Lesson Learned Statement:Some work permit jobs require several service providers or trades phased over a period of time. For jobs like this, the original work permit should be split into multiple work permits to keep the hazards, work controls, and pre-job briefing information well organized by job phase or job crew. The multiple work permits can utilize the original work permit number with suffix letters (A, B, C, etc.) attached for tracking purposes
At the Brookhaven National Laboratory (BNL),a moderate-rated work permit was issued for a work request to clean up and secure a building that had been vacated for several years. A biohazard concern had been identified due to animal droppings. The work involved spraying with a 10% bleach solution, general clean up, and installing a fence around the building.
The job and the work permit were assigned to a multi-trade supervisor within Plant Engineering, who delegated the spraying portion to the grounds supervisor. The multi-trade supervisor kept the original permit while sending a copy to the site maintenance supervisor. This supervisor visited the vacated building with a Safety & Health Services professional (Industrial Hygenist) who provided advice on the cleanup requirements and specified that acid gas respirator cartridges were needed. This information was not included on the work permit. The workers were not informed of this requirement and used HEPA cartridges instead. The workers did not receive a pre-job briefing nor did they know that a work permit existed.
Approximately 20 minutes into the spraying job, the two workers started to cough and their eyes and noses began to run. They exited the building to recover. Over the weekend, the workers experienced some tightness in their chests. They reported to medical for an examination and were subsequently released with no detectable health effects from the incident.
Analysis:The primary cause of this incident was a breakdown in communications concerning the respirator cartridge requirements. Contributing to the communication breakdown was the fact that an original "green" work permit was not used by the site maintenance supervisor to ensure a pre-job briefing and worker signoffs. Apparently, there was some misunderstanding by the grounds supervisor as to whether a work permit copy required any formal action. During the planning stage, this job should have been split into multiple work permits for the different work crews involved for clarity and ease of coordination.
Plant Engineering management should establish and reinforce the work planning process for multi-craft jobs that involve work permits. A lead supervisor must be assigned to coordinate all aspects of the job, the work permit, and the flow of information. Supporting supervisors must also recognize the lead supervisor' s role to coordinate work and information flow.
Establish the concept of generating multiple work permits against one work request where the moderate or high rated job is multi-craft and/or phased over a long time period.
BNL also revised several procedues to instituionalize these corrective actions.
Originator:Brookhaven National Laboratory
Validator:Edward A. Sierra
Contact:Steve Hoey, (631) 344-7936, firstname.lastname@example.org
Name Of Authorized Derivative Classifier:Kris S. Dahms
Name Of Reviewing Official:Russel J. Reaver
Priority Descriptor:Blue / Information
Keywords:work planning, work permits
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DOE Function / Work Categories:Conduct of Operations - Work Planning
ISM Category:Develop / Implement Controls
Hazard:Personal Injury / Exposure - Airborne Materials
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