Lesson Learned Statement:Hazard analysis must be an ongoing process that continues throughout the duration of a project. Supervisors and workers must recognize changes in job scope, work practices, methods, or operating conditions. Such information must be communicated to safety and health personnel for re-evaluation in order to determine whether new or modified controls will be necessary. Work plans or activity hazard analyses should contain provisions to temporarily suspend work under such conditions.Discussion:A project to install a waste collection tank involved removal of several liquid low-level waste and process pipe lines. Initial work plans were for the lines to be cut by use of a remotely-operated saw inside a glove-bag; the entire operation was to be performed inside a HEPA-filtered enclosure. During preparatory excavation, an unexpected drain line was found. The project team identified that the additional line was from a facility that handled alpha-emitting radionuclides and was not a typical low-level waste line. A subsequent decision, based on configuration of the work area, was made to excavate around the pipes and cut them with a portable band saw rather than a remotely-operated saw; the changed method did not require use of a glove-bag. During cutting activities, ground water seeped into the excavation and the walking surfaces became covered with slippery mud. A worker began performing a cut on the waste line when the saw blade slipped off the saw body and became stuck in the pipe. The worker tried to free the saw, slipped in the mud, and cut a finger on the contaminated saw blade and received an injection of radiological materialAnalysis:There were three aspects of this incident that were associated with less than adequate recognition and characterization of hazards. (1) Changes in job scope may impact characterization data. The decision to include another drain line in the project scope also introduced additional characterization data. If this information had been adequately communicated to appropriate project personnel, it could have been considered in selection of work methods and in development of more appropriate radiological work controls. (2) Changes in work methods and/or practices may present different potential hazards. The change in work methods, using a hand-held portable band saw instead of a remotely-operated saw, was not communicated to safety and health personnel for re-evaluation of hazards and controls. Had this exchange of information occurred, more appropriate personal protective clothing could have been specified, such as leather gloves for working with a saw. (3) Changes in local working conditions may introduce new potential hazards. Water seeped into the work area and created slippery walking and working conditions. This new condition was not recognized as a hazard by the workers. Had this change been recognized and communicated to their supervisor, absorbent material could have been used to ameliorate the situation or more appropriate footwear could have been selected for the workers.Recommended Actions:Workers and supervisors should be reminded to be aware of changes in the job scope, work methods, or work conditions. Workers and supervisors should exchange such information between themselves and with other key project personnel. If necessary, work on impacted activities should be temporarily suspended until a hazard re-evaluation is completed.Originator:Lockheed Martin Energy Systems; B. Roger Lankford, (423)576-4127, Energy Systems Safety & Health OrganizationValidator:N/AContact:C. M. Eubanks, (423)576-7763Name Of Authorized Derivative Classifier:N/AName Of Reviewing Official:P. L. McKenneyPriority Descriptor:Yellow / CautionKeywords:HAZARD ANALYSIS, HEPA, PERSONNAL PROTECTIVE CLOTHING, PPE, JHA, CONSTRUCTION, COMMUNICATION, CHANGING CONDITIONSReferences:Y/QS-0001, "Investigation of Issues Relating to Exposure to Radiological Workers", dated March 1997; NTS-ORO--LMES-LMESGEN-1997-0001, ORO--MKFO-X10CONSTRM-1995-0010, ORO--LMES-X10CM-1996-0004, ORO--LMES-X10CM-1997-0001Information in this report is accurate to the best of our knowledge. As means of measuring the effectiveness of this report please use the "Comment" link at the bottom of this page to notify the Lessons Learned Web Site Administrator of any action taken as a result of this report or of any technical inaccuracies you find. Your feedback is important and appreciated. DOE Function / Work Categories:Conduct of Operations - GeneralMaintenance - Other Occupational Safety & Health - General ISM Category:Hazard:Personal Injury / Exposure - Airborne MaterialsPersonal Injury / Exposure - Hazardous Material (General) Personal Injury / Exposure - Mechanical Injury (Striking / Crushing) Personal Injury / Exposure - Slips & Tripping Radiological Release
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