate to SSOs as an FYI.


                                   2. YELLOW - Waste Containers Having High As-Found Non-Destructive         Rejected – Fermilab does not have this kind of material on                   RColl Comments: No action necessary on this Lesson Learned.
                                   Assay (NDA) Results(Source: User Submitted - ID: Y-2011-LPPORTS-0301 )    site.                                                                        Fermilab isn’t a nuclear facility and we don’t have 350 grams
                91     17-Mar-11                                                                                                                                                17-Mar-11 of U-235.                                                            25-Mar-11       ES&H         Rejected-Close
                                   Process knowledge may not be adequate to bound the quantity of
                                   fissile material in legacy containers.
                                   1. YELLOW - Unattended Water Bath Boils Dry, Causes Paper Towel to        Reject – Fermilab training, procedures and expectations                        RColl- Agree
                                   Smolder(Source: User Submitted - ID: 2011-LL-PNNL-0004)                   already require this. Also, this looks like an issue of
                                                                                                             management personal discipline.
                                   Avoid using combustible materials near a hot plate. Configure
                92     22-Mar-11 experiments safely according to requirements; and leave them                                                                                   24-Mar-11                                                                      25-Mar-11       ES&H         Rejected-Close
                                   unattended only after checking conditions and securing processes. If
                                   overheating can result in a fire or explosion, unattended electrical
                                   heating equipment must be equipped with a manual reset over-
                                   temperature shutoff switch in addition to regular temperature controls.

                                 2. BLUE - Proper Method of Investigating and Implementing Actions           Reject – Fermilab procedures (concerning root cause, incident                  RColl- Agree
                                 Associated with Condition Reports(Source: User Submitted - ID: SRSO-        investigation, corrective action, etc.) already require this and
                93     22-Mar-11 MOXS-MOX- LL-2010-306)                                                      are being rewritten for better “harmonization” between             24-Mar-11                                                                      25-Mar-11       ES&H         Rejected-Close
                                   Inappropriate investigations and use of action items can cause            areas, processes and systems.
                                   conditions adverse to quality to appear resolved before the condition
                                   is finally corrected.
                                                                                                     Reject – Fermilab training, procedures and expectations
                                   3. BLUE - Ergonomic Conditions Can Impact Work Place Safety(Source:                                                                                      1. RColl- Will distribute to the ergonomic safety
                                   User Submitted - ID: 2011-RL-HNF-0007)                            already require this. Also, this looks like an issue of                                subcommittee and SSOs as an FYI.
                                   Communication rooms can be very congested areas cluttered with    management communication, attention to detail, and area
                                   electronic equipment, wiring, transformers and conduit which can  discipline.                                                                            2. FYI, below regarding LL and determination that it may be
                                   cause ergonomic challenges for Technicians and expose them to     Could be used as an FYI for a reminder for why management                              applicable to
                                   potential unsafe conditions. Congested work areas, such as
                                                                                                     should be actively engaged in performing area “walk-                                   BSS.
                                   communication rooms should be evaluated for ergonomic as well as
                                   safety and housekeeping conditions prior to commencing work. When
                                                                                                     throughs”.
                                   unsafe conditions are found the work should be stopped and the                                                                                           Greg
                                   building manager should be informed.
                94     22-Mar-11                                                                                                                                                24-Mar-11                                                                      25-Mar-11       ES&H             FYI Only
                                                                                                                                                                                            Greg,

                                                                                                                                                                                            There may indeed be areas at the lab with conditions similar
                                                                                                                                                                                            to those described below. I will review with John and Tim and
                                                                                                                                                                                            advise you if we have any questions.

                                                                                                                                                                                            Thank you.
                                                                                                                                                                                            ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
                                                                                                                                                                                            Nanette Larson




Fermi National Accelerator Laboratory Confidential                                                                                                        5/3/2013                                                                                                                                              Page 13
                                                                                                                                                        LL Initial Review




              Item #     Date                              2012-BNL-Bungee-0001)                                OQBP LLC (ERV, JFM) Initial Review Comments                     Date                 MSLLC or MPLLC Initial Review Comments                      Date      MS/MP (Area) Initial Review Status
                                   4. YELLOW - Operator Re-entry into Radiation Exposure Room while      Sending to Don Cossairt in order to verify Fermilab systems                      We found out about this one. We actually did a self-
                                   Gamma-ray Source Was Exposed(Source: User Submitted - ID: INL-BEA-ID- would cover this and/or things like this are already done.                       assessment on this to track down improvements. We did
                                   2011-693)                                                                                                                                              actually identify some improvements and are in the process of
                                 Interlocks installed on high-hazard equipment need to include audible                                                                                    implementing them. Nancy has the draft report for her review
                                 alarms to alert workers to abnormal conditions. Warning lights and                                                                                       right now. We will enter it into FRESHtrak and track corrective
                                 computer displays are passive status indicators and should not be                                                                                        actions. I would say that our systems covered this and we did
                                 relied upon as a substitute for alarms. Interlocks for sealed-source
                                                                                                                                                                                          it.
                                 irradiators should not rely solely on the interruption of an electrical                                                                                                                                                                                  Another System Covers
                95     22-Mar-11 circuit to terminate the radiation exposure. Rather, credible                                                                                24-Mar-11                                                                        25-Mar-11        ES&H
                                                                                                                                                                                          Note - This item is not being tracked in the Fermi LL Db,                                            This - Closed
                                 engineered features need to be provided to physically dislodge or
                                 force a stuck source into the shielded position. Workers and first-line                                                                                  vbecause it was already in progress via a notice for the DOE
                                 supervisors must remain focused and vigilant when performing high-                                                                                       Site Office.
                                 hazard operations. Procedures and training need to emphasize                                                                                             "FSO (D. Parzyck) noticed it and sent it directly."
                                 consistent and systematic use of warning lights and status displays.
                                 Management must observe worker performance and continually
                                 assess the worker's ability to recognize abnormal conditions.


                                   5. GREEN - Alpha Gamma Hot Cell Facility Excess Materials and Waste          Sending to Don Cossairt in order to verify this would even                I reject this one. The lesson is truly not applicable to Fermilab.
                                   Disposition Lessons Learned(Source: User Submitted - ID: 2011-ANL-002)       apply to Fermilab.

                                   In May 2009, the effort was started to inventory, package, and ship all
                96     22-Mar-11 of the sodium-bonded irradiated nuclear fuel specimens from                                                                                  24-Mar-11                                                                        24-Mar-11        ES&H           Rejected-Close
                                   Argonne'd Alpha Gamma Hot Cell Facility (AGHCF) to Idaho National
                                   Laboratory (INL). The effort concluded with a successful shipment of
                                   the material in December 2010. Some improvement opportunities, as
                                   well as some good work practices, were noted during the course of
                                   this effort.
                                 1. YELLOW - INL Employee Fractured Their Finger in a Reciprocating Saw     Sending on to verify Fermilab systems on sub-contractor                       RColl Comments: Will be sent to SSOs as an FYI without
                                 Pinch Point while Cutting a Brace(Source: User Submitted - ID: INL-BEA-ID- management, tool purchase and existing tools need to be                       further action necessary except for internal dissemination.
                                 2011-681)                                                                  reviewed.
                                 Contractors must examine all reciprocating saws and similar cutting        This also looks an issue of improper tool handling/operation
                                 tools to determine if retrofit of the guard is needed. If needed           that could be used as an FYI for a reminder or what can
                97     23-Mar-11 purchase and install guards. Contractors should review this lessons        happen.                                                           24-Mar-11                                                                        29-Mar-11        ES&H              FYI Only
                                   learned with workers to be alert for cutting tools of this or similar type
                                   where an unguarded pinch point might exist. An unguarded
                                   mechanical pinch point on hand tools increases the risk of injury.
                                   Avoid personnel injuries by retrofitting older equipment and reviewing
                                   the hazards of such equipment with personnel.

                                   2. BLUE - Hanford Incident Management Response Protocol(Source: User         Reject? - Sending on to verify Fermilab systems would cover
                                   Submitted - ID: 2011-RL-HNF-0005)                                            this.
                                 If a facility incident command post has been established, near the
                                 event scene, the Hanford Fire Department Incident Commander may
                                 be able to arrive there in a short period of time and establish an
                                 Incident Command Post at that location. If it is a long distance away
                                 from the event scene, the Incident Commander will likely respond to
                                 the event scene first, complete size up, and identify initial objectives,
                                 and then determine where the Incident Command Post will be located.
               98a     23-Mar-11                                                                                                                                              24-Mar-11                                                                                    Physical Security Awaiting LLC Review
                                 The Incident Commander may locate the Incident Command Post near
                                 the event scene or may determine that the event can be managed from
                                 the initial command post established by the Building Emergency
                                 Director and transition to that location. Lesson: In either case the
                                 Incident Commander is always responsible for identifying the location
                                 of the Incident Command Post AND the Incident Commander is always
                                 in charge of event response upon arrival at the event scene or initial
                                 command post.




Fermi National Accelerator Laboratory Confidential                                                                                                          5/3/2013                                                                                                                                               Page 14
                                                                                                                                                    LL Initial Review

              Item #     Date                              2012-BNL-Bungee-0001)                                     OQBP LLC (ERV, JFM) Initial Review Comments             Date               MSLLC or MPLLC Initial Review Comments                   Date      MS/MP (Area) Initial Review Status
                                  3. BLUE - Hanford 2010 Field Exercise Lessons to be Learned(Source: User   Reject? - Sending on to verify Fermilab systems would cover
                                  Submitted - ID: 2011-RL-HNF-0009)                                          this.
                                 Hanford site field exercises require coordination and communication
                                 between many different organizations and various personnel. All
                                 organizations involved must understand and comply with emergency
                                 operations protocol. Lessons to be learned: Personnel responsible for
                                 notifying the Patrol Operations Center must clearly state the essential
                                 information including the assistance that is needed and stay engaged
               99a     23-Mar-11                                                                                                                                           24-Mar-11                                                                               Physical Security Awaiting LLC Review
                                 with the POC until all the necessary information has been
                                 communicated. During field exercises, protective actions must be
                                 practiced. Unless specifically exempted, everyone is required to
                                 implement the protective action identified by the warning devices.
                                 Accountability is complete when all personnel are accounted for
                                 and/or the unaccounted for are identified. After accountability is
                                 complete a new activity should be assigned to locate missing
                                 personnel.
                                  2. BLUE - Hanford Incident Management Response Protocol(Source: User       Reject? - Sending on to verify Fermilab systems would cover             Close/ The Fermi site is smaller than Hanford and the
                                  Submitted - ID: 2011-RL-HNF-0005)                                          this.                                                                   situation cannot be duplicated here as the Incident
                                 If a facility incident command post has been established, near the                                                                                  Commander and responders are all physically located in the
                                 event scene, the Hanford Fire Department Incident Commander may                                                                                     same building and area. When an emergency arises the
                                 be able to arrive there in a short period of time and establish an                                                                                  incident commander and responders deploy as a unit and not
                                 Incident Command Post at that location. If it is a long distance away
                                                                                                                                                                                     individually. In fact, the incident commander leads the parade
                                 from the event scene, the Incident Commander will likely respond to
                                 the event scene first, complete size up, and identify initial objectives,
                                                                                                                                                                                     of responders in the majority of cases. The other response
                                 and then determine where the Incident Command Post will be located.                                                                                 group is Security who stays in contact with the incident
               98b     23-Mar-11                                                                                                                                           24-Mar-11 commander by radio. Additionally, the emergency net               14-Apr-11        ES&H           Rejected-Close
                                 The Incident Commander may locate the Incident Command Post near
                                 the event scene or may determine that the event can be managed from                                                                                 broadcasts the location and the problem over the Fermilab
                                 the initial command post established by the Building Emergency                                                                                      emergency radio which alerts key personnel in all divisions
                                 Director and transition to that location. Lesson: In either case the                                                                                and sections including medical regarding the nature of the
                                 Incident Commander is always responsible for identifying the location
                                                                                                                                                                                     emergency and the location. Our response system has
                                 of the Incident Command Post AND the Incident Commander is always
                                                                                                                                                                                     designated the battalion chief from the Fermi FD as the
                                 in charge of event response upon arrival at the event scene or initial
                                 command post.                                                                                                                                       incident commander.


                                  3. BLUE - Hanford 2010 Field Exercise Lessons to be Learned(Source: User   Reject? - Sending on to verify Fermilab systems would cover               Close/ Emergency situations are practiced during the year and
                                  Submitted - ID: 2011-RL-HNF-0009)                                          this.                                                                     desktop exercises planned to test the emergency response
                                 Hanford site field exercises require coordination and communication                                                                                   system up to an including activating the emergency response
                                 between many different organizations and various personnel. All                                                                                       center. This was placed into action in 2010 when actual
                                 organizations involved must understand and comply with emergency                                                                                      emergencies arose. As is customary, a critique is held to
                                 operations protocol. Lessons to be learned: Personnel responsible for
                                                                                                                                                                                       evaluate the response to see if improvements are necessary
                                 notifying the Patrol Operations Center must clearly state the essential
                                 information including the assistance that is needed and stay engaged
                                                                                                                                                                                       after each activation.
               99b     23-Mar-11                                                                                                                                           24-Mar-11                                                                   14-Apr-11        ES&H           Rejected-Close
                                 with the POC until all the necessary information has been
                                 communicated. During field exercises, protective actions must be
                                 practiced. Unless specifically exempted, everyone is required to
                                 implement the protective action identified by the warning devices.
                                 Accountability is complete when all personnel are accounted for
                                 and/or the unaccounted for are identified. After accountability is
                                 complete a new activity should be assigned to locate missing
                                 personnel.
                                  4. BLUE - Software Change Results in Inadvertent Data Change(Source:       Reject Vs Cyber security because the systems would protect                Hi Ed,
                                  User Submitted - ID: 2011-ID-AMWTP-0005)                                   from unintentional change and corruption? - Sending on to
                                 When developing new software design requirements, evaluate the              verify Fermilab systems would cover this.                               I don't see any Computer Security issues. You might want to
                                 impact of the proposed changes prior to approval. Approved changes                                                                                  contact Mike Kaiser, our Change Manager, to verify any
                                 were made to AMWTP software that should have only affected data                                                                                     applications within our current Change Management
              100a     23-Mar-11 generated after the date that the software change was initiated. The                                                                      24-Mar-11                                                                   28-Mar-11 Cyber Security        Rejected-Close
                                                                                                                                                                                     processes.
                                 requirements for the software change were stated in a manner that
                                 resulted in the alteration of existing data that was not intended to be
                                 changed. This resulted in the issuance of a formal Corrective Action                                                                                  Thanks and let me know if you have more questions.
                                 Report and rework in the form of a System Change Request to correct
                                 the data.                                                                                                                                             Ron c.

Fermi National Accelerator Laboratory Confidential                                                                                                     5/3/2013                                                                                                                                            Page 15
                                                                                                                                                        LL Initial Review

              Item #     Date                               2012-BNL-Bungee-0001)                                      OQBP LLC (ERV, JFM) Initial Review Comments              Date                MSLLC or MPLLC Initial Review Comments                    Date      MS/MP (Area) Initial Review Status
                                   4. BLUE - Software Change Results in Inadvertent Data Change(Source:        Sent to Mike Kaiser of CD for Change Management process                    Regarding the BLUE - Software Change Results in Inadvertent
                                   User Submitted - ID: 2011-ID-AMWTP-0005)                                    review.                                                                    Data Change DOE Lesson Learned (2011-ID-AMWTP-0005 ), I
                                 When developing new software design requirements, evaluate the                                                                                           Accept as an "FYI".
                                 impact of the proposed changes prior to approval. Approved changes
                                 were made to AMWTP software that should have only affected data
                                                                                                                                                                                                                                                                        Information
              100b     23-Mar-11 generated after the date that the software change was initiated. The                                                                         31-Mar-11                                                                     7-Apr-11                         FYI Only
                                 requirements for the software change were stated in a manner that
                                                                                                                                                                                                                                                                         Technology
                                 resulted in the alteration of existing data that was not intended to be
                                 changed. This resulted in the issuance of a formal Corrective Action
                                 Report and rework in the form of a System Change Request to correct
                                 the data.
                                   1. BLUE Safe Operation of Kubota Model 1100 RTVs in Cold Temperatures       Sending to Dave Carlson to see if we even have this item and               03/29/11: Dave Carlson, BSS, is having a search done for
                                   (Source: User Submitted - ID: 2011-UTB-ORNL-0008)                           if it applies.                                                             equipment at the lab:
                                   At temperatures below 35², Kubota Model 1100 RTV's must be allowed
                                   to warm-up 10-15 minutes to ensure proper operation of the hydraulic 03/30/11: Sent to Bruce Chrisman for decision based upon                          Gary,
                                   system. A combination of cold temperatures and water in the            equipment at Fermilab being owned by FESS.
                                   hydraulic system from outside storage could result in a failure of the
                                                                                                                                                                                        In Jack's absence this week, can you please check the Property
                                   hydraulic system filter imploding, thus, leading to loss of steering
                                   control and the release of hydraulic fluid to the environment. This
                                                                                                                                                                                        database and run me a list of all the Kubota "vehicles" and
                                   warm-up exercise allows any moisture in the hydraulic system to thaw                                                                                 who owns which ones? I think FESS has some. We are
                                   prior to putting the vehicle in motion.                                                                                                              interested in model number 1100 so please show model
               101     29-Mar-11                                                                                                                                              29-Mar-11 numbers if you have them. See the Lessons Learned below,            13-Apr-11    Operations      Rejected-Close
                                                                                                                                                                                        and comment back to this distribution only for now.

                                                                                                                                                                                          Thanks,
                                                                                                                                                                                          Dave

                                                                                                                                                                                          On Apr 13, 2011, at 4:38 PM, Randy Ortgiesen wrote:

                                                                                                                                                                                          For both the R&G and engineering Kabota's we had previously
                                                                                                                                                                                          reviewed the winter operations portion of the operating
                                   1. GREEN - Steel Worker Falls, Caught by Safety Harness, Lanyards, and      Recommend considering this as a good example to share as                   RColl Comments: I already use examples in my so Fermilab
                                                                                                                                                                                          manual and include this in our training sessionsfall protection
                                   Beam Crawlers(Source: User Submitted - ID: TJNAF-341-03-25-2011)            an FYI and/or use in training materials.                                 course. However, this particular one is more geared to steel
                                                                                                                                                                                        erection and I do not address this in my class because I do not
                                 A steel worker was saved from injury by following construction contractor                                                                              provide training to construction personnel.
                                 policy to use 100% fall protection (double tie off). The URL following this                                                                            It will be in my folder if and when I provide advice to
               102     29-Mar-11                                                                                                                                              30-Mar-11                                                                     29-Mar-11       ES&H             FYI Only
                                 sentence links to a brief video demonstrating the tie off technique.                                                                                   construction contractors during a walkthrough. I will also send
                                 http://www.youtube.com/watch?v=Qg5rXXPNoTc                                                                                                             a copy to Tom Gibbs and John Cassidy of the ES&H Section
                                                                                                                                                                                        whose group deals exclusively with construction personnel.
                                                                                                                                                                                        who does walkthroughs of construction sites.


                                   1. YELLOW - Tingle Event at the B-Area Fire Water Tank - Do Not Always  Reject? - Sending on to verify Fermilab systems would cover                    RColl Comments: Rejected. This is more in line with
                                   Assume That Work Conditions Are Safe(Source: User Submitted - ID: 2011- this.                                                                          maintenance and operations and not safety management
                                   SR-SRNS-0007)                                                           Could be used as an FYI.                                                       systems.
               103     30-Mar-11 Workers working in the field around equipment and outside of a lock-                                                                         30-Mar-11                                                                     30-Mar-11       ES&H         Rejected-Close
                                   out boundary should not assume that conditions are safe, have
                                   remained safe, and are up to current code since the original
                                   equipment installation.
                                   2. BLUE - Inadequate Design Development and Review for Seismic Air          Do not know who to go to review this. This looks to be an                  I Accept as "FYI" - Peter - Re: Reminder - this DOE lesson is
                                   Purge Modification(Source: User Submitted - ID: 2011-SR-SRNS-0008)          Engineering System issue.                                                  needing your review and input.

                                   During the design development and review process, personnel should After review with Bob Grant for a recommendation on person                        Of course, that is a basic feature of any QA plan. I am sure
               104     30-Mar-11 ensure that adequate reviews are completed to identify design                 to contact, lesson sent to Peter Garbincius.                   30-Mar-11 that this is in our QA documents and Engineering Manual. But        11-Apr-11    Engineering         FYI Only
                                   requirements, potential process changes, and field installation issues.                                                                              it is always good to be reminded to include all the stake-
                                   Failure to involve all the stake-holders can result in some aspects of
                                                                                                           Also, met with Peter and discussed what was going to be sent.                holders.
                                   the design, installation, or operation from being in compliance with
                                   facility requirements or fail to meet design expectations.


Fermi National Accelerator Laboratory Confidential                                                                                                            5/3/2013                                                                                                                                       Page 16
                                                                                                                                                     LL Initial Review

              Item #     Date                               2012-BNL-Bungee-0001)                                    OQBP LLC (ERV, JFM) Initial Review Comments                 Date                MSLLC or MPLLC Initial Review Comments                   Date      MS/MP (Area) Initial Review Status
                                  1. BLUE - Results of Paducah Transportation Compliance                     Sending to Quality to review:                                                 Reject as our systems already accomodate this lesson.
                                  Assessment(Source: User Submitted - ID: 2011B-LL-LATA-O201)                This appears to be about change management for corrective
                                 Preparation for transition to a new contractor impacts effective            action plans or action plans and ensuring all items are truly
                                 communication amongst functional groups and the availability of key         done or closed as well as all stakeholders know what is going
               105     31-Mar-11 personnel that are critical in closure of corrective actions. During                                                                          31-Mar-11                                                                    9-Apr-11        Quality         Rejected-Close
                                                                                                             on – communication. Need to verify the system and./or
                                 transitions, existing processes are introduced to new management,
                                                                                                             processes would adequately cover this.
                                 new key personnel, new schedules, new programs, new policies, and
                                 new procedures. Transition can adversely affect completion of
                                 corrective actions in process.
                                  2. BLUE - Partially Engaged Lifting Magnet(Source: User Submitted - ID:    Reject? – this would appear to be a violation of work process                 RColl Comments: Sent to SSOs as an FYI with no further action
                                  LBNL-LL11-0010)                                                            controls and/or job planning and analysis. An issue of                        necessary except for internal distribution if usable.
                                 Limited familiarity with a locking mechanism on a lifting magnet            discipline? Fermilab’s procedures would seem to cover this.
                                 resulted in a dropped load. It is possible to partially engage the          Could send as an fyi to AD.
                                 magnet and have it not be immediately obvious to a user unfamiliar
                                 with the mechanism. During a lift of an 18 inch square steel plate,
                                 weighing approximately 90 lbs, the lifting magnet failed to hold the
                                 load. The plate dropped approximately two feet to a pallet. The magnet
                                 operating mechanism was not oriented in the fully engaged position
                                 when it failed. There were no injuries, and no damage to the plate or
                                 shop floor. On Friday March 11, 2011, technicians were using a lifting
                                 magnet to load and unload steel plates in a vertical milling machine to
                                 drill a hole pattern. They had just attached the magnet to a completed
                                 plate and were using the overhead bridge crane to move and place it
               106     31-Mar-11                                                                                                                                               31-Mar-11                                                                    31-Mar-11        ES&H              FYI Only
                                 on a pallet nearby. The steel plates were one inch thick and 18 inches
                                 square and weighed approximately 90 pounds. The two operators
                                 were moving the plate with one person operating the crane and the
                                 other guiding the plate around some nearby shop machines. During
                                 the move the plate was roughly two feet off the floor. The magnet was
                                 suspended from the crane by a nylon sling and a shackle through the
                                 bail of the lifting magnet. By the nameplate rating for this material and
                                 surface condition, this lifting magnet is expected to have a lifting
                                 capacity of 750 lbs. As the operators approached the destination
                                 pallet, the plate disengaged from the magnet and fell to the floor
                                 unexpectedly. A stop work was called and an unofficial investigation
                                 was started to determine what caused the disengagement. There were
                                 no injuries or equipment damage from the dropping plate.


                                  3. BLUE - Protection of Government Property on a D&D Project with          Sent to Security for review:
                                  Limited Security Fencing(Source: User Submitted - ID: B-2011-OR-BJCBS-
                                  0302)                                                                      Rejected? - Does not seem to convey much in the way of a
                                 As remediation work and reindustrialization activities increase the         lesson. It looks like common sense and probably practices we
                                 footprint of the East Tennessee Technology Park, Security activities        would consider. However, I do not know what in the Fermilab
               107     31-Mar-11 are decreasing and access to areas once restricted is more                                                                                    31-Mar-11                                                                                Physical Security Awaiting LLC Review
                                                                                                             systems or processes would force this to be reviewed. So, I
                                 accessible. Thus, a reduction in security activities can result in
                                                                                                             am forwarding to you for review. Assuming this is rejected,
                                 property control issues.
                                                                                                             please explain what would ensure this kind of situation would
                                                                                                             get a review.

                                  1. Initial Data Loading for New Enterprise Resource Planning System or     Sending to Project Management to review:                                      I Reject this leasons learned as having applicability to OPMO.
                                  Module(Source: User Submitted - ID: PMLL-2011-BWY12-MOM-0001)              This appears to be about change management and/or
                                                                                                             planning and testing for software/project management tools
               108     31-Mar-11 When implementing a commercial-off-the-shelf (COTS) Enterprise              implementation. Need to verify the system and./or                 31-Mar-11                                                                    12-Apr-11    Project Mgmt       Rejected-Close
                                  Resource Planning (ERP) system or module, it is critical to perform        processes would adequately cover this.
                                  early data loads using actual production data to ensure system
                                  configuration and the augmenting custom software function properly.

                                  1. TA-21 Coordination iwth EP Base Programs leads to Building TA-21-209    Rejected – This should actually probably to Engineering as a                  Not sent to LLC
                                  D&D Cost Savings and Less Dangerous Work(Source: User Submitted - ID:      good practice if it was going to be evaluated further. This is
               109     1-Apr-11   PMLL-2011-LANL-ARRA-TA-21 DP East-003)                                     not being evaluated further, because Fermilab’s processes         1-Apr-11                                                                     1-Apr-11      Engineering       Rejected-Close
                                  TA-21 Coordination with EP Base Programs leads to Building TA-21-          requires a Value Engineering review for options including risks
                                  209 D&D Cost Savings and Less Dangerous Work                               and costs.


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                                                                                                                                                        LL Initial Review




              Item #     Date                               2012-BNL-Bungee-0001)                                     OQBP LLC (ERV, JFM) Initial Review Comments                   Date                  MSLLC or MPLLC Initial Review Comments                   Date      MS/MP (Area) Initial Review Status
                                  2. Prepare interface control document involving all parties.(Source: User   Reject? – This would seem to be a good practice, but I would                    I reject this lessons learned, because I believe we functionally
                                  Submitted - ID: PMLL-2011-LANL-ARRA-MDA-B-0004)                             expect this is the requirement today under Roles and                            do the same thing by inhancing the roles discribed in the PEP
               110     1-Apr-11                                                                               Responsibilities in the project plan or as part of things like a    1-Apr-11    in the Project Management Plan (PMP) and in the Memo of            12-Apr-11   Project Mgmt     Rejected-Close
                                  Prepare interface control document involving all parties.                   Communication Plan or Change Control Plan.                                      Understandings (MOUs).


                                  1. BLUE - Personnel Contamination and Potential Chemical                    Reject? – This looks like two issues to me:                                     Ed,
                                  Exposure(Source: User Submitted - ID: 2011-ANL-004)                         - A lack of discipline or planning issue, and
                                  Improper personal protective equipment (PPE), used in packaging             - There is not enough detail in what they changed to improve                    I concur with your recommendation to reject this one. It is,
               111     1-Apr-11   mixed waste, caused personnel contamination with a potential
                                                                                                                                                                                  1-Apr-11                                                                       1-Apr-11        ES&H         Rejected-Close
                                                                                                              things to tell how to apply it to Fermilab.                                     indeed, difficult to figure out how to apply it here.
                                  chemical exposure, in Radiological Buffer Area (RBA).                       Sending to Don Cossairt to review.
                                                                                                                                                                                              Don
                                  1. BLUE - Software change results in inadvertent impact to the display of   Reject? – This looks like to me an improperly done                              Regarding the BLUE - Software change results in inadvertent
                                  historical record(Source: User Submitted - ID: 2011-ID-AMWTP-0005)          requirements assessment and a lack of later more detailed                       impact to the display of historical record(2011-ID-AMWTP-
                                                                                                              design review.                                                                  0005), I Accept as an "FYI".
                                  When developing new software design requirements, evaluate the              Sending to Mike Kaiser for review versus the Fermilab
                                  impact of the proposed changes prior to approval. Approved changes          Software Change Management process.                                             Please let me know if you need anything else from me.
                                  were made to AMWTP software that affected the new and historical
                                  records when the desired result was to only affect the display of
                                  records generated after the date that the software change was                                                                                                                                                                              Information
               112     1-Apr-11                                                                                                                                                   1-Apr-11                                                                       11-Apr-11                        FYI Only
                                  initiated. The requirements for the software change were stated in a                                                                                                                                                                        Technology
                                  manner that did not address the need to differentiate the application of
                                  the change between data generated before the change and data
                                  generated after the change, which resulted in an inaccurate display of
                                  historical records when accessed with the modified software. This
                                  resulted in the issuance of a formal Corrective Action Report and
                                  rework in th e form of a System Change Request to correct the
                                  historical records.
                                  1. YELLOW - Eliminating Non-flame Retardant Wiring Will Reduce the    This one seems like it could and should apply to at least some                        Rejected by ESH. This LL needs to be routed to the
                                  Severity of Fires (Source: User Submitted - ID: 2011-CH-BNL-C-AD-0001)thing at the site. I do not know if this is something normally                        Engineering LLC.
                                                                                                        considered in the JHAs for updating or working on electrical
              113a     5-Apr-11   Wires that pre-date 1970 and are used to power electromagnetic relays systems at Fermilab, especially since there are many older                5-Apr-11                                                                       14-Apr-11       ES&H         Rejected-Close
                                  configured in stacks must be considered as flammable fuel loading     items at Fermilab.
                                  near an ignition source.                                              I would recommend a Safety Committee review and sending
                                                                                                        this as at least an FYI.
                                  1. YELLOW - Eliminating Non-flame Retardant Wiring Will Reduce the    This one seems like it could and should apply to at least some                        04/14/11 - Sent to Operations and Engineering for decision on
                                  Severity of Fires (Source: User Submitted - ID: 2011-CH-BNL-C-AD-0001)thing at the site. I do not know if this is something normally                        who should review.
                                                                                                        considered in the JHAs for updating or working on electrical
              113b     5-Apr-11   Wires that pre-date 1970 and are used to power electromagnetic relays systems at Fermilab, especially since there are many older                14-Apr-11                                                                      19-Apr-11    Engineering         FYI Only
                                  configured in stacks must be considered as flammable fuel loading     items at Fermilab.
                                  near an ignition source.                                              I would recommend a Safety Committee review and sending
                                                                                                        this as at least an FYI.
                                  1. BLUE - Event Scene Personnel Response to Protective Actions(Source:      Don, I am thinking this could be reviewed by Bill Flaherty, Bill                Don Cossairt's response:
                                  User Submitted - ID: 2011-RL-HNF-0012)                                      James, and/or you. Since it was from a radiological training                    Certainly let the two “Bill’s” respond, but I think we have this
                                                                                                              issue, I sent it to you.                                                        covered with the cross training Security and Fire Departments
                                                                                                              It would appear incident commanders and the response                            have with outside authorities.
                                                                                                              teams would coordinate and escalate or adjust to changes in                     Indeed, this issues is a key reason why we have our onsite Fire
                                                                                                              circumstances in the Fermilab system I also realize this site’s                 Department. This could be verified by asking Jack Steinhoff.
                                                                                                              alarms and responses are tailored to them. What is not clear
                                                                                                              to me is could something like this occur at Fermilab, would                     Bill James response:
                                                                                                              people know or have a set of rules/guidelines to follow on                      This is not applicable to FNAL-- period. We do not rely on
                                                                                                              when things change versus what to do and how do we know                         sounds to convey messages to our population.
Fermi National Accelerator Laboratory Confidential                                                                                                          5/3/2013                                                                                                                                              Page 18
                                                                                                              people have the level of familiarity allow them to respond in a                 Our system is based on protocols appropriate to the hazards
                                                                                                              live (or drilled) condition. Thus, I am asking for an evaluation.               present and the size of the site….and the use of VOICE
                                                                                                                                                      LL Initial Review
                                                                                                           Don, I am thinking this could be reviewed by Bill Flaherty, Bill                 Don Cossairt's response:
              Item #     Date                              2012-BNL-Bungee-0001)                           James, and/or LLC (ERV, JFM) Initial Review Comments
                                                                                                                    OQBP you. Since it was from a radiological training           Date                 MSLLC or “Bill’s” respond, but think we have this
                                                                                                                                                                                            Certainly let the twoMPLLC Initial Review IComments                  Date      MS/MP (Area) Initial Review Status
                                  Facility Emergency Response Organization personnel located outside issue, I sent it to you.                                                               covered with the cross training Security and Fire Departments
                                  a facility were confused as to their proper response when they heard     It would appear incident commanders and the response                             have with outside authorities.
                                  an area take cover siren. In this situation, Emergency Response          teams would coordinate and escalate or adjust to changes in                      Indeed, this issues is a key reason why we have our onsite Fire
                                  personnel were not required to shelter as they were providing the
                                                                                                           circumstances in the Fermilab system I also realize this site’s                  Department. This could be verified by asking Jack Steinhoff.
                                  necessary support to mitigate the event. Leaving the event scene
                                  could result in the delay of necessary mitigative actions to correct the
                                                                                                           alarms and responses are tailored to them. What is not clear
                                  emergency condition.                                                     to me is could something like this occur at Fermilab, would                      Bill James response:
                                                                                                           people know or have a set of rules/guidelines to follow on                       This is not applicable to FNAL-- period. We do not rely on
                                                                                                           when things change versus what to do and how do we know                          sounds to convey messages to our population.
                                                                                                           people have the level of familiarity allow them to respond in a                  Our system is based on protocols appropriate to the hazards
                                                                                                           live (or drilled) condition. Thus, I am asking for an evaluation.                present and the size of the site….and the use of VOICE
                                                                                                                                                                                            instructions
                                                                                                                                                                                            Outdoor warning sirens are used to warn personnel of an
               114     7-Apr-11                                                                                                                                                 7-Apr-11    approaching tornado and for personnel who are out of doors         7-Apr-11        ES&H         Rejected-Close
                                                                                                                                                                                            to move inside a building; at the same time indoor voice
                                                                                                                                                                                            devices are activated advising personnel to move to
                                                                                                                                                                                            designated tornado shelters. Follow-up voice messages are
                                                                                                                                                                                            issues based on the length of the storm and its aftermath.
                                                                                                                                                                                            (ESTABISHED PROCEDURE)
                                                                                                                                                                                            All buildings have internal alarm devices indicating when
                                                                                                                                                                                            personnel are to evacuate the area, many of which are ties
                                                                                                                                                                                            into our dispatch system and will automatically dispatch the
                                                                                                                                                                                            Fire and Security element to the scene and they will take
                                                                                                                                                                                            charge as IC.
                                                                                                                                                                                            At anytime the IC or Lab Director has the ability to transmit
                                                                                                                                                                                            instructions to the Lab population directing specific actions to
                                                                                                                                                                                            take. (More continued below)
                                                                                                                                                                                            What this other lab does as to its use of sirens and means of
                                  1. BLUE - Operating on Cultural Resource Sites(Source: User Submitted -     Need your review versus environmental and task or job                         Response to and #4 Reject. The has nothing to do with
                                                                                                                                                                                            notifications LL is required actionslab has mechanisms in place
                                  ID: 2011-RL-HNF-0016)                                                       management. It would seem Fermilab’s work/task analysis                     to address the impact to cultural resources prior to the
                                 When work is to be conducted within a cultural resource site, it is          and risk analysis for environmental should or does cover this               commencement of a project. We use our Environmental
                                 essential that a thorough structured cultural resource review and            kind of thing. Thus, why I am send to you for review.                       Evaluation and Notification Form (EENF) in the NEPA review
               115     12-Apr-11 approval process be completed. Any disturbance of a cultural                                                                                   13-Apr-11                                                                      20-Apr-11       ES&H         Rejected-Close
                                                                                                                                                                                          process to evaluate potential impacts. Cultural (archeological)
                                 resource site, its setting, artifacts, features, and / or ground surface
                                                                                                                                                                                          resources of the site are described in our Cultural Resources
                                 may be deemed as adverse. Adverse effects to a cultural resource site
                                 must be mitigated which is costly, time consuming, and has far
                                                                                                                                                                                          Management Plan.
                                 reaching business implications.
                                  2. YELLOW - Buyer Beware: Unmarked Hazards in Second/Third-Party            FYI only? This looks like something that should be reviewed                 RColl Comments: Rejected. We have a FESHM that requires
                                  Purchase (Source: User Submitted - ID: 2011-CH-BNL-DA-0001)                 by ES&H or a sub-committee. It appears to me the                            SSO review of purchases that may contain a hazardous
                                                                                                              Engineering Manual, JHA process, and Procurement processes                  material. Also, the ProCard purchase manual restricts
               116     12-Apr-11 Buyer beware. The purchase of commercially available items through           cover the responsibilities to examine for these kinds of risks.   13-Apr-11 dangerous items from being purchased with a ProCard.                 13-Apr-11       ES&H         Rejected-Close
                                  the internet or a second-or third-party transaction is risky when those     Thus, why I thought this might only be used as a reminder.
                                  items contain hazardous materials (e.g., radioactive, chemical, etc.)
                                  and there is no history associated with the vendor.

                                  3. BLUE - 230 Kilovolt Power Distribution Line Induces Static          Reject or FYI only? It appears to me the Job analysis, task                        RColl Comments: Rejected. This is known fact and not a lesson
                                  Charge(Source: User Submitted - ID: 2011-RL-HNF-0017)                  management and JHA processes cover the responsibilities to                         for those who work with electrical energy. Additionally we
                                  High voltage electrical transmission lines create many safety hazards. examine the task, job site, and work duties these kinds of risks.                  work with distribution systems and not High Voltage
                                  Working in proximity to high voltage power lines requires additional                                                                                      transmission lines like ComEd.
               117     12-Apr-11 precautions to ensure adequate worker protection. Induction of a                                                                               13-Apr-11                                                                      13-Apr-11       ES&H         Rejected-Close
                                  static charge is a potential hazard which often goes unrecognized.
                                  Recognition and inclusion of the potential for an induced static charge
                                  should be part of work site hazard assessment.

                                 4. GREEN - Evaluation of Facility Checklist Requirements May Result in Cost Fyi only or possibly accept for further evaluation? This seems                 … reject as we already do it.
                                 Efficiencies(Source: User Submitted - ID: G-2011-OR-BWY12-0203)             to be an item Operations, FESS and/or Building Managers
                                                                                                             might want to review, especially given the current budget
               118     12-Apr-11                                                                                                                                                                                                                               21-Apr-11    Operations      Rejected-Close
                                 Evaluation of a Twelve-hour Checklist to eliminate unnecessary              climate. I am not assuming this is not currently done, but I
                                 activities leads to cost efficiencies.                                      thought this lesson needed further review for doing
                                                                                                             something like it at Fermilab.

Fermi National Accelerator Laboratory Confidential                                                                                                        5/3/2013                                                                                                                                              Page 19
                                                                                                                                                      LL Initial Review




              Item #     Date                              2012-BNL-Bungee-0001)                                   OQBP LLC (ERV, JFM) Initial Review Comments                    Date              MSLLC or MPLLC Initial Review Comments                      Date      MS/MP (Area) Initial Review Status
                                   1. BLUE - Removable Beryllium Contamination on Radiological              Needs review by Radiological SME. I do not know if                              We do not have any radiation instruments with beryllium
                                   Instrumentation(Source: User Submitted - ID: 2011B-LL-LATA-0232)         equipment like this exists at Fermilab.                                         windows and therefore this lessons-learned is not applicable.
               119     14-Apr-11                                                                                                                                                15-Apr-11                                                                     15-Apr-11       ES&H         Rejected-Close
                                   Actively used radiological instrumentation with entrance windows
                                   constructed from beryllium metal should be routinely inspected for
                                   removable beryllium.
                                   2. YELLOW - Adverse Trend in Lockout/Tagout Performance(Source: User     Need review by ES&H and/or other LOTO program experts to                      RColl Comments: Rejected. Fermilab uses a permit and HA
                                   Submitted - ID: WRPS-2011-IB-012)                                        determine if any of these issues may be present within the                    process exclusively for electrical work (See FESHM 5042) that
                                 Setting and enforcing expectations for Lockout/Tagout (LO/TO)              Fermilab system.                                                              would prevent these trends. The remainder of the lesson
                                 performance, analyzing and addressing precursor issues, monitoring                                                                                       points to lack of supervision (supervisor quality) and lack of
                                 trends and reviewing operating experience are all important for a
               120     14-Apr-11 healthy LO/TO program. Washington River Protection Solutions                                                                                   15-Apr-11 work ethics that cannot be regulated except by disciplinary         15-Apr-11       ES&H         Rejected-Close
                                                                                                                                                                                          actions.
                                 (WRPS) identified an adverse trend in LO/TO performance, and has
                                 since established a single point of authority to ensure continued focus
                                 on these areas. Flawless performance of Lockout/Tagout (LO/TO)
                                 activities is imperative, due to the potential for injury or death of
                                 personnel.
                                   3. YELLOW - Trolley Crane Operator Experiences Shock while Holding      I would assume either Engineering and/or JHA processes                           RColl Comments: Rejected. We have instituted a preventive
                                   Crane's Control(Source: User Submitted - ID: RCCC-2011-0004)            should review the requirements to do something like what is                      maintenance program that is controlled by FESS and uses
                                                                                                           described in this lesson. I would further expect these                           commercial contractors to maintain the overhead cranes.
                                 When inheriting legacy equipment, a thorough examination is in order processes would consider this situation a non-normal
                                 when it is anticipated the equipment will be utilized. This should        condition due to not knowing many items about the
                                 include examining the original manufacturer's manual to understand        equipment and/or just strictly on code/safety requirements
                                 the operating system of the equipment when it was installed and what
               121     14-Apr-11                                                                           changes since the machine or tool was manufactured and last          15-Apr-11                                                                     15-Apr-11       ES&H         Rejected-Close
                                 current condition it is in. This will help to determine if more intensive
                                 maintenance is needed before using the equipment.
                                                                                                           used. However, I do not know if we would have anything at
                                                                                                           Fermilab that is this old or prone to being “inherited or
                                                                                                           reactivated” and if Fermilab would be vulnerable to an issue.
                                                                                                            Since I do not know if the previous items are true, I am
                                                                                                           forwarding to ES&H for review.

                                   4. BLUE - DNFSB Activity Level Work Planning and Control Process         Need review by ES&H/JHA program experts to determine if                         RColl comments: Rejected. Fermilab already operates at the
                                   Observations(Source: User Submitted - ID: RCCC-2011-0007)                any of these issues may be present within the Fermilab                          level DNSFB recommends.
               122     14-Apr-11 Following a review of activity-level work planning and control             system.                                                             15-Apr-11                                                                     15-Apr-11       ES&H         Rejected-Close
                                   processes and their implementation, the Defense Nuclear Facilities
                                   Safety Board (DNFSB) provided observations for process
                                   enhancements.
                                   5. BLUE - Contaminated Material left in Non-Radiological Area(Source:    Needs review by Fermilab Radiological and/or Hazardous                          Due the limited extent of removable radiological
                                   User Submitted - ID: 2011-RL-HNF-0013)                                   Material Transport, Storage and Disposal SME’s. I do not                        contamination and the high quality of our waste handling
                                   Radioactive material with actual or potential radioactivity above        know if procedures would prevent and/or catch an issue like                     procedures, this lessons-learned is of no value to Fermilab.
               123     14-Apr-11 specific thresholds must be identified, stored and or controlled.                                                                              15-Apr-11                                                                     15-Apr-11       ES&H         Rejected-Close
                                                                                                            this.
                                   Materials destined for scrap recycling areas have been surveyed and
                                   released prior to delivery or drop off at recycle areas.

                                   1. YELLOW - Neighborhood Electric Vehicles Roll After Parking (Source:   Lesson does not provide a specific type, brand, or model of                     RColl Comments: Accepted as an FYI. I will brief this LL at the
                                   User Submitted - ID: 2011-OR-BWY12-0401)                                 vehicle. I do not know if all NEV’s could have this problem                     next SSO meeting. Please enter in the ES&H LL Database and
                                   Effective parking of Neighborhood Electric Vehicles (NEV) requires       and if Fermilab has any of NEV’s. Sending for review to                         also download the attachment that comes with it as a psf file.
               124     19-Apr-11 attention to detail to ensure they do not roll unexpectedly.               determine what kinds of electric vehicles Fermilab has, if any,     19-Apr-11                                                                     19-May-11       ES&H             FYI Only
                                                                                                            and then, if there is a potential issue similar to the one listed
                                                                                                            in the lesson.
                                   1. YELLOW - Loss of Insulation Vacuum of the Right-HRS Quadruple         Sent to Peter Garbincius for instructions on how he would like                  I think this should be an FYI to AD, PPD, and TD Heads (Roger
                                   Q1(Source: User Submitted - ID: TJNAF-344-04-18-2011)                    to handle lessons like this.                                                    Dixon, Mike Lindgren, Giorgio Apollinari).

                                                                                                            "I can reject this kind of item and not forward to you for
                                                                                                            review if it is acceptable with you.

                                                                                                            To me, this lesson does not provide enough details for you to
Fermi National Accelerator Laboratory Confidential                                                                                                         5/3/2013
                                                                                                            evaluate if relates only to a specific instance, it is a                                                                                                                                           Page 20
               125 19-Apr-11                                                                                fundamental system or process flaw within the engineering           19-Apr-11                                                                     19-Apr-11    Engineering         FYI Only
                                                                                                            system, and/or what would really need to be done differently.
                                                                                                                                                        LL Initial Review

                                                                                                               Sent to Peter Garbincius for instructions on how he would like                 I think this should be an FYI to AD, PPD, and TD Heads (Roger
                                                                                                               to handle lessons like this.                                                   Dixon, Mike Lindgren, Giorgio Apollinari).
              Item #     Date                               2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments                 Date                  MSLLC or MPLLC Initial Review Comments                Date      MS/MP (Area) Initial Review Status
                                   Improvements in design, planning and work controls would have               "I can reject this kind of item and not forward to you for
                                   prevented loss of vacuum during experiment.                                 review if it is acceptable with you.

                                                                                                               To me, this lesson does not provide enough details for you to
                                                                                                               evaluate if relates only to a specific instance, it is a
               125     19-Apr-11                                                                               fundamental system or process flaw within the engineering          19-Apr-11                                                                   19-Apr-11    Engineering         FYI Only
                                                                                                               system, and/or what would really need to be done differently.
                                                                                                                Thus, I would normally consider rejecting this.

                                                                                                               Please let me know how to proceed – do you want to evaluate
                                                                                                               this lesson or not and how you want to handle things like this
                                                                                                               lesson in the future. "


                                                                                                         How does Fermilab keep animals like rabbits, mice and birds
                                   1. BLUE - Feeding of Wildlife leads to Contamination Spread by Biological                                                                                  Don Cossairt recommends we reject based upon risk, our
                                   Vectors(Source: User Submitted - ID: RCCC-2010-0021)                  from getting exposure and/or taking something like wild                              procedures cover this, and we review environmental routinely
                                 Radioactive material was found to have been spread outside              flower seed or plants outside the boundary? (I realize                               conditions.
                                 radiological boundaries by rodents following the demolition of the 327 Hanford has a different level of material and risk based on                           Eric agreed.
                                 Facility in the 300 area of Hanford. The actual safety significance was what they have at the site.)
               126     20-Apr-11 ultimately low and limited to a small area. However, the implications                                                                            20-Apr-11                                                                                   ES&H       Awaiting SME Review
                                   went far beyond the actual safety significance. The occurrence
                                   became the subject of satire by the news-media and ultimately
                                   consumed far more resources than would have been expended to
                                   have prevented its occurrence.

                                                                                                      Reject? This appears to be a failure to follow existing
                                   1. YELLOW - Hot Cell Fire Due to Size Reducing Activities (ARRA)(Source:                                                                                 Rejected. This one is due to not following established
                                   User Submitted - ID: TWPC-LLI-2011-04-002)                         procedures and/or a lack of awareness. Also, Fermilab has                             procedures thus it is a management failure not a safety
               127     21-Apr-11 Personnel must always be alert of changing conditions. Personnel did work planning and JHA procedures requiring the items noted                  21-Apr-11 program failure.                                                  2-May-11        ES&H         Rejected-Close
                                 not recognize the hazards and conditions that resulted in a fire     as an issue be done.
                                   involving spent HEPA filters in the Building 7880 Hot Cell during size
                                   reduction activities.
                                   2. BLUE - Managing Fabrication and Delivery of Vital Time-Critical          Reject? This looks like to me this kind of situation would be                  Reject, this is already covered in our procurement processes.
                                   Equipment(Source: User Submitted - ID: 2011-RL-HNF-0018)                    already be covered under Fermilab's procedures, especially
                                   Dispatching key technical and quality experts to a manufacturer's           JHA, and is a normal expectation to do one's work. It should
                                   facility ensured that vital time-critical equipment was restored            be a normal part of business and any response plan should
                                   promptly.                                                                   examine types of personnel are needed, their qualifications
                                                                                                               and match the correct personnel to the situation. As a part of
                                                                                                               doing an Activity Analysis and JHA, there should have an
               128     21-Apr-11                                                                               examination this kind of situation, because it is an event that    21-Apr-11                                                                   21-Apr-11    Operations      Rejected-Close
                                                                                                               could happen and does elsewhere frequently enough to be a
                                                                                                               normal consideration. Thus, the planning should have already
                                                                                                               been in place and executing the communication and/or
                                                                                                               coordination should have also already been considered. It
                                                                                                               could be used as a reminder (FYI) of why to do these things.



                                 1. BLUE - Preconstruction Radiological Background Survey of Remote            Reject? Don’t think many of the issues apply to this site,                     RColl Comments: Rejected. The situation and conditions as
                                 Rugged Terrain Near Dam and Lakes(Source: User Submitted - ID: B-2011-        because Fermilab’s procedures cover proper planning and the                    described are not applicable to Fermilab operations.
               129     26-Apr-11 OR-BJCSSI-0401)                                                               types of terrain issues do not really exist by comparison to the   18-May-10                                                                   18-May-11       ES&H         Rejected-Close
                                   More thorough planning of hazards controls and timing of                    situation in the lesson.
                                   implementation of these controls can improve safety for remote
                                   survey work done over rugged terrain.
                                   2. GREEN - Correct Emergency Contact Information is Critical(Source: User I do not know how this information is made available at                        RColl Comments: Rejected. We have in-house emergency
                                   Submitted - ID: LL-2011-LLNL-01)                                          Fermilab, especially for contractors.                                          response and ambulance/paramedic service activated by a
                                                                                                                                                                                            3131 call. Subcontractors are briefed during subcontractor
                                                                                                                                                                                            orientation and also emergency phone numbers are printed in
                                                                                                                                                                                            the orientation card. Additionally, emergency contact
               130 26-Apr-11                                                                                                                                                      18-May-10                                                                   18-May-11       ES&H         Rejected-Close
Fermi National Accelerator Laboratory Confidential                                                                                                          5/3/2013                        information is kept by the contractor office and the                                                               Page 21
                                                                                                                                                                                            superintendent in accordance with the contract. Once we
                                                                                                                                                                                            transport the remaining responsibility is on the company who
                                                                                                                                                        LL Initial Review
                                                                                                              I do not know how this information is made available at                   RColl Comments: Rejected. We have in-house emergency
              Item #     Date                               2012-BNL-Bungee-0001)                             Fermilab, especially for contractors. Review Comments
                                                                                                                      OQBP LLC (ERV, JFM) Initial                               Date               MSLLC or MPLLC Initial Review Comments
                                                                                                                                                                                        response and ambulance/paramedic service activated by a            Date      MS/MP (Area) Initial Review Status
                                   Time is precious in a medical emergency. Emergency responders                                                                                        3131 call. Subcontractors are briefed during subcontractor
                                   dispatching help or providing treatment may need your emergency                                                                                      orientation and also emergency phone numbers are printed in
                                   contact's information to help you.                                                                                                                   the orientation card. Additionally, emergency contact
               130     26-Apr-11                                                                                                                                              18-May-10                                                                  18-May-11       ES&H         Rejected-Close
                                                                                                                                                                                        information is kept by the contractor office and the
                                                                                                                                                                                        superintendent in accordance with the contract. Once we
                                                                                                                                                                                        transport the remaining responsibility is on the company who
                                                                                                                                                                                        hires and pay the worker.

                                   3. GREEN - "Back to the Basics" Improves Operations(Source: User           FYI only? A good example of how management can either                     RColl Comments: Rejected- We have beaten this horse to
                                   Submitted - ID: 2011-RL-HNF-0019)                                          place emphasis on the right issues or by not stressing things             death. Our employees are well versed in ISM and the
               131     26-Apr-11 Utilizing the Integrated Safety Management System (ISMS) Core                allow changes that cause issues or allow the wrong practice.    18-May-10 application of ISM. FESHM chapters have the structure. The       18-May-11       ES&H         Rejected-Close
                                   Functions while implementing the T Plant Facility Improvement                                                                                        rest would be employee misconduct if they fail to follow the
                                   Initiatives returns facility operations to a higher standard for Conduct                                                                             process.
                                   of Operations and Operational Safety.
                                 1. BLUE - Recurring Event - Lockout/Tagout Events(Source: User Submitted Reject? This seems to be something required by Fermilab                      RColl Comments: Rejected. The Fermilab program is specific
                                 - ID: 2011-RL-HNF-0022)                                                  JHA Procedure and I know Fermilab has an active LOTO                         and formal. FESHM 5120/5042 establish the program that
                                 When a safety program is a critical safety function, as is the case with program. So, I would think the only additional actions might                 meets 29CFR1910.147. Lessons and incident are reviewed
                                 hazardous energy control, that program must be performed with a          be a review of occurrences and/or data analysis procedures                   during meetings of the electrical safety subcommittee when
               132     29-Apr-11 level of formal documented rigor, and as specifically directed by the    to verify something like a trend would be caught and sent           3-May-11 available. Additionally, the US DOE performs audits on            3-May-11        ES&H         Rejected-Close
                                 procedure, to ensure that all aspects of that safety program are used
                                                                                                          this lesson as an FYI.                                                       electrical safety as well as Fermilab D/S safety departments
                                   to keep workers safe and the equipment or environment free from
                                   damage.
                                                                                                                                                                                       who also audit electrical safety programs.


                                   1. BLUE - Change in Work Scope Defeats Process Barrier(Source: User        Reject? We have sent several examples and Fermilab’s                        RColl Comments: Rejected. Our procedures cover this and
                                   Submitted - ID: 2011-RL-HNF-0010)                                          procedures cover this.                                                      also only environmental personnel from ES&H Section deal
                                   A thorough structured review and approval of planned work is                                                                                           with these wells.
               133     6-May-11 essential to ensure process compliance and the safe and efficient                                                                             19-May-11                                                                  20-May-11       ES&H         Rejected-Close
                                   delivery of work product. If conditions change and work plans are
                                   modified or altered, then changes must be thoroughly communicated,
                                   reviewed and approved before implementation.

                                   2. BLUE - Improper Chemical Storage - Includes End-of-Shift LessonsReject or action needed? This looks like an issue of discipline           RColl Comments: Agree. LL rejected.
                                   Learned and Chemical Storage-Procurement Lessons Learned           and/or lack of a system to pick up special needs planning.
                                   (ARRA)(Source: User Submitted - ID: 2011-SR--SRNS-0009)            Does Fermilab have requirements (a way) they would
                                Personnel should not allow the approaching end of the shift to affect capture special receiving constraints that would ensure
                                the completeness of their actions and/or reviews. Personnel receiving notification and a change or special treatment would occur?
               134     6-May-11 chemicals should ensure that the storage requirements are reviewed    I have been told this is done through Procurement by the        19-May-11                                                                          20-May-11       ES&H         Rejected-Close
                                during the receipt process to ensure that the chemicals are properly
                                                                                                      requestor, but I am not sure how notice is given to force
                                stored. Personnel involved in chemical procurement should ensure
                                that appropriate information is passed on to the receipt and handling
                                                                                                      closure.
                                   organization to allow for preparations for the proper storage of the
                                   chemical.

                                   3. BLUE - Lessons Learned for 85 Ton Crane Upgrade Project - Compliance    Reject or action needed? I have been told this is done                      ES&H response 05/20/11: RColl Comments: Not in my area of
                                   to Site Policies and Procedures(Source: User Submitted - ID: 2011-SR--     through Procurement by the requestor, but I am not sure                     activity or expertise.
                                   SRNS-0010)                                                                 how notice is given to force closure.
                                   During the bid evaluation process, personnel should ensure that all                                                                                    05/20/11 - Discussed with COO on who to send this to for
                                   the National Codes and Standards, as invoked in the procurement                                                                                        evaluation; he suggested Head of BSS.
                                   documents (i.e., Procurement Specification or Statement of Work
                                   [SOW] etc.,) are met and any exceptions taken by the vendor are
                                                                                                                                                                                          05/23/11 - Email sent to Head of BSS to request meeting.
                                   processed and appropriate approvals obtained before awarding the
               135     6-May-11    contract.                                                                                                                                  19-May-11                                                                  25-May-11    Operations      Rejected-Close
                                                                                                                                                                                          05/25/11 - Dave Carlson:
                                                                                                                                                                                          Reject. Procurement makes sure that the specifications and
                                                                                                                                                                                          SOW provided by the requestors are incorporated in
                                                                                                                                                                                          contracts, and exceptions are always cleared through the
                                                                                                                                                                                          requestors before award. Procurement does not accept
                                                                                                                                                                                          exceptions without requestor clearance and any such
                                                                                                                                                                                          dialogue is incorporated in the appropriate procurement file
                                                                                                                                                                                          section (e.g., "correspondence").

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              Item #     Date                               2012-BNL-Bungee-0001)                                    OQBP LLC (ERV, JFM) Initial Review Comments               Date               MSLLC or MPLLC Initial Review Comments                     Date      MS/MP (Area) Initial Review Status
                                  4. BLUE - Use of Qualitative Comparisons between Nuclear Facility         Reject or FYI? This looks like not understanding of                          RColl comments: Reject.
                                  Buildings Results in an Unreviewed Safety Question(Source: User           requirements and/or proper procedures within a system or
                                  Submitted - ID: 2011-RL-HNF-0024)                                         utilizing a system. Also, this example is for a Nuclear site.
               136     6-May-11 When using previously developed models, key assumptions and                                                                                  19-May-11                                                                     20-May-11       ES&H         Rejected-Close
                                  critical features must be identified to establish the validity of the
                                  comparison. Failure to do so may lead to degraded safety
                                  performance.
                                  5. YELLOW - Broken Mercury Thermometer(Source: User Submitted - ID:       Accept? In my past discussion concerning customer owned                      ES&H Response 05/20/11: RColl Comments: Belongs to the
                                  LBNL-LL11-0009)                                                           property or things coming to the site in the care of others                  projects LLC as this has to do with users of the facility.
                                  Equipment brought to the Lab from other institutions requires             (not owned by Fermilab, but used here), the system has
                                  thorough review for any hazardous materials such as mercury.              limited controls. In fact, I believe the intention is to use                 05/20/11 - Discussed with COO on who to send this to for
                                                                                                            something like an MOU, but there is nothing requiring this                   evaluation; he suggested Head of BSS.
                                                                                                            be done. Also, people can walk on the site and carry things
                                                                                                            in for use. Is there something that prevents either of these                 05/23/11 - Email sent to Head of BSS to request meeting.
                                                                                                            today?
                                                                                                                                                                                       05/25/11 Dave Carlson:
               137     6-May-11                                                                                                                                              19-May-11 Reject. Equipment or materials brought to Fermilab from             25-May-11    Operations      Rejected-Close
                                                                                                                                                                                       other institutions are covered in MOU's, and restrictions on
                                                                                                                                                                                       items that are brought on site are also covered in the
                                                                                                                                                                                       procedures for researchers ("PFX" -- procedures for
                                                                                                                                                                                       experimenters). In addition, Receiving and Property perform
                                                                                                                                                                                       cursory inspection of all incoming items, and raise alerts if
                                                                                                                                                                                       there are questionable items. Also, Transportation Services
                                                                                                                                                                                       and Property personnel have HazMat training.



                                  6. BLUE - Gasket Materials found to be Inconsistent with Gasket Map (CM) Reject or action needed? This looks like an issue of discipline               ES&H response 05/20/11: RColl Comments: This has to do
                                  Drawings (Source: User Submitted - ID: L-2010-OR-BWY12-0710)             and/or lack of a system to pick up a change. Does Fermilab                    with personnel not following the specifications. This has to do
                                                                                                           have requirements (a way) they would capture special                          with management more than safety. I have no opinion on the
                                  1.When executing a change package, it is important that all affected     requirements or requirements reevaluation that would                          matter as it seems more an engineering and supervision
                                  Configuration Management (CM) documents are captured and revised ensure a change review, notification and documentation                                problem not a safety management system problem.
                                  to reflect the work. 2.When executing a maintenance package, it is       occur?
                                  important to ensure that materials used in the work conform to the
                                                                                                                                                                                         05/20/11 - Discussed with COO on who to send this to for
                                  available CM documents.
                                                                                                                                                                                         evaluation; he suggested Head of OPPS for Engineering
                                                                                                                                                                                         System review.
               138     6-May-11                                                                                                                                              19-May-11                                                                     20-Jun-11    Engineering     Rejected-Close
                                                                                                                                                                                         05/23/11 - Email sent to Head of OPPS to request review.

                                                                                                                                                                                         05/24/11 - Received response, but need to review with Head
                                                                                                                                                                                         of OQBP.

                                                                                                                                                                                         06/21/11 - Met with Bob Grant. His view was this is already
                                                                                                                                                                                         implemented at Fermilab and an issue of lack of discipline.



                                7. BLUE - The Importance of Good Emergency Exercise Planning(Source:        Reject or FYI? Fermilab has an active “exercise” or Drill                    RColl Comments: Agree. Reject
               139     6-May-11 User Submitted - ID: 2011-RL-HNF-0023)                                      system. Is this part of normal planning?                         19-May-11                                                                     20-May-11       ES&H         Rejected-Close
                                  An administrative procedure violation occurred during the pre-staging
                                  1. simulation aids prior to conducting an emergency exercise. Facility Rejected - Does not apply to Fermilab. Do not have these
                                  of BLUE - Tethered Helium Balloon with Instrument Payload: Primary and                                                                                 Not sent to LLC
                                  Backup Tethers Broke, Balloon and Payload Lost(Source: User Submitted -   types of experiments.
                                  ID: SSO-SNL-2011-06913-01)




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                                                                                                                                                    LL Initial Review




                                                                                                           Rejected - Does not apply to Fermilab. Do not have these                       Not sent to LLC
                                                                                                           types of experiments.
              Item #     Date                              2012-BNL-Bungee-0001)                                  OQBP LLC (ERV, JFM) Initial Review Comments                   Date                MSLLC or MPLLC Initial Review Comments                       Date      MS/MP (Area) Initial Review Status
                                 Arctic Lower Troposphere Observed Structure (ALTOS) ARM field
                                 experiment was scheduled for mid October through early December,
                                 2010. It involved a study of the properties of arctic clouds using an
                                 instrumented tethered balloon to be fielded in restricted airspace
                                 R2204 controlled by DOE at the USAF Oliktok Point Long Range Radar
                                 Station on the Arctic Ocean coast of Alaska. On the third day that the
               140     11-May-11 tethered balloon was deployed (October 28), both the primary and the                                                                         11-May-11                                                                        11-May-11      Science       Rejected-Close
                                 backup tethers parted, and the balloon with its instrument payload
                                 floated free. A radio cutdown command was immediately sent, and the
                                 instrumented balloon was observed to descend west northwest of
                                 Oliktok Point a few miles from the experiment site. It was not known if
                                 the balloon fell onto recently-formed sea ice or into water. A detailed
                                 incident report that included contributions from Sandia participants as
                                 well as the balloon-operations contractor was written and sent to DOE
                                 Office of Aviation Management for review. Lessons learned include the
                                 need for information about winds aloft in the flight range, adequate
                                 testing of tether and brake systems, and improved flight information
                                 systems such as location tracking systems.Dirt Work
                                 1. YELLOW - Watermaster Tipped-over during                              Fyi or reject? This seems to be related to operator error.                       RColl Comments: Rejected. Not equipment that is used
                                   Operations(Source: User Submitted - ID: 2011-NV-NNSS-393)               However, since there is a concern, particularly with CoG and                   regularly if at all at Fermilab. Have not seen one here for years.
                                   Equipment operators must understand equipment capabilities and          weight shifting versus different lengths and weight loads in
               141     13-May-11 characteristics and analyze terrain before operating equipment.           this and/or other equipment like this, would reminder or           18-May-11                                                                        18-May-11       ES&H         Rejected-Close
                                                                                                           some systematic change be useful at Fermilab?


                                   1. YELLOW - Custodian Stuck by Improperly Disposed Syringe              Fyi or a need to take action? It looks like this situation could               RColl Comments: Enter into ES&H LL Database. I will brief this
                                   (Sharp)(Source: User Submitted - ID: LANL-2011-LL-STO1408)              happen at Fermilab to me. Places I have been have disposal                     one at the next SSO meeting in June.
                                 While keeping sharps containers near the work area where they are         boxes in the restrooms or a requirement to the Medical
                                 used, keep other trash containers away to reduce the likelihood of a      Office even to give yourself shots and site-wide or new
                                 sharp falling into or being accidently placed in a non-sharps trash       employee training that covers this issue. I do not know what
               142     17-May-11 container. If possible, dispose of blunts along with sharps in sharps                                                                        18-May-11                                                                        18-May-11       ES&H             FYI Only
                                                                                                           Fermilab’s policy and practice is. This situation was not
                                 containers to reduce the likelihood of mistakenly throwing a sharps
                                 into regular room trash. Maintain good housekeeping especially in
                                                                                                           covered with me in Orientation; however, things may have
                                 shared space, and if sharps must be stored rather than disposed in        changed.
                                 sharps container, ensure they are covered and also placed in a labeled
                                 container.
                                 2. YELLOW - Cryogenic Dewar Movement Incident - Worker Sustains Injury Would this help Fermilab (i.e. changing to use a different                      RColl Comments: Accepted. I will brief this LL at the next SSO
                                 to Two Fingers(Source: User Submitted - ID: 2011-LANL-LL-ESHSUPT-0001) cart) or does Fermi already use these carts? Also, are there                    meeting in June. Enter this LL in the LL database and make
               143     17-May-11                                                                        any of the procedural changes being suggested that would              18-May-11 sure to download the PDF files and upload to ES&H Doc DB.              18-May-11       ES&H             FYI Only
                                 Older carts used to transport dewars may not be sufficient to          apply or help Fermilab?                                                         Action will be considered complete after the SSO meeting.
                                   transport the cylinders safely. The use of Anthony 86U-4 carts have
                                   proved to address more of the hazards of moving dewars.
                                 1. YELLOW - Vehicle Towing Operations(Source: User Submitted - ID: 2011- Reject, FYI, and/or do you have something like the                            RColl Comments: Rejected. Agree it is operator error and lack
                                 NV-WSI-002)                                                              recommended checklist already or want one? This appears                       of quality supervision. Supervisor did not inquired about the
                                 Employees engaged in towing activities must have adequate                to be operator error. A reminder – systematic like a                          operator knowledge and towing requirements/parameters
               144     25-May-11 knowledge to correctly and safely perform the activity.                                                                                      25-May-11                                                                        25-May-11       ES&H         Rejected-Close
                                                                                                          checklist or just routinely reviewing procedures - may be                     and just made an assumption.
                                                                                                          useful to promote awareness of how little things matter and
                                                                                                          vigilance in checking the details.
                                   1. BLUE - Documented Safety Analysis did not Analyze Variations on      Reject? First, I do not know if Fermilab would have a                          RColl Comments: This high level review is done at a projects
                                   Accident Scenarios(Source: User Submitted - ID: 2011-RL-HNF-0021)       situation like this, release of a large amount of hydrogen                     level during project planning and is very broad in scope. This
                                                                                                           and/or the ability to generate hydrogen through heating.                       belongs more to the project LLC. The level of detail we place
                                                                                                           Next, this appears to be not following procedures and                          in HAs at my level does not rise to the level or degree of detail
                                                                                                           redoing an HA when the situation is different than originally                  that this analysis is discussing. Fault Tree Analysis is made at
                                                                                                           planned. Also, there did not seems to be an independent                        a higher level.
                                                                                                           review until after the issue.
               145     27-May-11                                                                                                                                              30-May-11                                                                        20-Jun-11       ES&H         Rejected-Close
                                                                                                                                                                                          Need to review with Head of OQBP to see what to do.

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                                                                                                                                                                                          comments.
                                                                                                                                                         LL Initial Review




                                                                                                               Reject? First, I do not know if Fermilab would have a                           RColl Comments: This high level review is done at a projects
                                                                                                               situation like this, release of a large amount of hydrogen                      level during project planning and is very broad in scope. This
              Item #     Date                               2012-BNL-Bungee-0001)                              and/or the ability (ERV, JFM) Initial Review Comments
                                                                                                                       OQBP LLC to generate hydrogen through heating.                Date                 MSLLC or project LLC. Review of detail we
                                                                                                                                                                                               belongs more to theMPLLC InitialThe levelComments place               Date      MS/MP (Area) Initial Review Status
                                 Collaborative in-depth reviews are essential in developing Safety             Next, this appears to be not following procedures and                           in HAs at my level does not rise to the level or degree of detail
                                 Basis documents. An independent review identified two instances               redoing an HA when the situation is different than originally                   that this analysis is discussing. Fault Tree Analysis is made at
                                 where the Waste Encapsulation and Storage Facility (WESF)                     planned. Also, there did not seems to be an independent                         a higher level.
                                 Documented Safety Analysis (DSA) did not analyze variations on
                                                                                                               review until after the issue.
               145     27-May-11 accident scenarios.                                                                                                                               30-May-11                                                                       20-Jun-11       ES&H         Rejected-Close
                                                                                                                                                                                               Need to review with Head of OQBP to see what to do.

                                                                                                                                                                                               06/17/11 - Meet with Bob Grant; awaiting his review
                                                                                                                                                                                               comments.

                                                                                                                                                                                               06/21/11 - Met with Bob Grant. His view was this is already
                                                                                                                                                                                               implemented at Fermilab.
                                   2. GREEN - Using E-Crates for Your Office Move(Source: User Submitted -     Might be a useful idea. Does Fermilab have an alternative                       RColl Comments: We do not use these crates at Fermilab. We
                                   ID: LL-2011-LLNL-03)                                                        method?                                                                         use boxes. Rejected.
               146     27-May-11 E-crates, the colorful plastic crates introduced to ease and speed                                                                                30-May-11                                                                       31-May-11       ES&H         Rejected-Close
                                   office moves while reducing the associated costs, are sometimes
                                   involved in preventable injuries resulting from their use.

                                   3. YELLOW - Inaccurate As-Built Drawings Cause Delay in Demolition Work Sending this to Peter Garbincius as this seems to be                                06/17/11 - Meet with Bob Grant; awaiting his review
                                   (Source: User Submitted - ID: 2011-BNL-ERP-0001)                        something covered under the Engineering Manual.                                     comments.

                                 Organizations need to maintain facility as-built drawings so that future                                                                                    06/21/11 - Bob Grant agreed this is a requirement and
               147     27-May-11 demolition/decommissioning projects have access to as-built details.                                                                              30-May-11 practice in Fermilab.                                                              Engineering     Rejected-Close
                                 Additionally, organizations performing facility demolition activities
                                 should use as-built drawings in the facility characterization process to
                                 validate assumptions upon which engineering controls are based.



                                   4. GREEN - Having a Vendor Representative on Site for Construction          Not sure if this should go to Operations (due to FESS role)                   Reject" with the reason being that "Fermilab personnel do not
                                   Activities Saves Time (Source: User Submitted - ID: 2011-BNL-ERP-0002)      and/or Science and/or OPMO for Project Management. I am                       assemble large purchased structures. On those occasions
                                                                                                               sending to Bruce Chrisman first.                                              when we have had the need to lease/rent structures, such as
                                   For the assembly of large purchased structures and/or components,                                                                                         tents, we subcontract through a knowledgeable vendor for
               148     27-May-11 having a knowledgeable vendor representative on site for consultation                                                                             30-May-11 the assembly of the tent. Should Fermilab have the need to            7-Jun-11     Operations      Rejected-Close
                                   and assistance overseeing construction improves work efficiency,                                                                                          purchase a structure, the assembly of the structure would be
                                   minimizes cost, and promotes safety.
                                                                                                                                                                                             subcontracted to an experienced company to perform the
                                                                                                                                                                                             activity."
                                   5. YELLOW - Haul Truck Electrical Fire(Source: User Submitted - ID: 2011-   Reject or should Fermi examine to ensure nothing like this                      RColl Comments: This is an issue with not following
                                   MB-002)                                                                     has been done? This appears to be some previously                               procedures, supervision or lack thereof and discipline. Safety
                                 A small electrical fire on a project haul truck occurred on March 10,         improperly doing work on a vehicle. It also appears that a                      Management programs will not be able to stop this kind of
                                 2011. Following that incident the mechanics removed the fuses that            double-check of the circuit was not done by when it was                         improper activity.
                                 serviced the wires which caused the fire. On May 06, 2011 the same            repaired the first time.
               149     27-May-11 type of wires caused another small electrical fire. Upon further                                                                                  30-May-11                                                                       31-May-11       ES&H         Rejected-Close
                                                                                                               Also, it appears the trucks were intentionally modified
                                 investigation the project mechanics found a by-pass wire attached to
                                 the haul trucks batteries circumventing the removed fuses and
                                                                                                               before being placed into active duty. This brings into
                                 providing low-voltage power to the wires connected to a junction box          question the original work done and the hazard analysis.
                                 at the back end of the haul truck.                                            This is not covered in the explanation. So, it is hard to tell if
                                                                                                               or why it was missed.
                                   1. JLab Workers Advocate Safety for Six Month Scheduled Accelerator         I would recommend this be examined for the potential to do                      RColl Comments: Rejected. With the accelerator shutdown
                                   Down (SAD)(Source: User Submitted - ID: TJNAF-353-06-01-2011)               something similar. It might be a good way to get employees                      scheduled for the end of September there is no further need
                                                                                                               from around the lab involved. Have a contest where each                         for this lesson or advisory.
                                                                                                               D/S/C can have a winner? This way there is more than one
                                                                                                               recognition and the messages can be tailored to their work
                                                                                                               areas. Another way to approach it is look for the most
                                                                                                               frequent type of events or easiest things to forget or take for
               150      8-Jun-11                                                                                                                                                    8-Jun-11                                                                       17-Jun-10       ES&H         Rejected-Close
                                                                                                               granted and have each area do something about this.
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                                                                                                                                                          LL Initial Review


                                                                                                                 I would recommend this be examined for the potential to do                    RColl Comments: Rejected. With the accelerator shutdown
                                                                                                                 something similar. It might be a good way to get employees                    scheduled for the end of September there is no further need
              Item #     Date                               2012-BNL-Bungee-0001)                                from around the lab involved. Have a contest where each
                                                                                                                        OQBP LLC (ERV, JFM) Initial Review Comments                  Date                  MSLLC or MPLLC
                                                                                                                                                                                               for this lesson or advisory. Initial Review Comments               Date      MS/MP (Area) Initial Review Status
                                  Safety messages, delivered by co-workers, may enhance / influence a            D/S/C can have a winner? This way there is more than one
                                  positive Safety attitude. View the video at URL:                               recognition and the messages can be tailored to their work
                                  http://www.youtube.com/watch?v=Dnuv1g_ForQ                                     areas. Another way to approach it is look for the most
                                                                                                                 frequent type of events or easiest things to forget or take for
               150     8-Jun-11                                                                                                                                                    8-Jun-11                                                                     17-Jun-10       ES&H         Rejected-Close
                                                                                                                 granted and have each area do something about this.




                                  1. YELLOW - STIHL Recalls Yard Power Products due To Burn and Fire             I sent the recall notice to you last week and I believe you                   RColl Comments: Already distributed to SSOs and the CPSC list.
                                  Hazards - Important to Grounds Maintenance Personnel(Source: User              were going to see what we had on site.
                                  Submitted - ID: 2011-SR-SRNS-0011)                                                                                                                           RColl Comments: Sent to Roads and Grounds as an FYI only.
                                 The U.S. Consumer Product Safety Commission, in cooperation with
               151     14-Jun-11 STIHL Inc., of Virginia Beach, Va., announced a voluntary recall of                                                                               14-Jun-11                                                                    16-Jun-11       ES&H             FYI Only
                                 several STIHL products (see Attachment 1 below). Consumers should
                                 stop using recalled products immediately. It is illegal to resell or
                                 attempt to resell a recalled consumer product.

                                  2. BLUE - Respirex Plastic Suit User Experiences Loss of Air to Suit - Users   I sent the recall notice to you last week and I believe you                   RColl Comments: Already distributed to SSOs and the CPSC list.
                                  Should Inspect Valve Assembly Prior to Use(Source: User Submitted - ID:        were going to see what we had on site.
                                  2011-SR-SRNS-0012)                                                                                                                                           RColl Comments: Rejected. We do not have these suits here.
                                 This lesson learned is intended for facilities that utilize "Respirex"
                                 plastic suits. Once the Respirex suit has been connected to the
                                 breathing air hose and the air has been valved on, users should rotate
                                 the flow control valve counter-clockwise using the breathing air hose
                                 connection to the flow control valve. If the internal retaining collar is
               152     14-Jun-11 not properly engaged, the assembly will come apart. If seated                                                                                     14-Jun-11                                                                    16-Jun-11       ES&H             FYI Only
                                 properly, the flow control valve body will remain intact and turn freely.
                                 Wearers of the Respirex plastic suit in combination with additional
                                 accessories (i.e., wireless communications, personal air samplers,
                                 etc.) should be reminded to position the accessories to ensure that
                                 the escape cartridge mouthpiece is always accessible. As a good
                                 practice the user should check the ability to engage the mouthpiece as
                                 part of the donning process.


                                  3. BLUE - Technical Safety Requirement Violation Related to Source             I believe JHA Fermilab procedures require this. However, I                    RColl Comments: This is more in the arena of project
                                  Strength Limit Exceeded(Source: User Submitted - ID: 2010-RL-HNF-0054)         do not know what guarantees the review of change versus                       management and not at my LLC level for ES&H.
                                                                                                                 boundary or initial requirements and all associated
                                 Confirm that defense in depth for compliance has not been                       procedures and controls.                                                      Need to get with Bob Grant on how to get this evaluated.
                                 compromised, when an operational process is modified. If a process
                                 is to be used to support compliance with a Technical Safety                                                                                                 06/17/11 - Meet with Bob Grant; awaiting his review
                                 Requirement (TSR), the process owner must be contacted to confirm
               153     14-Jun-11 that their system can adequately support the proposed use.                                                                                        14-Jun-11 comments.                                                          16-Jun-11       ES&H         Rejected-Close

                                                                                                                                                                                               06/20/11 - Met with Bob Grant; rejecting. Agreed with OQBP
                                                                                                                                                                                               LLC assessment.

                                                                                                                                                                                               RColl Comments: Rejected. Agree with your evaluation.


                                  4. BLUE - Due Diligence Can Prevent Noncompliance Issues(Source: User          Is this already done within your data analysis and data                       RColl Comments: This is the direction we have taken with our
                                  Submitted - ID: 2011-ID-AMWTP-0008)                                            management and/or Management Review?                                          frESHTRK database for entering recommended actions after
                                                                                                                                                                                               findings. The Preventive and Corrective actions entry is now
                                                                                                                                                                                               mandatory to be entered.

                                                                                                                                                                                             RColl Comments: Rejected. Our frESHTRK system is designed
Fermi National Accelerator Laboratory Confidential                                                                                                           5/3/2013                                                                                                                                            Page 26
                                                                                                                                                                                             to track findings and non-conformance issues until all
               154    14-Jun-11                                                                                                                                                    14-Jun-11                                                                    16-Jun-11       ES&H         Rejected-Close
                                                                                                                                                                                             actions are closed. Part of our system is root causes,
                                                                                                                                                    LL Initial Review
                                                                                                            Is this already done within your data analysis and data                      RColl Comments: This is the direction we have taken with our
              Item #     Date                             2012-BNL-Bungee-0001)                             management and/or Management Review?Comments
                                                                                                                     OQBP LLC (ERV, JFM) Initial Review                        Date                 MSLLC or MPLLC Initial Review Comments
                                                                                                                                                                                         frESHTRK database for entering recommended actions after            Date      MS/MP (Area) Initial Review Status
                                 Ensure recommended actions identified during assessments are                                                                                            findings. The Preventive and Corrective actions entry is now
                                 thoroughly evaluated for implementation and if appropriate, tangibly                                                                                    mandatory to be entered.
                                 complete prior to closing the tracking of the recommendation. A
                                 recommended action had been created requiring periodic reviews of
                                                                                                                                                                                       RColl Comments: Rejected. Our frESHTRK system is designed
                                 paperwork. The recommended action was cancelled based on the
                                                                                                                                                                                       to track findings and non-conformance issues until all
               154     14-Jun-11 belief that the requirement would be incorporated into an imminent                                                                          14-Jun-11                                                                     16-Jun-11       ES&H         Rejected-Close
                                 procedure revision. The procedure revision did not incorporate the                                                                                    actions are closed. Part of our system is root causes,
                                 recommended action as planned and implementation of the                                                                                               preventive and corrective actions. To close an issue it
                                 recommended action never occurred. If the recommended action had                                                                                      requires entries in these fields.
                                 been implemented, administrative weaknesses may have been
                                 identified, which would have prevented several Lockout/Tagout
                                 administrative issues that resulted in Fact Findings, a Root Cause
                                 Analysis, an d an ORPS report.
                                  5. YELLOW - Avoid Stepping onto Unstable Surfaces(Source: User        FYI? Do not know what you can do in a constant awareness                         RColl Comments: This type of semi-truck is rarely if ever seen
                                  Submitted - ID: 2011-RL-HNF-0026)                                     mode other than reminders at the start of the job or lunch                       at Fermilab. I will only send this to the chair of the
                                 When accessing or exiting from an elevated work location, verify that box meetings and/or spot checks. These things should be a                         Subcontractor Safety Subcommittee as an FYI.
               155     14-Jun-11 the step or platform onto which you are stepping is positively secured normal set of job activities along with people taking the time       14-Jun-11                                                                     16-Jun-11       ES&H             FYI Only
                                 to prevent movement.                                                   to examine the hazards of their job before they start.                           RColl Comments: Rejected. This is a matter of personal
                                                                                                                                                                                         responsibility and awareness not of a safety management
                                                                                                                                                                                         system.
                                 6. YELLOW - Communicating Facility Technical Safety Requirement (TSR) to Should anything in the system, processes or procedures be                      RColl Comments: Our Work Entry Permit requires notification
                                 Subcontractor(Source: User Submitted - ID: Y-2011-OR-BJCWD-0601)         changed in order ensure what looks to be the current                           of the landowner SSO and the building manager. This is the
                                                                                                          expectations at Fermilab are understood and accomplished                       document in the management system to implements this
                                 Training on TSR documents alone, may not be adequate to ensure that for any time a task is undertaken, especially items with                            lesson.
                                 unescorted personnel entering a facility are knowledgeable of all the    potentially significant hazards and/or consequences?
               156     14-Jun-11 requirements associated with the facility. Additional rigor is needed                                                                       14-Jun-11                                                                     16-Jun-11       ES&H         Rejected-Close
                                                                                                          Examples might be pre-flight checklist, testing, verbal                        RColl Comments: Rejected. We provide an orientation to
                                 when work is being performed by other prime contractors to ensure
                                                                                                          review, etc.                                                                   new employees and subcontractors alike. Additionally, there
                                  implementation of Documented Safety Analysis (DSA) requirements.
                                                                                                                                                                                         is a preconstruction meeting with subcontractors to bring
                                                                                                                                                                                         forth all this information. Lastly, any safety issues are
                                                                                                                                                                                         covered in the JHA.
                                  1. YELLOW - Anticipate Human Error When Planning and Implementing         Reject? Fermilab has an active HPI training program and                      RColl Comments: Agree.
                                  Controls (Source: User Submitted - ID: Y-2011-OR-BWY12-0601)              stresses examination of human performance factors in their
                                                                                                            job and hazard analysis programs. However, this lesson also
                                  Recognize the potential, and anticipate human error when designing        talks about making an error in this examination by assuming
               157     17-Jun-11 and implementing work controls. Inadequate consideration for human                                                                          17-Jun-11                                                                     17-Jun-11       ES&H         Rejected-Close
                                                                                                            or improperly performing the analysis. Is there something in
                                  performance variables when designing and implementing procedural          training that highlights or provides a warning to ensure
                                  controls leads to an unspoken acceptance of control failure rates
                                                                                                            assumptions and analyses are reviewed during the HPI
                                  which often go unrecognized until the control "unexpectedly" fails.
                                                                                                            process?
                                  2. YELLOW - Increased Workload or Urgent Deadlines Can Lead to Harmful    Reject or FYI? Situational reviews and job briefings are to be               RColl Comments: This is more in the realm of management
                                  Work Habits(Source: User Submitted - ID: LL11-0015)                       done before you start any job. Are periodic reviews of the                   and supervision even though there are safety undertones.
                                 Changes in employee work habits to meet project deadlines can lead         work environment and practices required at Fermilab (once                    Attitudes and behaviors are controlled by managers and
                                 to fatigue and injury, which will likely have long-term negative impacts   developed, does something just continue until it breaks or                   supervisor rather than by procedures. Thus, we have systems
                                 on an employee's health and productivity. Changes in work demands          there is an issue)? I know there are “walk-through                           in place that if followed, will drive this point home. However,
                                 should always be accompanied by a discussion between the employee
                                                                                                            assessments”, but is there something that causes a review of                 if managers do not use the tools nothing will stop the actions.
                                 and supervisor about safety, which includes setting clear expectations
                                 about safe work practices. Consideration should be given to
                                                                                                            how things are changing in the area and/or staying the same                  Thus, Rejected.
               158     17-Jun-11 developing process changes that will reduce ergonomic risk.                that could result in an issue?                                   17-Jun-11                                                                     17-Jun-11       ES&H         Rejected-Close
                                                                                                            Personally in this lesson, the issue appears to be one of
                                                                                                            developing or ensuring the discipline to make this a routine
                                                                                                            and not letting a response to just get the job done take over.
                                                                                                             Also, there does not appear to be good communication
                                                                                                            and/or a review of tasks between the supervisor and
                                                                                                            employee.

                                  3. YELLOW - Floor Port Cover Weight Limitations(Source: User Submitted - Does Fermilab have places like this?                                          RColl Comments: Computer rooms have this type of flooring
                                  ID: LL-2011-LLNL-04)                                                                                                                                   but forklifts do not operate in these areas. This has never
                                                                                                                                                                                         been a problem. (Rejected)
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               159    17-Jun-11                                                                                                                                              17-Jun-11                                                                     17-Jun-11       ES&H         Rejected-Close
                                                                                                                                                      LL Initial Review



                                                                                                             Does Fermilab have places like this?                                          RColl Comments: Computer rooms have this type of flooring
              Item #     Date                               2012-BNL-Bungee-0001)                                   OQBP LLC (ERV, JFM) Initial Review Comments                  Date                 MSLLC or MPLLC in these areas. This has never
                                                                                                                                                                                           but forklifts do not operate Initial Review Comments             Date      MS/MP (Area) Initial Review Status
                                 Many buildings have in-floor channels or conduit running through the                                                                                      been a problem. (Rejected)
                                 floors used to provide electrical wiring for equipment and outlets. Port
               159     17-Jun-11 covers or cover plates for these channels often support light traffic                                                                         17-Jun-11                                                                  17-Jun-11       ES&H         Rejected-Close
                                 conditions found in aisles and material handling paths. Heavy material
                                 handling equipment such as powered industrial trucks (e.g., forklifts)
                                 can exceed the load ratings for these covers and could result in a risk
                                 of electrical exposure or shock.

                                   4. YELLOW - Nuclear Safety Issue Identified in 54-year-old Radioactive    Reject or is there something to do? This site is getting older.               RColl Comments: Send to Don Cossairt
                                   Waste Storage Facility(Source: User Submitted - ID: 2011-ANL-005)         Is there an active review program or something systematic
                                                                                                             being done to ensure the state of all safety related                          06/19/11 - Sent request for evalaution to Don Cossairt.
                                 Continuous scrutiny of safety-related equipment is needed even if the       equipment? I realize there are maintenance plans. What
                                 facility is over 50 years old. Be alert to local conditions and be          ensures all safety related items get on the plans? Also, is                 06/20/11 - Don Cossairt's response: Concerning the LL that
                                 scrupulous in comparing actual site conditions to those described in        there a review for aging items or potentially changing
               160     17-Jun-11                                                                                                                                               17-Jun-11 was forwarded to me, I see no need for a further response on     20-Jun-11       ES&H         Rejected-Close
                                 the facility safety basis documents. Having a thorough and complete
                                                                                                             circumstances? I realize there is an annual review of the site              our part. Our radioactive waste facility is relatively new and
                                 process in place to evaluate issues is important to a quick and
                                 comprehensive resolution of any questionable situation.
                                                                                                             plan (grounds and facilities). But, there are would appear                  meticulously inspected on a regular basis by the Lab, DOE,
                                                                                                             the potential to miss items, because equipment and                          and outside regulators. It is in excellent shape.
                                                                                                             maintenance is distributed and a consolidated picture may
                                                                                                             not exist.
                                   5. BLUE - Gas Cylinder Breach(Source: User Submitted - ID: 2011-EM-SEC- Reject or FYI? This looks like an issue in work planning or                     RColl Comments: JHAs and Compressed Gas Cylinder Training
                                   006)                                                                    discipline. However, I assume Fermilab does have                                covers these issues. D/S process procedures also cover the
                                 Proper inspection of discovered cylinders during demolition activities pressurized cylinders on this site. What does Fermilab do                          issue.
                                 is essential prior to executing size reduction activities. The inspection today to ensure there would not be an issue with
               161     17-Jun-11 should be evaluated by assigned safety personnel and result in a                                                                              17-Jun-11                                                                  17-Jun-11       ES&H         Rejected-Close
                                                                                                           pressurized vessels, especially around disposal or storage? I
                                 determination that the cylinder has been adequately evacuated and/or
                                                                                                           understand Fermilab does have JHA and design processes. It
                                 voided.
                                                                                                           is in the day in, day out operational procedures and
                                                                                                           practices I am asking about.
                                   1. BLUE - Congested Work Environments Impact Respiratory                  Reject or should something be done, even if it is only an FYI?                RColl Comments: Accepted as an FYI. At Fermilab physical
                                   Protection(Source: User Submitted - ID: 2011-RL-HNF-0027)                  It would appear this should be something people do when                      limitations along with respirator type are considered when
                                 Evaluate the environment to include the physical hazards of tight or        they plan and know to require use of a respirator for anyone                  applicable. IH members notified with this email. No further
                                 congested work locations that may have an effect on the functionality       having to work in a congested space. However, are the                         action required.
                                 of prescribed personal protective equipment (PPE). Collaboration            issues raised in this LL something the user would be made
               162     21-Jun-11 between Radiological Engineering (RE) and Industrial Hygiene (IH) is                                                                          21-Jun-11                                                                  21-Jun-11       ES&H             FYI Only
                                                                                                             aware to watch for and be reminded to protect themselves
                                 essential in evaluating the limitations of PPE in congested work areas
                                 and ensuring that the right protective equipment is selected for both
                                                                                                             against?
                                 the work area respiratory hazard and the physical constraints of the
                                 work area itself.

                                   2. BLUE - Employees Crossed Radiation Barrier(Source: User Submitted -    Reject or FYI? This does not appear to give enough detail to                RColl Comments: Rejected. This activity is covered with the
                                   ID: SRSO-MOXS-MOX- LL-2011-121)                                           say things were missing that directly relate to the actions                 HA and furthermore barriers. S/C workers must read the HA
                                   Proper communication between subcontractors and awareness of              taken. It appears daily briefings were not done. If daily                   and sign before entering the work area. The violation is
               163     21-Jun-11 surroundings can prevent radiation exposure.                                briefings were not done prior to this issue, then this is a       21-Jun-11 mainly a worker who ignores a barrier that is plainly visible.   21-Jun-11       ES&H         Rejected-Close
                                                                                                             failure to follow normal protocols.                                         This falls under management, supervisory functions and
                                                                                                                                                                                         discipline area.
                                   1. YELLOW - Contaminated Trailers Found During Free Release Surveys       Can anything like this really happen here and are these                     We have a boatload of survey and inspection procedures that
                                   (Source: User Submitted - ID: Y-2011-FBPORTS-0601)                        recommendations/actions part of Fermilab                                    I am quite confident would prevent either of these events
               164     22-Jun-11 Radiological contamination was discovered by the Nevada National            procedures/protocols/practices or what was considered in          22-Jun-11 from happening here.                                             22-Jun-11       ES&H         Rejected-Close
                                   Security Site (NNSS) on the wood floor of trailers used to ship waste     creating the Fermilab processes?
                                   boxes from LATA/Parallax Portsmouth, LLC (LPP), Portsmouth
                                   Gaseous Diffusion Plant (PORTS).
                                   2. YELLOW - Bulging Sandia Box Discovered During Characterization         Should processes, procedures, and practices be reviewed for                   We have a boatload of survey and inspection procedures that
                                   (Source: User Submitted - ID: 2011-ID-AMWTP-0009)                         a similar possibility? This looks an error in analysis or a                   I am quite confident would prevent either of these events
                                                                                                             missed potential issue. Not sure how you would tell                           from happening here.
                                                                                                             someone don’t overlook something they may not think
                                                                                                             about.
               165     22-Jun-11                                                                                                                                               22-Jun-11                                                                  22-Jun-11       ES&H         Rejected-Close
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                                                                                                                                                  LL Initial Review
                                                                                                        Should processes, procedures, and practices be reviewed for                        We have a boatload of survey and inspection procedures that
                                                                                                        a similar possibility? This looks an error in analysis or a                        I am quite confident would prevent either of these events
              Item #     Date                              2012-BNL-Bungee-0001)                        missed potential issue. JFM)sure how you would tell
                                                                                                                OQBP LLC (ERV, Not Initial Review Comments                       Date                MSLLC or MPLLC Initial Review Comments
                                                                                                                                                                                           from happening here.                                              Date      MS/MP (Area) Initial Review Status
                                   Maintain situational awareness to enable recognition of abnormal     someone don’t overlook something they may not think
                                   conditions. A box containing radioactive waste was being loaded onto about.
                                   a Real Time Radiography (RTR) cart for examination when the
               165     22-Jun-11                                                                                                                                               22-Jun-11                                                                   22-Jun-11       ES&H         Rejected-Close
                                   Operator Technician (OT) observed that the top of the box was bowed
                                   upward and the sides of the box were bowed outward. The OT
                                   recognized that this was not a normal situation and notified the Shift
                                   Supervisor (SS). The abnormal condition of the box resulted in the
                                   performance of a discovery screen, an Unreviewed Safety Question
                                   Determination, and the filing of an ORPS report.

                                   1. YELLOW - Employee Receives Electrical Energy Discharge while            Does Fermilab have anything like this (i.e. leaded glass                   We do not have equipment of this type at Fermilab with oil-
                                   Demolishing a Hot Cell Viewing Window(Source: User Submitted - ID: ICP-    shielding windows)? If so, are there controls in place to                  filled lead glass windows. This type is installation is, indeed
                                   2011-010)                                                                  prevent the issue?                                                         common at nuclear facilities but we do not have them here.
               166     23-Jun-11 The objective of this Lessons Learned is to alert personnel working                                                                           23-Jun-11 We do have a few locations with lead glass blocks that are        5-Jul-11        ES&H         Rejected-Close
                                   with hot cells that leaded glass radiation shielding windows can                                                                                      solid, but not oil filled. We also do not have the EXTREME
                                   accumulate an electrical charge when exposed to radiation. This                                                                                       radiation levels that apparently set up this failure.
                                   electrical charge can be released either spontaneously or when the
                                   glass receives a mechanical impact.
                                 1. YELLOW - Hoist Chain Basket Failure (Source: User Submitted - ID: Y-      Reject or action needed? Do we have any chain hoists                         07/12/11 - Need to find an owner for evaluation.
               167     28-Jun-11 2011-OR-BWY12-0501)                                                          and/or could this happen here/are hoists and buckets              1-Jul-11   RColl Comments: Metallurgical failure not within the scope of                   ES&H             On Hold
                                   Failure of overhead mechanical equipment during operation may              routinely evaluated?                                                         abilities for Safety Departments
                                   present a falling hazard.
                                   2. YELLOW - Extended Reach Excavator Contacts Overhead 2400V Power   Reject of fyi? This seems like a failure to follow procedure                       RColl Comments: Rejected. Clearly lack of supervision and not
                                   Line(Source: User Submitted - ID: Y-2011-OR-BJCSM-0602)              and/or a lack of awareness of procedures and proper                                following management procedures and processes.
                                   A change in job sequence and/or equipment to perform a specific task protocols.
               168     28-Jun-11 needs to be reviewed with the appropriate workers and safety                                                                                   1-Jul-11                                                                   12-Jul-11       ES&H         Rejected-Close
                                   personnel prior to the start of the work. Additionally, a review of the
                                   Safety Task Analysis and Risk Reduction Talk (STARRT) Card needs
                                   to be accomplished.
                                   3. YELLOW - Wrist Fracture - Fall While Attempting to Dislodge Apparatus   Reject of fyi? This seems like a failure to follow procedure                 RColl Comments: Rejected: Lack of planning and using what
                                   Results in Lost Time Accident(Source: User Submitted - ID: Y-2011-OR-      and/or a lack of awareness of procedures and proper                          appears to be the wrong tool caused this accident. Walking
                                   BJCMSRE-0603)                                                              protocols.                                                                   the job thoroughly before the actions are taken and doing a
                                   Method of accomplishment should be addressed in work planning                                                                                           mental analysis of the work to be done would have shown the
               169     28-Jun-11 documents and pre-job briefing. Using the proper tool for the job is                                                                           1-Jul-11                                                                   12-Jul-11       ES&H         Rejected-Close
                                                                                                                                                                                           problems upfront. Planning and detailed observations of the
                                   paramount. Lack of rigor in the implementation of the Pause/Stop                                                                                        work area which cannot be regulated. Falls under personal
                                   Work process when conditions change can lead to worker injury.
                                                                                                                                                                                           responsibility to protect ourselves. No real LL here

                                   4. RED - Battery Pack Catastrophic Failure During Charging(Source: User    Reject or action needed? Does Fermilab have any battery                      RColl Comments: Rejected. This can happen anywhere with
                                   Submitted - ID: LL-2011-LLNL-08)                                           packs and/or could this happen here/are these items                          people who use battery packs with hand tools. Inspection of
                                 This incident is a reminder that rechargeable battery packs have a           routinely evaluated or have other controls like alert tags for               the pack a must which is always a manufacturers
                                 finite life, can contain and release a large amount of energy, and the       awareness?                                                                   recommendation. Did the prior user really inspected the pack
                                 consequences of failure can go beyond just the loss of the battery                                                                                        before the last charge? Not enough info here to determine
               170     28-Jun-11                                                                                                                                                1-Jul-11                                                                   12-Jul-11       ES&H         Rejected-Close
                                 pack.
                                                                                                                                                                                           this even though the worker stated that he/she did. However,
                                                                                                                                                                                           I question the statement because the worker may have
                                                                                                                                                                                           perceived a possible dress down by the supervisor or
                                                                                                                                                                                           investigator.
                                   5. YELLOW - Unexpected Pyrophoric Event(Source: User Submitted - ID:       Reject of fyi? This seems like multiple things were done                     RColl Comments: Rejected. Lack of adequate supervision- not
                                   2011-ANL-006)                                                              wrong - a failure to follow procedure, failure to perform the                a safety management issue.
                                   When a reaction does not proceed as expected, staff should stop to         HA properly and a lack of awareness of procedures and
                                   reevaluate the situation and plan what to do next, before continuing       proper protocols. Also, this tends to appear like an area
                                   work.                                                                      more prone to have an issue (a student doing the job) as this
                                                                                                              classification of person may not be fully acclimated to the
               171     28-Jun-11                                                                                                                                                1-Jul-11                                                                   12-Jul-11       ES&H         Rejected-Close
                                                                                                              culture and procedures as well as the system may not have a
                                                                                                              way to capture and ensure their training. How are students
                                                                                                              or temporary help at Fermilab covered to ensure there
                                                                                                              understanding and compliance? Could they slip through
                                                                                                              what is done and not get indoctrinated?



Fermi National Accelerator Laboratory Confidential                                                                                                        5/3/2013                                                                                                                                          Page 29
                                                                                                                                                   LL Initial Review
              Item #     Date                               2012-BNL-Bungee-0001)                                   OQBP LLC (ERV, JFM) Initial Review Comments              Date                 MSLLC or MPLLC Initial Review Comments                     Date      MS/MP (Area) Initial Review Status
                                  1. YELLOW - Positive Unreviewed Safety Question Determination (USQD)     Reject or fyi? This looks like to me the someone assumed                    RColl Comments: Rejected. Also we do not have this type of
                                  Associated with 5-inch NaF Traps(Source: User Submitted - ID: Y-2011-OR- rather than do a normal check of facts. However, what does                  trap at Fermilab.
                                  BJCK25-0604)                                                             not seem to fit is a new safety analysis as a solution without
                                  Historical documents, process knowledge, and procedures in place at understanding of the cause and the lesson did not come up
                                  the time of facility shutdown can be valuable resources, but cannot be with all the real or potential causes. This looks like
                                  counted on to be completely accurate. When unexpected materials or somewhere someone did not follow procedure and/or really
                                  conditions are discovered, it is essential to emplace immediate
                                                                                                           perform the task with due diligence. The lesson seems to be
                                  safeguards that address all associated hazards or potential accidents.
               172     1-Jul-11                                                                            missing or not make clear what occurred to allow an issue to     1-Jul-11                                                                        5-Jul-11       ES&H         Rejected-Close
                                                                                                           happen or if anything really occurred except there was
                                                                                                           insufficient data about the additional traps. Also, the lesson
                                                                                                           seems to talk about containment actions for a specific
                                                                                                           situation and state here’s an example of why not to rely on
                                                                                                           historical data, but not what to really do systematically to
                                                                                                           prevent issues.

                                  1. YELLOW - Nuclear Facility Fire Suppression Main Drain Test Failure     Reject, fyi, or do something else? I realize this is about a               Bruce Chrisman: The definition of a Nuclear Facility is very
                                  (Source: User Submitted - ID: 2011-ANL-007)                               nuclear fire suppression system. However, in looking at this               specific, and last time I looked Fermilab is not one. Don may
                                                                                                            lesson in a broader context, I was wondering if Fermilab has               correct me, but if my old information is still correct I don't see
                                                                                                            some sort of standard checklist(s) for “walk-through”                      the LL as directly applicable to us.
                                                                                                            surveillances and/or tests or any other means to prevent
                                                                                                            things being missed and ensure review and closure.                         Don Cossairt: Bruce is correct. We are not a nuclear facility.
                                                                                                                                                                                       We are very happy about that fact. This LL is not applicable.

                                  Management attention to surveillances is especially important when
                                  changes are expected due to procedure changes or maintenance.




              173a     6-Jul-11                                                                                                                                             6-Jul-11                                                                        6-Jul-11    Operations      Rejected-Close




                                  1. YELLOW - Nuclear Facility Fire Suppression Main Drain Test Failure     Reject, fyi, or do something else? I realize this is about a               We accept this Lessons Learned as an “FYI” and used it as a
                                  (Source: User Submitted - ID: 2011-ANL-007)                               nuclear fire suppression system. However, in looking at this               reminder during the weekly ESH and FESS fire protection
                                                                                                            lesson in a broader context, I was wondering if Fermilab has               meeting and was brought a topic at todays Fire Tech group
                                                                                                            some sort of standard checklist(s) for “walk-through”                      meeting. We have discussed this issue and are considering
              173b     6-Jul-11                                                                             surveillances and/or tests or any other means to prevent        6-Jul-11   incorporating a new question into the handheld device to             7-Jul-11       ES&H             FYI Only
                                                                                                            things being missed and ensure review and closure.                         compare the actual results with the expected value as listed
                                  Management attention to surveillances is especially important when                                                                                   on the Hydraulic Name Plate located on each sprinkler riser.
                                  changes are expected due to procedure changes or maintenance.                                                                                        No further action is required at this time.


Fermi National Accelerator Laboratory Confidential                                                                                                     5/3/2013                                                                                                                                             Page 30
                                                                                                                                                       LL Initial Review

              Item #     Date                               2012-BNL-Bungee-0001)                                      OQBP LLC (ERV, JFM) Initial Review Comments               Date               MSLLC or MPLLC Initial Review Comments                     Date      MS/MP (Area) Initial Review Status
                                   1. YELLOW - Vehicle Incident at EMWMF - Unattended Vehicle Rolls into       Reject or FYI? This looks like to failure to follow common                  RColl Comments: Rejected.
                                   Waste Cell(Source: User Submitted - ID: Y-2011-OR-BJCEMWMF-0701)            practices and proper procedures.
               174     12-Jul-11                                                                                                                                               12-Jul-11                                                                     12-Jul-11       ES&H         Rejected-Close
                                   Never leave vehicles unattended with the motor running.
                                   1. Inadequate Surface Preparation of Unplanned Concrete Construction        Reject? Looks like a couple of back to back planning and                    07/23/11:
                                   Joint(Source: User Submitted - ID: PMLL-SRS-2011-WSB-001)                   execution errors to me.                                                     Randy,
                                                                                                                                                                                           I agree this one is for FESS,I am just getting caught up with
                                   Inadequate surface preparation of a concrete construction joint may                                                                                     some old email. However, it seems to me that this is pretty
                                   result in a lack of concrete uniformity and a soft zone. The presence of                                                                                standard operations for people dealing with concrete.
                                   a soft zone can result in significant rework of the construction joint to                                                                               Bruce
                                   meet technical requirements. Proper preparation of concrete
                                                                                                                                                                                           07/25/11:
                                   construction joint surfaces, prior to the subsequent placement is
                                   necessary to ensure concrete uniformity and a complete bond.
                                                                                                                                                                                           Bruce, yes, our concrete construction specification covers this
                                                                                                                                                                                           and our construction coordinators specifically watch this
                                                                                                                                                                                           activity.
               175     14-Jul-11                                                                                                                                               14-Jul-11                                                                     25-Jul-11    Operations      Rejected-Close
                                                                                                                                                                                           Part 3 of FESS document 03300, CAST-IN-PLACE CONCRETE -
                                                                                                                                                                                           Execution covers prep before placing concrete and placement
                                                                                                                                                                                           at joints.
                                                                                                                                                                                           As this relates to the LL below, the Construction Coordinator
                                                                                                                                                                                           would have to approve the cold joint and the surface
                                                                                                                                                                                           approved by the CC. In any case, they must place the joints as
                                                                                                                                                                                           shown on the drawings or get our approval to deviate.



                                   1. YELLOW - Heat Stress Incident Performing Polychlorinated Biphenyls       Reject or FYI? Looks like a failure to follow procedure and a               We don't do any PCB work. On the broader issue of heat,
                                   (PCB) Trough Maintenance(Source: User Submitted - ID: 2011Y-LL-LATA-        management issue to me.                                                     ES&H has already dealt with this on the porcelain press.
              176a     14-Jul-11   0291)                                                                                                                                       14-Jul-11                                                                     23-Jul-11    Operations      Rejected-Close
                                   Prior to allowing personnel to enter a hot environment, supervisors
                                   must understand the hazard, the required controls, and factors that
                                   impact the effects of exposure.
                                   1. YELLOW - Heat Stress Incident Performing Polychlorinated Biphenyls       Reject or FYI? Looks like a failure to follow procedure and a               We accept this lessons learned as “FYI.”
                                   (PCB) Trough Maintenance(Source: User Submitted - ID: 2011Y-LL-LATA-        management issue to me.
                                   0291)                                                                                                                                                   Fermilab has a temperature extremes FESHM Chapter and
                                   Prior to allowing personnel to enter a hot environment, supervisors                                                                                     fully expects and communicates that such situations be
                                   must understand the hazard, the required controls, and factors that                                                                                     addressed as part of work planning (See FESHM 2060). The
                                   impact the effects of exposure.                                                                                                                         lab has also included temperature extreme information in
              176b     14-Jul-11                                                                                                                                               14-Jul-11                                                                     15-Jul-11       ES&H             FYI Only
                                                                                                                                                                                           FermiToday and other lab communications.

                                                                                                                                                                                           Additional Action: The LL below will be sent to D/S/C IHs as
                                                                                                                                                                                           an “FYI.”


                                   1. BLUE - Excavation Volume Determination Proves Inadequate(Source:         FYI or do something else? This appears to be something that
                                   User Submitted - ID: 2011B-LL-LATA-0278)                                    was done incorrectly. Maybe, Fermilab would just need to
                                   Excavation for the Paducah Surface Water Operable Unit (On-Site)            either remind people it could happen and/or examine the
               177     15-Jul-11   Removal Action Project was -50% greater than the initial project            Fermilab processes to be sure would be checked and caught?      15-Jul-11                                                                                  Engineering   Awaiting LLC Review
                                   excavation volume estimate. Projects should collect adequate
                                   samples at appropriate depths to fully bound the extent of
                                   contamination prior to excavation to know and understand the true
                                   estimated volume.
                                   2. BLUE - Storage Configuration for Standard Waste Boxes(Source: User       I do not know if we have anything which might have this                     Don Cossairt: Billy Arnold, our regulated waste manager is
                                   Submitted - ID: 2011-RL-HNF-0031)                                           issue at Fermilab. Copying Don Cossairt in case we do.                      well aware of the extreme measures needed to keep in
               178     15-Jul-11   In order to prevent Real-Time Radiography (RTR) failures, Standard                                                                          15-Jul-11   compliance with stringent radioactive waste storage               15-Jul-11       ES&H         Rejected-Close
                                   Waste Boxes (SWBs) must be stored in a manner to prevent                                                                                                requirements and avoid problems of this kind. I am confident
                                   accumulation of rainwater.                                                                                                                              that all is in place to address this problem.
                                   3. GREEN - Forklift Air Pressure and Tire Ply Rating Issue(Source: User     Reject? I am assuming Fermilab has a maintenance schedule                   RColl Comments Accepted as FYI. LL sent to SSOs , vehicle
                                   Submitted - ID: 2011-ID-AMWTP-0010)                                         or plan that covers things listed in this lesson. I am                      maintenance and to the Training instructor to discuss in
                                                                                                               forwarding to make sure.                                                    future training sessions. All actions are completed 7/15/2011.
Fermi National Accelerator Laboratory Confidential
               179     15-Jul-11                                                                                                                             5/3/2013          15-Jul-11                                                                     15-Jul-11       ES&H             FYI Only        Page 31
                                                                                                                                                         LL Initial Review
                                                                                                              Reject? I am assuming Fermilab has a maintenance schedule                    RColl Comments Accepted as FYI. LL sent to SSOs , vehicle
              Item #     Date                               2012-BNL-Bungee-0001)                             or plan that covers things listed in this lesson. I am
                                                                                                                      OQBP LLC (ERV, JFM) Initial Review Comments                Date                 MSLLC to the Training Review Comments
                                                                                                                                                                                           maintenance andor MPLLC Initialinstructor to discuss in               Date      MS/MP (Area) Initial Review Status
                                   Perform pre-operational checks on rolling stock to ensure                  forwarding to make sure.                                                     future training sessions. All actions are completed 7/15/2011.
               179     15-Jul-11   manufacturers' operating conditions of equipment are met. Forklifts                                                                         15-Jul-11                                                                       15-Jul-11       ES&H             FYI Only
                                   were inspected and found to have tires which were not consistent with
                                   the manufacturer's specified nameplate data. The forklifts were placed
                                   out of service pending resolution with the forklift/tire manufacturers.

                                   4. BLUE - Announcements, Postings, and Signs (Source: User Submitted -     I do not know if we have anything which might have this                      Don Cossairt: In my opinion, this one simply states the
                                   ID: L-2011-OR-BWY12-0605)                                                  issue at Fermilab. Copying Don Cossairt in case we do.                       obvious. We do train people to look for postings and heed
                                   Personnel must maintain vigilance and heed and read                                                                                                     them. Indeed, one of the chronic problems with postings is
                                   announcements, postings, and signs, respectively.                                                                                                       that most doors, etc. collect many different postings. Some of
               180     15-Jul-11                                                                                                                                               15-Jul-11   us suspect that they all don’t get read. I suppose a knee-jerk,     15-Jul-11       ES&H         Rejected-Close
                                                                                                                                                                                           and in my opinion very ineffective, response to this LL would
                                                                                                                                                                                           be to add yet another sign that in BIG LETTERS says PLEASE
                                                                                                                                                                                           READ ALL SIGNS. I don’t think doing that would help at all.


                                   1. GREEN - Y-12 Integrated Safety Management System's New                  Reject? It would appear we are already working on changing                   RColl Comments: Reject. As you stated we have a robust
                                   Effectiveness Declaration Review Process(Source: User Submitted - ID: G-   some things in assessments. However, being ISO certified,                    assessment program with tri-partite audits and internal
                                   2011-OR-BWY12-0604)                                                        Fermilab will not gain from dropping the external audits,                    assessments as well as DOE-FSO assessments. The external
                                   Y-12 Integrated Safety Management new Effectiveness Declaration            because you have to have them to maintain your                               and FSO assessments are contractual and cannot be dropped.
                                   Review Process is consistent with the implementation of Line               certification. So, the same reasoning does not apply. Also, it               An ISM review is also done internally and reported to DOE-
               181     20-Jul-11   Oversight Contractor Assurance System (LOCAS) and may provide              looks like to me they had a very limited self-assessment         20-Jul-11   FSO. In short, our operating mode is vastly different. Thus,        20-Jul-11       ES&H         Rejected-Close
                                   timelier, as well as more cost effective, feedback. Utilizing this new
                                                                                                              program or it was not existent, because they seem to be                      this process would not be applicable to us.
                                   approach provides, to a greater extent, a real-time evaluation of ISM
                                   effectiveness by incorporating key leading and lagging indicators in
                                                                                                              saying they increased the line management role and
                                   conjunction with feedback mechanisms related to the conduct of             assessing/managing in order to get more timely feedback
                                   traditional assessments.                                                   and cut costs.

                                   1. BLUE - Failure to Conduct a 35-day follow-up on Hazardous Waste     This looks like a failure to perform the job properly and a                      RColl comments: Rejected for the same reasons stated above.
                                   Shipment Manifest(Source: User Submitted - ID: B-2011-OR-BJCK25-0702) lack of controls to ensure the job was completed or raise
                                                                                                          issues before there was a problem. Does Fermilab’s process
                                   In order to properly track waste shipments and comply with governing ensure something cannot escape?
               182     27-Jul-11   regulations, it is essential that completed, signed waste manifests be Copying Billy Arnold and putting the instructions for lesson’s       27-Jul-11                                                                       27-Jul-11       ES&H         Rejected-Close
                                   returned by the waste transporter in a timely manner to the specific   evaluation and a copy of the lesson at the bottom of this
                                   point of contact and address provided by the waste generator, and
                                                                                                          email.
                                   that the waste generator track shipments in a manner to ensure that it
                                   is aware of any manifests for which receipt has not been documented.

                                   2. YELLOW - Recognizing Changing Conditions(Source: User Submitted - ID: Reject? This looks like a failure to perform the job properly                  RColl comments: Rejected for the same reasons stated above.
                                   RCCC-2011-0014)                                                          by not taking responsibility to ensure understanding by the
                                   Washington Closure Hanford (WCH) management and Supervisors              parties involved.
               183     27-Jul-11   must ensure that employees involved in performing work activities                                                                           27-Jul-11                                                                       27-Jul-11       ES&H         Rejected-Close
                                   understand the work and are able to mitigate any new hazards that
                                   may be present when a design change is put into place.

                                   3. YELLOW - Use of Gas Powered Saw in Confined Space(Source: User          Reject or FYI? Fermilab’s processes and procedures seem to                   RColl comments: Rejected for the same reasons stated above.
                                   Submitted - ID: RCCC-2011-0011)                                            have this covered. However, this might be a useful example                   Our HA process covers this possibility and will, if done
                                   Workers must evaluate all hazards using the "worst case" scenario          of what assuming can do to hurt you and why you need to                      properly and conscientiously, prevent this from occurring.
                                   and must be trained to recognize and assess hazards on a                   reevaluate conditions.
               184     27-Jul-11   situational/task specific basis. Workers facing a change of condition                                                                       27-Jul-11                                                                       27-Jul-11       ES&H         Rejected-Close
                                   should not allow assumptions to overpower a questioning attitude of
                                   identified hazards. Employees should be motivated to accept personal
                                   responsibility and manage their own safety, with the sustained
                                   support of co-workers and management.

                                   4. GREEN - 100N Solar Powered Light Trailer(Source: User Submitted - ID:   Does Fermilab use something like this or have situations                     I accept this as an FYI (2), and will forward it to FESS as such.
                                   RCCC-2011-0009)                                                            where something like this would be useful?
                                   Washington Closure Hanford (WCH) installed a trailer Mounted solar         Larger issue: Is there an active plan to examine
               185     27-Jul-11   powered lighting tower at the corner of N Avenue and Route 4 in an                                                                          27-Jul-11                                                                       27-Jul-11    Operations          FYI Only
                                                                                                              opportunities for using solar lighting within the
                                   experiment to replace the standard diesel engine driven generator          sustainability or energy plans? If so, does Fermilab already
                                   street corner lighting tower that is prevalent around the Hanford site.
                                                                                                              have something like this considered?


Fermi National Accelerator Laboratory Confidential                                                                                                       5/3/2013                                                                                                                                               Page 32
                                                                                                                                                          LL Initial Review

              Item #     Date                               2012-BNL-Bungee-0001)                                      OQBP LLC (ERV, JFM) Initial Review Comments                   Date                MSLLC or MPLLC Initial Review Comments                   Date      MS/MP (Area) Initial Review Status
                                   1. YELLOW - Area Lighting Structures(Source: User Submitted - ID: 2011-      Does Fermilab have potential situations like this and/or have                  Bruce Chrisman: This is an FYI only. I am including FESS.
                                   NV-NNSS-398)                                                                 some scheduled/routine check on light fixtures such as
                                   Periodic inspection of long standing fixtures is necessary. Original         parking lot lamps and poles?                                                   Randy Ortgiesen: yes, we have an actual program of
               186     28-Jul-11   equipment installed at facilities, thought to be maintenance free, may                                                                          28-Jul-11   inspection and removal of the legacy light poles primarily       28-Jul-11    Operations          FYI Only
                                   not be.                                                                                                                                                     along the main ring when structures are deemed to be unsafe
                                                                                                                                                                                               and unnecessary to replace.

                                   1. YELLOW - Worker Struck by a Falling Concrete Form Waler(Source: User Looks like something Fermi would need to ensure, but I am                           This is another FYI.
                                   Submitted - ID: 2011-SR-SWPF-001)                                       not sure who would handle ensuring contractors would
                                   Personnel need to ensure concrete form braces walers are installed by know this, take care of covering this in the HA and ensure
                                   personnel familiar with assembly requirements of the forming system this was built into the procedures the contractor used at
               187     29-Jul-11   in use on the project to prevent improperly installed walers from       Fermilab?                                                               29-Jul-11                                                                    29-Jul-11    Operations          FYI Only
                                   becoming a falling object. Additionally, manufacturer's instructions
                                   may not address all installation situations that are likely to occur, and
                                   therefore it is prudent to provide a backup method to secure walers
                                   that have a limited number of attachment points (i.e., 2-bolt waler
                                   configurations)
                                   1. YELLOW - Worker Steps through 8-Foot High Transite Ceiling(Source:        Reject or FYI? This one looks like a failure to follow system                  RColl: Reject. Agree with your evaluation.
                                   User Submitted - ID: 2011-RL-HNF-0036)                                       and procedures as well as just not doing what was required.
                                   While performing asbestos abatement, a worker sustained minor
                                   injuries after stepping backward off of a temporary, plywood work
                                   platform and breaking through a concrete asbestos board (or transite)
               188     2-Aug-11    ceiling, eight-feet above the ground. All injuries are preventable and                                                                          2-Aug-11                                                                     3-Aug-11        ES&H         Rejected-Close
                                   this one is no exception. Improved communication, the determination
                                   to thoroughly evaluate new hazards, the commitment to follow written
                                   work instructions, and improved situational awareness could have
                                   prevented this event.

                                   2. YELLOW - Placement of NAMs and Locations of Cooling Shelters inside       FYI or change something? Is there something in the                             08/02/11 Bruce Chrisman response: I don't think this applies
                                   Containment(Source: User Submitted - ID: 2010Y-LL-LATA-0068)                 Facilities’ design system that would cause this check type of                  to us. Let's see what Randy says.
                                                                                                                thing to be caught in a review or in some way be prohibited?                   08/17/11 Randy's response: input from our SSO. NAM would
               189     2-Aug-11    When positioning intake ducts for Negative Air Machines (NAMS),                                                                                 2-Aug-11    be part of project planning and picked up in our                 17-Aug-11    Operations      Rejected-Close
                                   ensure that the air flow is away from the containment entry/exit points                                                                                     environmental checklist and mitigated in project HA.
                                   and cooling shelters. Place NAMs and ducts as far from the
                                   emergency egress pathways as possible.
                                   1. BLUE - Attention to Detail is Important When Operating                    This is an interesting one, because I think the lesson or                      RColl Comments: Rejected. Contractors operate mobile cranes
                                   Equipment(Source: User Submitted - ID: RCCC-2011-0015)                       description listed is wrong. Also, I think this is less an issue               in the majority of the cases. Under the management system,
                                   It is imperative that equipment operators possess a strong working           of operator knowledge (not that this would not help) and                       we verify licensing, certifications and medical certificate as
                                   knowledge of their equipment and understand the details of how it            the real cause/issue is a design problem. So, if I took the                    required by Federal Regs. Once done, we must assume a
               190     5-Aug-11    operates before performing work with the equipment. It is equally            path that this was a design issue, I would ask… Does               5-Aug-11    degree of competence is present.                                 5-Aug-11        ES&H         Rejected-Close
                                   important that equipment operators maintain a heightened level of
                                                                                                                Fermilab have any equipment like this, how would Fermilab
                                   awareness when operating equipment and to be prepared for
                                   unexpected situations to occur.
                                                                                                                ensure their vendors were aware, and how would Fermilab
                                                                                                                prevent this particular issue in the future?

                                   1. YELLOW - Employee Falls in Parking Lot (Source: User Submitted - ID: Y-   Reject, FYI, or check for similar situations (i.e. slick painted               RColl Comments: Rejected. Has to do more with paying
                                   2011-OR-BWY12-0302)                                                          surfaces)? The only things I could advise here are… Does                       attention to the areas where we choose to walk. Additionally,
                                   The use of painted curb markings which employ durable, reflective,           Fermilab have a requirement on what kind of paints or                          lack of information regarding use of cell phone or other
               191     9-Aug-11    and non-slip paint features may prevent falls by pedestrians.                materials are used on stairs, curbs and other possible slip        9-Aug-11    distractions that people engage in without paying attention to   9-Aug-11        ES&H         Rejected-Close
                                                                                                                hazards? Also, is there some kind of standard/routine walk-                    the task at hand.
                                                                                                                around assessment to examine areas for walkway hazards?

                                   1. BLUE - Consider Installation Location when Selecting Roughing Filter      I do not know if Fermilab has situations like this on site.
                                   Media(Source: User Submitted - ID: ICP-2011-0001)                            Also, even though I know there are JHA, fire safety and
                                   Roughing filter media installed outside of ductwork in occupied areas        design reviews, I think someone within Fermilab should be
               192     12-Aug-11 should limit the potential for combustion.                                                                                                        12-Aug-11                                                                                 Operations    Awaiting LLC Review
                                                                                                                the one to evaluate this lesson versus the processes and
                                                                                                                other possible routine checks or procedures for preventing
                                                                                                                this issue.
                                   2. BLUE - Worker Receives Minor Shock while Installing Network Switch        Reject or FYI? This looks like an individual’s error and/or                  RColl Comments: Rejected. This is a clear case of an employee
                                   Box(Source: User Submitted - ID: 2011-ANL-008)                               there was not a proper walk-down of the task prior to                        not paying attention to warning signs and not questioning the
                                                                                                                preforming it. This could be used as an example of making                    scope of the work. The planners failed to walk the job before
               193 12-Aug-11
Fermi National Accelerator Laboratory Confidential                                                              sure to review everything before you start 5/3/2013
                                                                                                                                                             a job.                12-Aug-11 assigning work. It was a failure in various levels that boils      12-Aug-11       ES&H         Rejected-Close      Page 33
                                                                                                                                                                                             down to the fact that as the last protective barrier people
                                                                                                                                                                                             MUST take an active part to protect themselves and not rely
                                                                                                                                                     LL Initial Review

                                                                                                             Reject or FYI? This looks like an individual’s error and/or                RColl Comments: Rejected. This is a clear case of an employee
              Item #     Date                              2012-BNL-Bungee-0001)                             there was not LLC (ERV, walk-down of the task prior to
                                                                                                                     OQBP a proper JFM) Initial Review Comments                 Date               attention to warning signs and not questioning the
                                                                                                                                                                                        not payingMSLLC or MPLLC Initial Review Comments                     Date      MS/MP (Area) Initial Review Status
                                 Routine, low hazard tasks may take place in an environment where            preforming it. This could be used as an example of making                  scope of the work. The planners failed to walk the job before
               193     12-Aug-11 higher hazards are present. It is essential that workers consider both      sure to review everything before you start a job.                12-Aug-11 assigning work. It was a failure in various levels that boils      12-Aug-11       ES&H         Rejected-Close
                                 the task and the environment in which the work in being performed.                                                                                     down to the fact that as the last protective barrier people
                                 Workers should always be alert for changing conditions and recognize
                                                                                                                                                                                        MUST take an active part to protect themselves and not rely
                                 when they are beyond their scope.
                                                                                                                                                                                        on others.
                                  1. GREEN - Conduct of Operations - Information Sharing(Source: User        Not sure how much if any is done here, but I think it would                RColl Comments: Accepted as an FYI. We have shared this
                                  Submitted - ID: 2011-EM-CBFO-WTS-WIPP-LL-2011-02)                          be. Also, who owns this?                                                   information with our environmental folks as an FYI.
               194     16-Aug-11 Groundwater monitoring wells (GMW) design drawings were inspected                                                                            18-Aug-11                                                                    24-Aug-11       ES&H             FYI Only
                                  and updated after an Occurrence Reporting and Processing System
                                  (ORPS) Report shared information of an electrical hazard.

                                                                                                    Might be a good fyi in order for people to look at jobs that
                                  2. GREEN - Safety - Old Wrench vs. New Swench(Source: User Submitted -                                                                                  RColl Comments: Rejected. Not a historical issue at Fermilab.
                                  ID: 2011-EM-CBFO-WTS-WIPP-LL-2011-03)                             might benefit by a tool change. The rest of this looks like
               195     16-Aug-11 Workers using a standard wrench were experiencing a sudden release procedural or improper analysis issues.                                   18-Aug-11                                                                    24-Aug-11       ES&H         Rejected-Close
                                  of energy. Supervisors took proactive steps to mitigate the hazard, by
                                  purchasing a wrench with energy conversion properties.

                                  3. BLUE - Possible Exposure to Asbestos while Cutting a Water              Not sure if this situation could occur at fermilab. Sending to             FESS or laboratory procedures adequately cover highlighted
                                  Pipe(Source: User Submitted - ID: 2011-PPPL-0001)                          Operations to review. Would appear this should be a                        items included in this e-mail:
               196     16-Aug-11 Older piping may have asbestos containing material throughout, not          normal part of work planning.                                    19-Aug-11 Asbestos pipe lagging, IPT’s for ARRA work, underground            23-Aug-11    Operations      Rejected-Close
                                  just in the outer layer. Plans for work that involves disturbing such                                                                                 utility locates, and hazard analyses.
                                  piping should consider the potential for asbestos exposure.

                                  4. GREEN - Implementation of an Integrated Project Team for Execution of Sending to Operations for review to decide who is                              FESS or laboratory procedures adequately cover highlighted
                                  Recovery Act Work Scope (ARRA)(Source: User Submitted - ID: WRPS-IB-10- appropriate party to get this.                                                  items included in this e-mail:
                                  020)                                                                                                                                                    Asbestos pipe lagging, IPT’s for ARRA work, underground
                                 Development and utilization of an Integrated Project Team (IPT) for                                                                                      utility locates, and hazard analyses.
                                 assistance in managing the execution of the Recovery Act work scope
               197     16-Aug-11 was very beneficial. Initially, weekly meetings were held with                                                                               19-Aug-11                                                                    23-Aug-11    Operations      Rejected-Close
                                 representatives from organizations critical to successful development
                                 and execution of the Recovery Act work scope. This steady interaction
                                 and team communication helped ensure that management knew of all
                                 issues and had the right people on the IPT to address those issues in
                                 a timely manner.

                                  5. BLUE - Electrical Lines Damaged during Excavation Activities(Source:    Not sure if this situation could occur at fermilab. Sending to               FESS or laboratory procedures adequately cover highlighted
                                  User Submitted - ID: WRPS-IB-10-023)                                       Operations to review. Would appear this should be a                          items included in this e-mail:
                                 Ground scan requests supporting excavation should include a clear           normal part of work planning.                                                Asbestos pipe lagging, IPT’s for ARRA work, underground
                                 indication of the specific excavation routes, and the resulting ground                                                                                   utility locates, and hazard analyses.
                                 scan reports should identify the boundary of the area actually scanned
                                 to allow for an accurate comparison and ensure that no areas where
                                 excavation will be performed are missed. In addition, walk-downs
                                 verifying that all ground markings and scanning maps are accurate
                                 and complete prior to actual excavation work is essential for good
                                 Conduct of Operations and application of controls. Failure to indicate
               198     16-Aug-11                                                                                                                                              19-Aug-11                                                                    23-Aug-11    Operations      Rejected-Close
                                 to the subcontractor which specific areas were to be scanned and not
                                 verifying that all required areas had been scanned resulted in damage
                                 to electrical lines. Due to a breakdown in communication between the
                                 ground scanning subcontractor and construction subcontractor, there
                                 was uncertainty as to whether re-marking was completed prior to
                                 beginning excavation. Complete work-site analysis and clear
                                 communication between all participants in the work evolution is
                                 essential to ensure safety of personnel and equipment in regard to
                                 hazardous electrical energy.

                                  6. BLUE - Meeting Schedule Milestones is Important to Mitigate the Effects This would look like a failure in managing a project and                    Rejected: The author of the JHA is the person responsible to
                                  of Hot Weather(Source: User Submitted - ID: WRPS-IB-10-024)                potentially a project rep for ES&H not ensuring the plans or               evaluate all hazards as assigned in our management system.
                                                                                                             JHA were used. I am also sending this to Operations for                    Failure of the writer to consider all hazards and failure of the
                                                                                                             review, because FESS would seem to be the party which                      reviewer in not considering the hot environment points to a
                                                                                                             would be involved in this kind of work.                                    lack of supervision or inattention to detail. Thus, this is a
               199a 16-Aug-11                                                                                                                                                 18-Aug-11                                                                    29-Aug-11       ES&H         Rejected-Close
Fermi National Accelerator Laboratory Confidential                                                                                                       5/3/2013                       management issue. However, the application of this LL is not                                                        Page 34
                                                                                                                                                                                        significant at Fermilab as we have many air conditioned
                                                                                                                                                                                        buildings within the campus that offer shelter from extreme
                                                                                                              This would look like a failure in managing a project and
                                                                                                                                                      LL Initial Review                  Rejected: The author of the JHA is the person responsible to
                                                                                                              potentially a project rep for ES&H not ensuring the plans or              evaluate all hazards as assigned in our management system.
              Item #     Date                              2012-BNL-Bungee-0001)                              JHA were used. I am also sending this to Operations for
                                                                                                                     OQBP LLC (ERV, JFM) Initial Review Comments                Date               MSLLC or to consider all hazards and failure
                                                                                                                                                                                        Failure of the writer MPLLC Initial Review Comments of the            Date      MS/MP (Area) Initial Review Status
                                 To mitigate environmental hazards in the workplace, clear roles and          review, because FESS would seem to be the party which                     reviewer in not considering the hot environment points to a
                                 responsibilities require documented management responsibility for            would be involved in this kind of work.                                   lack of supervision or inattention to detail. Thus, this is a
              199a     16-Aug-11 directing and conducting work safely. Although the tank farms had a                                                                          18-Aug-11                                                                     29-Aug-11       ES&H         Rejected-Close
                                                                                                                                                                                        management issue. However, the application of this LL is not
                                 process in place for mitigating the effects of hot weather, the delay in
                                                                                                                                                                                        significant at Fermilab as we have many air conditioned
                                 assigning responsibilities to an individual to plan the work and apply
                                 hazard and prevention control methods resulted in those controls not
                                                                                                                                                                                        buildings within the campus that offer shelter from extreme
                                 being in place when needed.                                                                                                                            heat different than a tank farm which may be isolated.

                                 6. BLUE - Meeting Schedule Milestones is Important to Mitigate the Effects This would look like a failure in managing a project and                      FESS or laboratory procedures adequately cover highlighted
                                 of Hot Weather(Source: User Submitted - ID: WRPS-IB-10-024)                potentially a project rep for ES&H not ensuring the plans or                  items included in this e-mail:
                                                                                                            JHA were used. I am also sending this to Operations for                       Asbestos pipe lagging, IPT’s for ARRA work, underground
                                 To mitigate environmental hazards in the workplace, clear roles and        review, because FESS would seem to be the party which                         utility locates, and hazard analyses.
                                 responsibilities require documented management responsibility for          would be involved in this kind of work.
              199b     16-Aug-11 directing and conducting work safely. Although the tank farms had a                                                                          19-Aug-11                                                                     23-Aug-11    Operations      Rejected-Close
                                   process in place for mitigating the effects of hot weather, the delay in
                                   assigning responsibilities to an individual to plan the work and apply
                                   hazard and prevention control methods resulted in those controls not
                                   being in place when needed.

                                   Engagement Simulation System (ESS) Weapons Inadequacies (SEC-201107- Does not apply to Fermilab                                                        Did not send to LLC for evaluation.
                                   BP-0014) - 08/08/2011
               200     8-Aug-11                                                                                                                                               19-Aug-11                                                                     19-Aug-11 Cyber Security     Rejected-Close



                                   Controlling Suspected Unauthorized Disclosures via Email (SEC-201105-BP- Sent to LLC to evaluate potential for issue at Fermilab.                      We should reject this lesson as not applicable to Fermilab.
                                   0013) - 05/31/2011
               201     31-May-11 The recurring issue of potential unauthorized disclosures through                                                                            19-Aug-11 There are no classified information, data or materials at           22-Aug-11 Cyber Security     Rejected-Close
                                   email increases the risk to LANL’s information security.                                                                                             Fermilab that would require email encryption.


                                   Using Human Performance to Raise Staff Awareness About Potential    Sent to LLC to evaluate potential for issue at Fermilab. On                        08/23/11 - Cannot download the videos to send to LLC. LLC
                                   Security Situations (SEC-201105-BP-0012) - 05/18/2011               this one, you may want to look at how some of this might be                        will have to get an account or sit with LLA to review videos.
                                   New Operating Experience “Videos” produced and submitted by         incorporated into employee or situational training. Please
                                   Pacific Northwest Laboratory show that understanding and preventing see the attachments in the lesson.                                                 08/30/11 - Accept as an "FYI"
               202     18-May-11 human error is a proven and effective way to prevent common security                                                                         19-Aug-11                                                                     30-Aug-11 Cyber Security         FYI Only
                                   incidents. Recognizing the behaviors that cause mistakes is the first
                                   step to avoiding repeat incidents. These Human Performance
                                   Improvement based videos show how mistakes are made and
                                   demonstrate how simple changes in behavior can improve the
                                   outcome.
                                   Unreviewed Web Content (SEC-201104-LL-0065) - 04/20/2011                   Sent to LLC to evaluate potential for issue at Fermilab. I do               We should reject this lesson as not applicable to Fermilab.
                                   Workers must consult a derivative classifier (DC) before publishing        not know if this situation can really happen here. But, it
                                   technical information in a potentially classified subject area. This       would seem possible, because people can maintain and post                   There are no classified information, data or materials at
                                   applies to technical information intended for a local or external          things to their own websites at Fermilab. However, I do not                 Fermilab
                                   audience, whether a hard copy publication or online.
                                                                                                              know what training or other ways this might be prevented, if
                                   Easy-to-use web-publishing capabilities make a huge amount of
                                                                                                              any.
               203     20-Apr-11 information available on the Internet. There is an assortment of                                                                             19-Aug-11                                                                     22-Aug-11 Cyber Security     Rejected-Close
                                   information available online, ranging from rumors and deliberate
                                   misinformation to genuine technical and scientific data. Some of the
                                   technical information available online is accurate and can be
                                   dangerous in the hands of hostile interests. Since many sites deal
                                   with nuclear material and weapons, workers must take extreme
                                   caution to protect information and ensure the information they publish
                                   is not classified. Our national security depends on it.
                                   M134D Broken Bolt (SEC-201103-LL-0064) - 03/21/2011                        Does not apply to Fermilab                                                  Did not send to LLC for evalautation.

               204     21-Mar-11                                                                                                                                              19-Aug-11                                                                     19-Aug-11 Cyber Security     Rejected-Close


                                   2011 Winter Performance Improvement Bulletin (SEC-201101-LL-0060) -        This lesson appears to be something you should already be                   08/22/11 - Requested Mary pull data for attachment and send
                                   01/10/2011                                                                 receiving in another way, But just in case it was not                       to Ron C.
                                                                                                              provided to you and thus not evaluated by Cyber-security, I
Fermi National Accelerator Laboratory Confidential                                                            am sending this lesson.                     5/3/2013                        08/23/11 - I would reject this lesson on the basis that, from a                                                    Page 35
                                                                                                                                                                                          Computer Security physical access point of view, it's non-
                                                                                                                                                                                          applicable. We already use a superior, card reader technology
                                                                                                                                                        LL Initial Review

                                                                                                                This lesson appears to be something you should already be                     08/22/11 - Requested Mary pull data for attachment and send
              Item #     Date                                2012-BNL-Bungee-0001)                              receiving in another way, But just in case itComments
                                                                                                                        OQBP LLC (ERV, JFM) Initial Review was not                  Date      to Ron C. MSLLC or MPLLC Initial Review Comments                    Date      MS/MP (Area) Initial Review Status
                                   This Bulletin summarizes the categories of security locks and keys           provided to you and thus not evaluated by Cyber-security, I
                                   and the requirements for controlling them. It also provides best             am sending this lesson.                                                     08/23/11 - I would reject this lesson on the basis that, from a
                                   practices, casual analysis and useful lessons learned from sites within                                                                                  Computer Security physical access point of view, it's non-
                                   the Enterprise.
                                                                                                                                                                                            applicable. We already use a superior, card reader technology
               205     10-Jan-11                                                                                                                                                  19-Aug-11                                                                     23-Aug-11 Cyber Security     Rejected-Close
                                                                                                                                                                                            for access to computer facilities like the FCC and GCC
                                                                                                                                                                                            buildings.

                                                                                                                                                                                              That's not to say there aren't other Divisions/sections using
                                                                                                                                                                                              metal keys and key tracking devices, but I don't know of any.

                                   Cooperating with Security Inquiries (SEC-201101-LL-0061) - 01/03/2011        Sent to LLC to evaluate potential for issue at Fermilab.                      08/29/11 Ron's response: This LL is not particularly applicable
                                                                                                                Frankly, I’m not quite sure why this is a lesson. It looks more               to Computer Security.
                                   Security inquiries are fact-finding procedures to assess risks to            like an issue of communication or errors without real
                                   classified matter and mitigate vulnerabilities. Employees should             solutions followed by personnel actions. I guess you could                    It might be more applicable to WDRS in general.
                                   cooperate willingly and openly throughout the inquiry process. This          consider an example to provide people of how serious things
               206     3-Jan-11    LL shows how an employee not only potentially compromised
                                                                                                                can get.                                                          19-Aug-11 08/30/11 - Sending to Operationsto review.                                       Operations      Rejected-Close
                                   classified information, but also misled their colleagues and inquiry
                                   officials.
                                                                                                                                                                                              08/30/11 Bruce's response: This has to do with Classified
                                                                                                                                                                                              material which we don't have so this is not applicable to the
                                                                                                                                                                                              lab.
                                   1. YELLOW - Aerosol Can Seam Failure Results in Content Dispersal within Looks like this might really should have been done under a                        RColl Comments: Rejected. Fermilab does not use this type of
                                   Storage Cabinet(Source: User Submitted - ID: 2011-LANL-CMR-2011-0002) product recall or an alert. I would recommend Fermilab                               aerosol.
                                                                                                            check to see if it has any of this item. Recommended
                                   Aerosol cans of "NoCount" Radioactive Decontamination Surface            expediting the review.
                                   Cleaner that DO NOT have a two-year expiration date printed on the
               207     24-Aug-11 label may rupture unexpectedly. Suspect cans should be immediately                                                                               24-Aug-11                                                                     13-Sep-11       ES&H         Rejected-Close
                                   removed from service using appropriate hazardous material disposal
                                   methods. Aerosol cans of "NoCount" that DO have a two-year
                                   expiration date printed on the label should also be removed from
                                   service immediately upon their expiration using appropriate
                                   hazardous material disposal methods.

                                   2. YELLOW - Fire Extinguishers on Mobile Equipment(Source: User  This looks like just being sure you comply with the                                     RColl Comments: Rejected. Fire extinguishers mounted on
                                   Submitted - ID: Y-2011-OR-UCORBOP-0801)                          requirements. Not sure why this is a lesson. Is Fermilab                                portable equipment such as forklifts are checked during the
               208     24-Aug-11 Fire Extinguishers mounted on mobile equipment should be inspected aware of this requirement and does it have a way to assure                    24-Aug-11 schedule preventive maintenance managed by the Business             13-Sep-11       ES&H         Rejected-Close
                                 and maintained as required by NFPA 10 requirements.                it meets the requirement?                                                               Services Section.

                                   1. BLUE - Defense in Depth Prevents Near Mishap with Energized               FYI or possibly add to training materials? Maybe use this as                  RColl Comments: Rejected. This is already incorporated in the
                                   Subsurface Electrical Lines(Source: User Submitted - ID: 2011-RL-HNF-        a positive example of what should be done and how it can                      manner we do business and how we do excavations.
                                   0002)                                                                        help?
                                   Teamwork, between workers and supervisors, results in the
               209     25-Aug-11 prevention of a near mishap. When an employee encounters an                                                                                      25-Aug-11                                                                     13-Sep-11       ES&H         Rejected-Close
                                   anomaly to the work plan, he stopped working and asked for his
                                   supervisor's assistance. The employee's questioning attitude,
                                   willingness to stop work, and request for help, coupled with the
                                   prompt and thorough response of his supervisor, prevented a near
                                   mishap.
                                   2. YELLOW - Bursting Chemical Container(Source: User Submitted - ID:         Is this covered somewhere in the training or procedures? If                 RColl Comments: Rejected. Our management system deals
                                   LBNL-LL11-0022)                                                              not, should it be?                                                          with the HazComm standard as it is laid out in OSHA. Lack of
                                 It is important to remember that container labeling and MSDSs may                                                                                          information on an MSDS will be identified when, as is the case
               210     25-Aug-11 sometimes lack specific hazard warnings. Therefore, you should                                                                                   25-Aug-11 in this LL, an incident occurs that leads to further                13-Sep-11       ES&H         Rejected-Close
                                 understand the properties of chemicals before ordering, handling,                                                                                          investigation. Investigating chemicals, beyond the
                                 using and storing them.
                                                                                                                                                                                            information in the MSDS is not an expectation we have for
                                                                                                                                                                                            our employees.
                                   1. BLUE - Insufficient Awareness to Aging Conditions Results in Electrical   FYI? This looks like something which people with the proper                   RColl Comments: Not for the ES&H LLC. Belongs to project
                                   Shock(Source: User Submitted - ID: 2011-RL-HNF-0037)                         background should do and the JHA procedure requires.                          management and end of life studies for a facility.

               211     31-Aug-11                                                                                                                                                  31-Aug-11                                                                                  Operations          On Hold
                                                                                                                                                                                              09/13/11 - Need to determne another reviewer.
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                                                                                                                                                     LL Initial Review
                                                                                                              FYI? This looks like something which people with the proper                  RColl Comments: Not for the ES&H LLC. Belongs to project
              Item #     Date                              2012-BNL-Bungee-0001)                              background should do and the JHA procedure requires.
                                                                                                                     OQBP LLC (ERV, JFM) Initial Review Comments                 Date               MSLLC end of life studies for a Comments
                                                                                                                                                                                           management andor MPLLC Initial Review facility.                 Date      MS/MP (Area) Initial Review Status
                                 Assumptions made during one phase of a facilities operating life may
               211     31-Aug-11 not be valid during subsequent phases. When an extended operating                                                                             31-Aug-11                                                                              Operations          On Hold
                                                                                                                                                                                           09/13/11 - Need to determne another reviewer.
                                 process is considered, the risk evaluation should consider the
                                 extended time and the increase in the number of mechanical cycles
                                 involved.
                                  2. BLUE - Operating in Close Proximity to Groundwater Wells Requires        FYI? This looks like something which people with the proper                  RColl Comments: Rejected. We do not have this type of wells
                                  Robust Work Management and Communication(Source: User Submitted -           background should do and the work planning system                            here. We only have monitoring wells with openings that do
                                  ID: 2011-RL-HNF-0041)                                                       requires.                                                                    not exceed 2 inches.
                                 When work is to be conducted in close proximity to groundwater
                                 wells, it is essential that a thorough structured work planning,
               212     31-Aug-11 authorization and release process be completed. Any unauthorized                                                                              31-Aug-11                                                                 13-Sep-11       ES&H         Rejected-Close
                                 disturbance of a groundwater well may adversely impact on-going
                                 activities and result in procedural and possible regulatory
                                 noncompliance. Adverse affects to a groundwater well must be
                                 mitigated which is costly, time consuming, and has far reaching
                                 business implications.
                                  3. BLUE - Control Rods Inadvertently Pulled from 105KE Reactor duringI realize we do not have a reactor on site. However, since                          RColl Comments: Rejected. Not applicable to Fermilab.
                                  Demolition(Source: User Submitted - ID: 2011-RL-HNF-0042)            we are about to eventually deal with moth-balling or D&D
                                                                                                       for parts of the Tev would any of this apply, especially the
                                  On January 13, 2011, at the 105KE reactor during demolition of the   potential for returning to work and having the situation
                                  outer rod room, a formal Stop Work was initiated by Radiological     encountered be different than just prior to leaving or
                                  Control management. A portion of the reactor Horizontal Control Rods originally planned.
                                 (HCR) and rod extensions had been inadvertently pulled out of the
                                 reactor core by an excavator during demolition activities. The final
                                 configuration expectation documented in the work plan was that the
                                 rod extensions be sheared at the inner rod room wall. Assumptions
               213     31-Aug-11 regarding demolition methods must be confirmed prior to the start of                                                                          31-Aug-11                                                                 13-Sep-11       ES&H         Rejected-Close
                                 the work evolution. When demolishing structures with significant
                                 source term, it is essential that the components with source term/dose
                                 be adequately researched to ensure that dose assumptions are
                                 bounded. When re turning to a task after a significant work delay, the
                                 pre-job briefing (PJB) should be as comprehensive as the original
                                 PJB. Visual identification of critical components is essential when
                                 deconstructing/demolishing facilities. It is imperative that safety
                                 documentation be clearly understood and collaborated with the
                                 customer, especially when events occur that are outside of the
                                 common expectations of the customer and contractor.
                                  1. YELLOW - Outdoor Walking and Working Surfaces (Source: User              Rejected - People have to pay attention to their                             Not sent to LLC
                                  Submitted - ID: Y-2011-OR-BWY12-0801)                                       surroundings as part of life. This is a practice that is built
               214     7-Sep-11   Outdoor areas can present some unique walking and working                   into the processes and procedures along with constant            9-Sep-11                                                                  9-Sep-11        ES&H         Rejected-Close
                                  surfaces, and personnel must keep their eyes on the path when               reminders at the site.
                                  walking and working in outdoor areas.
                                  2. YELLOW - Wood Spacer Installed in Pull Box Assembly at ATTA - Lessons Reject? This looks like what should be a normal practice by                     RColl Comments: Rejected. This is in the area of quality
                                  Learned For Foreign Material in Electrical Enclosures(Source: User       Fermilab expectations, practices and procedures. I guess it                     control. Looks like a failure of inspecting work once
                                  Submitted - ID: 2011-SR-SRNS-0013)                                       could be sent as a reminder.                                                    completed.
                                  Call a Time Out and consult Engineering if anything that is not part of
               215     7-Sep-11   the electrical system is found in an electrical enclosure. If foreign                                                                        9-Sep-11    110909 - Changed my mind and distributed to the S/C safety    9-Sep-11        ES&H             FYI Only
                                  material such as wood is found being used as an insulating barrier in                                                                                    subcommittee and the Electrical Safety Subcommittee.
                                  an electrical enclosure, contact Engineering for resolution.
                                                                                                                                                                                           The S3 will brief at the TM_CC Update meeting also.


                                  1. Questioning Attitude in the Field Leads to Safer Work Practice(Source:   Reject or FYI? This is or should be standard practice.                       RColl Comments: Rejected. The lesson is something we should
                                  User Submitted - ID: PMLL-2011-RL-ARRA_HNF-0005)                            Reemphasizing this or advertising it might be useful. But, it                always be doing and goes to the management style of people
                                                                                                              is part of the training and expectations at Fermilab.                        involved. Nothing to do with ES&H.
                                  Active participation, mental focus and a questioning attitude at pre-job
               216     8-Sep-11   briefs can make the difference between a safe work evolution and a                                                                           9-Sep-11                                                                  9-Sep-11        ES&H         Rejected-Close
                                  disaster. During a pre-job brief, an employee's question prompted a
                                  mock-up proving that material in a waste filled pipe could be ignited
                                  by the temperature of the cutting blade. All employees have a
                                  significant role in maintaining a safe work environment.

                                  2. Planning Volume of Excavated Material in Landfill Remediatio(Source:     Not sure who would review this and see if there is anything                  Does not apply at Fermilab; no landfill excavation or
                                                                                                              to be gained.                                                                remediation.
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               217     8-Sep-11                                                                                                                                                9-Sep-11                                                                  12-Sep-11      Site LLC      Rejected-Close
                                                                                                              09/12/11 - will continue to look for someone to review
                                                                                                                                                       LL Initial Review

              Item #     Date                              2012-BNL-Bungee-0001)                               Not sure who would review this and see if there is anything
                                                                                                                       OQBP LLC (ERV, JFM) Initial Review Comments              Date               MSLLC Fermilab; no landfill excavation or
                                                                                                                                                                                          Does not apply ator MPLLC Initial Review Comments                Date      MS/MP (Area) Initial Review Status
                                  Volumes of excavated materials from landfills are difficult to estimate      to be gained.                                                              remediation.
               217     8-Sep-11                                                                                                                                                9-Sep-11                                                                  12-Sep-11      Site LLC      Rejected-Close
                                                                                                               09/12/11 - will continue to look for someone to review
                                                                                                               and/or review applicablility of this lesson..

                                  3. Moble Enclosures Are Not Cost Effective (MDAB-3)(Source: User             Reject – Not enough data provided in the information to                    Not sent to LLC
               218     8-Sep-11   Submitted - ID: PMLL-2011-LANL-ARRA_MDAB 3-001)                              evaluate this lesson.                                           9-Sep-11                                                                  9-Sep-11       Site LLC      Rejected-Close
                                  Mobile enclosures are not cost effective in meeting schedule and
                                  construction milestones.
                                  4. Subcontract Strategy for Landfill Excavation(Source: User Submitted - ID: Reject – Not enough data provided in the information to                    Not sent to LLC
               219     8-Sep-11   PMLL-2010-LANL-ARRA_MDA B-001)                                               evaluate this lesson.                                           9-Sep-11                                                                  9-Sep-11       Site LLC      Rejected-Close
                                  Lump sum, fixed price subcontracting requires large contingency

                                  5. Torch Modification Avoids Tool Damage from Slag Buildup(Source: User      Does Fermilab have a similar situation or equipment where                  RColl Comments: Rejected. This is skills of the trade.
                                  Submitted - ID: PMLL-2011-BNL_ARRA-BGRR-0001)                                this could happen?

                                  1368 steel fuel ports were being torch cut in 4 locations so that the
               220     8-Sep-11   tubes would easily shear during demolition with an excavator. A                                                                              9-Sep-11                                                                  9-Sep-11        ES&H         Rejected-Close
                                  number of torch heads failed when slag was allowed to build up on or
                                  near the torch head itself. The installation of a low pressure air line
                                  along the torch handle to blow slag away from the torch head resulted
                                  in a reduced torch head failure rate.

                                  6. Risk Management(Source: User Submitted - ID: PMLL-2010-SR_ARRA-           Need Fermilab personnel to evaluate if there is anything in                RColl Comments: Reject. This is not ES&H but rather risk
                                  SRR-0004)                                                                    the lesson that might be of value to include or modify in the              management and project management.
                                  Conduct a risk brainstorming session, utilizing a prospective                Fermilab risk management process and procedures.
               221     8-Sep-11   hindsight technique, in the early stage of the project to pro-actively                                                                       9-Sep-11                                                                              Project Mgmt   Awaiting LLC Review
                                  identify and begin early management of major risks before a formal           09/12/11 - per ES&H, sending to OPMO to review.
                                  comprehensive risk identification is performed. The accepted term to
                                  describe this analysis techniques is a "Pre-mortem."

                                  1. YELLOW - Sling Failure Causes Box to Fall into Trench - Emphasizes        Need Fermilab personnel to evaluate if there is anything in                RColl Comments: Rejected. Personnel were not following
                                  Awareness of Error-Likely Steps and Situations(Source: User Submitted -      the lesson and new procedure that they would benefit from.                 procedures. Deviations occurred.
                                  ID: 2011-SR-SRNS-0014)
                                  When routinely used, the SAFER tool helps ensure error-free work
                                  performance. The SAFER process engages the work group in a review
                                  of the hazardous tasks, the critical error-likely steps involved with
               222     8-Sep-11   hazardous tasks, and the checks of the critical steps to ensure they                                                                         9-Sep-11                                                                  13-Sep-11       ES&H         Rejected-Close
                                  are performed error-free. See Analysis Section below for further
                                  details about the SAFER process. Peer checks should be applied to
                                  critical error-likely steps regardless of the high level of expertise. The
                                  synthetic sling was incorrectly used through the pin hole of the sister
                                  hook unprotected. The pin hole has square edges that, when left
                                  unprotected, can act like a knife edge.

                                  2. GREEN - Initial Lessons Learned - 2011 Las Conchas Fire Near Los Alamos Need Fermilab personnel to evaluate if there is anything in                  RColl Comments: Rejected. The conditions referred to in this
                                  National Laboratory(Source: User Submitted - ID: 2011-LANL-LANL-2011-      the lesson and new procedure that they would benefit from.                   LL are not applicable to Fermilab. Additionally we have a
                                  0002)                                                                                                                                                   robust emergency management system in place that is
                                  Emergency management is an ongoing activity, not one that occurs                                                                                        regularly exercised.
                                  only in reaction to an initiating event. Los Alamos National Laboratory
                                  has experienced two significant wildfire events in the past eleven
                                  years. Key lessons learned from the Laboratory closure due to the
                                  nearby Las Conchas Fire include: - Improvements related to the
               223     8-Sep-11   lessons learned from the Cerro Grande Fire in 2000 were proven to be                                                                         9-Sep-11                                                                  13-Sep-11       ES&H         Rejected-Close
                                  beneficial during the 2011 Las Conchas Fire; - For large wildfire-
                                  related emergency closures, effective teams are required to support
                                  emergency operations, multi-media communications, computing and
                                  communications infrastructure, environmental monitoring and data
                                  analysis, and facility and site recovery; and - Employees and the
                                  public rely on multiple sources, including social media, to keep
                                  themselves informed, but no single method will reach all employees or
                                  all audiences.

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                                                                                                                                                   LL Initial Review


              Item #     Date                              2012-BNL-Bungee-0001)                                  OQBP LLC (ERV, JFM) Initial Review Comments                 Date                 MSLLC or MPLLC Initial Review Comments                  Date      MS/MP (Area) Initial Review Status
                                  3. BLUE - Near-Miss: Lab Oven Explosion during Energetic Material        Does Fermilab have a similar situation where this could                      RColl Comments: Rejected. We do not handle explosive
               224     8-Sep-11   Deactivation(Source: User Submitted - ID: 2011-KCP-0001)                 happen?                                                          9-Sep-11    materials.                                                       13-Sep-11       ES&H         Rejected-Close
                                  Ensure processes address current activities conducted. Ensure
                                  compatibilities of materials when processing.
                                  4. YELLOW - Open Toolbox Drawer Scrapes Worker's Back(Source: User       Reject or FYI? Looks like a like a lack of housekeeping or a                 RColl Comments: Rejected. No change to management
                                  Submitted - ID: 2011-ANL-009)                                            general workmanship and pride in ownership issue to me.                      systems needed. This boils down to workers maintaining a
                                  Toolbox drawers should be closed after you retrieve tools, hardware,                                                                                  degree of awareness of their surroundings.
               225     8-Sep-11   or other items, even if you are going to put them back in the drawer                                                                      9-Sep-11                                                                     13-Sep-11       ES&H         Rejected-Close
                                  within a short time. You may become distracted with your work and
                                  forget to close the drawer. This is especially important in tight work
                                  areas that have multiple users.

                                  5. YELLOW - Failure to Follow Approved Hazard Analysis Document and   Yes, I would tend to think this a lack of following procedures.                 RColl Comments: Reject. Agree with your assumption.
                                  Approved Work Plan (Source: User Submitted - ID: Y-2011-OR-BWY12-      However, I would recommend Fermilab personnel evaluate                         Additionally, we have provided training on HAs and
                                  0802)                                                                 their processes and procedures to see if there is anything                      embedded the HA process in the culture. The rest is left to
               226     8-Sep-11   Failure to adequately train personnel on the approved hazard analysis they might need or want to change.                                  9-Sep-11    worker ethics that cannot be regulated regarding how they        13-Sep-11       ES&H         Rejected-Close
                                  document and to ensure that personnel complied with the approved                                                                                      use the tools provided.
                                  work plan while performing work resulted in personnel encountering a
                                  live electrical wire on a demolition project at the Y-12 National
                                  Security Site.
                                  6. GREEN - Risk Profiling Helps PNNL Managers Identify and Mitigate      Need Fermilab personnel to evaluate if there is anything in                  RColl Comments: Not in the skill set of ES&H and more in
                                  Risks(Source: User Submitted - ID: 2011-LL-PNNL-0006)                    the lesson that might be of value to include or modify in the                project risk management.
                                  Pilot project examines risks and performance in over 100 program         Fermilab risk management process and procedures.
               227     8-Sep-11   areas. The project's holistic approach was not stove-piped by                                                                             9-Sep-11    09/13/11 - Need to send to project Management for review.                    Project Mgmt   Awaiting LLC Review
                                  function. It went beyond safety and compliance to examine how the
                                  interactions of people, processes and the external environment can
                                  create risks for an entire organization.

                                  7. YELLOW - Staff Member, Spouse Exposed to High Levels of Carbon        FYI or Reject? This might be a good safety topic for Fermilab                RColl Comments: Rejected. Clear instructions come with these
                                  Monoxide at Home(Source: User Submitted - ID: 2011-LL-PNNL-0007)         Today or sent as a reminder.                                                 CO detectors. Replacing the battery after the alarm sounds is
                                                                                                                                                                                        not the solution. This is a clear case of a family not knowing
                                  After the alarm sounded on their carbon monoxide (CO) detector, a                                                                                     how these CO detectors work.
                                  PNNL staff member and his wife replaced the batteries. His wife
                                  worried that recurring headaches were related to the detector incident
                                  and called the gas company. Testing indicated dangerous levels of CO
               228     8-Sep-11   in their home that could cause headaches. Blood tests showed she                                                                          9-Sep-11                                                                     13-Sep-11       ES&H         Rejected-Close
                                  and her husband had inhaled unsafe levels of CO and both of them
                                  suffered lingering effects from their exposure. Lessons Learned:
                                  Carbon monoxide is odorless and colorless. If your CO detector goes
                                  off, leave the house immediately and call your gas company or local
                                  fire department. "The risks are real and the impact can be long-term
                                  and maybe permanent," the staff member reported.


                                  8. YELLOW - Abandoned, Exposed Wires May Create a Potential Electrical   FYI or Reject? Improper execution of work? Looks like this                   RColl Comments: Rejected. Agree with your assumptions.
                                  Hazard (Source: User Submitted - ID: 2011-BNL-SHSD-0001)                 should be a skills of craft expectation and practice. Also,
               229     8-Sep-11                                                                            Fermilab HA and safety training would cover this.                9-Sep-11                                                                     13-Sep-11       ES&H         Rejected-Close
                                  Treat exposed, untagged conductors as energized until verified de-
                                  energized.
                                  1. YELLOW - Scissors Jack Failure while Changing a Tire Leads to Minor   FYI or might want to put something in Fermi Today or                         RColl Comments: Sent to vehicle maintenance as an FYI.
                                  Injuries and Vehicle Damage(Source: User Submitted - ID: 2011-NV-NNSS-   “bathroom press” as a reminder?
                                  403)
                                  Even when following the manufacturer recommended directions for
               230     14-Sep-11 changing a vehicle tire, an unexpected failure of equipment may result                                                                     14-Sep-11                                                                    20-Sep-11       ES&H             FYI Only
                                  in injury and/or vehicle damage. Always expect the unexpected and
                                  minimize injury by keeping your hands away from potential pinch
                                  points, especially when operating equipment/tools.

                                  2. BLUE - Commitment to Achieving Readiness Help PNNL Ace                I believe Fermilab does not do radiochemical processing.                     RColl Comments: Clearly a project management best practice
                                  Assessment(Source: User Submitted - ID: 2011-LL-PNNL-0008)               However, I recommend Fermilab personnel evaluate if there                    and thus belongs to Project Management LLC. No further
                                                                                                           is anything in the lesson that might be of value to include in               action or responses from ES&H.
                                                                                                           their processes oand procedures.
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                                                                                                                                                       LL Initial Review




                                                                                                               I believe Fermilab does not do radiochemical processing.                     RColl Comments: Clearly a project management best practice
              Item #     Date                              2012-BNL-Bungee-0001)                               However, I recommend JFM) Initial Review Comments there
                                                                                                                       OQBP LLC (ERV, Fermilab personnel evaluate if              Date                 MSLLC to Project Management LLC. No further
                                                                                                                                                                                            and thus belongs or MPLLC Initial Review Comments                Date      MS/MP (Area) Initial Review Status
                                 The keys to PNNL's successful Readiness Assessment (RA) for the               is anything in the lesson that might be of value to include in               action or responses from ES&H.
                                 Radiochemical Processing Laboratory (RPL) included not only hard              their processes oand procedures.
                                 work, commitment, team effort and sacrifice, but also a steadfast
                                 dedication to assuring all aspects of this nuclear facility--"people,
                                 parts, and paperwork"--were absolutely ready to support research
               231     14-Sep-11 operations. PNNL clearly defined expectations for readiness when                                                                               14-Sep-11                                                                               Operations    Awaiting LLC Review
                                 RPL's plan of action (POA) was written and management prepared for
                                 and conducted a rigorous Management Self-Assessment (MSA) to
                                 assure that readiness had been achieved prior to the RA. Preparing for
                                 the MSA assured that trained, qualified personnel, flawlessly operable
                                 equipment, and accurate procedures and documentation achieved
                                 readiness before the planned formal MSA was conducted to confirm
                                 readiness.
                                  3. YELLOW - Improperly Parked Pickup Unexpectedly Rolls and Injures  FYI or Reject? Looks like something that should part of                              RColl Comments: Rejected. Agree with your eval.
                                  Worker(Source: User Submitted - ID: 2011-LL-PNNL-0009)               driver’s training to get a license, but people may not have
                                  When an employee of a PNNL subcontractor arrived at Bonneville Dam encountered the situation or possibility. Might want to put
                                  to support fisheries research, he parked on a gradual slope and put  something in Fermi Today or “bathroom press” as a
                                  his pickup in gear. After working 10 minutes nearby, he heard a yell reminder?
                                 and ran back to find his truck had rolled about 20 feet down the
                                 incline, hit an Army Corps of Engineers employee, and struck a chain
               232     14-Sep-11 link fence. Lessons Learned: When parking on any slope, use multiple                                                                           14-Sep-11                                                                  20-Sep-11       ES&H         Rejected-Close
                                 methods to secure your vehicle to prevent it from rolling accidentally.
                                 Put an automatic transmission in park, set the emergency brake and
                                 turn the wheels into a curb, if available. For manual transmissions, put
                                 the vehicle in reverse if facing downhill or in a low forward gear if
                                 facing uphill and always set the brake. Turn the wheels into a curb if
                                 available. If not secured, a vehicle can quickly roll--even on a gradual
                                 incline.
                                  4. YELLOW - Application of Bulk Characterization to Individual Containers:   I realize Fermilab does not pursue D&D clean-up projects.                    Accept as an "FYI"- Passed to our waste managers.
                                  The Demolition Effect (Source: User Submitted - ID: 2011-BNL-ERP-0006)       However, since Fermilab is about to eventually deal with
                                                                                                               moth-balling or D&D for parts of the Tev would any of this
                                 When pursuing cleanup or Decontamination/Decommissioning (D&D)                apply?
                                 projects, characterization of the material to be removed is often
               233     14-Sep-11 performed when the material is in-situ. The actual demolition and                                                                              14-Sep-11                                                                  15-Sep-11       ES&H             FYI Only
                                 removal of the material can result in individual containers varying
                                 significantly from the mass characterization profile. This variance, if
                                 not detected, can result in individual containers exceeding DOT or
                                 waste disposal site acceptance criteria.

                                 5. YELLOW - Placement of Airborne Sampling Device is Important When           Need Fermilab personnel to evaluate if there is anything in                  RColl Comments: The LL is already an established monitoring
                                 Assessing Exposure to Metal Fumes (Source: User Submitted - ID: 2011-         the lesson that they would benefit from.                                     procedure at Fermilab.
               234     14-Sep-11 BNL-ERP-0005)                                                                                                                                  14-Sep-11                                                                  14-Sep-11       ES&H         Rejected-Close
                                  Placement of airborne sampling devices is an important consideration
                                  for accurate assessment of metal fume exposure during welding and
                                  cutting operations.
                                  6. BLUE - Radcalc V4.1 Software Defect(Source: User Submitted - ID: HSS      Does this apply to Fermilab/does Fermilab use this software?                 RColl Comments: Rejected. Fermilab does not use this
                                  OE-3 2011-01)                                                                                                                                             computer code and therefore this LL is not applicable.
               235     14-Sep-11 An Operating Experience Level 3 (OE-3) report was issued to provide                                                                            14-Sep-11                                                                  14-Sep-11       ES&H         Rejected-Close
                                  information on software quality assurance problems related to the use
                                  of the Radcalc V4.1 computer code related to the packaging and
                                  transportation of radioactive material.
                                  1. YELLOW - Latent Error Leads to Equipment Damage (Source: User             Reject or FYI? Could be used as a reminder. However, this                    09/20/11 - Bruce Chrsiman's comments: I'll send to Randy,
                                  Submitted - ID: 2011-BNL-EAWG-0003)                                          should be standard practice in performing the job and as                     but on item 1 I see this as an FYI as to the importance of
                                                                                                               part of the review/sign-off the job has been done.                           maintaining up to date drawings and using them when
                                                                                                               Verfication and validation are a part of the requirements in                 planing work.
                                                                                                               the Engineering Manual.
                                                                                                                                                                                            09/20/11 - Randy's comments: ..., but FESS doesn’t work on
                                                                                                                                                                                            any programmatic equipment and our water systems should
Fermi National Accelerator Laboratory Confidential                                                                                                        5/3/2013                                                                                                                                          Page 40
                                                                                                                                                                                            not be considered critical since there is no single point of
                                                                                                                                                                                            failure affecting science. The only work that is perhaps
                                                                                                                                                           LL Initial Review




                                                                                                                  Reject or FYI? Could be used as a reminder. However, this                  09/20/11 - Bruce Chrsiman's comments: I'll send to Randy,
              Item #     Date                                2012-BNL-Bungee-0001)                                should be standard practice in performing the job and as
                                                                                                                          OQBP LLC (ERV, JFM) Initial Review Comments              Date                MSLLC or MPLLC Initial Review importance
                                                                                                                                                                                             but on item 1 I see this as an FYI as to the Comments of            Date      MS/MP (Area) Initial Review Status
                                   At Brookhaven National Laboratory, a wiring error made years ago               part of the review/sign-off the job has been done.                         maintaining up to date drawings and using them when
                                   during initial installation resulted in equipment damage and lost              Verfication and validation are a part of the requirements in               planing work.
                                   experiment time for scientists at three beam lines. There was no               the Engineering Manual.
                                   personnel risk involved, but the science program was impacted.
                                                                                                                                                                                           09/20/11 - Randy's comments: ..., but FESS doesn’t work on
                                   Effective quality programs are necessary to ensure that errors are
                                   prevented or detected during testing/validation and that equipment of
                                                                                                                                                                                           any programmatic equipment and our water systems should
                                   programmatic importance is well analyzed, managed, and functioning                                                                                      not be considered critical since there is no single point of
                                   as intended.                                                                                                                                            failure affecting science. The only work that is perhaps
                                                                                                                                                                                           related is our DDC Metasys control systems in CUB that get
                                                                                                                                                                                           tested vigorously when changes are made before going
                                                                                                                                                                                           online. I have copied FESS ops for information, but again I
               236     20-Sep-11                                                                                                                                                 20-Sep-11                                                                     21-Sep-11    Operations      Rejected-Close
                                                                                                                                                                                           think this more relates to AD.

                                                                                                                                                                                             09/20/11- Bruce sent to AD and TD for review.

                                                                                                                                                                                             09/21/11 - AD/Paul's response: This has been our policy for at
                                                                                                                                                                                             least the 39 years that I have been at the lab. This has been
                                                                                                                                                                                             true in my former lifetime in the Research Division and in
                                                                                                                                                                                             Accelerator Division. We have built this policy into everything
                                                                                                                                                                                             that gets done here. I don't know the details of what
                                                                                                                                                                                             happened but checking equipment and personnel interlocks
                                                                                                                                                                                             has always been part of the job.


                                   2. BLUE - Avoid Relying Solely on Indirect Indication of Status of Valves or   Reject? This seems like a good practice to do. I do not know               09/20/11 - Bruce Chrsiman's comments: On 2 Randy can
                                   Switches (Source: User Submitted - ID: 2011-BNL-EAWG-0002)                     that Fermilab does not already do this. Need Fermilab to                   comment, but I think this is part of his procedures.
                                   Instead of relying on an indirect or remote indication of the                  evaluate versus their current processes, procedures and
                                   functioning of valves or switches, it is important to verify the physical      expected practices.                                                      09/20/11 - Randy's comments: ..., but FESS doesn’t work on
                                   state of the equipment/system after any maintenance, modifications,                                                                                     any programmatic equipment and our water systems should
                                   or configuration changes.                                                                                                                               not be considered critical since there is no single point of
                                                                                                                                                                                           failure affecting science. The only work that is perhaps
                                                                                                                                                                                           related is our DDC Metasys control systems in CUB that get
                                                                                                                                                                                           tested vigorously when changes are made before going
               237     20-Sep-11                                                                                                                                                 20-Sep-11                                                                     21-Sep-11    Operations      Rejected-Close
                                                                                                                                                                                           online. I have copied FESS ops for information, but again I
                                                                                                                                                                                           think this more relates to AD.

                                                                                                                                                                                             09/20/11- Bruce sent to AD and TD for review.

                                                                                                                                                                                             09/21/11 - AD/Paul's response: As for the valves, we don't
                                                                                                                                                                                             rely on remote indications before performing work just like
                                                                                                                                                                                             we don't rely on the electrical safety system to keep power
                                                                                                                                                                                             supplies off. LOTO is the key here.
                                   3. BLUE - Classification Review of Completed Forms (Source: User               Reject - No classified matieral at Fermilab.                               Not sent to Physical Security LLC
                                   Submitted - ID: L-2011-OR-BWY12-0803)
               238     20-Sep-11                                                                                                                                                 20-Sep-11                                                                     20-Sep-11      Site LLC      Rejected-Close
                                   Completion of normally unclassified forms with potentially classified
                                   data can result in classification concerns.




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                                                                                                                                                      LL Initial Review



              Item #     Date                               2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments            Date                MSLLC or MPLLC Initial Review Comments                   Date      MS/MP (Area) Initial Review Status
                                   4. YELLOW - Diesel Fire Pump Battery Rupture during Starting Operation      Do not know if Fermilab has this equipment or a like                      09/20/11- RColl Comments: See SME comments below.
                                   (Source: User Submitted - ID: Y-2011-OR-BWY12-0904)                         situation nor what their current processes and practice are               Clearly has to do with maintenance thus I suggest sending this
                                                                                                               for this situation. Need Fermilab SME to evaluate.                        to FESS Ops and follow up to insure that they include this in
                                                                                                                                                                                         their maintenance database requirements for the preventive
                                                                                                                                                                                         maintenance of these generators. There is no further action
                                                                                                                                                                                         or response from me on this specific LL.

                                                                                                                                                                                       09/20/11 - SME responses: While we only have one diesel fire
                                                                                                                                                                                       pump at C-4 pump house and there is the diesel emergency
                                                                                                                                                                                       sump at Minos . This is a problem that could occur with any
                                                                                                                                                                                       diesel generator not just a fire pump most of which are used
                                                                                                                                                                                       for back up of Life safety systems . Gen Sets at WH diesel,
                                                                                                                                                                                       Minos, CO sumps, and fire dept, both Switch yards. I am
                                                                                                                                                                                       going to pass this to FESS to insure that the Maintenance
                                                                                                                                                                                       includes the life cycle of the batteries on the units. We cover
                                                                                                                                                                                       this on the fire panels and Firus and replace before the
                                                                                                                                                                                       battery life. So never hurts to check.
                                                                                                                                                                                       FYI -- Clarification. There are two electric motor driven (fire)
                                                                                                                                                                                       pumps at C-4, one is backup by a diesel generator.
                                                                                                                                                                                       FESS-Ops has maintenance contracts on the generators. The
                                                                                                                                                                                       WH and FCC has a 2-year maintenance with the generator
                                                                                                                                                                                       vendor. It was part of the bid specifications. Likewise, C-0
                                                                                                                                                                                       generators has maintenance agreements set-up by FESS-Ops.
                                                                                                                                                                                       All maintenance and testing is in accordance with NFPA 110;
                                                                                                                                                                                       however, Randy Wielgos is passing this along and is verifying
               239     20-Sep-11                                                                                                                                             20-Sep-11                                                                    22-Sep-11    Operations      Rejected-Close
                                                                                                                                                                                       with batteries are being checked with the outside vendors.

                                   Overcharging, skipping regular preventative maintenance tasks or use                                                                                  09/22/11 - FESS response: I believe the attached FESS
                                   of battery past its manufacturer's specified useful life may lead to loss                                                                             procedure satisfies what this is offering so I submit” the
                                   of electrolyte, hydrogen build-up, rupture and/or catastrophic failure.                                                                               following:

                                                                                                                                                                                         4. Reject and state the reason.

                                                                                                                                                                                         The reasons for rejection will generally be one of the
                                                                                                                                                                                         following:

                                                                                                                                                                                         • Fermilab already has something which in some other way
                                                                                                                                                                                         considers what the sender/originator has offered in the
                                                                                                                                                                                         lesson, to ensure the following is covered:
                                                                                                                                                                                         • 1. Batteries should be removed from service prior to the
                                                                                                                                                                                         end of the manufacturer's recommended useful life.
                                                                                                                                                                                         2. Batteries should be removed from services that are unable
                                                                                                                                                                                         to hold a charge such that overcharging may occur.
                                                                                                                                                                                         3. The frequency and preventative maintenance activities for
                                                                                                                                                                                         batteries should ensure that electrolyte loss or hydrogen gas
                                                                                                                                                                                         evolution does not occur.




                                   5. BLUE - System for Analysis of Soil-Structure Interaction Software        Do not know if Fermilab has this software. Need Fermilab                  09/20/11- RColl Comments: This has to do with software and
                                   Problem(Source: User Submitted - ID: HSS OE-3 2011-02)                      SME to evaluate.                                                          nothing with Safety. Send it to the Computing Division for
                                                                                                                                                                                         eval. ES&H is not involved with codes and software.
               240     20-Sep-11                                                                                                                                             20-Sep-11                                                                    21-Sep-11    Operations      Rejected-Close
                                                                                                                                                                                         09/21/11 - FESS does not use this software described in this
Fermi National Accelerator Laboratory Confidential                                                                                                       5/3/2013                                                                                                                                          Page 42
                                                                                                                                                                                         Lessons learned.
                                                                                                                                                         LL Need Fermilab
                                                                                                                 Do not know if Fermilab has this software.Initial Review                      09/20/11- RColl Comments: This has to do with software and
              Item #     Date                               2012-BNL-Bungee-0001)                                SME to evaluate. (ERV, JFM) Initial Review Comments
                                                                                                                        OQBP LLC                                                     Date                MSLLC or Send it to the Computing Division
                                                                                                                                                                                               nothing with Safety.MPLLC Initial Review Comments for                 Date      MS/MP (Area) Initial Review Status
                                 An Operating Experience Level 3 (OE-3) report was issued to provide                                                                                           eval. ES&H is not involved with codes and software.
               240     20-Sep-11 information on a software technical problem related to the use of the                                                                             20-Sep-11                                                                       21-Sep-11    Operations      Rejected-Close
                                 subtraction method in the System for Analysis of Soil-Structure                                                                                               09/21/11 - FESS does not use this software described in this
                                 Interaction (SASSI) computer code.
                                                                                                                                                                                               Lessons learned.

                                   1. BLUE - Property Damage to Crane(Source: User Submitted - ID: SRSO-         Reject? The lesson does not appear to address a cause. This
                                   MOXS-MOX- LL-2011-188)                                                        looks like human error plus an error in either incorrectly
                                 Crane operators must pay close attention to the signals given by the            evaluating or not evaluating the task/situation prior to doing
               241     23-Sep-11 flagmen and use radio communication with spotters when possible.                the work. Also, there is not enough detail to show any            23-Sep-11
                                                                                                                 briefings or walk-through of the task was done prior to
                                                                                                                 trying to move the crane.

                                                                                                                 accept - RColl working                                                      3/2/12: forwarded to Niehoff, Cassidy, and Gibbs for
                                   Scissor lift should only be used to assist in the setting of formwork if                                                                                  resolution
               242     24-Feb-12 compelling reasons dictate the use.Lesson ID: SRSO-MOXS-MOX-LL-                                                                                   24-Feb-12 3/12/12: accepted as FYI by James Niehoff ; Subcontractor             12-Mar-12       ES&H             FYI Only
                                   2011-297 (Source: User Submitted). Gust of wind blew form into                                                                                            Safety Subcommittee (S3) will discuss at next meeting 3/15.
                                   scirrors lift, knocking it over.
                                                                                                                 accept - RColl working                                                     4/2/2012: forwarded to FESS for resolution              4/17/12:
                                                                                                                                                                                            conditionally acccepted by FESS
                                                                                                                                                                                            5/29/2012: We are going to consider the LL as an FYI as we do
                                                                                                                                                                                            have some fixtures where this may apply.
                                                                                                                                                                                            The LL has been discussed with the Ops Electrical Supervisor
                                   High Intensity Discharge (HID) lighting fixture bulbs have failed,                                                                                       and he stated that our current practices of not operating                                        Conditionally Accept-
               243     22-Mar-12 causing a small fire in the diffusers that fell to the floorLesson ID:                                                                           22-Mar-12                                                                         2-Apr-12       ES&H
                                                                                                                                                                                            lights on a 24/7, and group re-lamps should extend our bulb                                       Action Plan Needed
                                   2012-SR-SRNS-0004 (Source: User Submitted)
                                                                                                                                                                                            life spans to significantly reduce the possibility of an event like
                                                                                                                                                                                            this from occurring on-site. He also stated that do use type-O
                                                                                                                                                                                            bulbs in certain application (alone with –S, and –E)and will
                                                                                                                                                                                            look for the opportunity to use more.

                                   1. YELLOW - Transporting Shifting Loads(Source: User Submitted - ID: LBNL- Reject - This is a case of employees not following the process                   Did not forward to MSLLC, but discussed with RColl
                                   LL12-0020)

               244     4-Apr-12    Workers loading, moving and unloading cargo are exposed to the                                                                                 27-Apr-12                                                                       27-Apr-12        ES&H         Rejected-Close
                                   potential of serious injury and even fatality. A collaborative detailed
                                   analysis of work steps helps to reveal the hazards, and identify the
                                   controls and work processes necessary to perform the work safely.
                                   1. BLUE - Forklift/Personnel Vehicle Collide(Source: User Submitted - ID: B- Reject - we do not have this type of equipment at Fermilab;                    Did not forward to MSLLC, but discussed with RColl
                                   2012-OR-UCORBOP-0401)
                                   Job planning should not automatically allow prior hazard controls for
                                   similar tasks to be the same controls in the succeeding effort when
                                   conditions change. The Tank W-1A project generally only employs one
               245     4-Apr-12    spotter when moving a forklift from the staging area to the tank site                                                                          27-Apr-12                                                                       27-Apr-12        ES&H         Rejected-Close
                                   about one block away. In this incident, one spotter was used to
                                   relocate a Taylor 550 forklift which is substantially larger than a typical
                                   forklift. The Taylor 550 forklift had only recently been brought on site
                                   for a new task. The resulting impedance to line of sight created a
                                   safety hazard and resulting accident that could have been prevented
                                   had a more thorough review been conducted.

                                   1. BLUE - Radioactive Waste Storage Facility Positive Pressure Event          Reject - we are not a nuclear facility                                        Did not forward to MSLLC, but discussed with RColl
                                   (Source: User Submitted - ID: 2012-ANL-003)
                                   Nuclear facilities, which depend on exhaust ventilation systems
               246     11-Apr-12 providing negative pressure, must verify that critical controls,                                                                                  1-May-12                                                                        1-May-12        ES&H         Rejected-Close
                                   operability criterion and surveillances are closely aligned with the
                                   safety functions of these controls. It is important to continuously
                                   scrutinize and maintain safety-related systems and equipment.
                                   1. BLUE - Unsatisfactory Radiological Postings Discovered(Source: User        Reject, this lessons learned has been seen and dealt with in                  Did not forward to MSLLC, but discussed with RColl
                                   Submitted - ID: 2012-PTX-LL-1104)                                             the past
Fermi National Accelerator Laboratory Confidential
               247 11-Apr-12                                                                                                                                5/3/2013               1-May-12                                                                        1-May-12        ES&H         Rejected-Close       Page 43
                                                                                                                                                        LL Initial Review


                                                                                                              Reject, this lessons learned has been seen and dealt with in               Did not forward to MSLLC, but discussed with RColl
              Item #     Date                              2012-BNL-Bungee-0001)                              the pastOQBP LLC (ERV, JFM) Initial Review Comments               Date               MSLLC or MPLLC Initial Review Comments                Date     MS/MP (Area) Initial Review Status
                                 Facility Managers and Production Section Managers owning
               247     11-Apr-12 processes or facilities having radiological postings can assist the                                                                          1-May-12                                                                 1-May-12       ES&H         Rejected-Close
                                 Radiation Safety Department in maintaining adequate and consistent
                                 postings by reporting observed deficiencies to the Radiation Safety
                                 Office.
                                  1. YELLOW - Charged Capacitor Bank Shorted by Terminal Block                reject, it is up to the individual writing the HA to know and              Did not forward to MSLLC, but discussed with RColl
                                  Failure(Source: User Submitted - ID: 2012-PTX-LL-1001)                      document the hazards.
                                  The physical condition of components within a piece of equipment
               248     11-Apr-12 should be a part of the hazard analysis prior to starting work and                                                                           1-May-12                                                                 1-May-12       ES&H         Rejected-Close
                                  during the course of troubleshooting. If you are dealing with damaged
                                  parts, you should evaluate the risk of exposing yourself to a higher
                                  hazard. Stabilize or replace the damaged part before you proceed.
                                  1. BLUE - Safety Control Violation during High Explosives Machining Results Reject - This is a case of a person purposely not following                Did not forward to MSLLC, but discussed with RColl
                                  in Temporary Suspension of Machining Operations(Source: User Submitted procedures and overriding safety controls.
                                  - ID: 2012-PTX-LL-1108)
                                  Willfully overriding a safety control can introduce significant
               249     11-Apr-12 consequences to yourself, your co-worker, or the environment.                                                                                1-May-12                                                                 1-May-12       ES&H         Rejected-Close
                                  Detailed operating procedures, safety systems, and machine
                                  interlocks are provided to ensure operations are performed in a safe
                                  manner. It is important to understand the safety controls and to
                                  operate within the bounds of these controls.
                                                                                                              Reject - This is a case of a person failing to follow their                Did not forward to MSLLC, but discussed with RColl
                                  1. YELLOW - TSR Violation - Failure to Meet Limiting Condition for
                                                                                                              procedure
                                  Operations for Radiation Criticality Accident Alarm System Alarm
                                  Notification(Source: User Submitted - ID: Y-2012-OR-UCORK25-0402)

                                 The impacts of all work activities, even seemingly benign work,
                                 conducted on or in close proximity to safety basis credited structures,
                                 systems, and component (SSCs) must be evaluated for the potential to
               250     13-Apr-12                                                                                                                                              1-May-12                                                                 1-May-12       ES&H         Rejected-Close
                                 adversely affect the SSC's ability to perform its credited safety
                                 function, thereby introducing additional hazards to the task(s). Facility
                                 personnel in the work control chain must have the knowledge
                                 necessary to recognize those hazards during the planning phase of
                                 the work activities in question. Work control processes must include
                                 the necessary checks and balances to ensure these reviews are done
                                 and that required compensatory measures are implemented prior to
                                 negative ly impacting credited SSCs.
                                  1. YELLOW - Hand Protection(Source: User Submitted - ID: Y-2012-            Reject - there is nothing pertinent to learn from this event.              Did not forward to MSLLC, but discussed with RColl
                                  WEMSPORTS-001)
               251     13-Apr-12 Everyone is reminded to take time to evaluate conditions prior to                                                                            1-May-12                                                                 1-May-12       ES&H         Rejected-Close
                                  placing ones hands in any configuration. If the situation feels
                                  awkward, injury may occur.
                                  1. YELLOW - Chemical Operator Inadvertently Contaminated during             Reject - person was not following HA                                       Did not forward to MSLLC, but discussed with RColl
                                  Maintenance Evolution(Source: User Submitted - ID: Y-2012-FBPORTS-
                                  0401)
               252     17-Apr-12 Even when work evolutions are thoroughly planned, unexpected                                                                                 1-May-12                                                                 1-May-12       ES&H         Rejected-Close
                                  situations or changes in plant conditions may occur that affect
                                  personnel not directly involved in the planned work activity or that are
                                  not in the immediate work area.
                                  1. YELLOW - Strontium (90Sr) Dial Source Failure(Source: User Submitted - Accept - forward to RColl for processing                                     5/2/12: Don Cossairt rejected because we do not have any of
                                  ID: Y-2012-OR-UCORESHQ-0403)                                                                                                                           this type of source.
                                 Awareness of manufacturing defects can mitigate uncontrolled
                                 radiation exposures and loss of radioactive material. Examination of
               253     18-Apr-12 strontium dial sources (1994 models) showed degradation of the                                                                               1-May-12                                                                 2-May-12       ES&H         Rejected-Close
                                 plastic retaining insert, allowing the source to dislodge and drop out
                                 of the jig/holder. If the condition goes unchecked, exposure to
                                 personnel, off-site loss of radioactive material, or a spread of
                                 contamination could result.



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                                                                                                                                                         LL Initial Review

              Item #     Date                               2012-BNL-Bungee-0001)                                     OQBP LLC (ERV, JFM) Initial Review Comments              Date              MSLLC or MPLLC Initial Review Comments                Date     MS/MP (Area) Initial Review Status
                                                                                                               Accept - forward to RColl for processing                               This one is already being dealt with at the FCOG level. 5/3:
                                                                                                                                                                                      Besides EFCOG actions regarding DC Systems our Electrical
                                                                                                                                                                                      Safety Subcommittee (ESS) has taken the actions: 1. Fully
                                   1. YELLOW - Arc Hazard from DC Systems(Source: User Submitted - ID:
                                                                                                                                                                                      Accept
                                   2012-LL-PNSO-0001)                                                                                                                                                                                                                             Fully Accept-
               254     20-Apr-12                                                                                                                                             1-May-12 We have made an inventory of all large battery systems         1-May-12       ES&H
                                                                                                                                                                                                                                                                               Action Plan Needed
                                                                                                                                                                                      at Fermilab and have gathered maintenance contractors'
                                                                                                                                                                                      methods of hazard mitigation and a draft report to the
                                   Protection from Arc Flash Hazard in DC systems may be inadequate at                                                                                DOE committee inquiring about this is complete.
                                   some sites across the DOE complex.
                                   1. YELLOW - Radiological Contamination Found on Laundered Respiratory       reject - we do not contract with Unitech or any company to               Did not forward to MSLLC, but discussed with RColl
                                   Protection Equipment (Source: User Submitted - ID: Y-2012-OR-BWY12-         launder respiratory protection equipment
                                   0401)
               255     20-Apr-12 Failure to use a rigorous risk-based approach to evaluate the                                                                               1-May-12                                                                1-May-12       ES&H         Rejected-Close
                                   consequences of failure of sub-contracted services resulted in
                                   untimely identification of contaminated respiratory protection
                                   equipment received from a laundry service vendor.
                                   1. BLUE - Radiologically Contaminated Respirators(Source: User Submitted - reject - we do not contract with Unitech or any company to                Did not forward to MSLLC, but discussed with RColl
                                   ID: HSS OE-3 2012-02)                                                      launder respiratory protection equipment
               256     24-Apr-12 This Operating Experience Level 3 (OE-3) document provides                                                                                  1-May-12                                                                1-May-12       ES&H         Rejected-Close
                                   information on a safety concern related to radiological contamination
                                   of laundered/reconditioned respirators and parts that have been
                                   certified as clean.
                                   1. YELLOW - Establish Proper Identification of Work Control Hazards         Reject - This is a case of a person failing to follow their              Did not forward to MSLLC, but discussed with RColl
                                   through All Sources of Documentation and Experience(Source: User            procedure
                                   Submitted - ID: INL-BEA-ID-2012-920)
                                   During the planning of a work activity, proper identification of the
               257     25-Apr-12                                                                                                                                             1-May-12                                                                1-May-12       ES&H         Rejected-Close
                                   hazards through all sources of documentation and experience,
                                   analysis of the hazards identified, and mitigation of those hazards is
                                   paramount to the protection of workers. Additionally, management
                                   must respond appropriately to time out, stop work, and questioning
                                   attitudes exhibited by work performers.
                                   1. BLUE - Repair to Legacy Non-Nationally Recognized Testing Laboratory    reject - everything we buy is UL certified                                Did not forward to MSLLC, but discussed with RColl
                                   Blower Calls Attention to Other Hazards(Source: User Submitted - ID: 2012-
                                   LL-PNNL-0001)

                                 A Pacific Northwest National Laboratory (PNNL) electrician was called
                                 to the Radiochemical Processing Laboratory (RPL) to repair a
                                 damaged on/off switch box on a Bartlett blower. While working on the
               258     25-Apr-12 unit, he noticed other deficiencies that called attention to the fact that                                                                  1-May-12                                                                1-May-12       ES&H         Rejected-Close
                                 none of the four blowers in use at RPL were certified by a Nationally
                                 Recognized Testing Laboratory (NRTL) and did not meet the Lab's
                                 current requirements When electrical equipment purchased for use at
                                 the Lab is not NRTL-certified, it must be inspected and approved by an
                                 electrical safety Subject Matter Expert/Authority Having Jurisdiction
                                 (SME/AHJ) before being used. Legacy equipment must be inspected if
                                 it does not have an NRTL or PNNL electrical AHJ-approved sticker.
                                                                                                               reject - this is a case of worker error                                  Did not forward to MSLLC, but discussed with RColl
                                   1. YELLOW - Misinterpretation of Lockout/Tagout Requirements in Work
                                   Documents Lead to Work Performance without Lockout/Tagout(Source:
                                   User Submitted - ID: 2012-ID-AMWTP-0003)

                                 When performing work, all work documents (Work Orders, Approved
                                 Method of Work, Permit to Work, etc.) need be understood by the
               259     26-Apr-12                                                                                                                                             1-May-12                                                                1-May-12       ES&H         Rejected-Close
                                 supervisor performing the pre-job brief prior to performing the
                                 briefing. All work documents need to have the Lockout/Tagout
                                 (LO/TO) requirements clearly explained and annotated on the
                                 documents. Maintenance work was performed on without a LO/TO,
                                 contrary to the prerequisites of a work order, which subsequently
                                 resulted in a Fact Finding and the filing of an ORPS report for the
                                 failure to follow a prescribed hazardous energy control process.

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              Item #     Date                              2012-BNL-Bungee-0001)                                        OQBP LLC (ERV, JFM) Initial Review Comments              Date               MSLLC or MPLLC Initial Review Comments                    Date      MS/MP (Area) Initial Review Status
                                   1. GREEN - Unexpected Alpha Contamination Discovered on Waste Box in        reject - there is no actionable information here                           Did not forward to MSLLC, but discussed with RColl
                                   Unrestricted Storage Area (Source: User Submitted - ID: 2012-ID-AMWTP-
                                   0004)
                                 Ongoing inspections and prompt action when abnormal conditions are
                                 discovered are cornerstones to the radiological controls
               260     26-Apr-12 contamination prevention program. A radiological technician (RT)                                                                             1-May-12                                                                      1-May-12        ES&H         Rejected-Close
                                 found unexpected alpha contamination levels while performing
                                 radiological surveys on a waste box in an unrestricted storage area.
                                 The RT recognized the abnormal conditions and work was
                                 immediately stopped. An ORPS report was filed and a
                                 nonconformance report was filed to document the abnormal
                                 conditions.
                                   1. BLUE - Asbestos Discovered in Legacy Electrical Equipment(Source: User Accept - forward to RColl for processing                                  5/2/12: Accepted as an FYI by Tom Gibbs. "Since my Asbestos
                                   Submitted - ID: 2012-RL-HNF-0017)                                                                                                                   Awareness class is aimed at Task Managers, the focus is on
                                                                                                                                                                                       building materials that may contain asbestos. This Lessons
                                 Evaluate visible and hidden hazards of High-Lift Pump Assembly                                                                                        Learned should also be distributed to the SSO’s and other
                                                                                                                                                                                       personnel who are involved in the dismantling and/or
               261     26-Apr-12 rotors prior to disassembly or transport. Asbestos containing                                                                                1-May-12                                                                      1-May-12        ES&H             FYI Only
                                 materials may be discovered in the motor windings. A thorough                                                                                         decommissioning of equipment."                    5/2/12:
                                 evaluation may reveal hidden hazards, such as asbestos containing                                                                                     Accepted as an FYI Jim Niehoff.                     5/312: RColl:
                                 components, that will influence the planning and preparation for                                                                                      distributed to the chair of the S3 and also distributed to task
                                 disassembly, removal and disposition.                                                                                                                 managers/construction coordinators and the Asbestos work
                                                                                                                                                                                       inspector.
                                   1. YELLOW - Hand Injury during Jersey Bouncer Movement - Awareness of       Accept - forwarded to RColl for processing                              The chair of the Suncontractor Safety Subcommittee accepted
                                   Line-of-Fire Activities and Extension of Suspended Load Principle(Source:                                                                           as an FYI only and distributed to all task managers and
                                   User Submitted - ID: 2012-SR-SRNS-0005)                                                                                                             construction coordinators.

                                 A lessons learned from this incident was the not-so-obvious extension
                                 of the suspended barrier load that created an unrecognized line-of-fire
                                 condition. Rigging training will be improved to address this concept of
               262     11-May-12 extended loads.                   This incident also emphasizes the                                                                          11-May-12                                                                     20-Jul-12       ES&H             FYI Only
                                 value of discussing the critical steps and the use of checks to ensure
                                 the steps are ready to be performed error-free. In this instance,
                                 verifying connecting ring to lift truck tine engagement prior to placing
                                 the cribbing would have reduced the likelihood of injury. Broader
                                 Applicability - The conditions that existed in this event can apply to
                                 any job where an object placed under a suspended load becomes an
                                 extended suspended load with line-of-fire potential.
                                    1. YELLOW - Plastic Lockout Devices for Circuit Breakers can be            Accept - forwarded to RColl for processing.                              We use this type of device and we also understand the
                                    Dislodged by Bumping (Source: User Submitted - ID: 2012-BNL-LOTO-                                                                                   weakness explained in this LL. I am accepting as an FYI and
                                    0005)                                                                                                                                               will distribute to SSOs, task managers/construction
                                 A plastic lockout device, enabling a LOTO padlock and tag to be                                                                                        coordinators and all those who took LOTO Level 2. I will be
                                                                                                                                                                                        talking at the ASSE conference in Colorado to manufacturers
               263     11-May-12 fastened to a circuit breaker was installed in an electrical panel as part                                                                   11-May-12                                                                     11-May-12       ES&H             FYI Only
                                 of job requiring the breaker to be locked in the off position. As a                                                                                    to see what they have to say about this incident. I just sent
                                 result, the panel door must be partially open. A building occupant                                                                                     this Yellow LL to 692 employees who have completed LOTO 2
                                 inadvertently bumped the panel door, resulting in the lockout device                                                                                   training. It went earlier to task managers, construction
                                 falling off the breaker. Electricians reported that these types of LOTO
                                                                                                                                                                                        coordinators and SSOs. I will add a warning in my LOTO 2
                                 devices have been known to come off of breakers from minimal
                                                                                                                                                                                        class. I consider this item closed.
                                 impact/effort.
                                    1. YELLOW - Radioactive Waste Storage Facility Floor Loading/Lifting    reject - Fermilab does not use the floor color coding that is               not sent to LLC
                                    Capacity Inaccurately Designated(Source: User Submitted - ID: 2012-ANL- described here and the issue was caused by people not
                                    004)                                                                    following their process.
               264     11-May-12 A positive Unreviewed Safety Question Determination (USQD) was                                                                               11-May-12                                                                     11-May-12       ES&H         Rejected-Close
                                   discovered as a result of having a positive questioning attitude and a
                                   thorough and complete process to evaluate an issue for swift, yet
                                   comprehensive, resolution.
                                   1. YELLOW - Failure to Perform Start Test Resulted in Improper Lockout of   accept - forward to RColl for processing
                                   a Low-Voltage Power Circuit Breaker(Source: User Submitted - ID: LBNL-
                                                                                                                                                                                          Conditionally Accepted and assigned to the chair of ESS (Mike
                                                                                                                                                                                          Utes). FESHM 5120 includes a verification step but not a
                                                                                                                                                                                          validation process- we do not have a start test in our program.
Fermi National Accelerator Laboratory Confidential                                                                                                           5/3/2013                                                                                                                                        Page 46
                                                                                                                                                                                          However, NFPA 70E has more detail regarding the verification
                                                                                                                                                                                          process. LOTO 2 training includes the NFPA 70E requirement
                                                                                                                                                        LL Initial Review


                                                                                                              accept - forward to RColl for processing
              Item #     Date                              2012-BNL-Bungee-0001)                                      OQBP LLC (ERV, JFM) Initial Review Comments                  Date              MSLLC or MPLLC Initial Review Comments                    Date     MS/MP (Area) Initial Review Status
                                   The start test is an essential and mandatory part of the lockout/taglock                                                                               Conditionally Accepted and assigned to the chair of ESS (Mike
                                   (LOTO) process. LOTO devices can be applied improperly if the                                                                                          Utes). FESHM 5120 includes a verification step but not a
                                   qualified person is not experienced with the specific type of                                                                                          validation process- we do not have a start test in our program.
                                   equipment. Attempting to operate the isolation verifies that the LOTO                                                                                  However, NFPA 70E has more detail regarding the verification
                                   device is properly applied and is effective in preventing operation.
                                                                                                                                                                                          process. LOTO 2 training includes the NFPA 70E requirement
                                                                                                                                                                                          of verifying and validating absence of energy even though
                                                                                                                                                                                          FESHM 5120 does not have the same degree of detail. Actions
                                                                                                                                                                                          we will take: Training in LOTO 2 already includes details that
                                                                                                                                                                                          5120 does not such as art 120.1 of NFPA 70E. By copy of this
                                                                                                                                                                                          message I am asking the Chair of the ESS to include as an
                                                                                                                                                                                          agenda item a discussion regarding inclusion of article 120.1
                                                                                                                                                                                                                                                                                      Conditionally Accept-
               265     11-May-12                                                                                                                                                11-May-12 of NFPA 70E-2012 in the next revision of FESHM 5120 and to        11-May-12       ES&H
                                                                                                                                                                                                                                                                                       Action Plan Needed
                                                                                                                                                                                          reply back regarding acceptance or rejection of this LL after
                                                                                                                                                                                          consultation with the committee. 5/14/12: From 5120
                                                                                                                                                                                          Section 11 "General LOTO Procedure", please see the
                                                                                                                                                                                          following from page 5120-16: VERIFY: The authorized
                                                                                                                                                                                          employee shall check by conclusive test that the source of
                                                                                                                                                                                          energy has actually been isolated and that the machine or
                                                                                                                                                                                          equipment is inoperable. If applicable or reasonable, use the
                                                                                                                                                                                          normal operating controls to attempt to start the machine or
                                                                                                                                                                                          equipment and then return these controls to the “safe” or
                                                                                                                                                                                          “off” positions. Verification is the most critical step of the
                                                                                                                                                                                          LOTO procedure. I've also included the chapter file.


                                    1. YELLOW - Unexpected Work Area Hazard Results in Injury (Source:        reject - employee bumped his head when standing up                22-May-12   Did not forward to MSLLC                                        22-May-12   ES&H
                                    User Submitted - ID: Y-2012-OR-BWY12-0301)
                                   Prevent injury by being alert to potential hazards in work areas.
               266     22-May-12 Consider body position and moving at a safe pace appropriate for                                                                                                                                                                                        Rejected-Close
                                   conditions. Look for hazards in the path below, above and to the
                                   sides, when changing body position. Scan area for obstructions or
                                   objects before conducting tasks.
                                                                                                              reject - this is a procurement issue that is already covered in               Did not forward to MSLLC
                                    1. BLUE - Purchase of Measuring and Testing Equipment from Non-
                                                                                                              Fermilab procurement procedures as well as in the
                                    Approved Supplier(Source: User Submitted - ID: 2012B-LL-LATA-0508)
                                                                                                              procurement and M&TE sections of the IQA
               267     22-May-12 When purchasing critical items such as Measuring and Testing                                                                                   22-May-12                                                                   22-May-12      quality       Rejected-Close
                                   Equipment (M&TE), it is imperative that items be purchased through
                                   an approved supplier to ensure Quality Control (QC) programs are in
                                   place for the manufacture and calibration of these items.

                                                                                                              reject - workers were performing work in an unauthorized                      Did not forward to MSLLC
                                    1. YELLOW - Degradation of Paint Used to Encapsulate Legacy
                                                                                                              location. This is a case of workers not following written
                                    Contamination(Source: User Submitted - ID: 2012-ANL-005)
                                                                                                              instructions
               268     22-May-12 When defining work authorizations and work scope, work                                                                                         22-May-12                                                                   22-May-12       ES&H         Rejected-Close
                                   authorization limits must be clearly identified for the personnel
                                   conducting the work. Work authorization limits must be clearly
                                   defined and heeded when work is being performed.
                                   1. YELLOW - Door Closure Failure - Near Miss(Source: User Submitted - ID: accept - forward to RColl for processing                                       Not accepted - no practical lesson here
                                   2012-RL-HNF-0018)
                                 Facilities should evaluate automatic door closure mechanisms for
                                 improper operation, unusual wear and for potential fluid leaks. A
               269     22-May-12 threaded cap on the end of a door closure unit broke causing the cap                                                                           22-May-12                                                                   23-May-12       ES&H         Rejected-Close
                                 and spring to propel over a partition and into a wall mounted smart
                                 board.The stored energy within a hydraulic door closer mechanism is
                                 sufficient to eject the internal components with enough force to cause
                                 severe injury and/or property damage



Fermi National Accelerator Laboratory Confidential                                                                                                         5/3/2013                                                                                                                                           Page 47
                                                                                                                                                          LL Initial Review
              Item #     Date                               2012-BNL-Bungee-0001)                                 OQBP LLC (ERV, JFM) Initial Review Comments                    Date                MSLLC or MPLLC Initial Review Comments                    Date      MS/MP (Area) Initial Review Status
                                                                                                         reject - this is a case of workers simply doing their job and                     Did not forward to MSLLC
                                    1. YELLOW - Enhanced Pre-Job Briefing and Pre-Job Walkdown Helped to
                                                                                                         recognizing a container that is larger than the others stored
                                    Identify a Potential Nuclear Criticality Safety, Anomalous
                                                                                                         with it.
                                    Condition(Source: User Submitted - ID: Y-2012-FBPORTS-0502)
               270     23-May-12 Enhanced Pre-Job Briefings and Pre-Job Walkdowns which included                                                                               23-May-12                                                                     23-May-12       ES&H         Rejected-Close
                                   reviewing Section 8 of X-744G Boundary, Nuclear Criticality Safety
                                   Evaluation signage and discussions between supervision and
                                   workers, enabled the workers to recognize a "change of condition"
                                   situation and the discovery of a potential Anomalous Condition.

                                                                                                               accept - forward to RColl for processing                                    Rafel Coll accepted this LL and forwarded to the SSOs as an FYI
                                   1. YELLOW - Plastic Bottle Breaks Spilling Waste Solvent on Researcher's
                                   Clothing(Source: User Submitted - ID: LL-NETL-2012-001)
               271     23-May-12 Laboratory staff should immediately inspect all plastic bottles                                                                               23-May-12                                                                     23-May-12       ES&H             FYI Only
                                   presently in service and replace the containers if there is any
                                   uncertainty regarding their integrity based upon service, age, or
                                   condition.
                                 1. YELLOW - Asbestos Containing Material Discovered in Process                reject - this is a case of employees doing their jobs                       Did not forward to MSLLC
                                 Equipment (Steel Belt Dryer)(Source: User Submitted - ID: LL-NETL-2012-
               272     23-May-12 002)                                                                                                                                          23-May-12                                                                     23-May-12       ES&H         Rejected-Close
                                   Employees should remain diligent during work efforts to look for
                                   changes in work or site conditions that could potentially impact work
                                   activities or introduce new hazards.
                                   1. BLUE - Proper Disposition of Sealed Sources during Decommissioning       reject - this is a case of a process not being followed                     Did not forward to MSLLC
                                   Prevent Future Legacy Issues(Source: User Submitted - ID: 2012-BNL-
                                   MDCL-0001)
               273     23-May-12 Processes should be enforced to ensure that all project sealed                                                                                23-May-12                                                                     23-May-12       ES&H         Rejected-Close
                                   radioactive sources or radioactive material are properly dispositioned
                                   at the end of a project to guarantee no legacy materials or issues are
                                   left behind.
                                   1. BLUE - Safe Management of Mercury (Hg)(Source: User Submitted - ID:      reject - this information has already been disseminated at                  Did not forward to MSLLC, but discussed with RColl
                                   HSS OE-3-2012-03)                                                           Fermilab and is available in Fermilab training and
               274     28-May-12 This Operating Experience Level 3 (OE(3)) was issued to raise                 documentation                                                   28-May-12                                                                     28-May-12       ES&H         Rejected-Close
                                   awareness about mercury hazards and to reinforce the information in
                                   Safety and Health Bulletin 2005-08, Safe Management of Mercury.

                                                                                                          reject - this is a single occurrence of failure of a light fixture               Did not forward to MSLLC
                                   1. YELLOW - Falling Globe from Ceiling Light Fixture Results in
                                                                                                          with circumstances not applicable to Fermilab
                                   Occupational Injury(Source: User Submitted - ID: WSI-NV-NSO-2012-0001)
               275     28-May-12                                                                                                                                               28-May-12                                                                     28-May-12       ES&H         Rejected-Close
                                   Failure to follow-up on routine maintenance issues can have
                                   devastating results.
                                   1. YELLOW - Entering Work Area without Proper Notification (Source: User reject - this is a case of poor coummunication and not                         Did not forward to MSLLC
                                   Submitted - ID: Y-2012-FBPORTS-0501)                                     following procedures
                                   It is imperative that communication of Fluor-B&W Portsmouth (FBP)
               276     28-May-12 contract requirements between the prime contractor, subcontractor,                                                                            28-May-12                                                                     28-May-12       ES&H         Rejected-Close
                                   sub-tier contractor and vendor is understood in regards to
                                   notification, training requirements, postings and personal protective
                                   equipment (PPE) requirements
                                   1. YELLOW - Miscategorization of Work Hazard Contributes to            reject -after discussion with Dan Hellberg of FESS, Fermilab                     Did not forward to MSLLC
                                   Injury(Source: User Submitted - ID: 2012-BNL-FO-Tree-0001)             employs a professional arborist on staff for tree trimming
               277      1-Jun-12   The miscategorization of work as low hazard contributed to lax control and reomval. A hazard analysis is developed each time a tree         1-Jun-12                                                                      1-Jun-12        ES&H         Rejected-Close
                                   of the hazards even though a work permit was generated. An injury      is trimmed or removed.
                                   resulted.
                                                                                                               reject - this is a case of workers not following documented                 Did not forward to MSLLC
                                   1. YELLOW - Worker Inspection of Respiratory Protective Equipment Prior
                                                                                                               procedures
                                   To Use(Source: User Submitted - ID: Y-2012-OR-UCORESHQ-0501)
               278      1-Jun-12                                                                                                                                               1-Jun-12                                                                      1-Jun-12        ES&H         Rejected-Close
                                   Worker inspection prior to use of respiratory protective equipment is
                                   key to ensuring that respirator cartridges are properly installed and
                                   seated.
                                                                                                               reject - this is a case of a worker not following                           Did not forward to MSLLC
                                   1. YELLOW - Mild Electrical Shock during Usage of Portable Office Heater
                                                                                                               guidelines/procedures
                                   (Federal Employee)(Source: User Submitted - ID: 2012-SRSO-0001)

               279     1-Jun-12
Fermi National Accelerator Laboratory Confidential                                                                                                           5/3/2013          1-Jun-12                                                                      1-Jun-12        ES&H         Rejected-Close      Page 48
                                                                                                                reject - this is a case of a worker not following                           Did not forward to MSLLC
                                                                                                                                                           LL Initial Review
                                                                                                                guidelines/procedures
              Item #     Date                                2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments              Date                MSLLC or MPLLC Initial Review Comments     Date      MS/MP (Area) Initial Review Status
                279    1-Jun-12    Personnel need to inspect electrical cords for damage prior to use.                                                                          1-Jun-12                                                       1-Jun-12       ES&H         Rejected-Close
                                   Also, ensure electrical equipment is turned off before removing or
                                   inserting the plug into the receptacle. This resulted in a post job
                                   review and the filing of a Significance Category 2E(1) ORPS report.
                                                                                                                accept - forward to RColl for processing                                    Not applicable at Fermilab
                                   1. YELLOW - Improper Cleaning of Capillary Array Glass Plates Led to
                                   Laboratory Oven Fire(Source: User Submitted - ID: 2012-ANL-006)

                                   In the process of cleaning and drying capillary array glass plates,
               280     6-Jun-12    careful attention needs to be made to the procedure. When a volatile                                                                         6-Jun-12                                                       15-Jun-12       ES&H         Rejected-Close
                                   solvent is used in the cleaning process prior to heating, adopt
                                   procedures that will remove a significant amount of the solvent before
                                   heating. If oven heating is to be used, use an oven that does not have
                                   exposed heating coils. Alternative non-heating methods of drying,
                                   such as vacuum drying, should be considered.
                                   1. YELLOW - Improper Collection and Discard of Low Level Radioactive   reject - this is a case of an employee not following                              Did not forward to MSLLC
                                   Waste into Non-Rad Trash Stream(Source: User Submitted - ID: 2012-ANL- documented procedures
                                   007)
               281     6-Jun-12                                                                                                                                                 6-Jun-12                                                       6-Jun-12        ES&H         Rejected-Close
                                   Supervisors need to carefully consider the need for closer
                                   supervision, refresher training, and workplace observations for
                                   employees when changes in work assignments take place, especially
                                   when new or different operating conditions or hazards are introduced.
                                   1. GREEN - Transfer of Patient Care - Medical Emergency(Source: User         accept - forward to RColl for processing                                    rejected - we have our own forms.
                                   Submitted - ID: 2011-SPR-DM-NO-009)
               282     12-Jun-12 Use of a standardized form to record patient information and care                                                                              12-Jun-12                                                      15-Jun-12       ES&H         Rejected-Close
                                   provided should be implemented during all emergency medical
                                   responses.
                                                                                                                reject - Fermilab does not use the type of demolition                       Did not forward to MSLLC
                                                                                                                equipment described in this lessons learned. In addition, a
                                   1. BLUE - Projectile Results In Broken Excavator Window(Source: User
                                                                                                                safety device that may have prevented this incident had
                                   Submitted - ID: RCCC-2012-0013)
                                                                                                                been removed from the demolition equipment prior to the
               283     12-Jun-12                                                                                incident                                                        12-Jun-12                                                      12-Jun-12       ES&H         Rejected-Close
                                   Management of demolition activities should evaluate the adequacy of
                                   heavy equipment cab protection based on hazards associated with the
                                   task to be performed. Heavy equipment may generate a variety of
                                   different projectiles depending upon the application and materials
                                   being worked.
                                   1. BLUE - Excavation Safety(Source: User Submitted - ID: 2012-SPR-DM-BC- accept - forward to RColl for processing                                        rejected - our process covers this situation
                                   0001)
                                   1. When a decision is made to move beyond the original area of
               284     13-Jun-12 excavation, a new permit should be initiated based on the job hazard                                                                           14-Jun-12                                                      15-Jun-12       ES&H         Rejected-Close
                                   analysis of the new location. 2. Electrical one-line drawings may not
                                   be adequately detailed for confirmation of area hazards. 3. A sense of
                                   urgency should not overshadow employees normal safe work
                                   philosophy.
                                   1. BLUE - Forklift Strikes Bollard while Transporting a Port-O-Let(Source:   reject - this is a case of operator error. Driver and spotter               Did not forward to MSLLC
                                   User Submitted - ID: RCCC-2012-0010)                                         both failed to see sationary objects
                                   Properly identifying potential hazards is important to safe field
               285     13-Jun-12                                                                                                                                                13-Jun-12                                                      13-Jun-12       ES&H         Rejected-Close
                                   operations. Field work supervisors need to have the training and
                                   experience to be able to identify hazards and that could require
                                   additional mitigations.
                                   1. BLUE - Hydraulic Cylinder Taken Off-Site with Radiological Label Still    reject - this is a case of poor coummunication and not                      Did not forward to MSLLC
                                   Attached(Source: User Submitted - ID: RCCC-2012-0011)                        following procedures
                                 An attention to detail is critical when processing any radiologically
                                 controlled items for off-site release. Understanding the requirements
               286     13-Jun-12 of the process for releasing radiologically controlled items is                                                                                13-Jun-12                                                      13-Jun-12       ES&H         Rejected-Close
                                 important and should be understood by all personnel involved in the
                                 process. When communicating essential information about an item for
                                 release, ensure the information being provided is understood and
                                 personnel should not make assumptions about the process

Fermi National Accelerator Laboratory Confidential                                                                                                            5/3/2013                                                                                                                          Page 49
                                                                                                                                                          LL Initial Review
              Item #     Date                               2012-BNL-Bungee-0001)                                      OQBP LLC (ERV, JFM) Initial Review Comments              Date               MSLLC or MPLLC Initial Review Comments                  Date      MS/MP (Area) Initial Review Status
                                                                                                               accept - forward to RColl for processing                                 Sent for information and any action deemed necessary. No
                                 1. YELLOW - Electric Shock Hazard - Multi-outlet Strip(Source: User                                                                                    feedback needed unless you find these RPT’s. If you do please
               287     15-Jun-12 Submitted - ID: LL-2012-LLNL-06)                                                                                                             15-Jun-12 remove and destroy and report the number of RPTs found.          15-Jun-12       ES&H             FYI Only
                                   A Fellowes model 99082 RPT was involved in a recent shock incident
                                   at LLNL.
                                                                                                               accept - forward to RColl for processing                                 Not accepted. Our programs do address the hazards of
                                                                                                                                                                                        chemicals and also makes available the MSDS to the workers
                                                                                                                                                                                        during their shift. This is clearly a fault of supervision and
                                   1. YELLOW - Aerosol Lubricant Hazard Identification (Source: User
                                                                                                                                                                                        worker attitudes where assumptions are made even though
                                   Submitted - ID: Y-2012-OR-BWY12-0604)
               288     15-Jun-12                                                                                                                                              15-Jun-12 the information is readily available. Our HA system also         15-Jun-12       ES&H         Rejected-Close
                                                                                                                                                                                        addresses the hazards of chemicals used and directs the
                                                                                                                                                                                        workers to read the MSDS.
                                   Job Specific hazard identification and mitigation must include the
                                   identification and evaluation of materials brought to a job site for use.

                                   1. BLUE - OSHA's Revised Hazard Communication Standard(Source: User         accept - forward to RColl for processing                                   We are aware of this new requirement. We will be updating
                                   Submitted - ID: HSS OE-3-2012-04)                                                                                                                      our FESHM and modifying our training course accordingly.


                                 On March 26, 2012, the Occupational Safety and Health Administration
                                 (OSHA) published a final rule that updates its 25-year-old title 29, Code
               289     15-Jun-12 of Federal Regulations CFR), part 1910.1200, Hazard Communication                                                                            15-Jun-12                                                                  15-Jun-12       ES&H             FYI Only
                                 Standard (HCS). The revised standard is consistent with the United
                                 Nations project's Globally Harmonized System of Classification and
                                 Labeling of Chemicals (GHS). Adopting this international system will
                                 improve the quality, consistency, and clarity of hazard information for
                                 workers. The revised standard goes into effect on May 25, 2012, with
                                 future deadlines for training workers and for full implementation.
                                   1. YELLOW - Respirator Cartridge Comes Off during Cell Entry(Source: User reject - there is no actionable information here other than to               Did not forward to MSLLC
                                   Submitted - ID: 2012-ID-AMWTP-0007)                                       continue to execut your process
                                 Respirator users need to continually inspect respirators closely and
                                 aggressively in both the user inspection and peer review to minimize
               290     15-Jun-12 the potential for respirator or cartridge failure during use. On 5/16/12,                                                                    15-Jun-12                                                                  15-Jun-12       ES&H         Rejected-Close
                                 an operator's respirator cartridge came out of the cartridge housing
                                 during a cell entry to operate a plasma cutter. This resulted in a fact
                                 finding. The respirator will be sent to the manufacture (MSA) for
                                 inspection to determine if there is damage or defect that would explain
                                 the cartridge coming out of the housing.
                                 1. BLUE - First Non-Radioactive Non-Hazardous Classified Shipment to          reject - this is a case of 2 procedures, not applicable to                 Did not forward to MSLLC
                                 NNSS Violates Approved Transportation Routes(Source: User Submitted -         Fermilab, that contained ambiguous information.
               291     26-Jun-12 ID: 2012-NV-NNSS-439)                                                                                                                        26-Jun-12                                                                  26-Jun-12    Operations      Rejected-Close
                                   Drivers of waste shipments need to be aware of routes prohibited
                                   before traveling to other sites.
                                                                                                           reject - high winds creating door damage is not a problem at                   Did not forward to MSLLC
                                   1. BLUE - Prevent Vehicle Damage on Windy Days(Source: User Submitted - Fermilab. Also, common sense and concentration are more
                                   ID: 2012-NV-NNSS-445)                                                   appropriate than a lessons learned for this condition.
               292     26-Jun-12                                                                                                                                              26-Jun-12                                                                  26-Jun-12    Operations      Rejected-Close
                                   Reduce the possibility of door damage from force of wind when
                                   opening your door by parking the front end of the vehicle facing
                                   against the wind when possible.
                                   1. BLUE - Kansas City Plant's Request for Approval to Ship Classified Items reject - Fermilab does not now, nor has ever shipped any                   Did not forward to MSLLC
                                   to the Nevada National Security Site(Source: User Submitted - ID: 2012-NV- material to the Nevada National Security site
                                   NNSS-446)
               293     26-Jun-12 Understand what Information Security directive Nevada National                                                                               27-Jun-12                                                                  27-Jun-12    Operations      Rejected-Close
                                   Security Site (NNSS) Waste Generators must comply with prior to
                                   preparing "Request for Approval to Ship Classified Items to the
                                   Nevada National Security Site" letter.
                                   1. BLUE - Uninterruptible Power Supply Installation Can Result in           reject - this is a case of insufficient planning leading to                Did not forward to MSLLC
                                   Unplanned Problems if Not Properly Evaluated(Source: User Submitted -       unforeseen circumstances during the power outage
                                   ID: 2012-NV-NNSS-448)
               294    26-Jun-12                                                                                                                                               27-Jun-12                                                                  27-Jun-12    Operations      Rejected-Close
Fermi National Accelerator Laboratory Confidential                                                                                                           5/3/2013                                                                                                                                     Page 50
                                                                                                             reject - this is a case of insufficient planning leading to
                                                                                                                                                         LL Initial Review               Did not forward to MSLLC
                                                                                                             unforeseen circumstances during the power outage
              Item #   Date                               2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments              Date                MSLLC or MPLLC Initial Review Comments                  Date      MS/MP (Area) Initial Review Status
                294  26-Jun-12                                                                                                                                               27-Jun-12                                                                   27-Jun-12    Operations     Rejected-Close
                                  Planned power outages and associated lockout/tagout (LOTO)
                                  involving the installation of an uninterruptible power supply (UPS)
                                  require thorough and detailed planning to avoid operational problems.
                                                                                                             accept - forward to RColl for processing                                    rejected - We include this in our Compressed Gas Cylinder
                                  1. BLUE - Mercury Found during Sink Removal(Source: User Submitted - ID:
                                                                                                                                                                                         Training course besides being common sense item.
                                  2012-NV-NNSS-450)
               295    26-Jun-12                                                                                                                                              26-Jun-12                                                                   19-Jul-12       ES&H         Rejected-Close
                                  Removal of plumbing fixtures in older buildings with multiple
                                  purposes has the potential to encounter unanticipated hazards from
                                  prior uses.
                                                                                                             accept - forward to RColl for processing                                  rejected by Tom Gibbs: Fermilab already has the Hazard
                                1. GREEN - Operations around Heavy Equipment(Source: User Submitted -                                                                                  Analysis in place where applicable on construction jobsites
               296    26-Jun-12 ID: 2012-NV-NNSS-451)                                                                                                                        26-Jun-12 and they are reviewed and signed by all workers who enter         23-Jul-12       ES&H         Rejected-Close
                                                                                                                                                                                       the site.
                                  Formalized communication between personnel and heavy equipment
                                  operators can ensure safe operations.
                                                                                                             accept - forward to RColl for processing                                  rejected - There is no lesson here. This was people not
                                1. YELLOW - Aerosol Propellant Container Burst due to Increased
                                                                                                                                                                                       following established processes and getting in trouble. This
                                Temperatures in Privately-Owned Vehicle (Source: User Submitted - ID:
               297    26-Jun-12 2012-NV-NNSS-452)                                                                                                                            26-Jun-12 belongs in the “management” arena as a disciplinary issue         19-Jul-12       ES&H         Rejected-Close
                                                                                                                                                                                       Not a safety issue.
                                  Storing aerosol propellant containers such as pepper spray in
                                  passenger compartment of vehicles should be avoided.
                                                                                                             reject - this is a case of workers not following procedures                 Did not forward to MSLLC
                                  1. BLUE - Conflicting Work Documents Result in Workers Entering
                                                                                                             and of conflicting radiological work permits being generated
                                  Contaminated Area(Source: User Submitted - ID: RCCC-2012-0014)
               298    27-Jun-12 As work on the river corridor nears completion, it is inevitable that                                                                        27-Jun-12                                                                   27-Jun-12       ES&H         Rejected-Close
                                  work groups with different work scope and requirements will be
                                  working in close proximity. Care should be taken so that these do not
                                  conflict.
                                  1. BLUE - Work Control Requirements Not Implemented Properly(Source:       reject - this is a case of workers not following documented                 Did not forward to MSLLC
                                  User Submitted - ID: RCCC-2012-0015)                                       procedures
                                Ensuring that all Work Control requirements are completed properly
                                before the start of the work evolution is critical for making sure work
               299    27-Jun-12 is performed in a safe manner. The Integrated Work Control Procedure                                                                         27-Jun-12                                                                   27-Jun-12       ES&H         Rejected-Close
                                (IWCP) applies to all work including activities performed by
                                subcontractors and a strong understanding of the process is essential
                                to performing work safely.
                                                                                                             reject - this is a case of an incomplete HA being used, an HA               Did not forward to MSLLC
                                1. BLUE - Ineffective Communication Leads to Subcontractors' Recurring
                                                                                                             not being followed, and an ineffective communication of
                                Failure to Recognize Silica as a Hazard during the Work Planning
               300    27-Jun-12 Process(Source: User Submitted - ID: TJNAF-373-06-19-2012)                   lessons learned to subcontractors                               27-Jun-12                                                                   27-Jun-12       ES&H         Rejected-Close
                                  Effective flow down of information to subcontractors requires
                                  significant attention to detail.
                                  1. YELLOW - Hazards Associated with Elastic Tie-Downs (Bungee Cords) can accept - forward to RCColl for processing                                     Rejected - This elastic tie down lesson is a common one and a
                                  Result in Severe Injury (Source: User Submitted - ID: 2012-BNL-Bungee-                                                                                 recognized hazard
                                  0001)
               301    27-Jun-12 Elastic (bungee) cords are common, inexpensive tools used for a                                                                              27-Jun-12                                                                   26-Sep-12       ES&H         Rejected-Close
                                  variety of fastening applications. Two recent injuries in office and
                                  shop work areas at Brookhaven National Laboratory point out the
                                  hazard potential of these common tools.
                                                                                                             accept - forward to RCColl for processing                                   Rejected - There is no lesson here. This was people not
                                  1. YELLOW - A Dangerous Precedent(Source: User Submitted - ID: 2012-LL-                                                                                following established processes and getting in trouble. This
                                  PNNL-0002)                                                                                                                                             belongs in the “management” arena as a disciplinary issue
                                                                                                                                                                                         Not a safety issue.
               302    27-Jun-12 Do not deviate from standard processes without consulting a Subject                                                                          27-Jun-12                                                                   20-Jul-12       ES&H         Rejected-Close
                                  Matter Expert first. When using a flammable liquid near a heat source,
                                  make sure ventilation is adequate. Determine the flash point and the
                                  upper and lower explosives limits then err on the side of caution.
                                  Make sure ventilation is adequate. Finally, avoid heating isopropyl
                                  alcohol or other liquids in a convection oven.


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                                                                                                                                                          LL Initial Review

              Item #     Date                               2012-BNL-Bungee-0001)                                        OQBP LLC (ERV, JFM) Initial Review Comments               Date                MSLLC or MPLLC Initial Review Comments                   Date      MS/MP (Area) Initial Review Status
                                                                                                                 accept - forward to RCColl for processing                                   discussed at the Subcontractor Safety Subcommittee with no
                                   1. BLUE - Shop Built Tools/Equipment Concerns(Source: User Submitted -
                                                                                                                                                                                             further action contemplated by the committee.
                                   ID: RCCC-2012-0012)
               303     28-Jun-12 All tools should be inspected prior to use and taken out of service if                                                                          28-Jun-12                                                                    17-Aug-12       ES&H             FYI Only
                                   not in a safe condition. In addition, home made, shop made, or
                                   modified tools that are not engineered to meet safety specifications
                                   should not be used.
                                                                                                                 reject - this is a case of poor coummunication.                             Did not forward to MSLLC
                                   1. BLUE - Lack of Communication Results in Entry into an Unposted High
                                   Contamination Area(Source: User Submitted - ID: RCCC-2012-0017)
               304     28-Jun-12                                                                                                                                                 28-Jun-12                                                                    28-Jun-12       ES&H         Rejected-Close
                                   Communication and coordination between work groups is always
                                   important, especially when groups are working in close proximity and
                                   transferring ownership of work areas.
                                   1. YELLOW - Fall off Scissor Lift Results in Injuries (Source: User Submitted - reject - this is a case of workers not following documented               Did not forward to MSLLC
                                   ID: 2012-BNL-ERP-0002)                                                          procedures
               305     28-Jun-12 Workers need to inspect personnel lifts, scaffolds and similar                                                                                  28-Jun-12                                                                    28-Jun-12       ES&H         Rejected-Close
                                   equipment providing fall protection prior to use; management needs
                                   to ensure that this pre-use inspection is performed.
                                   1. BLUE - Crane Card Should Be Kept or Posted Where Operators and             reject - this is a case of workers not following documented                 Did not forward to MSLLC
                                   Maintenance Personnel Can Easily Access It (Source: User Submitted - ID:      procedures
                                   LANL-RADIOCHEM-2012-0002)
                                 The record of annual inspection for a hoist, winch, crane, or lift must
                                 be readily available to operators in order to conduct a pre-use
                                 inspection of the equipment. This prevents equipment with expired
                                 annual inspection from being used and acts as a reminder to schedule
               306     28-Jun-12 preventive maintenance and inspection work. Putting such                                                                                        28-Jun-12                                                                    28-Jun-12       ES&H         Rejected-Close
                                 information in places that are inaccessible or difficult to access can
                                 lead to: 1. Equipment with expired maintenance and inspection being
                                 kept in service in violation of P101-25, 10 CFR 851, 29 CFR
                                 1910.179(j)(2)(vi), 29 CFR 1910.179(j)(3), and ANSI B30 series. 2. Loss
                                 of maintenance and inspection continuity. 3. In extreme
                                 circumstances, an undiscovered defect due to lack of maintenance
                                 and inspection may result in a serious failure and affect worker safety
                                 and programmatic performance
                                                                                                                 reject - this is a case of workers not following documented                 Did not forward to MSLLC
                                   1. BLUE - Inadequate Radiological Work Permit Implementation(Source:
                                                                                                                 procedures
                                   User Submitted - ID: L-2011-OR-BWY12-0610)
                                 The Radiological Work Permit (RWP) is the principal administrative
                                 mechanism to establish radiological controls to be used in the
                                 conduct of radiological work activities. Compliance with RWPs applies
                                 to all personnel, including subcontractors and visitors, entering and
                                 performing work in radiological areas or in areas where potential
                                 radiological hazards are present. Compliance with the RWP prevents
                                 spread of radioactivity and radioactive contamination or loss of
               307     28-Jun-12 radioactive material control and personal contamination. It is the                                                                              28-Jun-12                                                                    28-Jun-12       ES&H         Rejected-Close
                                 responsibility of all individuals to read, understand, and comply with
                                 the instructions and conditions specified on the RWP. If the RWP
                                 cannot be understood, then it is the individualҳ responsibility to then
                                 contact the Radiological Control Organization personnel or the Work
                                 Group Supervisor for clarification. Signing in on the applicable RWP
                                 indicates the RWP has been read and understood. It is expected that
                                 RWPs are to be reviewed and discussed, which include the job
                                 hazards present and their associated risks, prior to beginning work.
                                 Personal protective equipment (PPE) requirements to include anti-
                                 contamination (anti-c) clothing, as determined by the Radiological
                                 Control Organization, are identified in the RWP. In some instances      accept - forward to RCColl for processing                                           Rejected- Piping used in fire suppression systems are
                                   1. BLUE - Improper Slope of Piping for Dry Pipe Fire Suppression Systems                                                                                  inspected yearly by fire techs, quarterly by Fire Dept. during
                                   Can Result in Accelerated Accumulation of Corrosion Products (Source:                                                                                     quarterly inspector water flow tests and also during HPI
                                   User Submitted - ID: L-2012-OR-BWY12-0605)                                                                                                                inspections. Any discrepancies found are noted and placed on
                                                                                                                                                                                             a schedule for fix or repairs.
               308     28-Jun-12                                                                                                                                                 28-Jun-12                                                                    11-Jul-12       ES&H         Rejected-Close
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                                                                                                                                                                                           inspected yearly by fire techs, quarterly by Fire Dept. during
                                                                                                                                                                                           quarterly inspector water flow tests and also during HPI
                                                                                                                                                       LL Initial Review                   inspections. Any discrepancies found are noted and placed on
              Item #   Date                                2012-BNL-Bungee-0001)                                      OQBP LLC (ERV, JFM) Initial Review Comments                Date                 MSLLC or repairs.
                                                                                                                                                                                           a schedule for fix or MPLLC Initial Review Comments                  Date      MS/MP (Area) Initial Review Status
                308  28-Jun-12                                                                                                                                                 28-Jun-12                                                                      11-Jul-12      ES&H         Rejected-Close
                                  Build-up of corrosion products in dry pipe sprinkler system piping
                                  may be accelerated where piping is not appropriately sloped to
                                  prevent accumulation of water at low points that cannot be drained.
                                  Unauthorized modifications to piping slope can result from vehicular
                                  impact (powered industrial trucks) and from improper installation of
                                  collocated process piping.
                                                                                                              accept - forward to RCColl for processing                                    This is a Fermilab generated lesson learned. It is already being
                                  1. YELLOW- Overheated Connection caused by Equipment                                                                                                     implemented and tracked through ES&H. This spreadsheet wil
                                  Modification(Source: User Submitted - ID: 2012-FSO-FNAL-013)                                                                                             be updated to reflect that status.                                                               Fully Accept-
               309    10-Jul-12                                                                                                                                                10-Jul-12                                                                      10-Jul-12       ES&H
                                                                                                                                                                                                                                                                                         Action Plan Needed
                                  Improper equipment modification can lead to unsafe conditions and
                                  equipment failure.
                                  1. YELLOW - Air Handling Unit Replacement and Lack of Position              accept - forward to RCColl for processing                                    This is a Fermilab generated lesson learned. It is already being
                                  Verification Leads to Bridge Crane Interference(Source: User Submitted -                                                                                 implemented and tracked through ES&H. This spreadsheet wil
                                  ID: 2012-FSO-FNAL-014)                                                                                                                                   be updated to reflect that status.

                                  When installing, replacing, or modifying equipment or structures be
                                  sure to check for interferences with other equipment and personnel
                                  before completing the task. During installation, construction,
                                  modification, etc., always leave the equipment in a safe state free of                                                                                                                                                                                    Fully Accept-
               310    10-Jul-12   interferences and other hazards when leaving the worksite or placing                                                                         10-Jul-12                                                                      10-Jul-12       ES&H
                                                                                                                                                                                                                                                                                         Action Plan Needed
                                  the task in standby. A contractor replaced an air handling unit in
                                  stages. The task manager did not verify the positioning of the newly
                                  installed air handling unit in relation to the bridge crane. After the
                                  installation a technician began operating the crane and noticed that it
                                  might not clear the newly installed air handler. The operator slowed
                                  progress of the bridge crane and noticed it would contact the air
                                  handler in its current position. The technician contacted the building
                                  manager who contacted the contractor to reposition the air handler.
                                  1. YELLOW - Modular Desk Failure(Source: User Submitted - ID: 24590-        reject - According to Gary Van Zandbergen, Fermilabd does                    Did not forward to MSLLC
                                  WTP-LL-MGT-12-0006)                                                         not use the type of office furniture described in this lessons
                                  Users of modular desks should evaluate current desktop loading and          learened (manufactured by Rosemount, Celerity - Standard
                                  reduce if necessary to prevent potential failure of desk. On February       Series), nor have their been any incidents of office furniture
               311    10-Jul-12   24, 2012, a Waste Treatment Plant (WTP) employee's modular desk
                                                                                                                                                                               10-Jul-12                                                                      10-Jul-12       ES&H         Rejected-Close
                                                                                                              collapses here.
                                  collapsed when the employee leaned onto the desk adding additional
                                  load to a dangerously overloaded desk. The employee sustained
                                  minor injuries when the middle section of a modular furniture desk
                                  countertop collapsed.
                                  1. BLUE - Spark/Arc Flash Incident (Source: User Submitted - ID: B-2012-    accept - forward to RCColl for processing                                    reject based on Jerry Grant's explanation that our system
                                  FBPORTS-0601)                                                                                                                                            exceeds the LL recommendation
                                  It is through efficient communication that most incidents can be
                                  avoided. This communication can be in the form of verbal statements,
               312    10-Jul-12   visual indicators, written turnovers, signage, etc. The key is that                                                                          11-Jul-12                                                                      18-Jul-12       ES&H         Rejected-Close
                                  information is exchanged. The information can be a notification of
                                  unexpected conditions, hidden dangers, or a simple "DO NOT
                                  OPERATE" tag to name a few. Information, if shared can stop a series
                                  of unrelated events from causing a single accident/incident.

                                  1. YELLOW - Electric Cart Accident Resulting in Multiple Fractures of the   reject - this is a case of personnel not trained and careless                Did not forward to MSLLC
                                  Leg(Source: User Submitted - ID: Y-2012-FBPORTS-0602)                       driving of a cart indoors
               313    10-Jul-12   Even routine operations using equipment that may appear to be low                                                                            10-Jul-12                                                                      10-Jul-12       ES&H         Rejected-Close
                                  risk could pose a significant potential hazard. An incomplete
                                  identification of a potential hazard may cause insufficient Job Hazard
                                  Analysis (JHA), controls, and oversight.
                                                                                                             reject - thi is a case where the safety piece of the equipment                Did not forward to MSLLC
                                  1. YELLOW - Cigarette Butt Receptacle Fire(Source: User Submitted - ID: Y-
                                                                                                             (the metal liner) was removed, rendering it a safety hazard.
               314    11-Jul-12   2012-OR-UCORESHQ-0602)                                                                                                                       11-Jul-12                                                                      11-Jul-12       ES&H         Rejected-Close
                                  Failure to have a routine cigarette butt receptacle maintenance and
                                  inspection program can result in an unexpected fire.
                                                                                                              accept - forward to Jed Heyes for processing                                 Rejected by MSLLC - another system covers this
                                  1. BLUE - Improving the Lessons Learned/Operating Experience
                                  Program(Source: User Submitted - ID: 2012-NV-NNSS-424)
               315     11-Jul-12                                                                                                                                               11-Jul-12                                                                      27-Sep-12      quality       Rejected-Close
Fermi National Accelerator Laboratory Confidential                                                                                                         5/3/2013                                                                                                                                            Page 53
                                                                                                                accept - forward to Jed Heyes for processing                                    Rejected by MSLLC - another system covers this
                                                                                                                                                       LL Initial Review
              Item #     Date                               2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments                   Date               MSLLC or MPLLC Initial Review Comments          Date      MS/MP (Area) Initial Review Status
                315    11-Jul-12                                                                                                                                                    11-Jul-12                                                          27-Sep-12      quality      Rejected-Close
                                   Capturing Lessons Learned successes can be difficult. Utilizing
                                   monthly stakeholder meetings and developing metrics can generate
                                   ideas to improve the effectiveness of Lessons Learned programs.
                                                                                                                reject - this is the same problem as itme 263 (ID: 2012-BNL-                    Did not forward to MSLLC
                                   1. YELLOW - Lock-Out Devices on Single Pole Breakers May Not Ensure a
                                                                                                                LOTO- 0005) above, which has laready been accepted and
                                   Positive Lock-Out(Source: User Submitted - ID: LANL-LANL-2012-0001)
                                                                                                                processed

                                   Lock-out devices for use on single pole circuit breakers may prove to
                                   not maintain a positive locked condition when in actual use. This
                                   applies even to those recommended by the electrical equipment
                                   manufacturer. Single pole circuit breakers are commonly found on
               316     11-Jul-12   branch circuits and in lighting panels. The product is a compact                                                                                 11-Jul-12                                                          11-Jul-12       ES&H         Rejected-Close
                                   device with a small plastic lever arm that is used to close, open, or
                                   reset the breaker. Most are not manufactured with a "built-in" lock-
                                   ability, therefore necessitating the use of an add-on device to achieve
                                   lock-out. These devices can fall free of the breaker with little force, in
                                   some cases leaving the breaker unprotected and workers unprotected.
                                   Additional measures may be warranted when using these devices
                                   since LOTO is a life critical safety function that protects workers from
                                   accidental injury or death when working on equipment and systems.
                                   1. BLUE - Configuration Control Concerns for Safety Basis                    reject - this is a case of an ineffective document control                      Did not forward to MSLLC
                                   Documents(Source: User Submitted - ID: 2012-RL-HNF-0024)                     procedure in use
                                   Review and approval processes for configuration control need to
               317     17-Jul-12   identify and recognize vulnerabilities as there are numerous potential                                                                           17-Jul-12                                                          17-Jul-12      Quality       Rejected-Close
                                   opportunities for key documents to lose configuration control as they
                                   progress through development, review, approval, and issuance.

                                   1. BLUE - Level 3 Anomalous Condition Report on Nuclear Criticality Safety reject - there is nothing actionable in this LL                                   Did not forward to MSLLC
                                   Program for High Mass Converter Storage(Source: User Submitted - ID: B-
                                   2012-OR-UCORK25-0701)

                                   The lesson that can be learned from the Level 3 Anomalous Condition
                                   Report and resultant Potentially Inadequate Safety Analysis (PISA)
                                   determination associated with this occurrence report (OR) is the value
               318     17-Jul-12   that is gained from ensuring individuals conducting field activities                                                                             17-Jul-12                                                          17-Jul-12      Quality       Rejected-Close
                                   have a good understanding of the basis for the control sets associated
                                   with the work controls being employed and the experience to
                                   recognize when that basis is no longer satisfied. With this information
                                   and experience, employees are more likely to be able to recognize
                                   conflict with assumptions made when the control sets were
                                   established, and stop work to allow for further analysis prior to
                                   performing work under what might be an inadequa te control set.

                                   1. YELLOW - Subcontract Food Handler Cuts Hand Requiring Surgery             accept - forward to RCColl for processing                                       Accepted as an FYI by the SSO and cafeteria manager.
                                   (Source: User Submitted - ID: 2012-UTB-ORNL-0008)
                                   Personnel should avoid contact with sharp edges and or wear gloves
               319     25-Jul-12   suited for kitchen operations when conducting activities associated                                                                              25-Jul-12                                                          6-Aug-12        ES&H             FYI Only
                                   with opening cans or containers. When the wrong tool is used, or the
                                   right tool is used improperly, as in this routine work evolution, hand
                                   injuries are likely to happen.
                                   1. YELLOW - SRS Fire Department Experiences Two Draeger SCBA Air Pak       accept - forward to RCColl for processing - actually we                           Forwarded to Dave Baird for processing
                                   Connection Failures (Preliminary Information)(Source: User Submitted - ID: received this as a "first alert" from Jed Heyes on 7/20. That
                                   2012-SR-SRNS-0006)                                                         is why the date of initial review comments is earlier than the
                                                                                                              date entered into the spreadsheet
               320     26-Jul-12   The Savannah River Site Fire Department (SRSFD) has experienced
                                                                                                                                                                                    20-Jul-12                                                          20-Jul-12       ES&H             FYI Only
                                   two similar failures of a Draeger PSS-100, 4500 psi SCBA unit. The
                                   failure appears to be a fatigue failure of a nipple on the connection
                                   between the pressurized air tank and the regulator.

                                   1. YELLOW - Consideration of Chemical Sampling Technique during JHA          reject - this is a case of incorrectly defining a process and the               Did not forward to MSLLC
                                   Development(Source: User Submitted - ID: 2012-SR-SWPF-003)                   resulting JHA

               321     26-Jul-12                                                                                                                                                    26-Jul-12                                                          26-Jul-12       ES&H         Rejected-Close
Fermi National Accelerator Laboratory Confidential                                                                                                           5/3/2013                                                                                                                                   Page 54
                                                                                                                                                         LL Initial Review
                                                                                                             reject - this is a case of incorrectly defining a process and the               Did not forward to MSLLC
                                                                                                             resulting JHA
              Item #     Date                              2012-BNL-Bungee-0001)                                      OQBP LLC (ERV, JFM) Initial Review Comments                  Date                MSLLC or MPLLC Initial Review Comments               Date      MS/MP (Area) Initial Review Status
                321    26-Jul-12   Job Hazards Analyses (JHA) and controls for work evolutions                                                                                   26-Jul-12                                                                26-Jul-12      ES&H         Rejected-Close
                                   involving caustic chemicals should give consideration to preventing
                                   chemical exposures for all possible body positions and work practice
                                   techniques that may be utilized by workers.
                                   1. YELLOW - Unstable Load at Construction Site(Source: User Submitted -   reject - this is a case of operator error                                       Did not forward to MSLLC
                                   ID: 2012-SRSO-0002)
                                   Operators of equipment should fully utilize spotters and inspection
                                   personnel to ensure that collocated material/supports are not
                                   damaged during removal of equipment/material from delivery vehicles.
                                   This should include inspection during the lifting process to ensure
               322     27-Jul-12   that adjacent pallets, etc. are not damaged during previous lifting                                                                           27-Jul-12                                                                27-Jul-12       ES&H         Rejected-Close
                                   activities. On July 9, 2012, at approximately 0945 a safety incident
                                   occurred in the Tritium Processing Area. The masonry contractor was
                                   unloading a pallet of block when the load became unstable causing
                                   several blocks to fall to the ground. A post job review was conducted
                                   and it was determined that this incident did not require an ORPS
                                   report.
                                   1. BLUE - Loss of Grounding on Commercially Available Equipment (Source: accept - forward to RCColl for processing                                        The LL below accepted as an FYI by the chair of the
                                   User Submitted - ID: 2012-UTB-ORNL-0009)                                                                                                                  mechanical safety subcommittee.
               323     27-Jul-12                                                                                                                                                 27-Jul-12                                                                31-Jul-12       ES&H             FYI Only
                                   If equipment grounding is lost, some types of equipment will exhibit
                                   current leakage typically in the range of approximately 3 milliamps at
                                   approximately 50 VAC.
                                   1. YELLOW - Using the Correct Job Specific Lockout/Tagout (Source: User   reject - ths is a case of personnel not following documented                    Did not forward to MSLLC
                                   Submitted - ID: Y-2012-OR-BWY12-0601)                                     procedures.
               324     27-Jul-12   When performing Preventive Maintenance (PM) activities, it is                                                                                 27-Jul-12                                                                27-Jul-12       ES&H         Rejected-Close
                                   important to ensure that the proper job-specific Lockout/Tagout
                                   (LO/TO) is used as provided in the work package.
                                                                                                             reject - ths is a case of not following documented                              Did not forward to MSLLC
                                   1. BLUE - When the Work Scope Changes, It is Paramount that a Hazard
                                                                                                             procedures; not updating documented procdures to reflect
                                   Evaluation Be Completed(Source: User Submitted - ID: 2012-ANL-008)
                                                                                                             current practice and poor communication of process
                                                                                                             requirements to workers.
                                   When planning work scope, work planning documents must contain
               325     31-Jul-12                                                                                                                                                 7-Aug-12                                                                 7-Aug-12        ES&H         Rejected-Close
                                   enough detail to ensure that the hazards are appropriately evaluated
                                   and re-evaluated when questions arise prior to or during work
                                   implementation. If the work is not described or scoped appropriately,
                                   there can be a failure in identification of hazards, and mitigative
                                   measures to manage hazards can be missed.
                                                                                                             reject - ths is a case of poor management to worker                             Did not forward to MSLLC
                                   1. BLUE - Improvement Opportunities during Area Closure and Significant
                                                                                                             communication
                                   Personnel Moves(Source: User Submitted - ID: RCCC-2012-0018)
                                   During a recent 100N Area/building closure activities and personnel
               326     1-Aug-12                                                                                                                                                  7-Aug-12                                                                 7-Aug-12        ES&H         Rejected-Close
                                   moves, employees felt uninformed, and uninvolved in the planning
                                   and implementation process. This created an unsafe work
                                   environment, distracting employees from the work hazards associated
                                   with their day to day work activities.
                                   1. YELLOW - Sheared Bolts Discovered on JLG Aerial Lift Boom Connections accept - forrwarded to Rafael Coll for processing                                Rejected. Fermilab does not have this model. Please close.
               327     1-Aug-12    to Platform after Physical Inspection(Source: User Submitted - ID: 2012-
                                   BNL-Aerial-0001)
                                   On July 26, 2012, at Brookhaven National Laboratory (BNL) a JLG
                                   model 860SJ aerial lift was found to have all eight of its platform                                                                           7-Aug-12                                                                 22-Aug-12       ES&H         Rejected-Close
                                   rotator attachment bolts sheared in half. This condition is not obvious
                                   during a visual inspection. Although there was no risk of the platform
                                   detaching from the boom the horizontal rotation capacity of the
                                   platform was severely compromised
                                                                                                     reject - ths is a case of personnel not following sound
                                    1. YELLOW - Employee Struck by Vehicle(Source: User Submitted - ID: Y-                                                                                   Did not forward to MSLLC
                                    2012-FBPORTS-0701)                                               judgement while backing up a vehicle - poor visibility behind
               328     1-Aug-12                                                                                                                                                  7-Aug-12                                                                 7-Aug-12        ES&H         Rejected-Close
                                            Expected the unexpected when backing vehicles; even when vehicle was ignored and the backup was continued anyway.
                                            you confirm the area is clear, it may not stay clear.



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                                                                                                                                                         LL Initial Review



              Item #     Date                              2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments                   Date              MSLLC or MPLLC Initial Review Comments         Date      MS/MP (Area) Initial Review Status
                                  1. BLUE - Unexpected Crane Movement after Parking - Emphasizes               accept - forrwarded to Rafael Coll for processing                              This LL has been accepted by Fermilab as an FYI and
                                  Questioning Attitude and Conservative Decision Making(Source: User                                                                                          distributed to SSOs and TM/CC
                                  Submitted - ID: 2012-SR-SRNS-0008)

                                  A questioning attitude, conservative decision making, and involving
                                  others will help with the evaluation of an issue and in determining
               329     1-Aug-12   appropriate responses. Operability checks do not necessarily prove                                                                               7-Aug-12                                                         7-Aug-12        ES&H             FYI Only
                                  functionality of safety systems. In this instance, placing the crane in
                                  2nd gear to see if it moved with the brake engaged did not detect the
                                  weakened state of the brake. Although it held on the level surface that
                                  the check was performed on, it did not hold when the crane was
                                  parked on an inclined surface. Additional understanding and
                                  determination between operational checks and "performance" checks
                                  are needed and decision tree defined as to when/how each is applied.
                                    1. BLUE - Under Reported Curies in Heat Exchangers to E-Area Slit Trench reject - this is a case of human error during a calculation                      Did not forward to MSLLC
                                    - Emphasizes Use of "Fresh Eyes" in the Field(Source: User Submitted -   review
                                    ID: 2012-SR-SRNS-0009)

                                  An error in the calculation note resulted in under reporting the curies
                                  for the 30 heat exchangers sent to the E-area slit trench for disposal.
                                  When the same two personnel are involved in multiple iterations of
                                  preparing and then performing a peer review of a technical
               330     1-Aug-12   calculation, management should consider appointing a different                                                                                   7-Aug-12                                                         7-Aug-12        ES&H         Rejected-Close
                                  person to perform the final peer review. Due to the repeated versions
                                  of the calculation, the same peer reviewer may build overconfidence in
                                  the details of the calculation and miss minor details as was the case in
                                  this particular instance. If the option does not exist to have a different
                                  peer reviewer involved, then management needs to ensure that the
                                  peer reviewer is approaching each version of the technical calculation
                                  with the mindset that preparer has made an error and that it is his/her
                                  job as the peer reviewer to identify it.

                                  1. BLUE - Applying Case Decisions Regarding Lockout/Tagout(Source: User      reject - there is no actionable lesson here.                                   Did not forward to MSLLC
               331     2-Aug-12   Submitted - ID: CWI-ICP-2012-002)                                                                                                                7-Aug-12                                                         7-Aug-12        ES&H         Rejected-Close
                                  Prior case decisions in the use of Lockout/Tagout should be carefully
                                  considered and applied only where appropriate.
                                  1. YELLOW - Pressurized System Calibration Incident(Source: User             accept - forrwarded to Rafael Coll for processing                              The LL has been accepted by the SME as an FYI.
                                  Submitted - ID: LL-2012-LLNL-05)
                                  Establishing proper work controls depends upon multiple factors,
               332     3-Aug-12   including understanding the system and work requirements;                                                                                        7-Aug-12                                                         14-Aug-12       ES&H             FYI Only
                                  evaluating, understanding and controlling the potential consequences
                                  of process decisions; and ensuring that the equipment is capable of
                                  performing as expected.
                                  1. YELLOW - Five Things to Help You Recognize a Changed Condition            reject - this is a case of workers failing to re-evaluate process
                                  (Source: User Submitted - ID: 2012-UTB-ORNL-0007)                            hazards after a new task (sawing lead bricks) was added to
                                                                                                               the original process
                                 The best response to a condition or task that has changed, or is
                                 perceived to have changed, is to stop the work, discuss the situation,
               333     21-Aug-12 and ask for help. Routine operational and research work tasks that                                                                                21-Aug-12 Did not forward to MSLLC                               21-Aug-12       ES&H         Rejected-Close
                                 have been completed successfully in the past have the potential to
                                 produce undesired outcomes. In this work evolution, unrecognized
                                 changing conditions coupled with a task considered routine resulted
                                 in ORNL workers registering lead air concentrations above OSHA
                                 permissible exposure limits.

                                                                                                        reject - this is a case of lack of communication - both written
                                  1. YELLOW - Excavator Damages Underground PVC Conduit Containing 120
                                                                                                        and verbal
                                  Volt Energized Cable(Source: User Submitted - ID: 2012-UTB-ORNL-0010)



               334 22-Aug-12                                                                                                                                                       22-Aug-12 Did not forward to MSLLC                               22-Aug-12       ES&H         Rejected-Close
Fermi National Accelerator Laboratory Confidential                                                                                                            5/3/2013                                                                                                                               Page 56
                                                                                                            reject - this is a case of lack of communication - both written
                                                                                                                                                      LL Initial Review
                                                                                                            and verbal
              Item #     Date                              2012-BNL-Bungee-0001)                                     OQBP LLC (ERV, JFM) Initial Review Comments                Date                MSLLC or MPLLC Initial Review Comments                    Date      MS/MP (Area) Initial Review Status
                                 Excavation in areas congested with buried utilities or in areas where
                                 previous activities likely required buried utilities presents a risk to
               334     22-Aug-12 discover undocumented or undetected utilities. The importance of                                                                             22-Aug-12 Did not forward to MSLLC                                            22-Aug-12       ES&H         Rejected-Close
                                 documented field determinations of potential utility locations on
                                 excavation permits and communication of these field markings to
                                 workers are critical steps in a hazard energy control process - a
                                 rigorous process to ensure the identification of the hazards that may
                                 expose workers to potential injuries.

                                  1. YELLOW - Injury Leads to Replacement of Door Closure                   reject - this is a case of incorrect operation of the door
                                  Mechanism(Source: User Submitted - ID: LL-2012-LLNL-08)                   handle andl atch mecanism. Fermilab does not use the bullet
                                  Multiple incident-free uses of a device or system can lead its users to   proof door described in this lesson.
               335     22-Aug-12 lose awareness of the latent hazards which may be present. Mitigating                                                                        22-Aug-12 Did not forward to MSLLC                                            22-Aug-12       ES&H         Rejected-Close
                                  actions considered for use in response that device's not functioning
                                  properly need to be evaluated to ensure safe implementation and
                                  execution before the actions are used.

                                  1. YELLOW - Partial Evacuation of Building 400 due to Fire Alarms from    accept - forward to Rafael Coll for processing                                rejected - this is not a lesson but a malfunction of a piece of
                                  Overheated Magnet Coil Fumes(Source: User Submitted - ID: 2012-ANL-                                                                                     equipment.
                                  009)
               336     22-Aug-12 Never bypass any circuit in troubleshooting if it might compromise                                                                           22-Aug-12                                                                     26-Sep-12       ES&H         Rejected-Close
                                  personnel safety. Equipment protection circuit may be bypassed only
                                  when an alternative way or technique is used to safeguard the
                                  equipment
                                  1. YELLOW - Field Changes Rolled into Procedure Revision without an     reject - the document review procedure referred to in this LL
                                  Unreviewed Safety Question Review(Source: User Submitted - ID: 2012-ID- is not applicable at Fermilab
                                  AMWTP-0009)
                                 Perform an Unreviewed Safety Question (USQ) review for all
                                 procedure revisions or Field Changes to ensure procedure changes
                                 are bounded by the AMWTP Safety Basis. Document Services
               337     22-Aug-12                                                                                                                                              22-Aug-12 Did not forward to MSLLC                                            22-Aug-12       ES&H         Rejected-Close
                                 procedural notes should be unambiguous with clear direction to
                                 ensure protocol is followed under all circumstances. Ambiguous
                                 procedural notes have resulted in six procedures inadvertently
                                 bypassing the USQ review process since 10/01/11. This resulted in the
                                 filing of an ORPS report, a fact finding, and a corrective action report
                                 (CAR).
                                 1. BLUE - Emergency Instructions - Listen and Follow(Source: User          reject - this is a case of people not following documented
               338     22-Aug-12 Submitted - ID: WIPP-LL-2012-01)                                           emergency procedures.                                             22-Aug-12 Did not forward to MSLLC                                            22-Aug-12       ES&H         Rejected-Close
                                  During a surface medical emergency, several non-emergency actions
                                  could have hindered the emergency response.
                                  1. PMW Small Business Procurement Teamed to Provide NQA-l Quality  reject -this is a case of poor supplier quality managemnt by
                                  Program(Source: User Submitted - ID: PMLL-2012-Y12-PMW-0608)       project management. The Fermilab Engineering Manual has
                                                                                                     a risk analysis step that is designed to preclude this type of                                                                                                       project
               339     22-Aug-12                                                                                                                                              22-Aug-12 Did not forward to MSLLC                                            22-Aug-12                    Rejected-Close
                                 Procurements that involve a teaming arrangement to provide the NQA- issue.                                                                                                                                                             management
                                  1 Quality Program increase the risk of the project and can cause
                                  significant schedule and cost delays.
                                                                                                            reject -this is a case of an inadequate design and engineering
                                    1. PMW Site Acceptance Testing to Verify Design Requirements(Source:    procedure (design/requirements verification). The Fermilab
                                    User Submitted - ID: PMLL-2012-Y12-PMW-0607)                            Engineering Manual describes design and enginerring
                                                                                                            requirements at FNAL
               340     22-Aug-12 A testing methodology to verify each design requirement should be                                                                            22-Aug-12 Did not forward to MSLLC                                            22-Aug-12    engineering     Rejected-Close
                                  developed and mutually accepted early in the development of the
                                  system requirements document (SRD). This document, when
                                  completed, is also a valuable tool at CD-4 to verify to the customer
                                  that key project parameters and system requirements were met.
                                  1. PMW Integrator Contractor to Coordinate & Test Systems(Source: User    reject -this is a case of an inadequate design and engineering
                                  Submitted - ID: PMLL-2012-Y12-PMW-0606)                                   procedure (integration test). The Fermilab Engineering
                                 An integrator contractor is a vendor who takes all the varied              Manual describes design and enginerring requirements at
               341     22-Aug-12 equipment purchased from separate vendors and assembles it for an          FNAL                                                              22-Aug-12 Did not forward to MSLLC                                            22-Aug-12    engineering     Rejected-Close
                                 integrated "test run." An integrator contractor could have ensured that
                                 the material transfer mechanism and the microwave system worked
                                 well together before transfer to Y-12, thus greatly benefitting the PMW
                                 project.
Fermi National Accelerator Laboratory Confidential                                                                                                      5/3/2013                                                                                                                                             Page 57
                                                                                                                                                      LL Initial Review
              Item #     Date                              2012-BNL-Bungee-0001)                                    OQBP LLC (ERV, JFM) Initial Review Comments                 Date              MSLLC or MPLLC Initial Review Comments     Date      MS/MP (Area) Initial Review Status
                                                                                                           reject -this is a case of poor project management decision
                                   1. PMW Demolition, Decontamination, and Removal Activities Prior to CD-
                                                                                                           making
                                   2 '(Source: User Submitted - ID: PMLL-2012-Y12-PMW-0605)                                                                                                                                                              project
               342     22-Aug-12                                                                                                                                              22-Aug-12 Did not forward to MSLLC                           22-Aug-12                    Rejected-Close
                                   Ensure all waste is disposed off site before baseline at CD-2, or                                                                                                                                                   management
                                   indude risk of revised requirements, revised treatment, (re-)packaging,
                                   and/or disposal costs in the contingency estimate
                                   1. PMW Use of Surrogate Test Materials(Source: User Submitted - ID:       reject -this is a case of an inadequate specifciations
                                   PMLL-2012-Y12-PMW-0604)                                                   development and review procedure. The Fermilab
               343     22-Aug-12 The surrogate material used for testing should closely match the            Engineering Manual describes FNAL requirements for               22-Aug-12 Did not forward to MSLLC                           22-Aug-12    engineering     Rejected-Close
                                   characteristics ofthe material to be used in actual operations.           specifciation development and review

                                 1. PMW Testing New Technology(Source: User Submitted - ID: PMLL-2012- reject -this is a case of poor project planning and risk
                                                                                                                                                                                                                                                         project
               344     22-Aug-12 Y12-PMW-0603)                                                         analysis. The Fermilab Engineering Manual describes a                  22-Aug-12 Did not forward to MSLLC                           22-Aug-12                    Rejected-Close
                                 The factory acceptance test (FAT) should resemble the site            rigorous risk analysis process.                                                                                                                 management
                                   acceptance test (SAT) as accurately as possible.
                                 1. Life Cycle Oven (LCO) Use of Test and Evaluation (T&E) funds(Source:     reject -this is a case of project management processes not
                                                                                                                                                                                                                                                         project
               345     22-Aug-12 User Submitted - ID: PMLL-2012-Y12-PWSU-0501)                               being followed. Also, the processes described are not            22-Aug-12 Did not forward to MSLLC                           22-Aug-12                    Rejected-Close
                                   Project Test & Evaluation process requires prior approval to utilize      relevant at Fermilab                                                                                                                      management
                                   Expense funds
                                                                                                    reject -this is a case of inadequate specifciations
                                   1. PMW Furnace Control System(Source: User Submitted - ID: PMLL-2012-
                                   Y12-PMW-0614)                                                    development and review. The Fermilab Engineering Manual
                                 Development of the control system by a PMW Furnace vendor was not describes FNAL requirements for specifciation development
               346     22-Aug-12 well documented and did not obtain adequate review by Y12, leading                                                                           22-Aug-12 Did not forward to MSLLC                           22-Aug-12    engineering     Rejected-Close
                                                                                                    and review
                                   to additional costs and work during start-up testing on the system and
                                   during preparation of operating procedures and planning maintenance
                                   activities
                                   1. MW Furnace Factory Acceptance Test (FAT)(Source: User Submitted -      reject -this is a case of inadequate acceptance test
                                   ID: PMLL-2012-Y12-PMW-0613)                                               development and review. The Fermilab Engineering Manual
               347     22-Aug-12 Demonstration of equipment performance was not adequately                   describes FNAL requirements for test documntation and            22-Aug-12 Did not forward to MSLLC                           22-Aug-12    engineering     Rejected-Close
                                   addressed in Factory Acceptance Test (FAT) and caused additional          review
                                   work for on-site testing.
                                   1. PMW Furnace Equipment Procurement(Source: User Submitted - ID:         reject -this is a case of poor supplier quality managemnt by
                                   PMLL-2012-Y12-PMW-0612)                                                   project management. The Fermilab Engineering Manual has
                                 When working with a small business vendor for the primary                   a risk analysis step that is designed to preclude this type of
                                 equipment design and fabrication, particularly when the technology          issue.                                                                                                                                      project
               348     22-Aug-12 application is relatively unique, significant effort needs to be placed                                                                      22-Aug-12 Did not forward to MSLLC                           22-Aug-12                    Rejected-Close
                                                                                                                                                                                                                                                       management
                                 on recognizing the vendor's weaknesses early and plan for additional
                                 support (testing, design documentation, project management,
                                 procurement, expediting, and QA)

                                   1. PMW Furnace Start-up Testing(Source: User Submitted - ID: PMLL-2012- reject -this is a case of insufficient planning being performed
                                   Y12-PMW-0611)                                                           for the testing portion of this project
                                 Several issues related to start-up testing need to be addressed: 1)
                                 Schedule and budget must be adequate to address portions of the
                                                                                                                                                                                                                                                         project
               349     23-Aug-12 installation that cannot be tested by Construction but must be                                                                               23-Aug-12 Did not forward to MSLLC                           23-Aug-12                    Rejected-Close
                                 completed under the Testing program, prior to actual start-testing. 2)                                                                                                                                                management
                                 With unique technology projects, such as MW metal furnace, SME's
                                 and/or vendor should participate with Test Engineer in start-up
                                 testing. 3)Adequate spare parts must be on hand to support start-up
                                 testing.
                                   1. PMW Furnace Design Documentation(Source: User Submitted - ID:          reject -this is a case of inadequate design/engineering
                                   PMLL-2012-Y12-PMW-0610)                                                   processes. FNAL Design and Engineering processes are
               350     23-Aug-12 Two aspects of design documentation need improvement to provide             described in the Fermilab Engineering Manual                     23-Aug-12 Did not forward to MSLLC                           23-Aug-12    engineering     Rejected-Close
                                   maximum value to the project; the Systems Design Description (SDD)
                                   and a formal means of documenting the set points and allowable
                                   ranges for instrumentation.
                                   1. PMW Furnace System Requirements Document (SRD)                   reject -this is a case of inappropriate deisgn information
                                   Development(Source: User Submitted - ID: PMLL-2012-Y12-PMW-0609)    being placed in the system requirements document. FNAL
                                                                                                       Design and Engineering processes as described in the
               351     23-Aug-12 The inclusion of detailed design direction in the Systems Requirement Fermilab Engineering Manual preclude this issue from                   23-Aug-12 Did not forward to MSLLC                           23-Aug-12    engineering     Rejected-Close
                                 Document (SRD) led to unnecessary coordination and revision of of     happening.
                                   testing and verification documentation late in the project.

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                                                                                                                                                       LL Initial Review



              Item #     Date                              2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments                Date               MSLLC or MPLLC Initial Review Comments                  Date      MS/MP (Area) Initial Review Status
                                   1. PMW Small Business Procurement with Teaming Partners & Increased        reject -this is a case of insufficient planning being performed
                                   Reviews ‫(נ‬Source: User Submitted - ID: PMLL-2012-Y12-PMW-0602)             for supplier design review portion of this project.
                                                                                                                                                                                                                                                                         project
               352     23-Aug-12 Additional time for design reviews should be planned for each                                                                                  23-Aug-12 Did not forward to MSLLC                                         23-Aug-12                    Rejected-Close
                                                                                                                                                                                                                                                                       management
                                   organization within each company when small business procurements
                                   team with partners for Design and Quality even if the vendor does not
                                   include the time in their bid schedule.
                                   1. PMW Furnace Vendor Support(Source: User Submitted - ID: PMLL-2012- reject -this is a case of insufficient planning being performed
                                   Y12-PMW-0615)                                                         product installation and test.                                                                                                                                  project
               353     23-Aug-12 Minimal involvement of vendor on-site during installation and start-up                                                                         23-Aug-12 Did not forward to MSLLC                                         23-Aug-12                    Rejected-Close
                                                                                                                                                                                                                                                                       management
                                   testing complicated and lengthened the time required for both
                                   activities.
                                   1. YELLOW - Advanced Test Reactor Emergency Firewater Injection Valves     reject -this is a case of equipment design errors and operator
                                   Failure(Source: User Submitted - ID: INL-BEA-ID-2011-722)                  errors for nuclear power plant equipment that is not present
                                                                                                              at Fermilab
                                 On March 9, 2011, at 1305, during time response testing, the bottom
                                 head Emergency Firewater Injection System (EFIS) level control valves
                                 were observed to undergo catastrophic failure at their yokes. Several
                                 lessons were learned from this event. Any air controlled system where
                                 the maximum inlet pressure to the regulator exceeds the maximum
                                 pressure rating of downstream equipment should have overpressure
               354     24-Aug-12                                                                                                                                                24-Aug-12 Did not forward to MSLLC                                         24-Aug-12       ES&H         Rejected-Close
                                 protection. Pressure regulators should not be set under flow
                                 conditions. When abnormal or unplanned conditions occur during
                                 component testing, proper work control processes (troubleshooting,
                                 document change, work order change) must be used when responding
                                 outside the bounds of the procedure being used. In recovery from a
                                 problem, personnel must consider the proper long term solution to
                                 prevent recurrence and not just a solution (work around) to finish the
                                 work in process.


                                   1. BLUE - Factory Installed Locking Device May Not Provide Positive Control Accept - forwarded to Rafael Coll for processing                             For your information and distribution as you deem necessary.
                                   of Isolation Device Position(Source: User Submitted - ID: INL-BEA-ID-2012-                                                                               See attached photos of the equipment in question.
                                   870)
                                 Examine effectiveness of locking devices when performing a
                                 Lockout/Tagout (LO/TO). At the Idaho National Laboratory, during a
                                 management observation at Space and Security Power Systems
               355     24-Aug-12 Facility (SSPSF), MFC 792A, of the placement of locks and tags for a                                                                           24-Aug-12                                                                  27-Aug-12       ES&H             FYI Only
                                 LO/TO, it was identified by the SSPSF Operators hanging the LO/TO
                                 that the factory installed locking device would not prevent operation
                                 of the valve from the required position. The factory installed locking
                                 device when locked in place had enough movement to allow operation
                                 of the valve while the lock was still applied. Operators did an
                                 outstanding job to examine the effectiveness of factory installed
                                 locking devices when performing LO/TO.
                                   1. YELLOW - Attempts to Keep the Mission Moving Can Result in Potential reject -this is a case of a worker not following documented
                                   Safety System Degradation(Source: User Submitted - ID: 2012-PTX-LL-0401) procedures

                                 Job package procedures must be followed as written to assure the
                                 safety envelope is maintained. -Always remain within the parameters
               356     24-Aug-12 of the scope of work as written in the associated job package and                                                                              24-Aug-12 Did not forward to MSLLC                                         23-Aug-12       ES&H         Rejected-Close
                                 contact a supervisor if there are any questions or potential need to
                                 deviate. -Craft workers must never accept task direction from non-
                                 supervisory crafts personnel. -Managers/supervisors must avoid
                                 placing employees in situations that pose a false sense of urgency.

                                   1. BLUE - Groundwater Sampling Conducted Incorrectly(Source: User          reject -this is a case of human error in transposing 2
                                   Submitted - ID: 2012-PTX-LL-0402)                                          numbers in a spreadsheet



Fermi National Accelerator Laboratory Confidential                                                                                                        5/3/2013                                                                                                                                          Page 59
               357     24-Aug-12                                                                                                                                                24-Aug-12 Did not forward to MSLLC                                         23-Aug-12      quality       Rejected-Close
                                                                                                                                                        LL Initial Review
                                                                                                             reject -this is a case of human error in transposing 2
              Item #     Date                               2012-BNL-Bungee-0001)                            numbers in a spreadsheet Initial Review Comments
                                                                                                                      OQBP LLC (ERV, JFM)                                     Date               MSLLC or MPLLC Initial Review Comments     Date      MS/MP (Area) Initial Review Status
                                 1. In a High Reliability Organization (HRO), supervisors and process
                                 owners never assume processes and control procedures will be
                                 consistently executed as written before thoroughly understanding the
                                 activity through process mapping, barrier analysis, or other
                                 techniques that can help identify and minimize gaps in how the work
               357     24-Aug-12                                                                                                                                            24-Aug-12 Did not forward to MSLLC                            23-Aug-12      quality       Rejected-Close
                                 is actually done. 2. Informal processes that potentially affect safety,
                                 security, quality, or have a business impact should be identified and
                                 managed by formalizing the processes, incorporating the processes
                                 into similar procedures, or discontinuing the informal process. This
                                 supports HRO practice #1, Manage the System, not the Parts, and
                                 practice #2, Reduce Variability in the System.


                                   1. YELLOW - Verify Email Addresses Prior to Sending(Source: User          reject - this is a case of an employee not following
                                   Submitted - ID: 2012-PTX-LL-0408)                                         procedures and ignoring a warning message. In addition, we
                                                                                                             do not have access to unclassified controlled nuclear
               358     28-Aug-12                                                                             documents at Fermilab.                                         28-Aug-12 Did not forward to MSLLC                            28-Aug-12       ES&H         Rejected-Close
                                   Use of one's home/personal email address on the on-site email system
                                   is not recommended. Many email systems assume that one address is
                                   to be used versus another, i.e. home email address versus on-plant
                                   email address.
                                                                                                             accept - forward to Jed Heyes for processing                               Accepted as FYI only
                                 1. GREEN - Independent Review and Validation of Assessments Assures
               359     28-Aug-12 Effectiveness(Source: User Submitted - ID: 2012-PTX-LL-0307)                                                                               28-Aug-12                                                     27-Sep-12      quality           FYI Only
                                   Systematic reviews, feedback, and trending are vital for promoting
                                   organizational improvements.
                                   1. YELLOW - Failure to Identify Hazards Results in Work Being Performed   reject - this Is a case of lack of communication.
                                   without a Lockout/Tagout(Source: User Submitted - ID: 2012-ID-AMWTP-
                                   0010)
                                 When conducting work planning, ensure all involved departments are
                                 included in the work planning process to ensure correct
                                 methods/practices/procedures are applied. On June 10, 2012,
                                 maintenance was performed to replace a broken retaining nut and
               360     28-Aug-12                                                                                                                                            28-Aug-12 Did not forward to MSLLC                            28-Aug-12       ES&H         Rejected-Close
                                 cotter pin on an end effecter of the Northwest Brokk robotic arm
                                 without hazardous energy controls in place. The personnel involved in
                                 planning the work incorrectly applied minor watch station
                                 maintenance and minor adjustments to equipment instead of
                                 performing a walk down and applying a lockout/tagout. This resulted
                                 in a fact finding, the filing of an ORPS report, and the initiation of a
                                 corrective action report (CAR).

                                   1. YELLOW - Golf Cart Tips over after Hitting Cinderblock(Source: User    reject - this Is a case of poor concentration while driving
                                   Submitted - ID: 2012-ID-AMWTP-0011)
                                 When doing routine tasks, remain cognizant and focused on the task
                                 at hand and on changing conditions to aid in accident prevention. An
                                 operator was driving a golf cart along a familiar path and did not
               361     28-Aug-12 recognize that a cinderblock had been re positioned on a candlestick                                                                       28-Aug-12 Did not forward to MSLLC                            28-Aug-12       ES&H         Rejected-Close
                                 holding a boundary rope to prevent it from blowing over in the wind.
                                 The golf cart struck the cinderblock, tipped over, and pinned the
                                 operator's leg and foot to the ground. The incident resulted in a fact
                                 finding, the filing of an ORPS report, and the initiation of a corrective
                                 action report.

                                   1. BLUE - Early Identification of Potential System Weaknesses is Key to   reject - this is a case of poor process planning, design and
                                   Bringing Control to Uncontrolled Processes(Source: User Submitted - ID:   review
                                   2012-RL-HNF-0030)
                                 The introduction of formal control to previously uncontrolled
                                 processes can produce unexpected results. Proposed controls
               362     29-Aug-12 emplaced to correct system weaknesses and potential failure points                                                                         29-Aug-12 Did not forward to MSLLC                            29-Aug-12      Quality       Rejected-Close
                                 must also be analyzed carefully for their potential to cause unexpected
                                 adverse affects. Correcting unexpected results after the process has
                                 been formalized is time consuming, costly, and unfavorably impacts
                                 budgets and schedules.

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                                                                                                                                                       LL Initial Review

              Item #     Date                               2012-BNL-Bungee-0001)                                    OQBP LLC (ERV, JFM) Initial Review Comments                  Date                MSLLC or MPLLC Initial Review Comments                Date      MS/MP (Area) Initial Review Status
                                   1. GREEN - Breathing Tube for 3M GVP Belt-Mounted Powered Air-             Accept - forwarded to Rafael Coll for processing                              Fermilab does not use this model of 3M respirator. David I.
                                   Purifying Respirator Separated from Helmet Clip(Source: User Submitted -                                                                                 Baird, MS, CIH, CSP
                                   ID: G-2012-OR-UCORESHQ-0802)
               363     29-Aug-12 A thorough and timely investigation of a respiratory protective                                                                                29-Aug-12                                                                 4-Sep-12        ES&H         Rejected-Close
                                   equipment anomaly that includes the early involvement of respirator
                                   manufacturer technical specialists improves employee protection and
                                   prevents productivity losses.
                                   1. YELLOW - Necessity of Calling 911 Immediately (Source: User Submitted reject - this is a case of personnel not following documented
                                   - ID: Y-2012-OR-BWY12-0701)                                              procedures andnot using common sense
                                 In the event of a fire, call 911 immediately! Calling 911 immediately
                                 communicates to trained fire response personnel and other
               364     29-Aug-12 emergency responders, the type of fire hazards that could be                                                                                   29-Aug-12 Did not forward to MSLLC                                        29-Aug-12       ES&H         Rejected-Close
                                 encountered upon arrival and the necessary controls needed to
                                 protect themselves and others in the work area and site. Calling 911
                                 also communicates the need to execute procedures to evaluate
                                 fighting fire from unknown materials.
                                   1. YELLOW - Developing and Using Adequate Work Control Documents           reject - this is a case of personnel not following documented
                                   (Source: User Submitted - ID: Y-2012-OR-BWY12-0702)                        procedures.
               365     29-Aug-12 Adequate work control documents must be available and able to be                                                                               29-Aug-12 Did not forward to MSLLC                                        29-Aug-12       ES&H         Rejected-Close
                                   implemented as written, or activities must be suspended/stopped until
                                   adequate work control documents are available.

                                   1. BLUE - Avoiding Problems with Wasps(Source: User Submitted - ID: LL-    reject - this is simply information on what to do if you
                                   2012-LLNL-09)                                                              encounter wasps or wasp nests
               366     30-Aug-12 Various types of wasps are native to many areas and often go                                                                                   30-Aug-12 Did not forward to MSLLC                                        30-Aug-12       ES&H         Rejected-Close
                                   undetected. Wasps can become defensive and even attack when they
                                   or their nests are intruded upon or disturbed.
                                   1. BLUE - Single Task Lead Designation(Source: User Submitted - ID: B-     reject - this is a case of poor project planning and
                                   2012-OR-UCORORNL-0803)                                                     performance

                                   When performing work involving various work groups and multiple
               367     13-Sep-12                                                                                                                                                14-Sep-12 Did not forward to MSLLC                                        30-Aug-12       ES&H         Rejected-Close
                                   craft personnel, a single task lead must be identified as a focal point
                                   to coordinate all work activities to ensure all tasks are understood and
                                   performed in the correct sequence. A pre-job briefing shall be
                                   performed with all personnel involved prior to starting the job.
                                   1. YELLOW - Failure of Material Handling Device Reinforces Need for        reject - this is a case of personnel performing an insufficient
                                   Appropriate Pre-Use Inspections(Source: User Submitted - ID: 2012-ANL-     inspection
                                   010)
                                   It is important to identify, direct, and execute inspections of process
               368     13-Sep-12                                                                                                                                                14-Sep-12 Did not forward to MSLLC                                        30-Aug-12       ES&H         Rejected-Close
                                   critical equipment/components before use. Early identification of the
                                   need for and rigor of inspections guarantees that the appropriate
                                   documentation (such as checklists) is included in work control
                                   documents. As a result, workers become aware and knowledgeable of
                                   specific inspection requirements prior to work commencing.
                                   1. BLUE - Gas Cylinders Tip Over and Strike Worker during Delivery on a    reject - this is a case of personnel not following procedures
                                   Wheeled Cart(Source: User Submitted - ID: 2012 - BNL - Cylinder Fall -
                                   0001)
                                   When moving loads with high center of gravity on wheeled carts, the
               369     13-Sep-12                                                                                                                                                14-Sep-12 Did not forward to MSLLC                                        14-Sep-12       ES&H         Rejected-Close
                                   following should be carefully considered: Be aware of all possible
                                   sources of loss of control including gaps on ramps; uneven surfaces;
                                   slope of travel; caster wheels' alignment; and center of gravity of the
                                   load. Training and procedures should be in place to mitigate potential
                                   hazards and increase worker awareness of hazards.
                                   1. BLUE - Temporary Recovery Actions and Consequences of Changing          reject - this is a case of an inadequate procedure
                                   Conditions(Source: User Submitted - ID: 2012B-LL-LATA-0617)

               370     13-Sep-12 Additional work and potential consequences can be avoided by                                                                                   14-Sep-12 Did not forward to MSLLC                                        14-Sep-12       ES&H         Rejected-Close
                                   recognizing changing conditions and/or assumptions following
                                   completion of temporary recovery actions for an unexpected condition.


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              Item #     Date                              2012-BNL-Bungee-0001)                                     OQBP LLC (ERV, JFM) Initial Review Comments                  Date                 MSLLC or MPLLC Initial Review Comments                 Date      MS/MP (Area) Initial Review Status
                                  1. BLUE - Safety Concern: Occurrences of Crushing Injuries to Operators of accept - forward to Rafael Coll for processing                                 The MSS committee recommends this get accepted as an FYI
                                  Industrial Equipment(Source: User Submitted - ID: HSS OE-3 2012-05)                                                                                       with distribution to supervisors / group leaders in charge of
                                                                                                                                                                                            employees who use this type of industrial equipment.

               371     13-Sep-12 This Operating Experience Level 3 (OE-3) document provides                                                                                     14-Sep-12                                                                   30-Oct-12       ES&H             FYI Only
                                  information about a safety concern related to the dangers of crushing
                                  injuries faced by workers who operate various types of equipment,
                                  including electric carts, skid-steers, and lift equipment.

                                                                                                                accept - forward to Rafael Coll for processing                              This was sent to the IH Subcommittee as an FYI for further
                                  1. BLUE - Filter Cartridge Loss on Powered Air Purifying Respirator(Source:
                                                                                                                                                                                            distribution to their organizations even though we do not
                                  User Submitted - ID: 2012-ID-AMWTP-0013)
                                                                                                                                                                                            have this type of filter.
                                  When performing work, maintain situational awareness to ensure
               372     13-Sep-12 continued safety. An operator who was utilizing a Powered Air                                                                                  14-Sep-12                                                                   26-Oct-12       ES&H             FYI Only
                                  Purifying Respirator (PAPR) thought he noticed a sudden increase in
                                  airflow coming into his hood from the PAPR. The operator then
                                  discovered that the filter cartridge of his PAPR had become dislodged
                                  and had fallen out. This situation resulted in a fact finding.
                                                                                                                accept - forward to Rafael Coll for processing                              Accepted as an FYI by our licensed asbestos abatement
                                                                                                                                                                                            technician.


                                  1. BLUE - Control of Asbestos Hazards during and Post Demolition(Source:
                                  User Submitted - ID: 2012-RL-HNF-0035)




                                 In the demolition of legacy facilities, management of friable and non-
                                 friable asbestos utilizing Alternative Asbestos Control Methods
               373     13-Sep-12 (AACM) standards was stopped on January 12, 2012. On that date,                                                                                14-Sep-12                                                                   17-Sep-12       ES&H             FYI Only
                                 safety concerns were raised through the Stop Work and Employee
                                 Concerns processes. These concerns prompted a closer look at
                                 former demolition sites as well as existing facilities and structures,
                                 including steam lines that may include Presumed Asbestos
                                 Containing Material (PACM). During demolition, and the evaluation
                                 conducted to resolve the concerns, CHPRC gained valuable insight
                                 into demolition of structures containing asbestos and control of
                                 related post-demolition hazards. Thoroughly incorporating this
                                 experience and knowledge into work planning and execution supports
                                 the CHPRC mandate to "continually improve our environmental
                                 performance and reduce our impact on the environment." Pollution-
                                 prevention and safety will be enhanced and compliance with
                                 regulatory requirements will be maintained.
                                  1. BLUE - National Fire Protection Association 70E - Exposed Electrical       reject - this is a case of personnel not following procedures
                                  Conductors(Source: User Submitted - ID: WIPP-LL-2012-02)

               374     21-Sep-12 A defective or failed 120 volt receptacle resulted in the discovery of                                                                         21-Sep-12 Did not forward to MSLLC                                          21-Sep-12       ES&H         Rejected-Close
                                  uncontrolled hazardous energy. Exposed energized electrical
                                  conductors must be put into an electrically safe work condition.

                                  1. BLUE - Safe Practices for Working with Nanomaterials in                    accept - forward to Rafael Coll for processing                              rejected by MSLLC - we do not do nanotechnology research at
                                  Laboratories(Source: User Submitted - ID: HSS OE-3 2012-06)                                                                                               Fermilab




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                                                                                                               accept - forward to Rafael Coll for processing                            rejected by MSLLC - we do not do nanotechnology research at
              Item #     Date                              2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments             Date      Fermilab MSLLC or MPLLC Initial Review Comments                  Date      MS/MP (Area) Initial Review Status
                                 The purpose of this Operating Experience summary is to make the
                                 Department of Energy's (DOE) nanotechnology community aware of a
                                 new publication as it relates to DOE's nanoscale safety policy and
                                 engineered nanoparticles requirements. In June 2012, the National
                                 Institute for Occupational Safety and Health (NIOSH) released General
                                 Safe Practices for Working with Engineered Nanomaterials in
                                 Research Laboratories, Department of Health and Human Services
                                 (HHS), NIOSH, Publication Number 2012-147. By means of this
               375     21-Sep-12                                                                                                                                             21-Sep-12                                                                  21-Sep-12       ES&H         Rejected-Close
                                 document, NIOSH seeks to raise awareness of the occupational safety
                                 and health practices that should be followed during the synthesis,
                                 characterization, and experimentation with engineered nanomaterials
                                 in laboratories and some pilot scale operatio ns. The publication
                                 opens with NIOSH noting the growing body of evidence indicating that
                                 exposure to some engineered nanomaterials can cause adverse health
                                 effects. It continues with several relatively short sections dealing with
                                 risk management, hazard identification, and exposure assessment of
                                 nanomaterials. The remainder of the document addresses
                                 nanomaterial risk management program elements such as methods of
                                 controlling exposure in research laboratories andat LANL(Source: User reject - these LLS pertain to excavation of radioactive waste
                                 1. BLUE - Lessons Learned from ARRA/D&D Projects methods for
                                   Submitted - ID: 2012-LASO-LANL-LA-UR-12-24668)                              and are not pertinenet to Fermilab

                                 Several Lessons were learned while executing D&D and ARRA
                                 projects at LANL. These include: -Spend more effort up front to better
                                 characterize landfills; -The older the landfill and the less investigation,
               376     21-Sep-12 the more MR and contingency; -Keep the public and all stakeholders                                                                          21-Sep-12 Did not forward to MSLLC                                         21-Sep-12       ES&H         Rejected-Close
                                 well informed; -Hose application of dust suppressants, while generally
                                 effective, frequently challenges SWPPP features to control runoff from
                                 the site; -Promote use of mister technologies in future D&D projects; -
                                 Embrace use of oversized (D&D) equipment in future procurements
                                 and demolition plans, drawings, etc. to assure robust stand-off
                                 distances.

                                 1. BLUE - Inspect Chemical Gloves Prior to Use (Source: User Submitted -      accept - forward to Rafael Coll for processing                            rejected by MSLLC - this is already part of our training
               377     21-Sep-12 ID: 2012-ANL-011)                                                                                                                           21-Sep-12                                                                  21-Sep-12       ES&H         Rejected-Close
                                   Reusable chemical gloves must be inspected for integrity before each
                                   use and replaced regularly.
                                   1. YELLOW - LLNL Conference Room Chair Fails Unexpectedly(Source: User accept - forward to Rafael Coll for processing                                 rejected by MSLLC - investigation found only 1 Haworth chair
                                   Submitted - ID: LL-2012-LLNL-10)                                                                                                                      at Fermilab and it was not the models cited in the LL
               378     26-Sep-12                                                                                                                                             1-Oct-12                                                                   5-Oct-12        ES&H         Rejected-Close
                                   LLNL recently experienced an incident in which a key backrest
                                   component of a chair used in a conference room broke while an
                                   employee was sitting on the chair
                                                                                                            reject - the conditions cited in the LL are not present at                   did not forward toMS LLC
                                   1. BLUE - Commuting - Lessons Learned(Source: User Submitted - ID: WIPP-
                                                                                                            Fermilab; Fermilab ES&H generates reminders of winter
                                   LL-2012-03)
                                                                                                            driving hazards
               379     26-Sep-12                                                                                                                                             26-Sep-12                                                                  26-Sep-12       ES&H         Rejected-Close
                                   Driving to and from work can be one of the most hazardous activities
                                   that an employee encounters. Reminding employees of defensive
                                   driving techniques can help avoid traffic accidents and injuries.
                                   1. YELLOW - Lessons Learned to Reduce Exposure to Diesel Fumes from         reject - we do not use the type of dust reduction equipment               did not forward toMS LLC
                                   Dust Suppression Trucks (Source: User Submitted - ID: 2012-LANL-MDA B-      descrbed in this lesson learned at Fermilab
                                   08112011)
               380     26-Sep-12 When applying dust suppression (water spray), be aware of the                                                                               26-Sep-12                                                                  26-Sep-12       ES&H         Rejected-Close
                                   proximity of truck exhaust to workers. Ensure workers are at a safe
                                   distance from the exhaust through use of longer hoses or run the
                                   vehicle only when actively spraying.
                                   1. YELLOW - False Non-Load Bearing Wall Falls at TA-21-209(Source: User     accept - forward to Rafael Coll for processing                            Rejected. Not applicable to Fermilab construction or
                                   Submitted - ID: 2012-LANL-DPWEST-2010-0003)                                                                                                           demolition operations.


               381 26-Sep-12                                                                                                                                                 26-Sep-12                                                                  26-Sep-12       ES&H         Rejected-Close
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                                                                                                               accept - forward to Rafael Coll for processing                               Rejected. Not applicable to Fermilab construction or
              Item #     Date                              2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments                Date                MSLLC or MPLLC Initial Review Comments
                                                                                                                                                                                            demolition operations.                                            Date      MS/MP (Area) Initial Review Status
                                 Ceiling mounted false or partial walls or structures need to be
                                 removed or evaluated for safety of design before allowing work
               381     26-Sep-12 activities underneath the structure/s. False or partial wall structures                                                                        26-Sep-12                                                                   26-Sep-12       ES&H         Rejected-Close
                                 may be as-found legacy conditions or resultant of
                                 demolition/construction activities. The structure/s may appear stable
                                 and adequately attached to the ceiling. Concurrent
                                 demolition/construction activities can lead to degradation of these
                                 walls/structures.
                                  1. YELLOW - Sub-Surface Investigation and Engineering Drawings Did Not       reject - this is a case where a contractor did not perform the               did not forward to MS LLC
                                  Identify Water Line in Work Area(Source: User Submitted - ID: 2012-ID-       requested procedure and where out of date drawings were
                                  AMWTP-0014)                                                                  used.
                                 Accurate engineering drawings and proper performance of a sub-
                                 surface investigation are necessary to ensure that contact with
                                 underground utilities and structures are avoided. Sub-surface
               382     27-Sep-12 investigations need to be independent of drawings identifying utilities                                                                        27-Sep-12                                                                   27-Sep-12       ES&H         Rejected-Close
                                 or structures to ensure an adequate investigation is conducted
                                 without a pre-conceived notion by the operator resulting in inaccurate
                                 perceptions of the conditions. Inaccurate drawings and an inadequate
                                 sub-surface investigation resulted in a water line being broken during
                                 excavation. This resulted in a fact finding, the filing of an ORPS report,
                                 and a Corrective Action Report (CAR).

                                  1. YELLOW - Special Training Required to Operate Electrical Circuit          accept - forward to Rafael Coll for processing                               Rejected. The Electrical Safety Subcommittee already made a
                                  Breakers at BNL (Source: User Submitted - ID: 2012-BNL-circuit-0012)                                                                                      determination last month regarding the operation of a circuit
                                                                                                                                                                                            breakers with covers on.
               383     5-Oct-12   To avoid potential serious injury, employees at Brookhaven National                                                                           5-Oct-12                                                                    5-Oct-12        ES&H         Rejected-Close
                                  Laboratory (BNL) may not reset circuit breakers without the proper
                                  training or personal protective equipment. This occurred in a non-
                                  industrial setting (the Main Gate Trailer) at a readily accessible
                                  breaker panel.
                                  1. BLUE - The Invalidation of One Safety Basis Assumption May Have          reject - this is a case of human error in the updating of risk                did not forward to MS LLC
                                  "Cascading" Effects on Other Safety Basis(Source: User Submitted - ID: INL- documentation
                                  BEA-ID-2012-960)
               384     5-Oct-12   The invalidation of one Safety Basis assumption (a change in the                                                                              10/5/212                                                                    5-Oct-12        ES&H         Rejected-Close
                                  probability for clad fuel failure) had a "cascading" effect resulting in a
                                  Potential Inadequacy in the Safety Analysis Reasonability
                                  Determination (PISA RD) and a positive Unreviewed Safety Question
                                  (USQ).
                                  1. BLUE - Evaluation of Safety Basis Documentation(Source: User              reject - this is a case of poor communication and not                        did not forward toMS LLC
                                  Submitted - ID: INL-BEA-ID-2012-954)                                         following documented procedures

               385     5-Oct-12   The invalidation of one assumption may cause the invalidation of                                                                              10/5/212                                                                    5-Oct-12        ES&H         Rejected-Close
                                  other assumptions in safety basis documents. When Nuclear Facilities
                                  transition from one program to another, assumptions in the Safety
                                  Basis Documentation should be evaluated for authentication/validation
                                  1. BLUE - Inadequately Performed Unreviewed Safety Question (USQ)            reject - this is a case of both not following and inadequately               did not forward to MS LLC
                                  Evaluation Results in Related Subsequent USQ(Source: User Submitted -        following documented procedures.
                                  ID: INL-BEA-ID-2011-664)
                                  Ensure personnel that routinely conduct, review, and approve USQ
                                  evaluations fully understand their responsibility to and importance of
                                  identifying all safety basis issues that are related to an in-process
               386     5-Oct-12   evaluation, i.e., ensure all applicable safety basis documents (e.g.,
                                                                                                                                                                                10/5/212                                                                    5-Oct-12        ES&H         Rejected-Close
                                  Documented Safety Analysis, Safety Analysis Report, basis for interim
                                  operation, technical safety requirements, etc.) are addressed in the
                                  evaluation. An inadequately performed USQ evaluation resulted in an
                                  incomplete evaluation of the situation. Less than adequate USQ
                                  evaluations potentially could leave a facility's operations or
                                  configuration outside the safety basis
                                  1. YELLOW - Incident with Powder Actuated Fastening Tool(Source: User        accept - forward to Rafael Coll for processing                               Accepted by MS LLC as FYI only - he will forward to S3
                                  Submitted - ID: 2012-PPPL-0001)                                                                                                                           subcommittee chair, task managers and contsruction
                                                                                                                                                                                            coordinators
               387    12-Oct-12                                                                                                                                                 12-Oct-12                                                                   12-Oct-12       ES&H             FYI Only
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                                                                                                               accept - forward to Rafael Coll for processing                                 Accepted by MS LLC as FYI only - he will forward to S3
              Item #     Date                               2012-BNL-Bungee-0001)                                      OQBP LLC (ERV, JFM) Initial Review Comments                  Date               MSLLC or task managers and Comments
                                                                                                                                                                                              subcommittee chair,MPLLC Initial Reviewcontsruction                Date      MS/MP (Area) Initial Review Status
                                 Powder actuated tools used to fasten roof decking have the potential                                                                                         coordinators
               387     12-Oct-12 to cause fasteners to penetrate roof decking and ceiling tiles, which                                                                            12-Oct-12                                                                    12-Oct-12       ES&H             FYI Only
                                 could injure people working below. Proper selection of such tools,
                                 training for their use and maintenance, and understanding of hazards
                                 is essential for their safe use.
                                   1. YELLOW - Eye Protection(Source: User Submitted - ID: 2012-SPR-DM-        accept - forward to Rafael Coll for processing                               Rejected. We do not have these tanks in our property. Also,
                                   BM-0007)                                                                                                                                                 this shows poor work planning without consideration of the
               388     12-Oct-12                                                                                                                                                  12-Oct-12 by products of the grind.                                          12-Oct-12       ES&H         Rejected-Close
                                   A foreign object can be forced into the eye when using an air                                                                                            It is obvious that if you have debris and an air current blowing
                                   ventilator during the process of grinding an anchor plate.                                                                                               in your direction, the debris will get airborne.
                                   1. BLUE - Unexpected Discovery of an Underground Electrical Line(Source:    accept - forward to Rafael Coll for processing                               Rejected - we have a GPS system to mark exactly where
                                   User Submitted - ID: B-2012-FBPORTS-1002)                                                                                                                utilities are found that were not shown in engineering
                                                                                                                                                                                            drawings. New utilities are likewise located and entered into
               389     12-Oct-12                                                                                                                                                  12-Oct-12 as builts drawings with the exact location. Additionally,          12-Oct-12       ES&H         Rejected-Close
                                   Management needs to clearly define, and document via written                                                                                             photos are taken and made part of the record before trenches
                                   procedure, expectations for the transfer of information between
                                                                                                                                                                                            and excavations are closed. Our procedures also prevent this
                                   organizations, especially that which is used to safeguard workers in
                                   an industrial hazard environment
                                                                                                                                                                                            type of incident.
                                   1. BLUE - Exposure to1,2-dichloroethane from Eye Splash (Source: User       reject - this is a case of lack of a procedure and failure to                  did not forward to MS LLC
                                   Submitted - ID: 2012-ANL-012)                                               wear PPE when required
                                 It is imperative to acknowledge the differing stages and/or status of
                                 equipment and operations required to perform Research &
                                 Development activities. Setup, operations, data collection,
               390     12-Oct-12 disassembly and diagnostics, as specific examples of stages, can                                                                                 12-Oct-12                                                                    12-Oct-12       ES&H         Rejected-Close
                                 present specific hazard sets that require separate control sets for
                                 those various stages. Hazard analysis and the application of
                                 appropriate control sets for each stage are necessary. Just as
                                 important is recognition and awareness of those performing the work
                                 of which stage and control set applies for those activities.
                                   1. BLUE - Mishandling Hazardous Chemicals Led to Methanol Spill and         reject - this is a case of not following documented procedures                 did not forward to MS LLC
                                   Exposure (Source: User Submitted - ID: 2012-ANL-013)
                                   It is important to recognize and adhere to all of the controls identified
               391     17-Oct-12 for work activities. Just as important is the recognition that changes                                                                           17-Oct-12                                                                    17-Oct-12       ES&H         Rejected-Close
                                   in methods and means that may appear to be menial tasks can greatly
                                   increase the risk by introducing new hazards that could be performed
                                   without appropriate controls.
                                   1. BLUE - Exposure to Toluene from Eye Splash (Source: User Submitted -     reject - this is a case of an ineffective procedure and a safety               did not forward to MS LLC
                                   ID: 2012-ANL-014)                                                           analysis that was incomplete relative to PPE
                                 Work planning and control processes need to contain appropriate
                                 hazard analysis and implementation of controls regarding potential
               392     17-Oct-12 residual chemicals that are introduced for maintenance and/or rinsing                                                                            17-Oct-12                                                                    17-Oct-12       ES&H         Rejected-Close
                                 evolutions. These controls can consist of processes or practices that
                                 negate the possibility of exposure to the rinse solutions prior to re-
                                 assembly or additional PPE during assembly to prevent potential
                                 exposure, or a combination.

                                   1. BLUE - Fire System Inspections (Source: User Submitted - ID: WIPP-LL-    accept - forward to Rafael Coll for processing                               Rejected. We already have a system in place to inspect fire
                                   2012-04)                                                                                                                                                 protection systems. This is our HPR inspections conducted by
                                   Including the fire protection engineer to participate in fire system                                                                                     the Fire Protection Engineer. This is a scheduled inspection,
               393     17-Oct-12 engineer walkdowns can enhance the detection of system non-                                                                                      17-Oct-12                                                                    12-Oct-12       ES&H         Rejected-Close
                                                                                                                                                                                            the frequency and report formats which are mandated by
                                   compliances or impairments.                                                                                                                              DOE Orders. Actually our program was copied by other labs

                                                                                                               reject - this is a case of reminding personnel to follow                       did not forward to MS LLC
                                   1. YELLOW - Radiography Processes and Procedures for Erecting and
                                                                                                               procedures
                                   Monitoring(Source: User Submitted - ID: 24590-WTP-LL-MGT-12-0028)


               394     17-Oct-12                                                                                                                                                  17-Oct-12                                                                    17-Oct-12       ES&H         Rejected-Close

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                                                                                                                reject - this is a case of reminding personnel to follow
                                                                                                                                                          LL Initial Review                 did not forward to MS LLC
                                                                                                                procedures
              Item #     Date                               2012-BNL-Bungee-0001)                                        OQBP LLC (ERV, JFM) Initial Review Comments              Date                MSLLC or MPLLC Initial Review Comments                   Date      MS/MP (Area) Initial Review Status
                                   The improper setup or management of Radiation warning signs and
               394     17-Oct-12 barricades can result in unnecessary radiation hazard to affected                                                                              17-Oct-12                                                                    17-Oct-12       ES&H         Rejected-Close
                                   personnel. The purpose for displaying the radiological tape/rope and
                                   signage is to keep unauthorized or untrained personnel who come
                                   across a barricaded area from entering it. Radiation warning signs and
                                   barricades are placed around work areas undergoing radiographic
                                   examination for personnel protection.
                                   1. YELLOW - Crane Tip during Routine Maintenance(Source: User                reject - this is a case of lack of training                                 did not forward to MS LLC
                                   Submitted - ID: 2012-RLHNF-0034)
                                 Previous experience applied to different equipment, led to the tip-over
                                 of a Grove truck mounted crane at Hanford. Required training for
                                 crane mechanics provided the necessary knowledge and skills
                                 necessary to perform load chart calculations and familiarize
                                 mechanics with the equipment. However, the mechanic had not
               395     18-Oct-12 completed the training prior to performing the work and management                                                                             18-Oct-12                                                                    18-Oct-12       ES&H         Rejected-Close
                                 was unaware that the worker was not sufficiently trained to perform
                                 the work. Organizational changes coupled with unclear and complex
                                 training requirements can lead to inadvertent miss-assigned work
                                 activities. New management must be diligent to review employee
                                 training requirements to identify gaps and prevent an unwanted
                                 outcome. Workers should be wary of incorporating past practices
                                 when working on a different equipment

                                   1. BLUE - Inspectors Enter Confined Space without Proper Training or         reject - this is a case of ineffective posting of a confined                did not forward to MS LLC
                                   Monitoring (Non-reportable)(Source: User Submitted - ID: 2012-BNL-           space.
                                   confined space-0001)
               396     18-Oct-12 Employees who may encounter confined spaces in their work must be                                                                              18-Oct-12                                                                    18-Oct-12       ES&H         Rejected-Close
                                   cautious about confined space issues even if there is no placard or
                                   other indication that confined space requirements apply. Employees
                                   should verify that a space is not a confined space if there is any doubt
                                   about its status.
                                   1. YELLOW - Excessive Liquid in Waste Drum(Source: User Submitted - ID:      reject - the subject matter waste drums are not applicable at               did not forward to MS LLC
                                   Y-2012-FBPORTS-1004)                                                         Fermilab
               397     24-Oct-12 Waste generated and packaged for storage and disposal by prior                                                                                 24-Oct-12                                                                    24-Oct-12       ES&H         Rejected-Close
                                   contractors to Fluor B&W (FBP) shall be fully certified by Waste
                                   Certification organization before shipment to off-site vendor or
                                   disposal.
                                   1. YELLOW - Chemical Operator's Skin Contamination and Acid                  accept - forward to Rafael Coll for processing                              Even though there are no lessons learned, the chair of the IH
                                   Burn(Source: User Submitted - ID: Y-2012-FBPORTS-1001)                                                                                                   subcommittee will distribute to the IH committee members as
                                 Pre-operational, personal protective equipment (PPE) and Pre-Job
                                                                                                                                                                                            an FYI.
                                 Brief (PJB) reviews must be completed for all evolutions of a task
               398     24-Oct-12 being performed to ensure that all safety-related controls are included                                                                        24-Oct-12                                                                    24-Oct-12       ES&H             FYI Only
                                 for the purpose of precluding the recurrence of undesirable outcomes.
                                 However, the best protection for any worker is self awareness and a
                                 questioning attitude to ensure proper protection is always being
                                 utilized.
                                   1. BLUE - Container Falls Off Pallet during Movement (Source: User           reject - this was a matter of not following documented                      did not forward to MS LLC
                                   Submitted - ID: L-2012-OR-BWY12-0901)                                        procedures
               399     24-Oct-12                                                                                                                                                24-Oct-12                                                                    24-Oct-12       ES&H         Rejected-Close
                                   All palletized drum container loads should be secured before
                                   transport with a fork truck to minimize the risk of any drums falling off
                                   1. BLUE - Tank Farms - Identification of Onsite Contamination Outside of a   reject - this was a matter of not following documented                      did not forward to MS LLC
                                   Controlled Area(Source: User Submitted - ID: 2012-SR-SRR-0002)               procedures

                                   Maintaining a questioning attitude, in addition to identifying,
               400     25-Oct-12 reporting, and correcting potential problems, are principles of a                                                                              2-Oct-12                                                                     25-Oct-12       ES&H         Rejected-Close
                                   strong nuclear safety culture environment. This event demonstrates
                                   how one individual's questioning attitude, decision to use a Time Out,
                                   and self-reporting prevented the further spread of contamination.

                                   1. BLUE - Incompatible Greases Used In Motor Bearing Lubrication(Source: accept - forward to Rafael Coll for processing                                  Rejected- not a LL. Not in the realm of Safety but more in the
                                   User Submitted - ID: 2012-SR-SRNS-0013)                                                                                                                  technical area of the trades.

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               401    25-Oct-12                                                                                                                                                 25-Oct-12                                                                    25-Oct-12       ES&H         Rejected-Close
                                                                                                                                                          LL Initial Review
                                                                                                               accept - forward to Rafael Coll for processing                                Rejected- not a LL. Not in the realm of Safety but more in the
              Item #     Date                              2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments                 Date                MSLLC or trades.
                                                                                                                                                                                             technical area of theMPLLC Initial Review Comments                 Date      MS/MP (Area) Initial Review Status
                                  Lack of knowledge/inexperience led to the application of incompatible
               401     25-Oct-12 greases within a Safety Significant (SS) electrical motor bearing.                                                                              25-Oct-12                                                                    25-Oct-12       ES&H         Rejected-Close
                                  During a subsequent lubrication preventive maintenance (PM), after
                                  the System Engineer exhibited a questioning attitude and utilized a
                                  timeout after identifying the different colors of grease, work was
                                  stopped until a path forward could be established.
                                 1. YELLOW - Contact with Heavy Equipment Dislodges Hard Hat(Source:           reject - this was a matter developing and implementing an                     did not forward to MS LLC
               402     25-Oct-12 User Submitted - ID: 2012Y-LL-LATA-0678)                                      unsafe procedure                                                  25-Oct-12                                                                    25-Oct-12       ES&H         Rejected-Close
                                  Change in work practice resulted in the grapple of an excavator
                                  making contact with an Operator's hard hat
                                  1. BLUE - Severed Underground De-energized Electrical Street Lighting   Rejected - we have a GPS system to mark exactly where                              did not forward to MS LLC
                                  Cable(Source: User Submitted - ID: 2012-ANL-015)                        utilities are found that were not shown in engineering
                                 Buried electrical line legacy documents may not be always accurate.      drawings. New utilities are likewise located and entered into
               403     25-Oct-12 Locating instruments may only give a best guess as to the location       as builts drawings with the exact location. Additionally,              25-Oct-12                                                                    25-Oct-12       ES&H         Rejected-Close
                                 and depending on physical makeup it may be missed completely. As a photos are taken and made part of the record before
                                 result, procedures for locating buried electrical lines are improved and
                                                                                                          trenches and excavations are closed. Our procedures also
                                 updated.
                                                                                                          prevent this type of incident.
                                  1. YELLOW - Vehicles and Safety(Source: User Submitted - ID: LL-2012-        reject - this is simply a case of staying alert when walking in               did not forward to MS LLC
                                  LLNL-13)                                                                     a parking lot or on a street
                                  Quiet vehicles, hybrids operated at low speeds and electric vehicles,
               404     26-Oct-12 are increasingly common among the general population and even                                                                                   26-Oct-12                                                                    26-Oct-12       ES&H         Rejected-Close
                                  more so at DOE sites. These vehicles present an identifiable and
                                  familiar potential hazard that lacks some of the indicators people use
                                  to sense that they are in use.
                                  1. YELLOW - The Hazards of Falling Objects Around Negative                   reject - this is a case of failure to identify a job hazard                   did not forward to MS LLC
                                  Elevation/Below Grade Work Areas(Source: User Submitted - ID: INL-BEA-
                                  ID-2012-0943)
                                  An evaluation to address the potential hazards of unsecured objects
                                  staged or stored too close to a negative elevation work area is critical
               405     1-Nov-12                                                                                                                                                  1-Nov-12                                                                     1-Nov-12        ES&H         Rejected-Close
                                  to personnel safety. Prior to the start of operational activities adjacent
                                  or near below grade work areas, personnel must perform
                                  housekeeping checks to mitigate the potential hazard of falling
                                  objects. In addition, it must be noted that allowing multiple jobs to be
                                  worked in the same area can create hazards not originally identified
                                  and mitigated for by the hazards analysis process.
                                  1. GREEN - Green River Wet Well Entry(Source: User Submitted - ID: 2013- reject - there is no lessons learned here - this is an example                    did not forward to MS LLC
                                  The Crescent Crew completed a successful wet well entry at the Green of a successful use of integrated safety planning
                                  MB-001)
                                  River pump station in order to perform required maintenance nearly 40
                                  feet below ground, adjacent to a running river, and which was
                                  accomplished for the first time on the project as a double entry into a
                                  confined space. The Crescent Disposal Cell operates a 21 mile long 6
                                  inch diameter water supply line which runs from the Green River to an
                                  onsite construction pond, supplying water for moisture content
                                  balance in placing residual radioactive material. The Green River
               406     1-Nov-12   pump station has a 40 foot deep wet well that extends below the water                                                                          1-Nov-12                                                                     1-Nov-12        ES&H         Rejected-Close
                                  table associated with the adjacent river level. The vertical shaft is 8
                                  feet in diameter, used to collect river water for pumping, and must be
                                  entered at times for maintenance. A series of four previous wet well
                                  entries had already been completed at this location and the process
                                  continuously improved over the course of a few years. This most
                                  recent entry required a crew of two to descend 40 feet into the bottom
                                  of the wet well, while two dedicated attendants were posted at the top
                                  for support; and perform a non-entry extraction if necessary. Previous
                                  entries had contained a crew of one, but this heavy pipe gasket repair
                                  required a crew of two. The Crescent Crew credits their successful
                                  1. BLUE - Controlling Exposure to Hazardous Energy while Performing          reject - this was a matter of not following documented                        did not forward to MS LLC
                                  Servicing and Maintenance vs. Demolition or Construction(Source: User        procedures
                                  Submitted - ID: INL-BEA-ID-2012-0926)

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               407     1-Nov-12                                                                                                                                                  1-Nov-12                                                                     1-Nov-12        ES&H         Rejected-Close
                                                                                                                                                         LL Initial Review




                                                                                                                reject - this was a matter of not following documented                     did not forward to MS LLC
                                                                                                                procedures
              Item #     Date                               2012-BNL-Bungee-0001)                                        OQBP LLC (ERV, JFM) Initial Review Comments             Date               MSLLC or MPLLC Initial Review Comments                   Date      MS/MP (Area) Initial Review Status
                                  Disconnecting energy sources to create an "air gap" is never an
                                  acceptable substitute for lockout/tagout (LO/TO) for performing
                                  servicing or maintenance of systems, equipment, or components.
               407     1-Nov-12   Recent LO/TO issues have involved the utilization of an "air gap" to                                                                          1-Nov-12                                                                   1-Nov-12        ES&H         Rejected-Close
                                  remove a hazard from a work area rather than use LO/TO, or to justify
                                  why a LO/TO was not required. Application of LO/TO to mitigate
                                  potential hazardous energy sources during the performance of
                                  servicing and maintenance will protect the worker from the
                                  unexpected energization or startup of the system, equipment, or
                                  component upon which the work is being performed.

                                  1. YELLOW - An Energized Conductor was Cut during D&D                         accept - forward to Rafael Coll for processing                             Rejected. We have seen this lesson many times. Nothing new
                                  Activities(Source: User Submitted - ID: INL-BEA-ID-2012-948)                                                                                             to learn that we do not already know
                                  While performing D&D in support of the floor installation at the Zero
               408     1-Nov-12   Power Physics Reactor (ZPPR) facility, subcontractor personnel cut an                                                                         1-Nov-12                                                                   1-Nov-12        ES&H         Rejected-Close
                                  energized conductor. The conductors were located in the ZPPR Cell
                                  Pit and all indications were that these conductors were isolated from
                                  electrical energy sources (air gapped) from a previous 2009 D&D
                                  activity.
                                  1. BLUE - Two Separate, and Similar Life Safety Systems Operational           reject - this is a case of not following procedures and human              did not forward to MS LLC
                                  Incidents Indicate Human Performance Issue Trend(Source: User                 error
                                  Submitted - ID: INL-BEA-ID-2012-940)
               409     2-Nov-12 It is important to maintain a questioning attitude and situational                                                                              2-Nov-12                                                                   2-Nov-12        ES&H         Rejected-Close
                                  awareness while performing work tasks, specifically routine/frequently
                                  performed procedures. Complacency and over-confidence can
                                  contribute to operational errors.
                                  1. BLUE - Ensure Controls are Provided for Critical Steps to Ensure Effective reject - this is a case of insufficient documentation of                   did not forward to MS LLC
                                  Communication between Groups(Source: User Submitted - ID: 24590-WTP- procedures
                                  LL-MGT-12-0033)
                                  Establish clear directions in work instructions that adequately
                                  implement and record completion of critical activities, particularly
               410     2-Nov-12   when multiple organizations are involved in the execution of a task.                                                                          2-Nov-12                                                                   2-Nov-12        ES&H         Rejected-Close
                                  During a quarterly verification of temporary modifications, four
                                  temporary modifications were found to be installed without the
                                  associated documentation completed and issued. This resulted in
                                  energized equipment that was not documented for lockout/tagout and
                                  configuration management purposes.

                                  1. BLUE - Observer Sees Something-Says Something About At-Risk                reject - this is a case of not following documented                        did not forward to MS LLC
                                  Behavior - Improvements for Procedure Knowledge and Work                      procedures.
                                  Planning(Source: User Submitted - ID: 2012-SR-SRNS-0014)
                                  A person not involved with the job observed possible at-risk behavior
                                  and alerted the Area Safety Engineer - actively participating in the See
                                  Something-Say Something Safety Approach. Lessons Learned Our
               411     6-Nov-12   process of communicating and reinforcing site procedure changes is                                                                            6-Nov-12                                                                   6-Nov-12        ES&H         Rejected-Close
                                  not always adequate. We have to develop a re-enforcement process to
                                  ensure people understand new requirements that apply to their work
                                  scope when procedures are revised. In addition, this event highlights
                                  the need for the planner to perform field walkdowns so they have a
                                  clear understanding of the work scope and associated hazards. Other
                                  Positives from This Incident

                                  1. BLUE - Recent Glovebox Glove Breaches(Source: User Submitted - ID:         accept - forward to Rafael Coll for processing                             Accepted as an FYI and passed to our SSOs. We have a few glove boxes in the Laboratory.
                                  2012-SR-SRNS-0015)




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               412     6-Nov-12                                                                                                                                                 6-Nov-12                                                                  11-Dec-12        ES&H             FYI Only
                                                                                                                                                          LL Initial Review

                                                                                                                accept - forward to Rafael Coll for processing                              Accepted as an FYI and passed to our SSOs. We have a few glove boxes in the Laboratory.
              Item #     Date                               2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments               Date               MSLLC or MPLLC Initial Review Comments                  Date       MS/MP (Area) Initial Review Status
                                   A series of glovebox glove breaches has occurred within SRNL and a
                                   number have resulted in contamination of glovebox worker personal
                                   protective equipment . Glovebox gloves should not be considered
                                   personal protective equipment. Their primary function is for providing
                                   glovebox containment. It is important to protect the soft polymer of
                                   the glovebox glove from sharps, abrasions and chemicals. Major
               412     6-Nov-12    emphasis has always been placed on handling "sharps" however,                                                                                6-Nov-12                                                                    11-Dec-12     ES&H              FYI Only
                                   there are many other contributors that will result in a "breached"
                                   glovebox glove. Directly handling abrasive components such as
                                   ceramic bricks, "knurled" equipment and rusted components will lead
                                   to excessive glovebox polymer degradation. These events reaffirmed
                                   the importance of self-monitoring upon exiting a glovebox and the
                                   proper protection of the glovebox glove from sharps, abrasions,
                                   striking hard objects and chemicals.


                                   1. GREEN - Full-Scale Emergency Management Exercise Performed                reject - Not applicable since Fermilab does not conduct "full               did not forward to MS LLC
                                   Efficiently by Using Color-Coded Master Scenario Events List(Source: User    scale exercises"
                                   Submitted - ID: 2012-ANL-016)
                                   Emergency management exercise documentation such as the Master
               413     6-Nov-12 Scenario Events List (MSEL) needs to be "user-friendly" so that                                                                                 6-Nov-12                                                                    6-Nov-12      ES&H           Rejected-Close
                                   controllers can guide the exercise as efficiently as possible using the
                                   documentation provided. The Color-Coded MSEL was determined to
                                   be used to easily differentiate MSEL activities for each participating
                                   department or agency.
                                   1. YELLOW - Skid Steer Operator Injury Incident(Source: User Submitted -     reject -this is a case of personnel not following procedures                did not forward to MS LLC
                                   ID: 2012-PPPL-0002)
               414     6-Nov-12 Workers, supervisors, senior managers and support groups must                                                                                   6-Nov-12                                                                    6-Nov-12      ES&H           Rejected-Close
                                   maintain comprehensive awareness of hazards of powered equipment,
                                   and apply the tenets of Integrated Safety Management (ISM) to all
                                   aspects of these machines.
                                   1. GREEN - Questioning Attitude with Respect to Unexpected                   reject -there is no lesson learned here                                     did not forward to MS LLC
                                   Conditions(Source: User Submitted - ID: TWPC-LLI-2012-09-001)
               415     20-Nov-12 When confronted with an unexpected condition personnel should                                                                                  20-Nov-12                                                                   20-Nov-12     ES&H           Rejected-Close
                                   initiate a "Timeout" to determine if continuation of activities could
                                   result in less than desirable outcome, i.e., procedure violation.

                                                                                                                accept - forward to Rafael Coll for processing                              Sent as an FYI to SSOs for Distribution within their
                                   1. YELLOW - Nitric Acid Spill(Source: User Submitted - ID: Y-2012-FBPORTS-
                                                                                                                                                                                            organizations. No further actions needed. This was taken as
                                   1101)
                                                                                                                                                                                            an FYI by the EP subcommittee.
                                   Handle hazardous laboratory liquids in a manner to prevent spills due
               416     20-Nov-12 to breakage of the container. Highly hazardous, acidic, and caustic                                                                            20-Nov-12                                                                   20-Nov-12     ES&H              FYI Only
                                   reagents can be purchased in glass containers. If these glass
                                   containers are not safety-coated, netted, or handled in secondary
                                   containers, the reagent can cause personnel injury (e.g. acid burn)
                                   upon breaking.
                                   1. YELLOW - Routine Operations Lead to Near Miss(Source: User                reject -there is no lesson learned here - there was no                      did not forward to MS LLC
                                   Submitted - ID: Y-2012-FBPORTS-1003)                                         determination made as to how or why the valve fell to the
                                   Even routine operations that have been performed numerous times              floor
               417     20-Nov-12 before and may appear to be low risk could pose a significant                                                                                  20-Nov-12                                                                   20-Nov-12     ES&H           Rejected-Close
                                   potential hazard. Incomplete identification of potential hazards may
                                   cause insufficient planning, controls, and oversight.

                                   1. RED - Product Safety Alert - Fire Hazard - Dynasen Power Supplies to be   accept - forward to Rafael Coll for processing                            Advise if any group uses this type of power supply. If your
                                   Removed from Service(Source: User Submitted - ID: LL-2012-LLNL-14)                                                                                     group does, follow the steps under “actions” and follow up
                                                                                                                                                                                          with your supplier and the manufacturer regarding
               418     20-Nov-12                                                                                                                                                20-Nov-12 disposition. Advise originator if any are found at Fermilab and   11-Dec-12     ES&H            Fully Accept-
                                                                                                                                                                                          disposition of the power supply. Include John Martzel (
                                   The LLNL Authority having Jurisdiction (AHJ) revoked all approvals                                                                                     martzel@fnal.gov ) as an info addressee in any
                                   for use of Dynasen Model CK2-50 power supplies at LLNL until this                                                                                      correspondence regarding this RED.
                                   concern is resolved.


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                                                                                                                                                        LL Initial Review

              Item #     Date                              2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments                  Date                MSLLC or MPLLC Initial Review Comments     Date      MS/MP (Area) Initial Review Status
                                                                                                              reject -this is a case of failing to follow procedures, incorrect               did not forward to MS LLC
                                  1. BLUE - Misunderstanding of Proper Wiring Configuration during
                                                                                                              labelling, and missing labelling
                                  Maintenance Activity Results in Incomplete Safety Interlock Control of
                                  Radiation Hazard (Source: User Submitted - ID: 2012 - BNL- UED - 0001)

                                 During a routine electrical maintenance activity, due to lack of
                                 standardization of power source wiring for safety interlocks, one part
                                 of a two part redundant radiation safety interlock system was not
               419     26-Nov-12 properly re-installed to maintain redundant protection. Maintaining                                                                              26-Nov-12                                                      26-Nov-12       ES&H         Rejected-Close
                                 constant control of the systems and processes needed to operate a
                                 complex accelerator facility is a challenge. Under the broad title of
                                 "configuration control" comes requirements for defining and
                                 maintaining shielding, hardware, documentation, procedures,
                                 recordkeeping, worker qualification and most other elements needed
                                 for safe, reliable operations. The importance of these programs is well
                                 respected and established, but still errors are made and unintended
                                 consequences result.
                                  1. YELLOW - Insufficient Training and Supervision Lead to Cavity Window     reject -this is a case of failing to follow procedures, and a                   did not forward to MS LLC
                                  Failure(Source: User Submitted - ID: JLabCOE376)                            lack of training
                                  Supervisors should treat training requirements for students the same
               420     26-Nov-12 as employees performing similar tasks. Supervisors should review all                                                                             26-Nov-12                                                      26-Nov-12       ES&H         Rejected-Close
                                  tasks performed by students at the same level as that of full time
                                  employees performing similar tasks. Communicate all task hazards to
                                  everyone working in an area. Supervisors are to ensure all workers in
                                  the area don appropriate PPE in accordance with the hazard issues.
                                  1. BLUE - Inconsistent Land Survey Methods(Source: User Submitted - ID:     reject -this is a case of survey data becoming corrupted                        did not forward to MS LLC
                                  2012-NV-NNSS-479)
                                  Standardized survey methodology must be identified during the
               421     26-Nov-12 planning phase of a project. During data collection for as-built                                                                                 26-Nov-12                                                      26-Nov-12       ES&H         Rejected-Close
                                  drawings of a soil cover over radiologically contaminated piping,
                                  inconsistencies were identified that required additional work to be
                                  performed to complete the project.
                                  1. Clearly Defined Roles, Responsibilities, and Authorities are Important reject -this is a case of failing to follow basic project                         did not forward to MS LLC
                                  Even for Small Non-Line Item Projects(Source: User Submitted - ID: PMLL-  management procedures of defining and communicating
                                  2012-Y12-OTH-0902)                                                        roles, responsibilities, and design requirements to sub                                                                                            project
               422     4-Dec-12   Roles, responsibilities, and authorities need to be clearly defined early contractors.                                                          4-Dec-12                                                       4-Dec-12                     Rejected-Close
                                                                                                                                                                                                                                                             management
                                  in the project planning process and flowed down in contract language
                                  when executing federally managed small business task order
                                  design/build construction projects
                                  1. Fully Developed Technical Performance Baseline Important Even for     reject -this is a case of poor definition of project scope and                     did not forward to MS LLC
                                  Small Non-Line Item Projects(Source: User Submitted - ID: PMLL-2012-Y12- acceptance criteria prior to contract signing
                                  OTH-0903)                                                                                                                                                                                                                    project
               423     4-Dec-12   The lack of a fully developed technical performance baseline for a                                                                              4-Dec-12                                                       4-Dec-12                     Rejected-Close
                                                                                                                                                                                                                                                             management
                                  direct federal small business task order design/build construction
                                  contract led to challenges during project execution (design,
                                  construction, test, and turnover).
                                  1. Small Business Task Order Design-Build Procurement/Contract              reject -this is a case of poor sub-contractor evaluation                        did not forward to MS LLC
                                  Challenges on a Small Non-Line Item Project(Source: User Submitted - ID:    resulting in a sub-contractor that was not qualified to build
                                  PMLL-2012-Y12-OTH-0904)                                                     the requested product.                                                                                                                           project
               424     4-Dec-12                                                                                                                                                   4-Dec-12                                                       4-Dec-12                     Rejected-Close
                                  Federal procurement/contract administration challenges were                                                                                                                                                                management
                                  encountered both pre- and post-award for a direct federal small
                                  business task order design/build contract.
                                  1. Need to Apply Tailored DOE Order 413.3B Principles to Small Non-Line     reject -this is a case of failing to follow project management                  did not forward to MS LLC
                                  Item Projects(Source: User Submitted - ID: PMLL-2012-Y12-OTH-0905)          procedures of risk management, integrated sub-contractor
                                                                                                              scheduling, and change control                                                                                                                   project
               425     4-Dec-12                                                                                                                                                   4-Dec-12                                                       4-Dec-12                     Rejected-Close
                                  It is important to appropriately tailor DOE Order 413.3B principles                                                                                                                                                        management
                                  even for low risk non-line item projects such as general plant projects.

                                  1. Inclusion of Construction Contracting and Contracting Officer in IPT     reject - this positive lessons learned is simply to hold regular                did not forward to MS LLC
                                  Meeting Facilitated Issue Resolution(Source: User Submitted - ID: PMLL-     meetings with all project stakeholders. This is a basic project
                                  2012-Y12-OTH-0906)                                                          management action.
                                                                                                                                                                                                                                                               project
               426     4-Dec-12
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                                                                                                                                                                                                                                                             management
                                                                                                                                                       LL Initial Review




                                                                                                              reject - this positive lessons learned is simply to hold regular               did not forward to MS LLC
                                                                                                              meetings with all project stakeholders. This is a basic project
              Item #     Date                               2012-BNL-Bungee-0001)                             management action. JFM) Initial Review Comments
                                                                                                                       OQBP LLC (ERV,                                              Date               MSLLC or MPLLC Initial Review Comments     Date      MS/MP (Area) Initial Review Status
                                   Inclusion of key stakeholders (especially the fixed price construction                                                                                                                                                    project
               426     4-Dec-12    contractor(s) and the contracting officer) in routine Integrated Project                                                                      4-Dec-12                                                      4-Dec-12                    Rejected-Close
                                                                                                                                                                                                                                                           management
                                   Team (IPT) meetings for a federally managed small business task
                                   order design/build construction project reduces project risk and
                                   promotes effective communications.

                                   1. BLUE - Excavator Contacts Overhead Electrical Line(Source: User         reject -this is a case of a person not performing their work                   did not forward to MS LLC
                                   Submitted - ID: B-2012-FBPORTS-1103)                                       task.
                                 Use a dedicated spotter when moving heavy construction equipment
                                 near or under overhead lines or obstructions with equipment capable
               427     11-Dec-12 of entering required clearance limitations or contacting an                                                                                     11-Dec-12                                                     11-Dec-12       ES&H         Rejected-Close
                                 obstruction. The use of high profile heavy construction equipment
                                 near overhead lines or obstructions may result in an unsafe condition.
                                 The use of a non-dedicated spotter resulted in the near-miss at Fluor-
                                 B&W Portsmouth as described below.
                                   1. YELLOW - Unsafe Elevated Work Practices(Source: User Submitted - ID:    reject -these are cases of persons not performing their work                   did not forward to MS LLC
                                   Y-2012-OR-BWY12-0802)                                                      tasks according to established procedures.
               428     11-Dec-12 Consistent practice of requirements for Aerial Lifts, Fall Protection                                                                           11-Dec-12                                                     11-Dec-12       ES&H         Rejected-Close
                                   and Personal Protective Equipment (PPE) are necessary for
                                   performing work in a safe and effective manner.
                                   1. BLUE - Inadvertent Disturbance of Asbestos Containing Material -        reject -this is a case of an incomplete hazard analysis being                  did not forward to MS LLC
                                   Emphasizes Hazard Identification and Questioning Attitude(Source: User     performed.
                                   Submitted - ID: 2012-SR-SRNS-0016)
                                   Thorough field walkdowns and hazard identification with a
               429     12-Dec-12 questioning attitude should be performed for every work task. When                                                                              12-Dec-12                                                     12-Dec-12       ES&H         Rejected-Close
                                   existing conditions (such as standing water or dirt) prevent a
                                   complete review/inspection of an area where work will be performed,
                                   efforts should be made to further inspect the area once those
                                   conditions have been addressed.
                                   1. BLUE - Reactor Process and Disassembly Area Waste Characterization      reject -this is a case of human error during peer review of                    did not forward to MS LLC
                                   Revision - Limiting Distractions during Peer Checks(Source: User Submitted documents
                                   - ID: 2012-SR-SRNS-0017)
               430     12-Dec-12 There should be limited interruptions and distractions during                                                                                   12-Dec-12                                                     12-Dec-12       ES&H         Rejected-Close
                                   preparation and peer review of technical documents. Also personnel
                                   performing peer reviews should review documents with a questioning
                                   attitude and with the thought that "there is an error and I have to find
                                   it".
                                                                                                              reject -this is a case of not following documented procedures                  did not forward to MS LLC
                                   1. BLUE - Tank 21 High Liquid Level Conductivity Probe Not Set/Installed
                                   Properly(Source: User Submitted - ID: 2012-SR-SRR-0003)

                                   Acceptance criteria in procedures should be written and formatted
               431     12-Dec-12 clearly so there is no ambiguity which could lead to potential errors. In                                                                       12-Dec-12                                                     12-Dec-12       ES&H         Rejected-Close
                                   this event the procedural acceptance criteria in determining proper
                                   High Liquid Level Conductivity Probe (HLLCP) probe installation was
                                   less than adequate. A second causal factor was the quality of the
                                   video used in determining proper HLLCP probe installation was less
                                   than adequate.
                                   1. YELLOW - Vendor Contact with Energized Electrical Wire - Emphasized     reject -this is a case of human error - not using the correct                  did not forward to MS LLC
                                   Second Independent Review of Work Packages(Source: User Submitted -        drawings in performing hazard analysis
                                   ID: 2012-SR-SRR-0004)




               432     12-Dec-12                                                                                                                                                 12-Dec-12                                                     12-Dec-12       ES&H         Rejected-Close

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                                                                                                                                                        LL Initial Review
                                                                                                               reject -this is a case of human error - not using the correct               did not forward to MS LLC
                                                                                                               drawings in performing hazard analysis
              Item #     Date                               2012-BNL-Bungee-0001)                                       OQBP LLC (ERV, JFM) Initial Review Comments              Date                MSLLC or MPLLC Initial Review Comments                  Date      MS/MP (Area) Initial Review Status
                                 Use a second independent review of work packages containing
                                 electrical lock outs to prevent single point approval failures. The
                                 Facility's relevant controlled drawings should always be reviewed
                                 during the approval process. In this event a hazardous energy source
               432     12-Dec-12 was not identified during preparation and approval of a work package                                                                          12-Dec-12                                                                   12-Dec-12       ES&H         Rejected-Close
                                 for vendor use in repairing an air compressor controller. Savannah
                                 River Remediation (SRR) has implemented additional controls, above
                                 and beyond those required by Site Manual 8Q, Procedure 32, to ensure
                                 certain types of lockouts receive a second independent review by a
                                 reviewer authorized by SRR. These additional controls were extended
                                 to subcontract technical representative (STR) initiated vendor work as
                                 one of the corrective actions.
                                 1. BLUE - Heavy Equipment Maintenance and/or Fueling "Do Not Operate" accepted -forwarded to Rafael Coll for processing                                   Rejected. Not applicable here. Our heavy equipment is not
                                 Process and Controls(Source: User Submitted - ID: B-2012-OR-                                                                                              fueled by contractors but by the operator.
               433     12-Dec-12 UCOREMWMF-1101)                                                                                                                               12-Dec-12                                                                   12-Dec-12       ES&H         Rejected-Close
                                   Lack of positive control when fueling and/or servicing of heavy
                                   equipment can result in injury to personnel.
                                   1. YELLOW - Follow Approved Activity Level Work Document (Source: User reject -this is a case of not following documented procedures                    did not forward to MS LLC
                                   Submitted - ID: 2012-NV-NNSS-468)
                                   Experience and discipline expertise do not take precedence over
               434     13-Dec-12 management approved Activity Level Work Document (ALWDs). The                                                                                 13-Dec-12                                                                   13-Dec-12    engineering     Rejected-Close
                                   approved work package/procedure is the only acceptable direction
                                   applicable to any work performed on a DOE/NNSA/NNSS system.

                                 1. GREEN - Implementation of Procedure Case History File                      reject -Fermilab does not have procedure case history files                 did not forward to MS LLC
                                                                                                                                                                                                                                                                         project
               435     13-Dec-12 Checklist(Source: User Submitted - ID: 2012-NV-NNSS-466)                                                                                      13-Dec-12                                                                   13-Dec-12                    Rejected-Close
                                   Develop a mechanism to determine if a quality check has been                                                                                                                                                                        management
                                   conducted to ensure authentication requirements are met.
                                   1. YELLOW - Spill of Nitric Acid on Decontamination Building Roof(Source:   reject -this is a case of not following documented procedures               did not forward to MS LLC
                                   User Submitted - ID: Y-2012-FBPORTS-1201)
                                   Continuous process safety vigilance, attention to detail, and
               436     13-Dec-12 adherence to the elements of an effective Conduct of Operations                                                                               13-Dec-12                                                                   13-Dec-12       ES&H         Rejected-Close
                                   Program are the organizational tools that should be used to prevent or
                                   mitigate the results of failures in equipment, processes, and personnel
                                   decision-making
                                   1. BLUE - Importance of Conduct of Operations and Training for Effective   reject -this is a case of not following documented procedures                did not forward to MS LLC
                                   Criticality Safety Programs(Source: User Submitted - ID: HSS OE-3 2012-07)
               437     13-Dec-12                                                                                                                                               13-Dec-12                                                                   13-Dec-12       ES&H         Rejected-Close
                                   This Operating Experience Level 3 (OE-3) document provides
                                   information on criticality safety concerns manifested through
                                   deficiencies in associated training and conduct of operations.
                                                                                                               accepted -forwarded to Rafael Coll for processing                           Task managers - FYI- Please read and consider in your project
                                   1. YELLOW - Employee Brushed by Flatbed Truck (Source: User Submitted -
                                                                                                                                                                                           planning and Ha’s. No additional actions necessary.
                                   ID: LBNL-LL12-0055)
                                   Traffic flaggers should always position their control station in a
               438     13-Dec-12                                                                                                                                               14-Dec-12                                                                   14-Dec-12       ES&H             FYI Only
                                   location that provides a rapid and unobstructed escape route. Work
                                   planning and control for flagging activities should include
                                   establishing a proper control zone or deferring work to a time when
                                   the roadway is less congested.
                                   1. YELLOW - Work was Not Performed in Accordance with the Work              reject -this is a case of not following documented procedures               did not forward to MS LLC
                                   Control Process.(Source: User Submitted - ID: CWI-ICP-2012-06)
               439     21-Dec-12                                                                                                                                               21-Dec-12                                                                   21-Dec-12       ES&H         Rejected-Close
                                   Questioning attitude identifies failure to implement work control
                                   process/rework of nonconforming item.
                                   1. BLUE - Naturally Occurring Radioactive Material Identified on Non-         accepted -forwarded to Rafael Coll for processing                         rejected as not applicable at Fermilab
                                   radiologically Controlled Ventilation Intake Filters(Source: User Submitted -
                                    ID: 2012-ID-AMWTP-0015)



Fermi National Accelerator Laboratory Confidential                                                                                                          5/3/2013                                                                                                                                        Page 72
                                                                                                             accepted -forwarded to Rafael Coll for processing                            rejected as not applicable at Fermilab
                                                                                                                                                     LL Initial Review
              Item #     Date                              2012-BNL-Bungee-0001)                                     OQBP LLC (ERV, JFM) Initial Review Comments                Date                MSLLC or MPLLC Initial Review Comments     Date      MS/MP (Area) Initial Review Status

                                 Waste with the potential of Naturally Occurring Radioactive Material
                                 (NORM) or man-made radioactive contamination should be surveyed
                                 at the generator location to ensure it meets the waste acceptance
                                 criteria of the proposed disposal site prior to shipment, and further
                                 isotopic analysis should be conducted if contamination is detected.
                                 Waste generators should confirm the waste can be accepted at the
               440     21-Dec-12 proposed disposal site prior to shipment. On 9-25-2012 at                                                                                    21-Dec-12                                                      21-Dec-12       ES&H           Rejected-Close
                                 approximately 1630, the Advanced Mixed Waste Treatment Project,
                                 operated by Idaho Treatment Group LLC, was informed that ventilation
                                 filters which had originated from the Advanced Mixed Waste
                                 Treatment Facility (AMWTF) had been discovered to have beta/g amma
                                 contamination when surveyed at the Idaho National Laboratory's (INL)
                                 Central Facilities Area (CFA) landfill. This resulted in AMWTP
                                 recovering the filters from the landfill and retaining the filters for
                                 radioactive decay and subsequent disposal. A local requirement to
                                 perform radiological surveys on non-radiological ventilation filters
                                 which could concentrate NORM/TENORM isotopes was instituted.
                                  1. YELLOW - Near Miss: Lathe Operations Result in Flying Projectile(Source: reject -this is a case of not following documented procedures               did not forward to MS LLC
                                  User Submitted - ID: BNL-Lathe-2012-0001)
                                  Extreme care must be exercised when engaging a lathe drive
               441     21-Dec-12 mechanism at high RPM with an unsupported tube extending from the                                                                            21-Dec-12                                                      21-Dec-12       ES&H           Rejected-Close
                                  rear of the headstock. The rotational momentum can cause the tube to
                                  deform and strike the worker or nearby object.




                                                                                                                                                                                                                                                            ES&H            Rejected-Close
                                                                                                                                                                                                                                                            Quality       Awaiting LLC Review
                                                                                                                                                                                                                                                         Project Mgmt     Awaiting SME Review

                                                                                                                                                                                                                                                         Cyber Security        On Hold
                                                                                                                                                                                                                                                           Physical          Fully Accept-
                                                                                                                                                                                                                                                           Security       Action Plan Needed

Fermi National Accelerator Laboratory Confidential                                                                                                       5/3/2013                                                                                                                               Page 73
                                                                                                          LL Initial Review




              Item #     Date                        2012-BNL-Bungee-0001)   OQBP LLC (ERV, JFM) Initial Review Comments      Date   MSLLC or MPLLC Initial Review Comments   Date   MS/MP (Area) Initial Review Status
                                                                                                                                                                                      Engineering         FYI Only
                                                                                                                                                                                                   Conditionally Accept-
                                                                                                                                                                                      Operations
                                                                                                                                                                                                    Action Plan Needed
                                                                                                                                                                                     Information
                                                                                                                                                                                                   Awaiting OQBP Review
                                                                                                                                                                                      Technology
                                                                                                                                                                                                   Another System Covers
                                                                                                                                                                                        Science
                                                                                                                                                                                                        This - Closed
                                                                                                                                                                                        Site LLC




Fermi National Accelerator Laboratory Confidential                                                           5/3/2013                                                                                                      Page 74
                                                                        LL Initial Review


                                                     Notes or Comments
                                                     HSS LL system notification was changed and
                                                     email at Fermilab was having a problem. No
                                                     error messages were visible.

                                                     Problem with email was discovered late in
                                                     February 2011. Notification emails were
                                                     restored early March 2011.

                                                     Efforts will be made as time and resources
                                                     permit to go back and review these lessons.




Fermi National Accelerator Laboratory Confidential                          5/3/2013               Page 75
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 76
                                                                     LL Initial Review


                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 77
                                                                     LL Initial Review
                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 78
                                                                     LL Initial Review
                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 79
                                                                     LL Initial Review
                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 80
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 81
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 82
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 83
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 84
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 85
                                                                     LL Initial Review


                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 86
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 87
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 88
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 89
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 90
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 91
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 92
                                                                     LL Initial Review
                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 93
                                                                         LL Initial Review




                                                     Notes or Comments




                                                     05/18/11 Sent late notification




Fermi National Accelerator Laboratory Confidential                          5/3/2013         Page 94
                                                                         LL Initial Review




                                                     Notes or Comments




                                                     Late sending things out due to conversion to
                                                     Office 2010 an windows 7. Several days of
                                                     different computer problems, especially
                                                     with email.




Fermi National Accelerator Laboratory Confidential                          5/3/2013                Page 95
                                                     with email.

                                                                          LL Initial Review

                                                     Notes or Comments




                                                     ERV (URS support for OQBP) out of the
                                                     office and staffing level does not allow a
                                                     back-up within OQBP.




Fermi National Accelerator Laboratory Confidential                           5/3/2013             Page 96
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 97
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 98
                                                                          LL Initial Review




                                                     Notes or Comments




                                                     05/31/11 - Sent the following comments
                                                     from ES&H to PG:
                                                     RColl comments: the issue of single line
                                                     drawings is being dealt with by the ESS. We
                                                     have an AdHoc group meeting tomorrow to
                                                     discuss how to go forward with SLEDs. have
                                                     Dr. Garbincius touch base with Mike Utes
                                                     (Chair ESS) to avoid duplicating efforts.




                                                     06/08/11 ERV suggestion: ...forward to
                                                     Nancy to see if there is any interest, even if
                                                     it is longer term.

                                                     Remember, things can be put with an
                                                     extended date for evaluation. I just need a
                                                     date for a return response from this longer
                                                     evaluation.
Fermi National Accelerator Laboratory Confidential                           5/3/2013                 Page 99
                                                     Or, if you have some way as a group, ES&H,
                                                     to capture items for future work (like a
                                                                           LL Initial Review


                                                     06/08/11 ERV suggestion: ...forward to
                                                     Nancy to see if there is any interest, even if
                                                     it is longer term.
                                                     Notes or Comments

                                                     Remember, things can be put with an
                                                     extended date for evaluation. I just need a
                                                     date for a return response from this longer
                                                     evaluation.

                                                     Or, if you have some way as a group, ES&H,
                                                     to capture items for future work (like a
                                                     “parking lot” list), putting in your list of “to-
                                                     dos” is an acceptable answer too.

                                                     08/24/11 - Notes in red are from a random
                                                     revaluation/validity check to verify original
                                                     decisions were valid and to see if something
                                                     would or should change.




                                                     08/24/11 - Notes in red are from a random
                                                     revaluation/validity check to verify original
                                                     decisions were valid and to see if something
                                                     would or should change.




                                                     08/24/11 - Notes in red are from a random
                                                     revaluation/validity check to verify original
                                                     decisions were valid and to see if something
                                                     would or should change.




                                                     08/24/11 - Notes in red are from a random
                                                     revaluation/validity check to verify original
                                                     decisions were valid and to see if something
                                                     would or should change.


Fermi National Accelerator Laboratory Confidential                             5/3/2013                  Page 100
                                                                         LL Initial Review
                                                     08/24/11 - Notes in red are from a random
                                                     revaluation/validity
                                                     Notes or Commentscheck to verify original
                                                     decisions were valid and to see if something
                                                     would or should change.




                                                     08/24/11 - Notes in red are from a random
                                                     revaluation/validity check to verify original
                                                     decisions were valid and to see if something
                                                     would or should change.




                                                     08/24/11 - Notes in red are from a random
                                                     revaluation/validity check to verify original
                                                     decisions were valid and to see if something
                                                     would or should change.




Fermi National Accelerator Laboratory Confidential                          5/3/2013                 Page 101
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 102
                                                                       LL Initial Review

                                                     Notes or Comments




                                                     07/12/11 - Sent reminder to ES&H LLC



                                                     07/12/11 - Sent reminder to ES&H LLC




                                                     07/12/11 - Sent reminder to ES&H LLC




                                                     07/12/11 - Sent reminder to ES&H LLC




                                                     07/12/11 - Sent reminder to ES&H LLC




Fermi National Accelerator Laboratory Confidential                         5/3/2013         Page 103
                                                                          LL Initial Review
                                                     Notes or Comments




                                                     Also, Don Cossairt (Radcon) for review.

                                                     ERV response to closure: I am closing this
                                                     lesson as requested. However I am
                                                     concerned that I did not make myself clear.
                                                     I was looking at a specific, more general
                                                     portion of the issue being raised
                                                     surrounding part of the causes found and
                                                     did realize this was a nuclear facility. As
                                                     noted in my previous comments shown
                                                     below, I was considering or asking about
                                                     “walk-though” audits and what was done to
                                                     ensure things were not missed and closed:
                                                     My previous comments:
                                                     Reject, fyi, or do something else? I realize
                                                     this is about a nuclear fire suppression
                                                     system. However, in looking at this lesson
                                                     in a broader context, I was wondering if
                                                     Fermilab has some sort of standard
                                                     checklist(s) for “walk-through” surveillances
                                                     and/or tests or any other means to prevent
                                                     things being missed and ensure review and
                                                     closure.
                                                     I want to be sure we did not throw this
                                                     lesson out when there maybe something of
                                                     value if we looked in a more general context.




                                                     Also, sent this to Bruce Chrisman
                                                     (Operations) and Don Cossairt (Radcon) for
                                                     review.

                                                     Rafael sent to Jim Priest, Senior Fire
                                                     Strategist, for review




Fermi National Accelerator Laboratory Confidential                           5/3/2013                Page 104
                                                                        LL Initial Review

                                                     Notes or Comments




                                                     Also copied Don Cossairt.




Fermi National Accelerator Laboratory Confidential                          5/3/2013        Page 105
                                                                        LL Initial Review

                                                     Notes or Comments




                                                     Also copied Don Cossairt.




Fermi National Accelerator Laboratory Confidential                          5/3/2013        Page 106
                                                                        LL Initial Review

                                                     Notes or Comments




                                                     08/16/11 Sent reminder to Randy.




                                                     08/12/11: Talked to Rafael to remind him.
                                                     08/16/11: Sent reminder to Rafael.
                                                     08/16/11: Rafael sent previous email to
                                                     close. Do not know why original email did
                                                     not get to my account.




Fermi National Accelerator Laboratory Confidential                         5/3/2013              Page 107
                                                                        LL Initial Review



                                                     Notes or Comments




                                                     08/29/11 - Sent follow-up message to
                                                     Rafael, LLC.




Fermi National Accelerator Laboratory Confidential                         5/3/2013         Page 108
                                                     08/29/11 - Sent follow-up message to
                                                                          LL Initial Review
                                                     Rafael, LLC.
                                                     Notes or Comments




                                                     I cannot access or receive lesson from the
                                                     HSS db on Security. Another person had to
                                                     pull and forward them. Thus, this lesson
                                                     was late being evaluated.

                                                     I cannot access or receive lesson from the
                                                     HSS db on Security. Another person had to
                                                     pull and forward them. Thus, this lesson
                                                     was late being evaluated.


                                                     I cannot access or receive lesson from the
                                                     HSS db on Security. Another person had to
                                                     pull and forward them. Thus, this lesson
                                                     was late being evaluated.




                                                     I cannot access or receive lesson from the
                                                     HSS db on Security. Another person had to
                                                     pull and forward them. Thus, this lesson
                                                     was late being evaluated.




                                                     I cannot access or receive lesson from the
                                                     HSS db on Security. Another person had to
                                                     pull and forward them. Thus, this lesson
                                                     was late being evaluated.
                                                     I cannot access or receive lesson from the
                                                     HSS db on Security. Another person had to
                                                     pull and forward them. Thus, this lesson
Fermi National Accelerator Laboratory Confidential                           5/3/2013
                                                     was late being evaluated.                    Page 109
                                                                        LL Initial Review

                                                     I cannot access or receive lesson from the
                                                     HSS db on Security.
                                                     Notes or Comments Another person had to
                                                     pull and forward them. Thus, this lesson
                                                     was late being evaluated.




                                                     I cannot access or receive lesson from the
                                                     HSS db on Security. Another person had to
                                                     pull and forward them. Thus, this lesson
                                                     was late being evaluated.

                                                     08/29/11 - Sent a follow-up message to
                                                     Ron, Cyber LLC.




                                                     09/13/11 Resent to LLC; a record of the
                                                     their review and response could not be
                                                     found.




                                                     09/13/11 Resent to LLC; a record of the
                                                     their review and response could not be
                                                     found.


                                                     09/13/11 Resent to LLC; a record of the
                                                     their review and response could not be
                                                     found.




                                                     09/13/11 Resent to LLC; a record of the
                                                     their review and response could not be
                                                     found.




                                                     09/13/11 Resent to LLC; a record of the
                                                     their review and response could not be
                                                     found.

Fermi National Accelerator Laboratory Confidential                          5/3/2013              Page 110
                                                                         LL Initial Review
                                                     09/13/11 Resent to LLC; a record of the
                                                     their review and response could not be
                                                     Notes or Comments
                                                     found.




                                                     09/13/11 Resent to LLC; a record of the
                                                     their review and response could not be
                                                     found.




                                                     09/13/11 Resent to LLC; a record of the
                                                     their review and response could not be
                                                     found.




                                                     DOE website was not responding on original
                                                     day this lesson was sent.



                                                     DOE website was not responding on original
                                                     day this lesson was sent.




                                                     DOE website was not responding on original
                                                     day this lesson was sent.




                                                     DOE website was not responding on original
                                                     day this lesson was sent.
Fermi National Accelerator Laboratory Confidential                          5/3/2013              Page 111
                                                                        LL Initial Review

                                                     DOE website was not
                                                     Notes or Comments responding on original
                                                     day this lesson was sent.




                                                     DOE website was not responding on original
                                                     day this lesson was sent.


                                                     DOE website was not responding on original
                                                     day this lesson was sent.


                                                     DOE website was not responding on original
                                                     day this lesson was sent.




                                                     DOE website was not responding on original
                                                     day this lesson was sent.




                                                     DOE website was not responding on original
                                                     day this lesson was sent.




                                                     DOE website was not responding on original
                                                     day this lesson was sent.




Fermi National Accelerator Laboratory Confidential                         5/3/2013               Page 112
                                                                        LL Initial Review


                                                     Notes or Comments
                                                     DOE website was not responding on original
                                                     day this lesson was sent.


                                                     DOE website was not responding on original
                                                     day this lesson was sent.




                                                     DOE website was not responding on original
                                                     day this lesson was sent.




                                                     DOE website was not responding on original
                                                     day this lesson was sent.




                                                     DOE website was not responding on original
                                                     day this lesson was sent.




                                                     DOE website was not responding on original
                                                     day this lesson was sent.




                                                     09/20/11- Sent to Operations LLC for review
                                                     per ES&H LLC.


Fermi National Accelerator Laboratory Confidential                         5/3/2013                Page 113
                                                                         LL Initial Review




                                                     09/20/11- Sent to Operations LLC for review
                                                     per ES&H LLC.
                                                     Notes or Comments




                                                     09/20/11 - Also, copied Engineering LLC.




Fermi National Accelerator Laboratory Confidential                          5/3/2013               Page 114
                                                                         LL Initial Review




                                                     09/20/11 - Also, copied Engineering LLC.
                                                     Notes or Comments




                                                     This could also be Cyber-security.




Fermi National Accelerator Laboratory Confidential                          5/3/2013            Page 115
                                                                        LL Initial Review



                                                     Notes or Comments
                                                     09/20/11- Sent to Operations LLC for review
                                                     per ES&H LLC.




                                                     09/20/11- Sent to Operations LLC for review




Fermi National Accelerator Laboratory Confidential                         5/3/2013                Page 116
                                                                        LL Initial Review
                                                     09/20/11- Sent to Operations LLC for review
                                                     Notes or Comments




                                                                                                   JM LL
                                                                                                   admin
                                                                                                   starts
                                                                                                   here
                                                     closed 5/29/2012




Fermi National Accelerator Laboratory Confidential                         5/3/2013                         Page 117
                                                                     LL Initial Review



                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 118
                                                                         LL Initial Review

                                                     Notes or Comments
                                                     ACTION PLAN: We have made an inventory
                                                     of all large battery systems at Fermilab and
                                                     have gathered maintenance contractors'
                                                     methods of hazard mitigation and a draft
                                                     report to the DOE committee inquiring
                                                     about this is complete. Closed.




Fermi National Accelerator Laboratory Confidential                           5/3/2013               Page 119
                                                                        LL Initial Review



                                                     Notes or Comments




                                                                       Closed




                                                                       Closed




                                                     Closed




                                                     5/15/12: Close the LL with the explanation
                                                     given below:                    Our
                                                     program between FESHM and training cover
                                                     all aspects.
Fermi National Accelerator Laboratory Confidential                          5/3/2013              Page 120
                                                     Regards,
                                                                        LL Initial Review


                                                     5/15/12: Close the LL with the explanation
                                                     Notesbelow:
                                                     given or Comments               Our
                                                     program between FESHM and training cover
                                                     all aspects.

                                                     Regards,

                                                     Rafael




Fermi National Accelerator Laboratory Confidential                         5/3/2013               Page 121
                                                                     LL Initial Review
                                                     Notes or Comments




                                                                     closed




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 122
                                                                     LL Initial Review
                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 123
                                                                       LL Initial Review
                                                     Notes or Comments
                                                                     closed




                                                                       closed




                                                     discussed with Kathy Graden who stated
                                                     that we do not and never have shipped
                                                     anything to NNSA




Fermi National Accelerator Laboratory Confidential                         5/3/2013           Page 124
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 125
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 126
                                                                         LL Initial Review
                                                     Notes or Comments




                                                     The LL is rejected. The basis for this
                                                     rejection is: “Fermilab's system already
                                                     exceeds what is being recommended”. Jerry
                                                     Grant




                                                       closure is late because the original notice
                                                      from HSS to MSLLC failed with no warning
                                                                         message
Fermi National Accelerator Laboratory Confidential                           5/3/2013                Page 127
                                                       closure is late because the original notice
                                                      from HSS to MSLLCLL Initial Review
                                                                           failed with no warning
                                                     Notes or Comments   message




                                                     this is the same problem as itme 263 (ID:
                                                     2012-BNL-LOTO- 0005) above




                                                     Fermilab’s Fire Department does not use
                                                     Draeger SCBAs. Regardless as a FYI, I am
                                                     forwarding this information to Larry Meyer
                                                     with this email.




Fermi National Accelerator Laboratory Confidential                           5/3/2013                Page 128
                                                                     LL Initial Review


                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 129
                                                                     LL Initial Review



                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 130
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 131
                                                                     LL Initial Review
                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 132
                                                                     LL Initial Review



                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 133
                                                                         LL Initial Review
                                                     Notes or Comments




                                                     This one is late because the initial email
                                                     from HSS to MSLLC failed with no warning
                                                     message




Fermi National Accelerator Laboratory Confidential                          5/3/2013              Page 134
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 135
                                                                          LL Initial Review




                                                     Notes or Comments




                                                     Our asbestos manager is trained and
                                                     licensed in the State of Illinois. The asbestos
                                                     contractor is similarly licensed for this type
                                                     of work. Facilities are evaluated by our
                                                     asbestos inspector and when in doubt tests
                                                     are performed. He also personally overseas
                                                     all work that the contractor does.




Fermi National Accelerator Laboratory Confidential                            5/3/2013                 Page 136
                                                                     LL Initial Review



                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 137
                                                                     LL Initial Review


                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 138
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 139
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 140
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 141
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 142
                                                                     LL Initial Review


                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 143
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 144
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 145
                                                                     LL Initial Review



                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 146
                                                                     LL Initial Review

                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 147
                                                                     LL Initial Review




                                                     Notes or Comments




Fermi National Accelerator Laboratory Confidential                       5/3/2013        Page 148

				
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